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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 2024:10.1007/s00467-024-06422-5. [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] [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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Liu J, Deng F, Wang X, Liu C, Sun S, Zhang R, Zhang A, Jiang X, Yan W, Dou Y, Zhang Y, Xie L, Qian B, Shen Q, Xu H. Early Rituximab as an Add-On Therapy in Children With the Initial Episode of Nephrotic Syndrome. Kidney Int Rep 2024; 9:1220-1227. [PMID: 38707815 PMCID: PMC11069012 DOI: 10.1016/j.ekir.2024.02.1395] [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: 09/09/2023] [Revised: 02/04/2024] [Accepted: 02/12/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction The approximately 70% 12-month relapse in children experiencing the initial episode of steroid-sensitive nephrotic syndrome (SSNS) is a significant concern, with over 50% developing frequent relapses or steroid-dependent nephrotic syndrome (FRNS/SDNS). There is a lack of strategies to reduce relapse after the onset. Whether early administration of rituximab, which effectively reduces relapses in FRNS/SDNS, may be a solution has not been evaluated. Methods A prospective, multicenter, open-label, single-arm trial was conducted in China, with a 12-month follow-up. Children aged 1 to 18 years with the first episode of nephrotic syndrome (NS) were screened for eligibility. Proteinuria was evaluated daily using dipsticks. A dose of 375 mg/m2 of rituximab was intravenously infused within 1 week after achieving corticosteroid-induced remission. The main outcome was 12-month relapse-free survival. Results Out of the initially 66 children screened, 44 were enrolled and received rituximab, with all but 1 participant completing the 12-month follow-up. The median age at diagnosis was 4.3 years (interquartile range [IQR]: 3.4-5.9), and 33 (77%) of the participants were male. In the rituximab group, the 12-month relapse-free survival was significantly higher compared to historical controls (32 of 43 [74.4%] vs. 10 of 33 [30.3%]; P < 0.001; hazard ratio [HR], 3.76; 95% confidence interval [CI], 1.80-7.81). The post hoc analysis revealed a higher 24-month relapse-free survival and a lower incidence of FRNS/SDNS at the 12-month follow-up. Treatment with rituximab was well-tolerated. Conclusion Our findings support that early administration of rituximab may be associated with a higher 12-month relapse-free survival and a reduced incidence of FRNS/SDNS in children experiencing the initial episode of SSNS.
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Affiliation(s)
- Jialu Liu
- Department of Nephrology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Fang Deng
- Department of Nephrology, Children’s Hospital of Anhui Medical University, Anhui, China
| | - Xiaowen Wang
- Department of Nephrology and Rheumatology, Wuhan Children's Hospital, Wuhan, China
| | - Cuihua Liu
- Department of Nephrology and Rheumatology, Children's Hospital affiliated to Zhengzhou University, Zhengzhou, China
| | - Shuzhen Sun
- Department of Nephrology and Rheumatology, Shandong Provincial Hospital, Shandong, China
| | - Ruifeng Zhang
- Department of Nephrology and Rheumatology, Xuzhou Children’s Hospital, Xuzhou, China
| | - Aihua Zhang
- Department of Nephrology, Children's Hospital of Nanjing Medical University Nanjing, China
| | - Xiaoyun Jiang
- Department of Pediatric, The First Affiliated Hospital of Zhongshan University, Guangzhou, China
| | - Weili Yan
- Department of Clinical Epidemiology, Children’s Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yalan Dou
- Department of Clinical Epidemiology, Children’s Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yi Zhang
- Department of Clinical Epidemiology, Children’s Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Clinical Research Promotion and Development Center, Shanghai Hospital Development Center, Shanghai, China
| | - Biyun Qian
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Clinical Research Promotion and Development Center, Shanghai Hospital Development Center, Shanghai, China
| | - Qian Shen
- Department of Nephrology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Hong Xu
- Department of Nephrology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
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Kim JH, Song YK. Utilizing temporal pattern of adverse event reports to identify potential late-onset adverse events. Expert Opin Drug Saf 2024:1-8. [PMID: 38251864 DOI: 10.1080/14740338.2024.2309223] [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: 09/14/2023] [Accepted: 01/03/2024] [Indexed: 01/23/2024]
Abstract
OBJECTIVES Through the use of FDA adverse event reporting system (FAERS) dataset, this study analyzes the pattern of time-to-event (TTE) for drugs and adverse events, and suggest ways to identify candidate late-onset events for monitoring. METHODS The duration between administration date of the drug and the onset of adverse events was explored with using FAERS data from 2012-2021. The fold change of proportional reporting ratios or reporting odds ratios were calculated to identify enriched events in the later period and to suggest the late-onset events for further monitoring. To compare the findings, we used the claims database of the Korean National Health Insurance Service (NHIS). RESULTS A total of 1,426,781 reports were included. The median TTE was 10 days (interquartile range [IQR]: 0-98 days), with 11.5% (n = 164,093) reporting events that occurred at least one year after administration. TTE and fold change analysis captured historical cases of late-onset events, while generating an additional less-explored list of events. The results for tumor necrosis factor (TNF) inhibitors were compared using the NHIS dataset. CONCLUSION Our study provides a comprehensive analysis of the FAERS dataset, focusing on TTE data. Periodic summarization of reports would be helpful in monitoring the late-onset events.
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Affiliation(s)
- Jae Hyun Kim
- School of Pharmacy and Institute of New Drug Development, Jeonbuk National University, Jeonju Republic of Korea
| | - Yun-Kyoung Song
- College of Pharmacy, Daegu Catholic University, Gyeongbuk Republic of Korea
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Ohyama R, Fujinaga S, Sakuraya K, Hirano D, Ito S. Predictive factors of long-term disease remission after rituximab administration in patients with childhood-onset complicated steroid-dependent nephrotic syndrome: a single-center retrospective study. Clin Exp Nephrol 2023; 27:865-872. [PMID: 37477752 DOI: 10.1007/s10157-023-02374-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/19/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Despite the fact that rituximab (RTX)-associated adverse events may be relatively frequent in younger patients, recent studies have reported RTX as a suitable first-line steroid-sparing agent for maintaining remission in children with steroid-dependent nephrotic syndrome (SDNS). However, the impact of age at RTX initiation on the long-term outcome remains unknown in this cohort. METHODS We retrospectively reviewed the clinical course of 61 patients with complicated SDNS who received a single dose of RTX (375 mg/m2) followed by maintenance immunosuppressive agents (IS) from January 2008 to March 2021. In patients who achieved > 12 months of prednisolone-free remission, IS tapering within 6 months was tried to achieve. The primary endpoint was the probability of achieving long-term treatment-free remission at the last follow-up. RESULTS After RTX initiation, 52 patients (85.2%) relapsed after a median of 665 days, and 44 patients (72.1%) received additional RTX doses (total, 226 infusions). At the last follow-up (median observation period, 8.3 years; median age, 18.3 years), 16 patients (26.2%) achieved long-term remission. Multivariate analysis showed that older age at RTX initiation was the independent predictive factor for achieving long-term remission (odds ratio, 1.25; p < 0.05). The proportion of those who achieved long-term remission was significantly higher in patients aged ≥ 13.5 years than in those aged < 13.5 years at RTX initiation (52.6 vs 14.3%, p < 0.05). Persistent severe hypogammaglobulinemia did not develop in older children (≥ 13.5 years) at RTX initiation. CONCLUSION For older children with complicated SDNS, RTX appeared to be a suitable disease-modifying therapy without persistent adverse events.
