Rituximab (Nephrology)

How it works

It binds the CD20 antigen on B lymphocytes and depletes them through complement- and antibody-dependent cytotoxicity and apoptosis, reducing pathogenic antibody production and B-cell-driven immune injury.

Prescribing in practice

• Screen for hepatitis B before treatment because rituximab can reactivate the virus and cause fulminant hepatitis, sometimes long after therapy; infusion reactions can also be severe.
• It increases infection risk and, rarely, progressive multifocal leukoencephalopathy, so new neurological symptoms warrant urgent assessment.
• Give premedication and a graded infusion to reduce infusion-related reactions, and ensure vaccinations are addressed before B-cell depletion.

Monitoring

Monitor for infusion reactions, infection and hepatitis B reactivation, with B-cell counts and immunoglobulins guiding follow-up.

Counselling the patient

• Tell staff at once of any rash, breathlessness, fever or chills during the infusion.
• Report new infections, or any neurological symptoms such as confusion or weakness.

Evidence & guidelines

Randomised trials support rituximab in ANCA vasculitis and membranous nephropathy, and current prescribing references and the SPC detail screening and monitoring requirements.