Acta Clinica Belgica

International Journal of Clinical and Laboratory Medicine

ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20

Rituximab in children with steroid-dependent

nephrotic syndrome: experience of a tertiary
center and review of the literature

Ilse Van Horebeek, Noël Knops, Maria Van Dyck, Elena Levtchenko & Djalila
Mekahli

To cite this article: Ilse Van Horebeek, Noël Knops, Maria Van Dyck, Elena Levtchenko &
Djalila Mekahli (2016): Rituximab in children with steroid-dependent nephrotic syndrome:
experience of a tertiary center and review of the literature, Acta Clinica Belgica, DOI:
10.1080/17843286.2016.1208955

To link to this article: http://dx.doi.org/10.1080/17843286.2016.1208955

Published online: 13 Jul 2016.

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 Original Paper
Rituximab in children with steroid-dependent
nephrotic syndrome: experience of a tertiary
center and review of the literature
Ilse Van Horebeek, Noël Knops, Maria Van Dyck, Elena Levtchenko,
Djalila Mekahli
Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium

Objectives: Rituximab (RTX) is a new treatment option in children with difficult-to-treat steroid-dependent nephrotic
syndrome (SDNS). We evaluated the experience of our tertiary center and reviewed the current literature.
Methods: This is a retrospective single-center study evaluating the efficacy and safety of RTX in children with
Downloaded by [University of Exeter] at 06:29 15 July 2016

difficult-to-treat SDNS. Age at diagnosis, type and duration of immunosuppression, age at administration, dose
of RTX, possible adverse events, number of relapses, duration of remission, and B-cell count after administration
of RTX were analyzed.
Results: Nine children with a median age at diagnosis of nephrotic syndrome of 4.75 (range 1.33–11.33) years
and a median age at administration of RTX of 16.08 (range 3.33–19.25) years were included. Before administration
of RTX they had a median number of relapses per year of 1.70 (range 0.82–4.80). At last follow-up (median
2.75 years, range 0.58–3.92), a reduction in the number of relapses per year to 0.26 (range 0–2.18) was noted,
despite cessation or lowering the dose of immunosuppressive therapy. Four patients achieved complete remission
after the first administration of RTX, four more patients after subsequent doses of RTX. No severe adverse events
were noted.
Conclusion: RTX was an effective and safe therapeutic option in our cohort of children with difficult-to-treat SDNS,
resulting in a significant reduction of yearly relapses in the absence of severe adverse events and facilitating the
reduction of other immunosuppressive medication.
Keywords:  Rituximab, Steroid-dependent nephrotic syndrome, Children

Introduction RTX is a chimeric monoclonal antibody directed

Idiopathic nephrotic syndrome (INS) is the most frequent
presentation of glomerular disease in children. Since the
majority of patients respond well to corticosteroids (CS),
the prognosis is generally good. However, up to 50% of these
children will experience frequent relapses or become ster-
oid-dependent (SDNS) or steroid-resistant (SRNS) and will
require additional treatment with immunosuppressive agents
such as cyclosporine (CsA), tacrolimus (Tac), or mycophe-
nolate mofetil (MMF).1 The high cumulative doses of CS
and the aforementioned drugs are associated with significant
adverse effects such as obesity, hypertension, growth retarda-
tion, and osteoporosis.2 Since a few years, rituximab (RTX)
is considered to be an alternative therapeutic option for
SDNS in children. Several studies have shown significantly
less relapses after RTX giving an opportunity to reduce doses
of CS and/or immunosuppressive agents (Table 1).
Correspondence to: Ilse Van Horebeek, Department of Pediatric
Nephrology, University Hospitals Leuven, Leuven, Belgium. Email:
ilsevanhorebeek@hotmail.com; ilse.1.vanhorebeek@uzleuven.be
against CD20 (a surface membrane protein on B-cells)
that induces B-cell depletion in peripheral blood and
lymph nodes via apoptosis or antibody- or complement-­
dependent cytotoxicity.3 RTX was originally developed
for the treatment of non-Hodgkin lymphomas and chronic
lymphocytic leukemia and was later introduced in the
treatment of autoimmune diseases such as rheumatoid
arthritis and systemic lupus erythematosus (often off-la-
bel).4–6 More recently, it has been used in INS, for either
SDNS or SRNS. The exact mechanism of action of RTX
in INS is still unclear. It is suggested that both immu-
nological mechanisms (by B-cell depletion and reduced
IL-17 production by T helper 17 cells) and a direct effect
on the podocytes (by stabilizing actin remodeling) might
play a role, not only by binding to CD20, but the latter
two mechanisms by binding of RTX to lipid-modifying
enzyme sphingomyelin phosphodiesterase acid-like 3B
(SMPDL-3b).3,7,8

