Efficacy and safety of rituximab in comparison with common induction therapies in pediatric active lupus nephritis

• Published in: Pediatric nephrology (Berlin, West) Vol. 32; no. 6; pp. 1013 - 1021
• Main Authors: Basu, Biswanath, Roy, Birendranath, Babu, Binu George
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01.06.2017; Springer; Springer Nature B.V
• Subjects: Adverse events; Child; Child, Preschool; Children; Clinical Protocols; Cyclophosphamide; Cyclophosphamide - therapeutic use; Disease-Free Survival; Diseases; Drug therapy; Female; Follow-Up Studies; Glucocorticoids; Humans; Immunosuppressive Agents - therapeutic use; Immunotherapy; Induction therapy; Lupus; Lupus nephritis; Lupus Nephritis - drug therapy; Lupus Nephritis - mortality; Male; Medicine; Medicine & Public Health; Methylprednisolone; Methylprednisolone - therapeutic use; Monoclonal antibodies; Mycophenolate mofetil; Mycophenolic acid; Mycophenolic Acid - therapeutic use; Nephritis; Nephrology; Original Article; Patient outcomes; Patients; Pediatrics; Prednisolone; Prednisone; Prednisone - therapeutic use; Remission; Remission Induction - methods; Retrospective Studies; Rituximab; Rituximab - therapeutic use; Survival Analysis; Systemic lupus erythematosus; Treatment Outcome; Urology; India; Rituximab; Pediatric SLE; Cyclophosphamide; Lupus nephritis; Mycophenolate mofetil
• ISSN: 0931-041X; 1432-198X
• DOI: 10.1007/s00467-017-3583-x

Background Childhood-onset lupus nephritis (LN) is one of the most severe manifestations of systemic lupus erythematosus (SLE). Despite treatment-related toxicities, cyclophosphamide (CYC) and glucocorticoid-based treatment protocols are still considered standard therapy in managing this multisystem disorder. An effective and safe alternative induction regimen is needed. Methods Forty-four pediatric patients with active LN aged 3.5–13.8 (median 8.4) years, of whom 32 entered the study at diagnosis of SLE, were followed over 36 months. Induction therapy consisted of methylprednisolone pulses followed by either rituximab (RTX) ( n  = 17), mycophenolate mofetil (MMF) ( n  = 12) or pulse-CYC ( n  = 15), with tapering dose of prednisolone orally. MMF was added as maintenance immunosuppressant (800 mg/m 2 daily) in all children from the third month onward. Results Flare-free survival was significantly higher at 36 months with RTX compared with MMF and CYC (100% for RTX vs. 83% for MMF. and 53% for CYC, p  = 0·006). Twelve patients (76.5%) achieved complete remission with RTX compared with five (41.7%) and seven (46.7%) with MMF and CYC, respectively, at last follow-up. Requirement of mean daily dosage of prednisone was significantly lower in RTX group [ p  = 0.005 (RTX vs MMF); 0.0001 (RTX vs CYC) at 36 months] compared with other groups after the 3-month follow-up. In comparison with few minor adverse events in the other two cohorts, several serious adverse events occurred in the CYC group. Conclusions Efficacy and medium-term safety of RTX induction followed by MMF maintenance therapy in inducing and maintaining remission among children with LN were evident in this study.