To Treat Or Not To Treat: Prednisone Treatment Of Minimal Change Disease In A Patient With Chronic HBV
INTRODUCTION: Minimal change disease (MCD) accounts for 10-15% of cases in adult nephrotic syndrome. Clinical presentation is characterized by marked proteinuria, hypoalbuminemia, and hyperlipidemia. The mainstay initial therapy is prednisone or prednisolone.
CASE DESCRIPTION: A 61-year-old female presented with acute hepatitis, transaminitis, hyperbilirubinemia, and hypoalbuminemia. Ultrasound of the liver with doppler revealed coarse nodular echotexture suggesting cirrhosis.
Five months prior, the patient was diagnosed with nephrotic syndrome. Her laboratory tests revealed marked proteinuria, diffuse edema, hypoalbuminemia, and hypercholesterolemia.. Renal biopsy demonstrated MCD and acute tubular necrosis. Hepatitis panel revealed positive HbsAg, HbcAb, and HbeAb, while HbcAb IgM and Hep C Ag were negative, suggesting chronic HepB infection. Diagnosis of chronic HepB was confirmed with HBV PCR DNA levels at 530 IU/mL. She was discharged on 80 mg daily prednisone and placed on dialysis three times a week for two months. Prednisone was tapered after four months of treatment; improved renal function allowed for discontinuation of dialysis.
During her present hospital course when she presented with hepatic failure, workup for hepatitis B reactivation showed HBV DNA levels had increased to 14.4 million IU/mL. Therapy with oral entecavir was initiated. The patient's hepatic function improved; liver enzymes consistently trended downward. At follow up visit, both renal and hepatic function remained stable.
DISCUSSION: While prednisone is the leading therapy for nephrotic syndrome secondary to minimal change disease in adults, this case highlights the importance of antiviral prophylaxis in patients with concurrent chronic hepatitis B infection.