© Acta Clinica Belgica 2016

DOI 10.1080/17843286.2016.1208955 Acta Clinica Belgica   2016   1
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2
Table 1  Overview of literature on RTX in children with SDNS
Year Study Author No. Dose RTX Result Follow-up B-cells Comment
2004 Case report Benz9 1 4 × 375 mg/m2 No more relapses 12 months n.a. First report in liter-
ature
2006 Case report Gilbert11 1 4 × 375 mg/m2, 2 × 375 mg/m2 No relapses during 18 months 9 months depletion
depletion
2007 Case report Francois12 1 4 × 375 mg/m2, 2 × 375 mg/m2 No more relapses, 28 months 12 months depletion RTX during protein-
stop CS uria
2007 Case report Smith10 1 1 × 375 mg/m2 No more relapses 10 months 3 months depletion
2007 Case report Hofstra13 1 2 × 1000 mg two-week interval Partial remission, 4 months n.a.

Acta Clinica Belgica   2016  

stop IS
2008 Prospective Guigonis14 22 2–4 × 375 mg/m2, in 12 patients retreatment: 1–3 IS reduced in 86%, Median 9.5 months Complete depletion 7 patients RTX dur-
courses of 1–3 × 375 mg/m2 no more oral therapy in all, recovery after ing proteinuria
in 23%, complete median 6 (range
remission in 4/7 with 2–11) months
proteinuria
2008 Retrospective Peters15 4 1–2 × 1000 mg or 4 × 375 mg/m2 Good response in 2/4 Minimal 11 months Depletion in 3/3
measured
2009 Prospective Kamei16 12 1 × 375 mg/m2 Significantly reduced Minimal 1 year Complete depletion Single dose of
relapse rate, 25% still in 88%, return to RTX effective, but
remission at 1 year baseline level at transient
6 months
2010 Retrospective survey Prytula27 28 Total dose 375–1874 mg/m2, most 4 × 375 mg/m2 82% no or mild pro- Median 4.5 (range 19/21 complete
Van Horebeek et al.  Rituximab in children with steroid-dependent nephrotic syndrome

