Research

JAMA Pediatrics | Original Investigation

Efficacy of Rituximab vs Tacrolimus in Pediatric

Corticosteroid-Dependent Nephrotic Syndrome
A Randomized Clinical Trial
Biswanath Basu, MD; Anja Sander, PhD; Birendranath Roy, MD; Stella Preussler, MSc; Shilpita Barua, MD; T. K. S. Mahapatra, MD; Franz Schaefer, MD

Editorial page 721

IMPORTANCE Calcineurin inhibitors are an established first-line corticosteroid-sparing therapy Supplemental content
for patients with corticosteroid-dependent nephrotic syndrome (CDNS), whereas
B-lymphocyte–depleting therapy is mostly used as a rescue for calcineurin inhibitor–resistant
cases. The positive efficacy and safety profile of rituximab raises the question of whether it
could be used as a first-line alternative to calcineurin inhibitor therapy.

OBJECTIVE To compare the efficacy of rituximab and tacrolimus in maintaining relapse-free

survival among children with CDNS.

DESIGN, SETTING, AND PARTICIPANTS A parallel-arm, open-label, randomized clinical trial was
performed from May 8, 2015, to September 20, 2016, with 1-year follow-up in a single-center,
tertiary care unit. A total of 176 consecutive children aged 3 to 16 years with CDNS not
previously treated with corticosteroid-sparing agents were screened for eligibility.

INTERVENTIONS The children received either tacrolimus (along with tapering alternate-day
prednisolone) for 12 months or a single course of rituximab (2 infusions of 375 mg/m2).

MAIN OUTCOMES AND MEASURES Twelve-month relapse-free survival in the

intention-to-treat population.

RESULTS Of the 176 children screened for eligibility, 120 were randomized and all but 3
patients completed 1 year of follow-up. The groups were comparable, with mean (SD) age of
7.2 (2.8) years, 32 boys (53.3%) in each group, mean (SD) disease duration of 2.5 (1.5) years
and 2.3 (1.7) in the tacrolimus and rituximab groups, respectively, disease duration less than 1
year among 15 children (25.0%) in each group, median (interquartile range) of 4 (3-5)
relapses in each group, and mean (SD) cumulative prednisolone dose of 246 (48) mg/kg and
239 (52) mg/kg in the prestudy year in the tacrolimus and rituximab groups, respectively.
Rituximab therapy was associated with a higher 12-month relapse-free survival rate than
tacrolimus (54 [90.0%] vs 38 [63.3%] children; P < .001; odds ratio, 5.21; 95% CI, 1.93-14.07).
Among the patients who experienced relapse, median time to first relapse was 40 weeks in
the rituximab group and 29 weeks in the tacrolimus group. Only 2 patients in the rituximab
group had more than 1 relapse during the study period compared with 10 patients in the
tacrolimus group. The cumulative corticosteroid dose during the 12-month study period was
lower with rituximab compared with tacrolimus (mean [SD], 25.8 [27.8] vs 86.3 [58.0] Author Affiliations: Author
mg/kg). Although both treatments were well tolerated, mild to moderate infections were affiliations are listed at the end of this
twice as common in the tacrolimus group (26 [43.3%] vs 13 [21.7%] events). article.
Corresponding Author: Biswanath
CONCLUSIONS AND RELEVANCE In children with CDNS, rituximab appears to be more effective Basu, MD, Division of Pediatric
Nephrology, Department of
than tacrolimus in maintaining disease remission and minimizing corticosteroid exposure and, Pediatrics, Nilratan Sircar Medical
given its good tolerability and lack of nephrotoxic effects, may be considered as first-line College and Hospital, 138 AJC Bose
corticosteroid-sparing therapy. Rd, Kolkata 700014, West Bengal,
India (basuv3000@gmail.com);
Franz Schaefer, MD, Division of
TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02438982; Pediatric Nephrology, Center for
Clinical Trial Registry of India: CTRI/2014/01/004355 Pediatrics and Adolescent Medicine,
University of Heidelberg, Im
Neuenheimer Feld 430, Heidelberg,
JAMA Pediatr. 2018;172(8):757-764. doi:10.1001/jamapediatrics.2018.1323 Germany (franz.schaefer@med
Published online June 18, 2018. .uni-heidelberg.de).

