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Francis A, Emma F. Preventing Relapses in Childhood Nephrotic Syndrome. Kidney Int Rep 2024; 9:1149-1151. [PMID: 38707824 PMCID: PMC11069005 DOI: 10.1016/j.ekir.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Affiliation(s)
- Anna Francis
- Department of Nephrology, Queensland Children’s Hospital, Brisbane, Australia
| | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
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Choi N, Min J, Kim JH, Kang HG, Ahn YH. Efficacy and safety of long-term repeated use of rituximab in pediatric patients with nephrotic syndrome. Pediatr Nephrol 2024; 39:771-780. [PMID: 37682369 DOI: 10.1007/s00467-023-06124-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/02/2023] [Accepted: 08/02/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND We aimed to investigate the efficacy and safety of repeated use of rituximab (RTX) in pediatric patients with nephrotic syndrome (NS). METHODS Retrospective review of 50 patients with steroid-dependent NS (SDNS) who had received more than three cycles of RTX was conducted; each consisted of one to four infusions until B lymphocytes were depleted. RESULTS The median age of starting the first RTX cycle was 12.4 years (interquartile ranges (IQR) 10.2-14.6). During a median follow-up period of 6.3 (IQR 3.6-8.6) years, patients received a median of 5.0 RTX cycles (IQR 4.0-7.3). The number of relapses decreased from a median of 2.0 relapses per year (IQR 1.0-3.0) to 0.2 relapses per year (IQR 0.0-0.5) after long-term RTX treatments (P < 0.001). Longer relapse-free periods were associated with more than four RTX cycles, longer B-cell depletion, older age at each RTX treatment, and lower cholesterol levels. B lymphocytes recovered to 1% at a median of 5.9 months (95% confidence interval 5.7-6.1) after RTX administration. Factors related to a longer period of B-cell depletion included more than five RTX cycles, a higher dose of RTX, older age at treatment, and concurrent use of antimetabolites. During repeated RTX treatments, 8.0%, 6.0%, and 2.0% of patients developed hypogammaglobulinemia, severe infection, and severe neutropenia, respectively. CONCLUSIONS Long-term repeated use of RTX may be effective and safe in pediatric NS patients. Furthermore, the redosing of RTX could be chosen by considering predictive factors for relapse-free and B-cell depletion periods.
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Affiliation(s)
- Naye Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeesu Min
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Pediatrics, Chungnam National University Sejong Hospital, Sejong, Republic of Korea
| | - Ji Hyun Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
- Kidney Research Institute, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Kidney Research Institute, Seoul National University Medical Research Center, Seoul, Republic of Korea.
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3
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Zhu Y, Chen J, Zhang Y, Wang X, Wang J. Immunosuppressive agents for frequently relapsing/steroid-dependent nephrotic syndrome in children: a systematic review and network meta-analysis. Front Immunol 2024; 15:1310032. [PMID: 38464533 PMCID: PMC10920238 DOI: 10.3389/fimmu.2024.1310032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/06/2024] [Indexed: 03/12/2024] Open
Abstract
Aim This study aimed to systematically compare the efficacy of various immunosuppressive agents in treating pediatric frequently relapsing or steroid-dependent nephrotic syndrome (FRSDNS). Methods We conducted systematic searches of PubMed, Embase, the Cochrane Library, and the Web of Science up to May 23, 2023. Outcome measures included relapses within 1 year, mean cumulative exposure to corticosteroids, patients with treatment failure at 1 year, relapse-free survival during 1 year, and adverse events. The quality of the included studies was evaluated using the modified Jadad scale, the Methodological Index for Non-Randomized Studies (MINORS), and the modified Newcastle-Ottawa Scale (NOS). Results Rituximab was found to be the most likely (92.44%) to be associated with the fewest relapses within 1 year and was also most likely (99.99%) to result in the lowest mean cumulative exposure to corticosteroids. Rituximab had the highest likelihood (45.98%) of being associated with the smallest number of patients experiencing treatment failure at 1 year. CsA was most likely (57.93%) to achieve the highest relapse-free survival during 1 year, followed by tacrolimus (26.47%) and rituximab (30.48%). Rituximab showed no association with serious side effects and had comparable adverse effects to ofatumumab and tacrolimus. Conclusion Rituximab may be the most favorable immunosuppressive agent for treating pediatric FRSDNS. Nephrologists should consider this drug, along with their clinical experience, patient characteristics, and cost considerations, when choosing a treatment approach.
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Affiliation(s)
- Yu Zhu
- Department of Traditional Chinese Medicine, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, Hangzhou, China
| | - Junyi Chen
- Department of Nephrology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, Hangzhou, China
| | - Yao Zhang
- Department of Traditional Chinese Medicine, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, Hangzhou, China
| | - Xiaoai Wang
- Department of Traditional Chinese Medicine, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, Hangzhou, China
| | - Jingjing Wang
- Department of Nephrology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, Hangzhou, China
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Chen Y, Shen Q, Xiong Y, Dong M, Xu H, Li Z. Using real-world data to inform dosing strategies of rituximab for pediatric patients with frequent-relapsing or steroid-dependent nephrotic syndrome: a prospective pharmacokinetic-pharmacodynamic study. Front Pharmacol 2024; 14:1319744. [PMID: 38264525 PMCID: PMC10803641 DOI: 10.3389/fphar.2023.1319744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/28/2023] [Indexed: 01/25/2024] Open
Abstract
Objectives: Rituximab is frequently used off-label for the treatment of frequent-relapsing/steroid-dependent nephrotic syndrome (FRNS/SDNS). However, the optimal dosing schedules remain undetermined. The objective of this study was to establish a population pharmacokinetic-pharmacodynamic (PK-PD) model in pediatric patients with FRNS/SDNS, and to investigate dosing regimens that provide adequate suppression of B lymphocytes. Methods: A prospective, open-label, single-center study was conducted in Nephrology Department at Children's Hospital of Fudan University, and a two-compartment PK model of rituximab in pediatric FRNS/SDNS has been developed previously by our group. CD19+ lymphocyte count profiles were obtained from these patients. The presence of anti-rituximab antibodies was assessed prior to medication in children who had previously received rituximab or during follow-up at the last sampling point for PK analysis. PK-PD analyses were performed to describe the changes of CD19+ lymphocytes, with rituximab assumed to increase their death rate. Monte Carlo simulation was conducted to evaluate different dosing regimens. Results: In total, 102 measurements of CD19+ lymphocyte counts were available for PK-PD analysis. No detectable levels of anti-rituximab antibodies were observed during the PK follow-up period. A turnover model with saturable stimulatory action of rituximab on the removal of lymphocytes best characterized the relationship between rituximab concentration and CD19+ lymphocyte counts, where the Emax and EC50 were estimated to be 99.6*106/L and 5.87 μg/mL, respectively. Simulations indicated that a single infusion of 750 mg/m2 and 2 infusions of 375 mg/m2 both yielded a 10-week suppression of CD19+ lymphocytes. Conclusion: This study represents a first attempt to quantitatively describe the PK-PD relationship of rituximab in pediatric patients with FRNS/SDNS, and provide a potential pathway for future precision dosing strategy for rituximab therapy. Further clinical studies are warranted to evaluate the efficacy and safety of different dosing schemes.
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Affiliation(s)
- Yewei Chen
- Department of Pharmacy, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Qian Shen
- Department of Nephrology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Ye Xiong
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Min Dong
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Hong Xu
- Department of Nephrology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Zhiping Li
- Department of Pharmacy, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
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Lai FFY, Chan EYH, Tullus K, Ma ALT. Therapeutic drug monitoring in childhood idiopathic nephrotic syndrome: a state of the art review. Pediatr Nephrol 2024; 39:85-103. [PMID: 37147510 DOI: 10.1007/s00467-023-05974-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/30/2023] [Accepted: 03/30/2023] [Indexed: 05/07/2023]
Abstract
Immunosuppressants are commonly used as steroid-sparing agents in childhood idiopathic nephrotic syndrome (NS) to induce and sustain remissions. These drugs have narrow therapeutic indices with high inter- and intra-patient variability. Therapeutic drug monitoring (TDM) would therefore be essential to guide the prescription. Multiple factors in NS contribute to additional variability in drug concentrations, especially during relapses. In this article, we review the currently available evidence of TDM in NS and suggest a practical approach for clinicians' reference.
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Affiliation(s)
- Fiona Fung-Yee Lai
- Department of Pharmacy, Hong Kong Children's Hospital, Kowloon City, Hong Kong
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon City, Hong Kong
| | - Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon City, Hong Kong.
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Alison Lap-Tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon City, Hong Kong
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Rehan ST, Ali E, Eqbal F, Ahsan MN, Asghar MS. Meta-analysis on the efficacy and safety of rituximab versus tacrolimus for nephrotic syndrome in the paediatric age group. Clin Kidney J 2024; 17:sfad263. [PMID: 38186898 PMCID: PMC10768748 DOI: 10.1093/ckj/sfad263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Indexed: 01/09/2024] Open
Affiliation(s)
| | - Eman Ali
- Dow University of Health Sciences, Karachi, Pakistan
| | - Farea Eqbal
- Dow University of Health Sciences, Karachi, Pakistan
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Dossier C, Bonneric S, Baudouin V, Kwon T, Prim B, Cambier A, Couderc A, Moreau C, Deschenes G, Hogan J. Obinutuzumab in Frequently Relapsing and Steroid-Dependent Nephrotic Syndrome in Children. Clin J Am Soc Nephrol 2023; 18:1555-1562. [PMID: 37678236 PMCID: PMC10723910 DOI: 10.2215/cjn.0000000000000288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/31/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND B-cell depletion with rituximab induces sustained remission in children with steroid-dependent or frequently relapsing nephrotic syndrome. However, most patients relapse after B-cell recovery, and some patients do not achieve B-cell depletion. Obinutuzumab is a second-generation anti-CD20 antibody designed to overcome such situations in B-cell malignancies and was recently reported to be safe and effective in other autoimmune diseases affecting the kidneys. METHODS We retrospectively report 41 children with steroid-dependent or frequently relapsing nephrotic syndrome treated with a single low-dose infusion of obinutuzumab at Robert-Debre Hospital between April 2018 and December 2020. Participants were treated because of rituximab resistance or relapse after rituximab and received a single infusion of 300 mg/1.73 m 2 obinutuzumab with cessation of oral immunosuppressors within 2 months. RESULTS B-cell depletion was achieved in all participants and lasted a median of 8.3 months (interquartile range, 6.4-11.1), a duration exceeding that for last rituximab treatment. At 12 and 24 months, 92% (38/41) and 68% (28/41) of patients, respectively, were in sustained remission. Mild infusion reactions occurred in five participants (12%) and neutropenia in nine (21%). No significant decrease in IgG level was reported during treatment, and whereas IgM levels decreased in 34 patients (83%), they were normal at last follow-up in 32 (78%). CONCLUSIONS These results identified low-dose obinituzumab as a promising treatment option in children with steroid-dependent or frequently relapsing nephrotic syndrome, including those resistant to rituximab. The tolerance profile of obinutuzumab was similar to that of rituximab, but hemogram and immunoglobulin levels should be monitored.
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Affiliation(s)
- Claire Dossier
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, Paris, France
| | - Stéphanie Bonneric
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, Paris, France
| | - Véronique Baudouin
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, Paris, France
| | - Thérésa Kwon
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, Paris, France
| | - Benjamin Prim
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, Paris, France
| | - Alexandra Cambier
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, Paris, France
| | - Anne Couderc
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, Paris, France
| | | | - Georges Deschenes
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, Paris, France
| | - Julien Hogan
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, Paris, France
- Université Paris Cité, INSERM, UMR-S970, PARCC, Paris Translational Research Center for Organ Transplantation, Paris, France
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Whelan R, Feemster A, Laskowski J, Renner B, Kulik L, Poppelaars F, Lee C, Holers VM, Thurman JM. Female but Not Male Mice Deficient in Soluble IgM Are Susceptible to Chemically Induced Glomerular Injury. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2023; 211:1240-1248. [PMID: 37682538 PMCID: PMC10592129 DOI: 10.4049/jimmunol.2200292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/11/2023] [Indexed: 09/09/2023]
Abstract
B cell-targeted therapies are effective for treating multiple different kidney diseases in humans and also protect mice from Adriamycin nephropathy. Because glomerular IgM is frequently seen in both humans and mice with "nonimmune" forms of glomerular disease, we hypothesized that natural IgM binds to epitopes displayed in the injured glomerulus, exacerbating injury. To test this hypothesis, we induced Adriamycin nephropathy in BALB/C mice that cannot secrete soluble IgM (sIgM-/- mice) and compared them with BALB/C controls. Contrary to our prediction, we found that female sIgM-/- mice developed higher mortality and more severe kidney injury after injection of Adriamycin. The absence of soluble IgM did not reduce glomerular complement activation, and IgG was seen deposited within the injured glomeruli. Furthermore, we discovered that female sIgM-/- mice have higher levels of anti-cardiolipin IgG, and that IgG from these mice binds to epitopes in the injured kidney. These findings indicate that natural IgM may prevent generation of autoreactive IgG. Circulating levels of anti-cardiolipin IgG decreased after induction of kidney injury in female mice, consistent with deposition of the Abs in injured tissues. Better understanding of the mechanisms by which the immune system modulates and amplifies kidney injury may enable the development of targeted therapies to slow kidney disease progression.