or 2 × 750 mg/m2 teinuria and albumin 1–10) months depletion

>30 g/l
2010 Retrospective Sellier-Leclerc17 22 1–4 × 375 mg/m2, retreatment: 1–4 courses At last FU 9/22 Minimal 15 months Complete depletion Retreatment after
1 × 375 mg/m2 sustained remission, in all, recovery at 7.9 B-cell recovery →
17 no oral therapy, (3.0–15.3) months, 15 months depletion
significant reduction similar after 1–2 or
of all oral therapy 3–4 initial infusions
2010 Retrospective Gulati18 24 2 × 375 mg/m2 83.3% sustained re- 16.8 +/− 5.9 months Depletion in 9/9
mission at 12 months, measured
95% reduction of
relapses, IS reduced
in 50% of patients
2011 RCT Ravani19 27 1–2 × 375 mg/m2 50% in remission and 1 year Complete depletion RTX with lower
free of oral therapy at in all, 24/27 still de- doses of CS and CI
6 months pletion at 3 months non-inferior to stand-
ard therapy
2011 Prospective Ito28 16 1 × 375 mg/m2 Significantly less 1 year Recovery at 149 Maintenance therapy
relapses after RTX, +/− 33 and 131 +/− with MMF good
significantly less if 72 days (difference clinical option
MMF continued not significant)
2012 Retrospective Sinha36 10 2–3 × 375 mg/m2 Similar number of Minimal 12 months Complete depletion Two to three doses
relapses at 6 months, in all of RTX as effective
12 months and last as one year of tac-
FU, both groups sig- rolimus
nificantly reduced
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2012 Retrospective Sellier-Leclerc34 30 1–4 × 375 mg/m2, retreatment 1 × 375 mg/m2 to 63% no relapse 17.4 +/− 1.9 Recovery at 20.5 No difference in
maintain 15 months depletion after 15 months of (4.7–33.3) months +/− 0.92 (11.0–32.6) duration of depletion
depletion, 28 no oral after B-cell recovery months based on number of
therapy at last FU infusions
2012 Retrospective Kemper30 37 1–4 × 375 mg/m2, 1–4 courses 70.3% sustained re- Median 36 (range n.a.
mission at 12 months, 24–92.8) months (29
41% at 24 months; patients)
59% no oral therapy
at 12 months, 24% at
24 months
2013 Retrospective survey Ito21 55 1–4 × 375 mg/m2, 1–5 courses 77% stop CS, 24.2 Recovery at Less relapses with
60% stop CsA, +/−19.8 months 5.2+/−1.4 months maintenance therapy
51% relapsed 6.6
+/−5.57 months
2013 Retrospective Tellier31 18 1–4 × 375 mg/m2, retreatment max 6× At last FU 22% Mean 3.2 (2–5.3) n.a. Retreatment at re-
sustained remission, years lapse, B-cell recov-
44.5% free of oral ery or systematically
therapy
2013 Prospective Ravani38 46 1–2 × 375 mg/m2, 1–5 courses 48% remission at Median 3 (range 195 days deple- Probability of
6 months, 20% at 1–5) years tion after first RTX, remission higher if
1 year, 10% at 2 years 219 days after >9.4 years at RTX
subsequent RTX
2013 Retrospective El Koumi46 7 2 × 750 mg/m2, retreatment 1–4 courses 6/7 sustained remis- Minimal 12 months Depletion in
1 × 750 mg/m2 sion all, recovery at
4–16 months
2013 Prospective Kimata32 5 1 × 375 mg/m2 every 3 months for 1 year Median remission 3.2 (1.9–3.8) years Complete deple- Retreatment every
2.1 years; stop CS tion in 4, recovery 3 months good
in all at 11.8 (9.7–12.2) clinical option
months
2014 Retrospective Sato20 13 1–4 × 375 mg/m2 77% significantly 2.3 years n.a. RTX efficacy results
improved height, 92% in less adverse
significantly improved effects from CS
obesity index, sig-
nificantly decreased
number of relapses
and CS dose
2014 Retrospective Sun47 9 1–2 × 375 mg/m2 (max. 500 mg) 8/9 complete re- 4–16 months Depletion in all, Two infusions if
mission, 1/9 partial, recovery at mean proteinuria at RTX,
77.78% CS reduction 4.38 months 1 if not
2014 Prospective Ruggenenti22 10 1–2 × 375 mg/m2 4-fold relapse reduc- 1 year Depletion in all, re-
tion, 30% no relapses, covery at 6 months
40% free of oral to 1 year
therapy
2014 Retrospective Sinha23 101 2–4 × 375 mg/m2 81.8% less relapses 30.6 +/− 19.1 Documented in No correlation be-
and reduction of (15–43) months 96.5% tween B-cell recov-
CS in 70.6% after ery and occurrence
12 months of relapse

(Continued).