(Reprinted) 757
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 Research Original Investigation Efficacy of Rituximab vs Tacrolimus in Pediatric Corticosteroid-Dependent Nephrotic Syndrome
I
diopathic nephrotic syndrome is the most common disor-
der of glomerular function in children. Most children re-
spond well to glucocorticoid therapy; however, as many as
40% develop a complicated course resulting in frequent re-
lapses or corticosteroid-dependent nephrotic syndrome
(CDNS).1 The adverse effects of chronic glucocorticoid treat-
ment have prompted the use of corticosteroid-sparing immu-
nosuppressive therapies in patients with CDNS. Calcineurin
inhibitors (CNIs) are presently the preferred corticosteroid-
sparing drug class. However, the efficacy of CNIs varies de-
pending on patient characteristics.2 Moreover, CNIs are po-
tentially nephrotoxic, neurotoxic, and diabetogenic and require
regular therapeutic drug monitoring.2-4 In patients with CDNS
who experience tacrolimus intolerance or insufficient respon-
siveness, rituximab, a B-lymphocyte–depleting monoclonal an-
tibody, has been demonstrated to be a valid therapeutic
alternative.5-7 A single course of rituximab reliably retains dis-
ease remission for 6 to 12 months and the adverse effect pro-
file observed to date is benign.5-11 The successful use of ritux-
imab as second-line corticosteroid-sparing therapy has raised
the question whether and when anti-B–cell therapy should be
considered for first-line use to minimize corticosteroid expo-
sure and avoid CNI toxic effects. To provide an evidence base
to this discussion, we performed a randomized clinical trial
comparing a single course of rituximab with standard tacro-
limus maintenance therapy during a 1-year period in children
with CDNS. The high incidence of childhood idiopathic ne-
phrotic syndrome in India12 and the large catchment area of
Nilratan Sircar Medical College and Hospital, with more than
1000 new children with nephrosis attending each year,
permitted us to conduct the trial efficiently in a single-center
effort.
Methods
Study Design
Rituximab for Relapse Prevention in Nephrotic Syndrome
(RITURNS) was a prospective, single-center, open-label,
2-parallel-arm, phase 3 randomized clinical trial to test the ef-
ficacy of single-course rituximab compared with mainte-
nance tacrolimus to maintain relapse-free survival at the end
of 1 year among children with CDNS.
The study protocol (available in Supplement 1) was
approved by the institutional review board of Nilratan Sircar
Medical College and Hospital and the drug regulatory
authority of India. The institutional review board was
granted continuous access to the trial data and oversaw the
safety of the study patients. Informed written and audiovi-
sual consent were obtained from the parents (and assent of
patients older than 7 years) after provision of detailed oral
and written information concerning the context of the study,
potential benefit to the child, and comprehensive safety
aspects. There was no financial compensation. Study prog-
ress was reported regularly both to the institutional review
board and the National Drug Regulatory of India. An inde-
pendent data safety monitoring board reviewed the study
regularly.
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Key Points
Question Is B-cell–depleting therapy more efficacious than
calcineurin inhibition in maintaining relapse-free survival in
children with corticosteroid-dependent nephrotic syndrome?
Findings In this randomized clinical trial that included 120
children with corticosteroid-dependent nephrotic syndrome, a
single course of rituximab therapy was associated with a
significantly higher 12-month relapse-free survival rate than daily
tacrolimus therapy (90.0% vs 63.3%) during 12 months of
follow-up. The mean cumulative corticosteroid dose during the
12-month study period was lower with rituximab compared with
tacrolimus (25.8 vs 86.3 mg/kg).
Meaning In children with corticosteroid-dependent nephrotic
syndrome, rituximab is more effective than tacrolimus in
maintaining disease remission and may be considered as first-line
corticosteroid-sparing therapy.
Study Patients
All children between ages 3 and 16 years with CDNS attending
the study center were consecutively screened for eligibility and,
if considered eligible, invited to participate in the study. Stan-
dard definitions were used for nephrotic syndrome, re-
mission, and relapses (eTable 1 in Supplement 2). Inclusion
requirements comprised, among others, an estimated glomer-
ular filtration rate13 (eGFR) greater than 80 mL/min/1.73 m2,
current proteinuria remission, no previous exposure to a cor-
ticosteroid-sparing agent, and exclusion of a secondary form
of nephrotic syndrome and active infection. All patients had
undergone kidney biopsy with light and immunofluores-
cence microscopy within 3 months prior to enrollment. There
were no changes in protocol after trial commencement. De-
tailed definitions and inclusion and exclusion criteria are pro-
vided in the trial protocol (Supplement 1).
Randomization and Masking
The children were randomly allocated in concealed fashion to
receive either rituximab or tacrolimus along with alternate-
day prednisolone over a 12-month period. Randomization was
performed 1:1 using a web-based tool including stratified block
randomization with varying block sizes and sex, age (≤7 vs >7
years), and renal histologic characteristics (minimal change dis-
ease vs focal segmental glomerulosclerosis) as stratification
factors. 14 The trial was open-label, with no masking of
patients or study staff to treatment allocation.
Study Intervention
Following randomization, children received either oral tacro-
limus for 12 months or a single course of rituximab infusions.
In the tacrolimus arm, children received tacrolimus, 0.2 mg/
kg/d, targeting trough levels of 5 to 7 ng/mL along with taper-
ing doses of alternate-day prednisolone. The duration of
tapering varied depending on the prednisolone dose at study
entry; however, prednisolone was discontinued in all
patients within 6 months of relapse-free survival. In the ritux-
imab arm, children were scheduled to receive 2 to 4 ritux-
imab infusions at weekly intervals (375 mg/m2, maximum dose,
500 mg) depending on the circulating B-cell count along with
