Articles

Rituximab for childhood-onset, complicated, frequently

relapsing nephrotic syndrome or steroid-dependent
nephrotic syndrome: a multicentre, double-blind,
randomised, placebo-controlled trial
Kazumoto Iijima, Mayumi Sako, Kandai Nozu, Rintaro Mori, Nao Tuchida, Koichi Kamei, Kenichiro Miura, Kunihiko Aya, Koichi Nakanishi,
Yoshiyuki Ohtomo, Shori Takahashi, Ryojiro Tanaka, Hiroshi Kaito, Hidefumi Nakamura, Kenji Ishikura, Shuichi Ito, Yasuo Ohashi, on behalf of the
Rituximab for Childhood-onset Refractory Nephrotic Syndrome (RCRNS) Study Group

Summary
Background Rituximab could be an effective treatment for childhood-onset, complicated, frequently relapsing Lancet 2014; 384: 1273–81
nephrotic syndrome (FRNS) and steroid-dependent nephrotic syndrome (SDNS). We investigated the efficacy and Published Online
safety of rituximab in patients with high disease activity. June 23, 2014
http://dx.doi.org/10.1016/
S0140-6736(14)60541-9
Methods We did a multicentre, double-blind, randomised, placebo-controlled trial at nine centres in Japan. We
See Comment page 1242
screened patients aged 2 years or older experiencing a relapse of FRNS or SDNS, which had originally been diagnosed
Department of Pediatrics,
as nephrotic syndrome when aged 1–18 years. Patients with complicated FRNS or SDNS who met all other criteria Kobe University Graduate
were eligible for inclusion after remission of the relapse at screening. We used a computer-generated sequence to School of Medicine, Chuo-ku,
randomly assign patients (1:1) to receive rituximab (375 mg/m²) or placebo once weekly for 4 weeks, with age, Kobe, Japan (Prof K Iijima MD,
institution, treatment history, and the intervals between the previous three relapses as adjustment factors. Patients, K Nozu MD, H Kaito MD);
Division for Clinical Trials,
guardians, caregivers, physicians, and individuals assessing outcomes were masked to assignments. All patients Department of Development
received standard steroid treatment for the relapse at screening and stopped taking immunosuppressive agents by Strategy (M Sako MD,
169 days after randomisation. Patients were followed up for 1 year. The primary endpoint was the relapse-free period. H Nakamura MD), and
Safety endpoints were frequency and severity of adverse events. Patients who received their assigned intervention Department of Health Policy
(R Mori MD), Center for Social
were included in analyses. This trial is registered with the University Hospital Medical Information Network clinical and Clinical Research, National
trials registry, number UMIN000001405. Research Institute for Child
Health and Development,
National Center for Child
Findings Patients were centrally registered between Nov 13, 2008, and May 19, 2010. Of 52 patients who underwent
Health and Development,
randomisation, 48 received the assigned intervention (24 were given rituximab and 24 placebo). The median relapse- Setagaya-ku, Tokyo, Japan;
free period was significantly longer in the rituximab group (267 days, 95% CI 223–374) than in the placebo group Department of General
(101 days, 70–155; hazard ratio: 0·27, 0·14–0·53; p<0·0001). Ten patients (42%) in the rituximab group and six (25%) Pediatrics and
Interdisciplinary Medicine
in the placebo group had at least one serious adverse event (p=0·36).
(N Tuchida MD) and
Department of Nephrology
Interpretation Rituximab is an effective and safe treatment for childhood-onset, complicated FRNS and SDNS. and Rheumatology
(K Kamei MD, S Ito MD),
National Center for Child
Funding Japanese Ministry of Health, Labour and Welfare.
Health and Development,
Setagaya-ku, Tokyo, Japan;
Introduction Standard treatments for FRNS, SDNS, and steroid- Department of Pediatrics,
Childhood nephrotic syndrome is a disorder affecting resistant nephrotic syndrome are immunosuppressive Graduate School of Medicine,
University of Tokyo, Bunkyo-
the kidneys in which a large amount of protein passes agents: cyclophosphamide, chlorambucil, ciclosporin,
ku, Tokyo, Japan (K Miura MD);
through the glomerular filter, resulting in hypo- tacrolimus, and levamisole are used for paediatric FRNS or Chuo University, Bunkyo-ku,
proteinaemia and generalised oedema. Idiopathic SDNS, and ciclosporin for paediatric steroid-resistant Tokyo, Japan
nephrotic syndrome occurs in two or more of every nephrotic syndrome.3–5 Most children are effectively treated (Prof Y Ohashi PhD);
Department of Pediatrics,
100 000 children1 and is the most common chronic with these drugs; however, some have frequent relapses. In Okayama University Graduate
glomerular disease in paediatric nephrology practice. two studies,6,7 10–20% of children taking ciclosporin had School of Medicine, Dentistry
Minimal change nephrotic syndrome is the most frequent relapses, and in another study,8 about 30% of the and Pharmaceutical Sciences,
common form of the disorder, for which steroid therapy patients with steroid-resistant nephrotic syndrome after Shikata-cho, Okayama, Japan
(K Aya MD); Department of
is effective for most patients.2 Those who respond well ciclosporin had steroid-sensitive, frequent relapses after Pediatrics, Wakayama Medical
rarely progress to chronic renal failure, but up to half complete remission. In addition to being ineffective in University, Wakayama, Japan
develop frequently relapsing nephrotic syndrome (FRNS) some patients, ciclosporin can cause side-effects—the most (K Nakanishi MD); Department
or steroid-dependent nephrotic syndrome (SDNS; common of which is chronic nephrotoxicity9,10—suggesting of Pediatrics, Juntendo
University Nerima Hospital,
table 1).2 Moreover, 10–20% of patients with idiopathic that it should be discontinued within 24 months. However, Nerima-ku, Tokyo, Japan
nephrotic syndrome have steroid-resistant nephrotic discontinuation of ciclosporin almost always results in (Y Ohtomo MD);
syndrome (table 1).2 frequent relapses requiring long-term steroid treatment,11