Acta Clinica Belgica  2016  

3
Van Horebeek et al.  Rituximab in children with steroid-dependent nephrotic syndrome
 Downloaded by [University of Exeter] at 06:29 15 July 2016

4
Table 1  (Continued).

Year Study Author No. Dose RTX Result Follow-up B-cells Comment
2014 RCT Iijima24 24 4 × 375 mg/m2 Relapse-free period 1 year Depletion in all, Multicenter, dou-
significantly longer in recovery at mean ble-blind RCT
RTX group (267 days 148 days
vs 101 days,
p<0.0001), relapse
rate significantly lower
in RTX group (1.54 vs
4.17, p<0.0001)

Acta Clinica Belgica   2016  

2015 Retrospective Fujinaga33 11 1 × 375 mg/m2 7/11 CS free remis- 28.8 +/− 9.9 months 7 (4–20) months MMF with single
sion >1 year depletion if remission dose of RTX safe
>1 year, 5.3 (2.5–7) and effective
months if <1 year
2015 RCT Ravani7 15 1 × 375 mg/m2 Three-month protein- Median 22 Depletion in all, re- RTX non-inferior to
uria 42% lower in RTX (1–60 months) covery at 5.5 (range steroids in ear-
group 4–12) months ly-stage uncompli-
cated SDNS
2015 Retrospective Webb48 42 1–2 × 750 mg/m2 Median time to Minimal 1 year n.a. RTX superior to Cyc
relapse 14 months,
32% >24 months
remission
2016 Retrospective Kamei35 81 1 × 375 mg/m2, 63% additional doses (n.a.) 94% discontinued 38 (13–90) months Depletion in all but Only history of SRNS
Van Horebeek et al.  Rituximab in children with steroid-dependent nephrotic syndrome

CS, decrease of mean three, recovery at significant risk factor

relapses per year from 160 (39–311) days for relapse
4.5 to 0.9
2016 Retrospective Van Horebeek 9 1–4 × 375 mg/m2, 1–5 courses Reduction of yearly Median 2.75 year Depletion in all, Present study
relapse rate from 1.70 recovery at 230
to 0.26 (189–426) days
Notes: RTX rituximab, SDNS steroid-dependent nephrotic syndrome, No. number of patients included, n.a. not available, IS immunosuppression (not corticosteroids), CS corticosteroids, FU follow-up, MMF
­mycophenolate mofetil, RCT randomized controlled trial, CsA cyclosporine, and Cyc cyclophosphamide
 Van Horebeek et al.  Rituximab in children with steroid-dependent nephrotic syndrome

After the publication of several case reports9–13 and
small case series on RTX in SDNS,14–18 two randomized
controlled trials demonstrated that RTX with lower doses
of prednisone and CsA or Tac is non-inferior to stand-
ard therapy in maintaining short-term remission.7,19
Furthermore, it allows the tapering of prednisone and
calcineurin inhibitors resulting in less adverse effects.20–23
Recently, a multicenter double-blind, randomized, place-
bo-controlled trial on RTX in 48 children with SDNS has
been published, with a significantly longer median relapse-
free period and a significantly lower relapse rate in the
RTX group at one year follow-up.24
In this paper we describe our experience with RTX
treatment in children with SDNS and we present a review
of the literature on this topic.
Patients and methods
We retrospectively analyzed data of patients with diffi-
cult-to-treat SDNS who received RTX in the University
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clearance. A renal biopsy was performed in patients with
frequent relapses (two or more relapses in six months or four
or more relapses per year) before and/or after CsA or Cyc,
abnormal kidney function, macroscopic hematuria, persistent
hypertension, age at diagnosis younger than one year or older
than ten years, immunological abnormalities, family history
of nephrotic syndrome or after two years of CsA treatment.
Initially, all patients received one or two infusions of
375 mg/m² RTX (once weekly in case of two infusions)
when complete remission under CS therapy had been
achieved. All patients received cetirizine and paracetamol
as pretreatment before the infusion.
Additional RTX doses were administered based on the
specific clinical situation of each patient either because
of a relapse or after reappearance of B-cells (CD19+
cells > 1% of total lymphocyte count).
Results
Patients demographics