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Affiliation(s)
- Rie Ohyama
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-Ku, Saitama, 330-8777, Japan
- Department of Pediatrics, Yokohama City University Hospital, 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Shuichiro Fujinaga
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-Ku, Saitama, 330-8777, Japan.
| | - Koji Sakuraya
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-Ku, Saitama, 330-8777, Japan
| | - Daishi Hirano
- Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University, Graduate School of Medicine, Yokohama, Kanagawa, Japan
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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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6
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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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Takao H, Nishi K, Funaki T, Inoki Y, Osaka K, Nada T, Yokota S, Sato M, Ogura M, Ishikura K, Ishiguro A, Kamei K. Changes in Patterns of Infection Associated with Pediatric Idiopathic Nephrotic Syndrome: A Single-Center Experience in Japan. J Pediatr 2023; 254:11-16.e1. [PMID: 36223870 DOI: 10.1016/j.jpeds.2022.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/30/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE We studied infection rates and risk factors for infection in current patients with idiopathic nephrotic syndrome (INS). STUDY DESIGN This retrospective cohort study included the clinical data for children with diagnosed INS in our center between January 2010 and December 2020. The infection rates and risk factors were analyzed. RESULTS We enrolled 187 patients, including 85 cases with steroid-dependent/frequently relapsing nephrotic syndrome and 45 with steroid-resistant nephrotic syndrome. Infection was observed a total of 84 times in 55 patients (95.5 per 1000 person-years). Pneumonia was the most common infection (21 cases, 23.9 per 1000 person-years), followed by febrile neutropenia (12 cases, 13.7 per 1000 person-years), whereas peritonitis and bacteremia were observed in only 3 and 2 cases, respectively. The multivariate analyses by logistic regression showed that rituximab treatment was significantly associated with infections in pediatric INS (P = .001). The infection rate during the B-cell-depleted state with immunosuppressants (318 per 1000 person-years) was greater than that with normal B-cell count with immunosuppressants (109 per 1000 person-years) or without immunosuppressants (76 per 1000 person-years). CONCLUSION Common infections, such as peritonitis and bacteremia, decreased, whereas infections associated with medication (eg, rituximab) increased. The rate of infection increases during B-cell depletion after treatments with rituximab and other immunosuppressants.
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Affiliation(s)
- Hiroyuki Takao
- Center for Postgraduate Education and Training, National Center for Child Health and Development, Tokyo, Japan
| | - Kentaro Nishi
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan.
| | - Takanori Funaki
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Yuta Inoki
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kei Osaka
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Taishi Nada
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan; Department of Pediatrics, Yokohama City University Medical Center, Kanagawa, Japan
| | - Shunsuke Yokota
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kenji Ishikura
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Akira Ishiguro
- Center for Postgraduate Education and Training, National Center for Child Health and Development, Tokyo, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
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Safdar OY, Basunbul LI, Alhazmi LS, Almughamisi SA, Habib LA, Basaeed AJ, Kalaktawi NM, Alharithi ET, Aljaaly HA, Alzahrani WA. Necrotizing Fasciitis: A Side Effect of Rituximab Administration in Steroid-Dependent Nephrotic Syndrome. Int Med Case Rep J 2022; 15:587-592. [PMID: 36281444 PMCID: PMC9587699 DOI: 10.2147/imcrj.s347389] [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: 12/09/2021] [Accepted: 09/17/2022] [Indexed: 11/08/2022] Open
Abstract
Steroid-dependent nephrotic syndrome (SDNS) is a common type of childhood nephrotic syndrome. Remission following steroid therapy is achieved in 80-90% of the patients, while the remainder show steroid-resistant nephrotic syndrome (SRNS). Rituximab is an anti-CD20 chimeric monoclonal antibody with proven therapeutic effects in several diseases and has been used with great success in the treatment of NS since its discovery. We report a case of a 4-year-old girl diagnosed with SDNS at the age of 3. As treatment with steroids, enalapril, and mycophenolate failed to produce complete remission, rituximab was initiated, and remission was successfully achieved after administration of the first dose. Due to this response, rituximab therapy was continued; however, a day after being admitted to the nephrology ward for the second dose, she started to develop a high fever, which reached up to 40°C. In addition, she also displayed symptoms of upper respiratory tract infection and an ulcerated wound on her left cheek. The patient became drowsy with reactive pupils, cold peripheries, and weak peripheral pulses. The capillary refill time was prolonged to 3-4 seconds and it was decided to withhold the second dose of rituximab. The patient was shifted to the PICU as a case of septic shock secondary to facial cellulitis and started on inotropes (epinephrine and norepinephrine), meropenem, vancomycin, and hydrocortisone 15 mg. Thereafter, surgical debridement of the wound was carried out. The patient remained in remission with regard to nephrotic syndrome and was discharged in a healthy condition. In conclusion, rituximab used in conjunction with steroids and other immunosuppressants may increase the risk of serious infections like necrotizing fasciitis (NF). Further studies are needed to explore the relationship between rituximab and NF.
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Affiliation(s)
- Osama Yousif Safdar
- Pediatric Nephrology Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Lama Islem Basunbul
- Pediatric Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | | | | | - Laura Ahmed Habib
- Pediatric Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | | | - Nada M Kalaktawi
- Pediatric Nephrology Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | | | - Hataan A Aljaaly
- Plastic Surgery Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Walaa A Alzahrani
- Pediatric Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia,Correspondence: Walaa A Alzahrani, Pediatric Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia, Tel +966 546239898, Email
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9
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Chan EYH, Ma ALT, Tullus K. Hypogammaglobulinaemia following rituximab therapy in childhood nephrotic syndrome. Pediatr Nephrol 2022; 37:927-931. [PMID: 34999985 DOI: 10.1007/s00467-021-05345-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong.
