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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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2
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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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3
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Hartinger JM, Kratky V, Hruskova Z, Slanar O, Tesar V. Implications of rituximab pharmacokinetic and pharmacodynamic alterations in various immune-mediated glomerulopathies and potential anti-CD20 therapy alternatives. Front Immunol 2022; 13:1024068. [PMID: 36420256 PMCID: PMC9676507 DOI: 10.3389/fimmu.2022.1024068] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 10/13/2022] [Indexed: 11/09/2022] Open
Abstract
The specific B-cell depleting anti-CD20 monoclonal antibody rituximab (RTX) is effective in terms of the treatment of various immune-mediated glomerulopathies. The administration of RTX has been shown to be reliable and highly effective particularly in patients with ANCA-associated vasculitis, which is manifested predominantly with non-nephrotic proteinuria. Stable long-term B-cell depletion is usually readily attained in such patients using standard dosing regimens. However, in patients with nephrotic syndrome and non-selective proteinuria, the RTX pharmacokinetics is altered profoundly and RTX does not maintain high enough levels for a sufficiently long period, which may render RTX treatment ineffective. Since complement-derived cytotoxicity is one of the important modes of action of RTX, hypocomplementemia, frequently associated with systemic lupus erythematodes, may act to hamper the efficacy of RTX in the treatment of patients with lupus nephritis. This review provides a description of RTX pharmacokinetics and pharmacodynamics in several selected glomerulopathies, as well as the impact of proteinuria, anti-drug antibodies and other clinical variables on the clearance and volume of distribution of RTX. The impact of plasmapheresis and peritoneal dialysis on the clearance of RTX is also discussed in the paper. A review is provided of the potential association between pharmacokinetic and pharmacodynamic alterations in various kidney-affecting glomerular diseases, the sustainability of B-cell depletion and the clinical efficacy of RTX, with proposals for potential dosing implications. The role of therapeutic drug monitoring in treatment tailoring is also discussed, and various previously tested RTX dosing schedules are compared in terms of their clinical and laboratory treatment responses. Since alternative anti-CD20 molecules may prove effective in RTX unresponsive patients, their pharmacokinetics, pharmacodynamics and current role in the treatment of glomerulopathies are also mentioned.
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Affiliation(s)
- Jan Miroslav Hartinger
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
- *Correspondence: Jan Miroslav Hartinger,
| | - Vojtech Kratky
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
| | - Zdenka Hruskova
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
| | - Ondrej Slanar
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital Prague, Prague, Czechia
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4
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Sinha A, Mathew G, Arushi A, Govindarajan S, Ghanapriya K, Grewal N, Rai K, Brijwal M, Kalluru SL, Tewari P, Misra A, Khandelwal P, Hari P, Bagga A. Sequential rituximab therapy sustains remission of nephrotic syndrome but carries high risk of adverse effects. Nephrol Dial Transplant 2022; 38:939-949. [PMID: 36071552 DOI: 10.1093/ndt/gfac228] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Sequential rituximab (RTX) administration has emerged as an important strategy to sustain remission of disease in patients with difficult-to-treat nephrotic syndrome. METHODS We report the efficacy and safety of sequential therapy with two or more courses of intravenous RTX in 250 patients with difficult-to-treat steroid dependence (n = 127) and calcineurin inhibitor (CNI)-dependent or CNI-refractory steroid resistance (n = 123) managed at one center during 2015-2021. Subsets of patients were cross-sectionally tested for hypogammaglobulinemia, seroprotection against and hyporesponsiveness to vaccines for hepatitis B and tetanus, BK/JC viruria and human antichimeric antibodies (HACAs). RESULTS Sequential RTX therapy, initiated at a median of 10 years [interquartile range (IQR) 7.3-14.4], was administered for 1.8 courses/person-year [95% confidence interval (CI) 1.7-2.0] over 2.0 years (95% CI 1.2-3.0). Therapy was associated with postponement of relapses by a median of 3 years in patients with steroid-sensitive disease and 2 years in those with steroid resistance. Relapses were reduced by a mean of 2.0 relapses/person-year (95% CI 1.8-2.2), enabling a reduction in prednisolone dose to 0.04 mg/kg/day (95% CI 0.01-0.11) and withdrawal of additional immunosuppression in 154 (62%) patients. RTX-associated adverse events, occurring at 0.20 events/person-year (95% CI 0.17-0.23), were chiefly comprised of infusion reactions (n = 108) and infections (n = 46); serious adverse events were observed in 10.8% patients, at 0.03 events/person-year (95% CI 0.02-0.05). Hypogammaglobulinemia was observed in 35% of 177 patients and was moderate to severe in 8.5% of cases. Rates of seroprotection at baseline and response following vaccination were lower for hepatitis B [1.9% and 29.4% (n = 52)] than tetanus [65.5% and 34.5% (n = 58)]. BK/JC viruria, without viremia, was observed in 7.3% of 109 cases. A total of 19 of 107 patients (17.8%) had HACAs, which were associated with B cell nondepletion and serum sickness. Age at therapy of <9-10 years was associated with a risk of early relapse, treatment failure and hypogammaglobulinemia following RTX therapy. CONCLUSIONS Sequential therapy with RTX effectively reduces relapses in patients with difficult-to-treat steroid- and/or CNI-dependent or CNI-refractory nephrotic syndrome. Therapy is associated with high rates of hypogammaglobulinemia and infusion reactions.
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Affiliation(s)
- Aditi Sinha
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Georgie Mathew
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.,Division of Pediatric Nephrology, Department of Child Health, Christian Medical College, Vellore, Tamil Nadu, India
| | - Arushi Arushi
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Srinivasavaradan Govindarajan
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kshetrimayum Ghanapriya
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Neetu Grewal
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Khushboo Rai
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Megha Brijwal
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sree Laya Kalluru
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Prachi Tewari
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Priyanka Khandelwal
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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5
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Ural Z, Helvacı Ö, Özbaş B, Güz G, Derici Ü. Unexpected Late Response to Ofatumumab in Adult Post-Transplantation Recurrent Focal Segmental Glomerulosclerosis, Case Report. Transplant Proc 2022; 54:1632-1635. [PMID: 35853766 DOI: 10.1016/j.transproceed.2022.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/12/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Idiopathic focal segmental glomerulosclerosis is an important cause of kidney failure in adults, which is associated with a high risk of disease recurrence after transplantation. Plasmapheresis, rituximab, immunoadsorption, and high-dose cyclosporine are used to treat post-transplant recurrent focal segmental glomerulosclerosis (rFSGS). However, the response rate is variable, and few options remain for unresponsive patients. CASE REPORT We present a 44-year-old man with an early post-transplant rFSGS. After peritransplant plasmapheresis, rituximab, and abatacept treatments failed, we employed ofatumumab. After 9 months without apparent benefit, we observed an unexpected partial remission thereafter, without severe side effects. Furthermore, remission has been sustained in 30-month follow-up. CONCLUSIONS We believe ofatumumab can be considered an alternative for patients with plasmapheresis and rituximab-resistant post-transplant rFSGS.
