Rituximab in glomerular diseases: Indications, long-term use, complications and research gaps

Rituximab (RTX) is a monoclonal antibody targeted against the B-cell surface antigen CD20 that plays a significant role in the treatment of glomerular diseases. It is approved for the induction and maintenance of remission of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, and it is used as off-label treatment in several other diseases. Despite the increased use, there is a lack of high-quality evidence for some indications. More specifically, the optimal initial dosing and subsequent frequency of administration, if even indicated, remain to be established. There are short and long-term risks associated with its use, including serious infectious complications, late-onset neutropenia, sustained B-cell depletion, hypogammaglobulinemia, and impaired response to vaccines. In this review, we aimed to summarize the indications for RTX use in the management of glomerular diseases, addressed the potential risks of this treatment, and highlighted some knowledge gaps which are unlikely to be answered in future clinical trials. While newer B-cell targeting therapies, including CD20-depleting antibodies, are tested and might be more effective or approved based on randomized controlled trials, RTX will remain relevant due to the limited costs to healthcare providers, the good safety profile and the long-standing experience of glomerular disease physician to use it.