Efficacy of low-dose rituximab in minimal change disease and prevention of relapse

Abstract

Background Minimal change disease (MCD) is a major cause of nephrotic syndrome (NS) in children and a minority of adults. The higher tendency to relapse put patients at risk for prolonged exposure to steroids and other immunosuppressive agents. B cell depletion with rituximab (RTX) may be beneficial to the treatment and prevention of frequently relapsing MCD. Therefore, this study aimed to verify the therapeutic/preventive effects of low-dose RTX on the relapse in adult with MCD. Methods A total of 33 adult patients were selected for the study, including 22 patients with relapsing MCD in relapse treatment group who were treated with low-dose RTX (200 mg per week × 4 following by 200 mg every 6 months) and 11 patients in relapse prevention group with complete remission (CR) after steroid therapy were treated with RTX (200 mg ×1 every 6 months) for preventing the relapse of MCD. Results Of the 22 patients with MCD in relapse treatment group, there were 21 cases (95.45%) of remission [2 (9.09%) partial remission (PR), 19 (86.36%) CR], 1 (4.56%) no remission (NR) and 20 (90.90%) relapse-free. The Median duration of sustained remission was 16.3 months (3, 23.5 months, inter quartile range (IQR)). 11 patients in the relapse prevention group during a follow-up of 12 months (9–31 months) had no relapse. The average dose of prednisone in two groups after RTX treatment was significantly lower than before treatment. Conclusion The results of this study suggested low-dose RTX can significantly reduce relapse rate and steroid dose in adults with MCD with fewer side effects. Low-dose RTX regimens may be beneficial for the treatment of relapsing MCD in adults and may be the preferred regimen for patients at high risk for the development of adverse events from corticosteroids.

Immunosuppression for adult steroid-dependent or frequently relapsing nephrotic syndrome: A systematic review and meta-analysis

“…There are 9 prospective studies [ 27 , 39 , 42 , 44 – 46 , 48 – 49 , 52 ] and 19 retrospective studies [ 26 , 28 – 38 , 40 – 41 , 43 , 47 , 50 – 51 , 53 ]. Five studies were conducted in USA [ 28 , 33 , 36 – 37 , 51 ], six studies in India [ 26 , 31 , 35 , 45 , 49 , 52 ], five in China [ 30 , 41 , 44 , 47 , 48 ], four studies in Japan [ 34 , 39 , 42 , 46 ], two each in France [ 40 , 43 ] and Spain [ 29 , 50 ] as well as one each in Netherlands [ 38 ], Sweden [ 27 ], Tunisia [ 32 ] and Pakistan [ 53 ].…”

“…21 studies [ 28 – 35 , 37 , 39 – 40 , 42 – 48 , 50 – 51 , 53 ] reported the baseline creatinine level of patients. 9 studies [ 28 , 29 , 31 , 32 , 35 , 40 , 43 , 51 , 53 ] reported a mean baseline creatinine of 1.08 mg/dL, 2 [ 33 , 34 ] studies reported a median baseline creatinine level of 0.69mg/dL and 0.9 mg/dL respectively whereas the other 10 studies [ 30 , 37 , 39 , 42 , 44 – 48 , 50 ] did not mention whether baseline creatinine level was calculated in mean or median. Extracted data from 11 studies [ 26 – 28 , 35 , 41 , 46 – 48 , 50 – 52 ] reported a mean rate of relapse of 33.33%, while the duration of remission from 6 studies [ 27 , 37 , 41 , 44 , 48 , 51 ] ranges between 1 to 43 months.…”

“…For previous therapies, 8 studies [ 27 , 28 , 34 , 37 , 38 , 43 , 48 , 51 ] reported the use of cyclophosphamide, 11 studies [ 27 , 28 , 31 , 34 , 37 – 39 , 43 , 48 , 51 , 53 ] reported the use of cyclosporine, 10 studies [ 27 , 28 , 34 , 37 – 40 , 43 , 47 , 48 ] reported the use of mycophenolate mofetil, 7 studies [ 27 , 28 , 31 , 34 , 37 , 39 , 43 ] reported the use of tacrolimus, 3 studies [ 27 , 38 , 43 ] reported the use of levamisole and 2 studies [ 34 , 39 ] reported the use of mizoribine. Azathioprine, abatacept, rituximab, mechlorethamine, basiliximab, chimeric antigen receptor (CAR), chlorambucil, pefloxacin were reported in 1 study respectively [ 28 , 30 , 43 ].…”

Japanese clinical practice patterns of rituximab treatment for minimal change disease in adults 2021: A web-based questionnaire survey of certified nephrologists

“…On the other hand, it is noteworthy that several respondents chose a substandard dosage. This reality may reflect findings from both Japanese and foreign studies that reported the effectiveness of a single 200-mg dose of RTX [22,23].…”

Management of adult patients with podocytopathies: an update from the ERA Immunonephrology Working Group

“…The recent discovery of anti-nephrin antibodies as a driver of autoimmunity in a subset of MCD underlines the importance of B cells in the pathogenesis of MCD [ 3 ]. There is evidence that rituximab is effective in the management of adult MCD [ 35 ]. A retrospective comparison of different second line therapies used in a single center to manage FR/SD MCD indicated that the median time to relapse after rituximab was longer (66 versus 28 months) compared with other measures (CNIs, mycophenolate mofetil, and cyclophosphamide) but the difference fell short of statistical significance [ 36 ].…”