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Affiliation(s)
- Zeynep Ural
- Gazi University, Faculty of Medicine, Department of Nephrology, Ankara, Turkey.
| | - Özant Helvacı
- Gazi University, Faculty of Medicine, Department of Nephrology, Ankara, Turkey
| | - Burak Özbaş
- Erciyes University, Faculty of Medicine, Department of Endocrinology, Kayseri, Turkey
| | - Galip Güz
- Gazi University, Faculty of Medicine, Department of Nephrology, Ankara, Turkey
| | - Ülver Derici
- Gazi University, Faculty of Medicine, Department of Nephrology, Ankara, Turkey
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6
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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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7
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Kim J, Islam SMT, Qiao F, Singh AK, Khan M, Won J, Singh I. Regulation of B cell functions by S-nitrosoglutathione in the EAE model. Redox Biol 2021; 45:102053. [PMID: 34175668 PMCID: PMC8246645 DOI: 10.1016/j.redox.2021.102053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/09/2021] [Accepted: 06/18/2021] [Indexed: 12/26/2022] Open
Abstract
B cells play both protective and pathogenic roles in T cell-mediated autoimmune diseases by releasing regulatory vs. pathogenic cytokines. B cell-depleting therapy has been attempted in various autoimmune diseases but its efficacy varies and can even worsen symptoms due to depletion of B cells releasing regulatory cytokines along with B cells releasing pathogenic cytokines. Here, we report that S-nitrosoglutathione (GSNO) and GSNO-reductase (GSNOR) inhibitor N6022 drive upregulation of regulatory cytokine (IL-10) and downregulation of pathogenic effector cytokine (IL-6) in B cells and protected against the neuroinflammatory disease of experimental autoimmune encephalomyelitis (EAE). In human and mouse B cells, the GSNO/N6022-mediated regulation of IL-10 vs. IL-6 was not limited to regulatory B cells but also to a broad range of B cell subsets and antibody-secreting cells. Adoptive transfer of B cells from N6022 treated EAE mice or EAE mice deficient in the GSNOR gene also regulated T cell balance (Treg > Th17) and reduced clinical disease in the recipient EAE mice. The data presented here provide evidence of the role of GSNO in shifting B cell immune balance (IL-10 > IL-6) and the preclinical relevance of N6022, a first-in-class drug targeting GSNOR with proven human safety, as therapeutics for autoimmune disorders including multiple sclerosis. GSNO and GSNOR inhibitor (N6022) upregulates IL-10 and downregulates IL-6 in B cells. GSNO/N6022-mediated cytokine regulation occurs in a broad range of B cell subsets. GSNO/N6022 treatment ameliorates autoimmune disease of EAE. B cell transfer from N6022-treated or GSNOR null EAE mice to EAE mice shifts T cell balance (Treg > Th17) and alleviates EAE. The data provide the first insight into the therapeutic potential of GSNO/N6022 targeting B cells in multiple sclerosis.
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Affiliation(s)
- Judong Kim
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - S M Touhidul Islam
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Fei Qiao
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Avtar K Singh
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC, USA; Pathology and Laboratory Medicine Service, Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
| | - Mushfiquddin Khan
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Jeseong Won
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Inderjit Singh
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA; Research Service, Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA.
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8
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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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9
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Odales J, Guzman Valle J, Martínez-Cortés F, Manoutcharian K. Immunogenic properties of immunoglobulin superfamily members within complex biological networks. Cell Immunol 2020; 358:104235. [PMID: 33137645 PMCID: PMC7548077 DOI: 10.1016/j.cellimm.2020.104235] [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: 07/31/2020] [Revised: 10/04/2020] [Accepted: 10/04/2020] [Indexed: 12/01/2022]
Abstract
Antibody-based therapies induce CDR-specific T and B cell responses. Idiotype-anti-idiotype network alters immune system memory compartment. Antigenized antibodies are efficient vaccine immunogen.
Antibodies, T cell receptors and major histocompatibility complex molecules are members of the immunoglobulin superfamily and have pivotal roles in the immune system. The fine interrelation between them regulates several immune functions. Here, we describe lesser-known functions ascribed to these molecules in generating and maintaining immune response. Particularly, we outline the contribution of antibody- and T cell receptor-derived complementarity-determining region neoantigens, antigenized antibodies, as well as major histocompatibility complex class I molecules-derived epitopes to the induction of protective/therapeutic immune responses against pathogens and cancer. We discuss findings of our own and other studies describing protective mechanisms, based on immunogenic properties of immunoglobulin superfamily members, and evaluate the perspectives of application of this class of immunogens in molecular vaccines design.
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Affiliation(s)
- Josué Odales
- Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México (UNAM), AP 70228, Ciudad Universitaria, México, DF 04510, Mexico
| | - Jesus Guzman Valle
- Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México (UNAM), AP 70228, Ciudad Universitaria, México, DF 04510, Mexico
| | - Fernando Martínez-Cortés
- Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México (UNAM), AP 70228, Ciudad Universitaria, México, DF 04510, Mexico
| | - Karen Manoutcharian
- Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México (UNAM), AP 70228, Ciudad Universitaria, México, DF 04510, Mexico.