jamapediatrics.com
 Efficacy of Rituximab vs Tacrolimus in Pediatric Corticosteroid-Dependent Nephrotic Syndrome
alternate-day prednisolone for 4 weeks (the protocol
[Supplement 1] includes details). Owing to adequate B-cell
depletion observed in all patients after the second dose, all pa-
tients received 2 infusions of rituximab. Patients who experi-
enced 2 or more or 4 or more relapses within 6 or 12 months,
respectively, were considered as treatment failures and shifted
to the other experimental therapy as per center practice.
Study Procedures
Within 1 week after randomization, children received the first
dose of their assigned drug. Data regarding the number of re-
lapses, adverse effects, cumulative corticosteroid dose, circu-
lating B-cell count (number per cubic millimeter) measured via
flow cytometry, tacrolimus trough serum level, and hemato-
logic and biochemical test results were noted during regular
study visits and, if necessary, relapse.
Study medication was distributed at every visit and fami-
lies were asked to return the used vials for pill counting. Medi-
cation intake and proteinuria dipstick results were recorded
daily in a patient diary. Home proteinuria monitoring was
performed using urine dipstick analysis. Urine protein-
creatinine ratio was performed during each scheduled visit and
at relapse.
Relapse was identified through urine dipstick and con-
firmed by urine protein-creatinine ratio. Relapse was defined
by 3+ or 4+ results on albuminuria dipstick testing for 3 con-
secutive early-morning specimens, and remission was de-
fined by urine albumin nil or trace results for 3 consecutive
early-morning specimens (eTable 1 in Supplement 2). Circu-
lating B-cell count was measured at the time of enrollment; at
the end of weeks 2, 4, 12, 26, 39, and 52; and at the time of any
relapse. Retrospective data from the previous year regarding
relapses and cumulative corticosteroid dose were also
collected.
Study Outcomes
The primary end point was the 12-month, relapse-free sur-
vival rate. Prespecified key secondary end points were the fre-
quency of relapses, time to first relapse, cumulative predniso-
lone dosage (milligrams per kilogram per year), changes in
serum biochemistry, peripheral blood B-cell count, the num-
ber of children not receiving corticosteroids, and the rates of
adverse events. Adverse events were graded according to the
Common Terminology Criteria for Adverse Events, version 3.15
Statistical Analysis
Based on previous study findings, 50% of patients in the ta-
crolimus arm and 80% of those in the rituximab arm were as-
sumed to remain relapse free during the 12-month observa-
tion period. 16,17 Sixty patients per arm were required to
demonstrate superiority at 90% power and 5% 2-sided, type I
error rate, including an expected 20% dropout rate.
The primary end point was analyzed using the χ2 test based
on the intention-to-treat set. For 1 patient with missing pri-
mary end point information, the most common value in the
respective group was imputed.18 As a sensitivity analysis, the
primary end point was also analyzed based on the per-
protocol set.
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Original Investigation Research
A logistic regression model was used to evaluate the in-
fluence of treatment on the odds of having at least 1 relapse
within the 12-month observation period, taking into account
the stratification variables (sex, age, renal histopathologic sta-
tus) and adjusting for disease duration, which is known to in-
fluence the risk of relapse. Kaplan-Meier curves were used to
visualize time to first relapse and graphically compare the treat-
ment groups. In addition, time to first relapse was analyzed
using a Cox proportional hazards regression model including
the same variables. All secondary end points were analyzed
based on the intention-to-treat set without imputation. The
B-cell counts over time were visualized for patients who ex-
perienced at least 1 relapse vs patients without a relapse. For
analysis of safety end points, all patients who were treated for
at least 1 day were included.
Data are expressed as absolute number (percentage), me-
dian (25th quantile; 75th quantile), mean (SD), mean differ-
ence, odds ratios (ORs) and hazard ratio with 95% CIs as ap-
propriate. Except for the primary end point, all further analyses
are of descriptive values. Significance level was set at P = .05
with 2-tailed, unpaired testing. Analyses were performed with
the use of SAS software, version 9.4 (SAS Institute).
Results
Patient Population
A total of 176 patients were screened between May 8 and
August 10, 2015, of whom 120 were randomized; the study end
date was September 20, 2016. The baseline demographic and
clinical characteristics were well balanced between the treat-
ment groups (Table 1), and 91.7% (55 of a total of 60 in each
group) of patients in each group reported adverse effects of cor-
ticosteroid treatment at the time of enrollment. The predomi-
nant histologic type in both groups was minimal-change ne-
phrotic syndrome. Diary reviews and returned pill counts
suggested good drug adherence in the tacrolimus group. Three
patients were excluded from the per-protocol set owing to loss
of follow-up or treatment switching (Figure 1).
Primary Outcome
The 12-month relapse-free survival rate in the intention-to-
treat set was significantly higher with rituximab compared with
tacrolimus (54 [90.0%] vs 38 [63.3%]; P < .001; OR, 5.21; 95%
CI, 1.93-14.07). The sensitivity analyses confirmed the results
of the primary analysis. Logistic regression analysis showed
an adjusted 88% relative risk reduction in the odds of relapse
associated with the use of rituximab vs tacrolimus (eTable 2
in Supplement 2).
Secondary Outcomes
Time to First Relapse
Among the relapsing patients, the median time to first re-
lapse was 40 weeks in the rituximab group and 29 weeks in
the tacrolimus group. Figure 2 illustrates the differences in time
to first relapse between the groups.
The relative risk of developing a relapse was 5 times higher
in the tacrolimus group compared with the rituximab group
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 Research Original Investigation Efficacy of Rituximab vs Tacrolimus in Pediatric Corticosteroid-Dependent Nephrotic Syndrome