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Affiliation(s)
- Russell Whelan
- Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Andrew Feemster
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Jennifer Laskowski
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Brandon Renner
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Liudmila Kulik
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Felix Poppelaars
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Cameron Lee
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - V. Michael Holers
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Joshua M. Thurman
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
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Ohyama R, Fujinaga S, Sakuraya K, Hirano D, Ito S. Predictive factors of long-term disease remission after rituximab administration in patients with childhood-onset complicated steroid-dependent nephrotic syndrome: a single-center retrospective study. Clin Exp Nephrol 2023; 27:865-872. [PMID: 37477752 DOI: 10.1007/s10157-023-02374-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/19/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Despite the fact that rituximab (RTX)-associated adverse events may be relatively frequent in younger patients, recent studies have reported RTX as a suitable first-line steroid-sparing agent for maintaining remission in children with steroid-dependent nephrotic syndrome (SDNS). However, the impact of age at RTX initiation on the long-term outcome remains unknown in this cohort. METHODS We retrospectively reviewed the clinical course of 61 patients with complicated SDNS who received a single dose of RTX (375 mg/m2) followed by maintenance immunosuppressive agents (IS) from January 2008 to March 2021. In patients who achieved > 12 months of prednisolone-free remission, IS tapering within 6 months was tried to achieve. The primary endpoint was the probability of achieving long-term treatment-free remission at the last follow-up. RESULTS After RTX initiation, 52 patients (85.2%) relapsed after a median of 665 days, and 44 patients (72.1%) received additional RTX doses (total, 226 infusions). At the last follow-up (median observation period, 8.3 years; median age, 18.3 years), 16 patients (26.2%) achieved long-term remission. Multivariate analysis showed that older age at RTX initiation was the independent predictive factor for achieving long-term remission (odds ratio, 1.25; p < 0.05). The proportion of those who achieved long-term remission was significantly higher in patients aged ≥ 13.5 years than in those aged < 13.5 years at RTX initiation (52.6 vs 14.3%, p < 0.05). Persistent severe hypogammaglobulinemia did not develop in older children (≥ 13.5 years) at RTX initiation. CONCLUSION For older children with complicated SDNS, RTX appeared to be a suitable disease-modifying therapy without persistent adverse events.
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Affiliation(s)
- Rie Ohyama
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-Ku, Saitama, 330-8777, Japan
- Department of Pediatrics, Yokohama City University Hospital, 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Shuichiro Fujinaga
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-Ku, Saitama, 330-8777, Japan.
| | - Koji Sakuraya
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-Ku, Saitama, 330-8777, Japan
| | - Daishi Hirano
- Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University, Graduate School of Medicine, Yokohama, Kanagawa, Japan
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Vivarelli M, Gibson K, Sinha A, Boyer O. Childhood nephrotic syndrome. Lancet 2023; 402:809-824. [PMID: 37659779 DOI: 10.1016/s0140-6736(23)01051-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 05/04/2023] [Accepted: 05/19/2023] [Indexed: 09/04/2023]
Abstract
Idiopathic nephrotic syndrome is the most common glomerular disease in children. Corticosteroids are the cornerstone of its treatment, and steroid response is the main prognostic factor. Most children respond to a cycle of oral steroids, and are defined as having steroid-sensitive nephrotic syndrome. Among the children who do not respond, defined as having steroid-resistant nephrotic syndrome, most respond to second-line immunosuppression, mainly with calcineurin inhibitors, and children in whom a response is not observed are described as multidrug resistant. The pathophysiology of nephrotic syndrome remains elusive. In cases of immune-mediated origin, dysregulation of immune cells and production of circulating factors that damage the glomerular filtration barrier have been described. Conversely, up to a third of cases of steroid-resistant nephrotic syndrome have a monogenic origin. Multidrug resistant nephrotic syndrome often leads to kidney failure and can cause relapse after kidney transplant. Although steroid-sensitive nephrotic syndrome does not affect renal function, most children with steroid-sensitive nephrotic syndrome have a relapsing course that requires repeated steroid cycles with significant side-effects. To minimise morbidity, some patients require steroid-sparing immunosuppressive agents, including levamisole, mycophenolate mofetil, calcineurin inhibitors, anti-CD20 monoclonal antibodies, and cyclophosphamide. Close monitoring and preventive measures are warranted at onset and during relapse to prevent acute complications (eg, hypovolaemia, acute kidney injury, infections, and thrombosis), whereas long-term management requires minimising treatment-related side-effects. A subset of patients have active disease into adulthood.
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Affiliation(s)
- Marina Vivarelli
- Division of Nephrology, Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
| | - Keisha Gibson
- Division of Nephrology and Hypertension, University of North Carolina Kidney Center, University of North Carolina at Chapel Hill, NC, USA
| | - Aditi Sinha
- Division of Nephrology, Indian Council of Medical Research Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Olivia Boyer
- Néphrologie Pédiatrique, Centre de Référence Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Hôpital Necker - Enfants Malades, Assistance Publique Hôpitaux de Paris, Inserm U1163, Institut Imagine, Université Paris Cité, Paris, France
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Qader MA, Vivarelli M. Children with Steroid Dependent Nephrotic Syndrome: Rituximab or Tacrolimus? It's All in the Timing. Kidney Int Rep 2023; 8:1708-1710. [PMID: 37705906 PMCID: PMC10496064 DOI: 10.1016/j.ekir.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Affiliation(s)
- Md Abdul Qader
- Department of Pediatric Nephrology, Square Hospitals Ltd, Dhaka, Bangladesh
| | - Marina Vivarelli
- Division of Nephrology, Laboratory of Nephrology, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
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Zurowska A, Drozynska-Duklas M, Topaloglu R, Bouts A, Boyer O, Shenoy M, Vivarelli M. Rituximab-associated hypogammaglobulinemia in children with idiopathic nephrotic syndrome: results of an ESPN survey. Pediatr Nephrol 2023; 38:3035-3042. [PMID: 37014530 PMCID: PMC10432325 DOI: 10.1007/s00467-023-05913-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/13/2023] [Accepted: 02/08/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND There is paucity of information on rituximab-associated hypogammaglobulinemia (HGG) and its potential infectious consequences in children treated for idiopathic nephrotic syndrome (INS). METHODS A survey was distributed by the European Society Pediatric Nephrology to its members. It addressed the screening and management practices of pediatric nephrology units for recognizing and treating RTX-associated HGG and its morbidity and mortality. Eighty-four centers which had treated an overall 1328 INS children with RTX responded. RESULTS The majority of centers administered several courses of RTX and continued concomitant immunosuppressive therapy. Sixty-five percent of centers routinely screened children for HGG prior to RTX infusion, 59% during, and 52% following RTX treatment. Forty-seven percent had observed HGG prior to RTX administration, 61% during and 47% >9 months following treatment in 121, 210, and 128 subjects respectively. Thirty-three severe infections were reported among the cohort of 1328 RTX-treated subjects, of whom 3 children died. HGG had been recognized in 30/33 (80%) of them. CONCLUSIONS HGG in steroid-dependent/frequently relapsing nephrotic syndrome (SDNS/FRNS) children is probably multifactorial and can be observed prior to RTX administration in children with SDNS/FRNS. Persistent HGG lasting >9 months from RTX infusion is not uncommon and may increase the risk of severe infections in this cohort. We advocate for the obligatory screening for HGG in children with SDNS/FRNS prior to, during, and following RTX treatment. Further research is necessary to identify risk factors for developing both HGG and severe infections before recommendations are made for its optimal management. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Aleksandra Zurowska
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdańsk, ul. Debinki 7, 80-952, Gdańsk, Poland.
- Centre for Rare Diseases, Medical University of Gdańsk, Gdańsk, Poland.
| | - Magdalena Drozynska-Duklas
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdańsk, ul. Debinki 7, 80-952, Gdańsk, Poland
| | - Rezan Topaloglu
- Department of Pediatric Nephrology, Hacettepe University School of Medicine Hacettepe University, Ankara, Turkey
| | - Antonia Bouts
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Olivia Boyer
- Department of Pediatric Nephrology, Reference Center for Idiopathic Nephrotic Syndrome in Children and Adults, Necker Hospital, Paris, France
- Laboratory of Hereditary Kidney Diseases, Imagine Institute, Paris Descartes University, Paris, France
| | - Mohan Shenoy
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Marina Vivarelli
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
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Basu B, Erdmann S, Sander A, Mahapatra TKS, Meis J, Schaefer F. Long-Term Efficacy and Safety of Rituximab Versus Tacrolimus in Children With Steroid Dependent Nephrotic Syndrome. Kidney Int Rep 2023; 8:1575-1584. [PMID: 37547526 PMCID: PMC10403658 DOI: 10.1016/j.ekir.2023.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction In the Rituximab for Relapse Prevention in Nephrotic Syndrome (RITURNS) trial, we demonstrated superior efficacy of single-course rituximab over maintenance tacrolimus in preventing relapses in children with steroid dependent nephrotic syndrome (SDNS) during a 1-year observation. Here we present the long-term outcomes of all 117 trial completers, who were followed up for another 2 years. Methods Relapsing patients in the rituximab arm received a second course of rituximab, either with (n = 44) or without mycophenolate mofetil (MMF) cotreatment (n = 15). In the tacrolimus arm, second line rituximab monotherapy was initiated after relapses (n = 32) or electively (n = 24). Results All 12-month relapse-free patients in the rituximab arm relapsed in the second postexposure year, resulting in similar median relapse-free survival times in the 2 trial arms (62 vs. 59 weeks). Second line rituximab in the tacrolimus arm was less effective than first-line therapy in patients switched to rituximab following a relapse (relapse-free survival 55 vs. 63 weeks, P < 0.01). B-cell counts 6 months post-rituximab predicted relapse risk both for first and second line therapy. MMF cotreatment yielded much improved 2-year relapse-free survival as compared to rituximab monotherapy (67% vs. 9%, P < 0.0001). Higher grade 2 adverse event rates were observed post-rituximab versus on tacrolimus (0.87 vs. 0.53 per year). Conclusion The superior therapeutic effect of rituximab in SDNS vanishes during the second year post-exposure. Rituximab appears to yield longer remission when applied as first line as compared to second line therapy. Maintenance MMF following rituximab induces long-term disease remission.
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Affiliation(s)
- Biswanath Basu
- Division of Pediatric Nephrology, Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Stella Erdmann
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Anja Sander
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | | | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
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14
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Song Y, Ding L, An X, Zhao Y, Li X, Yang X, Xiao X. Hypokalemia after rituximab administration in nephrotic syndrome: two case reports. BMC Nephrol 2023; 24:214. [PMID: 37464309 DOI: 10.1186/s12882-023-03079-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/06/2023] [Indexed: 07/20/2023] Open
Abstract
Rituximab, a chimeric anti-CD20 monoclonal antibody, is an effective treatment for nephrotic syndrome. Hypokalemia is a rare adverse reaction among patients treated with rituximab although there have been extensive reports of acute and chronic adverse events with the administration of rituximab. We herein report two cases of symptomatic hypokalemia after intravenous rituximab administration in our center, to help health professionals consider the possibility of acute hypokalemia after rituximab administration, monitor potassium timely and develop an appropriate treatment plan.
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Affiliation(s)
- Yiyun Song
- Department of Nephrology, Qilu Hospital of Shandong University, No. 107 Wenhua West Road, 250000, Jinan, Shandong, PR China
| | - Lin Ding
- Department of Nephrology, Qilu Hospital of Shandong University, No. 107 Wenhua West Road, 250000, Jinan, Shandong, PR China
| | - Xin An
- Department of Nephrology, Qilu Hospital of Shandong University, No. 107 Wenhua West Road, 250000, Jinan, Shandong, PR China
| | - Yi Zhao
- Department of Nephrology, Qilu Hospital of Shandong University, No. 107 Wenhua West Road, 250000, Jinan, Shandong, PR China
| | - Xianhua Li
- Department of Nephrology, Qilu Hospital of Shandong University, No. 107 Wenhua West Road, 250000, Jinan, Shandong, PR China
| | - Xiangdong Yang
- Department of Nephrology, Qilu Hospital of Shandong University, No. 107 Wenhua West Road, 250000, Jinan, Shandong, PR China.
| | - Xiaoyan Xiao
- Department of Nephrology, Qilu Hospital of Shandong University, No. 107 Wenhua West Road, 250000, Jinan, Shandong, PR China.
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15
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Vincenti F, Angeletti A, Ghiggeri GM. State of the art in childhood nephrotic syndrome: concrete discoveries and unmet needs. Front Immunol 2023; 14:1167741. [PMID: 37503337 PMCID: PMC10368981 DOI: 10.3389/fimmu.2023.1167741] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/21/2023] [Indexed: 07/29/2023] Open
Abstract
Nephrotic syndrome (NS) is a clinical entity characterized by proteinuria, hypoalbuminemia, and peripheral edema. NS affects about 2-7 per 100,000 children aged below 18 years old yearly and is classified, based on the response to drugs, into steroid sensitive (SSNS), steroid dependent, (SDNS), multidrug dependent (MDNS), and multidrug resistant (MRNS). Forms of NS that are more difficult to treat are associated with a worse outcome with respect to renal function. In particular, MRNS commonly progresses to end stage renal failure requiring renal transplantation, with recurrence of the original disease in half of the cases. Histological presentations of NS may vary from minimal glomerular lesions (MCD) to focal segmental glomerulosclerosis (FSGS) and, of relevance, the histological patterns do not correlate with the response to treatments. Moreover, around half of MRNS cases are secondary to causative pathogenic variants in genes involved in maintaining the glomerular structure. The pathogenesis of NS is still poorly understood and therapeutic approaches are mostly based on clinical experience. Understanding of pathogenetic mechanisms of NS is one of the 'unmet needs' in nephrology and represents a significant challenge for the scientific community. The scope of the present review includes exploring relevant findings, identifying unmet needs, and reviewing therapeutic developments that characterize NS in the last decades. The main aim is to provide a basis for new perspectives and mechanistic studies in NS.