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10
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Fujinaga S, Nishino T, Endo S, Umeda C, Watanabe Y, Nakagawa M. Unfavorable impact of anti-rituximab antibodies on clinical outcomes in children with complicated steroid-dependent nephrotic syndrome. Pediatr Nephrol 2020; 35:2003-2008. [PMID: 32556955 DOI: 10.1007/s00467-020-04629-w] [Citation(s) in RCA: 8] [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: 04/03/2020] [Revised: 05/22/2020] [Accepted: 05/27/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Anti-rituximab antibodies (ARA) are associated not only with adverse events, such as infusion reactions (IR) and serum sickness, but also with rituximab efficacy. However, the clinical relevance of ARA in children with steroid-dependent nephrotic syndrome (SDNS) remains unknown. METHODS We retrospectively reviewed clinical outcomes of 13 children with complicated SDNS receiving repeated single-dose rituximab treatments at 375 mg/m2 to assess whether ARA formation could impact toxicity and efficacy of additional rituximab. Pre-rituximab 22 samples collected from patients who developed IR during the second or subsequent rituximab doses were measured by electrochemiluminescence analysis. RESULTS ARA were identified in 5 of 13 patients (9 of 22 samples). Median time to recovery of CD19+ B cells to > 1% of total lymphocytes and median relapse-free time after rituximab treatment were significantly shorter in the 9 ARA-positive samples than the 13 ARA-negative samples (41 vs. 100 days, p < 0.01 and 119 vs. 308 days, p < 0.05, respectively). Kaplan-Meier analysis showed that time to CD19+ B cell recovery after rituximab was significantly shorter in ARA-positive samples than in ARA-negative samples (p < 0.005). Severe IR developed in two ARA-positive patients and serum sickness in one ARA-positive patient. CONCLUSIONS The incidence of ARA formation was high in the pre-rituximab samples of patients with complicated SDNS who developed IR during the second or subsequent rituximab doses, suggesting that ARA formation might have an unfavorable impact on the toxicity and efficacy of additional rituximab doses in these patients.
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Affiliation(s)
- Shuichiro Fujinaga
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama, 330-8777, Japan.
| | - Tomohiko Nishino
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama, 330-8777, Japan
| | - Shota Endo
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama, 330-8777, Japan
| | - Chisato Umeda
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama, 330-8777, Japan
| | - Yoshitaka Watanabe
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama, 330-8777, Japan
| | - Mayu Nakagawa
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama, 330-8777, Japan
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George J, Alex S, Thomas ETA, Gracious N, Vineetha NS, Kumar S. Clinical Response and Pattern of B cell Suppression with Single Low Dose Rituximab in Nephrology. KIDNEY360 2020; 1:359-367. [PMID: 35369364 DOI: 10.34067/kid.0000072020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/20/2020] [Indexed: 02/08/2023]
Abstract
Background There is no consensus regarding dose and frequency of rituximab in nephrology with extrapolation of doses used in treating lymphoproliferative disorders. There are no guidelines on targeting initial and subsequent doses on the basis of CD19+ B cells. Methods Initially, 100 mg rituximab was given to 42 adults with steroid-dependent nephrotic syndrome (SDNS) and frequently relapsing nephrotic syndrome (FRNS), idiopathic membranous nephropathy (MN), and high-immunologic-risk kidney transplantation. Absolute and percentage levels of CD19 B cells and clinical status were assessed at baseline, days 30, 90, and 180, and at 1 year. Subsequent doses of rituximab were on the basis of CD19 B cell reconstitution and clinical response. Results CD19 B cell percentage decreased from 16.3 ± 7.6 to 0.3 ± 0.3 (P≤0.001), 1.9 ± 1.7 (P≤0.001), and 4.0 ± 4.5 (P=0.005) by 30, 90, and 180 days, respectively. Suppression of CD19 B cell count below 1% at days 30, 90, and 180 was seen in 40 of 42 (95.2%), 18 of 42 (42.9%), and 7 of 42 (16.7%) patients, respectively. Of 30 with SDNS and FRNS followed up for 1 year, 29 (96.7%) went into remission at day 30. Remission was sustained in 23 (76.6%) at day 180 and 21 (70%) at 1 year. There was a significant decrease (P<0.001) in the dose of steroids needed to maintain remission at 180 days after rituximab (0.27 ± 0.02 mg/kg to 0.02 ± 0.00 mg/kg). CD19 B cell percentage at 90 days correlated with relapse (P=0.001; odds ratio 1.42; 95% confidence interval, 1.25 to 2.57). Eighteen (60%) required an additional dose. Of five with MN, four achieved remission by 6 months, which was sustained in three by 1 year. Of the seven kidney transplant recipients, two had antibody-mediated rejections, although CD19 B cells were suppressed even at 1 year. Conclusions Low-dose rituximab induces sustained depletion of CD19 B cells for up to 90 days. Its role in preventing relapses in SDNS, FRNS, MN, and rejection needs further study.
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Affiliation(s)
- Jacob George
- Department of Nephrology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Sunu Alex
- Department of Nephrology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - E T Arun Thomas
- Department of Nephrology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Noble Gracious
- Department of Nephrology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Nalanda S Vineetha
- Department of Nephrology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Sajeev Kumar
- Department of Nephrology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
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12
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Ofatumumab rescue treatment in post-transplant recurrence of focal segmental glomerulosclerosis. Pediatr Nephrol 2020; 35:341-345. [PMID: 31667616 DOI: 10.1007/s00467-019-04365-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/08/2019] [Accepted: 09/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Treatment of post-transplant focal segmental glomerulosclerosis (FSGS) recurrence is still debated. The use of the fully human anti-CD20 monoclonal antibody ofatumumab has been suggested. CASE-DIAGNOSIS/TREATMENT Two boys with FSGS received a kidney transplantation at the age of 15 years from a deceased and a living donor. Maintenance therapy consisted of calcineurin inhibitors, antiproliferative agents, and prednisone. Early post-transplant FSGS recurrence was observed after 2 and 3 days. Rituximab infusion and plasmapheresis sessions were performed with transient clinical improvement in the first patient, and no apparent response in the second patient. Both patients were treated with two ofatumumab infusions, which induced in patient #1 a complete and stable remission for more than 12 months and in patient #2 a partial remission with a progressive reduction of proteinuria and normalization of serum protein levels. CONCLUSIONS Ofatumumab may be a therapeutic option for post-transplant FSGS recurrence in patients who respond poorly to rituximab.