Table 1. Baseline Demographic, Clinical, and Biologic Characteristics Figure 1. Trial Flowchart
of the Patients According to Randomization Group
in the Intention-to-Treat Populationa
176 Screened for eligibility
Tacrolimus Rituximab
Characteristic (n = 60) (n = 60)
56 Excluded
Demographics
27 Previous corticosteroid
Male, No. (%) 32 (53.3) 32 (53.3) sparing agent
5 CDNS not confirmed
Age, y 7.2 (2.8) 7.1 (2.8) 5 Inadequate initial
Anthropometry corticosteroid therapy
9 Declined to participate
Weight, kg 27.8 (8.8) 27.5 (8.6) 3 Not in complete remission
Height, cm 115 (16) 114 (15) 7 Other reasons

Height z score −1.2 (0.6) −1.4 (0.7)

BMI z score 2.2 (0.9) 2.2 (1.0) 120 Randomized
Disease history
Duration of disease, y 2.5 (1.5) 2.3 (1.7) 60 Allocated to tacrolimus 60 Allocated to rituximab
Duration of disease <1 y, No. (%) 15 (25.0) 15 (25.0)
No. of relapse episodes per patient in 4 (3-5) 4 (3-5)
2 Switch of treatment 1 Lost to follow-up
prestudy year, median (IQR)b
1 At 6 wk (opted for 1 At 10 wk
Renal histologic status rituximab)
Minimal change glomerulopathy, No. (%) 42 (70.0) 43 (71.7) 1 At 5 wk (opted for
rituximab)
Focal segmental glomerulosclerosis, 18 (30.0) 17 (28.3)
No. (%)
Prednisolone therapy 60 Analyzed ITT 60 Analyzed ITT
58 Analyzed PP 59 Analyzed PP
Cumulative prednisolone dose in prestudy 246 (48) 239 (52)
year, mg/kg/y
Current prednisolone dose, mg/kg/d 1.3 (0.2) 1.3 (0.2) CDNS indicates corticosteroid-dependent nephrotic syndrome;
Serum biochemistry ITT, intention to treat; and PP, per protocol.

