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Yokota S, Kamei K, Fujinaga S, Hamada R, Inaba A, Nishi K, Sato M, Ogura M, Sakuraya K, Ito S. Efficacy of rituximab and risk factors for poor prognosis in patients with childhood-onset steroid-resistant nephrotic syndrome: a multicenter study. Pediatr Nephrol 2024; 39:2979-2988. [PMID: 38834892 DOI: 10.1007/s00467-024-06422-5] [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: 02/19/2024] [Revised: 05/11/2024] [Accepted: 05/11/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND The efficacy of rituximab in steroid-resistant nephrotic syndrome (SRNS) is controversial. We previously reported that rituximab in combination with methylprednisolone pulse therapy (MPT) and immunosuppressants was associated with favorable outcomes. We determined risk factors for poor response following rituximab treatment, which remains unknown. METHODS This retrospective study included 45 patients with childhood-onset SRNS treated with rituximab across four pediatric kidney facilities. Treatment effects were categorized as complete remission (CR), partial remission (PR), and no remission (NR) at one year after rituximab treatment. The primary outcome was the rate of CR, PR, and NR. Risk factors for non-CR were calculated with multivariate logistic regression. Adverse events and the relationship between disease status at one year and long-term prognosis were also evaluated. RESULTS The rates of CR, PR, and NR at one year were 69%, 24%, and 7%, respectively. The median time from rituximab administration to CR was 90 days. The median follow-up period after rituximab administration was 7.4 years. In multivariate analysis, significant risk factors for poor response were the pathologic finding of focal segmental glomerular sclerosis and a long interval between SRNS diagnosis and rituximab administration. The rates of CR were 90.3% and 21.4% in patients receiving rituximab within and after 6 months following SRNS diagnosis, respectively (p < 0.001). Five patients developed chronic kidney disease stage G5, including 2 of the 11 patients with PR and all 3 patients with NR, whereas none of the 31 patients with CR developed chronic kidney disease stage G5. CONCLUSION Early administration of rituximab in combination with MPT and immunosuppressants might achieve favorable outcomes in patients with SRNS.
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Affiliation(s)
- Shunsuke Yokota
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
- Division of Nephrology, Saitama Children's Medical Center, Saitama, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Shuichiro Fujinaga
- Division of Nephrology, Saitama Children's Medical Center, Saitama, Japan
| | - Riku Hamada
- Division of Nephrology and Rheumatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Aya Inaba
- Department of Pediatrics, Yokohama City University Medical Center, Kanagawa, Japan
| | - Kentaro Nishi
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Koji Sakuraya
- Division of Nephrology, Saitama Children's Medical Center, Saitama, Japan
| | - Shuichi Ito
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Kanagawa, Japan
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Gaur S, Paul PP, Motamarri M. Rituximab/Mycophenolate Combination Therapy in Children with Calcineurin Inhibitor-Resistant FSGS. Indian J Nephrol 2024; 34:45-49. [PMID: 38645919 PMCID: PMC11003586 DOI: 10.4103/ijn.ijn_231_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/26/2022] [Indexed: 04/23/2024] Open
Abstract
Introduction There is a paucity of data and therapeutic options nationally and internationally on calcineurin inhibitor (CNI)-resistant forms of focal segmental glomerulosclerosis (FSGS) in children. CNI (tacrolimus or cyclosporine) are proven monotherapy in children with FSGS with a steroid-dependent (SD) or steroid-resistant (SR) course. We analyzed a novel therapeutic option in CNI-resistant FSGS by using the dual therapy of rituximab and mycophenolate to maintain remission. Methods This is a retrospective analysis of clinical, therapeutic profile, and treatment outcomes (sustained remission versus no remission) in subjects with CNI-resistant FSGS who received dual rituximab therapy along with mycophenolate as maintenance therapy for a minimum of 1 year. Results The median age of presentation of 13 recruited children was 7.8 years (range: 2.4-17.6 years); nine (69.2%) were males. Ten (76.9%) of them had an SD course and three (23.1%) had an SR course. Four (30.7%) had evidence of acute/chronic CNI toxicity, and the remaining nine (69.3%) showed no response to CNI therapy despite adequate trough levels. Post dual therapy, 11 (84.6%) had sustained remission for at 1 year and two (15.4%) children did not show remission. None reported adverse reactions or infections, and all had preserved renal functions. Conclusion Dual combination therapy with rituximab and mycophenolate among children with CNI-resistant FSGS can emerge as a promising and efficacious treatment strategy to ensure sustained remission in this subset of patients.