| | - Alison Lap-Tak Ma
- 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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10
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Chan E, Yu E, Angeletti A, Arslan Z, Basu B, Boyer O, Chan CY, Colucci M, Dorval G, Dossier C, Drovandi S, Ghiggeri GM, Gipson D, Hamada R, Hogan J, Ishikura K, Kamei K, Kemper M, Ma ALT, Parekh R, Radhakrishnan S, Saini P, Shen Q, Sinha R, Subun C, Teo S, Vivarelli M, Webb H, Xu H, Yap HK, Tullus K. Long-term Efficacy and Safety of Repeated Rituximab to Maintain Remission in Idiopathic Childhood Nephrotic Syndrome: An International Study. J Am Soc Nephrol 2022; 33:1193-1207. [PMID: 35354600 PMCID: PMC9161790 DOI: 10.1681/asn.2021111472] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/14/2022] [Indexed: 11/03/2022] Open
Abstract
Background: Long-term outcomes following multiple rituximab courses among children with frequently-relapsing, steroid-dependent nephrotic syndrome (FRSDNS) are unknown. Methods: A retrospective cohort study at 16 pediatric nephrology centers from 10 countries in Asia, Europe, and North America included children with FRSDNS who received ≥2 rituximab courses. Primary outcomes were relapse-free survival and adverse events. Results: 346 children (age 9.8 years, IQR 6.6-13.5; 73% boys) received 1149 rituximab courses. 145, 83, 50, 28, 22, and 18 children received 2, 3, 4, 5, 6 and ≥7 courses, respectively. Median follow-up was 5.9 years (IQR, 4.3-7.7). Relapse-free survival differed by treatment courses (clustered log-rank test p<0.001). Compared to the first course (10.0 months, 95% CI, 9.0-10.7), relapse-free period and relapse risk progressively improved following subsequent courses (12.0-16.0 months; HRadj, 0.03-0.13; 95% CI, 0.01-0.18; ps<0.001). B-cell depletion duration remained similar with repeated treatments (6.1 months, 95% CI, 6.0-6.3). Adverse events were mostly mild, most commonly hypogammaglobulinemia (50.9%), infection (4.5%), and neutropenia (3.7%). Side effects did not increase with more treatment courses nor higher cumulative dose. Only 78 of the 353 episodes of hypogammaglobulinemia were clinically significant. Younger age at presentation (2.8 vs 3.3 years; p=0.05) and at first rituximab (8.0 y vs 10.0 years; p=0.01) and history of steroid resistance (28% vs 18%; p=0.01) were associated with significant hypogammaglobulinemia. All 53 infective episodes resolved, except one patient with hepatitis B infection and another with EBV infection. There were 42 episodes of neutropenia, associated with history of steroid resistance (30% vs 20%, p=0.04). Upon last follow-up, 332 children (96%) had normal kidney function. Conclusion: Children receiving repeated rituximab for FRSDNS experience an improving clinical response. Side effects appear acceptable but significant complications can occur. These findings support repeated rituximab use in FRSDNS.
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Affiliation(s)
- Eugene Chan
- E Chan, Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
| | - Ellen Yu
- E Yu, Clinical Research Center, Princess Margaret Hospital, Toronto, Canada
| | - Andrea Angeletti
- A Angeletti, Division of Nephrology, Dialysis, and Transplantation, Instituto di ricovero e cura a carattere scientifico (IRRCS), Giannina Gaslini Children's Hospital, Genova, Italy
| | - Zainab Arslan
- Z Arslan, Department of Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Biswanath Basu
- B Basu, Division of Pediatric Nephrology, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Olivia Boyer
- O Boyer, Néphrologie pédiatrique, centre de référence du syndrome néphrotique de l'enfant et de l'adulte, Hôpital universitaire Necker-Enfants malades, Paris, France
| | - Chang-Yien Chan
- C Chan, Department of Paediatrics, NUS Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Manuela Colucci
- M Colucci, Renal Diseases Research Unit, Genetics and Rare Diseases Research Division, Bambino Gesù Children's Hospital, Rome, Italy
| | - Guillaume Dorval
- G Dorval, Néphrologie pédiatrique, centre de référence du syndrome néphrotique de l'enfant et de l'adulte, Hôpital universitaire Necker-Enfants malades, Paris, France
| | - Claire Dossier
- C Dossier, Department of Pediatric Nephrology, Centre de Référence Syndrome Néphrotique de l'Enfant et de l'Adulte (CMR SNI), Hopital Universitaire Robert-Debre, Paris, France
| | - Stefania Drovandi
- S Drovandi, Division of Nephrology, Dialysis, and Transplantation, Instituto di ricovero e cura a carattere scientifico (IRRCS), Giannina Gaslini Children's Hospital, Genova, Italy
| | - Gian Marco Ghiggeri
- G Ghiggeri, Division of Nephrology, Dialysis, and Transplantation, Instituto di ricovero e cura a carattere scientifico (IRRCS), Giannina Gaslini Children's Hospital, Genova, Italy
| | - Debbie Gipson
- D Gipson, Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, United States
| | - Riku Hamada
- R Hamada, Department of Nephrology and Rheumatology, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Julien Hogan
- J Hogan, Department of Pediatric Nephrology, Centre de Référence Syndrome Néphrotique de l'Enfant et de l'Adulte (CMR SNI), Hospital Robert Debré, Amboise, France
| | - Kenji Ishikura
- K Ishikura, Department of Pediatrics, Kitasato University School of Medicine, Japan, Japan
| | - Koichi Kamei
- K Kamei, Division of Nephrology and Rheumatology, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Markus Kemper
- M Kemper, Department of Pediatrics, Asklepios Medical School GmbH, Hamburg, Germany
| | - Alison Lap-Tak Ma
- A Ma, Paediatric Nephrology Centre, Princess Margaret Hospital, Hong Kong, Hong Kong
| | - Rulan Parekh
- R Parekh, Division of Pediatric Nephrology, Hospital for Sick Children, Toronto, Canada
| | - Seetha Radhakrishnan
- S Radhakrishnan, Division of Pediatric Nephrology, Hospital For Sick Children, London, United Kingdom of Great Britain and Northern Ireland
| | - Priya Saini
- P Saini, Division of Pediatric Nephrology, Hospital for Sick Children, Toronto, Canada
| | - Qian Shen
- Q Shen, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Rajiv Sinha
- R Sinha, Pediatric Nephrology Unit, Institute of Child Health, Kolkata, India
| | - Chantida Subun
- C Subun, Department of Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Sharon Teo
- S Teo, Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore, Singapore
| | - Marina Vivarelli
- M Vivarelli, Division of Nephrology, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Roma, Italy
| | - Hazel Webb
- H Webb, Department of Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Hong Xu
- H Xu, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Hui Kim Yap
- H Yap, Department of Paediatrics, NUS Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Kjell Tullus
- K Tullus, Department of Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
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11
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Chan CY, Teo S, Lu L, Chan YH, Lau PYW, Than M, Jordan SC, Lam KP, Ng KH, Yap HK. Low regulatory T-cells: A distinct immunological subgroup in minimal change nephrotic syndrome with early relapse following rituximab therapy. Transl Res 2021; 235:48-61. [PMID: 33812063 DOI: 10.1016/j.trsl.2021.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/22/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
