1
|
Wong ZY, Teo CY, Fiona Wong YQ, Ng KT, Lim SK. Immunosuppression for adult steroid-dependent or frequently relapsing nephrotic syndrome: A systematic review and meta-analysis. PLoS One 2024; 19:e0307981. [PMID: 39083488 PMCID: PMC11290670 DOI: 10.1371/journal.pone.0307981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/15/2024] [Indexed: 08/02/2024] Open
Abstract
OBJECTIVE There is limited evidence on which immunosuppressive agents produce the best outcomes for adult patients with steroid-dependent or frequently relapsing nephrotic syndrome (SDNS/FRNS). This review compares the remission rate and adverse effects of various immunosuppressants used. METHODS Studies of adult patients with biopsy-proven SDNS/FRNS, administered any immunosuppressive agents and reported complete remission results as one of the clinical outcomes were included. Articles were independently screened by two researchers. ROBINS-I was used for risk of bias assessment. Random-effects model was used for statistical analysis and corresponding 95% confidence intervals (CIs) were calculated. RESULTS 574 patients across 28 studies were included in the analysis. Patients receiving rituximab have a complete remission rate of 89% (95% CI = 83% to 94%; τ2 = 0.0070; I2 = 62%; overall p < 0.01, low certainty) and adverse event rate of 0.26, cyclosporine (CR 40%; 95% CI = 21% to 59%; τ2 = 0.0205; I2 = 55%; overall p = 0.08, low certainty), tacrolimus (CR 84%; 95% CI = 70% to 98%; τ2 = 0.0060; I2 = 33%; overall p = 0.21, moderate certainty), mycophenolate mofetil (CR 82%; 95% CI = 74% to 90%; τ2 < 0.0001; I2 = 15%; overall p = 0.32, moderate certainty) and cyclophosphamide (CR 79%; 95% CI = 69% to 89%; τ2 = 0; I2 = 0%; overall p = 0.52, moderate certainty). CONCLUSION Among the commonly used immunosuppressive agents, only rituximab has a statistically significant effect in achieving complete remission among patients with SDNS/FRNS and has a relatively good safety profile, but this is limited by low quality of evidence with high degree of heterogeneity causing a lack of statistical power.
Collapse
Affiliation(s)
- Zhi Yong Wong
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chiu Yee Teo
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Ka Ting Ng
- Faculty of Medicine, Department of Anesthesiology, University of Malaya, Kuala Lumpur, Malaysia
| | - Soo Kun Lim
- Faculty of Medicine, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
2
|
Aslam A, Koirala A. Review of the Role of Rituximab in the Management of Adult Minimal Change Disease and Immune-Mediated Focal and Segmental Glomerulosclerosis. GLOMERULAR DISEASES 2023; 3:211-219. [PMID: 37901702 PMCID: PMC10601923 DOI: 10.1159/000533695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 08/14/2023] [Indexed: 10/31/2023]
Abstract
Background Minimal change disease and primary FSGS are podocytopathies but are also immune-mediated diseases. Rituximab acts via multiple mechanisms by tilting the balance between autoreactive B and T cells in favor of regulatory B and T cells. The consequences are decreased production of cytokines, chemokines, and permeability factors by these cells. In the past decade, we have seen the discovery of autoantibodies mediating nephrotic syndrome (anti-annexin A2 antibody, anti-UCHL1 antibody, and anti-nephrin antibody), and rituximab decreases their production. Rituximab also binds to podocyte SMPDL3b and has direct podocyte actions. Summary Rituximab's role in managing these primary podocytopathies has been discussed in this brief review. Rituximab has been used extensively in children and adults with frequently relapsing and steroid-dependent nephrotic syndrome. However, rituximab is not very promising in adult steroid-resistant nephrotic syndrome. Although ofatumumab would cause prolonged B-cell depletion and is fully humanized, it is unclear if it is superior to rituximab in preventing relapse of nephrotic syndrome. Key Messages Rituximab therapy can induce prolonged remission in adults with frequently relapsing and steroid-dependent nephrotic syndrome. However, no good data exist on using rituximab in steroid-resistant nephrotic syndrome.
Collapse
Affiliation(s)
- Ahsan Aslam
- Division of Nephrology and Hypertension, Assistant Professor of Clinical Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Abbal Koirala
- Division of Nephrology, Clinical Assistant Professor of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
3
|
Xue C, Yang B, Xu J, Zhou C, Zhang L, Gao X, Dai B, Yu S, Mao Z, Mei C, Xu C. Efficacy and safety of rituximab in adult frequent-relapsing or steroid-dependent minimal change disease or focal segmental glomerulosclerosis: a systematic review and meta-analysis. Clin Kidney J 2020; 14:1042-1054. [PMID: 34094516 PMCID: PMC8173623 DOI: 10.1093/ckj/sfaa191] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Indexed: 12/11/2022] Open
Abstract
Background The efficacy and safety of rituximab (RTX) in adult frequent-relapsing (FR) or steroid-dependent (SD) nephrotic syndrome (NS), including minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS), are still inconclusive. Methods We performed a systematic review and meta-analysis registered in PROSPERO (CRD42019148102) by pooling data of cohort studies or case series on adult patients with difficult-to-treat NS. Steroid-resistant NS was excluded. The primary outcomes were the complete remission (CR) rate and the relapse rate. Partial remission (PR) rate, no response (NR) rate and adverse events were the secondary outcomes. A random-effects model was performed for all the outcomes. Results We included 21 studies involving 382 adult MCD/FSGS subjects with a median follow-up duration from 12 to 43 months. RTX treatment induced a pooled 84.2% CR rate [95% confidence interval (CI): 67.7–96.3%], while MCD patients had a high 91.6% CR rate and FSGS patients a moderate 43% CR rate. However, 27.4% (95% CI 20.7–34.5%) of the patients relapsed during the follow-up. The pooled PR and NR rates were 5.8% (95% CI 1.2–12.5%) and 5.2% (95% CI 0.0–15.0%), respectively. RTX was associated with trivial adverse events and good tolerance. Conclusions In summary, by pooling results of current pilot studies, RTX may be an effective and relatively safe alternative for most adult FR or SD MCD/FSGS to displace calcineurin inhibitors or prednisone in the hierarchy of treatment. More clinical trials comparing RTX with other immunosuppressants and concerning the long-term adverse events are needed.
Collapse
Affiliation(s)
- Cheng Xue
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Nephrology, the Third Affiliated Hospital of Second Military Medical University, Shanghai, China
| | - Bo Yang
- Department of Nephrology, Naval Medical Center of PLA (People's Liberation Army), Shanghai, China
| | - Jing Xu
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Chenchen Zhou
- Outpatient Department, Yangpu Third Military Retreat, Shanghai, China
| | - Liming Zhang
- Department of Nephrology, Zhabei Central Hospital of Jing'an District, Shanghai, China
| | - Xiang Gao
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Bing Dai
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Shengqiang Yu
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Zhiguo Mao
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Changlin Mei
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Chenggang Xu
- Division of Nephrology, Kidney Institute of CPLA (Chinese People's Liberation Army), Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Nephrology, the Third Affiliated Hospital of Second Military Medical University, Shanghai, China
| |
Collapse
|
4
|
Pinto H, Oliveira N, Costa F, Alves R. Minimal change disease with maximum immunosuppression: successful treatment of steroid-dependent minimal change disease with rituximab. BMJ Case Rep 2018; 2018:bcr-2017-223407. [DOI: 10.1136/bcr-2017-223407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
|