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Department of Pediatrics, which also poses a long-term risk to children. Therefore, a adjustment factors. Patients, patients’ guardians,
Surugadai Nihon University new treatment that does not involve steroids or immuno- caregivers, treating physicians, and individuals assessing
Hospital, Chiyoda-ku, Tokyo,
Japan (Prof S Takahashi MD);
suppressive agents is urgently needed. outcomes were masked to assignments. Investigators
Department of Nephrology, In the past 10 years, rituximab has had some success in and patients (or their legal representatives) were masked
Hyogo Prefectural Kobe complicated FRNS and SDNS,12,13 and several research to peripheral blood B-cell counts, which were centrally
Children’s Hospital, Suma-Ku, groups have done single-arm or short-term studies of this monitored. To maintain blinding, allocation codes were
Kobe, Japan (R Tanaka MD); and
Department of Nephrology,
drug.14–16 The 2012 Kidney Disease: Improving Global disclosed only after the entire clinical trial was completed
Tokyo Metropolitan Children’s Outcomes clinical practice guidelines17 introduced and all data were locked. However, investigators could
Medical Center, Fuchu, Japan rituximab as a treatment option for childhood-onset, request the disclosure of a patient’s allocation code
(K Ishikura MD) complicated FRNS and SDNS. However, the efficacy and urgently in the case of a serious adverse event that could
Correspondence to: safety of rituximab for complicated FRNS and SDNS are lead to death or was life-threatening, a serious adverse
Prof Kazumoto Iijima,
Department of Pediatrics, Kobe
yet to be established.17 We aimed to assess the efficacy and event for which the information was essential to establish
University Graduate School of safety of rituximab in patients with high disease activity. what treatment was necessary, or treatment failure.
Medicine, 7-5-2 Kusunoki-cho,
Chuo-ku, Kobe 650-0017, Japan Methods Procedures
iijima@med.kobe-u.ac.jp
Study design and participants Patients received the first dose of their assigned drug
In a multicentre, double-blind, randomised, placebo- within 2 weeks after randomisation. Patients assigned to
controlled trial, we enrolled patients at nine centres in rituximab received an intravenous dose of 375 mg/m²
See Online for appendix Japan. Full eligibility criteria are listed in the appendix. (maximum 500 mg) once weekly for 4 weeks. Because
Briefly, we screened patients aged 2 years or older the optimum dose for paediatric FRNS and SDNS has
experiencing a relapse of FRNS or SDNS, which had not been established, we selected this dosing schedule on
originally been diagnosed as nephrotic syndrome when the basis of previous reports of rituximab’s ability to
aged 1–18 years (appendix). Patients with complicated prevent relapses in patients with immunosuppressant-
FRNS or SDNS (table 1) who met all other criteria were resistant SDNS12,13,18 and on the recommended dose for
eligible for inclusion after remission of the relapse they treating B-cell lymphoma, which has a known safety
were experiencing at screening. profile. Patients assigned to placebo received intravenous
This study was approved by the institutional review injections of a matched placebo at the same frequency.
boards at each centre and complied with the Declaration We used pretreatments to prevent infusion reaction
of Helsinki. Participants aged 20 years or older or parents (appendix). Patients could cease assigned treatment if
of younger patients provided written informed consent. they met discontinuation criteria (appendix).
Participants receiving prednisolone for the relapse at
Randomisation and masking screening continued receiving the drug, taking 60 mg/m²
Once full eligibility was confirmed, patients were orally three times a day (maximum of 80 mg per day) for
randomly assigned (1:1) to rituximab or placebo. We 4 weeks. Participants not receiving prednisolone at
applied the minimisation method using a computer- screening received the same dose until 3 days after
generated sequence (SAS PROC PLAN), with age, complete remission was achieved. After 4 weeks (in
institution, treatment history (whether a steroid or an patients who received prednisolone at screening) or from
immunosuppressive drug, or both, was given during the 3 days after complete remission (in patients who did not
relapse immediately before randomisation), and the receive prednisolone at screening), patients took 60 mg/m²
intervals between the previous three relapses as prednisolone in the morning on alternate days (maximum

Definition
FRNS ≥2 relapses of nephrotic syndrome within 6 months after initial remission, or ≥4 relapses within any 12-month period
SDNS 2 relapses of nephrotic syndrome during the reduction of steroid treatment or within 2 weeks of discontinuation of steroid
treatment
SRNS Persistent proteinuria after 60 mg/m² oral prednisolone per day for 4 weeks
Complicated FRNS or SDNS Patients diagnosed with FRNS or SDNS when aged 2 years or older, who had ≥4 relapses in a 12-month period or steroid
dependence at any point in the 2 years before relapse at screening, after completion of immunosuppressive drug treatment
(eg, ciclosporin, cyclophosphamide, mizoribine, or mycophenolate mofetil); or patients diagnosed with FRNS or SDNS when
aged 2 years or older, who had ≥4 relapses in a 12-month period or steroid dependence diagnosed at any point in the 2 years
before relapse at screening, during immunosuppressive drug treatment (eg, ciclosporin, cyclophosphamide, mizoribine, or
mycophenolate mofetil); or patients with a history of SRNS and diagnosed with FRNS or SDNS when aged 2 years or older, who
had ≥4 relapses in a 12-month period or steroid dependence at any point in the 2 years before relapse at screening, during or
after the completion of immunosuppressive drug treatment (eg, ciclosporin or a combination of ciclosporin and
methylprednisolone)

FRNS=frequently relapsing nephrotic syndrome. SDNS=steroid-dependent nephrotic syndrome. SRNS=steroid-resistant nephrotic syndrome.