Rituximab is an important second line therapy in difficult nephrotic syndrome (NS), especially given toxicity of long-term glucocorticoid or calcineurin inhibitor (CNI) use. However, clinical response to rituximab is heterogenous. We hypothesized that this was underpinned by immunological differences amongst patients with NS. We recruited a cohort of 18 subjects with glucocorticoid-dependent or glucocorticoid-resistant childhood-onset minimal change NS who received rituximab either due to CNI nephrotoxicity, or due to persistent glucocorticoid toxicity with inadequate response to cyclophosphamide or CNIs. Immunological subsets, T-cell activation assays and plasma cytokines were measured at baseline and 6-months post-rituximab. Time to relapse was bifurcated: 56% relapsed within one year ("early relapse"), while the other 44% entered remission mainly lasting ≥3 years ("sustained remission"). At baseline, early relapse compared to sustained remission group had lower regulatory T-cells (Tregs) [2.94 (2.25, 3.33)% vs 6.48 (5.08, 7.24)%, P<0.001], PMA-stimulated IL-2 [0.03 (0, 1.85)% vs 4.78 (0.90, 9.18)%, P=0.014] and IFNγ [2.22 (0.18, 6.89)% vs 9.47 (2.72, 17.0)%, P=0.035] levels. Lower baseline Treg strongly predicted early relapse (ROC-AUC 0.99, 95% CI 0.97-1.00, P<0.001). There were no differences in baseline plasma cytokine levels. Following rituximab, there was significant downregulation of Th2 cytokines in sustained remission group (P=0.038). In particular, IL-13 showed a significant decrease in sustained remission group [-0.56 (-0.64, -0.35)pg/ml, P=0.007)], but not in the early relapse group. In conclusion, early relapse following rituximab is associated with baseline reductions in Treg and T-cell hyporesponsiveness, which suggest chronic T-cell activation and may be useful predictive biomarkers. Sustained remission, on the other hand, is associated with downregulation of Th2 cytokines following rituximab.
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Affiliation(s)
- Chang-Yien Chan
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Sharon Teo
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Liangjian Lu
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Yiong-Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Perry Yew-Weng Lau
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Mya Than
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | | | - Kong-Peng Lam
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Bioprocessing Technology Institute, Agency for Science, Technology and Research (A*STAR), Singapore; Singapore Immunology Network (SIgN), Agency for Science, Technology and Research (A*STAR), Singapore; Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kar-Hui Ng
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Hui-Kim Yap
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore.
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12
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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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13
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Okutsu M, Kamei K, Sato M, Kanamori T, Nishi K, Ishiwa S, Ogura M, Sako M, Ito S, Ishikura K. Prophylactic rituximab administration in children with complicated nephrotic syndrome. Pediatr Nephrol 2021; 36:611-619. [PMID: 32995922 DOI: 10.1007/s00467-020-04771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/10/2020] [Accepted: 09/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Rituximab is effective for maintaining remission in patients with complicated nephrotic syndrome, although a history of steroid-resistant nephrotic syndrome (SRNS) is a risk factor for early relapse. We investigated the efficacy of prophylactic rituximab treatment for maintaining remission after B cell recovery. METHODS Patients with complicated steroid-dependent or frequently relapsing nephrotic syndrome with history of SRNS who received a single dose of rituximab (375 mg/m2) and continued immunosuppressive agents were enrolled in this retrospective study. Patients were divided into two groups: a prophylaxis group, which received additional rituximab treatment at B cell recovery and a non-prophylaxis group. The relapse-free period from the last rituximab infusion (the second treatment in prophylaxis group and the first treatment in non-prophylaxis group) was compared between two groups using the Kaplan-Meier method, and risk factors for early relapse were calculated using multivariate analysis by Cox proportional hazards model. RESULTS Sixteen patients in the prophylaxis group and 45 in the non-prophylaxis group were enrolled. Fifty-percent relapse-free survival after the last rituximab treatment was 667 days in the former and 335 days in the latter (p = 0.001). Multivariate analysis showed that additional rituximab treatment was the only significant negative factor for early relapse, with a hazard ratio of 0.40 (p = 0.02). Fifty-percent relapse-free survival after B cell recovery was much longer in the prophylaxis group (954 vs. 205.5 days, p = 0.003). CONCLUSIONS Additional rituximab treatment at B cell recovery can maintain prolonged remission even after B cell recovery in patients with complicated nephrotic syndrome with history of SRNS.
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Affiliation(s)
- Mika Okutsu
- 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, Tokyo Medical and Dental University, Tokyo, 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.
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Toru Kanamori
- 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, Tokyo Medical and Dental University, Tokyo, 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
| | - Sho Ishiwa
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan.,Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, 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
| | - Mayumi Sako
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, 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, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
| | - Kenji Ishikura
- 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, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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14
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Laroche C, Lemieux D, Sylvestre P, Lapeyraque AL, Flahault A. Younger children treated with rituximab for nephrotic syndrome are at higher risk of adverse events. Nephrol Dial Transplant 2021; 36:gfab013. [PMID: 33538834 DOI: 10.1093/ndt/gfab013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Camille Laroche
- University of Montreal, Montreal, Quebec, Canada
- Division of Nephrology, Department of Pediatrics, Sainte-Justine University Hospital, Montreal, Quebec, Canada
| | - Dominique Lemieux
- University of Montreal, Montreal, Quebec, Canada
- Department of Pharmacy, Sainte-Justine University Hospital, Montreal, Quebec, Canada
| | | | - Anne-Laure Lapeyraque
- University of Montreal, Montreal, Quebec, Canada
- Division of Nephrology, Department of Pediatrics, Sainte-Justine University Hospital, Montreal, Quebec, Canada
- Sainte-Justine University Hospital Research Center, Montreal, Quebec, Canada
| | - Adrien Flahault
- University of Montreal, Montreal, Quebec, Canada
- Sainte-Justine University Hospital Research Center, Montreal, Quebec, Canada
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15
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Lee JM, Kronbichler A, Shin JI, Oh J. Current understandings in treating children with steroid-resistant nephrotic syndrome. Pediatr Nephrol 2021; 36:747-761. [PMID: 32086590 PMCID: PMC7910243 DOI: 10.1007/s00467-020-04476-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 12/22/2019] [Accepted: 01/07/2020] [Indexed: 12/27/2022]
Abstract
Steroid-resistant nephrotic syndrome (SRNS) remains a challenge for paediatric nephrologists. SRNS is viewed as a heterogeneous disease entity including immune-based and monogenic aetiologies. Because SRNS is rare, treatment strategies are individualized and vary among centres of expertise. Calcineurin inhibitors (CNI) have been effectively used to induce remission in patients with immune-based SRNS; however, there is still no consensus on treating children who become either CNI-dependent or CNI-resistant. Rituximab is a steroid-sparing agent for patients with steroid-sensitive nephrotic syndrome, but its efficacy in SRNS is controversial. Recently, several novel monoclonal antibodies are emerging as treatment option, but their efficacy remains to be seen. Non-immune therapies, such as angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, have been proven efficacious in children with SRNS and are recommended as adjuvant agents. This review summarizes and discusses our current understandings in treating children with idiopathic SRNS.
