Minimal Change Disease in a Healthy Man Following Nonsteroidal Anti-Inflammatory Drug (NSAID) and Herbal Supplement Use

Introduction: A 55-year-old previously healthy Amish man presented with a 4-week history of progressive bilateral lower extremity and scrotal edema. One month prior, he had been using Excedrin daily for headaches. As edema worsened, he began an herbal supplement labeled UR-W, marketed as a "cleanse," containing Cornsilk, Stoneroot, Buchu, Yarrow, and Uva Ursi Case Description: On presentation, BP was 190/108 mmHg, BMI 40.5 kg/m, creatinine 1.98 mg/dL, BUN 31 mg/dL, albumin 1.8 g/dL, vitamin D 7.46 ng/mL, and 24-hour urine protein 11.9 g. UA showed >300 mg/dL protein, 4–10 RBCs/hpf, with granular and hyaline casts. CT imaging revealed bilateral pleural effusions, anasarca, and small ascites. Serologic workup was negative for ANA, dsDNA, PLA2R, HIV, hepatitis B/C, and cryoglobulins; complements were normal. SPEP showed hypogammaglobulinemia. Free light chains were kappa 35.3 mg/L, lambda 28.8 mg/L (kappa/lambda ratio: 1.23). Renal biopsy showed 25 glomeruli (2 globally sclerosed), with enlarged but otherwise unremarkable glomeruli, preserved mesangial architecture, and no crescents or immune complex deposition. Immunofluorescence revealed minimal nonspecific staining. Tubular findings included focal isometric vacuolization, suggestive of osmotic injury. Preliminary electron microscopy showed ~90% podocyte foot process effacement, confirming a podocytopathy consistent with minimal change disease (MCD). No evidence of FSGS, membranous features, or immune complex GN was found. MCD was diagnosed, likely triggered by NSAID use. The contribution of the UR-W supplement is uncertain, but its diuretic components may have caused the vacuolar injury. Age-appropriate malignancy screening is ongoing although less likely. The patient was discharged on prednisone 80 mg daily with a taper plan, diuretics, and prophylactic dapsone and enoxaparin Discussion: Minimal Change Disease (MCD) accounts for 10–15% of adult nephrotic syndrome. Unlike in children, adults may present insidiously with hypertension or AKI. This case showed classic MCD features—nephrotic-range proteinuria, hypoalbuminemia, no immune deposits, and diffuse foot process effacement on EM. EM also revealed isometric vacuolization, likely linked to chronic use of the herbal diuretic UR-W, raising concern for tubular injury from unregulated supplements and alternative therapies