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Drug Insight: rituximab in renal disease and transplantation

Abstract

Rituximab, a monoclonal antibody directed against the CD20 molecule found on pre-B cells and mature B cells (but not on plasma cells), was introduced in the late 1990s for the treatment of non-Hodgkin's lymphoma. Recently, this antibody has been used to treat autoimmune diseases, especially those associated with a prominent humoral component and with potentially pathogenic autoantibodies. Small cohort studies have indicated that rituximab could have an important role in the management of these disorders. Rituximab has also been utilized in the transplant setting, to diminish levels of alloreactive antibodies in highly sensitized patients, to manage ABO-incompatible transplants, and to treat rejection associated with B cells and antibodies. The exact mechanism by which rituximab exerts its effects in autoimmunity and transplantation remains unclear, as specific autoantibody or alloantibody levels often seem not to diminish in parallel with clinical improvement. A role for rituximab in depleting B cells and compromising their antigen-presenting function seems likely; rituximab might also inhibit T-cell activation. A synergistic effect has been noted in vitro following administration of corticosteroids to B-cell lines, with accentuation of B-cell cytotoxicity; this observation might be relevant to certain studies, as some regimens have utilized both agents simultaneously. This article reviews the current use of rituximab in renal disease and transplantation, and includes discussion of the drug's potential role in novel therapeutic protocols.

Key Points

  • Immune responses mediated by B cells (which produce antibodies and cytokines and present antigen to T cells) are important in autoimmune renal disease and transplantation

  • B-cell depletion can alter the course of autoimmune and alloimmune responses

  • Monoclonal antibodies to B-cell antigens can effectively deplete circulating B cells, diminishing their effector functions

  • Rituximab, a monoclonal antibody directed against CD20, has been successfully used in hematological B-cell disorders

  • Rituximab has been used in a number of autoimmune conditions and in transplantation with some success

  • Randomized trials are required to compare the short-term and long-term efficacy of B-cell deletional strategies with conventional immuno-suppressants in the treatment of renal disease

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Figure 1: B-cell development and antigen expression.
Figure 2: B-cell functions are inhibited following cell depletion by rituximab.

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Correspondence to Alan D Salama.

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Salama, A., Pusey, C. Drug Insight: rituximab in renal disease and transplantation. Nat Rev Nephrol 2, 221–230 (2006). https://doi.org/10.1038/ncpneph0133

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