title: Rituximab is not a "magic drug" in post-transplant recurrence of nephrotic syndrome.
abstract: Pediatric patients with end-stage renal failure due to severe drug-resistant nephrotic syndrome are at risk of rapid recurrence after renal transplantation. Treatment options include plasmapheresis, high-dose of cyclosporine A/methylprednisolone and more recently-rituximab (anti-B CD20 monoclonal depleting antibody). We report five patients with immediate (1-2 days) post-transplant recurrence of nephrotic syndrome, treated with this kind of combined therapy including 2-4 weekly doses of 375 mg/m(2) of rituximab. Only two (of five) patients have showed full long-term remission, while the partial remission was seen in two cases, and no clinical effect at all was achieved in one patient. The correlation between B CD19 cells depletion and clinical effect was present in two cases only. Severe adverse events were present in two patients, including one fatal rituximab-related acute lung injury.
  
  
  CONCLUSIONS
  The anti-CD20 monoclonal antibody may be not effective in all pediatric cases of rapid post-transplant recurrence of nephrotic syndrome, and benefit/risk ratio must be carefully balanced on individual basis before taking the decision to use this protocol.
  
  
  BACKGROUND
  • nephrotic syndrome may recur immediately after renal transplantation • plasmapheresis combined with pharmacotherapy is used as rescue management • rituximab was reported as effective drug both in primary and post-transplant nephrotic syndrome What is New: • rituximab may not be effective is several cases of post-transplant nephrotic syndrome due to variety of underlying mechanisms of the disease, which may be or not be responsive to this drug • there may be no correlation between drug-induced depletion of specific B cells and clinical effect; this might suggest B-cell independent manner of rituximab action.
authors.affiliation: Department of Nephrology, Kidney Transplantation & Hypertension, The Children's Memorial Health Institute, Warsaw, Poland. r.grenda@czd.pl.
authors.forename: Ryszard
authors.initials: R
authors.lastname: Grenda
authors.affiliation: Department of Nephrology, Kidney Transplantation & Hypertension, The Children's Memorial Health Institute, Warsaw, Poland.
authors.forename: Wioletta
authors.initials: W
authors.lastname: Jarmużek
authors.affiliation: Department of Nephrology, Kidney Transplantation & Hypertension, The Children's Memorial Health Institute, Warsaw, Poland.
authors.forename: Jacek
authors.initials: J
authors.lastname: Rubik
authors.affiliation: Histocompatibility Lab, The Children's Memorial Health Institute, Warsaw, Poland.
authors.forename: Barbara
authors.initials: B
authors.lastname: Piątosa
authors.affiliation: Department of Nephrology, Kidney Transplantation & Hypertension, The Children's Memorial Health Institute, Warsaw, Poland.
authors.forename: Sylwester
authors.initials: S
authors.lastname: Prokurat
mesh_terms: D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007155:Immunologic Factors / Q000008:administration & dosage / Q000009:adverse effects*; D007676:Kidney Failure, Chronic / Q000209:etiology / Q000601:surgery; D016030:Kidney Transplantation; D008168:Lung / Q000187:drug effects; D055370:Lung Injury / Q000139:chemically induced; D008297:Male; D009404:Nephrotic Syndrome / Q000188:drug therapy* / Q000209:etiology; D011183:Postoperative Complications / Q000188:drug therapy*; D012008:Recurrence; D012074:Remission Induction; D012189:Retrospective Studies; D000069283:Rituximab / Q000008:administration & dosage / Q000009:adverse effects*
chemical_list: D007155:Immunologic Factors; D000069283:Rituximab
keywords: Nephrotic syndrome; Rapid recurrence; Renal transplantation; Rituximab