Albumin, g/dL 4.34 (0.81) 4.18 (0.73)

Cholesterol, mg/dL 115 (24) 109 (23)
Figure 2. Probability of Relapse-Free Survival According
eGFR, mL/min/1.73 m2 103.0 (10.8) 100.2 (8.6) to Treatment Group
Patients with hypertension, No. (%) 24 (40.0) 20 (33.3)
100
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided
90
by height in meters squared); eGFR, estimated glomerular filtration rate; Rituximab
80
Survival Probability, %

IQR, interquartile range.

Overall Relapse-Free

70
SI conversion factors: To convert albumin to grams per liter, multiply by 10;
60
cholesterol to millimoles per liter, multiply by 0.0259. Tacrolimus
50
a
Unless otherwise indicated, values are given as mean (SD). 40
b
Median (25th quantile-75th quantile). 30
20
10
in the Cox proportional hazards regression model (eTable 2 0
0 10 20 30 40 50 60
in Supplement 2). The additive effect of treatment and
Weeks Since Randomization
histopathologic diagnosis are illustrated in the eFigure in No. at risk
Supplement 2. Rituximab 60 60 59 58 56 53
Tacrolimus 60 58 53 49 44 38

Number of Relapses
The overall relapse rate declined in both treatment groups rela-
tive to the prestudy year by a median of 3 relapses in the ta-
crolimus group and 4 relapses in the rituximab group. Only 2
patients in the rituximab group had more than 1 relapse dur-
ing the study period compared with 10 patients in the tacro-
limus group. Treatment failure was reported in 2 patients (3.3%)
in the rituximab group compared with 6 patients (10.0%) in
the tacrolimus group. The detailed trial results regarding re-
lapses during the study period are given in Table 2.
Biochemical Measures
The children receiving rituximab exhibited higher serum al-
bumin and lower serum cholesterol levels than the tacrolimus-
The 12-month relapse-free survival rate was significantly higher with rituximab
compared with tacrolimus (log rank P < .001).
treated patients at 12 months (mean difference, 0.76; 95% CI,
0.43-1.09, and −18.8; 95% CI, −25.8 to −11.7). The eGFR in-
creased from baseline to the 12-month visit in both treatment
arms; however, the final eGFR was higher in the rituximab
group (mean difference, 6.6; 95% CI, 2.5-10.7).
Cumulative Prednisolone Dose
Whereas both tacrolimus and rituximab treatment resulted in
a significant decrease in the cumulative dose of prednisolone
from the prestudy year, the cumulative corticosteroid dose ad-
ministered during the 12-month study period was lower in the

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 Efficacy of Rituximab vs Tacrolimus in Pediatric Corticosteroid-Dependent Nephrotic Syndrome Original Investigation Research

