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

Abstract Background B cell depletion with anti-CD 20 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. Methods Retrospective case series evaluating outcomes in patients with relapsing, refractory and severe LN at diagnosis who received RTX-induced continuous B cell depletion for both induction and maintenance at Massachusetts General Hospital from 2008—2023. Results 26 patients with active LN were included. 88% (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 (IQR 14–68); median cumulative dose of RTX was 10 grams (IQR 6–17). At RTX initiation, all patients received prednisone and oral IS with an intention to taper off oral agents in 12 months. 81% (21/26) achieved at least partial remission. Median prednisone dose decreased from 30 to 5 mg/day at 6 months (P < 0.01). 58% (15/26) of patients at 12 months and 79% (11/14) at 24 months were on RTX monotherapy. 6 renal relapses occurred in 5 patients with median time-to-first relapse of 43 months (range 24–142), all but 1 episode were preceded by B cell repopulation. 5 patients developed end-stage kidney disease, all had creatinine >2 mg/dL at RTX initiation. 31% (8/26) experienced severe infections requiring hospitalization. No deaths occurred. Conclusion 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.