Rituximab in a desensitization protocol as a rescue therapy in severe nephrotic syndrome—a case report

Idiopathic nephrotic syndrome is the most common glomerulopathy in children, and minimal change disease (MCD) is the most common histological pattern. First-line treatment involves glucocorticosteroids, but frequent relapses and steroid dependence may lead to steroid-related complications. Rituximab (RTX) is recommended in cases of lack of response or treatment side effects, reducing relapse rates and limiting the need for other medications. The mechanism of RTX involves B-cell depletion through various cytotoxic mechanisms. Its efficacy in nephrotic syndrome (NS) may stem from its influence on cytokines produced by B cells and a further effect on the podocyte cytoskeleton has been postulated. The present case describes a 19-year-old male with NS resulting from MCD, with a frequently relapsing, steroid-dependent, multidrug-resistant disease. He experienced a hypersensitivity reaction to RTX after the third dose, which contraindicated therapy continuation with traditional infusion. Due to the limited therapeutic options, a 12-step RTX desensitization protocol was adopted, allowing for safe administration of subsequent doses, achievement of remission, and gradual discontinuation of glucocorticosteroids.