Table 1: Definitions

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80 mg per day) for 2 weeks, then 30 mg/m² on alternate blood B-cell depletion period, human antichimeric
days (maximum 40 mg per day) for 2 weeks, and then antibody production rate, and rituximab blood
15 mg/m² on alternate days (maximum 20 mg per day) for concentration. Safety endpoints were frequency and
2 weeks. When patients had relapses during the study severity of adverse events, and abnormal values in
period (1 year of follow-up), they received 60 mg/m² oral biochemical tests and haematology assessments. We did
prednisolone three times a day (maximum 80 mg per day) post-hoc analyses of the effects of age at time of treatment
until 3 days after complete remission was obtained, when and age at disease onset on median relapse-free period,
tapering began. If patients were receiving ciclosporin at the effect of concomitant angiotensin-converting-enzyme
screening, tapering of this drug began at day 85 (patients inhibitors and angiotensin-receptor blockers on median
received their first dose of rituximab or placebo on day 1), relapse-free period, time to FRNS or SDNS, the
with discontinuation by day 169 (figure 1). If patients were proportion of patients who could discontinue steroid
taking any other immunosuppressive drugs, these drugs treatment after study drug infusion, the time between
were discontinued by day 85 (figure 1). cessation of steroid treatment and first relapse, the
Patients were followed up for 1 year (figure 1). Study frequency of infections that required treatment, the
visits occurred at baseline; at weeks 1, 2, 3, and 4; and effect of B-cell depletion on infections that required
every 4 weeks from week 5. Patients were deemed to have treatment and relapses, and changes in characteristics
treatment failure if a relapse had occurred by day 85, between baseline and 1 year.
FRNS or SDNS was diagnosed between days 86 and 365,
or steroid resistance was noted (figure 1, appendix). We Statistical analysis
designed the study protocol with consideration for the On the basis of previous reports,12,13,18 we assumed that For the trial protocol see http://
placebo group as much as possible. When patients had 40% of the patients in the rituximab group and 10% of www.med.kobe-u.ac.jp/pediat/
pdf/rcrn01.pdf
treatment failure, their allocation code was urgently the patients in the placebo group would maintain
disclosed. If a patient with treatment failure was in the remission 6 months after registration. 30 patients in
placebo group, he or she could then choose to begin the each group would be needed to establish the superiority
treatment deemed the best by investigators—eg, new of the test treatment for the primary endpoint with 90%
immunosuppressive drugs—and continue in our study, power at a 2·5% one-sided significance level under the
or to enter a separate rituximab pharmacokinetic study assumption of exponential distribution of relapse-free
after discontinuation or completion of our trial. survival time and proportionality of hazards.
We used the log-rank test to analyse the primary
Outcomes endpoint and other time-to-event endpoints. We did an
The primary endpoint was the relapse-free period (time interim analysis (appendix) after 30 patients had relapsed,
of randomisation to the time of first relapse after starting with a significance level set at 0·25% (one-sided). We
the study treatment). The prespecified secondary summarised time-to-event data with the Kaplan-Meier
endpoints were time to treatment failure, relapse rate method and estimated therapeutic effect hazard ratios
(number of relapses per person-year), time to four (HRs) and their 95% CIs with Cox regression.
relapses of nephrotic syndrome in the study period, time We made no multiplicity adjustment in the analysis of
to two relapses during reduction of steroid treatment or secondary endpoints. We set the significance level at 5%
within 2 weeks of discontinuation of steroid treatment, (two-sided) and report two-sided p values. We calculated
time to transition to steroid resistance, steroid dose after the relapse rate and the frequency of infection with the
randomisation, changes in steroid dose before and after number of events per person-years. We compared groups
randomisation, peripheral blood B-cell count, peripheral with the computer-based permutation test, and calculated

Other immunosuppressive drugs

(eg, mycophenolate mofetil and mizoribine)

Ciclosporin

First dose of assigned Treatment failure: relapse by week 13 Treatment failure: FRNS or SDNS between weeks 13 and 53
drug

Week 1 Week 13 Week 25 Week 53

(day 1) (day 85) (day 169) (day 365)

Treatment failure: steroid resistance between weeks 1 and 53

Relapse Assignment at remission

Figure 1: Study design

FRNS=frequently relapsing nephrotic syndrome. SDNS=steroid-dependent nephrotic syndrome.

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specified in the protocol. Therefore, randomisation ended

63 patients screened for study earlier than planned, on May 21, 2010.
52 patients underwent randomisation (figure 2).
11 patients excluded 48 patients received the assigned intervention (figure 2)
4 did not meet inclusion criteria and were included in analyses. 20 patients given rituximab
7 declined to participate
and 23 given placebo received all four doses. No patient
dropped out before the first relapse. All 20 patients with
52 randomly assigned
treatment failure in the placebo group were enrolled into a
separate rituximab pharmacokinetic study after
discontinuation (n=18) or completion (n=2) of this trial.
27 assigned to rituximab 25 assigned to placebo Baseline characteristics in the two groups were similar
(table 2). The predominant histological type in both
groups was minimal change nephrotic syndrome
3 excluded before receiving rituximab 1 excluded before receiving placebo
2 had influenza infection because of uncontrolled hypertension (table 2). All patients were given steroids or immuno-
1 had another relapse suppressants, or both, at relapse immediately before
assignment (table 2). More than 70% of patients in both
24 received rituximab 24 received placebo
groups reported side-effects of steroid treatment (table 2).
By the end of 1 year of follow-up, 17 patients in the
rituximab group and 23 in the placebo group had relapsed.
4 discontinued 20 discontinued interventions The median relapse-free period was significantly longer in
2 had treatment failure* 18 had treatment failure†
2 other reasons 2 other reasons the rituximab group (267 days, 95% CI 223–374) than in
the placebo group (101 days, 70–155; HR 0·27,
95% CI 0·14–0·53; p<0·0001; figure 3A). Post-hoc
20 completed week 53 4 completed week 53 analyses showed that age at disease onset and age at time
of treatment did not affect the median relapse-free period
Figure 2: Trial profile in the rituximab group (appendix). Concomitant
*One patient relapsed by week 13, and one was diagnosed with steroid resistance. †Ten relapsed by week 13, and angiotensin-converting-enzyme inhibitors or angiotensin-
eight were diagnosed with frequently relapsing nephrotic syndrome or steroid-dependent nephrotic syndrome
after week 13.
receptor blockers, or both, decreased the median relapse-
free period in the rituximab group, although the difference
the 95% CI of rate ratios fitting the negative binomial was marginally significant (appendix).
distribution and taking account of overdispersion. With Treatment failure was reported in ten patients in the
the Wilcoxon rank-sum test, we compared daily steroid rituximab group and 20 in the placebo group. The time
doses after randomisation and steroid doses before and to treatment failure was significantly longer in the
after randomisation in both groups. We used the Kaplan- rituximab group than in the placebo group (HR 0·27,
Meier method to assess the proportion of patients with 95% CI 0·12–0·59; p=0·0005; figure 3B). The relapse
human antichimeric antibody. Analyses were by modified rate was significantly lower in the rituximab group
intention to treat, including patients who received their (1·54 relapses per person-year [29 relapses in
assigned intervention. All analyses were done in SAS 18·81 person-years]) than in the placebo group
(version 9.1). (4·17 relapses per person-year [46 relapses in
This trial is registered with the University Hospital 11·03 person-years]; HR 0·37, 95% CI 0·23–0·59;
Medical Information Network clinical trial registry, p<0·0001). Only two patients in each group had frequent
number UMIN000001405. relapses in the study period. Time to two relapses during
reduction of steroid treatment or within 2 weeks of
Role of the funding source discontinuation of steroid treatment was significantly
The funder of the study had no role in study design, data longer in the rituximab group than in the placebo group
analysis, data interpretation, or writing of the report. The (HR 0·19, 95% CI 0·07–0·54; p=0·0005). A post-hoc
corresponding author had full access to all the data in the analysis showed that significantly more patients in the
study and had final responsibility for the decision to rituximab group did not experience frequent relapses or
submit for publication. steroid dependence than in the placebo group (0·17,
0·06–0·46; p=0·0001; figure 3C). Two patients in the
Results rituximab group had steroid-resistant relapses, compared
Between Nov 13, 2008, and May 19, 2010, 52 patients were with no patients in the placebo group.
randomly assigned to rituximab or placebo. Follow-up Mean daily steroid dose after randomisation was
ended on Nov 10, 2011. The preplanned interim analysis significantly lower in the rituximab group than in the
showed that rituximab was superior to placebo, after placebo group (9·12 mg/m² per day [SD 5·88] vs
which the independent data and safety monitoring 20·85 mg/m² per day [9·28]; p<0·0001). Mean daily
committee advised us to discontinue randomisation as steroid (prednisolone) dose in the rituximab group