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Affiliation(s)
- Jiwon M. Lee
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, South Korea
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, C.P.O. Box 8044, Seoul, 120-752 South Korea ,Division of Pediatric Nephrology, Severance Children’s Hospital, Seoul, South Korea ,Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Oh
- Department of Pediatrics Nephrology, University Hamburg-Eppendorf, Martinistrasse, 52 20246, Hamburg, Germany.
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16
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Zonozi R, Wallace ZS, Laliberte K, Huizenga NR, Rosenthal JM, Rhee EP, Cortazar FB, Niles JL. Incidence, Clinical Features, and Outcomes of Late-Onset Neutropenia From Rituximab for Autoimmune Disease. Arthritis Rheumatol 2020; 73:347-354. [PMID: 32892495 DOI: 10.1002/art.41501] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 08/20/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Late-onset neutropenia (LON) is an underrecognized complication of rituximab treatment. We undertook this study to describe its incidence, risk factors, clinical features, management, and recurrence. METHODS We conducted a single-center retrospective cohort study of 738 adult patients with autoimmune disease who were treated with rituximab to induce continuous B cell depletion. The primary outcome measure was LON, defined as an unexplained absolute neutrophil count of <1,000 cells/µl during B cell depletion. Secondary outcome measures included incidental diagnosis, fever, sepsis, filgrastim use, and recurrent LON. We assessed predictors of LON using Cox proportional hazards regression models. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated. RESULTS We identified 107 episodes of LON in 71 patients. The cumulative incidence at 1 year of B cell depletion therapy was 6.6% (95% CI 5.0-8.7). The incidence rate during the first year was higher compared to thereafter (7.2 cases per 100 person-years [95% CI 5.4-9.6] versus 1.5 cases per 100 person-years [95% CI 1.0-2.3]). Systemic lupus erythematosus and combination therapy with cyclophosphamide were each independently associated with an increased risk of LON (adjusted HR 2.96 [95% CI 1.10-8.01] and 1.98 [95% CI 1.06-3.71], respectively). LON was not observed in minimal change disease or focal segmental glomerulosclerosis. The majority of episodes (59.4%) were asymptomatic. Fever and sepsis complicated 31.3% and 8.5% of episodes, respectively. Most patients (69%) were treated with filgrastim. Rituximab rechallenge occurred in 87% of patients, of whom 21% developed recurrent LON. CONCLUSION LON is common and often incidental. Most cases are reversible and respond well to filgrastim. However, LON can be associated with serious infections and thus warrants vigilant monitoring.
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Affiliation(s)
| | | | | | | | | | | | - Frank B Cortazar
- Massachusetts General Hospital, Boston, and New York Nephrology Vasculitis and Glomerular Center, Albany
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17
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Abstract
Podocytopathies are kidney diseases in which direct or indirect podocyte injury drives proteinuria or nephrotic syndrome. In children and young adults, genetic variants in >50 podocyte-expressed genes, syndromal non-podocyte-specific genes and phenocopies with other underlying genetic abnormalities cause podocytopathies associated with steroid-resistant nephrotic syndrome or severe proteinuria. A variety of genetic variants likely contribute to disease development. Among genes with non-Mendelian inheritance, variants in APOL1 have the largest effect size. In addition to genetic variants, environmental triggers such as immune-related, infection-related, toxic and haemodynamic factors and obesity are also important causes of podocyte injury and frequently combine to cause various degrees of proteinuria in children and adults. Typical manifestations on kidney biopsy are minimal change lesions and focal segmental glomerulosclerosis lesions. Standard treatment for primary podocytopathies manifesting with focal segmental glomerulosclerosis lesions includes glucocorticoids and other immunosuppressive drugs; individuals not responding with a resolution of proteinuria have a poor renal prognosis. Renin-angiotensin system antagonists help to control proteinuria and slow the progression of fibrosis. Symptomatic management may include the use of diuretics, statins, infection prophylaxis and anticoagulation. This Primer discusses a shift in paradigm from patient stratification based on kidney biopsy findings towards personalized management based on clinical, morphological and genetic data as well as pathophysiological understanding.
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18
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Lee JM, Kronbichler A, Shin JI, Oh J. Review on long-term non-renal complications of childhood nephrotic syndrome. Acta Paediatr 2020; 109:460-470. [PMID: 31561270 DOI: 10.1111/apa.15035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/15/2019] [Accepted: 09/25/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Nephrotic syndrome (NS) is the most common glomerular childhood disease. A body of literature has described the long-term renal prognosis of childhood-onset idiopathic NS. However, the nonrenal outcomes have not been studied as much. AIM We aimed to discuss the long-term non-renal outcomes of childhood NS, highlighting studies with a follow-up period of more than 10 years. RESULTS We reviewed the literature and found that a number of immunosuppressive agents have stopped inflammation, stabilised the podocyte cytoskeleton and reduce proteinuria. However, prolonged treatment has frequently been associated with a high risk of renal and non-renal complications in patients with a complicated disease course, defined as frequent relapses or steroid dependency. Non-renal complications may include impaired longitudinal growth and pubertal development, undesirable fertility outcomes, ocular complications, bone mineral diseases and potential malignancies. CONCLUSION This review discusses and summarises the non-renal outcomes of idiopathic childhood NS.