Hospitals of Leuven between April 2010 and February
2015. Nephrotic proteinuria was defined as more than
50 mg/kg/day or more than 2 g/g creatinine. Every episode
of proteinuria of 3+ or 4+ on stick or more than 2 g/g cre-
atinine for more than one day was considered as a relapse.
After two relapses during tapering of CS or within 14 days
after stop of CS patients were considered steroid-depend-
ent (definition according to the 2012 KDIGO guidelines25).
Relapses were treated with prednisolone 60 mg/m2/day
in two doses for six weeks, followed by 40 mg/m2 in one
or two doses on alternate days for six more weeks and
then tapering of prednisolone in four more weeks to stop.
Patients with steroid-resistant nephrotic syndrome (SRNS,
no complete remission attained after 8 weeks of CS ther-
apy) were excluded.
Age at diagnosis, dose and duration of CS therapy, type
and duration of immunosuppression, dose of RTX, age at
RTX administration, adverse events, number of relapses,
duration of remission, and duration of B-cell depletion
(based on CD19+ cell count) after administration of RTX
were analyzed. Renal function was estimated according to the
Schwartz formula and/or directly measured by 51Cr-EDTA
Nine patients (eight boys and one girl) were included.
Median age at diagnosis of INS was 4.75 (range 1.33–
11.33) years and median duration of disease at first RTX
administration was 11.00 (range 1.25–17.58) years. Renal
biopsy showed minimal change disease (MCD) in eight
patients and focal segmental glomerulosclerosis (FSGS) in
one. The immunosuppressive drugs taken by these patients
before RTX were MMF (n = 8), CsA (n = 7), levamisol
(Lev, n = 7), Tac (n = 5), chlorambucil (CMB, n = 4), and
cyclophosphamide (Cyc, n = 2). Median yearly number
of relapses before RTX was 1.70 (range 0.82–4.80). RTX
was considered because of toxicity of the used immuno-
suppressive drugs or multiple relapses despite these drugs.
Renal function at the time of RTX administration was nor-
mal in eight out of nine patients; one patient had a GFR
of 84 mL/min/1.73 m2 at the first RTX administration, but
fully recovered afterwards (>90 mL/min/1.73 m2). Patient
characteristics are summarized in Table 2.
Effect of RTX
Three patients initially received a single infusion of
375 mg/m2 RTX and six patients received two infusions

Table 2  Patient characteristics

Yearly number of
Age at diagnosis of INS Disease duration at relapses before
Patient (years) Sex Biopsy Treatment before RTX first RTX (years) RTX
1 4.75 M MCD Lev 11.00 0.82
2 4.58 M MCD CsA – Lev – CMB – MMF 12.83 1.56
3 9.58 M MCD CsA – Lev – CMB – MMF 9.67 1.96
4 2.33 M MCD CsA – CMB – MMF 9.42 1.70
5 2.25 F MCD CsA – Lev – CMB – MMF – Tac 13.75 1.53
6 6.58 M FSGS CsA – Lev – MMF – Tac – Cyc 11.25 2.58
7 1.33 M MCD CsA – Lev – MMF – Tac 17.58 1.37
8 2.08 M MCD CsA – MMF – Tac – Cyc 1.25 4.80
9 11.33 M MCD Lev – MMF – Tac 4.75 3.16
Median 4.75 11.00 1.70
Range 1.33–11.33 1.25–17.58 0.82–4.80
Notes: M male, F female, MCD minimal change disease, FSGS focal segmental glomerulosclerosis, CsA cyclosporine, Lev levamisole, CMB
chlorambucil, MMF mycophenolate mofetil, Tac tacrolimus, Cyc cyclophosphamide, and RTX rituximab