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decreased significantly after randomisation, but did not Discussion

change significantly in the placebo group (table 3). We have shown that the relapse-free period increases
Exploratory analyses showed that the proportion of with rituximab in patients with childhood-onset,
patients who could discontinue steroid treatment after complicated FRNS and SDNS. Adverse events were
the study drug infusion was similar in the rituximab generally mild and the frequency of serious adverse
group (21 of 24, 88%) and the placebo group
(19 of 24, 79%; p=0·70). However, median time between Rituximab (n=24) Placebo (n=24)
cessation of steroid treatment and first relapse was
Age (years) 11·5 (5·0) 13·6 (6·9)
significantly longer in the rituximab group
Duration of disease (years) 7·9 (4·7) 8·0 (5·4)
(211 days, 95% CI 166–317) than in the placebo group
Sex
(42 days, 14–98; HR 0·27, 95% CI 0·14–0·54; p<0·0001).
The height-for-age Z score improved slightly 1 year after Male 18 (75%) 16 (67%)

rituximab treatment compared with baseline, although Female 6 (25%) 8 (33%)

the difference was not significant (appendix). Height Height (cm) 137·7 (21·4) 143·4 (20·4)
Z score also seemed to improve in children with residual Height-for-age Z score −0·96 (1·37) −0·88 (1·26)
growth potential in the rituximab group, but again the Weight (kg) 44·0 (18·6) 47·5 (15·6)
difference was not significant (appendix). Body-mass index 22·3 (4·9) 22·6 (4·3)
Most adverse events were mild, and no patients died Systolic blood pressure (mm Hg) 112·3 (11·0) 111·0 (9·6)
during the trial. Although more patients had serious Diastolic blood pressure (mm Hg) 65·6 (9·9) 66·8 (8·2)
adverse events in the rituximab group than in the placebo Serum creatinine (μmol/L) 39·78 (13·26) 44·20 (15·91)
group (table 4), the difference was not significant Estimated glomerular filtration rate (mL/m per 1·73 m²) 128·9 (20·6) 126·4 (26·0)
(p=0·36). The most common grade 3–4 adverse events in Serum total protein (g/L) 58 (6) 59 (6)
the rituximab group were hypoproteinemia, lympho- Serum albumin (g/L) 34 (6) 34 (5)
cytopenia, and neutropenia (table 5). Post-hoc analyses of Urinary protein to creatinine ratio (mg/mg) 0·13 (0·11) 0·11 (0·10)
adverse events showed that the incidence of infections Steroid and immunosuppressant use at relapse immediately before assignment
that required treatment were similar in both groups Ciclosporin, mycophenolate mofetil, and daily steroids 1 (4%) 0
(4·55 infections per person-year [105 infections in Ciclosporin, mizoribine, and daily steroids 3 (13%) 3 (13%)
23·08 person-years] vs 3·45 infections per person-year Ciclosporin and daily steroids 0 1 (4%)
[42 infections in 12·18 person-years]; HR 1·27, Mycophenolate mofetil and daily steroids 0 1 (4%)
95% CI 0·77–2·07, p=0·21). More patients had mild Mizoribine and daily steroids 1 (4%) 1 (4%)
infusion reactions in the rituximab group than in the Daily steroids with no immunosuppressant 1 (4%) 0
placebo group (table 4), but the difference was not Ciclosporin, mycophenolate mofetil, and steroids on alternate days 2 (8%) 0
significant (p=0·12). No grade 3 or 4 infusion reactions Ciclosporin, mizoribine, and steroids on alternate days 6 (25%) 4 (17%)
were reported in either group (table 4). Ciclosporin and steroids on alternate days 2 (8%) 5 (21%)
The peripheral blood B-cell count decreased Mycophenolate mofetil and steroids on alternate days 0 0
substantially immediately after the first dose of rituximab Mizoribine and steroids on alternate days 3 (13%) 3 (13%)
(figure 4), with a median period of B-cell depletion Steroids on alternate days with no immunosuppressant 1 (4%) 2 (8%)
(<5 cells per μL) of 148 days (95% CI 131–170). B-cell Ciclosporin and mycophenolate mofetil, with no steroids 0 0
counts returned to within the normal range in all patients Ciclosporin and mizoribine, with no steroids 1 (4%) 1 (4%)
given rituximab by day 253 (median 118 cells
Ciclosporin, with no steroids 1 (4%) 2 (8%)
per μL, 95% CI 113–250). By contrast, peripheral blood
Mycophenolate mofetil, with no steroids 0 0
B-cell count did not change in the placebo group (data
Mizoribine, with no steroids 2 (8%) 1 (4%)
not shown).
No steroids or immunosuppressant 0 0
We did a post-hoc analysis of the effects of B-cell
Renal histology
depeletion on relapses and infections. No relapses were
Minimal change 21 (88%) 23 (96%)
reported in the rituximab group during the period of
Focal segmental glomerulosclerosis 2 (8%) 1 (4%)
B-cell depletion. However, the rate of infections requiring
Unknown 1 (4%) 0
treatment was higher during the B-cell depletion period
Steroid toxicity* 17 (71%) 19 (79%)
(8·43 infections per person-year [49 infections in
Time between relapse immediately before screening and previous relapse
5·81 person-years]) than outside of this period
(3·24 infections per person-year [56 infections in <180 days 15 (63%) 18 (75%)

17·27 person-years]; HR 0·39, 95% CI 0·27–0·58; ≥180 days 9 (38%) 6 (25%)

p<0·0001); although most were grade 1 respiratory-tract Time from assignment to start of assigned intervention (days) 6·3 (2·7) 6·3 (3·4)
infections. The cumulative proportion of patients with Data are mean (SD) or n (%). *Complications induced by steroid treatments, such as hypertension, short stature,
human antichimeric antibody at day 365 was 14% diabetes, glaucoma, cataract, central obesity, and osteoporosis.
(95% CI 5–38). Blood concentrations of rituximab are
Table 2: Baseline characteristics
shown in table 6.