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Affiliation(s)
- Saumil Gaur
- Consultant Paediatrician and Transplant Nephrologist, Rainbow Children Hospital, Marathahalli, Bangalore, Karnataka, India
| | - Partha P. Paul
- Department of Paediatric Nephrology, Rainbow Children Hospital, Marathahalli, Bangalore, Karnataka, India
| | - Mounika Motamarri
- Department of Paediatric Nephrology, Rainbow Children Hospital, Marathahalli, Bangalore, Karnataka, India
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Pouransiri Z, Assadi F, Mohkam M, Hooman N, Rostami Z, Mazaheri M, Azarfar A, Sharbaf FG. A Systematic Review and Meta-analysis of Rituximab-Associated Infections Among Children and Adolescents With Glomerular Disease: Focus on the Risk of Infections. J Pediatr Pharmacol Ther 2023; 28:308-315. [PMID: 37795285 PMCID: PMC10547046 DOI: 10.5863/1551-6776-28.4.308] [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: 05/16/2022] [Accepted: 09/21/2022] [Indexed: 10/06/2023]
Abstract
OBJECTIVE This systematic review and meta-analysis aimed to explore rituximab (RTX) associated infectious complications in children with glomerular disease. METHODS We performed an electronic search of PubMed, International Scientific Information (ISI), Scopus, and EMBASE between January 2010 and July 2021. Infection rates and total drug-related adverse events were the outcomes. Statistical heterogeneity was evaluated by using the I2 statistic. When there was statistical evidence of heterogeneity (I2 > 50%, p > 0.1), a random-effect model was adopted. Data analysis was performed with Stata17.0 software. RESULTS A total of 7 studies with 668 patients (136 with lupus nephritis [LN] and 532 with nephrotic syndrome were included in the meta-analysis. The pooled risk ratio showed that the administration of RTX was significantly associated with lower risk of infectious complications in patients with LN and nephrotic syndrome (0.72 [95% CI 0.58, 0.85]) when compared with population data of patients without glomerular disease (p = 0.2). There was no significant difference between the LN and nephrotic syndrome groups in terms of total serious adverse events or the occurrence of infections. There was significant heterogeneity among the reported studies (Q = 42.39, p < 0.001, I2 = 81%). CONCLUSION Administration of RTX in children with glomerular disease is associated with a lower rate of infections when compared with population data of patients without LN or nephrotic syndrome. Additional high-quality randomized controlled trials with long-term follow-up are needed to identify the long-term potential complications. Trial registration PROPERO ID: CRD42021274869 (https://www.crd.york.ac/prospero/display_record.php?).
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Affiliation(s)
- Zhara Pouransiri
- Pediatric Nephrology Research Center (ZP, MaM), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farahnak Assadi
- Department of Pediatrics, Division of Nephrology (FA), Rush University of Medical Center, Chicago, IL, USA
| | - Masoumeh Mohkam
- Pediatric Nephrology Research Center (MM), Shahid Beheshi University of Medical Sciences, Tehran, Iran
| | - Nakysa Hooman
- Aliasghar Clinical Research Development Center NH), Aliasghar Children’s Hospital, Department of Pediatrics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Rostami
- Education Development Center (ZR), Zanjan University of Medical Sciences, Zanjan, Iran
| | - Mojgan Mazaheri
- Department of Pediatrics, Section of Nephrology (MoM), Semnan University of Medical Sciences, Semnan, Iran
| | - Anoush Azarfar
- Kidney Transplantation Complications Research Center (AA), Mashhad University of Medical Sciences, Mashhad, Iran, and
| | - Fatemeh Ghane Sharbaf
- Kidney Transplantation Complications Research Center (AA, FGS), Mashhad University of Medical Sciences, Mashhad, Iran
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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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Ambarsari CG, Saraswati M, Laudza GS. Rituximab, Mycophenolic Acid, and Calcineurin Inhibitors Achieve Long-Term Remission in Pediatric Focal Segmental Glomerulosclerosis with Steroid-Resistant and Frequently Relapsing Nephrotic Syndrome: A Report of Two Cases. Case Rep Nephrol Dial 2022; 12:167-177. [PMID: 36518356 PMCID: PMC9743143 DOI: 10.1159/000525776] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/19/2022] [Indexed: 11/05/2022] Open
Abstract
Studies investigating the effect of rituximab in children with nephrotic syndrome (NS) due to focal segmental glomerulosclerosis (FSGS) have reported conflicting results, with some concluding that patients may require additional immunosuppressive therapy to achieve and/or maintain long-term remission. We report successful treatment of pediatric FSGS with rituximab infusions, followed by maintenance immunosuppression with mycophenolic acid (MPA) and a calcineurin inhibitor (CNI) in 1 patient with refractory steroid-resistant NS (SRNS), and one with frequently relapsing NS (FRNS). Case 1 is a patient with refractory SRNS due to FSGS. MPA and tacrolimus induced complete remission within 6 months following rituximab treatment. Remission was maintained for over 2 years, and the patient's kidney function and body height also returned to normal ranges within this time. Case 2 is a patient with FRNS due to FSGS, who was treated with rituximab followed by MPA and cyclosporine, which successfully prevented relapses for 18 months, that is, at the end point of the observation. Our case report demonstrates that rituximab and a combination of CNIs and MPA can be effective in achieving complete remission in pediatric refractory SRNS and sustaining remission in pediatric FSGS with FRNS and SRNS for several years. This treatment regimen has the advantage of eliminating the need for long-term high-dose steroid treatments, allowing 1 patient to achieve normal growth and recover from other adverse steroid effects.
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Affiliation(s)
- Cahyani Gita Ambarsari
- aDepartment of Child Health, Faculty of Medicine Universitas Indonesia − Cipto Mangunkusumo Hospital, Jakarta, Indonesia,bSchool of Medicine, University of Nottingham, Nottingham, UK,cPediatric Centre, Pondok Indah Bintaro Jaya Hospital, South Tangerang, Indonesia,*Cahyani Gita Ambarsari,
| | - Meilania Saraswati
- dDepartment of Pathology Anatomy, Faculty of Medicine Universitas Indonesia − Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Genta Syaifrin Laudza
- aDepartment of Child Health, Faculty of Medicine Universitas Indonesia − Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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Assadi F, Mazaheri M, Sadeghi‐Bodj S. Randomized controlled trial to compare safety and efficacy of mycophenolate vs. cyclosporine after rituximab in children with steroid‐resistant nephrotic syndrome. Pharmacotherapy 2022; 42:690-696. [DOI: 10.1002/phar.2721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Farahnak Assadi
- Division of Nephrology, Department of Pediatrics Rush University Medical Center Chicago Illinois USA
| | - Mojgan Mazaheri
- Section of Nephrology, Department of Pediatrics Semnan University of Medical Science Semnan Iran
| | - Simin Sadeghi‐Bodj
- Division of Nephrology, Department of Pediatrics Zahedan University of Medical Sciences Zahedan Iran
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