Good Responses to Rituximab in Severe Lupus Nephritis

Early B-cell depletion with rituximab may improve the long-term outcomes of severe lupus nephritis, suggests a French experience reported in the Clinical Journal of the American Society of Nephrology.

Led by Catherine Melander, MD, of Hôpital Necker, Paris, the researchers analyzed the outcomes of 20 patients with severe lupus nephritis receiving induction therapy with rituximab between 2003 and 2006. Median follow-up was 22 months. Fifteen patients had active class III or IV lupus nephritis, while five had class V disease. Rituximab was given for refractory lupus nephritis in 12 cases, relapsing disease in six, and as first-line therapy in two. Three patients received concomitant cyclophosphamide; 10 received additional maintenance doses of rituximab.

Twelve patients achieved complete or partial renal remission, for a response rate of 60 percent. One case of relapsed lupus nephritis responded to repeated treatment with rituximab. The occurrence of B-cell depletion within one month after rituximab treatment was strongly associated with renal response—only one of 12 patients with early B-cell depletion did not have a positive renal outcome.

Black patients and those with hypoalbuminuria were less likely to have early B-cell depletion. Patients with rapidly progressive glomerulonephritis did not respond to rituximab.

Treatment with corticosteroids plus cyclophosphamide has improved the prognosis of lupus nephritis, but patients remain at risk of resistance, relapse, or adverse effects. Rituximab is an “interesting therapeutic option” for relapsing or refractory lupus nephritis, Melander and colleagues concluded. When early B-cell depletion is obtained, the renal response rate is very high [Melander C, Sallé M, Trolliet P, Balsam EG, Candon S, Belenfant X, Daugas E, Remy P, Zarrouk V, Pillebout E, Jacquot C, Boffa J-J, Karras A, Masse V, Lesavre P, Elie C, Brocheriou I, Knebelmann B, Noel L-H, and Fakhouri F: Rituximab in severe lupus nephritis: early B-cell depletion impacts long-term renal outcome. Clin J Am Soc Nephrol 2009; 4:579–586].