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A 3-year-old child develops severe generalized edema following a viral infection. On the basis of clinical
chemistry tests, a renal biopsy is performed, with normal light microscopic findings. Which of the following
abnormal laboratory values might be expected in this individual?
A. Decreased alpha globulin levels
B. Decreased fibrinogen
C. Increased serum calcium levels
D. Low serum albumin levels
E. Red blood cell casts in the urine
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The correct answer is D. This child has minimal change disease, which is the major cause (over 90% of cases)
of nephrotic syndrome in children aged 2 to 6 years. The most prominent clinical chemistry finding in these
patients is massive proteinuria. The urinary protein in minimal change disease, in contrast to other causes of
nephrotic syndrome, is often composed predominantly of albumin. Many other clinical chemistry changes may
also be seen, including decreased serum albumin levels, hyperlipidemia, increased serum levels of alpha2- and
beta-globulins, decreased IgG, and increased fibrinogen. Minimal change disease characteristically shows
normal or near normal appearance of the glomeruli by light microscopy and extensive fusion of foot processes
of the glomerular podocytes by electron microscopy. A point not always recognized by beginners is that the
podocyte alterations may represent a reaction to, rather than a cause of, the proteinuria (e.g., an attempt to
"seal the holes" in the glomerulus), since varying degrees of foot process fusion (together with more specific
features) may sometimes be seen in other glomerular diseases associated with the nephrotic syndrome.
