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Chan EYH, Yu EL, Angeletti A, Arslan Z, Basu B, Boyer O, Chan CY, Colucci M, Dorval G, Dossier C, Drovandi S, Ghiggeri GM, Gipson DS, Hamada R, Hogan J, Ishikura K, Kamei K, Kemper MJ, Ma ALT, Parekh RS, 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] [Key Words] [MESH Headings] [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 after multiple courses of rituximab among children with frequently relapsing, steroid-dependent nephrotic syndrome (FRSDNS) are unknown. METHODS A retrospective cohort study at 16 pediatric nephrology centers from ten countries in Asia, Europe, and North America included children with FRSDNS who received two or more courses of rituximab. Primary outcomes were relapse-free survival and adverse events. RESULTS A total of 346 children (age, 9.8 years; IQR, 6.6-13.5 years; 73% boys) received 1149 courses of rituximab. A total of 145, 83, 50, 28, 22, and 18 children received two, three, four, five, six, and seven or more courses, respectively. Median (IQR) follow-up was 5.9 (4.3-7.7) years. Relapse-free survival differed by treatment courses (clustered log-rank test P<0.001). Compared with the first course (10.0 months; 95% CI, 9.0 to 10.7 months), relapse-free period and relapse risk progressively improved after subsequent courses (12.0-16.0 months; HRadj, 0.03-0.13; 95% CI, 0.01 to 0.18; P<0.001). The duration of B-cell depletion remained similar with repeated treatments (6.1 months; 95% CI, 6.0 to 6.3 months). Adverse events were mostly mild; the most common adverse events were hypogammaglobulinemia (50.9%), infection (4.5%), and neutropenia (3.7%). Side effects did not increase with more treatment courses nor a higher cumulative dose. Only 78 of the 353 episodes of hypogammaglobulinemia were clinically significant. Younger age at presentation (2.8 versus 3.3 years; P=0.05), age at first rituximab treatment (8.0 versus 10.0 years; P=0.01), and history of steroid resistance (28% versus 18%; P=0.01) were associated with significant hypogammaglobulinemia. All 53 infective episodes resolved, except for one patient with hepatitis B infection and another with EBV infection. There were 42 episodes of neutropenia, associated with history of steroid resistance (30% versus 20%; P=0.04). Upon last follow-up, 332 children (96%) had normal kidney function. CONCLUSIONS Children receiving repeated courses of 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 Yu-hin Chan
- Paediatric Nephrology Centre, Hong Kong Children’s Hospital, Hong Kong SAR
- Department of Paediatrics and Adolescent Medicine, University of Hong Kong, Hong Kong SAR
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, National Health Service Trust, London, United Kingdom
| | - Ellen L.M. Yu
- Clinical Research Center, Princess Margaret Hospital, Hong Kong SAR
| | - Andrea Angeletti
- Nephrology, Dialysis and Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Zainab Arslan
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, National Health Service Trust, London, United Kingdom
| | - Biswanath Basu
- Division of Pediatric Nephrology, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Olivia Boyer
- Pediatric Nephrology, Reference Center for Nephrotic Syndrome in Children and Adults, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Imagine, Institut National de la Santé et de la Recherche Médicale (INSERM) U1163, Université Paris Cité, Paris, France
| | - 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
| | - Manuela Colucci
- Renal Diseases Research Unit, Genetics and Rare Diseases Research Division, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Guillaume Dorval
- Pediatric Nephrology, Reference Center for Nephrotic Syndrome in Children and Adults, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Imagine, Institut National de la Santé et de la Recherche Médicale (INSERM) U1163, Université Paris Cité, Paris, France
| | - Claire Dossier
- Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France
| | - Stefania Drovandi
- Nephrology, Dialysis and Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Gian Marco Ghiggeri
- Nephrology, Dialysis and Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Debbie S. Gipson
- Division of Nephrology, Department of Pediatrics, University of Michigan, CS Mott Children’s Hospital, Ann Arbor, Michigan
| | - Riku Hamada
- Department of Nephrology and Rheumatology, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
| | - Julien Hogan
- Department of Pediatric Nephrology, Robert-Debré Hospital, Reference Center for Nephrotic Syndrome in Children and Adults, Centre de Référence Syndrome Néphrotique de l’Enfant et de l’Adulte (CMR SNI), AP-HP, Université Paris Cité, Paris, France
| | - Kenji Ishikura
- Department of Pediatrics, Kitasato University School of Medicine, Tokyo, Japan
- Department of Pediatrics, Kitasato University Hospital, Tokyo, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Markus J. Kemper
- Department of Pediatrics, Asklepios Medical School, Hamburg, Germany
| | - Alison Lap-tak Ma
- Paediatric Nephrology Centre, Hong Kong Children’s Hospital, Hong Kong SAR
- Department of Paediatrics and Adolescent Medicine, University of Hong Kong, Hong Kong SAR
| | - Rulan S. Parekh
- Division of Pediatric Nephrology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Seetha Radhakrishnan
- Division of Pediatric Nephrology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Priya Saini
- Division of Pediatric Nephrology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Qian Shen
- Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Rajiv Sinha
- Pediatric Nephrology Unit, Institute of Child Health, Kolkata, India
| | - Chantida Subun
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, National Health Service Trust, London, United Kingdom
| | - Sharon Teo
- Khoo Teck Puat – National University Children’s Medical Institute, National University Health System, Singapore
| | - Marina Vivarelli
- Division of Nephrology, Department of Pediatric Subspecialties, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Hazel Webb
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, National Health Service Trust, London, United Kingdom
| | - Hong Xu
- Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - 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
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, National Health Service Trust, London, United Kingdom
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Wang L, Zhu J, Xia M, Hua R, Deng F. Comparison of rituximab, cyclophosphamide, and tacrolimus as first steroid-sparing agents for complicated relapsing/steroid-dependent nephrotic syndrome in children: an evaluation of the health-related quality of life. Arch Med Sci 2022; 18:275-278. [PMID: 35154548 PMCID: PMC8826811 DOI: 10.5114/aoms/145587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/06/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Frequently-relapsing/steroid-dependent nephrotic syndrome (FRSDNS) leads to steroid toxicity impairing quality of life (QOL), thus prompting the use of steroid-sparing drugs. METHODS 51 FRSDNS children not previously treated with steroid-sparing agents were randomized to receive rituximab, cyclophosphamide, or tacrolimus. Clinical findings and QOL were evaluated before and after treatment. RESULTS The mean relapse rate in all groups declined six months after treatment, however, 1-year relapse-free survival rate, number of relapses, and cumulative prednisolone dosage were lower with rituximab than with tacrolimus and cyclophosphamide. Cyclophosphamide group had twice frequency of infections compared to the other groups. At 1 year after treatment, total scores showed greater improvement with rituximab. CONCLUSIONS As first-line steroid-sparing agent, rituximab is more effective and safer than cyclophosphamide and tacrolimus in FRSDNS, and improve QOL.
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Affiliation(s)
- Li Wang
- Children’s Hospital of Anhui Medical University, Anhui, China
- The First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Jialiang Zhu
- Children’s Hospital of Anhui Medical University, Anhui, China
- The fifth Clinical Medical College of Anhui Medical University, Anhui, China
| | - Mingyun Xia
- Children’s Hospital of Anhui Medical University, Anhui, China
- The fifth Clinical Medical College of Anhui Medical University, Anhui, China
| | - Ran Hua
- The First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Fang Deng
- Children’s Hospital of Anhui Medical University, Anhui, China
- The fifth Clinical Medical College of Anhui Medical University, Anhui, China
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