Table 2. Primary and Secondary Study End Points According to Treatment Group
in the Intention-to-Treat Populationa
Between-Group Difference
End Point Tacrolimus Rituximab (95% CI)b
Primary, No. 60 60
Patients with sustained remission (0-12 mo), 38/60 (63.3) 54/60 (90.0) 5.21 (1.93 to 14.07)
No. (%)
Secondary, No. 58 59
Frequency of patients with relapse (0-12 mo),
No. (%)
0 Relapse 37 (63.8) 53 (89.8)
1 Relapse 11 (19.0) 4 (6.8)
2 Relapses 6 (10.3) 2 (3.4)
3 Relapses 4 (7.0) 0
Change in relapse rate from prestudy year, −3 (−4 to −2) −4 (−4 to −3)
median (IQR)c
Patients with sustained remission (0-6 mo), 48/58 (82.8) 59/59 (100)
No. (%)
Patients with treatment failure, No. (%) 6/60 (10.0) 2/60 (3.3) 0.31 (0.06 to 1.60)
Serum albumin at month 12, g/dL 4.87 (0.78) 5.63 (0.99) 0.76 (0.43 to 1.09)
12-mo Change in serum albumin, g/dL 0.54 (0.96) 1.47 (0.49) 0.93 (0.65 to 1.21)
Serum cholesterol at month 12, mg/dL 98.4 (16.1) 79.6 (22.1) −18.8 (−25.8 to −11.7)
12-mo Change in serum cholesterol, mg/dL −16.8 (19.8) −29.6 (17.8) −12.8 (−19.7 to −5.9) Abbreviations: BMI, body mass index
(calculated as weight in kilograms
eGFR at month 12, mL/min/1.73 m2 111.8 (11) 118.4 (11) 6.6 (2.5 to 10.7)
divided by height in meters squared);
12-mo eGFR change, mL/min/1.73 m2 8.4 (6.9) 18.2 (8.3) 9.8 (7.0 to 12.6) eGFR, estimated glomerular filtration
Cumulative prednisolone dose in study year, 86.3 (58.0) 25.8 (27.8) −60.5 (−77.1 to −43.9) rate; IQR, interquartile range.
mg/kg SI conversion factors: To convert
Change in cumulative prednisolone dose from −161 (68) −213 (49) −52.5 (−74.2 to −30.8) albumin to grams per liter, multiply by
prestudy year, mg/kg 10; cholesterol to millimoles per liter,
Prednisolone dose at month 12, mg/kg/d 0.62 (1.33) 0.19 (0.76) −0.43 (−0.82 to 0.03) multiply by 0.0259.
12-mo Change in prednisolone dose, mg/kg/d −0.70 (1.32) −1.12 (0.74) −0.42 (−0.81 to 0.03) a
Unless otherwise indicated, values
Children not receiving corticosteroids at month 46/58 (79.3) 55/59 (93.2) 0.28 (0.08 to 0.92) d are given as mean (SD).
12, No. (%) b
The between-group difference is
Height z score at month 12 −1.20 (0.48) −1.00 (0.63) 0.19 (−0.01 to 0.40) given as mean difference or odds
12-mo Absolute change in height z score 0.07 (0.08) 0.42 (0.13) 0.35 (0.31 to 0.39) ratio and corresponding 95% CI
with the tacrolimus group being the
BMI z score at month 12 1.66 (0.76) 1.63 (0.79) −0.03 (−0.31 to 0.26) reference.
12-mo Absolute change in BMI z score −0.51 (0.18) −0.61 (0.30) −0.10 (−0.19 to 0.01) c
Median (25th quantile-75th
d quantile).
Patients with hypertension at month 12, 3/58 (5.2) 2/59 (3.4) 0.64 (0.10 to 4.00)
No. (%) d
Odds ratio.

rituximab group compared with the tacrolimus group (25.8
[27.8] vs 86.3 [58.0] mg/kg) (Table 2). At 12 months, 55 of 59
children (93.2%) of the rituximab group compared with 46 of
58 (79.3%) in the tacrolimus group were not receiving corti-
costeroids.
Anthropometry
While the height-for-age z score increased and body mass in-
dex BMI z score decreased over 1 year in both treatment arms
compared with baseline, the absolute changes were greater
with rituximab (mean difference, 0.35; 95% CI, 0.31-0.39 for
height z score and −0.10; 95% CI, −0.19 to 0.01 for body mass
index z score). Two patients in the rituximab group and 3 in
the tacrolimus group had hypertension.
Therapeutic Monitoring
In the tacrolimus group, mean (SD) trough tacrolimus serum
levels at day 14 were 6.0 (0.5) μg/L. Among the patients who
developed relapses, the mean (SD) level at the time of the first
relapse was 5.9 (0.4) μg/L.
In the rituximab group, the peripheral blood B-cell count
decreased to less than 5/mm3 in all patients following 2 doses
of rituximab and no patient required further doses (Figure 3).
B-cell counts had recovered to the reference range for age in
11.9% (7 of 59), 39.0% (23 of 59), and 93.2% (55 of 59) of pa-
tients at 6, 9, and 12 months, respectively. Starting at 4 weeks
and persisting for 9 months after treatment, the 6 patients who
subsequently developed relapses displayed higher B-cell counts
than the 54 who did not relapse. All relapses occurred after full
B-cell recovery.
Adverse Events
A total of 268 adverse events were recorded: 145 in the
tacrolimus arm and 123 in the rituximab arm (eTable 3 in
Supplement 2). Grade 2 events were observed more often in
the tacrolimus arm (51 vs 24 events). The difference was
mainly accounted for by infections, which occurred twice as
often in the tacrolimus than rituximab group (26 [43.3%] vs
13 [21.7%] grade 2/3 infectious events). There were a total of
23 transfusion reactions with rituximab, most of which

