Rituximab monotherapy for remission induction of proliferative lupus nephritis flares: Description of 3 cases

Background: The efficacy and safety of rituximab when not associated with other immunosuppressive therapy in induction of remission of proliferative lupus nephritis (PLN) has not until now been proven. Methods: We report on 3 patients with PLN (class IV), 1 with a nephritic flare and 2 with a proteinuric flare (all with nephrotic syndrome (NS)) treated with 3 intravenous methylprednisolone pulses for 3 consecutive days and with rituximab at day 3 and day 18 associated with oral prednisone. At the beginning of the fourth month of therapy, mycophenolate mofetil was combined with prednisone. Results: Three months after the beginning of therapy, renal function improved in the patient with the nephritic flare, and proteinuria fell to within the non-nephrotic range in all 3 patients. At the end of a follow-up of 24 months, the patient with the nephritic flare had normal renal function (serum creatinine from 1.7 to 1 mg/dL) and mild proteinuria (from 6 to 0.7 g/24 hours). The second patient was in complete remission (proteinuria from 5 to 0.127 g/24 hours) 27 months after the beginning of therapy. In the last patient, followed for 10 months, mild proteinuria persisted (from 6.6 to 0.7 g/24 hours). The therapy was well tolerated by all patients. No adverse effects occurred during the follow-up. Conclusion: Although our results must be confirmed by larger prospective studies, rituximab associated with methylprednisolone pulses without any other concomitant immunosuppressive drug seems to be effective and safe for induction therapy of severe flares of PLN.