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13
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Chan EYH, Webb H, Yu E, Ghiggeri GM, Kemper MJ, Ma ALT, Yamamura T, Sinha A, Bagga A, Hogan J, Dossier C, Vivarelli M, Liu ID, Kamei K, Ishikura K, Saini P, Tullus K. Both the rituximab dose and maintenance immunosuppression in steroid-dependent/frequently-relapsing nephrotic syndrome have important effects on outcomes. Kidney Int 2019; 97:393-401. [PMID: 31874801 DOI: 10.1016/j.kint.2019.09.033] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/21/2019] [Accepted: 09/26/2019] [Indexed: 12/15/2022]
Abstract
Rituximab is an effective treatment for steroid-dependent/ frequently-relapsing nephrotic syndrome (SDFRNS) in children. However, the optimal rituximab regimen remains unknown. To help determine this we conducted an international, multicenter retrospective study at 11 tertiary pediatric nephrology centers in Asia, Europe and North America of children 1-18 years of age with complicated SDFRNS receiving rituximab between 2005-2016 for 18 or more months follow-up. The effect of rituximab prescribed at three dosing levels: low (375mg/m2), medium (750mg/m2) and high (1125-1500mg/m2), with or without maintenance immunosuppression (defined as concurrent use of corticosteroids, mycophenolate motile or calcineurin inhibition at first relapse or for at least six months following the rituximab treatment) was examined. Among the 511 children (median age 11.5 year, 67% boys), 191, 208 and 112 received low, medium and high dose rituximab, respectively. Within this total cohort of 511 children, 283 (55%) received maintenance immunosuppression. Renal biopsies were performed in 317 children indicating the predominant histology was minimal change disease (74%). Without maintenance immunosuppression, low-dose rituximab had a shorter relapse-free period and a higher relapse risk (8.5 months) than medium (12.7 months; adjusted hazard ratio, 0.62) and high dose (14.3 months; adjusted hazard ratio, 0.50; all significant). With maintenance immunosuppression, the relapse-free survival in low-dose rituximab (14 months) was similar to medium (10.9 months; adjusted hazard ratio, 1.23) and high dose (12.0 months; adjusted hazard ratio, 0.92; all non-significant). Most adverse events were mild. Thus, children receiving low-dose rituximab without maintenance immunosuppression had the shortest relapse-free survival. Hence, both rituximab dose and maintenance immunosuppression have important effects on the treatment outcomes.
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Affiliation(s)
- Eugene Yu-Hin Chan
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children National Health Service Trust, London, UK; Paediatric Nephrology Centre, Department of Paediatrics, Princess Margaret Hospital, Hong Kong; Paediatric Nephrology Centre, Department of Paediatrics, Hong Kong Children's Hospital, Hong Kong
| | - Hazel Webb
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children National Health Service Trust, London, UK
| | - Ellen Yu
- Clinical Research Centre, Princess Margaret Hospital, Hong Kong
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis and Transplantation and Laboratory on Molecular Nephrology, Istituto G. Gaslini, Genoa, Italy
| | - Markus J Kemper
- Department of Pediatrics, Asklepios Medical School, Hamburg, Germany
| | - Alison Lap-Tak Ma
- Paediatric Nephrology Centre, Department of Paediatrics, Princess Margaret Hospital, Hong Kong; Paediatric Nephrology Centre, Department of Paediatrics, Hong Kong Children's Hospital, Hong Kong
| | - Tomohiko Yamamura
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Aditi Sinha
- Department of Pediatrics, Indian Council of Medical Research Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Department of Pediatrics, Indian Council of Medical Research Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Julien Hogan
- Service de néphrologie pédiatrique, Hôpital Robert-debré, Paris, France
| | - Claire Dossier
- Service de néphrologie pédiatrique, Hôpital Robert-debré, Paris, France
| | - Marina Vivarelli
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Ospedale Pediatrico "Bambino Gesù" Istituto di Ricovero e Cura a Carettere Scientifico, Rome, Italy
| | - Isaac Desheng Liu
- Department of Paediatric Medicine, Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan; Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Priya Saini
- Division of Pediatric Nephrology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children National Health Service Trust, London, UK.
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14
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Hogan J, Dossier C, Kwon T, Macher MA, Maisin A, Couderc A, Niel O, Baudouin V, Deschênes G. Effect of different rituximab regimens on B cell depletion and time to relapse in children with steroid-dependent nephrotic syndrome. Pediatr Nephrol 2019; 34:253-259. [PMID: 30109447 DOI: 10.1007/s00467-018-4052-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 07/30/2018] [Accepted: 08/08/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Several studies have demonstrated that rituximab (RTX) improves relapse-free survival in patients with steroid-dependent nephrotic syndrome (SDNS). However, these studies used various RTX regimens and there are few data comparing these regimens in children with SDNS. In this retrospective study, we assessed the effect of three different initial RTX regimens on both time to B cell reconstitution and to first relapse. METHODS Sixty-one SDNS patients receiving a first course of RTX were included. Group 1 received one injection of 100 mg/m2, group 2 received one injection of 375 mg/m2, and group 3 received two injections of 375 mg/m2 at day 0 and day 7. Time to B cell reconstitution and time to first relapse and respective risk factors were studied. RESULTS Median time to B cell reconstitution was 2.5 [1.8-3.5], 5.0 [3.9-6.0], and 6.6 [4.6-7.8] months in groups 1, 2, and 3, respectively. RTX regimen was associated with time to B cell reconstitution (HRs group 2 vs. 3, 4.07 [1.96-8.48]; group 1 vs. 3, 11.13 [4.04-30.67]). One-year relapse-free survival was 50% [58-77], 59% [42-76], and 72% [46-87] in groups 1, 2, and 3, respectively. RTX regimen was associated with risk of relapse (HRs group 2 vs. 3, 1.55 [0.51-4.65]; group 1 vs. 3, 4.98 [1.15-21.60]). CONCLUSIONS The initial dose of rituximab impacts time to B cell reconstitution and the probability of relapse. Risk of relapse is also associated with patient characteristics, suggesting that RTX regimen could be modified for each patient to balance efficacy, cost, and side effects.