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A Number of Daily Daily p value

100 patients* prednisolone prednisolone
Rituximab
90 Placebo dose in the dose after
365 days before randomisation
80 randomisation (mg/m² per day)
Patients without relapse (%)

70 (mg/m² per day)

60 Rituximab 19 19·13 (9·94) 8·37 (5·62) <0·0001
50 Placebo 21 18·02 (10·15) 21·02 (9·81) 0·21
40
Data are mean (SD), unless otherwise stated. *Number of patients in each group
30 for whom prednisolone doses were available for 365 days before randomisation.
20
Table 3: Change in daily prednisolone dose before and after
10 randomisation, by group
Log-rank p<0·0001
0
0 50 100 150 200 250 300 350 400
Number at risk
Rituximab Placebo
Rituximab 24 20 20 20 18 13 11 11
Placebo 24 20 12 9 2 2 2 1 (n=24) (n=24)
Number of adverse events 357 251
B
100
Patients with ≥1 adverse event 24 (100%) 23 (96%)
Number of serious adverse events 16 7
90
Patients without treatment failure (%)

Patients with ≥1 serious adverse event 10 (42%) 6 (25%)

80
Deaths 0 0
70
Number of grade 3 adverse events 24 15
60
Patients with ≥1 grade 3 adverse event 8 (33%) 3 (13%)
50
Number of grade 4 adverse events 3 0
40
Patients with ≥1 grade 4 adverse event 1 (4%) 0
30 Cases of infections that required treatment 105 42
20 Grade 1 1 0
10 Grade 2 101 42
Log-rank p=0·0005
0 Grade 3 3 0
0 50 100 150 200 250 300 350 400
Number at risk Grade 4 0 0
Rituximab 24 20 20 20 19 18 14 13 Patients with ≥1 infection 23 (96%) 18 (75%)
Placebo 24 20 14 14 8 6 3 3
Total number of infusion reactions 41 26
C Grade 1 36 25
100
Grade 2 5 1
90 Grade 3 0 0
Patients without frequent relapses

80 Grade 4 0 0
or steroid dependence (%)

70 Patients with ≥1 infusion reaction 19 (79%) 13 (54%)

60
Data are n or n (%). Adverse events were categorised according to the National
50 Cancer Institute’s Common Terminology Criteria for Adverse Events (version 3.0).
40
Table 4: Adverse events
30
20
Patients with complicated FRNS or SDNS usually have
10
Log-rank p=0·0001 a long history of the disease, and many of those included
0
0 50 100 150 200 250 300 350 400 in our trial were receiving fairly high daily doses of
Time since randomisation (days) steroids with or without immunosuppressive agents to
Number at risk
Rituximab 24 24 24 24 22 21 17 15 prevent frequent relapses. Therefore, some patients did
Placebo 24 22 15 14 8 6 3 3 not meet the usual criteria for frequent relapses or
steroid dependence before randomisation. However,
Figure 3: Kaplan-Meier curves for primary and secondary outcomes
(A) Patients without relapse. (B) Patients without treatment failure. (C) Patients without frequent relapses or steroid more than 80% of patients in our study were treated with
dependence. Vertical lines indicate censoring. prednisolone at the relapse immediately before
randomisation, and the mean daily prednisolone dose
events did not differ significantly between groups. As far for 1 year before randomisation was about 20 mg/m².
as we are aware, we are the first to show that rituximab is These facts indicate that overall disease activity was high.
safe and effective for at least 1 year of treatment in To allow enrolment of these patients into our trial, we
a multicentre, double-blind, randomised, placebo- modified the definitions of frequent relapses and steroid
controlled trial (panel). dependence immediately before the trial.

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A fairly large study16 of rituximab treatment for patients

Rituximab (n=24) Placebo (n=24)
with steroid-dependent and calcineurin inhibitor-
dependent idiopathic nephrotic syndrome, similar to Grade 3 Grade 4 Grade 3 Grade 4
those enrolled in our trial showed that the 6-month Gastritis 1 (4%) 0 0 0
probability of remission after the first infusion was 48%. Gastroenteritis 1 (4%) 0 0 0
The relapse-free period was similar to that in our study, Gum infection 1 (4%) 0 0 0
further emphasising the efficacy of the drug. Our finding Cellulitis 1 (4%) 0 0 0
that the age at disease onset and age at time of treatment Hypertension 1 (4%) 0 0 0
did not greatly affect the outcome is fairly consistent with Respiratory disturbance 1 (4%) 0 0 0
data from an uncontrolled study that also included adult Acute kidney failure 1 (4%) 0 0 0
patients.19 The fact that patients in the rituximab group Haemorrhagic cystitis 1 (4%) 0 0 0
who were concomitantly treated with angiotensin- Hyperuricaemia 0 1 (4%) 0 0
converting-enzyme inhibitors or angiotensin-receptor Hypoproteinaemia* 6 (25%) 0 6 (25%) 0
blockers, or both, had earlier relapses suggests that these Adrenal insufficiency 1 (4%) 0 0 0
drugs did not prevent relapses and patients treated with Nettle rash 1 (4%) 0 0 0
those drugs had more active disease. Lymphocytopenia 4 (17%) 0 4 0
More than half the patients in the rituximab group could Neutropenia 2 (8%) 2 (8%) 0 0
discontinue steroids for more than 200 days without Increased aspartate aminotransferase 0 0 1 (4%) 0
relapses after receiving rituximab. A long steroid-free Increased alanine aminotransferase 1 (4%) 0 2 (8%) 0
period would allow patients to recover from side-effects, Increased γ-glutamyl transpeptidase 0 0 1 (4%) 0
such as impaired growth. Indeed, the height Z score
Increased creatine phosphokinase 1 (4%) 0 0 0
seemed to improve 1 year after treatment in the rituximab
Hypophosphataemia 0 0 1 (4%) 0
group, although the difference was not significant. Long-
term follow-up studies are needed to clarify the effects of Data are n (%). *Not known to be a side-effect of rituximab and was probably caused by the original disease rather than
by rituximab or placebo, because occurred at time of relapse in both groups; other adverse events were known to be
rituximab treatment for recovery from impaired growth.
caused by the study drug.
Rituximab does not increase the frequency of infection
when used to treat rheumatoid arthritis.20,21 However, the Table 5: Grade 3–4 adverse events
rate of infections requiring treatment was higher during
the period of B-cell depletion in the rituximab group in 1000
our study than when B cells were not depleted. Therefore,
900
attention should be paid to infections during this phase,
although most infections in our study were mild and 800
treatable. In studies of patients with complicated
Peripheral B-cell count (cells per mm3)