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 Research Original Investigation
Figure 3. Course of Circulating B-Cell Counts in the Rituximab Group
800
Peripheral Lymphocyte Count, No. per mm3
Relapse
400
200
100
50
25
10
4
2
1
0
0 10 20
Time Since First Rituximab Dose, wk
Data are expressed on a logarithmic scale as median and interquartile range.
were mild and transient (grade 1 events), and none required
hospitalization. No fatality or serious adverse events oc-
curred in either study arm.
Discussion
To our knowledge, this study is one of the largest random-
ized clinical trials of corticosteroid-sparing agents performed
to date in children with CDNS and represents the first prospec-
tive comparison of tacrolimus and rituximab therapy in this
condition. We demonstrate a significant and clinically rel-
evant reduction of relapse rates by primary use of rituximab
compared with standard CNI therapy. The cumulative re-
lapse risk at 12 months was reduced by 80% in the rituximab
group (adjusted for age, sex, renal histopathologic status, and
previous disease duration). The difference in the primary end
point went along with reduced corticosteroid exposure, bet-
ter catch-up growth, and higher eGFR in the rituximab-
treated children.
In concordance with previous observations, both treat-
ment protocols effectively reduced relapse rates and
allowed efficient corticosteroid sparing. The 63% 12-month
relapse-free survival rate observed with tacrolimus was
comparable to that of previous studies.16,19 In the rituximab
arm, no relapse episodes occurred within the first 6 months
and relapse-free survival was 90% at 12 months. Somewhat
lower 12-month remission rates (40%-80%) were observed
in previous trials, possibly owing to the fact that rituximab
was usually administered as a last therapeutic option in
patients with high disease activity who had not responded
to other steroid-sparing therapies.6,7,11,20,21 Also, whereas
most previous rituximab studies adopted a single-dose pro-
tocol, 2 infusions were administered in this trial, potentially
leading to more-persistent B-cell depletion.6,7,9,22,23
In addition to the direct medical and psychological ben-
efit of the reduced relapse incidence, several clinical ben-
efits attributable to more efficient corticosteroid sparing
were observed in the rituximab group. These benefits
included significant catch-up growth, a slightly more
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Efficacy of Rituximab vs Tacrolimus in Pediatric Corticosteroid-Dependent Nephrotic Syndrome
marked reduction of overweight, and 20% lower serum cho-
lesterol levels at the end of the study period, confirming
findings of a previous uncontrolled trial in a limited number
of adults and children with corticosteroid-dependent or fre-
quently relapsing nephrotic syndrome.9 Furthermore, eGFR
No relapse
was significantly higher in the rituximab group, most likely
because of the absence of CNI-associated renal vasocon-
striction and/or chronic nephrotoxicity.24,25
We confirmed several important relapse risk factors,
which were independent of the pharmacologic therapy
applied. Young children and those with longer previous
disease duration were more prone to relapse during
corticosteroid-sparing treatment, likely reflecting their
30 40 50 60 greater underlying disease activity. 9 Likewise, although
both drugs were confirmed to be effective in reducing
relapse frequency across histopathologic entities, patients
with focal segmental glomerulosclerosis retained a higher
relative relapse risk than those with minimal change in dis-
ease in both treatment arms.9,26 Inferior disease control by
corticosteroid-sparing therapies in focal segmental glo-
merulosclerosis, including rituximab, has previously been
reported.27
Therapeutic drug monitoring revealed that, although
there was no evidence for an association of relapse risk and
tacrolimus trough blood levels, the patients who relapsed 6
to 12 months after rituximab administration displayed sig-
nificantly earlier B-cell recovery, with cell count differences
emerging as early as 4 weeks post dosing. Future research
should explore whether and how the duration of disease
remission can be optimized by individualized, B-cell count–
guided rituximab administration.
Treatment choices in CDNS are not only driven by
efficacy but also by drug tolerability and safety consider-
ations. Our head-to-head comparison showed, apart from a
minimally compromised eGFR and common mild infusion re-
actions to rituximab, excellent tolerability of both treatment
protocols. Mild intercurrent infections appeared to occur more
frequently in the tacrolimus group. None of the serious
adverse events anecdotally reported after rituximab expo-
sure, such as progressive multifocal leukoencephalopathy,28
pulmonary fibrosis, Pneumocystis jiroveci pneumonia, fulmi-
nant myocarditis, and ulcerative colitis, were observed in the
present study; however, sample size and duration of therapy
were underpowered to estimate the true incidence of such rare
complications.
A further relevant aspect to consider regarding the choice
of corticosteroid-sparing therapy in childhood CDNS is treat-
ment adherence, which is often suboptimal with chronic CNI
and glucocorticoid therapy. The reliable achievement of dis-
ease remission by a single course of intravenous therapy
without the need for maintenance oral drug intake is a
major practical argument in favor of rituximab to many
families. Furthermore, the cumulative cost of treatment is
an issue, particularly in developing countries. Within the
12-month time frame considered in this study, the cost of 2
doses of rituximab was up to 20% less than the cumulative
expense for even the generic tacrolimus preparation used in
India.
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 Efficacy of Rituximab vs Tacrolimus in Pediatric Corticosteroid-Dependent Nephrotic Syndrome Original Investigation Research