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Affiliation(s)
- Julien Hogan
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, 48 bld Sérurier, 75019, Paris, France.
| | - Claire Dossier
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, 48 bld Sérurier, 75019, Paris, France
| | - Thérésa Kwon
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, 48 bld Sérurier, 75019, Paris, France
| | - Marie-Alice Macher
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, 48 bld Sérurier, 75019, Paris, France
| | - Anne Maisin
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, 48 bld Sérurier, 75019, Paris, France
| | - Anne Couderc
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, 48 bld Sérurier, 75019, Paris, France
| | - Olivier Niel
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, 48 bld Sérurier, 75019, Paris, France
| | - Véronique Baudouin
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, 48 bld Sérurier, 75019, Paris, France
| | - Georges Deschênes
- Pediatric Nephrology Department, Robert-Debré Hospital, APHP, 48 bld Sérurier, 75019, Paris, France
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15
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Takahashi T, Okamoto T, Sato Y, Yamazaki T, Hayashi A, Aoyagi H, Ueno M, Kobayashi N, Uetake K, Nakanishi M, Ariga T. Periodically repeated rituximab administrations in children with refractory nephrotic syndrome: 2-year multicenter observational study. Pediatr Nephrol 2019; 34:87-96. [PMID: 30141179 DOI: 10.1007/s00467-018-4063-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 08/09/2018] [Accepted: 08/16/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Rituximab (RTX) is effective in maintaining remission in patients with nephrotic syndrome (NS), but a standard protocol of RTX administration has not been established. METHODS This study was a 2-year multicenter observational study, in which consistent treatments and evaluations were performed. We enrolled pediatric patients with refractory NS between January 2015 and December 2015. RTX infusion was performed four times at 6-month intervals, followed by mizoribine pulse therapy with early discontinuation of calcineurin inhibitor (CNI). Primary endpoints were the relapse-free survival rate and the number of relapses after RTX administration. Secondary endpoints were changes in side effects associated with long-term steroid administration. RESULTS Twenty-two patients were analyzed. The relapse-free survival rate at 1 year and 2 years was 50 and 46%, respectively. Twenty-one patients accomplished our protocol and the frequency of relapse was reduced under the discontinuation of CNI. Although two patients were diagnosed with frequent relapse and/or steroid dependency during the observation period, the frequency of relapse decreased with each rituximab dose. Statistically significant improvements in all steroid complications were observed in the final examination, but no significant improvements were observed from 1 to 2 years after RTX administration. One patient had agranulocytosis, and three patients showed electrocardiographic abnormalities. CONCLUSIONS Our protocol was useful and safe for refractory NS. However, RTX administration four times might have been excessive in patients who had no relapse by 1 year after the initial RTX administration. Further investigation of the most appropriate method of RTX administration is required.
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Affiliation(s)
- Toshiyuki Takahashi
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, North 15, West 7, Sapporo, Hokkaido, 060-8638, Japan
| | - Takayuki Okamoto
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, North 15, West 7, Sapporo, Hokkaido, 060-8638, Japan.
| | - Yasuyuki Sato
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, North 15, West 7, Sapporo, Hokkaido, 060-8638, Japan
| | - Takeshi Yamazaki
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, North 15, West 7, Sapporo, Hokkaido, 060-8638, Japan
| | - Asako Hayashi
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, North 15, West 7, Sapporo, Hokkaido, 060-8638, Japan
| | - Hayato Aoyagi
- Department of Pediatrics, Obihiro Kyokai Hospital, Obihiro, Japan
| | - Michihiko Ueno
- Department of Pediatrics, Nikko Memorial Hospital, Muroran, Japan
| | - Norio Kobayashi
- Department of Pediatrics, Oji General Hospital, Tomakomai, Japan
| | - Kimiaki Uetake
- Department of Pediatrics, Obihiro Kosei Hospital, Obihiro, Japan
| | | | - Tadashi Ariga
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, North 15, West 7, Sapporo, Hokkaido, 060-8638, Japan
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16
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Kallash M, Smoyer WE, Mahan JD. Rituximab Use in the Management of Childhood Nephrotic Syndrome. Front Pediatr 2019; 7:178. [PMID: 31134169 PMCID: PMC6524616 DOI: 10.3389/fped.2019.00178] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/17/2019] [Indexed: 12/19/2022] Open
Abstract
Childhood nephrotic syndrome is a challenging and often persistent renal disorder, and its incidence varies between different ethnicities and regions. Corticosteroids have been the main treatment for decades and are effective in most children with idiopathic NS, although 10-15% of these children become steroid resistant. Furthermore, some initially steroid sensitive children follow a steroid dependent or frequently relapsing course and are therefore at increased risk for developing steroid toxicity. In such children, alternative immunosuppressive medications are used to induce and/or maintain remission of NS. One such drug, rituximab, is a monoclonal antibody directed against the B lymphocyte CD20 marker which induces depletion of B cells, and has shown promising results in the management of NS in children. In this review, we summarize recent studies on the efficacy and safety of rituximab in the different types of childhood nephrotic syndrome, the known and potential mechanisms of action of rituximab, its possible complications and side effects, and the available and potential biomarkers of rituximab activity.
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Affiliation(s)
- Mahmoud Kallash
- Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| | - William E Smoyer
- Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| | - John D Mahan
- Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
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17
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Basu B, Sander A, Roy B, Preussler S, Barua S, Mahapatra TKS, Schaefer F. Efficacy of Rituximab vs Tacrolimus in Pediatric Corticosteroid-Dependent Nephrotic Syndrome: A Randomized Clinical Trial. JAMA Pediatr 2018; 172:757-764. [PMID: 29913001 PMCID: PMC6142920 DOI: 10.1001/jamapediatrics.2018.1323] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Calcineurin inhibitors are an established first-line corticosteroid-sparing therapy for patients with corticosteroid-dependent nephrotic syndrome (CDNS), whereas B-lymphocyte-depleting therapy is mostly used as a rescue for calcineurin inhibitor-resistant cases. The positive efficacy and safety profile of rituximab raises the question of whether it could be used as a first-line alternative to calcineurin inhibitor therapy. OBJECTIVE To compare the efficacy of rituximab and tacrolimus in maintaining relapse-free survival among children with CDNS. DESIGN, SETTING, AND PARTICIPANTS A parallel-arm, open-label, randomized clinical trial was performed from May 8, 2015, to September 20, 2016, with 1-year follow-up in a single-center, tertiary care unit. A total of 176 consecutive children aged 3 to 16 years with CDNS not previously treated with corticosteroid-sparing agents were screened for eligibility. INTERVENTIONS The children received either tacrolimus (along with tapering alternate-day prednisolone) for 12 months or a single course of rituximab (2 infusions of 375 mg/m2). MAIN OUTCOMES AND MEASURES Twelve-month relapse-free survival in the intention-to-treat population. RESULTS Of the 176 children screened for eligibility, 120 were randomized and all but 3 patients completed 1 year of follow-up. The groups were comparable, with mean (SD) age of 7.2 (2.8) years, 32 boys (53.3%) in each group, mean (SD) disease duration of 2.5 (1.5) years and 2.3 (1.7) in the tacrolimus and rituximab groups, respectively, disease duration less than 1 year among 15 children (25.0%) in each group, median (interquartile range) of 4 (3-5) relapses in each group, and mean (SD) cumulative prednisolone dose of 246 (48) mg/kg and 239 (52) mg/kg in the prestudy year in the tacrolimus and rituximab groups, respectively. Rituximab therapy was associated with a higher 12-month relapse-free survival rate than tacrolimus (54 [90.0%] vs 38 [63.3%] children; P < .001; odds ratio, 5.21; 95% CI, 1.93-14.07). Among the patients who experienced relapse, median time to first relapse was 40 weeks in the rituximab group and 29 weeks in the tacrolimus group. Only 2 patients in the rituximab group had more than 1 relapse during the study period compared with 10 patients in the tacrolimus group. The cumulative corticosteroid dose during the 12-month study period was lower with rituximab compared with tacrolimus (mean [SD], 25.8 [27.8] vs 86.3 [58.0] mg/kg). Although both treatments were well tolerated, mild to moderate infections were twice as common in the tacrolimus group (26 [43.3%] vs 13 [21.7%] events). CONCLUSIONS AND RELEVANCE In children with CDNS, rituximab appears to be more effective than tacrolimus in maintaining disease remission and minimizing corticosteroid exposure and, given its good tolerability and lack of nephrotoxic effects, may be considered as first-line corticosteroid-sparing therapy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02438982; Clinical Trial Registry of India: CTRI/2014/01/004355.
