When Minimal Becomes Massive: A Case Report of Childhood-Onset Minimal Change Disease Marching to End Stage Renal Disease Despite Modern Immunotherapy

We report a rare case of childhood-onset Minimal Change Disease (MCD) in a 31-year-old male, originally diagnosed at age 2.5 with nephrotic syndrome. Repeated biopsies throughout his childhood and adolescence revealed normal glomeruli on light microscopy and diffuse effacement of podocyte foot processes on electron microscopy, confirming pure MCD. Despite multiple relapses, prolonged corticosteroid therapy, and adjunctive immunosuppressants including cyclosporine, tacrolimus, and 2 courses of Rituximab, the patient developed progressive renal decline culminating in end-stage renal disease (ESRD) and initiation of maintenance hemodialysis in August 2025. His course also included an ischemic stroke at age 20. This case illustrates an atypical, aggressive phenotype of MCD, without transformation to focal segmental glomerulosclerosis, that challenges the conventional prognosis of MCD and underscores the need for long-term monitoring and reporting of such exceptional cases.