 Acta Clinica Belgica  2016   5

 Van Horebeek et al.  Rituximab in children with steroid-dependent nephrotic syndrome
of 375 mg/m2 in two consecutive weeks. Four patients
received an additional course of RTX because of clinical
relapse: two infusions once weekly in two patients and
four infusions once weekly in two other patients. Three
patients received preemptive additional courses of RTX
at the reappearance of B-cells: one patient received three
courses of two infusions of 375 mg/m2 once weekly, one
received two courses of one infusion of 375 mg/m2 and
a third one received only a single course of RTX (two
infusions of 375 mg/m2 once weekly). A rapid depletion
of B-cells (CD19+ cells < 1% of total lymphocyte count)
was seen in all patients.
Median follow-up after the initial RTX administration
was 2.75 (range 0.58–3.92) years.
Four patients did not experience any relapses after the
initial RTX administration with, respectively 0.58, 1.08,
1.50, and 3.17 years of follow-up, despite recovery of
B-cells in three patients. Relapses in the remaining five
patients occurred after a median of 0.84 years (approxi-
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mately ten months). With one or more additional courses
of RTX, four more patients attained a sustained remission
for, respectively 2.25, 3.83, 3.92, and 3.92 years.
Median number of relapses per year after RTX was 0.26
(range 0–2.18) (Fig. 1).
Median duration of B-cell depletion after RTX in seven
patients was 230 (range 189–426) days. In four patients,
relapses occurred after B-cell recovery (median inter-
val between B-cell reappearance and relapse 50 days),
one patient relapsed six times despite sustained B-cell
­depletion until last follow-up (2.75 years after RTX).
At last follow-up, two patients were still on CS, both
of them on lower doses than at the time of RTX admin-
istration. Only three patients continued immunosuppres-
sive drugs as maintenance therapy (two patients MMF and
one Tac), no new immunosuppressive agents were started
(Fig. 2). Five patients (two of those in sustained remission
after the initial RTX administration and three in sustained
remission with one or more additional courses) were free
of any oral therapy.
Figure 1  Yearly number of relapses before and after RTX for
each of nine patients and median values.
6 Acta Clinica Belgica   2016  
Figure 2  Number of patients on different immunosuppressive
drugs at the time of first RTX administration and at last follow-
up.
All patients but one received an angiotensin converting
enzyme inhibitor (ACE-I) at the time of RTX administra-
tion; this could be stopped in five patients.
Side effects of RTX
One patient had hypertension during and immediately after
the first RTX administration, without need for intervention
and with spontaneous recovery within 24 h. Subsequent
administrations were all well tolerated.
Two patients experienced hypogammaglobulinemia
after RTX, not related to relapses and without concurrent
hypoalbuminemia, for which they both received intrave-
nous immunoglobulins and cotrimoxazole in prophylactic
dose. One encountered multiple infections of the gastro-­
intestinal and upper pulmonary tract.
These findings are summarized in Table 3.
Discussion
We report a small case series of nine children from a single
center, showing beneficial effect of RTX in difficult-to-treat
SDNS. We demonstrated a reduction in relapse rate after
RTX in all patients, despite tapering of CS and immuno-
suppression (Figs. 1–2). Furthermore, no serious adverse
events have been documented in our cohort.
We would like to point out that RTX is not available for
this indication in Belgium in contrast to other European
countries or Japan,26 stressing the need to document the
experience of our off-label use.
Not only in our experience, but also in the available
literature (Table 1), RTX has been shown to be an efficient
and relatively safe treatment option in difficult-to-treat
SDNS. Nonetheless, documented experience is limited and
possibly biased and therefore more large double-blind pla-
cebo-controlled trials, with especially a longer follow-up
are needed to confirm the efficacy and safety of this
drug. Furthermore, the available data are characterized
by heterogeneity in patient selection, treatment protocol
and maintenance therapy, so at this point it is not only
impossible to draw strong conclusions on the exact effect
of RTX, but also on the optimal treatment strategy and
patient selection.
Indeed, the fact that there is no consensus on the num-
ber of initial infusions leads to notable heterogeneity in
 Van Horebeek et al.  Rituximab in children with steroid-dependent nephrotic syndrome

