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Osterholt T, Todorova P, Kühne L, Ehren R, Weber LT, Grundmann F, Benzing T, Brinkkötter PT, Völker LA. Repetitive administration of rituximab can achieve and maintain clinical remission in patients with MCD or FSGS. Sci Rep 2023; 13:6980. [PMID: 37117201 PMCID: PMC10141841 DOI: 10.1038/s41598-023-32576-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 03/29/2023] [Indexed: 04/30/2023] Open
Abstract
Minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) are glomerulopathies associated with nephrotic syndrome. Primary forms of these diseases are treated with various regimes of immunosuppression. Frequently relapsing or glucocorticoid-dependent courses remain challenging. Here, a B-cell-depleting strategy with rituximab represents a salvage option although data are sparse in the adult population. In particular, there is limited evidence on the efficacy of restoring remission after initial successful treatment with rituximab and whether patients benefit from an individualized, relapse-based approach. We identified 13 patients who received multiple therapies with rituximab from the FOrMe-registry (NCT03949972), a nationwide registry for MCD and FSGS in Germany, or from the University Hospital of Cologne. Disease status, changes in serum creatinine, proteinuria, and time to relapse were evaluated. Relapse-free survival was compared to the patients' previous therapy regimens. Through all treatment cycles, an improvement of disease activity was shown leading to a complete remission in 72% and partial remission in 26% after 3 ([Formula: see text]0.001) and 6 months ([Formula: see text]0.001). Relapse-free survival increased from 4.5 months (95%-CI 3-10 months) to 21 months (95%-CI 16-32 months) ([Formula: see text]0.001) compared to previous immunosuppression regimens with no loss in estimated glomerular filtration over time (p = 0.53). Compared to continuous B-cell depletion, an individualized relapse-based approach led to a reduced rituximab exposure and significant cost savings. Relapse-based administration of rituximab in patients with MCD/FSGS with an initial good clinical response did not result in a decreased efficacy at a median follow-up duration of 110 months. Thus, reinduction therapies may provide an alternative to continuous B-cell-depletion and reduce the long-term side effects of continuous immunosuppression.
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Affiliation(s)
- Thomas Osterholt
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Polina Todorova
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Lucas Kühne
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Rasmus Ehren
- Faculty of Medicine, Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Lutz Thorsten Weber
- Faculty of Medicine, Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Franziska Grundmann
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Thomas Benzing
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany
| | - Paul Thomas Brinkkötter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany.
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany.
| | - Linus Alexander Völker
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
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Greve AS, Prakash S, Krag S, Randers E. Focal segmental glomerulosclerosis in a patient with multiple sclerosis treated with Teriflunomide and Ocrelizumab. J Nephrol 2023; 36:659-661. [PMID: 36414886 DOI: 10.1007/s40620-022-01504-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/12/2022] [Indexed: 11/24/2022]
Abstract
We describe the case of a 24-year-old male patient with multiple sclerosis (MS) who was treated with Teriflunomide for eight months. However, due to MS progression, treatment was switched to Ocrelizumab. After 15 months of therapy with Ocrelizumab the patient developed edema and nephrotic-range albuminuria. Kidney biopsy showed focal segmental glomerulosclerosis (FSGS) and Ocrelizumab treatment was stopped. Teriflunomide is less likely to have caused FSGS due to a three week wash-out period and a timespan of 15 months between the last Teriflunomide dose and development of albuminuria. Treatment with Ocrelizumab has been associated with organ-specific inflammation in MS-patients, thus an association between the development of FSGS and Ocrelizumab therapy is possible, and this case suggests considering this potential association.
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Affiliation(s)
- Anne-Sofie Greve
- Department of Medicine, Viborg Regional Hospital, Viborg, Denmark.
| | - Sivagini Prakash
- Department of Neurology, Viborg Regional Hospital, Viborg, Denmark
| | - Søren Krag
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Else Randers
- Department of Medicine, Viborg Regional Hospital, Viborg, Denmark
- Research Unit of Multimorbidity, Viborg Regional Hospital, Viborg, Denmark
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New Insights into the Treatment of Glomerular Diseases: When Mechanisms Become Vivid. Int J Mol Sci 2022; 23:ijms23073525. [PMID: 35408886 PMCID: PMC8998908 DOI: 10.3390/ijms23073525] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/18/2022] [Accepted: 03/22/2022] [Indexed: 12/23/2022] Open
Abstract
Treatment for glomerular diseases has been extrapolated from the experience of other autoimmune disorders while the underlying pathogenic mechanisms were still not well understood. As the classification of glomerular diseases was based on patterns of juries instead of mechanisms, treatments were typically the art of try and error. With the advancement of molecular biology, the role of the immune agent in glomerular diseases is becoming more evident. The four-hit theory based on the discovery of gd-IgA1 gives a more transparent outline of the pathogenesis of IgA nephropathy (IgAN), and dysregulation of Treg plays a crucial role in the pathogenesis of minimal change disease (MCD). An epoch-making breakthrough is the discovery of PLA2R antibodies in the primary membranous nephropathy (pMN). This is the first biomarker applied for precision medicine in kidney disease. Understanding the immune system’s role in glomerular diseases allows the use of various immunosuppressants or other novel treatments, such as complement inhibitors, to treat glomerular diseases more reasonable. In this era of advocating personalized medicine, it is inevitable to develop precision medicine with mechanism-based novel biomarkers and novel therapies in kidney disease.