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Affiliation(s)
- Flavio Vincenti
- Division of Nephrology, Department of Medicine and Department of Surgery, University of California San Francisco, San Francisco, CA, United States
| | - Andrea Angeletti
- Nephrology Dialysis and Transplantation, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Gian Marco Ghiggeri
- Nephrology Dialysis and Transplantation, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
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16
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Gomes R, Mosca S, Bastos-Gomes M, Correia-Costa L, Rocha L, Teixeira A, Costa T, Sameiro-Faria M, Matos P, Mota C. Rituximab therapy for childhood onset idiopathic nephrotic syndrome: experience of a Portuguese tertiary center. J Bras Nefrol 2023; 45:326-334. [PMID: 36259942 PMCID: PMC10697169 DOI: 10.1590/2175-8239-jbn-2022-0056en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/29/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Rituximab (RTX) is a therapeutic option in pediatric difficult-to-treat idiopathic nephrotic syndrome (NS). We aimed to assess the efficacy and safety of RTX use in these patients. METHOD A retrospective study of all patients with idiopathic NS treated with RTX was conducted in a pediatric nephrology division of a tertiary hospital. Demographic, anthropometric, clinical and analytical data were collected prior to treatment and at 6, 12, and 24 months. RESULTS Sixteen patients were included (11 males), with a median (25th-75th percentile, P25-P75) age at diagnosis of 2 (2.0-2.8) years. Fifteen were steroid-sensitive and 1 was steroid-resistant and sensitive to cyclosporine. The median age at administration of RTX was 10 (6.3-14.0) years. Throughout a median follow-up time of 2.5 (1.0-3.0) years, 6 (37.5%) patients achieved partial remission and 7 (43.8%) had no relapses and were not taking any immunosuppressants at the 24-month follow-up visit. Regarding complications, 1 patient presented persistent hypogammaglobulinemia. Compared with the 12-month period before RTX, there was a decrease in the median number of relapses at 6 and 12 months [3 (3.0-4.0) vs 0 (0-0.8) and 0.50 (0-1.0), respectively; p = 0.001] and in the daily steroids dose (mg/kg/day) at 6, 12, and 24 months [0.29 (0.15-0.67)vs [0.10 (0.07-0.13); p = 0.001], [0.12 (0.05-0.22); p = 0.005] and [0.07(0.04-0.18); p = 0.021]], respectively. There was also a reduction in the median BMI z score at 24 months [2.11 (0.45-3.70) vs. 2.93 (2.01-3.98); p = 0.049]. CONCLUSION Our results confirm the efficacy and safety of RTX use in pediatric idiopathic NS and highlight its' potential cardiometabolic benefits.
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Affiliation(s)
- Rita Gomes
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Porto, Portugal
| | - Sara Mosca
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Porto, Portugal
| | - Mariana Bastos-Gomes
- Unidade Local de Saúde do Alto Minho, Serviço de Pediatria, EPE,
Viana do Castelo, Portugal
| | - Liane Correia-Costa
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
| | - Liliana Rocha
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
| | - Ana Teixeira
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
| | - Teresa Costa
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
| | - Maria Sameiro-Faria
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
| | - Paula Matos
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
| | - Conceição Mota
- Centro Hospitalar Universitário do Porto, Centro Materno-Infantil do
Norte, Serviço de Pediatria, Unidade de Nefrologia Pediátrica, Porto,
Portugal
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17
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朱 颖, 吴 琳, 王 云, 朱 亚, 彭 寅, 方 韶, 张 罗, 邓 芳. [Efficacy and safety of low-dose rituximab in treatment of pediatric nephrotic syndrome: a prospective randomized controlled trial]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:606-611. [PMID: 37382130 PMCID: PMC10321428 DOI: 10.7499/j.issn.1008-8830.2301026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/27/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVES To study the efficacy and safety of repeated application of rituximab (RTX) at a low dose (200 mg/m2) versus the recommended dose (375 mg/m2) for remission maintenance in frequently relapsing nephrotic syndrome (FRNS) or steroid-dependent nephrotic syndrome (SDNS). METHODS A randomized controlled trial was conducted for 29 children with FRNS/SDNS who received systemic treatment in the Department of Nephrology, Anhui Provincial Children's Hospital, from September 2020 to December 2021. These children were divided into a recommended dose group (n=14) and a low dose group (n=15) using a random number table. The two groups were compared in terms of general characteristics, changes in CD19 expression after RTX treatment, number of relapses, glucocorticoid dose, adverse reactions of RTX, and hospital costs. RESULTS After RTX treatment, both the low dose group and the recommended dose group achieved B-lymphocyte depletion and had significant reductions in the number of relapses and glucocorticoid dose (P<0.05). The low dose group had a comparable clinical effect to the recommended dose group after RTX treatment (P>0.05), and the low dose group had a significant reduction in hospital costs for the second, third, and fourth times of hospitalization (P<0.05). There were no serious adverse reactions in either group during RTX treatment and late follow-up, and there was no significant difference in adverse reactions between the two groups (P>0.05). CONCLUSIONS Repeated RTX treatment at a low dose has comparable clinical efficacy and safety to that at the recommended dose and can significantly reduce the number of FRNS/SDNS relapses and the amount of glucocorticoids used, with little adverse effect throughout the treatment cycle. Therefore, it holds promise for clinical application.
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18
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Osterholt T, Todorova P, Kühne L, Ehren R, Weber LT, Grundmann F, Benzing T, Brinkkötter PT, Völker LA. Repetitive administration of rituximab can achieve and maintain clinical remission in patients with MCD or FSGS. Sci Rep 2023; 13:6980. [PMID: 37117201 PMCID: PMC10141841 DOI: 10.1038/s41598-023-32576-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 03/29/2023] [Indexed: 04/30/2023] Open
Abstract
Minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) are glomerulopathies associated with nephrotic syndrome. Primary forms of these diseases are treated with various regimes of immunosuppression. Frequently relapsing or glucocorticoid-dependent courses remain challenging. Here, a B-cell-depleting strategy with rituximab represents a salvage option although data are sparse in the adult population. In particular, there is limited evidence on the efficacy of restoring remission after initial successful treatment with rituximab and whether patients benefit from an individualized, relapse-based approach. We identified 13 patients who received multiple therapies with rituximab from the FOrMe-registry (NCT03949972), a nationwide registry for MCD and FSGS in Germany, or from the University Hospital of Cologne. Disease status, changes in serum creatinine, proteinuria, and time to relapse were evaluated. Relapse-free survival was compared to the patients' previous therapy regimens. Through all treatment cycles, an improvement of disease activity was shown leading to a complete remission in 72% and partial remission in 26% after 3 ([Formula: see text]0.001) and 6 months ([Formula: see text]0.001). Relapse-free survival increased from 4.5 months (95%-CI 3-10 months) to 21 months (95%-CI 16-32 months) ([Formula: see text]0.001) compared to previous immunosuppression regimens with no loss in estimated glomerular filtration over time (p = 0.53). Compared to continuous B-cell depletion, an individualized relapse-based approach led to a reduced rituximab exposure and significant cost savings. Relapse-based administration of rituximab in patients with MCD/FSGS with an initial good clinical response did not result in a decreased efficacy at a median follow-up duration of 110 months. Thus, reinduction therapies may provide an alternative to continuous B-cell-depletion and reduce the long-term side effects of continuous immunosuppression.
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Affiliation(s)
- Thomas Osterholt
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Polina Todorova
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Lucas Kühne
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Rasmus Ehren
- Faculty of Medicine, Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Lutz Thorsten Weber
- Faculty of Medicine, Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Franziska Grundmann
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Thomas Benzing
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany
| | - Paul Thomas Brinkkötter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany.
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany.
| | - Linus Alexander Völker
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
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19
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Chan EYH, Yap DYH, Colucci M, Ma ALT, Parekh RS, Tullus K. Use of Rituximab in Childhood Idiopathic Nephrotic Syndrome. Clin J Am Soc Nephrol 2023; 18:533-548. [PMID: 36456193 PMCID: PMC10103321 DOI: 10.2215/cjn.08570722] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/11/2022] [Accepted: 10/31/2022] [Indexed: 12/04/2022]
Abstract
Rituximab is an established therapy in children with idiopathic nephrotic syndrome to sustain short- to medium-term disease remission and avoid steroid toxicities. Recent trials focus on its use as a first-line agent among those with milder disease severity. Rituximab is used in multidrug refractory nephrotic syndrome and post-transplant disease recurrence, although the evidence is much less substantial. Available data suggest that the treatment response to rituximab depends on various patient factors, dosing regimen, and the concomitant use of maintenance immunosuppression. After repeated treatments, patients are found to have an improving response overall with a longer relapse-free period. The drug effect, however, is not permanent, and 80% of patients eventually relapse and many will require an additional course of rituximab. This underpins the importance of understanding the long-term safety profile on repeated treatments. Although rituximab appears to be generally safe, there are concerns about long-term hypogammaglobulinemia, especially in young children. Reliable immunophenotyping and biomarkers are yet to be discovered to predict treatment success, risk of both rare and severe side effects, e.g. , persistent hypogammaglobulinemia, and guiding of redosing strategy. In this review, we highlight recent advances in the use of rituximab for childhood nephrotic syndrome and how the therapeutic landscape is evolving.
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Affiliation(s)
- Eugene Yu-hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
- Department of Paediatric and Adolescent Medicine, Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Desmond Yat-hin Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Manuela Colucci
- Renal Diseases Research Unit, Genetics and Rare Diseases Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alison Lap-tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
- Department of Paediatric and Adolescent Medicine, Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Rulan S. Parekh
- Departments of Medicine and Pediatrics, Women's College Hospital, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
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20
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Ye Q, Wang DJ, Lan B, Mao JH. T-cell and B-cell repertoire diversity are selectively skewed in children with idiopathic nephrotic syndrome revealed by high-throughput sequencing. World J Pediatr 2023; 19:273-282. [PMID: 36449136 DOI: 10.1007/s12519-022-00640-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/12/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Clinical studies suggest that the dysfunction of T cells and B cells may play an essential role in the pathogenesis of idiopathic nephrotic syndrome (INS), but laboratory evidence is lacking. Therefore, this study explored T-cell receptor (TCR) and B-cell receptor (BCR) profiling in children with idiopathic nephrotic syndrome. METHODS High-throughput sequencing technology was used to profile the TCR and BCR repertoires in children with INS. Peripheral blood was collected from ten INS patients, including five vinculin autoantibody-positive patients and five vinculin autoantibody-negative patients, before and after treatment. TCR and BCR libraries were constructed by 5'-RACE and sequenced by a DNBSEQ-T7 sequencer, and sequence analyses were performed using ReSeqTools, FastP, MiXCR, and VDJtools. RESULTS The TRA (T-cell receptor α), TRG (T-cell receptor γ), and IGH (immunoglobulin heavy chain) repertoires of the INS group were occupied by highly abundant clonotypes, whereas small clonotypes occupied the healthy group, especially TRA. A significant increase in the Shannon-Weaver index was observed for the TRA and TRG repertoires after treatment in vinculin autoantibody-negative patients, but a significant increase in the IGH repertoire after treatment was observed in vinculin autoantibody-positive patients. The frequency of some V-J pairs was significantly enriched in steroid-sensitive nephrotic syndrome patients. The usage frequency of the V and J genes was skewed in patients, which seemed not related to immunosuppressive therapy. However, after effective treatment, dynamic changes in the size of the individual clonotype were observed. CONCLUSION T-cell and B-cell immunity contribute to the pathogenesis of different INSs. Video: (MP4 99,786 KB).
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Affiliation(s)
- Qing Ye
- Department of Clinical Laboratory, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, 310052, China
| | - Dong-Jie Wang
- Department of Nephrology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, 310052, China
| | - Bing Lan
- Department of Nephrology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, 310052, China
| | - Jian-Hua Mao
- Department of Nephrology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, 310052, China.
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21
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Dong Z, Zhou J, Xu Z, Ni Z, He Y, Lin H, Jiang G, Sun X, Zhang L, Chen X. Efficacy and Safety of Mizoribine in comparison with Cyclophosphamide for Treatment of Refractory Nephrotic Syndrome: Protocol for a Multi-center, Controlled, Open-label, Randomized Controlled Trial (Preprint). JMIR Res Protoc 2023. [PMID: 36990111 DOI: 10.2196/46101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Nephrotic syndrome that is resistant to steroidal therapy is termed refractory nephrotic syndrome (RNS), a condition that is associated with an increased risk of end-stage renal disease (ESRD). Immunosuppressants are utilized to treat RNS, however prolonged may lead to significant adverse effects. Mizoribine (MZR) is a novel agent used in long-term immunosuppressive therapy that has few adverse effects, but data on its long-term use in patients with RNS are unavailable. OBJECTIVE We propose a trial to examine the efficacy and safety of MZR compared to cyclophosphamide (CYC) in Chinese adult patients with RNS. METHODS This is a multi-center, randomized, controlled interventional study with a screening phase (1 week) and a treatment phase (52 weeks). This study was reviewed and approved by the Medical Ethics Committees of all 34 medical centers. Patients with RNS consented to participation, and were enrolled and randomized into an MZR group or a CYC group (1:1 ratio), with each group receiving tapering doses of oral corticosteroids. Participants were assessed for adverse effects and collection of laboratory results at 8 visits during the treatment phase on week-4, week-8, week-12, week-16, week-20, week-32, week-44, and week-52 (exit visit). Participants were able to withdraw voluntarily and investigators were required to remove patients when there were safety concerns or deviations from protocol. RESULTS The study started in November 2014, and was completed in March 2019. A total of 239 participants from 34 hospitals in China were enrolled. Data analysis is completed. The results are waiting to be finalized by Center for Drug Evaluation. CONCLUSIONS The purpose of the current study is to evaluate the efficacy and safety of MZR in comparison with CYC for treatment of RNS in Chinese adult patients with glomerular diseases. It is the longest lasting and largest randomized controlled trial to examine MZR in Chinese patients. The results can help determine whether RNS should be considered as an additional indication for MZR treatment in China. CLINICALTRIAL ClinicalTrials.gov Register, NCT02257697. Registered 2014-10-01, https://clinicaltrials.gov/ct2/show/NCT02257697?term=MZR&rank=2.