Table 3  Clinical course after RTX

Yearly B-cell Duration of
number of ­depletion remission Follow-up
Age at first relapses after Treatment after first after first after first Adverse
Patient Dose of RTX RTX (years) RTX after RTX RTX (days) RTX (days) RTX (years) events
1 1 × 375 mg/m2 15.75 0 – 189 … 1.50 –
2 2 × 375 mg/m2 17.42 0 – 426 … 3.17 –
3 2 × 375 mg/m2 19.25 0 CS … … 0.58 –
4 2 × 375 mg/m2 11.75 0 MMF 197 … 1.08 –
2 × 375 mg/m2
5 2 × 375 mg/m2 16 0.26 MMF 274 603 3.92 hypoγ
2 × 375 mg/m2
6 1 × 375 mg/m2 17.83 0.44 – 230 307 2.25 HTN
2 × 375 mg/m2
1 × 375 mg/m2
1 × 375 mg/m2
7 2 × 375 mg/m2 18.92 0.52 – 311 333 3.83 –
4 × 375 mg/m2
8 2 × 375 mg/m2 3.33 1.79 – 225 248 3.92 hypoγ
4 × 375 mg/m2
2 × 375 mg/m2
2 × 375 mg/m2
2 × 375 mg/m2
9 1 × 375 mg/m2 16.08 2.18 CS – Tac … 79 2.75 –
Median 16.08 0.26 230 (of 7) 307 (of 5) 2.75
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Range 3.33–19.25 0–2.18 189–426 79–603 0.58–3.92

Notes: RTX rituximab, CS corticosteroids, MMF mycophenolate mofetil, Tac tacrolimus, hypoγ hypogamma-globulinemia, HTN hyperten-
sion, … ongoing at last follow-up.

treatment regimen both in literature and in our center.
Since the first report on RTX in nephrotic syndrome
in 2004,9 RTX has mostly been administered in a dose
of 375 mg/m2 once weekly for four weeks, a regimen
based on that used for lymphomas. Now, more and
more evidence emerges that less initial infusions could
be sufficient to maintain remission in INS.14,16,27 One
single infusion seems to be sufficient for short-term
remission10,16,28,29 and several studies suggested that
administration of more than two initial doses does not
seem to have an additional advantage.14,17,30,31 Kemper
et al. showed that three or four initial infusions lead
to a longer remission before the first relapse, but with
no impact on long-term remission.30 Our retrospective
study showed that one or two infusions of RTX were
able to induce or to prolong remission of SDNS when
combined with low doses of CS or immunosuppressive
drugs, which could afterwards be tapered.
In our cohort there was a clear relation between reap-
pearance of B-cells and the occurrence of relapses, except
for one patient who relapsed after RTX despite ongoing
complete B-cell depletion. Bad adherence to the concur-
rent medication (CS and Tac) might play a role in the
disease course of this patient. In the other patients relapses
occurred almost each time a few weeks after B-cell reap-
pearance, suggesting a relation between reappearance of
B-cells and the occurrence of relapses as described many
times before.14,16–18,22,28,29,31–33 B-cell follow-up might thus
help determine the right timing for subsequent RTX
infusions to prolong the remission period. However, this
relationship is not absolute since some patients relapse
despite B-cell depletion,15,17,34,35 whereas others remain in
remission even long after reappearance of B-cells.7,14,16,27
Furthermore, the levels of B-cells at which relapses occur
are highly variable, between 3 and 59% of total lympho-
cyte count.14,31. Consequently, there is no specific B-cell
threshold predictive for relapse.
Usually, B-cells recover 6 to 12 months after admin-
istration of RTX.14,30,31,36,37 Our observation confirms this
finding with a median of approximately eight months
between RTX administration and recovery of B-cells.
There seems to be no correlation between number of RTX
infusions and duration of B-cell depletion 14,17; moreover,
Ito et al. found no significant difference in duration of
B-cell depletion between patients who relapsed and those
who remained in remission.21 Maintenance therapy does
not seem to influence the duration of B-cell depletion.21,28,29
The fact that certain studies show longer B-cell deple-
tion38 and longer median time between relapses31 after mul-
tiple courses of RTX compared to only one course and that
long-term remission is attained in two-thirds of patients
after 15 months of RTX-induced B-cell depletion,34 sug-
gests that multiple courses of RTX can possibly lead to
even better outcome than only one course. A recent study
by Colucci et al. analyzed subsets of B- and T-cells before
and after RTX and found that only sustained depletion of
switched memory B-cells was protective against relapse.39
This has to be further investigated.
In general, RTX is well tolerated, as was observed in
our cohort. Most frequent adverse effects are infusion
reactions (up to half of the patients), which disappear
at slowing infusion rate or stopping the infusion, often
without need for specific treatment and not reoccurring
after subsequent infusions.10,14,16–21,23,28–31,35 On the other
hand, our study confirmed the risk of hypogammablobu-
linemia after RTX,14,40–42 but with limited consequences.