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Affiliation(s)
- Jiwon M. Lee
- Department of Pediatrics Chungnam National University Hospital and College of Medicine Daejeon Korea
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension) Medical University Innsbruck Innsbruck Austria
| | - Jae Il Shin
- Department of Pediatrics Yonsei University College of Medicine Seoul Korea
- Division of Pediatric Nephrology Severance Children's Hospital Seoul Korea
- Institute of Kidney Disease Research Yonsei University College of Medicine Seoul Korea
| | - Jun Oh
- Department of Pediatrics University Hamburg‐Eppendorf Hamburg Germany
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19
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Kamei K, Ishikura K, Sako M, Ito S, Nozu K, Iijima K. Rituximab therapy for refractory steroid-resistant nephrotic syndrome in children. Pediatr Nephrol 2020; 35:17-24. [PMID: 30564879 DOI: 10.1007/s00467-018-4166-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/30/2018] [Accepted: 12/03/2018] [Indexed: 12/24/2022]
Abstract
Patients with steroid-resistant nephrotic syndrome (SRNS) who develop resistance to immunosuppressive agents, defined as refractory SRNS, have poor renal outcomes. Although the chimeric anti-CD20 monoclonal antibody rituximab has shown efficacy for frequently relapsing nephrotic syndrome and steroid-dependent nephrotic syndrome, its efficacy for refractory SRNS remains uncertain due to limited data. According to previous case reports, 50.4% of patients with refractory SRNS showed clinical improvements after rituximab treatment. Remission rates in patients with initial steroid resistance and late steroid resistance were 43.9 and 57.7%, respectively, and 41.5 and 63.6% in patients with focal segmental glomerulosclerosis and minor glomerular abnormalities, respectively. However, various factors (race, disease severity, number of rituximab doses, concomitant treatments, and observation period) differed among these observational studies and their consensus may also have been affected by potential publication bias. Rituximab monotherapy may have some degree of efficacy and lead to satisfactory outcomes in a subset of patients with refractory SRNS. However, administration of concomitant treatments during rituximab-mediated B cell depletion, such as methylprednisolone pulse therapy, daily oral prednisolone therapy, and immunosuppressive agents, may lead to better outcomes in these patients. Large-scale, multi-center prospective studies are needed to evaluate the efficacy and safety of such regimens.
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Affiliation(s)
- Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, 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
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
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20
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Ashtari F, Hakamifard A, Hariri A, Gholipour-Shahraki T. Rituximab associated necrosis: A case report. Mult Scler Relat Disord 2019; 37:101429. [PMID: 31675638 DOI: 10.1016/j.msard.2019.101429] [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: 07/11/2019] [Revised: 09/18/2019] [Accepted: 10/01/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Rituximab is a B-cell-depleting unconjugated monoclonal IgG1 antibody that targets the transmembrane protein CD20. This article reports on a case with the rare complication known as Rituximab-associated mucosal necrosis. CASE PRESENTATION The present case report addresses, for the first time, a patient affected by Devic's syndrome presenting with oral manifestations of palatal necrosis after rituximab treatment. CONCLUSION The present case raises the possibility of anti-CD20 antibody contributing to the development of palatal mucosal necrosis in some patients. Given the increasing administration of rituximab as a result of its efficacy against several diseases, a report on the potential iatrogenic effects of this drug is essential.
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Affiliation(s)
- Fereshteh Ashtari
- Isfahan Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Atousa Hakamifard
- Department of Infectious Diseases, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Amirali Hariri
- School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Tahereh Gholipour-Shahraki
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
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21
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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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22
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Fujinaga S, Tomii Y. Predictors of rituximab-related neutropenia in Japanese children with steroid-dependent nephrotic syndrome. Pediatr Nephrol 2019; 34:1303-1304. [PMID: 30887110 DOI: 10.1007/s00467-019-04235-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 03/08/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Shuichiro Fujinaga
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama City, Saitama, 330-8777, Japan.
| | - Yuji Tomii
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama City, Saitama, 330-8777, Japan
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23
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Fujinaga S, Nishino T, Umeda C, Tomii Y, Watanabe Y, Sakuraya K. Long-term outcomes after early treatment with rituximab for Japanese children with cyclosporine- and steroid-resistant nephrotic syndrome. Pediatr Nephrol 2019; 34:353-357. [PMID: 30426219 DOI: 10.1007/s00467-018-4145-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 10/25/2018] [Accepted: 11/07/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Although rituximab (RTX) may be effective treatment in children with nephrotic syndrome who are resistant to cyclosporine A and steroid (CsA-SRNS), long-term outcomes after B cell depleting therapy remain unclear. CASE-DIAGNOSIS/TREATMENT We retrospectively reviewed the clinical courses (median follow-up, 5.1 years) of six CsA-SRNS children (three boys; median age at RTX, 4.2 years) unresponsive to oral cyclosporine combined with ≥ 2 courses of intravenous methylprednisolone pulses, who received RTX within 6 months after disease onset (median 11 weeks). After initial RTX treatment (median two doses of 375 mg/m2) followed by retreatment with intravenous methylprednisolone pulses and/or high-dose prednisolone, all patients achieved complete remission at a median of 158 days. Although 17 relapses occurred in five patients during follow-up, all but one patient became steroid sensitive. Severe neutropenia and hypogammaglobulinemia developed in two and four patients, respectively. However, no life-threatening infections were identified in the cohort. At last visit (median age, 11.3 years), all patients maintained complete remission without renal insufficiency. CONCLUSIONS Although late-onset adverse events should be considered, particularly for young patients, early RTX treatment may have positive outcomes in children with CsA-SRNS in the long term.
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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
| | - Chisato Umeda
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama city, Saitama, 330-8777, Japan
| | - Yuji Tomii
- Division of Nephrology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama city, Saitama, 330-8777, Japan
| | - Yoshitaka Watanabe
- 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
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24
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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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25
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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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26
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Tullus K, Webb H, Bagga A. Management of steroid-resistant nephrotic syndrome in children and adolescents. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:880-890. [PMID: 30342869 DOI: 10.1016/s2352-4642(18)30283-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/18/2018] [Accepted: 08/21/2018] [Indexed: 02/08/2023]
Abstract
More than 85% of children and adolescents (majority between 1-12 years old) with idiopathic nephrotic syndrome show complete remission of proteinuria following daily treatment with corticosteroids. Patients who do not show remission after 4 weeks' treatment with daily prednisolone are considered to have steroid-resistant nephrotic syndrome (SRNS). Renal histology in most patients shows presence of focal segmental glomerulosclerosis, minimal change disease, and (rarely) mesangioproliferative glomerulonephritis. A third of patients with SRNS show mutations in one of the key podocyte genes. The remaining cases of SRNS are probably caused by an undefined circulating factor. Treatment with calcineurin inhibitors (ciclosporin and tacrolimus) is the standard of care for patients with non-genetic SRNS, and approximately 70% of patients achieve a complete or partial remission and show satisfactory long-term outcome. Additional treatment with drugs that inhibit the renin-angiotensin axis is recommended for hypertension and for reducing remaining proteinuria. Patients with SRNS who do not respond to treatment with calcineurin inhibitors or other immunosuppressive drugs can show declining kidney function and are at risk for end-stage renal failure. Approximately a third of those who undergo renal transplantation show recurrent focal segmental glomerulosclerosis in the allograft and often respond to combined treatment with plasma exchange, rituximab, and intensified immunosuppression.
