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

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Abstract

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/m2 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.

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Acknowledgements

We thank all participating children and their parents. We also thank the nursing staff, dialysis technician, and lab technician at the pediatric nephrology clinics at NRS Medical College, Kolkata. Additionally, we thank all doctors who referred patients to us and our health administration.

Authors contributions

B. Basu and B Babu: study design and execution, data collection and analysis, preparation of manuscript; BN Roy: preparation of manuscript.

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Author notes

  1. Binu George Babu

    Present address: Department of Pediatrics, Caritas Hospital, Kerala, India

Authors and Affiliations

  1. Division of Pediatric Nephrology, Department of Pediatrics, NRS Medical College & Hospital, Kolkata, 700014, West Bengal, India

    Biswanath Basu

  2. Department of Pediatrics, NRS Medical College & Hospital, Kolkata, India

    Birendranath Roy

  3. Division of Pediatric Nephrology, Department of Pediatrics, NRS Medical College & Hospital, Kolkata, India

    Binu George Babu

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  1. Biswanath Basu
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Correspondence to Biswanath Basu.

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The study was approved by the Institutional Review Board of our institute.

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Basu, B., Roy, B. & Babu, B.G. Efficacy and safety of rituximab in comparison with common induction therapies in pediatric active lupus nephritis. Pediatr Nephrol 32, 1013–1021 (2017). https://doi.org/10.1007/s00467-017-3583-x

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