Limitations remission at acceptable adverse effect rates would have

We recognize several limitations to our study. The intrinsic
difference in efficacy of tacrolimus and rituximab may have
been somewhat underestimated by study design owing to
the longer corticosteroid coadministration in the tacrolimus
arm. However, we cannot exclude temporary study drug
nonadherence in the tacrolimus arm, although patient dia-
ries, returned pill counts, and tacrolimus blood levels at
time of relapse suggested good treatment adherence. In
addition, the 12 months’ exposure to the study drugs did
not permit a valid assessment of the long-term safety of
both drugs in children with nephrotic syndrome. Further-
more, the efficacy and safety of the drugs may vary depend-
ing on patient ethnicity and geographic location; thus, the
findings of this single-center trial in India may not be read-
ily generalizable to other ethnic groups and regions. Fur-
thermore, changes in quality of life with the 2 treatment
protocols were not assessed systematically. Finally, our trial
was designed to compare the corticosteroid-sparing poten-
tial of monotherapies. It is possible that better long-term
been achieved and the difference in efficacy would have
been attenuated by combining different corticosteroid-
sparing agents. Future research will need to explore the use-
fulness of such combined therapies, which may include the
sequential use of rituximab and low-toxicity immunomodu-
latory agents, such as mycophenolate mofetil,29,30 to avoid
the long-term risks of repetitive B-cell depletion, such as
opportunistic infections, autoimmune pathologic effects,
and formation of neutralizing antibodies.31
Conclusions
The findings of the study indicate that rituximab is more
effective than tacrolimus over a 12-month period in maintain-
ing disease remission and minimizing corticosteroid expo-
sure. Given its good tolerability and lack of nephrotoxic
effects, rituximab may be considered as first-line corticosteroid-
sparing therapy in children with CDNS.

ARTICLE INFORMATION
Accepted for Publication: April 13, 2018.
Published Online: June 18, 2018.
doi:10.1001/jamapediatrics.2018.1323
Author Affiliations: Division of Pediatric
Nephrology, Department of Pediatrics, Nilratan
Sircar Medical College and Hospital, Kolkata, India
(Basu); Institute of Medical Biometry and
Informatics, University of Heidelberg, Heidelberg,
Germany (Sander, Preussler); Department of
Pediatrics, Nilratan Sircar Medical College and
Hospital, Kolkata, India (Roy, Barua, Mahapatra);
Division of Pediatric Nephrology, Center for
Pediatrics and Adolescent Medicine, University of
Heidelberg, Heidelberg, Germany (Schaefer).
Author Contributions: Drs Basu and Sander
contributed equally to the study.
Dr Basu had full access to all of the data in the study
and takes responsibility for the integrity of the data
and the accuracy of the data analysis.
Concept and design: Basu, Roy, Mahapatra,
Schaefer.
Acquisition, analysis, or interpretation of data: Basu,
Sander, Roy, Preussler, Barua, Schaefer.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important
intellectual content: Basu, Sander, Preussler,
Mahapatra.
Statistical analysis: Sander, Preussler, Schaefer.
Obtained funding: Basu, Roy, Mahapatra.
Administrative, technical, or material support: Basu,
Roy, Barua, Mahapatra.
Supervision: Basu, Roy, Mahapatra, Schaefer.
Conflict of Interest Disclosures: None reported.
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