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Affiliation(s)
- Zheyi Dong
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Labor, Beijing, CN
| | - Jianhui Zhou
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Labor, Beijing, CN
| | - Zhonggao Xu
- The First Hospital of Jilin University, Changchun, CN
| | - Zhaohui Ni
- Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, CN
| | - Yani He
- Daping Hospital, Army Medical University, Chongqing, CN
| | - Hongli Lin
- Key Laboratory of Kidney Disease, The Center for the Transformation Medicine of Kidney Disease, The First Affiliated Hospital of Dalian Medical University, Dalian, CN
| | - Gengru Jiang
- XinHua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, CN
| | - Xuefeng Sun
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Labor, Beijing, CN
| | - Li Zhang
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Labor, Beijing, CN
| | - Xiangmei Chen
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Labor, Fuxing Road No.28, Beijing, CN
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22
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Therapeutic trials in difficult to treat steroid sensitive nephrotic syndrome: challenges and future directions. Pediatr Nephrol 2023; 38:17-34. [PMID: 35482099 PMCID: PMC9048617 DOI: 10.1007/s00467-022-05520-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/07/2022] [Accepted: 02/24/2022] [Indexed: 01/10/2023]
Abstract
Steroid sensitive nephrotic syndrome is a common condition in pediatric nephrology, and most children have excellent outcomes. Yet, 50% of children will require steroid-sparing agents due to frequently relapsing disease and may suffer consequences from steroid dependence or use of steroid-sparing agents. Several steroid-sparing therapeutic agents are available with few high quality randomized controlled trials to compare efficacy leading to reliance on observational data for clinical guidance. Reported trials focus on short-term outcomes such as time to first relapse, relapse rates up to 1-2 years of follow-up, and few have studied long-term remission. Trial designs often do not consider inter-individual variability, and differing response to treatments may occur due to heterogeneity in pathogenic mechanisms, and genetic and environmental influences. Strategies are proposed to improve the quantity and quality of trials in steroid sensitive nephrotic syndrome with integration of biomarkers, novel trial designs, and standardized outcomes, especially for long-term remission. Collaborative efforts among international trial networks will help move us toward a shared goal of finding a cure for children with nephrotic syndrome.
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23
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Trautmann A, Boyer O, Hodson E, Bagga A, Gipson DS, Samuel S, Wetzels J, Alhasan K, Banerjee S, Bhimma R, Bonilla-Felix M, Cano F, Christian M, Hahn D, Kang HG, Nakanishi K, Safouh H, Trachtman H, Xu H, Cook W, Vivarelli M, Haffner D. IPNA clinical practice recommendations for the diagnosis and management of children with steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2023; 38:877-919. [PMID: 36269406 PMCID: PMC9589698 DOI: 10.1007/s00467-022-05739-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/03/2022] [Accepted: 08/22/2022] [Indexed: 01/19/2023]
Abstract
Idiopathic nephrotic syndrome is the most frequent pediatric glomerular disease, affecting from 1.15 to 16.9 per 100,000 children per year globally. It is characterized by massive proteinuria, hypoalbuminemia, and/or concomitant edema. Approximately 85-90% of patients attain complete remission of proteinuria within 4-6 weeks of treatment with glucocorticoids, and therefore, have steroid-sensitive nephrotic syndrome (SSNS). Among those patients who are steroid sensitive, 70-80% will have at least one relapse during follow-up, and up to 50% of these patients will experience frequent relapses or become dependent on glucocorticoids to maintain remission. The dose and duration of steroid treatment to prolong time between relapses remains a subject of much debate, and patients continue to experience a high prevalence of steroid-related morbidity. Various steroid-sparing immunosuppressive drugs have been used in clinical practice; however, there is marked practice variation in the selection of these drugs and timing of their introduction during the course of the disease. Therefore, international evidence-based clinical practice recommendations (CPRs) are needed to guide clinical practice and reduce practice variation. The International Pediatric Nephrology Association (IPNA) convened a team of experts including pediatric nephrologists, an adult nephrologist, and a patient representative to develop comprehensive CPRs on the diagnosis and management of SSNS in children. After performing a systematic literature review on 12 clinically relevant PICO (Patient or Population covered, Intervention, Comparator, Outcome) questions, recommendations were formulated and formally graded at several virtual consensus meetings. New definitions for treatment outcomes to help guide change of therapy and recommendations for important research questions are given.
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Affiliation(s)
- Agnes Trautmann
- grid.7700.00000 0001 2190 4373Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Olivia Boyer
- grid.50550.350000 0001 2175 4109Department of Pediatric Nephrology, Reference Center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Children’s Hospital, APHP, Paris, France
| | - Elisabeth Hodson
- grid.413973.b0000 0000 9690 854XCochrane Kidney and Transplant, Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia
| | - Arvind Bagga
- grid.413618.90000 0004 1767 6103Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Debbie S. Gipson
- grid.214458.e0000000086837370Department of Pediatrics, Division of Nephrology, University of Michigan, Ann Arbor, MI USA
| | - Susan Samuel
- grid.22072.350000 0004 1936 7697Section of Pediatric Nephrology, Department of Pediatrics, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada
| | - Jack Wetzels
- grid.10417.330000 0004 0444 9382Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Khalid Alhasan
- grid.56302.320000 0004 1773 5396Pediatric Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sushmita Banerjee
- grid.414710.70000 0004 1801 0469Department of Pediatric Nephrology, Institute of Child Health, Kolkata, India
| | - Rajendra Bhimma
- grid.16463.360000 0001 0723 4123University of KwaZulu-Natal, Durban, South Africa
| | - Melvin Bonilla-Felix
- grid.267034.40000 0001 0153 191XDepartment of Pediatrics, University of Puerto Rico-Medical Sciences Campus, San Juan, Puerto Rico
| | - Francisco Cano
- grid.443909.30000 0004 0385 4466Department of Pediatric Nephrology, Luis Calvo Mackenna Children’s Hospital, University of Chile, Santiago, Chile
| | - Martin Christian
- Children’s Kidney Unit, Nottingham Children’s Hospital, Nottingham, UK
| | - Deirdre Hahn
- grid.413973.b0000 0000 9690 854XDivision of Pediatric Nephrology, Department of Paediatrics, The Children’s Hospital at Westmead, Sydney, Australia
| | - Hee Gyung Kang
- grid.31501.360000 0004 0470 5905Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital & Seoul National University College of Medicine, Seoul, Korea
| | - Koichi Nakanishi
- grid.267625.20000 0001 0685 5104Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Hesham Safouh
- grid.7776.10000 0004 0639 9286Pediatric Nephrology Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Howard Trachtman
- grid.214458.e0000000086837370Department of Pediatrics, Division of Nephrology, University of Michigan, Ann Arbor, MI USA
| | - Hong Xu
- grid.411333.70000 0004 0407 2968Department of Nephrology, Children’s Hospital of Fudan University, Shanghai, China
| | - Wendy Cook
- Nephrotic Syndrome Trust (NeST), Somerset, UK
| | - Marina Vivarelli
- grid.414125.70000 0001 0727 6809Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Rome, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover and Center for Rare Diseases, Hannover Medical School, Hannover, Germany.
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24
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Mattoo TK, Sanjad S. Current Understanding of Nephrotic Syndrome in Children. Pediatr Clin North Am 2022; 69:1079-1098. [PMID: 36880923 DOI: 10.1016/j.pcl.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Nephrotic syndrome in children is mostly idiopathic in origin. About 90% of patients respond to corticosteroids; 80-90% have at least one relapse and 3-10% become corticosteroid resistant after the initial response. A kidney biopsy is seldom indicated for diagnosis except in patients with atypical presentation or corticosteroid resistance. For those in remission, the risk of relapse is reduced by the administration of daily low dose corticosteroids for 5-7 days at the onset of an upper respiratory infection. Some patients may continue having relapses through adult life. Many country-specific practice guidelines have been published, which are very similar with clinically insignificant differences.
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Affiliation(s)
- Tej K Mattoo
- Department of Pediatrics, Wayne State University School of Medicine, 400 Mack Avenue, Suite 1 East, Detroit, MI 48201, USA.
| | - Sami Sanjad
- American University of Beirut Medical Center, Beirut, Lebanon
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25
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Abstract
Idiopathic nephrotic syndrome often responds to immunosuppressive treatment. Nevertheless, this syndrome-and the drugs used to treat it-remain important causes of patient morbidity. Idiopathic nephrotic syndrome is usually caused by minimal change disease or FSGS, diseases that primarily affect the podocytes. In spite of decades of research, the underlying causes of both diseases remain incompletely understood. There is, however, a large body of observational and experimental data linking the immune system with both minimal change disease and FSGS, including associations with systemic infections and hematologic malignancies. Perhaps most compellingly, many different immunomodulatory drugs are effective for treating idiopathic nephrotic syndrome, including biologic agents that have well-defined immune targets. In fact, the unexpected efficacy of targeted therapeutic agents has provided important new insights into the pathogenesis of these diseases. Given the large number of drugs that are available to deplete or block specific cells and molecules within the immune system, a better understanding of the immunologic causes of idiopathic nephrotic syndrome may lead to better diagnostic and therapeutic approaches.
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Affiliation(s)
- Ruth E. Campbell
- Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colorado
| | - Joshua M. Thurman
- Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colorado
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26
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Gomes R, Mosca S, Bastos-Gomes M, Correia-Costa L, Rocha L, Teixeira A, Costa T, Sameiro-Faria M, Matos P, Mota C. Terapia com Rituximabe para síndrome nefrótica idiopática de início na infância: experiência de um centro terciário português. J Bras Nefrol 2022. [DOI: 10.1590/2175-8239-jbn-2022-0056pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Resumo Introdução: Rituximabe (RTX) é uma opção terapêutica na síndrome nefrótica (SN) idiopática pediátrica de difícil tratamento. Visamos avaliar eficácia e segurança do uso de RTX nestes pacientes. Método: Realizou-se estudo retrospectivo de todos os pacientes com SN idiopática tratados com RTX, em uma unidade de nefrologia pediátrica de um hospital terciário. Dados demográficos, antropométricos, clínicos e analíticos foram coletados antes do tratamento e aos 6, 12 e 24 meses. Resultados: Incluímos 16 pacientes (11 do sexo masculino), com idade mediana (percentil 25–75, P25–P75) de 2 (2,0–2,8) anos ao diagnóstico. Quinze eram sensíveis a esteroides, e 1 resistente a esteroides e sensível à ciclosporina.A idade mediana na administração do RTX foi 10 (6,3–14,0) anos. Durante um tempo mediano de acompanhamento de 2,5(1,0–3,0) anos, 6 (37,5%) pacientes alcançaram remissão parcial e 7 (43,8%) não tiveram recidivas e não estavam tomando imunossupressor no acompanhamento aos 24 meses. Quanto às complicações,1 paciente apresentou hipogamaglobulinemia persistente. Comparado ao período de12 meses anterior ao RTX, houve diminuição no número mediano de recidivas em 6 e 12 meses [3 (3,0–4,0) vs 0 (0–0,8) e 0,50 (0–1,0), respectivamente; p = 0,001] e na dose diária de esteroides (mg/kg/dia) aos 6, 12 e 24 meses [0,29 (0,15–0,67) >vs [0,10 (0,07–0,13); p = 0,001], [0,12 (0,05–0,22); p = 0,005] e [0,07 (0,04–0,18); p = 0,021], respectivamente. Houve também redução na mediana do escore z do IMC aos 24 meses [2,11 (0,45–3,70) vs 2,93 (2,01–3,98);p = 0,049]. Conclusões: Nossos resultados confirmam a eficácia e segurança do uso de RTX em SN idiopática pediátrica, destacando seus potenciais benefícios cardiometabólicos.
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Affiliation(s)
- Rita Gomes
- Centro Hospitalar Universitário do Porto, Portugal
| | - Sara Mosca
- Centro Hospitalar Universitário do Porto, Portugal
| | | | | | | | - Ana Teixeira
- Centro Hospitalar Universitário do Porto, Portugal
| | - Teresa Costa
- Centro Hospitalar Universitário do Porto, Portugal
| | | | - Paula Matos
- Centro Hospitalar Universitário do Porto, Portugal
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27
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Lin J, Sun J. Rituximab May Have Positive Effect on Refractory Nephrotic Syndrome: A Meta-Analysis of Randomized Trials. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:3008597. [PMID: 35813445 PMCID: PMC9262522 DOI: 10.1155/2022/3008597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/11/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022]
Abstract
Purpose This study was aimed at demonstrating the role of rituximab (RTX) on the influence of nephrotic syndrome (NS) and on urinary protein which was not significant. Methods The clinical randomized controlled trials were performed by eight databases. Meanwhile, the confidence interval (CI) of either relative risk or mean difference was set to 95%. Besides, the heterogeneity of the research results is tested by I 2. Results A total of 1658 references were found using the search method. This meta-analysis will be done by the ultimately eight different studies. Each study is described as random controlled trial. According to these eight studies, the remission of test group and control group was quite higher (OR: 1.60; 95% Cl: 1.17, 2.20; P < 0.01) than the control group, serum albumin (SMD: 4.19; 95% Cl: 1.49, 6.89; P < 0.01), and urine protein (SMD: 0.79; 95% Cl: -0.64, 2.22; P = 0.28). Despite the fact that the remission rate's funnel plot was asymmetrically distributed, Egger's test and Begg's test revealed no probable publish bias. Conclusion The results of this study suggest that rituximab (RTX) may be effective in RNS, as evidenced by remission rates and serum albumin. However, the effect on urinary protein was not significant. The clear evidence is missing in this literature. Therefore, large sample, multicenter, low risk of bias clinical studies, as well as basic medical research, is needed.
