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Long-term results of rituximab treatment for membranous nephropathy after allogeneic hematopoietic SCT: a case report

Bone Marrow Transplantation volume 45, pages 1111–1112 (2010)Cite this article

The entity of renal GVHD, specified as glomerular lesions resulting in nephrotic syndrome, was recently identified as an under-reported, late complication of both conventional and reduced-intensity or non-myeloablative allogeneic HSCT, usually associated with active manifestations of chronic GVHD and modification of immunosuppression.3, 4, 5, 6 Among the variable glomerular histologies described in this unique clinical setting, comprising mainly MN and less frequently minimal change disease or other renal diseases, MN occurred later and exhibited a worse prognosis in comparison with other histology findings.3, 4, 5 Combined treatment with immunosuppressive agents and corticosteroids remains the mainstay of initial treatment of MN in allogeneic HSCT recipients.3 Most recently, preliminary data have suggested that the anti-CD20 chimeric MoAb, rituximab, may prove helpful as a salvage treatment in patients with MN after allogeneic HSCT.4, 6 These results are in keeping with the observation that rituximab is an effective therapeutic option for extensive steroid-refractory chronic GVHD.7, 8 In contrast, other case series failed to show any role for rituximab in ameliorating MN associated with chronic GVHD.5, 9 However, the seemingly good prognosis of post-allogeneic HSCT MN treated with rituximab has to be weighed against the lack of long-term outcome data, as the longest available follow-up was only 7 months.6 This case is interesting owing to medical comorbidities and therapeutic problems, in that deterioration of renal function and the increased risk of spreading life-threatening fungal infection contraindicated further immunosuppressive or myelosuppressive treatments. Rituximab treatment was highly effective resulting in a persistent PR in the long term. However, we cannot exclude a beneficial effect of combined concomitant ACEi and corticosteroid therapy for proteinuria. Toxicity of this treatment was negligible. The temporal association between active symptoms of chronic GVHD and nephrotic syndrome development, and their concomitant improvement after rituximab treatment seems to confirm the existence of renal feature of chronic GVHD in our case. Although we do not have direct data on the clearance of peripheral blood B cells, we suppose on clinical grounds that rituximab efficacy in the secondary immunosuppression for MN might be related to its action on the B-cell component of chronic GVHD. In conclusion, this report points to the efficacy of rituximab as a salvage treatment for chronic GVHD with renal involvement and to its favourable risk--benefit profile. However, evidence of long-term benefit from rituximab treatment in this specific clinical setting is still lacking.

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Authors and Affiliations

  1. Department of Hematology, Santa Croce Hospital, Cuneo, Italy

    D Mattei, R Sorasio, N Mordini, D Rapezzi & A Gallamini

  2. Department of Nephrology, Santa Croce Hospital, Cuneo, Italy

    A Guarnieri, F Marazzi & M Formica

  3. Department of Pathology, Santa Croce Hospital, Cuneo, Italy

    M Fortunato

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  1. D Mattei
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Correspondence to D Mattei.

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Mattei, D., Sorasio, R., Guarnieri, A. et al. Long-term results of rituximab treatment for membranous nephropathy after allogeneic hematopoietic SCT: a case report. Bone Marrow Transplant 45, 1111–1112 (2010). https://doi.org/10.1038/bmt.2009.276

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