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Dias CB, Woronik V. Use of rituximab in glomerulopathies. J Bras Nefrol 2022; 44:145-146. [PMID: 35201257 PMCID: PMC9269178 DOI: 10.1590/2175-8239-jbn-2022-e004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/11/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
- Cristiane Bitencourt Dias
- Universidade de São Paulo, Faculdade de Medicina, Laboratório de Fisiopatologia Renal, São Paulo, SP, Brasil
| | - Viktoria Woronik
- Universidade de São Paulo, Faculdade de Medicina, Laboratório de Fisiopatologia Renal, São Paulo, SP, Brasil
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Sans-Pola C, Agustí A, Bosch JÀ, Agraz I, Alerany C, Danés I. Off-Label Use of Rituximab in Patients with Different Types of Nephropathies in a Tertiary Hospital: A Retrospective Study. J Clin Med 2021; 10:4941. [PMID: 34768461 PMCID: PMC8584949 DOI: 10.3390/jcm10214941] [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: 09/17/2021] [Revised: 10/20/2021] [Accepted: 10/24/2021] [Indexed: 11/17/2022] Open
Abstract
Off-label use of rituximab is commonly requested for patients with resistant nephropathies. The outcomes and tolerability of rituximab in adult patients with nephropathy treated at our hospital (from 2013 to 2018) were described. Data were retrieved from electronic medical records. Response was classified as complete remission (CR), partial remission (PR), or no response (NR) according to the KDIGO criteria. A total of 89 requests were received for 61 patients. Median age was 58 years (45.9% female). Idiopathic membranous nephropathy (MN) (n = 30) was the most frequent indication, followed by minimal change disease (MCD) (n = 15) and secondary membranoproliferative glomerulonephritis (MPGN) (n = 12). Three patients with focal segmental glomerulosclerosis (FSGS) were included. After most treatment cycles in MN, a CR or PR was observed; median proteinuria levels significantly decreased for these patients (6000 mg/24h (IQR 3584-10,300) vs. 1468.8 (IQR 500-4604.25), p < 0.01). In MPGN, no response was documented after 46.7% of rituximab cycles. A CR or PR was described with the majority of rituximab cycles in MCD, with a significant decrease in proteinuria (6000 mg/24 h (IQR 4007-11,426) vs. 196.8 (IQR 100-1300), p = 0.013). No cycles produced a response in FSGS. Mean CD19+ B-cell decreased in all types of nephropathy (10.44% vs. 0.29%, p < 0.0001). Eleven patients presented infusion-related reactions, and 17 presented infectious complications. The majority of patients with MN and MCD had complete or partial responses; however, neither MPGN nor FSGS had encouraging results.
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Affiliation(s)
- Carla Sans-Pola
- Department of Clinical Pharmacology, Vall d’Hebron Hospital Universitari, 08035 Barcelona, Spain; (C.S.-P.); (I.D.)
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Immunomediated Diseases and Innovative Therapies Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, 08035 Barcelona, Spain
| | - Antònia Agustí
- Department of Clinical Pharmacology, Vall d’Hebron Hospital Universitari, 08035 Barcelona, Spain; (C.S.-P.); (I.D.)
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Immunomediated Diseases and Innovative Therapies Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, 08035 Barcelona, Spain
| | - Josep Àngel Bosch
- Department of Internal Medicine, Vall d’Hebron Hospital Universitari, 08035 Barcelona, Spain;
- Department of Internal Medicine, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Irene Agraz
- Department of Nephrology, Referrer in Complex Glomerular Diseases in Adults, Vall d’Hebron Hospital Universitari, 08035 Barcelona, Spain;
| | - Carmen Alerany
- Pharmacy Service, Vall d’Hebron Hospital Universitari, 08035 Barcelona, Spain;
| | - Immaculada Danés
- Department of Clinical Pharmacology, Vall d’Hebron Hospital Universitari, 08035 Barcelona, Spain; (C.S.-P.); (I.D.)
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Immunomediated Diseases and Innovative Therapies Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, 08035 Barcelona, Spain
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Meinl E, Hohlfeld R. CD20 + T Cells as Pathogenic Players and Therapeutic Targets in MS. Ann Neurol 2021; 90:722-724. [PMID: 34585761 DOI: 10.1002/ana.26232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 09/25/2021] [Accepted: 09/27/2021] [Indexed: 12/28/2022]
Affiliation(s)
- Edgar Meinl
- Institute of Clinical Neuroimmunology, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.,Biomedical Center (BMC), Faculty of Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.,Biomedical Center (BMC), Faculty of Medicine, Ludwig-Maximilians-Universität München, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
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