nephrotic syndrome who had been taking rituximab, one 700

child died because of pulmonary fibrosis22 and another 600

patient with fulminant myocarditis due to enterovirus
underwent heart transplantation.23 However, we recorded 500
no deaths or cases of pulmonary fibrosis or myocarditis. 400
Although we recorded no relapses during B-cell
depletion, a low B-cell count could offer clues about 300
whether relapse is likely. Because our protocol did not
200
specify that peripheral B-cell count should be established at
time of relapse, a clear correlation between B-cell count and 100
relapse could not be identified. We believe that continued
0
monitoring of the B-cell count throughout the study period,
especially at the time of relapse, will be necessary in future –100
investigations. Another limitation of our study was the 1 29 57 85 113 141 169 197 225 253 281 309 337 365 393
Time since first dose (days)
fairly short observation period. Therefore, the long-term
prognosis of patients given rituximab is unclear. Figure 4: Mean peripheral B-cell counts in the rituximab group
Specifically, we are aware of the possibility that not all rare Error bars show SD.
and serious adverse effects were detected in our study—eg,
progressive multifocal leukoencephalopathy is known to be Additionally, a comparison of the efficacy, safety, and cost-
a serious side-effect of rituximab. effectiveness of various rituximab dosing regimens and
All patients in our trial had relapsed by 19 months after B-cell-driven regimens still needs to be done.24 An
randomisation. To extend the relapse-free period, further uncontrolled study19 showed the importance of long-term
modification of the rituximab treatment and possibly follow-up after a core trial assessing the risk and benefit of
adjunct immunosuppressive therapies might be necessary. rituximab treatment. We are preparing a retrospective

www.thelancet.com Vol 384 October 4, 2014 1279

 Articles

prevention of recurrent focal segmental glomerulo-

Number of patients for Mean rituximab blood
whom data available concentration (ng/mL) sclerosis. Whether a similar mechanism works in
complicated FRNS and SDNS remains to be established.
Day 1 (before the first infusion of rituximab) 24 0
Contributors
Day 22 (before the fourth infusion of rituximab) 23 156 000 (53 700)
KIi and MS were responsible for the study concept. KIi, MS, and NT
Day 85 24 28 800 (17 500) designed and managed the study. KNo, KK, KM, KA, KNa, YOht, ST, RT,
Day 169 24 2320 (2680) HK, KIs, and SI collected and interpreted data. YOha did statistical
Day 365* 23 0 analysis. RM did the systematic review. All authors were members of the
writing group and agreed on the content of the report, reviewed drafts,
Data in parentheses are SD. *Three samples included here were not assessed on day 365; assessments occurred on days and approved the final version.
189, 268, and 271, because these patients discontinued assigned treatment because of treatment failure. However, the Rituximab for Childhood-onset Refractory Nephrotic Syndrome Study
values were less than the detectable range and so were included as data for day 365. Group investigators
Kandai Nozu, Hiroshi Kaito, Yuya Hashimura, Takeshi Ninchoji
Table 6: Blood concentrations of rituximab
(Kobe University Graduate School of Medicine, Japan); Shori Takahashi,
Hiroshi Saito (Surugadai Nihon University Hospital, Japan);
Koichi Nakanishi, Yuko Shima (Wakayama Medical University, Japan);
Panel: Research in context Ryojiro Tanaka, Kyoko Morinaga (Hyogo Prefectural Kobe Children’s
Hospital, Japan); Kenichiro Miura, Takashi Sekine (Graduate School of
Systematic review Medicine, University of Tokyo); Yoshiyuki Ohtomo, Daisuke Umino
On completion of our trial, we did a systematic review to identify any randomised controlled (Juntendo University Nerima Hospital, Japan); Kunihiko Aya,
trial in which the effectiveness or safety of rituximab, or both, was assessed in children with Takayuki Miyai (Okayama University Hospital, Japan); Kenji Ishikura,
Hiroshi Hataya, Yuko Hamasaki (Tokyo Metropolitan Children’s Medical
complicated frequently relapsing nephrotic syndrome (FRNS) or steroid-dependent
Center, Japan); Shuichi Ito, Koichi Kamei, Masao Ogura,
nephrotic syndrome (SDNS). We searched Medline, Embase, and the Cochrane Library for Tomohiro Udagawa, Akiko Tsutsumi (National Center for Child Health
reports published in any language before Oct 5, 2013, with terms such as “nephrotic and Development, Japan).
syndrome”, “rituximab”, and “child” (appendix). We identified two open-label, randomised Clinical trial steering committee
controlled trial (appendix). Meta-analyses of remission frequency at 3 and 6 months Kazumoto Iijima (Kobe University Graduate School of Medicine, Japan),
confirmed the effectiveness of rituximab in these children, and showed an increase in the Mayumi Sako (National Center for Child Health and Development, Japan),
Nao Tsuchida (National Center for Child Health and Development, Japan).
remission rate of about 50% at 3 months and of more than 300% at 6 months (appendix).
Independent data and safety monitoring committee
Interpretation Takashi Igarashi (Graduate School of Medicine, University of Tokyo,
As far as we are aware, ours is the first randomised, placebo-controlled clinical trial in Japan), Masataka Honda (Tokyo Metropolitan Children’s Medical Center,
which the efficacy and safety of rituximab for childhood-onset, complicated FRNS and Japan), Satoshi Morita (Graduate School of Medicine, Yokohama City
University, Japan).
SDNS have been assessed. Rituximab should be considered as an effective treatment for
Declaration of interests
children with these disorders.
KIi has received grants from the Japanese Ministry of Health, Labour and
Welfare for the Large Scale Clinical Trial Network Project (Japan Medical
long-term follow-up study of patients enrolled in our trial, Association Center for Clinical Trials: CCT-B-2001), research on rare and
intractable diseases (H24-nanchitou (nan)-ippan-041), and clinical
with a focus on clinical courses, treatments after the research (H25-iryogijutu-ippan-008); has received research grants from
clinical trial, growth, and late adverse effects. the Japanese Ministry of Education, Culture, Sports, Science and
The exact pathogenesis of nephrotic syndrome is Technology (Grant-in-Aid for Scientific Research 23591192); has received
unclear, but T-cell-mediated immunological abnormalities research grants from Pfizer Japan, Kyowa Hakko Kirion, Abbot Japan,
Takeda Pharmaceutical, Asahi Kasei Pharma, Astellas Pharma, Terumo,
are thought to have a role.25 Several studies26–29 have shown Chugai Pharmaceutical, Benesis, Dainippon Sumitomo Pharma,
that B cells can promote T-cell activation, mediate Genzyme Japan, Novartis Pharmaceuticals, Mizutori Clinic, AbbVie, and
antibody-independent autoimmune damage, and provide Janssen Pharmaceutical; has received lecture fees from Novartis
costimulatory molecules and cytokines, which sustain Pharmaceuticals, Asahi Kasei Pharma, Baxter, Sanofi, Pfizer Japan, Meiji
Seika Pharma, Taisho Toyama Pharmaceutical, Kyorin Pharmaceutical,
T-cell activation in autoimmune diseases. Rituximab Kyowa Hakko Kirion, Dainippon Sumitomo Pharma, Astellas Pharma,
inhibits B-cell proliferation and induces B-cell apoptosis.30 and Chugai Pharmaceutical; and is a paid adviser for Zenyaku Kogyo. MS
This action leads to B-cell depletion and hence suppression has received grants from the Japanese Ministry of Health, Labour and
of interactions between B cells and T cells, which could Welfare, and is a paid adviser for Zenyaku Kogyo. RM has received
research grants from WHO; the Japanese Ministry of Health, Labour and
prevent recurrences of nephrotic syndrome. Impaired Welfare; the Japanese Ministry of Education, Culture, Sports, Science and
function of regulatory T cells in patients with minimal Technology; the Gates Foundation; the Japanese Ministry of Foreign
change nephrotic syndrome and induction of remission Affairs; and Save the Children. NT has received grants from Kaketsuken,
in nephrotic syndrome by regulatory T cells have been GlaxoSmithKline, and Daiichi Sankyo. KA has received grants from JCR
Pharmaceuticals and Teijin Pharma, and lecture fees from Boehringer
reported previously.31–33 Rituximab could induce an Ingelheim Japan, JMS, Asahi Kasei Pharma, Ono Pharmaceutical, and
increase in the number and function of regulatory T cells.34 Kyorin Pharmaceutical. KNa has received lecture fees from Asahi Kasei
Rituximab-maintained remission in nephrotic syndrome Pharma, Novartis Pharmaceuticals, Astellas Pharma, and Takeda
Pharmaceutical. YOht has received grants from Asahi Kasei Pharma,
could be due to the restoration of function of regulatory
Taiho Pharmaceutical, and Pfizer Japan; and lecture fees from Kyowa
T cells. Fornoni and colleagues reported35 that rituximab Hakko Kirin, Ferring Pharmaceuticals, Asahi Kasei Pharma, and Daiichi
binds directly to an acid sphingomyelinase-like phospho- Sankyo. ST has received grants from Sanofi and Novartis
diesterase 3b on the cell surface of podocytes, stabilising Pharmaceuticals. RT has received lecture fees from Pfizer Japan and
Novartis Pharmaceuticals. HK has received grants from the Danone
podocyte structure and function, which could lead to the

