Crohn’s disease following rituximab treatment in a patient with refractory nephrotic syndrome
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Rituximab (RTX) is increasingly used for the treatment of refractory nephrotic syndrome due to its inhibitory effect on B cells which extends the period of remission, while lowering the dose of steroids needed for disease management. However, RTX can lead to various side effects, including Crohn’s disease. Herein, we describe a case of a 15-year-old boy with refractory nephrotic syndrome diagnosed at age 9 years who developed Crohn’s disease following RTX treatment. RTX was initiated in this patient at the age of 13 years 6 months due to occurrence of 12 relapses of nephrotic syndrome over a 4-year period, despite treatment using cyclosporine, steroid pulse therapy, and mycophenolate mofetil. The patient received 4 doses of RTX over a 2-year period (dose, 375 mg/m2). Although the treatment was effective in extending the disease-free duration up to 6 months, at the age of 15 years 9 months, the patient developed abdominal pain, associated with frequent watery stools and rapid weight loss. Based on clinical and endoscopic findings, he was diagnosed with Crohn’s disease and treated using infliximab. Remission of Crohn’s disease was achieved with this treatment, with no further relapse of nephrotic syndrome. Infliximab is thought to extend the remission period of nephrotic syndrome. In this case, we propose that Crohn’s disease was caused by an abnormal immune tolerance, secondary to the use of RTX, although the exact underlying mechanism remains to be clarified. Therefore, inflammatory bowel disease should be considered if severe abdominal symptoms with weight loss following RTX administration are observed.
KeywordsRefractory nephrotic syndrome Rituximab Crohn’s disease Infliximab
Compliance with ethical standards
Informed consent was obtained from all individual participants included in the study.
Human and animal rights
This article does not contain any studies with human participants or animals performed by any of the authors.
Conflict of interest
The authors have declared that no conflict of interest exists.
- 2.Tarshish P. Prognostic significance of the early course of minimal change nephrotic syndrome: report of the International Study of Kidney Disease in Children. J Am Soc Nephrol. 1997;8:769–76.Google Scholar
- 4.Takei T, Sugiura H, Nitta K. Biological preparation rituximab. J Clin Exp Med. 2011;237:9.Google Scholar
- 5.Suzuki Group. The diagnostic criteria and guide to medical care of ulcerative colitis and Crohn’s disease: research study about the refractory inflammatory intestinal disorder. Public welfare labor science research expenses subsidy Policy study business such as refractory disease 2015. 2015.Google Scholar
- 7.Okazaki K, Chiba T. Cytokine network abnormality of the inflammatory bowel disease. Bioclinica. 2002;17:2833.Google Scholar
- 9.Iijima K. Rituximab physician-led clinical trial for childhood refractory nephrotic syndrome. Jpn Pharmacol Ther. 2014;42:2.Google Scholar
- 10.Takao M. Molecularly targeted therapy and progressive multifocal leukoencephalopathy. Jpn J Clin Med. 2015;73:869–76.Google Scholar
- 12.Tomohiro W, Tsutomu C. Immunopathogenesis of Crohn’s disease due to NOD2 mutations. J Clin Exp Med. 2012;241:191–5.Google Scholar
- 13.Tomohiro W. An automatic bacteriophage and Crohn’s disease. IBD. 2009;3:216–21.Google Scholar
- 15.McCarthy ET, Sharma R, Scharma M, Li JZ, Ge XL, Dileezpan KN. TNFα increases albumin permeability of isolated rat glomeruli through the generation of superoxide. J Am Soc Nephrol. 1998;9:433–8.Google Scholar
- 16.Tabrez J, Suraksha A, Abbas AM, Raj KS, et al. Cytokine gene polymorphism in idiopathic nephrotic syndrome children. Ind J Clin Biochem. 2011;3:296–302.Google Scholar