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Affiliation(s)
- Jingjing Lin
- Nephrology Department, First People's Hospital of Linping District, Hangzhou, China
| | - Jia Sun
- Nephrology Department, First People's Hospital of Linping District, Hangzhou, China
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28
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Tedesco M, Mescia F, Pisani I, Allinovi M, Casazza G, Del Vecchio L, Santostefano M, Cirillo L, Ferrario F, Esposito C, Esposito P, Santoro D, Lazzarin R, Rossi GM, Fiaccadori E, Ferrantelli A, Sinico RA, Cozzolino M, Gallieni M, Cirami L, Scolari F, Vaglio A, Alberici F. The Role of Rituximab in Primary Focal Segmental Glomerular Sclerosis of the Adult. Kidney Int Rep 2022; 7:1878-1886. [PMID: 35967114 PMCID: PMC9366368 DOI: 10.1016/j.ekir.2022.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/08/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Primary focal segmental glomerular sclerosis (FSGS) is a rare, likely immune-mediated disease. Rituximab (RTX) may play a role in management, although data in adults are scanty. Methods We collected cases of RTX-treated primary FSGS within the Italian Society of Nephrology Immunopathology Working Group and explored response rate (24-hour proteinuria <3.5 g and <50% compared with baseline, stable estimated glomerular filtration rate). Results A total of 31 patients were followed for at least 12 months; further follow-up (median 17 months, interquartile range [IQR] 15–33.5) was available for 11. At first RTX administration, median creatinine and 24-hour proteinuria were 1.17 mg/dl (IQR 0.83–1.62) and 5.2 g (IQR 3.3–8.81), respectively. Response rate at 3, 6, and 12 months was 39%, 52%, and 42%, respectively. In the first 12 months, creatinine level remained stable whereas proteinuria and serum albumin level improved, with an increase in the proportion of patients tapering other immunosuppressants. There were 6 patients who were retreated with RTX within 12 months, either for proteinuria increase or refractory disease; only the 2 responders to the first RTX course experienced a further response. At univariate analysis, 6-month response was more frequent in steroid-dependent patients (odds ratio [OR] 7.7 [95% CI 1.16–52.17]) and those with proteinuria <5 g/24 h (OR 8.25 [1.45–46.86]). During long-term follow-up, 4 of 5 responders at 12 months maintained a sustained response, either without further immunosuppression (2 of 4) or with pre-emptive RTX (2 of 4); 1 relapsed and responded to RTX retreatment. Conclusion RTX may be an option in primary FSGS, especially in steroid-dependent patients, with 24-hour proteinuria <5 g and previously responders to RTX. Optimal long-term management for responders is unclear, with some patients experiencing sustained remission and others requiring RTX retreatment, either preemptive or after rising proteinuria.
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Affiliation(s)
- Martina Tedesco
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Federica Mescia
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
- Correspondence: Federica Mescia, University of Brescia-ASST Spedali Civili, Piazzale Spedali Civili 1, 25125 Brescia, Italy.
| | - Isabella Pisani
- Nephrology Unit, Parma University Hospital, and Department of Medicine and Surgery, Parma University Medical School, Parma, Italy
| | - Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Marisa Santostefano
- Division of Nephrology, Dialysis and Hypertension, Policlinico S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Luigi Cirillo
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy
| | - Francesca Ferrario
- Division of Nephrology and Dialysis, Bassini Hospital, ASST Nord Milano, Cinisello Balsamo, Milan, Italy
| | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri SpA SB, Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - Pasquale Esposito
- Department of Internal Medicine, Nephrology, Dialysis and Transplantation Clinics, University of Genoa, Genoa, Italy
- Nephrology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Roberta Lazzarin
- Nephrology and Dialysis, Ospedale San Giacomo Apostolo, Castelfranco Veneto, Italy
| | - Giovanni Maria Rossi
- Nephrology Unit, Parma University Hospital, and Department of Medicine and Surgery, Parma University Medical School, Parma, Italy
| | - Enrico Fiaccadori
- Nephrology Unit, Parma University Hospital, and Department of Medicine and Surgery, Parma University Medical School, Parma, Italy
| | | | - Renato Alberto Sinico
- Department of Medicine and Surgery, University of Milano—Bicocca and Nephrology Unit, ASST-Monza, Monza, Italy
| | - Mario Cozzolino
- Department of Health Sciences, University of Milano, Milan, Italy
- Nephrology Unit and Immunology Clinic, ASST Santi Paolo e Carlo, Milan, Italy
| | - Maurizio Gallieni
- Department of Clinical and Biomedical Sciences “L. Sacco,” University of Milano, Milan, Italy
- ASST Fatebenefratelli-Sacco, Milan, Italy
| | | | - Lino Cirami
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy
| | - Francesco Scolari
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Augusto Vaglio
- Department of Biomedical, Experimental and Clinical Sciences “Mario Serio,” University of Firenze, Firenze, Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Firenze, Italy
| | - Federico Alberici
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
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29
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Chan E, Yu E, Angeletti A, Arslan Z, Basu B, Boyer O, Chan CY, Colucci M, Dorval G, Dossier C, Drovandi S, Ghiggeri GM, Gipson D, Hamada R, Hogan J, Ishikura K, Kamei K, Kemper M, Ma ALT, Parekh R, Radhakrishnan S, Saini P, Shen Q, Sinha R, Subun C, Teo S, Vivarelli M, Webb H, Xu H, Yap HK, Tullus K. Long-term Efficacy and Safety of Repeated Rituximab to Maintain Remission in Idiopathic Childhood Nephrotic Syndrome: An International Study. J Am Soc Nephrol 2022; 33:1193-1207. [PMID: 35354600 PMCID: PMC9161790 DOI: 10.1681/asn.2021111472] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/14/2022] [Indexed: 11/03/2022] Open
Abstract
Background: Long-term outcomes following multiple rituximab courses among children with frequently-relapsing, steroid-dependent nephrotic syndrome (FRSDNS) are unknown. Methods: A retrospective cohort study at 16 pediatric nephrology centers from 10 countries in Asia, Europe, and North America included children with FRSDNS who received ≥2 rituximab courses. Primary outcomes were relapse-free survival and adverse events. Results: 346 children (age 9.8 years, IQR 6.6-13.5; 73% boys) received 1149 rituximab courses. 145, 83, 50, 28, 22, and 18 children received 2, 3, 4, 5, 6 and ≥7 courses, respectively. Median follow-up was 5.9 years (IQR, 4.3-7.7). Relapse-free survival differed by treatment courses (clustered log-rank test p<0.001). Compared to the first course (10.0 months, 95% CI, 9.0-10.7), relapse-free period and relapse risk progressively improved following subsequent courses (12.0-16.0 months; HRadj, 0.03-0.13; 95% CI, 0.01-0.18; ps<0.001). B-cell depletion duration remained similar with repeated treatments (6.1 months, 95% CI, 6.0-6.3). Adverse events were mostly mild, most commonly hypogammaglobulinemia (50.9%), infection (4.5%), and neutropenia (3.7%). Side effects did not increase with more treatment courses nor higher cumulative dose. Only 78 of the 353 episodes of hypogammaglobulinemia were clinically significant. Younger age at presentation (2.8 vs 3.3 years; p=0.05) and at first rituximab (8.0 y vs 10.0 years; p=0.01) and history of steroid resistance (28% vs 18%; p=0.01) were associated with significant hypogammaglobulinemia. All 53 infective episodes resolved, except one patient with hepatitis B infection and another with EBV infection. There were 42 episodes of neutropenia, associated with history of steroid resistance (30% vs 20%, p=0.04). Upon last follow-up, 332 children (96%) had normal kidney function. Conclusion: Children receiving repeated rituximab for FRSDNS experience an improving clinical response. Side effects appear acceptable but significant complications can occur. These findings support repeated rituximab use in FRSDNS.
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Affiliation(s)
- Eugene Chan
- E Chan, Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
| | - Ellen Yu
- E Yu, Clinical Research Center, Princess Margaret Hospital, Toronto, Canada
| | - Andrea Angeletti
- A Angeletti, Division of Nephrology, Dialysis, and Transplantation, Instituto di ricovero e cura a carattere scientifico (IRRCS), Giannina Gaslini Children's Hospital, Genova, Italy
| | - Zainab Arslan
- Z Arslan, Department of Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Biswanath Basu
- B Basu, Division of Pediatric Nephrology, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Olivia Boyer
- O Boyer, Néphrologie pédiatrique, centre de référence du syndrome néphrotique de l'enfant et de l'adulte, Hôpital universitaire Necker-Enfants malades, Paris, France
| | - Chang-Yien Chan
- C Chan, Department of Paediatrics, NUS Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Manuela Colucci
- M Colucci, Renal Diseases Research Unit, Genetics and Rare Diseases Research Division, Bambino Gesù Children's Hospital, Rome, Italy
| | - Guillaume Dorval
- G Dorval, Néphrologie pédiatrique, centre de référence du syndrome néphrotique de l'enfant et de l'adulte, Hôpital universitaire Necker-Enfants malades, Paris, France
| | - Claire Dossier
- C Dossier, Department of Pediatric Nephrology, Centre de Référence Syndrome Néphrotique de l'Enfant et de l'Adulte (CMR SNI), Hopital Universitaire Robert-Debre, Paris, France
| | - Stefania Drovandi
- S Drovandi, Division of Nephrology, Dialysis, and Transplantation, Instituto di ricovero e cura a carattere scientifico (IRRCS), Giannina Gaslini Children's Hospital, Genova, Italy
| | - Gian Marco Ghiggeri
- G Ghiggeri, Division of Nephrology, Dialysis, and Transplantation, Instituto di ricovero e cura a carattere scientifico (IRRCS), Giannina Gaslini Children's Hospital, Genova, Italy
| | - Debbie Gipson
- D Gipson, Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, United States
| | - Riku Hamada
- R Hamada, Department of Nephrology and Rheumatology, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Julien Hogan
- J Hogan, Department of Pediatric Nephrology, Centre de Référence Syndrome Néphrotique de l'Enfant et de l'Adulte (CMR SNI), Hospital Robert Debré, Amboise, France
| | - Kenji Ishikura
- K Ishikura, Department of Pediatrics, Kitasato University School of Medicine, Japan, Japan
| | - Koichi Kamei
- K Kamei, Division of Nephrology and Rheumatology, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Markus Kemper
- M Kemper, Department of Pediatrics, Asklepios Medical School GmbH, Hamburg, Germany
| | - Alison Lap-Tak Ma
- A Ma, Paediatric Nephrology Centre, Princess Margaret Hospital, Hong Kong, Hong Kong
| | - Rulan Parekh
- R Parekh, Division of Pediatric Nephrology, Hospital for Sick Children, Toronto, Canada
| | - Seetha Radhakrishnan
- S Radhakrishnan, Division of Pediatric Nephrology, Hospital For Sick Children, London, United Kingdom of Great Britain and Northern Ireland
| | - Priya Saini
- P Saini, Division of Pediatric Nephrology, Hospital for Sick Children, Toronto, Canada
| | - Qian Shen
- Q Shen, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Rajiv Sinha
- R Sinha, Pediatric Nephrology Unit, Institute of Child Health, Kolkata, India
| | - Chantida Subun
- C Subun, Department of Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Sharon Teo
- S Teo, Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore, Singapore
| | - Marina Vivarelli
- M Vivarelli, Division of Nephrology, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Roma, Italy
| | - Hazel Webb
- H Webb, Department of Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Hong Xu
- H Xu, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Hui Kim Yap
- H Yap, Department of Paediatrics, NUS Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Kjell Tullus
- K Tullus, Department of Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
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Basu B, Angeletti A, Islam B, Ghiggeri GM. New and Old Anti-CD20 Monoclonal Antibodies for Nephrotic Syndrome. Where We Are? Front Immunol 2022; 13:805697. [PMID: 35222385 PMCID: PMC8873567 DOI: 10.3389/fimmu.2022.805697] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/25/2022] [Indexed: 12/16/2022] Open
Abstract
Nephrotic proteinuria is the hallmark of several glomerulonephritis determined by different pathogenetic mechanisms, including autoimmune, degenerative and inflammatory. Some conditions such as Minimal Change Nephropathy (MCN) and Focal Segmental Glomerulosclerosis (FSGS) are of uncertain pathogenesis. Chimeric anti-CD20 monoclonal antibodies have been used with success in a part of proteinuric conditions while some are resistant. New human and humanized monoclonal anti-CD 20 antibodies offer some advantages based on stronger effects on CD20 cell subtypes and have been already administered in hematology and oncology areas as substitutes of chimeric molecules. Here, we revised the literature on the use of human and humanized anti-CD 20 monoclonal antibodies in different proteinuric conditions, resulting effective in those conditions resistant to rituximab. Literature on the use of human anti-CD 20 monoclonal antibodies in different proteinuric diseases is mainly limited to ofatumumab, with several protocols and doses. Studies already performed with ofatumumab given in standard doses of 1,500 mg 1.73m2 suggest no superiority compared to rituximab in children and young adults with steroid dependent nephrotic syndrome. Ofatumumab given in very high doses (300 mg/1.73m2 followed by five infusion 2,000 mg/1.73 m2) seems more effective in patients who are not responsive to common therapies. The question of dose remains unresolved and the literature is not concordant on positive effects of high dose ofatumumab in patients with FSGS prior and after renal transplantation. Obinutuzumab may offer some advantages. In the unique study performed in patients with multidrug dependent nephrotic syndrome reporting positive effects, obinutuzumab was associated with the anti-CD38 monoclonal antibody daratumumab proposing the unexplored frontier of combined therapies. Obinutuzumab represent an evolution also in the treatment of autoimmune glomerulonephritis, such as membranous nephrotahy and lupus nephritis. Results of randomized trials, now in progress, are awaited to add new possibilities in those cases that are resistant to other drugs. The aim of the present review is to open a discussion among nephrologists, with the hope to achieve shared approaches in terms of type of antibodies and doses in the different proteinuric renal conditions.