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Affiliation(s)
- Biswanath Basu
- Division of Pediatric Nephrology, Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Anja Sander
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Birendranath Roy
- Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Stella Preussler
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Shilpita Barua
- Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - T. K. S. Mahapatra
- Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
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18
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Noone DG, Iijima K, Parekh R. Idiopathic nephrotic syndrome in children. Lancet 2018; 392:61-74. [PMID: 29910038 DOI: 10.1016/s0140-6736(18)30536-1] [Citation(s) in RCA: 276] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 02/15/2018] [Accepted: 02/23/2018] [Indexed: 12/19/2022]
Abstract
The incidence of idiopathic nephrotic syndrome (NS) is 1·15-16·9 per 100 000 children, varying by ethnicity and region. The cause remains unknown but the pathogenesis of idiopathic NS is thought to involve immune dysregulation, systemic circulating factors, or inherited structural abnormalities of the podocyte. Genetic risk is more commonly described among children with steroid-resistant disease. The mainstay of therapy is prednisone for the vast majority of patients who are steroid responsive; however, the disease can run a frequently relapsing course, necessitating the need for alternative immunosuppressive agents. Infection and venous thromboembolism are the main complications of NS with also increased risk of acute kidney injury. Prognosis in terms of long-term kidney outcome overall is excellent for steroid-responsive disease, and steroid resistance is an important determinant of future risk of chronic or end-stage kidney disease.
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Affiliation(s)
- Damien G Noone
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Rulan Parekh
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada; Dalla Lana School of Public Health, and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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19
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Fujinaga S, Nishino T. Is cytokine-release syndrome the cause of rituximab treatment-related infusion reactions in children with nephrotic syndrome? Impact of anti-rituximab antibodies. Pediatr Nephrol 2018; 33:1097-1098. [PMID: 29675809 DOI: 10.1007/s00467-018-3960-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 04/03/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Shuichiro Fujinaga
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama City, Saitama, 330-8777, Japan.
| | - Tomohiko Nishino
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama City, Saitama, 330-8777, Japan
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20
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Pickens CJ, Johnson SN, Pressnall MM, Leon MA, Berkland CJ. Practical Considerations, Challenges, and Limitations of Bioconjugation via Azide-Alkyne Cycloaddition. Bioconjug Chem 2018; 29:686-701. [PMID: 29287474 PMCID: PMC6310217 DOI: 10.1021/acs.bioconjchem.7b00633] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Interrogating biological systems is often limited by access to biological probes. The emergence of "click chemistry" has revolutionized bioconjugate chemistry by providing facile reaction conditions amenable to both biologic molecules and small molecule probes such as fluorophores, toxins, or therapeutics. One particularly popular version is the copper-catalyzed azide-alkyne cycloaddition (AAC) reaction, which has spawned new alternatives such as the strain-promoted azide-alkyne cycloaddition reaction, among others. This focused review highlights practical approaches to AAC reactions for the synthesis of peptide or protein bioconjugates and contrasts current challenges and limitations in light of recent advances in the field. The conical success of antibody drug conjugates has expanded the toolbox of linkers and payloads to facilitate practical applications of bioconjugation to create novel therapeutics and biologic probes. The AAC reaction in particular is poised to enable a large set of functionalized molecules as a combinatorial approach to high-throughput bioconjugate generation, screening, and honing of lead compounds.
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Affiliation(s)
- Chad J Pickens
- Department of Pharmaceutical Chemistry , University of Kansas , 2095 Constant Avenue , Lawrence , Kansas 66047 , United States
| | - Stephanie N Johnson
- Department of Pharmaceutical Chemistry , University of Kansas , 2095 Constant Avenue , Lawrence , Kansas 66047 , United States
| | - Melissa M Pressnall
- Department of Pharmaceutical Chemistry , University of Kansas , 2095 Constant Avenue , Lawrence , Kansas 66047 , United States
| | - Martin A Leon
- Department of Chemistry , University of Kansas , 1251 Wescoe Hall Drive , Lawrence , Kansas 66047 , United States
| | - Cory J Berkland
- Department of Pharmaceutical Chemistry , University of Kansas , 2095 Constant Avenue , Lawrence , Kansas 66047 , United States
- Department of Chemistry , University of Kansas , 1251 Wescoe Hall Drive , Lawrence , Kansas 66047 , United States
- Department of Chemical and Petroleum Engineering , University of Kansas , , 4132 Learned Hall, 1530 W. 15th , Lawrence , Kansas 66045 , United States
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21
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Fujinaga S, Sakuraya K. Single infusion of low-dose ofatumumab in a child with complicated nephrotic syndrome with anti-rituximab antibodies. Pediatr Nephrol 2018; 33:527-528. [PMID: 29247358 DOI: 10.1007/s00467-017-3866-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 12/01/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Shuichiro Fujinaga
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama City, Saitama, 330-8777, Japan.
