Rituximab-Belimumab Sequential Therapy in Refractory Minimal Change Disease

Frequent relapses and steroid dependence remain challenging in minimal change disease (MCD). Rituximab depletes B cells, yet post-treatment B-cell Activating Factor (BAFF) elevation may drive disease relapse. Sequential rituximab followed by belimumab (a BAFF inhibitor) has shown benefit in lupus, but its role in MCD is unknown. A 14-year-old male with biopsy-proven MCD and acute kidney injury failed multiple immunosuppressants, including two courses of rituximab (the first induced a 6-month remission, whereas the second failed despite B-cell depletion). After another relapse, he received single-dose rituximab followed by belimumab, achieving complete remission and maintaining relapse-free for 57 months.This case suggests that sequential rituximab-belimumab therapy may offer durable remission in MCD patients who are refractory to conventional immunosuppressive regimens.