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Affiliation(s)
- Biswanath Basu
- Division of Pediatric Nephrology, Department of Pediatrics, Nilratan Sircar (NRS) Medical College and Hospital, Kolkata, India
| | - Andrea Angeletti
- Division of Nephrology, Dialysis, Transplantation, IstitutoGianninaGaslini Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Genoa, Italy
- Laboratory on Molecular Nephrology, IstitutoGianninaGaslini Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Genoa, Italy
| | - Bilkish Islam
- Department of Pediatrics, Nil Ratan Sircar Medical College and Hospital, Kolkata, India
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis, Transplantation, IstitutoGianninaGaslini Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Genoa, Italy
- Laboratory on Molecular Nephrology, IstitutoGianninaGaslini Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Genoa, Italy
- *Correspondence: Gian Marco Ghiggeri,
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Zotta F, Vivarelli M, Emma F. Update on the treatment of steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2022; 37:303-314. [PMID: 33665752 DOI: 10.1007/s00467-021-04983-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/13/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
Steroid-sensitive nephrotic syndrome (SSNS) is a rare condition that develops primarily in preadolescent children after the age of 1 year. Since the 1950s, oral corticosteroids have been the mainstay of treatment of all children presenting with nephrotic syndrome, with most patients responding within 4 weeks to an oral course of prednisone (PDN). However, corticosteroids have important side effects and 60-80 % of patients relapse, developing frequently relapsing or steroid-dependent forms. For these reasons, many patients require second-line steroid-sparing immunosuppressive medications that have considerably improved relapse-free survival, while avoiding many PDN-related toxicities. Since most patients will eventually heal from their disease with a normal kidney function, the morbidity of SSNS is primarily related to side effects of drugs that are used to maintain prolonged remission. Therefore, treatment is essentially based on balancing the use of different drugs to achieve permanent remission with the lowest cumulative number of side effects. Treatment choice is based on the severity of SSNS, on patient age, and on drug tolerability. This review provides an update of currently available therapeutic strategies for SSNS.
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Affiliation(s)
- Federica Zotta
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Marina Vivarelli
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Francesco Emma
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
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Guzmán Morais B, Ordóñez Álvarez FÁ, Santos Rodríguez F, Martín Ramos S, Fernández Novo G. Rituximab treatment in pediatric patients with steroid-dependent nephrotic syndrome: A tertiary hospital. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2022; 96:83-90. [DOI: 10.1016/j.anpede.2020.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 12/09/2020] [Indexed: 11/16/2022] Open
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Bertrand Q, Mignot S, Kwon T, Couderc A, Maisin A, Cambier A, Baudouin V, Peyneau M, Deschênes G, Hogan J, Dossier C. Anti-rituximab antibodies in pediatric steroid-dependent nephrotic syndrome. Pediatr Nephrol 2022; 37:357-365. [PMID: 34132894 DOI: 10.1007/s00467-021-05069-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/12/2021] [Accepted: 03/24/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rituximab is a chimeric anti-CD20 monoclonal antibody that induces sustained remission in children with steroid-dependent nephrotic syndrome. However, there is no consensus on the optimal regimen and monitoring of rituximab. In other autoimmune diseases, anti-rituximab antibodies (ARA) have been reported in 10-40% of patients, but their clinical relevance remains unclear. In nephrotic syndrome, data are scarce. METHODS We report a single-center retrospective study with immuno- and pharmacological monitoring of rituximab treatment in children with frequent relapsing (FR) or steroid-dependent nephrotic syndrome (SDNS). We analyzed the monthly monitoring of 24 children, receiving a dose of rituximab (375 mg/m2) between December 2017 and April 2018 at the Pediatric Nephrology Department of Robert-Debré hospital, Paris. RESULTS ARA were detected in 7/24 patients (29%), sometimes after the first infusion of rituximab. ARA were present at baseline in two patients previously treated with rituximab. Both displayed no B-cell depletion. ARA were also reported in 5/22 patients during follow-up, with antibodies always detected in the first month following B-cell recovery. An incomplete CD19+CD20- B-cell depletion at M1 (5-25/mm3) and low serum rituximab levels was predictive of developing ARA. The development of de novo ARA during follow-up was not associated with shorter B-cell depletion. CONCLUSIONS This study shows that ARA are frequent in children with FR/SDNS and that close immuno- and pharmacological monitoring may help personalizing rituximab treatment in patients needing repeated injections.
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Affiliation(s)
- Quentin Bertrand
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Paris, France.
| | - Sabine Mignot
- Departement of Immunology, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Theresa Kwon
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Paris, France
| | - Anne Couderc
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Paris, France
| | - Anne Maisin
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Paris, France
| | - Alexandra Cambier
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Paris, France
| | - Véronique Baudouin
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Paris, France
| | - Marine Peyneau
- Departement of Immunology, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Georges Deschênes
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Paris, France
| | - Julien Hogan
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Paris, France
| | - Claire Dossier
- Pediatric Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Paris, France
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Abstract
Nephrotic syndrome (NS) encompasses a variety of disease processes leading to heavy proteinuria and edema. Minimal change disease (MCD) remains the most common primary cause of NS, as well as the most responsive to pharmacologic treatment with often minimal to no chronic kidney disease. Other causes of NS include focal segmental glomerulosclerosis, which follows MCD, and secondary causes, including extrarenal or systemic diseases, infections, and drugs. Although initial diagnosis relies on clinical findings as well as urine and blood chemistries, renal biopsy and genetic testing are important diagnostic tools, especially when considering non-MCD NS. Moreover, biomarkers in urine and serum have become important areas for research in this disease. NS progression and prognosis are variable and depend on etiology, with corticosteroids being the mainstay of treatment. Other alternative therapies found to be successful in inducing and maintaining remission include calcineurin inhibitors and rituximab. Disease course can range from recurrent disease relapse with or without acute kidney injury to end-stage renal disease in some cases. Given the complex pathogenesis of NS, which remains incompletely understood, complications are numerous and diverse and include infections, electrolyte abnormalities, acute kidney injury, and thrombosis. Pediatricians must be aware of the presentation, complications, and overall long-term implications of NS and its treatment.
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35
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Christian MT, Maxted AP. Optimizing the corticosteroid dose in steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2022; 37:37-47. [PMID: 33611671 PMCID: PMC7896825 DOI: 10.1007/s00467-021-04985-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/13/2021] [Accepted: 02/03/2021] [Indexed: 01/31/2023]
Abstract
The use of corticosteroids in the treatment of steroid-sensitive nephrotic (SSNS) syndrome in children has evolved surprisingly slowly since the ISKDC consensus over 50 years ago. From a move towards longer courses of corticosteroid to treat the first episode in the 1990s and 2000s, more recent large, well-designed randomized controlled trials (RCTs) have unequivocally shown no benefit from an extended course, although doubt remains whether this applies across all age groups. With regard to prevention of relapses, daily ultra-low-dose prednisolone has recently been shown to be more effective than low-dose alternate-day prednisolone. Daily low-dose prednisolone for a week at the time of acute viral infection seems to be effective in the prevention of relapses but the results of a larger RCT are awaited. Recently, corticosteroid dosing to treat relapses has been questioned, with data suggesting lower doses may be as effective. The need for large RCTs to address the question of whether corticosteroid doses can be reduced was the conclusion of the authors of the recent corticosteroid therapy for nephrotic syndrome in children Cochrane update. This review summarizes development in thinking on corticosteroid use in SSNS and makes suggestions for areas that merit further scrutiny.
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Affiliation(s)
- Martin T Christian
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, NG7 2UH, UK.
| | - Andrew P Maxted
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, NG7 2UH, UK
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36
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Wang L, Zhu J, Xia M, Hua R, Deng F. Comparison of rituximab, cyclophosphamide, and tacrolimus as first steroid-sparing agents for complicated relapsing/steroid-dependent nephrotic syndrome in children: an evaluation of the health-related quality of life. Arch Med Sci 2022; 18:275-278. [PMID: 35154548 PMCID: PMC8826811 DOI: 10.5114/aoms/145587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/06/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Frequently-relapsing/steroid-dependent nephrotic syndrome (FRSDNS) leads to steroid toxicity impairing quality of life (QOL), thus prompting the use of steroid-sparing drugs. METHODS 51 FRSDNS children not previously treated with steroid-sparing agents were randomized to receive rituximab, cyclophosphamide, or tacrolimus. Clinical findings and QOL were evaluated before and after treatment. RESULTS The mean relapse rate in all groups declined six months after treatment, however, 1-year relapse-free survival rate, number of relapses, and cumulative prednisolone dosage were lower with rituximab than with tacrolimus and cyclophosphamide. Cyclophosphamide group had twice frequency of infections compared to the other groups. At 1 year after treatment, total scores showed greater improvement with rituximab. CONCLUSIONS As first-line steroid-sparing agent, rituximab is more effective and safer than cyclophosphamide and tacrolimus in FRSDNS, and improve QOL.
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Affiliation(s)
- Li Wang
- Children’s Hospital of Anhui Medical University, Anhui, China
- The First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Jialiang Zhu
- Children’s Hospital of Anhui Medical University, Anhui, China
- The fifth Clinical Medical College of Anhui Medical University, Anhui, China
| | - Mingyun Xia
- Children’s Hospital of Anhui Medical University, Anhui, China
- The fifth Clinical Medical College of Anhui Medical University, Anhui, China
| | - Ran Hua
- The First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Fang Deng
- Children’s Hospital of Anhui Medical University, Anhui, China
- The fifth Clinical Medical College of Anhui Medical University, Anhui, China
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37
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Efficacy of rituximab versus tacrolimus in difficult-to-treat steroid-sensitive nephrotic syndrome: an open-label pilot randomized controlled trial. Pediatr Nephrol 2022; 37:3117-3126. [PMID: 35286456 PMCID: PMC8919684 DOI: 10.1007/s00467-022-05475-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Rituximab and tacrolimus are therapies reserved for patients with frequently relapsing or steroid-dependent nephrotic syndrome who have failed conventional steroid-sparing agents. Given their toxicities, demonstrating non-inferiority of rituximab to tacrolimus may enable choice between these medications. METHODS This investigator-initiated, single-center, open-label, pilot randomized controlled trial examined the non-inferiority of two doses of intravenous (IV) rituximab given one-week apart to oral therapy with tacrolimus (1:1 allocation), in maintaining sustained remission over 12 months follow-up, in patients with difficult-to-treat steroid-sensitive nephrotic syndrome, defined as frequently relapsing or steroid-dependent disease that had failed ≥ 2 steroid-sparing strategies. Secondary outcomes included frequency of relapses, proportion with frequent relapses, time to relapse and frequent relapses, and adverse events (CTRI/2018/11/016342). RESULTS Baseline characteristics were comparable for 41 patients randomized to receive rituximab (n = 21) or tacrolimus (n = 20). While 55% of patients in each limb were in sustained remission at 1 year, non-inferiority of rituximab to tacrolimus was not demonstrated (mean difference 0%; 95% CI - 30.8%, 30.8%; non-inferiority limit - 20%; P = 0.50). Frequent relapses were more common in patients administered rituximab compared to tacrolimus (risk difference 30%, 95% CI 7.0, 53.0, P = 0.023). Both groups showed similar reductions in relapse rates and prednisolone use. Common adverse events were infusion-related with rituximab and gastrointestinal symptoms with tacrolimus. CONCLUSIONS Therapy with rituximab was not shown to be non-inferior to 12-months treatment with tacrolimus in maintaining remission in patients with difficult-to-treat steroid-sensitive nephrotic syndrome. Frequent relapses were more common with rituximab. While effective, both agents require close monitoring for adverse events. A higher resolution version of the Graphical abstract is available as Supplementary information.
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38
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Liu L, Zheng W, Wang P, Wu Y, Zhu G, Yang R, Gu L, Huang W, Kang Y. Case Report: Successful treatment of severe pneumocystis carinii pneumonia in a case series of primary nephrotic syndrome after receiving anti-CD20 monoclonal antibody therapy. Front Pediatr 2022; 10:1067634. [PMID: 36683820 PMCID: PMC9845562 DOI: 10.3389/fped.2022.1067634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/29/2022] [Indexed: 01/06/2023] Open
Abstract
Rituximab is emerging as a new steroid sparing agent in children with difficult-to-treat nephrotic syndrome due to its ability of depleting CD20-positive B cells. Life-threatening adverse events such as pneumocystis carinii pneumonia may occur even though it seems to be well tolerated. Since rituximab is wildly used in immune-mediated diseases, it is important to manage its severe adverse events. To explore the importance of early diagnosis and treatment of pneumocystis carinii pneumonia in children with primary nephrotic syndrome (PNS) after receiving rituximab therapy, we retrospectively analyzed the clinical data of PNS patients younger than 18 years old with pneumocystis carinii pneumonia who were hospitalized in our center. Clinical features and laboratory test results were retrieved from the electronic medical records. Severe pneumocystis carinii pneumonia occurred in one child with steroid resistant nephrotic syndrome and two with steroid dependent nephrotic syndrome patients after rituximab treatment. These patients were diagnosed in time by metagenomic next-generation sequencing (mNGS) for pathogen detection. Fortunately, all three patients survived after antifungal treatment and achieved complete remission eventually. In conclusion, early diagnosis by using mNGS and timely antifungal treatment is the key to successful management of pneumocystis carinii pneumonia in children with difficult-to-treat PNS.