| | - Koji Sakuraya
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama City, Saitama, 330-8777, Japan
- Department of Pediatrics, School of Medicine, Juntendo University, Tokyo, Japan
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22
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Maeda R, Kawasaki Y, Ohara S, Suyama K, Hosoya M. Serum sickness with refractory nephrotic syndrome following treatment with rituximab. CEN Case Rep 2018; 7:69-72. [PMID: 29305810 DOI: 10.1007/s13730-017-0297-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 12/21/2017] [Indexed: 11/30/2022] Open
Abstract
Rituximab (RTX) is effective for treating childhood refractory nephrotic syndrome (NS), such as steroid-dependent (SD), frequently relapsing (FR), and steroid-resistant (SR) NS. While RTX has been proven to be effective in treating SDNS, FRNS, and SRNS, it may cause serum sickness, a rare illness characterized by fever, rash, and arthralgia, 10-14 days after primary antigen exposure or within a few days after secondary antigen exposure, by producing human anti-chimeric antibodies (HACAs). A 17-year-old girl with refractory SDNS treated with RTX and oral cyclosporine A was admitted with fever and arthralgia 10 days after the fifth RTX dose was administered. After RTX was started when she was 14-years-old, SDNS remission was then achieved, and prednisolone was discontinued. Although antibiotics and non-steroidal anti-inflammatory agents were administered, fever and arthralgia continued. After various inspections and clinical course, we considered her as RTX-induced serum sickness (RISS). The patient had an elevated HACA level and was diagnosed with RISS. Fever and arthralgia disappeared 5 days after onset. To the best of our knowledge, this is the first reported case of RISS with NS. Fever, rash, and arthralgia after RTX administration can be the initial symptoms.
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Affiliation(s)
- Ryo Maeda
- Department of Pediatrics, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima City, Fukushima, 960-1295, Japan
| | - Yukihiko Kawasaki
- Department of Pediatrics, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima City, Fukushima, 960-1295, Japan.
| | - Shinichiro Ohara
- Department of Pediatrics, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima City, Fukushima, 960-1295, Japan
| | - Kazuhide Suyama
- Department of Pediatrics, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima City, Fukushima, 960-1295, Japan
| | - Mitsuaki Hosoya
- Department of Pediatrics, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima City, Fukushima, 960-1295, Japan
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23
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Rituximab in steroid-sensitive nephrotic syndrome: lessons from clinical trials. Pediatr Nephrol 2018; 33:1449-1455. [PMID: 28717938 PMCID: PMC6061657 DOI: 10.1007/s00467-017-3746-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 06/23/2017] [Accepted: 06/23/2017] [Indexed: 01/31/2023]
Abstract
Idiopathic nephrotic syndrome is the most common chronic glomerular disease in children. A total of 80-90% of patients with childhood idiopathic nephrotic syndrome achieve remission with steroid therapy [steroid-sensitive nephrotic syndrome (SSNS)]. However, approximately 50% of children with SSNS develop frequently relapsing nephrotic syndrome (FRNS) or steroid-dependent nephrotic syndrome (SDNS). Children with FRNS or SDNS are usually treated with immunosuppressive agents, but 10-20% of children receiving immunosuppressive agents still show frequent relapses or steroid dependence during or after treatment, defined as complicated FRNS or SDNS. Rituximab, a chimeric anti-CD20 monoclonal antibody that was originally developed to treat patients with B-cell non-Hodgkin's lymphoma, is currently used for treating SSNS. In this review we highlight recent studies, mainly randomized controlled trials of rituximab for SSNS, including complicated and uncomplicated forms of FRNS or SDNS in children. We also discuss the effects of these studies on the management of patients suffering from these conditions.
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24
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Kim JH, Park E, Hyun HS, Cho MH, Ahn YH, Choi HJ, Kang HG, Ha IS, Cheong HI. Long-term repeated rituximab treatment for childhood steroid-dependent nephrotic syndrome. Kidney Res Clin Pract 2017; 36:257-263. [PMID: 28904877 PMCID: PMC5592893 DOI: 10.23876/j.krcp.2017.36.3.257] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 06/30/2017] [Accepted: 07/18/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Rituximab (RTX) can be used as a rescue therapy for steroid-dependent nephrotic syndrome (SDNS). However, the efficacy and safety of long-term, repeated use of RTX are not established. This study was conducted to assess the efficacy and safety of long-term, repeated RTX treatment in children. METHODS Eighteen consecutive child patients with SDNS who were treated with three or more cycles of RTX for one year or longer were recruited, and their medical records were retrospectively reviewed. RESULTS The patients were followed for 4.7 ± 1.9 years and received 5.2 ± 2.3 cycles of RTX over 2.8 ± 1.1 years. Approximately 70% of the additional RTX cycles were administered due to recovery of B-cells without relapse. The relapse rate decreased from 3.4 ± 2.0 per year initially to 0.4 ± 0.8 per year at the third year after RTX treatment. Approximately 10% of the RTX infusions were accompanied by mild infusion reactions. Eight patients showed sustained remission without any oral medication after the last cycle of RTX, while 10 patients had one or more episodes of relapse after the last cycle of RTX. The relapse rate in the latter group decreased from 2.8 ± 1.5 per year before RTX treatment to 1.3 ± 0.8 per year after cessation of RTX treatment. No significant differences in clinical parameters were found between the two groups. CONCLUSION This retrospective study showed that pre-emptive and long-term, repeated RTX treatment is relatively effective and safe in children with SDNS. However, well-designed prospective studies are needed to confirm these findings.
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Affiliation(s)
- Ji Hyun Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Eujin Park
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Hye Sun Hyun
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Myung Hyun Cho
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Yo Han Ahn
- Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Hyun Jin Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea
| | - Il-Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
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25
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Iijima K, Sako M, Nozu K. Rituximab for nephrotic syndrome in children. Clin Exp Nephrol 2017; 21:193-202. [PMID: 27422620 PMCID: PMC5388729 DOI: 10.1007/s10157-016-1313-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/11/2016] [Indexed: 12/31/2022]
Abstract
Idiopathic nephrotic syndrome is the most common chronic glomerular disease in children. At least 20 % of children with this syndrome show frequent relapses and/or steroid dependence during or after immunosuppressive therapies, a condition defined as complicated frequently relapsing/steroid-dependent nephrotic syndrome (FRNS/SDNS). Approximately 1-3 % of children with idiopathic nephrotic syndrome are resistant to steroids and all immunosuppressive agents, a condition defined as refractory steroid-resistant nephrotic syndrome (SRNS); these SRNS children have a high risk of end-stage renal failure. Rituximab, a chimeric anti-CD20 monoclonal antibody, has been shown to be effective for patients with complicated FRNS/SDNS and refractory SRNS. This review describes the recent results of rituximab treatment applied to pediatric nephrotic syndrome, as well as those of our recent study, a multicenter, double-blind, randomized, placebo-controlled trial of rituximab for childhood-onset complicated FRNS/SDNS (RCRNS01). The overall efficacy and safety of rituximab for this disease are discussed.
