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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 6  |  Page : 1085-1086
Rituximab to treat active SLE in a hemodialysis patient


King Faisal Specialist Hospital and Research Center, Department of Medicine, MBC # 46 P.O. Box 3354, Riyadh 11211, Saudi Arabia

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Date of Web Publication27-Oct-2009
 

How to cite this article:
Nadri QJ. Rituximab to treat active SLE in a hemodialysis patient. Saudi J Kidney Dis Transpl 2009;20:1085-6

How to cite this URL:
Nadri QJ. Rituximab to treat active SLE in a hemodialysis patient. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2019 Dec 13];20:1085-6. Available from: http://www.sjkdt.org/text.asp?2009/20/6/1085/57272
To the Editor,

Dialysis treatment has been associated with remission of systemic lupus erythematosus (SLE). Recently, an increased incidence of persistent of lupus activity both clinically and serolo­gically in chronic hemodialysis patients has been reported. Rituximab, a chimeric monoclonal antibody against CD20 located on mature and immature B cells, has been used in the treat­ment of non Hodgkins lymphoma and recently in autoimmune diseases such as rheumatoid arth­ritis, immune thrombocytopenic purpura, and lupus nephritis with some success. [1],[2] I would like to share my experience of treating active SLE, resistant to all conventional immunosup­pressive treatment, in 22-year-old woman who responded to Rituximab. She suffered from end­stage renal failure due to SLE and had been maintained on hemodialysis for five years. She received IV cyclophosphamide (NIH protocol) in the past, followed by mycophenolate mofetil (cellcept (R)) and cyclosporine along with ste­roids. Her main clinical manifestations included pancytopenia, severe discoid skin lupus, sero­sitis, arthralgia and alopecia. She had multiple admissions with flares. Intravenous immuno­globulin and total plasma exchanges were also tried with partial response.

Rituximab was administered at a dose of 375 mg/m i.v. weekly for 4 doses. The pre treatment WBC was 1.9 K (1.3-2.6), Hemoglobin (Hb) 85 g/L and platelet ≤ 150. Anti-nuclear antibodies (ANA): (1:2560), Anti-DNA: 214 U/mL, C3­0.3-0.49 g/L (N 0.90-1.80), C4-≤ 0.04-0.05 g/L (N 0.10-0.40). The patient dramatically respon­ded after the 4th dose with resolution of the skin rash and improvement in the general well­being. Her WBC increased to 4.37, Hb to12.3 g/L requiring decrease doses of erythropoietin she was receiving, and Platelets to 215. Her ANA and anti DNA decreased to 1:640 and 54.6 U/mL, respectively, and her C3 and C4 normalized. The patient tolerated rituximab well and remained asymptomatic and successfully later received a deceased donor kidney trans­plantation.

Rituximab is a promising therapeutic option in the treatment of resistant SLE, which can be safely used in hemodialysis patients with no major side effects and with great tolerability and efficacy. Therapeutic levels of this drug are maintained in patients undergoing dialysis, since it is not eliminated by hemodialysis. [3] This drug is commonly used off-label for the treat­ment of SLE. However, recently the Food and Drug Administration in the USA (FDA) has released a new safety warning regarding po­ssible incidence of progressive multifocal leuko­encephalopathy (PML) with the use of ritu­ximab in patients with rheumatiod arthritis; [4] PML has been reported in SLE. [5] Accordingly, cost effectiveness and risk of serious side effects such as PML should be kept in mind before embarking on therapy with rituximab.

 
   References Top

1.Goldblatt F, Isenberg DA. Anti-CD20 mono­clonal antibody in rheumatoid arthritis and systemic lupus erythematosus. Handb Exp Pharmacol 2008;181:163-81 Review.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Lindholm C, Borjesson-Asp K, Zendjanchi K, et al. Long term clinical and immunological effects of anti-CD20 treatment in patients with refrac­tory systemic lupus erythematosus. J Rheumatol 2008;35(5):826-33  Back to cited text no. 2      
3.Jillella AP, Dainer PM, Kallab AM, Ustun C. Treatment of a patient with end-stage renal disease with Rituximab: pharmacokinetic eva­luation suggests Rituximab is not eliminated by hemodialysis. Am J Hematol 2002;71(3):219­-22.  Back to cited text no. 3      
4.Molloy ES, Cabrese LH. Progressive multifocal leukoencephalopathy in patients with rheumatic diseases: Are patients with systemic lupus erythematosus at particular risk? Autoimmun Rev 2008;8:144-6.  Back to cited text no. 4      
5.Harris HE. Progressive multifocal leucoencepha­lopathy in a patient with systemic lupus erythe­matosus treated with rituximab. Rheumatology (Oxford) 2008;47(2):224-5.  Back to cited text no. 5      

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Correspondence Address:
Quaid J Nadri
King Faisal Specialist Hospital and Research Center, Department of Medicine, MBC # 46 P.O. Box 3354, Riyadh 11211
Saudi Arabia
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PMID: 19861879

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