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Affiliation(s)
- Lili Liu
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weihua Zheng
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ping Wang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Wu
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guanghua Zhu
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Rong Yang
- Department of Pediatrics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Li Gu
- Department of Pediatrics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wenyan Huang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yulin Kang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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39
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Watts AJ, Keller KH, Lerner G, Rosales I, Collins AB, Sekulic M, Waikar SS, Chandraker A, Riella LV, Alexander MP, Troost JP, Chen J, Fermin D, Yee JL, Sampson MG, Beck LH, Henderson JM, Greka A, Rennke HG, Weins A. Discovery of Autoantibodies Targeting Nephrin in Minimal Change Disease Supports a Novel Autoimmune Etiology. J Am Soc Nephrol 2022; 33:238-252. [PMID: 34732507 PMCID: PMC8763186 DOI: 10.1681/asn.2021060794] [Citation(s) in RCA: 102] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 10/10/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Failure of the glomerular filtration barrier, primarily by loss of slit diaphragm architecture, underlies nephrotic syndrome in minimal change disease. The etiology remains unknown. The efficacy of B cell-targeted therapies in some patients, together with the known proteinuric effect of anti-nephrin antibodies in rodent models, prompted us to hypothesize that nephrin autoantibodies may be present in patients with minimal change disease. METHODS We evaluated sera from patients with minimal change disease, enrolled in the Nephrotic Syndrome Study Network (NEPTUNE) cohort and from our own institutions, for circulating nephrin autoantibodies by indirect ELISA and by immunoprecipitation of full-length nephrin from human glomerular extract or a recombinant purified extracellular domain of human nephrin. We also evaluated renal biopsies from our institutions for podocyte-associated punctate IgG colocalizing with nephrin by immunofluorescence. RESULTS In two independent patient cohorts, we identified circulating nephrin autoantibodies during active disease that were significantly reduced or absent during treatment response in a subset of patients with minimal change disease. We correlated the presence of these autoantibodies with podocyte-associated punctate IgG in renal biopsies from our institutions. We also identified a patient with steroid-dependent childhood minimal change disease that progressed to end stage kidney disease; she developed a massive post-transplant recurrence of proteinuria that was associated with high pretransplant circulating nephrin autoantibodies. CONCLUSIONS Our discovery of nephrin autoantibodies in a subset of adults and children with minimal change disease aligns with published animal studies and provides further support for an autoimmune etiology. We propose a new molecular classification of nephrin autoantibody minimal change disease to serve as a framework for instigation of precision therapeutics for these patients.
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Affiliation(s)
- Andrew J.B. Watts
- Department of Pathology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts,Renal Division, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Keith H. Keller
- Department of Pathology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Gabriel Lerner
- Department of Pathology, Boston Medical Center and Boston University, Boston, Massachusetts,Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University, Boston, Massachusetts
| | - Ivy Rosales
- Department of Pathology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | - A. Bernard Collins
- Department of Pathology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Miroslav Sekulic
- Department of Pathology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts,Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Sushrut S. Waikar
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts,Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University, Boston, Massachusetts
| | - Anil Chandraker
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Leonardo V. Riella
- Division of Nephrology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Mariam P. Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Jonathan P. Troost
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Junbo Chen
- Department of Pathology, Boston Medical Center and Boston University, Boston, Massachusetts
| | - Damian Fermin
- Division of Medicine, Department of Pediatrics, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Jennifer L. Yee
- Division of Medicine, Department of Pediatrics, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Matthew G. Sampson
- Department of Medicine/Pediatric Nephrology, Boston Children’s Hospital, and Harvard Medical School, Boston, Massachusetts,Kidney Disease Initiative, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Laurence H. Beck
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University, Boston, Massachusetts
| | - Joel M. Henderson
- Department of Pathology, Boston Medical Center and Boston University, Boston, Massachusetts
| | - Anna Greka
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts,Kidney Disease Initiative, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Helmut G. Rennke
- Department of Pathology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Astrid Weins
- Department of Pathology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts,Renal Division, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
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40
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Del Vecchio L, Allinovi M, Rocco P, Brando B. Rituximab Therapy for Adults with Nephrotic Syndromes: Standard Schedules or B Cell-Targeted Therapy? J Clin Med 2021; 10:5847. [PMID: 34945143 PMCID: PMC8709396 DOI: 10.3390/jcm10245847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022] Open
Abstract
Rituximab is a chimeric anti-CD20 monoclonal antibody. It acts mainly through complement-dependent cytotoxicity on B cells expressing the CD20 marker. In this review, we analyse the efficacy and possible pitfalls of rituximab to treat nephrotic syndromes by taking into account pharmacological considerations and CD19 marker testing utility. Despite the fact that the drug has been in use for years, efficacy and treatment schedules in adults with nephrotic syndrome are still a matter of debate. Clinical trials have proven the efficacy and safety of rituximab in idiopathic membranous nephropathy. Data from observational studies also showed the efficacy of rituximab in minimal change disease and focal segmental glomerulosclerosis. Rituximab use is now widely recommended by new Kidney Disease Improved Outcome (KDIGO) guidelines in membranous nephropathy and in frequent-relapsing, steroid-dependent minimal change disease or focal segmental glomerulosclerosis. However, rituximab response has a large interindividual variability. One reason could be that rituximab is lost in the urine at a higher extent in patients with nonselective nephrotic proteinuria, exposing patients to different rituximab plasma levels. Moreover, the association between CD19+ levels and clinical response or relapses is not always present, making the use of this marker in clinical practice complex. High resolution flow cytometry has increased the capability of detecting residual CD19+ B cells. Moreover, it can identify specific B-cell subsets (including IgG-switched memory B cells), which can repopulate at different rates. Its wider use could become a useful tool for better understanding reasons of rituximab failure or avoiding unnecessary retreatments.
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Affiliation(s)
- Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant’Anna Hospital, ASST Lariana, 22042 Como, Italy
| | - Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Paolo Rocco
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo, 71-20133 Milan, Italy;
| | - Bruno Brando
- Haematology Laboratory and Transfusion Centre, Legnano General Hospital (Milan), 20025 Milan, Italy;
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Lugani F, Angeletti A, Ravani P, Vivarelli M, Colucci M, Caridi G, Verrina E, Emma F, Ghiggeri GM. Randomised controlled trial comparing rituximab to mycophenolate mofetil in children and young adults with steroid-dependent idiopathic nephrotic syndrome: study protocol. BMJ Open 2021; 11:e052450. [PMID: 34845071 PMCID: PMC8634023 DOI: 10.1136/bmjopen-2021-052450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Glucocorticoids induce remission in 90% of children with idiopathic nephrotic syndrome (INS). Some become steroid-dependent (SD) and require the addition of steroid sparing drugs such as calcineurin-inhibitors (CNI) or cyclophosphamide, to maintain remission. Considering the toxicity of these drugs, alternative interventions are needed for long-term treatment. The anti-CD20 antibody rituximab has shown promising steroid-sparing properties, with conflicting results in complicated forms of SD-INS. Mycophenolate mofetil (MMF) resulted effective in maintaining free-steroid remission, however, studies are limited to few uncontrolled trials with reported different dose of MMF. METHODS AND ANALYSIS This open-label, two-parallel-arm, superiority controlled randomised clinical trial will enrol children with SD-INS maintained in remission with oral glucocorticoids or CNI. Children and young adults will be randomised to either MMF (1.200 mg/m2) or rituximab (375 mg/m2) infusion. After enrolment, glucocorticoids will be tapered until complete withdrawal. We will enrol 160 children and young adults to detect as significant at the two-sided p value of 0.01 with a power >0.8 a reduction in the risk of 1-year relapse (primary end-point). As secondary endpoints, we will compare the amount of glucocorticoids required to maintain complete remission at 6 and 24 months. ETHICS AND DISSEMINATION The trial was approved by the local ethics boards (Comitato Etico Regione Liguria CER Liguria https://www.portalericerca-liguria.it/). We will publish the study results at international scientific meetings. TRIAL REGISTRATION NUMBERS NCT004585152.
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Affiliation(s)
- Francesca Lugani
- Laboratory on Molecular Nephrology, Division of Nephrology, Dialysis, Transplantation, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genova, Italy
| | - Andrea Angeletti
- Laboratory on Molecular Nephrology, Division of Nephrology, Dialysis, Transplantation, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genova, Italy
- Division of Nephrology, Dialysis and Transplantation, Istituto Giannina Gaslini Istituto Pediatrico di Ricovero e Cura a Carattere Scientifico, Genova, Italy
| | - Pietro Ravani
- Division of Nephrology, University of Calgary, Calgary, Alberta, Canada
| | - Marina Vivarelli
- Division of Nephrology, Bambino Gesù Children's Hospital Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Manuela Colucci
- Renal Diseases Research Unit, Genetics and Rare Diseases Division, Bambino Gesù Children's Hospital Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Gianluca Caridi
- Laboratory on Molecular Nephrology, Division of Nephrology, Dialysis, Transplantation, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genova, Italy
| | - Enrico Verrina
- Division of Nephrology, Dialysis and Transplantation, Istituto Giannina Gaslini Istituto Pediatrico di Ricovero e Cura a Carattere Scientifico, Genova, Italy
| | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children's Hospital Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Gian Marco Ghiggeri
- Laboratory on Molecular Nephrology, Division of Nephrology, Dialysis, Transplantation, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genova, Italy
- Division of Nephrology, Dialysis and Transplantation, Istituto Giannina Gaslini Istituto Pediatrico di Ricovero e Cura a Carattere Scientifico, Genova, Italy
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42
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Chang D, Gong M, Liu C, Zhang Q, Hu Z, Li Z. Efficacy and safety of rituximab for childhood refractory nephrotic syndrome: A meta-analysis of randomized controlled trials. Med Clin (Barc) 2021; 157:418-426. [PMID: 33070945 DOI: 10.1016/j.medcli.2020.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/03/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Idiopathic nephrotic syndrome is the most common glomerular disease in children, but there are still some difficulties in treating childhood steroid-dependent or steroid-resistant nephrotic syndrome (SDNS/SRNS). Rituximab (RTX) might be an effective and safe choice. METHODS Studies were searched from PubMed, Web of Science, Cochrane library and some Chinese databases up to April 2020. Only randomized controlled trials (RCT) were included. RESULTS Of 1383 screened articles, 6 RCTs with 334 participants were included. RTX was better than the control group at improving relapse-free rate in the short term [RR (risk ratio) (95% CI (confidence interval)), 1.84(1.41, 2.39)]. As for long-term, RTX did not show significant improvement [RR (95% CI), 4.43(.57, 34.67)]; but in subgroup analysis, RTX was still better than conventional drugs and tacrolimus [RR (95% CI), 9.91(1.95, 50.52) and 1.42(1.15, 1.75), respectively]. And there was a difference between the two groups of prednisolone dose after treatment [MD (mean difference) (95% CI), -.22(-.36, -.09) mg/kg/d)]. However, RTX did not significantly improve serum albumin and creatinine [MD (95% CI), 3.46(-1.40, 8.32)g/L and -3.66(-11.79, 4.48)μmol/L, respectively]. No significant differences between the RTX and the control group were found in total adverse events (AEs) or serious AEs. CONCLUSION Childhood SDNS/SRNS patients appear to benefit from RTX in relapse-free rate and dose of prednisolone use. Also, RTX did not significantly increase the incidence of AEs. But RTX did not show improvements in biological indicators, more studies are required to explain the effect of RTX.
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Affiliation(s)
- Dan Chang
- Department of Nephrology, University of Electronic Science and Technology, Sichuan Academy of Sciences & Sichuan Provincial People's Hospital, Chengdu 610072, Sichuan China
| | - Minmin Gong
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Chaofan Liu
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Quan Zhang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Ziwei Hu
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Zhuoguang Li
- Department of Endocrinology, Shenzhen Children's Hospital, Shenzhen 518038, China.
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43
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Chen Y, Shen Q, Dong M, Xiong Y, Xu H, Li Z. Population Pharmacokinetics of Rituximab in Pediatric Patients With Frequent-Relapsing or Steroid-Dependent Nephrotic Syndrome. Front Pharmacol 2021; 12:725665. [PMID: 34539407 PMCID: PMC8443776 DOI: 10.3389/fphar.2021.725665] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/19/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives: Rituximab is frequently used off-label for the treatment of frequent-relapsing nephrotic syndrome (FRNS) or steroid-dependent nephrotic syndrome (SDNS), but the relapse rate remained high and the dosing regimen varied widely. The objective of this study was to characterize rituximab pharmacokinetics (PK) in pediatric patients with FRNS/SDNS, and to investigate the differences in rituximab PK between patients with FRNS/SDNS and other disease populations. Methods: Fourteen pediatric patients received rituximab for FRNS/SDNS treatment were enrolled in a prospective, open-label, single-center PK study. A population PK model of rituximab was developed and validated, and PK parameters were derived for quantitative evaluation. Results: A two-compartment PK model best described the data. Body surface area was the most significant covariate for both central clearance (CL) and apparent central volume of distribution (V1). Patients with FRNS/SDNS exhibited a clinically relevant increase in rituximab CL compared to patient population with non-Hodgkin’s lymphoma (NHL). Conclusion: This pilot study indicated that higher doses or more frequent regimens of rituximab may be required for optimal therapeutic effects in patients with FRNS/SDNS. Further clinical studies with more patients are warranted to confirm this result.