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Affiliation(s)
- Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Mayumi Sako
- Division for Clinical Trials, Department of Clinical Research, Center for Clinical Research and Development, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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26
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Papakrivopoulou E, Shendi AM, Salama AD, Khosravi M, Connolly JO, Trompeter R. Effective treatment with rituximab for the maintenance of remission in frequently relapsing minimal change disease. Nephrology (Carlton) 2017; 21:893-900. [PMID: 26860320 PMCID: PMC5026064 DOI: 10.1111/nep.12744] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/20/2016] [Accepted: 02/07/2016] [Indexed: 12/18/2022]
Abstract
AIM Treatment of frequently relapsing or steroid-dependent minimal change disease (MCD) in children and adults remains challenging. Glucocorticoids and/or other immunosuppressive agents are the mainstay of treatment, but patients often experience toxicity from prolonged exposure and may either become treatment dependent and/or resistant. Increasing evidence suggests that rituximab (RTX) can be a useful alternative to standard immunosuppression and allow withdrawal of maintenance immunosuppressants; however, data on optimal treatment regimens, long-term efficacy and safety are still limited. METHODS We undertook a prospective study of RTX to allow immunosuppression minimization in 15 young adults with frequently relapsing or steroid-dependent, biopsy-proven MCD. All patients were in remission at the start of treatment and on a calcineurin inhibitor. Two doses of RTX (1 gr) were given 6 months apart. A subset of patients also received an additional dose 12 months later, in order to examine the benefit of re-treatment. Biochemical and clinical parameters were monitored over an extended follow-up period of up to 43 months. RESULTS Median steroid-free survival after RTX was 25 months (range 4-34). Mean relapse frequency decreased from 2.60 ± 0.28 to 0.4 ± 0.19 (P < 0.001) after RTX. Seven relapses occurred, five of which (71%) when CD19 counts were greater than 100 µ. Immunoglobulin levels remained unchanged, and no major side effects were observed throughout the follow-up period. CONCLUSIONS Rituximab therapy is effective at maintaining prolonged steroid-free remission and reducing relapse frequency in this group of patients. Our study lends further support for the role of RTX in the treatment of patients with frequently relapsing or steroid-dependent MCD.
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Affiliation(s)
- Eugenia Papakrivopoulou
- University College London Centre for Nephrology, Royal Free Campus, University College London, London, UK. .,University College London Institute of Child Health, University College London, London, UK.
| | - Ali M Shendi
- University College London Centre for Nephrology, Royal Free Campus, University College London, London, UK.,Nephrology Unit, Internal Medicine Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Alan D Salama
- University College London Centre for Nephrology, Royal Free Campus, University College London, London, UK
| | - Maryam Khosravi
- University College London Centre for Nephrology, Royal Free Campus, University College London, London, UK
| | - John O Connolly
- University College London Centre for Nephrology, Royal Free Campus, University College London, London, UK
| | - Richard Trompeter
- University College London Centre for Nephrology, Royal Free Campus, University College London, London, UK
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27
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Recent Advances in Treatments of Primary Focal Segmental Glomerulosclerosis in Children. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3053706. [PMID: 27195285 PMCID: PMC4852325 DOI: 10.1155/2016/3053706] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/21/2016] [Accepted: 03/30/2016] [Indexed: 11/18/2022]
Abstract
Focal segmental glomerulosclerosis (FSGS) is a nephrotic syndrome. Up to around 80% of cases of primary FSGS are resistant to steroid treatment. A large proportion of patients with steroid-resistant FSGS progress to end-stage renal disease. The purpose of treatment is to obtain a complete remission of proteinuria, a necessary step that precedes improved renal survival and reduces the risk of progression to chronic kidney disease. When this is not possible, the secondary goal is a partial remission of proteinuria. Reduction or remission of proteinuria is the most important factor predictive of renal survival. We will review the current updated strategies for treatment of primary FSGS in children, including traditional therapies consisting of corticosteroids and calcineurin inhibitors and novel therapies such as rituximab, abatacept, adalimumab, and fresolimumab.
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28
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Kang HG, Cheong HI. Nephrotic syndrome: what's new, what's hot? KOREAN JOURNAL OF PEDIATRICS 2015; 58:275-82. [PMID: 26388891 PMCID: PMC4573440 DOI: 10.3345/kjp.2015.58.8.275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 06/18/2015] [Indexed: 12/17/2022]
Abstract
While the incidence of nephrotic syndrome (NS) is decreasing in Korea, the morbidity of difficult-to-treat NS is significant. Efforts to minimize treatment toxicity showed that prolonged treatment after an initial treatment for 2-3 months with glucocorticosteroids was not effective in reducing frequent relapses. For steroid-dependent NS, rituximab, a monoclonal antibody against the CD20 antigen on B cells, was proven to be as effective, and short-term daily low-dose steroids during upper respiratory infections reduced relapses. Steroid resistance or congenital NS are indications for genetic study and renal biopsy, since the list of genes involved in NS is lengthening.
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Affiliation(s)
- Hee Gyung Kang
- Department of Pediatrics, Research Coordination Center for Rare Diseases, Seoul National University Children's Hospital, Seoul, Korea
| | - Hae Il Cheong
- Department of Pediatrics, Research Coordination Center for Rare Diseases, Seoul National University Children's Hospital, Seoul, Korea
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29
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Sinha A, Bhatia D, Gulati A, Rawat M, Dinda AK, Hari P, Bagga A. Efficacy and safety of rituximab in children with difficult-to-treat nephrotic syndrome. Nephrol Dial Transplant 2014; 30:96-106. [DOI: 10.1093/ndt/gfu267] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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