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Lan Lan; Lin Yuxin; Yu Binfeng; Wang Yin; Pan Hong; Wang Huijing; Lou Xiaowei; Lang Xiabing; Zhang Qiankun; Jin Lei; Yang Yi; Xiao Liang; Chen Jianghua; Han Fei: Efficacy of Rituximab for Minimal Change Disease and Focal Segmental Glomerulosclerosis with Frequently Relapsing or Steroid-Dependent Nephrotic Syndrome in Adults: A Chinese Multicenter Retrospective Study. American Journal of Nephrology DOI 10.1159/000535010

A role for rituximab (RTX and other anti-CD19/20 monoclonal antibodies, such as obinutuzumab [1] has been suggested for therapy of steroid-sensitive nephrotic syndrome (SSNS) with a frequently relapsing steroid-dependent (FR/SD) response in patients with apparently primary minimal change (MCL) or focal and sclerosing glomerulosclerosis (FSGS) lesions on kidney biopsy. Most of the studies supporting this suggestion have been carried out in children. 

Lan and colleagues retrospectively collected data on a cohort of young and older adults with these lesions and FR/SD SSNS in 3 centers in China (MCL in 67 and FSGS in 14 patients) treated with RTX. The treatment with RTX was used to induce a remission or to sustain a remission and reduce the intensity of concomitant immunosuppressive therapy and prevent relapses. The pre-RTX relapse rate was 1.71/year and the follow-up was 2 years. Patients received an average dose of RTX of 1.39 ± 0.62 g. B-cell depletion was observed after each infusion. 

Relapses were decreased to 0.04 per year and the post-RTX relapse-free interval was extended to 16.7 ± 8 months. No differences in effectiveness were seen between the two histological groups or between young and older adults. Adverse events were common (17%), mostly infusion reactions. Low serum albumin levels and high CD56+, CD16+ and NK cells in peripheral blood predicted a higher relapse rate. No studies of anti-nephrin autoantibodies were performed. 

The observational study has all of the limitations of a retrospective analysis, and the number of patients with FSGS lesions and the relatively short-term follow-up do not allow for any firm conclusions concerning long-term effectiveness in the FSGS subgroup. Nevertheless, the findings in FR/SD SSNS in the MCL subgroup generally support the suggestion of effectiveness in this subgroup. The lack of any information on anti-nephrin autoantibodies is a significant weakness. It appears that anti-CD19/20 monoclonal antibody therapy (RTX or obinutuzumab) for FR/SD SSNS in both children and adults can materially reduce relapse frequency and limit the intensity of concomitant immunosuppressives (e.g., steroids). Further randomized controlled studies are eagerly awaited. 

References 

  1. Dossier C, Bonneric S, Baudouin V, Kwon T, Prim B, Cambier A, et al. Obinutuzumab in frequently relapsing and steroid-dependent nephrotic syndrome in children. Clin J Am Soc Nephrol. 2023;18:1555–1562.

Quoted Karger Article

Efficacy of Rituximab for Minimal Change Disease and Focal Segmental Glomerulosclerosis with Frequently Relapsing or Steroid-Dependent Nephrotic Syndrome in Adults: A Chinese Multicenter Retrospective Study

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