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Affiliation(s)
- Kjell Tullus
- Nephrology Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London, UK.
| | - Hazel Webb
- Nephrology Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London, UK
| | - Arvind Bagga
- Division of Nephrology, Indian Council of Medical Research Advanced Center for Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
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27
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Kamei K, Ogura M, Sato M, Ito S, Ishikura K. Infusion reactions associated with rituximab treatment for childhood-onset complicated nephrotic syndrome. Pediatr Nephrol 2018; 33:1013-1018. [PMID: 29426974 DOI: 10.1007/s00467-018-3900-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/21/2018] [Accepted: 01/23/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Infusion reaction (IR) is defined as an adverse event within 24 h after monoclonal antibody infusion. In non-Hodgkin lymphoma, IR incidence following rituximab treatment is high (77-80%), but there are no data in complicated nephrotic syndrome. METHODS Records of rituximab infusions in patients with complicated nephrotic syndrome between February 2006 and December 2014 at the National Center for Child Health and Development were reviewed. Rituximab was administered at doses of 375 mg/m2. The severity of IR was evaluated using the Common Terminology Criteria for Adverse Events ver. 4.0. RESULTS For 309 rituximab infusions in 159 patients (male, 110; median age, 12 years), IR was observed in 165 infusions (53.4%). Respiratory symptoms were most common (66% of all events). Ninety-five percent of the IR was observed within 3 h after rituximab infusion initiation. Sixty-eight percent of the events were classified as grade 1 and others classified as grade 2. Only 18% required medical intervention. CD20 cell count in patients with IR was significantly higher than in patients without IR. Incidence of IR was similar in subsequent rituximab treatment after B-cell recovery. Patients who experienced IR at first rituximab treatment were more likely to experience recurrent IR with subsequent treatments compared to those not having IR at initial treatment (odds ratio 3.64; p < 0.001). CONCLUSIONS In patients with complicated nephrotic syndrome, respiratory symptoms were the major type of IR, mostly observed within 3 h of infusion. Incidence of IR was lower and its severity milder in patients with complicated nephrotic syndrome than those with lymphoma.
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Affiliation(s)
- Koichi Kamei
- 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
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University Graduate School pf Medicine, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
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28
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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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29
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Downie ML, Gallibois C, Parekh RS, Noone DG. Nephrotic syndrome in infants and children: pathophysiology and management. Paediatr Int Child Health 2017; 37:248-258. [PMID: 28914167 DOI: 10.1080/20469047.2017.1374003] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Nephrotic syndrome is defined by nephrotic-range proteinuria (≥40 mg/m2/hour or urine protein/creatinine ratio ≥200 mg/mL or 3+ protein on urine dipstick), hypoalbuminaemia (<25 g/L) and oedema. This review focuses on the classification, epidemiology, pathophysiology, management strategies and prognosis of idiopathic nephrotic syndrome of childhood, and includes a brief overview of the congenital forms.
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Affiliation(s)
- Mallory L Downie
- a Department of Paediatrics , Univeristy of Toronto , Toronto , Canada.,b Division of Nephrology , The Hospital for Sick Children , Toronto , Canada.,c Department of Paediatrics , University of Toronto , Toronto , Canada
| | - Claire Gallibois
- d Department of Medicine , Royal College of Surgeons in Ireland , Dublin , Ireland
| | - Rulan S Parekh
- a Department of Paediatrics , Univeristy of Toronto , Toronto , Canada.,b Division of Nephrology , The Hospital for Sick Children , Toronto , Canada.,c Department of Paediatrics , University of Toronto , Toronto , Canada.,d Department of Medicine , Royal College of Surgeons in Ireland , Dublin , Ireland.,e Child Health Evaluative Sciences, Research Institute , The Hospital for Sick Children , Toronto , Canada.,f Division of Nephrology , University Health Network , Toronto , Canada.,g Dalla Lana School of Public Health , University of Toronto , Toronto , Canada
| | - Damien G Noone
- a Department of Paediatrics , Univeristy of Toronto , Toronto , Canada.,b Division of Nephrology , The Hospital for Sick Children , Toronto , Canada.,c Department of Paediatrics , University of Toronto , Toronto , Canada
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30
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Pérez-De-Lis M, Retamozo S, Flores-Chávez A, Kostov B, Perez-Alvarez R, Brito-Zerón P, Ramos-Casals M. Autoimmune diseases induced by biological agents. A review of 12,731 cases (BIOGEAS Registry). Expert Opin Drug Saf 2017; 16:1255-1271. [DOI: 10.1080/14740338.2017.1372421] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Marta Pérez-De-Lis
- Servicio de Anestesiologia y Reanimación, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Soledad Retamozo
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Hospital Privado Universitario de Córdoba, Córdoba, Argentina
- Instituto De Investigaciones En Ciencias De La Salud (INICSA), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Córdoba, Argentina
| | - Alejandra Flores-Chávez
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Unidad de Investigación Biomédica 02, Unidad de Investigación en Epidemiología Clínica, Centro Médico Nacional de Occidente (CMNO), Instituto Mexicano del Seguro Social (IMSS), Hospital de Especialidades, Guadalajara, Mexico
- Programa de Doctorado en Ciencias Médicas, Centro Universitario de Investigaciones Biomédicas (CUIB), Universidad de Colima, Colima, Mexico
| | | | | | - Pilar Brito-Zerón
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA- Sanitas, Barcelona, Spain
| | - Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Department of Medicine, University of Barcelona, Barcelona, Spain
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Abstract
Bacteremia and sepsis are conditions associated with high mortality and are of great impact to health care operations. Among the top causes of mortality in the United States, these conditions cause over 600 fatalities each day. Empiric, broad-spectrum treatment is a common but often a costly approach that may fail to effectively target the correct microbe, may inadvertently harm patients via antimicrobial toxicity or downstream antimicrobial resistance. To meet the diagnostic challenges of bacteremia and sepsis, laboratories must understand the complexity of diagnosing and treating septic patients, in order to focus on creating algorithms that can help direct a more targeted approach to antimicrobial therapy and synergize with existing clinical practices defined in new Surviving Sepsis Guidelines. Significant advances have been made in improving blood culture media; as yet no molecular or antigen-based method has proven superior for the detection of bacteremia in terms of limit of detection. Several methods for rapid molecular identification of pathogens from blood cultures bottles are available and many more are on the diagnostic horizon. Ultimately, early intervention by molecular detection of bacteria and fungi directly from whole blood could provide the most patient benefit and contribute to tailored antibiotic coverage of the patient early on in the course of the disease. Although blood cultures remain as the best means of diagnosing bacteremia and candidemia, complementary testing with antigen tests, microbiologic investigations from other body sites, and histopathology can often aid in the diagnosis of disseminated disease, and application of emerging nucleic acid test methods and other new technology may greatly impact our ability to bacteremic and septic patients, particularly those who are immunocompromised.
