Case Presentation: A 49-year-old male with a history of warfarin non-compliance left popliteal deep vein thrombosis (DVT), was admitted for dyspnea, left arm pain and bilateral lower extremities edema. In addition to new evidence of DVTs, the patient was found with nephrotic syndrome (NS). Chest CT showed concern for bronchogenic malignancyand enlarged kidneys. He underwent lung and renal biopsy. Histopathology of the lung and the kidney revealed invasive, poorly differentiated lungadenocarcinoma and minimal-change disease (MCD), respectively.Since the patient was a poor surgical candidate, he only received stereotactic body radiation therapy (SBRT). For his MCD, patient receivedcalcineurin inhibitors and steroids. His anasarca and proteinuria were greatly reduced after 2 months of treatment, but never in complete remission.The serum creatinine level improved and remained around 0.6mg/dl. The patient was treated with palliative chemotherapy, Carboplatin and Pemetrexed.Three months later, the patient developed pneumonia. CT scan showed evidence of disease progression. Renal function also deteriorated with increased serum of 1.9mg/dl. Palliative radiation to the chest was scheduled but the patient and family elected comfort care.
Discussion: The association between neoplasia and MCD remains unclear. Paraneoplastic glomerulonephritis could be considered once other etiologies are ruled out. Diagnostic criteria for paraneoplastic glomerulonephritis included improvement, resolution, and relapse while the NS could precede, be contemporaneous, or follow the cancer diagnosis.Treatment for paraneoplastic nephrotic syndrome is based mainly on the treatment of the underlying malignancy. In our case, NS and lung adenocarcinoma were diagnosed at the same time. Due to advanced stage of the patient’s malignancy and severe manifestation of NS, prescribing curative chemotherapy would be impossible and therefore we decided to treat his MCD.Even though the patient’s proteinuria decreased after two months, however, he never reached complete remission. This was associated with his progressing adenocarcinoma and decline of renal function.
Conclusions: We postulate that in the presence of progressive malignancy, the standard therapy for NS is only partially effective and could be used primarily to lessen the symptoms, but not induce effective or lasting remission