 Acta Clinica Belgica  2016   7

 Van Horebeek et al.  Rituximab in children with steroid-dependent nephrotic syndrome
Interestingly, hypogammaglobulinemia in our patients
was present even before RTX, suggesting that RTX
doesn’t necessarily induce hypogammaglobulinemia
but rather prolongs or possibly worsens preexisting
hypogammaglobulinemia, as suggested by Delbe-Bertin
et al.40 Supplementation with intravenous immunoglob-
ulines is recommended in such cases.41 No cases of
progressive multifocal leukoencephalopathy, a dreaded
complication after RTX mostly seen in lupus patients,
are reported in INS. However, several other severe
adverse effects have been described, such as fulminant
myocarditis requiring heart transplantation,41 fatal pul-
monary fibrosis,43 severe ulcerative colitis44 and serious
infections.17,27 Longer B-cell depletion does not seem
to increase the risk of infections in the medium term34;
long-term follow-up data from oncology and rheuma-
toid arthritis suggest that no new adverse events arise
in the long term or after multiple courses of RTX.37,45
Our study has several limitations due to the retrospec-
Downloaded by [University of Exeter] at 06:29 15 July 2016
tive design and the small patients number. However, most
of the currently available literature is based on small series
and we believe these reports are an important tool to mon-
itor the use of and experience with this type of off-label
drugs.
Conclusion
Our study describes the experience of a single center and
demonstrates that RTX is an effective treatment option for
difficult-to-treat SDNS, with a reduction of median yearly
number of relapses from 1.70 to 0.26 despite reduction of
other immunosuppressive medication. Large, randomized
controlled trials are necessary to confirm the efficacy and
safety of RTX, to determine which patients may benefit
most from RTX and to determine the optimal treatment
strategy.
List of abbreviations
ACE-I  angiotensin converting enzyme inhibitor
CMB chlorambucil
Cr-EDTA  chromium ethylenediaminetetra-acetic acid
CS corticosteroids
Cyc cyclophosphamide
CsA cyclosporine
FSGS  focal segmental glomerulosclerosis
INS  idiopathic nephrotic syndrome
Lev levamisole
MCD  minimal change disease
MMF  mycophenolate mofetil
RTX rituximab
SDNS  steroid-dependent nephrotic syndrome
SRNS  steroid-resistant nephrotic syndrome
Tac tacrolimus
8 Acta Clinica Belgica   2016  
Contributors
All authors are part of the pediatric nephrology department
of University Hospitals Leuven, I Van Horebeek as resi-
dent, the others as senior physicians. Additional informa-
tion does not seem to be of supplemental value, all patients
are treated by this team.
Conflicts of interest  None
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