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Affiliation(s)
- Yewei Chen
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
| | - Qian Shen
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Min Dong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Ye Xiong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Zhiping Li
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
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44
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Chan EYH, Tullus K. Rituximab in children with steroid sensitive nephrotic syndrome: in quest of the optimal regimen. Pediatr Nephrol 2021; 36:1397-1405. [PMID: 32577808 DOI: 10.1007/s00467-020-04609-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/02/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
Rituximab has emerged as an effective and important therapy in children with complicated frequently relapsing and steroid-dependent nephrotic syndrome to induce long-term disease remission and avoid steroid toxicities. The optimal rituximab regimen is not totally well defined, and there are many varying practices worldwide. We will in this review describe how patient factors, rituximab dose, and use of maintenance immunosuppression affect treatment outcomes. Specifically, low-dose rituximab without concomitant immunosuppression is associated with shorter relapse-free duration while other regimens have comparable outcomes. Patients with more severe disease generally have worse response to rituximab. Although rituximab appears to be generally safe, there are growing concerns of chronic hypogammaglobulinemia and impaired immunity especially in young children. Reliable prognostications and biomarkers for guiding subsequent treatments to avoid excessive treatments are yet to be identified. In this review, we will outline the, as we see it, best approach of rituximab in childhood steroid sensitive nephrotic syndrome at the present state of knowledge.
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Affiliation(s)
- Eugene Yu-Hin Chan
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK.
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong.
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
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45
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Lin L, Wang W, Wu Y, Xie J, Li X, Pan X, Zhang W, Xu J, Cai Y, Ren H, Chen N. Consolidation Treatment and Long-Term Prognosis of Rituximab in Minimal Change Disease and Focal Segmental Glomerular Sclerosis. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:1945-1953. [PMID: 34007154 PMCID: PMC8121273 DOI: 10.2147/dddt.s302257] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 04/13/2021] [Indexed: 12/16/2022]
Abstract
Purpose There is currently a lack of studies investigating long-term prognosis and the necessity of further rituximab (RTX) consolidation treatment for minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS). The aim of this study was to evaluate the efficacy of RTX for these diseases and to investigate whether a consolidation treatment can lower risks of relapse and reinforce long-term remission. Patients and Methods A retrospective study was conducted. The relapse and remission of 70 patients treated with 1 course of RTX treatment (4 infusions of 375 mg/m2) over a median follow-up time of 27 months (12–60 months) were analyzed. The rates of patients that were able to achieve non-relapse for a duration of 24 months between RTX consolidation therapy and non-consolidation therapy were compared. Results There were 67 cases (95.71%) of remission and 3 cases (4.29%) of non-remission. The average number of relapses decreased from 3.7±2.5 times before the treatment to 0.8±1.8 times after treatment (P <0.001). The average avannual number of relapses decreased from 1.3±1.2 times/year to 0.2±0.3 times/year (P <0.001). The results from the Cox proportional-hazards model showed that the risk of relapse in patients who received RTX non-consolidation treatment was significantly higher than those with consolidation treatment (odds ratios (OR) 20.9, 95% confidence intervals (CI) OR 5.7–75.7, p<0.001). The 24-month relapse-free rate was also significantly higher in patients with consolidation therapy compared with non-consolidation therapy (86.36% vs 25%, p<0.001). No adverse events were recorded. Conclusion RTX is highly effective in treating MCD and FSGS, and RTX consolidation therapy may be recommended to reinforce long-term remissions.
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Affiliation(s)
- Li Lin
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Weiming Wang
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - YiFan Wu
- Biomedical and Health Informatics, University of Washington, Seattle, WA, USA
| | - JingYuan Xie
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Xiao Li
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - XiaoXia Pan
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Wen Zhang
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Jing Xu
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - YiKai Cai
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Hong Ren
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Nan Chen
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
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Schijvens AM, Sinha A, Bagga A, Schreuder MF. Need for uniform definitions in childhood nephrotic syndrome. Nephrol Dial Transplant 2021; 36:941-945. [PMID: 33367868 DOI: 10.1093/ndt/gfaa338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/12/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anne M Schijvens
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
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Chen J, Qiao XH, Mao JH. Immunopathogenesis of idiopathic nephrotic syndrome in children: two sides of the coin. World J Pediatr 2021; 17:115-122. [PMID: 33660135 DOI: 10.1007/s12519-020-00400-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 11/25/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Idiopathic nephrotic syndrome is a common form of glomerular nephropathy in children, with an incidence rate of 1.15-16.9/100,000 depending on different nationalities and ethnicities. The etiological factors and mechanisms of childhood idiopathic nephrotic syndrome have not yet been fully elucidated. This review summarizes the progress of the immunopathogenesis of idiopathic nephrotic syndrome in children. DATA SOURCES We review the literature on the immunopathogenesis of idiopathic nephrotic syndrome in children. Databases including Medline, Scopus, and Web of Science were searched for studies published in any language with the terms "children", "idiopathic nephrotic syndrome", "immunopathogenesis", "T cells", "circulating permeability factors", and "B cells". RESULTS Dysfunction in T lymphocytes and pathogenic circulatory factors were indicated to play key roles in the pathogenesis of idiopathic nephrotic syndrome. Recently, some studies have shown that cellular immune dysfunction may also be involved in the pathogenesis of idiopathic nephrotic syndrome. CONCLUSIONS Both T- and B-cell dysfunction may play significant roles in the pathogenesis of idiopathic nephrotic syndrome, like two sides of one coin, but the role of B cell seems more important than T cells.
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Affiliation(s)
- Jing Chen
- Department of Nephrology, Ningbo Women and Children's Hospital, 339 LiutingRd, Ningbo, 315012, China
| | - Xiao-Hui Qiao
- Department of Nephrology, Ningbo Women and Children's Hospital, 339 LiutingRd, Ningbo, 315012, China.
| | - Jian-Hua Mao
- Department of Nephrology, Children's Hospital, Zhejiang University School of Medicine, 57 Zhuganxiang, Hangzhou, 310003, China
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Guzmán Morais B, Ordóñez Álvarez FÁ, Santos Rodríguez F, Martín Ramos S, Fernández Novo G. [Rituximab treatment in pediatric patients with steroid-dependent nephrotic syndrome: a tertiary hospital]. An Pediatr (Barc) 2021; 96:S1695-4033(20)30529-4. [PMID: 33518484 DOI: 10.1016/j.anpedi.2020.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 11/30/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Corticosteroids have had a central role in the treatment of nephrotic syndrome. The management of these patients who become dependent to steroids is complex, involving different immunosuppressive drugs patterns. The monoclonal antibody anti CD20, Rituximab, is likely to have beneficial effects in cases of steroid-dependent nephrotic syndrome patients with no easy resolution, even when we cannot make a statement about the specific role in the impact. We bring our personal experience in pediatric patients treated with this medication during the last years, to provide a thorough overview and useful information about the role of Rituximab in this pathology. METHODS Retrospective study in patients with steroid-dependent idiopathic nephrotic syndrome controlled in the division of Pediatric Nephrology of a spanish tertiary hospital in those patients who had received at least one treatment cycle of Rituximab, at any moment along the evolution of the disease. RESULTS The study involved 8 patients. All of them previously received immunosuppressive therapy. The Rituximab were administered as an intravenous infusion, in a dose of 375 mg/m2, and all doses were administered in a period during which the disease was in remission. The depletion of lymphocytes B (CD 19%) were confirmed after the first dose of Rituximab except for one, with a lymphocyte count of 1%. The period of depletion lasts 10.3 months (median; range 6.5-16 months), and only one of the patients registered a relapse of the disease in this period. A reduction of relapses suffered by patients has been shown after the treatment began (3.6 relapses/year in the previous year to the start of the treatment vs. 0.1 relapses/year during the first year post-rituximab). The relapse-free survival in the first year reached 83.3% in patients who suffered more than one relapse (75% of patients), and without a relapse after the treatment began in 2 cases. One or more drugs could be removed in 87.5% of patients after the first cycle of rituximab. After the rituximab treatment, we reached a 96.5% decrease in the corticosteroids doses administered (28.5 mg/m2/day during the 3 months pre-treatment vs. 1 mg/m2/day in the last 3 months of patient monitoring). Not a significant observed adverse effect attributed to the drug after the post-rituximab monitoring period (median 46.5 months, range 5-97 months). CONCLUSION The favorable results reported after rituximab treatment in our patients seems to confirm the effectiveness of this drug in the steroid-dependent nephrotic syndrome, making that therapeutic option into consideration and legitimating the use of the drug in complex cases involving pediatric patients. Even so, it seems recommendable to design pertinent studies to clarify, among others, the optimum regimen of the treatment (dose, interval and cycles), clinical repercussion and potential adverse effects in long terms.
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Affiliation(s)
- Beatriz Guzmán Morais
- Servicio de Pediatría, Hospital Clínico Universitario de Valencia, Valencia, España.
| | | | - Fernando Santos Rodríguez
- Servicio de Nefrología Infantil, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Silvia Martín Ramos
- Servicio de Nefrología Infantil, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Gema Fernández Novo
- Servicio de Nefrología Infantil, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
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Liu S, Gui C, Lu Z, Li H, Fu Z, Deng Y. The Efficacy and Safety of Rituximab for Childhood Steroid-Dependent Nephrotic Syndrome: A Systematic Review and Meta-Analysis. Front Pediatr 2021; 9:728010. [PMID: 34490171 PMCID: PMC8417896 DOI: 10.3389/fped.2021.728010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 07/22/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Rituximab (RTX), a possible alternative treatment option, is recognized as a new therapeutic hope for the treatment of steroid-dependent nephrotic syndrome (SDNS) in children. However, the efficacy and safety of RTX in the treatment of childhood SDNS are still controversial. The objective of this study was to evaluate the efficacy and safety of RTX treatment in children with SDNS. Study Design: Six randomized controlled trials (RCTs) and one retrospective comparative control study data from studies, performed before January 2021 were collected, from PubMed, Cochrane Library, Embase, and Web of Science. The studies evaluating the efficacy and safety of RTX in childhood SDNS were included. Results: Six RCTs and one retrospective comparative control study were included in our analysis. Compared with the control group, the RTX treatment group achieved a higher complete remission rate (OR = 5.21; 95% CI, 3.18-8.54; p < 0.00001), and we found significant differences between the two groups on serum albumin level (MD = 0.88; 95% CI, 0.43-1.33; p = 0.0001) and estimated glomerular filtration rate (MD = 6.43; 95% CI, 2.68-10.19; p = 0.0008). However, RTX treatment did not significantly lower serum creatinine levels nor did it significantly reduce the occurrence of proteinuria. In addition, we found no advantages with RTX on treatment safety. Conclusions: RTX has shown satisfactory characteristics in terms of efficacy and may be a promising treatment method for SDNS in children. However, the long-term effects have not been fully evaluated and should be further studied through randomized clinical trials.
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Affiliation(s)
- Sidi Liu
- Department of Nephrology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chuying Gui
- Department of Nephrology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhenzhen Lu
- Department of Nephrology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Huijie Li
- Department of Nephrology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhike Fu
- Department of Nephrology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yueyi Deng
- Department of Nephrology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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50
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Gao X, Wang Y, Xu Z, Deng H, Yang H, Zhong F. Systematic Review and Meta-Analysis of Rituximab for Steroid-Dependent or Frequently Relapsing Nephrotic Syndrome in Children. Front Pediatr 2021; 9:626323. [PMID: 34368023 PMCID: PMC8339375 DOI: 10.3389/fped.2021.626323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/16/2021] [Indexed: 11/20/2022] Open
Abstract
Objective: To explore the effectiveness and safety of rituximab (RTX) for steroid-dependent or frequently relapsing nephrotic syndrome via a systematic review and meta-analysis. Methods: All the literature about RTX therapy for childhood nephrotic syndrome (NS) on PubMed, Web of Science, Cochrane Library, EMBASE, and Chinese biomedical literature database published before November 1, 2019, were conducted and selected according to the preset criteria. The Cochrane bias risk assessment tool was used to evaluate the quality of the literature included. The outcome data were analyzed by RevMan 5.3 software. Results: There were six RCT studies that met the inclusion criteria with a moderate quality after evaluation. At the end of the treatment, the relapse rate of NS in the RTX group reduced significantly when compared with that in the control group [odds ratio (OR) = 0.11, 95% confidence interval (CI) (0.03, 0.43), p = 0.001]. The number of patients in the RTX group used less steroid or/and calcineurin inhibitors significantly than that in the control group [OR = 0.05, 95% CI (0.01, 0.28), p = 0.0007]. For children who were steroid-dependent, RTX treatment significantly reduced the dosage of the steroid, compared with that in control [standardized mean difference (SMD) = -1.49, 95% CI (-2.00, -0.99), p < 0.00001]. There was no significant reduction in protein excretion between the two groups [SMD = -0.33, 95% CI (-0.71, 0.04), p = 0.08]. Fewer serious adverse reactions of RTX in the six studies were reported and most adverse events were mild. Conclusion: RTX is effective and safe for children with steroid-dependent or frequently relapsing nephrotic syndrome. Systematic Review Registration: Identifier: CRD 42020150933. https://www.crd.york.ac.uk/prospero/. This review has been registered to the PROSPERO on 27 Feb 2020.
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Affiliation(s)
- Xia Gao
- Nephrology Department, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Yan Wang
- Graduate School, Ningxia Medical University, Yinchuan, China.,Neonatology Department, Northwest Women and Children's Hospital, Xi'an, China
| | - Zichuan Xu
- Nephrology Department, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Huiying Deng
- Nephrology Department, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Huabin Yang
- Nephrology Department, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Fu Zhong
- Nephrology Department, Guangzhou Women and Children's Medical Center, Guangzhou, China
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