60-Year-Old Man Diagnosed with Nephrotic Syndrome Achieves Stable Recovery After Targeted Treatment

Summary: The appearance of persistent foamy urine, reduced urine output, and swelling in the lower limbs can be early warning signs of glomerular disease. Prompt diagnosis and targeted therapy are crucial for effective disease management. This case highlights a 60-year-old male who presented with these symptoms and was found to have heavy proteinuria and hypoalbuminemia. Following comprehensive evaluation, he was diagnosed with minimal change disease (MCD), a subtype of nephrotic syndrome. With timely corticosteroid treatment and supportive care, his condition stabilized significantly, and long-term follow-up over four years shows excellent clinical outcomes.

Patient Overview

Gender: MaleAge: 60 years oldDiagnosis: Primary Nephrotic Syndrome (Minimal Change Disease)Hospital: Peking University People's HospitalDate of Initial Visit: September 2018Treatment Approach: Pharmacological therapy including immunosuppressants, antihypertensives, diuretics, glucose-lowering agents, lipid regulators, anticoagulants, and bone-supportive supplementsTreatment Duration: 14-day hospitalization followed by 4 years of outpatient monitoringOutcome: Complete remission achieved; sustained improvement in kidney function and proteinuria levels

Initial Presentation and Clinical Assessment

The patient first noticed an increase in urinary foam about one week prior to seeking medical help. His daily urine volume had dropped from normal levels (~1500 ml) to approximately 1000 ml. Five days before consultation, after physical exertion, his urine output sharply declined to just 400–500 ml per day, accompanied by worsening foamy urine and noticeable swelling in both legs. He denied hematuria, dysuria, rash, joint pain, or photosensitivity.

Upon initial testing at the outpatient clinic, urinalysis revealed massive proteinuria (++++) and trace blood (+). Blood tests showed low serum albumin at 23.2 g/L and mildly elevated creatinine at 89.5 μmol/L, while complete blood count remained within normal limits. Despite short-term diuretic therapy providing partial relief from edema, follow-up labs indicated further decline in albumin (21.2 g/L), rising creatinine (90.9 μmol/L), and emerging hyperlipidemia—classic features pointing toward nephrotic syndrome.

Physical examination confirmed facial puffiness and severe pitting edema in the lower extremities. Further diagnostic workup revealed a staggering 7.5 grams of protein lost in urine over 24 hours, along with persistently low serum albumin—solidifying the preliminary diagnosis of nephrotic syndrome secondary to glomerular damage.

Diagnostic Workup and Treatment Strategy

Given the constellation of symptoms—including edema, significant protein loss, hypoalbuminemia, and pre-existing type 2 diabetes—treatment began immediately with symptom-focused interventions while awaiting definitive histopathological results:

Immediate Symptomatic Management

Edema Control: Sodium and fluid restriction combined with oral furosemide and spironolactone to enhance diuresis.
Proteinuria Reduction: Initiation of losartan potassium tablets, an angiotensin II receptor blocker known to reduce intraglomerular pressure and minimize protein leakage.
Diabetes Management: Continued use of metformin hydrochloride extended-release and repaglinide to maintain glycemic control without compromising renal safety.

Definitive Diagnosis via Renal Biopsy

To confirm the underlying pathology, a percutaneous renal biopsy was performed. Histological analysis revealed minimal change disease (MCD)—a common cause of nephrotic syndrome in adults, especially when no immune complex deposits are seen under microscopy. This finding guided the next phase of treatment: immunomodulation with corticosteroids.

Immunosuppressive Therapy and Supportive Care

The patient received intravenous methylprednisolone sodium succinate for one week, followed by a transition to oral prednisone acetate. Given the high risk of steroid-induced osteoporosis, prophylactic supplementation with calcium carbonate and calcitriol soft capsules was initiated. Due to markedly low albumin levels (<30 g/L), which elevate thrombotic risk, anticoagulation was critical:

Inpatient: Low molecular weight heparin calcium injections for deep vein thrombosis prevention.
Outpatient: Switched to aspirin enteric-coated tablets for long-term antiplatelet protection.

Later, due to recurrent episodes triggered by infections and fatigue, cyclosporine soft capsules were added to consolidate remission and prevent relapse.

Clinical Response and Long-Term Outcome

The patient responded remarkably well to glucocorticoid therapy. Within one week, urine output increased significantly. By the second week, 24-hour proteinuria dropped dramatically to 0.3 g/day, and serum albumin rose to 35.3 g/L. Creatinine stabilized between 80–90 μmol/L, indicating preserved kidney function.

Over the next four years, there were four documented relapses—each associated with physiological stressors such as upper respiratory infections or overexertion. Each episode was promptly managed with adjusted steroid dosing and the addition of cyclosporine, leading to rapid re-induction of remission.

Currently, the patient maintains near-normal kidney parameters:

Urine Protein: 0.14 g/24h
Serum Albumin: 38–43 g/L
Serum Creatinine: ~80 μmol/L

He remains asymptomatic and continues regular follow-ups every three months.

Key Recommendations for Patients with Nephrotic Syndrome

Achieving remission is only part of the journey. Sustained recovery requires ongoing vigilance and lifestyle discipline. Here are essential guidelines for long-term success:

1. Lifestyle and Dietary Modifications

Maintain a balanced routine with adequate sleep and emotional well-being. Adopt a kidney-friendly diet that emphasizes:

Low sodium intake to manage blood pressure and fluid retention
Moderate fat consumption to control cholesterol
High-quality protein sources (e.g., lean meats, eggs, dairy) while avoiding excess protein load

Crucially, avoid triggers like excessive physical strain and exposure to infectious environments, as these are major contributors to relapse in MCD.

2. Regular Monitoring and Follow-Up

Consistent laboratory surveillance is vital. Recommended tests include:

Complete blood count (CBC)
Urinalysis and 24-hour urine protein quantification
Blood chemistry panel: creatinine, urea, electrolytes
Serum albumin, lipid profile, and glucose levels

These metrics allow clinicians to assess disease activity, adjust medication doses (especially steroids), and detect complications early.

3. Medication Safety and Side Effect Awareness

Long-term corticosteroid use demands close monitoring of:

Blood glucose levels—steroids can worsen insulin resistance, particularly in diabetic patients
Blood pressure—some medications may contribute to hypertension
Bone health—continue vitamin D and calcium support throughout treatment

Patients should report any new symptoms—including mood changes, vision disturbances, or muscle weakness—to their healthcare provider immediately.

Insights on Minimal Change Disease and Kidney Health

Nephrotic syndrome encompasses a spectrum of glomerular disorders characterized by heavy proteinuria, hypoalbuminemia, edema, and hyperlipidemia. Among its subtypes, minimal change disease stands out for its excellent response to corticosteroids, even in older adults. While more commonly diagnosed in children, MCD accounts for up to 10–15% of adult-onset nephrotic cases.

It's important to distinguish primary (idiopathic) forms like MCD from secondary causes linked to diabetes, lupus, infections, or malignancies. In this case, despite the patient's history of diabetes, the renal biopsy ruled out diabetic nephropathy, confirming a primary glomerular disorder.

Although remission rates are high, relapses remain a concern—particularly in individuals exposed to stress, illness, or inconsistent treatment adherence. Therefore, patient education, proactive monitoring, and individualized therapy plans are key to achieving lasting kidney health.