RITUXIMAB VERSUS MODIFIED PONTICELLI REGIMEN IN THE MANAGEMENT OF PRIMARY MEMBRANOUS NEPHROPATHY IN A TERTIARY CARE CENTRE

Introduction:

Membranous nephropathy (MN) is one of the most common causes of nephrotic syndrome in adults . Treatment using the modified Ponticelli regimen (MPR) with cyclical steroids and cyclophosphamide has remained the standard of care for decades , but is associated with several adverse effects . Another line of therapy, Rituximab also offer promising results with reduced side effects. However, the cost of which is considered a barrier for its wide-spread use. 

Both these regimen, aim to achieve remission –i.e. the reduction of protein excretion in the urine. The aim of this study is to assess the effectiveness of rituximab versus the MPR in inducing remission (complete or partial ) in MN at the end of 6 months and to look for rate of relapse in both groups at end of 1 year 

Methods:

This is a  Retrospective Observational study done over a period of 2 years (Jan 2022- Jan 2024) , which evaluated outcomes of Primary MN patients either receiving Rituximab (500mg, 4 doses given weekly apart) or MPR (six month cyclic regimen with corticosteroids alternated with oral cyclophosphamide every other month). 

All participants included in analysis were >18 years old . Patients had their PLA2R status recorded at baseline. Events of partial and complete remission, defined as 50% reduction of proteinuria to <3.5g/day and proteinuria of <0.3g/day, were recorded.  Relapse and serious adverse events on Rituximab and MPR were documented. UPCR, Serum Albumin and creatinine levels were collected during presentation and 3, 6 ,12 months follow up period,  separately for Rituximab and MPR groups .Comparison was conducted through the Chi-square test 

Results:

A total of 32 patients (21 received MPR and 11 received Rituximab ) were included. The mean age for the Rituximab and MPR groups were 58.5 years and 48.6 years respectively. The M:F ratio was 9:2 in the Rituximab group and 12:9 in the MPR group.  9 patients were PLA2R+ve in the Rituximab group whilst 18 patients were PLA2R+ve in the MPR group.

Out of 21 patients who received MPR , at the end of 6 months ,13 patients( 61.90%)  had complete remission( CR) and 8 patients(38.09%) had partial remission (PR). At the end of one year, 4 patients (19.04%) had relapse .

 Out of 11 patients who received rituximab, at the end of 6 moths , 6 patients ( 54.5%) had CR and 5 patients(45.95%)  had PR .At the end of one year ,6 patients(54.54%)  had relapse .

At 6 months , the probability for complete or partial remission was not statistically significant overall [OR 1.354 (95%Cl : 0.308-5.93)] and p value of 0.687. At one year , relapse rate was significantly higher in rituximab group [OR 5.100 (95%Cl :1.018-25.53) and p value of 0.047.

Adverse event rates were less in the Rituximab group compared to those who received MPR (18.18% vs 42.8%,).

Conclusions:

In our study, Rituximab had almost similar outcomes compared to MPR in terms of remission (CR/PR) over a period of 6 months .But the relapse rate at the end of one year was significantly higher in Rituximab group .Despite this, it should be noted that Rituximab displayed a better adverse effect profile compared to MPR and is preferable in patients with multiple comorbidities and elderly age group. Further evaluation between these two treatment modalities of MN should involve a multicenter trial conducted with greater patient numbers and longer follow-up

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.