Long-term B-cell depletion with rituximab in relapsing, refractory and severe lupus nephritis: a retrospective case...

B-cell depletion with anti-CD20 agents has been evaluated as part of induction immunosuppression (IS) in lupus nephritis (LN). Data on its long-term efficacy for maintenance of remission remains limited.

Retrospective case series evaluating outcomes in patients with relapsing, refractory and severe LN at diagnosis who received rituximab (RTX)-induced continuous B-cell depletion for both induction and maintenance at Massachusetts General Hospital from 2008 to 2023.

A total of 26 patients with active LN were included. Eighty-eight percent (23/26) had class III/IV ± V on kidney biopsy; 12% (3/26) had pure class V LN. Median follow-up (from first to last RTX) was 32 months [interquartile range (IQR) 14-68]; median cumulative dose of RTX was 10 g (IQR 6-17). At RTX initiation, all patients received prednisone and oral IS with an intention to taper off oral agents in 12 months. Eighty-one percent (21/26) achieved at least partial remission. Median prednisone dose decreased from 30 to 5 mg/day at 6 months (P < .01). Fifty-eight percent (15/26) of patients at 12 months and 79% (11/14) at 24 months were on RTX monotherapy. Six renal relapses occurred in five patients with median time-to-first relapse of 43 months (range 24-142); all episodes but one were preceded by B-cell repopulation. Five patients developed end-stage kidney disease; all had creatinine >2 mg/dL at RTX initiation. Thirty-one percent (8/26) experienced severe infections requiring hospitalization. No deaths occurred.

Long-term continuous B-cell depletion may be an effective treatment strategy in patients with LN who have failed prior IS or with severe disease at diagnosis. Future controlled studies are needed to further evaluate this approach as the backbone therapy in LN.