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 Articles

Institute of Japan Foundation, the Hyogo Prefecture Health Promotion 14 Guigonis V, Dallocchio A, Baudouin V, et al. Rituximab treatment
Association, and Baxter; and lecture fees from Novartis Pharmaceuticals for severe steroid- or cyclosporine-dependent nephrotic syndrome: a
and Daiichi Sankyo. KIs has received lecture fees and travel expenses multicentric series of 22 cases. Pediatr Nephrol 2008; 23: 1269–79.
from Novartis Pharmaceuticals and Asahi Kasei Pharma. SI has received 15 Ravani P, Magnasco A, Edefonti A, et al. Short-term effects of
lecture fees from Asahi Kasei Pharma, Novartis Pharmaceuticals, and rituximab in children with steroid- and calcineurin-dependent
Chugai Pharmaceutical. YOha has received grants from the Japanese nephrotic syndrome: a randomized controlled trial.
Ministry of Health, Labour and Welfare; received unlimited educational Clin J Am Soc Nephrol 2011; 6: 1308–15.
grants from Kowa Pharmaceutical, Astellas Pharma, Kyowa Hakko Kirin, 16 Ravani P, Ponticelli A, Siciliano C, et al. Rituximab is a safe and
and Takeda Pharmaceutical during the study period; received lecture fees effective long-term treatment for children with steroid and
calcineurin inhibitor-dependent idiopathic nephrotic syndrome.
and honorarium of more than US$5000 for consultations with Chugai
Kidney Int 2013; 84: 1025–33.
Pharmaceutical, Shionogi, Sanofi, and DNP Media Create in the fiscal
17 Kidney Disease: Improving Global Outcomes. KDIGO clinical
year of 2012; and has served as the chairman of the board of directors for
practice guideline for glomerulonephritis. June, 2012. http://kdigo.
Statcom, owning stock. The other authors declare no competing interests. org/home/glomerulonephritis-gn/ (accessed Nov 20, 2013).
Acknowledgments 18 Kemper MJ, Gellermann J, Habbig S, et al. Long-term follow-up
This study was funded by the Health and Labour Sciences Research after rituximab for steroid-dependent idiopathic nephrotic
Grants for the Large Scale Clinical Trial Network Project (Japan Medical syndrome. Nephrol Dial Transplant 2012; 27: 1910–15.
Association Center for Clinical Trials: CCT-B-2001) from the Japanese 19 Ruggenenti P, Ruggiero B, Cravedi P, et al, for the Rituximab in
Ministry of Health, Labour and Welfare. Zenyaku Kogyo provided Nephrotic Syndrome of Steroid-Dependent or Frequently Relapsing
rituximab and placebo (which they received from Genentech) free of Minimal Change Disease Or Focal Segmental Glomerulosclerosis
charge. Zenyaku Kogy was responsible for measurement of human (NEMO) Study Group. Rituximab in steroid-dependent or
frequently relapsing idiopathic nephrotic syndrome.
antichimeric antibodies and rituximab blood concentrations, which they
J Am Soc Nephrol 2014; 25: 850–63.
delegated to Convence. The costs for these measurements was covered
20 Kelesidis T, Daikos G, Boumpas D, Tsiodras S. Does rituximab
by a fund from the Japanese Ministry of Health, Labour and Welfare.
increase the incidence of infectious complications? A narrative
This study was presented at Kidney Week 2012 (San Diego, CA, USA) on review. Int J Infect Dis 2011; 15: e2–16.
Nov 3, 2012, and was reported in abstract form. We thank all our patients
21 Buch MH, Smolen JS, Betteridge N, et al, and the Rituximab
and their families, the physicians who participated in this study, and Consensus Expert Committee. Updated consensus statement on
Emma Barber for editing assistancee. the use of rituximab in patients with rheumatoid arthritis.
References Ann Rheum Dis 2011; 70: 909–20.
1 Eddy AA, Symons JM. Nephrotic syndrome in childhood. Lancet 22 Chaumais MC, Garnier A, Chalard F, et al. Fatal pulmonary fibrosis
2003; 362: 629–39. after rituximab administration. Pediatr Nephrol 2009; 24: 1753–55.
2 Schulman SL, Kaiser BA, Polinsky MS, Srinivasan R, Baluarte HJ. 23 Sellier-Leclerc AL, Belli E, Guérin V, Dorfmüller P, Deschênes G.
Predicting the response to cytotoxic therapy for childhood nephrotic Fulminant viral myocarditis after rituximab therapy in pediatric
syndrome: superiority of response to corticosteroid therapy over nephrotic syndrome. Pediatr Nephrol 2013; 28: 1875–79.