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Kronbichler A, Windpessl M, Pieringer H, Jayne DRW. Rituximab for immunologic renal disease: What the nephrologist needs to know. Autoimmun Rev 2017; 16:633-643. [PMID: 28414152 DOI: 10.1016/j.autrev.2017.04.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/21/2017] [Indexed: 12/12/2022]
Abstract
Rituximab (RTX), a chimeric, monoclonal anti-CD20 antibody, is increasingly used in immune-mediated renal diseases. While licensed in the induction treatment of ANCA-associated vasculitis, it represents one of the most commonly prescribed off-label drugs. Much of the information regarding its safety has been drawn from experience in hematology and rheumatology. Ample evidence illustrates the safety of RTX, however, rare but serious adverse events have emerged that include progressive multifocal leucoencephalopathy and hepatitis B reactivation. Moderate to severe hypogammaglobulinemia and late-onset neutropenia following RTX therapy confer an increased infectious risk and factors predicting these side effects (i.e. a genetic basis) need to be identified. Nephrologists initiating RTX need to bear in mind that long-term risks and optimal dosing for many renal indications remain unclear. Special considerations must be given when RTX is used in women of childbearing age. We summarize practical aspects concerning the use of RTX. This review will provide nephrologists with information to guide their use of RTX alerting them to safety risks and the need for patient counselling.
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Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria.
| | - Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Herwig Pieringer
- Academic Research Unit, 2nd Department of Medicine, Kepler University Hospital, Med Campus III, Linz, Austria; Paracelsus Private Medical University Salzburg, Salzburg, Austria
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK; Department of Medicine, University of Cambridge, Cambridge, UK
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33
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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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34
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Kamei K, Ogura M, Sato M, Sako M, Iijima K, Ito S. Risk factors for relapse and long-term outcome in steroid-dependent nephrotic syndrome treated with rituximab. Pediatr Nephrol 2016; 31:89-95. [PMID: 26341251 DOI: 10.1007/s00467-015-3197-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 08/11/2015] [Accepted: 08/14/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Rituximab (RTX) is known to be effective for the treatment of refractory steroid-dependent nephrotic syndrome (SDNS). However, there are insufficient data on the risk factors for relapse and long-term outcome after RTX treatment. METHODS We administered a single dose of RTX to patients with refractory SDNS from November 2007 to December 2013 and continued with immunosuppressants. The risk factors for early relapse and long-term outcome were analyzed. RESULTS Eighty-one patients were included and the observation period was 13-90 months. Seventy-six patients (94 %) discontinued steroids. Median duration of B-cell depletion was 160 days and 50 % relapse-free survival was 482 days. In multivariate analyses, only a history of steroid-resistant nephrotic syndrome (SRNS) was a statistically significant risk factor (hazard ratio, 2.44; p = 0.048). Fifty percent relapse-free survival in patients without a history of SRNS was 615 days, longer than that of patients with a history of SRNS (393 days) (p=0.005) [corrected]. Fifty-one patients (63 %) received additional RTX treatments for relapses. At last observation, patients using calcineurin inhibitors decreased from 89 % to 23 %, and 12 patients (15 %) discontinued immunosuppressants. CONCLUSIONS Rituximab treatment followed by immunosuppressants is an effective option for patients with SDNS, although a history of SRNS is a risk factor for early relapse.
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Affiliation(s)
- Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Mayumi Sako
- Division for Clinical Trials, Department of Development Strategy, Center for Social and Clinical Research, National Research Institute for Child Health and Development, National Center for Child Health and Development, Tokyo, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Shuichi Ito
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan. .,Department of Pediatrics, Yokohama City University, 3-9, Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-0004, Japan.
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35
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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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36
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Ravani P, Rossi R, Bonanni A, Quinn RR, Sica F, Bodria M, Pasini A, Montini G, Edefonti A, Belingheri M, De Giovanni D, Barbano G, Degl'Innocenti L, Scolari F, Murer L, Reiser J, Fornoni A, Ghiggeri GM. Rituximab in Children with Steroid-Dependent Nephrotic Syndrome: A Multicenter, Open-Label, Noninferiority, Randomized Controlled Trial. J Am Soc Nephrol 2015; 26:2259-66. [PMID: 25592855 DOI: 10.1681/asn.2014080799] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 11/18/2014] [Indexed: 01/03/2023] Open
Abstract
Steroid-dependent nephrotic syndrome (SDNS) carries a high risk of toxicity from steroids or steroid-sparing agents. This open-label, noninferiority, randomized controlled trial at four sites in Italy tested whether rituximab is noninferior to steroids in maintaining remission in juvenile SDNS. We enrolled children age 1-16 years who had developed SDNS in the previous 6-12 months and were maintained in remission with high prednisone doses (≥0.7 mg/kg per day). We randomly assigned participants to continue prednisone alone for 1 month (control) or to add a single intravenous infusion of rituximab (375 mg/m(2); intervention). Prednisone was tapered in both groups after 1 month. For noninferiority, rituximab had to permit steroid withdrawal and maintain 3-month proteinuria (mg/m(2) per day) within a prespecified noninferiority margin of three times the levels among controls (primary outcome). We followed participants for ≥1 year to compare risk of relapse (secondary outcome). Fifteen children per group (21 boys; mean age, 7 years [range, 2.6-13.5 years]) were enrolled and followed for ≤60 months (median, 22 months). Three-month proteinuria was 42% lower in the rituximab group (geometric mean ratio, 0.58; 95% confidence interval, 0.18 to 1.95 [i.e., within the noninferiority margin of three times the levels in controls]). All but one child in the control group relapsed within 6 months; median time to relapse in the rituximab group was 18 months (95% confidence interval, 9 to 32 months). In the rituximab group, nausea and skin rash during infusion were common; transient acute arthritis occurred in one child. In conclusion, rituximab was noninferior to steroids for the treatment of juvenile SDNS.
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Affiliation(s)
- Pietro Ravani
- Division of Nephrology, University of Calgary, Calgary, Alberta, Canada;
| | - Roberta Rossi
- Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Alice Bonanni
- Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Robert R Quinn
- Division of Nephrology, University of Calgary, Calgary, Alberta, Canada
| | - Felice Sica
- Division of Pediatrics, Hospital of Foggia, Foggia, Italy
| | - Monica Bodria
- Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Andrea Pasini
- Nephrology and Pediatric Dialysis, Department of Pediatrics, Azienda Ospedaliera Universitaria Sant'Orsola, Bologna, Italy
| | - Giovanni Montini
- Nephrology and Pediatric Dialysis, Department of Pediatrics, Azienda Ospedaliera Universitaria Sant'Orsola, Bologna, Italy
| | - Alberto Edefonti
- Pediatric Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mirco Belingheri
- Pediatric Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Giancarlo Barbano
- Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Ludovica Degl'Innocenti
- Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Francesco Scolari
- Division of Nephrology and Dialysis, Ospedale di Montichiari Azienda Ospedaliera Spedali Civili di Brescia, Brescia, Italy
| | - Luisa Murer
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Pediatrics, University Hospital of Padua, Padua, Italy
| | - Jochen Reiser
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois; and
| | - Alessia Fornoni
- Miller School of Medicine, University of Miami, Miami, Florida
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
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