histopathologic patterns. J Pediatr 1988; 113: 996–1001. 24 Cravedi P, Ruggenenti P, Sghirlanzoni MC, Remuzzi G. Titrating
3 The Scientific Committee of the Japanese Society for Pediatric rituximab to circulating B cells to optimize lymphocytolytic therapy
Nephrology. The 2005 Japanese Society for Pediatric Nephrology in idiopathic membranous nephropathy. Clin J Am Soc Nephrol
treatment guideline for idiopathic nephrotic syndrome in children. 2007; 2: 932–37.
http://www.jspn.jp/pdf/0505guideline.pdf (accessed Nov 20, 2013; 25 Shalhoub RJ. Pathogenesis of lipoid nephrosis: a disorder of T-cell
in Japanese). function. Lancet 1974; 2: 556–60.
4 Hodson EM, Willis NS, Craig JC. Non-corticosteroid treatment for 26 Liu K, Mohan C. Altered B-cell signaling in lupus. Autoimmun Rev
nephrotic syndrome in children. Cochrane Database Syst Rev 2013; 2009; 8: 214–18.
10: CD002290. 27 Chan OT, Hannum LG, Haberman AM, Madaio MP,
5 Hodson EM, Willis NS, Craig JC. Interventions for idiopathic Shlomchik MJ. A novel mouse with B cells but lacking serum
steroid-resistant nephrotic syndrome in children. antibody reveals an antibody-independent role for B cells in murine
Cochrane Database Syst Rev 2010; 11: CD003594. lupus. J Exp Med 1999; 189: 1639–48.
6 Ishikura K, Ikeda M, Hattori S, et al. Effective and safe treatment 28 Sfikakis PP, Boletis JN, Lionaki S, et al. Remission of proliferative
with cyclosporine in nephrotic children: a prospective, randomized lupus nephritis following B cell depletion therapy is preceded by
multicenter trial. Kidney Int 2008; 73: 1167–73. down-regulation of the T cell costimulatory molecule CD40 ligand:
7 Ishikura K, Yoshikawa N, Hattori S, et al, and Japanese Study an open-label trial. Arthritis Rheum 2005; 52: 501–13.
Group of Renal Disease in Children. Treatment with 29 Bugatti S, Codullo V, Caporali R, Montecucco C. B cells in
microemulsified cyclosporine in children with frequently relapsing rheumatoid arthritis. Autoimmun Rev 2007; 7: 137–42.
nephrotic syndrome. Nephrol Dial Transplant 2010; 25: 3956–62. 30 Maloney DG. Mechanism of action of rituximab. Anticancer Drugs
8 Hamasaki Y, Yoshikawa N, Hattori S, et al, and the Japanese Study 2001; 12 (suppl 2): S1–4.
Group of Renal Disease. Cyclosporine and steroid therapy in 31 Araya C, Diaz L, Wasserfall C, et al. T regulatory cell function in
children with steroid-resistant nephrotic syndrome. Pediatr Nephrol idiopathic minimal lesion nephrotic syndrome. Pediatr Nephrol
2009; 24: 2177–85. 2009; 24: 1691–98.
9 Inoue Y, Iijima K, Nakamura H, Yoshikawa N. Two-year cyclosporin 32 Hashimura Y, Nozu K, Kanegane H, et al. Minimal change
treatment in children with steroid-dependent nephrotic syndrome. nephrotic syndrome associated with immune dysregulation,
Pediatr Nephrol 1999; 13: 33–38. polyendocrinopathy, enteropathy, X-linked syndrome.
10 Iijima K, Hamahira K, Tanaka R, et al. Risk factors for cyclosporine- Pediatr Nephrol 2009; 24: 1181–86.
induced tubulointerstitial lesions in children with minimal change 33 Le Berre L, Bruneau S, Naulet J, et al. Induction of T regulatory
nephrotic syndrome. Kidney Int 2002; 61: 1801–05. cells attenuates idiopathic nephrotic syndrome. J Am Soc Nephrol
11 Ishikura K, Yoshikawa N, Nakazato H, et al. Two-year follow-up of a 2009; 20: 57–67.
prospective clinical trial of ciclosporin for frequently relapsing 34 Stasi R, Cooper N, Del Poeta G, et al. Analysis of regulatory T-cell
nephrotic syndrome in children. Clin J Am Soc Nephrol 2012; changes in patients with idiopathic thrombocytopenic purpura
10: 1576–83. receiving B cell-depleting therapy with rituximab. Blood 2008;
12 Benz K, Dötsch J, Rascher W, Stachel D. Change of the course of 112: 1147–50.
steroid-dependent nephrotic syndrome after rituximab therapy. 35 Fornoni A, Sageshima J, Wei C, et al. Rituximab targets podocytes
Pediatr Nephrol 2004; 19: 794–97. in recurrent focal segmental glomerulosclerosis. Sci Transl Med
13 Gilbert RD, Hulse E, Rigden S. Rituximab therapy for steroid- 2011; 3: 85ra46.
dependent minimal change nephrotic syndrome. Pediatr Nephrol
2006; 21: 1698–700.

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