Persistent hypogammaglobulinaemia after rituximab in children with difficult-to-treat nephrotic syndrome: a multicentre cross-sectional observational study
- 1Department of Pediatrics, Institute of Child Health, Kolkata, India
- 2Department of Pediatrics, All India Institute of Medical Sciences, Kalyani, West Bengal, India
- 3Department of Paediatric Nephrology, Great North Children’s Hospital, Newcastle Upon Tyne, UK
Abstract
Background: Rituximab is widely used for difficult steroid-dependent and frequently relapsing nephrotic syndrome (SDNS/FRNS). Persistent hypogammaglobulinaemia (PH) after rituximab is increasingly recognised, but data from low- and middle-income settings remain limited.
Methods: In this multicentre cross-sectional study, children <18 years with SDNS/FRNS who had received rituximab ≥12 months earlier were evaluated for serum immunoglobulin G (IgG) levels. PH was defined as IgG<2 SD below age-adjusted norms ≥12 months after the last rituximab dose. Logistic regression was performed to identify predictors of PH. Infection-related hospitalisation rates were compared between groups.
Results: Among 109 children (median age 10.2 years; median 24 months since last rituximab), 27 (25%) had PH. Younger age at first rituximab independently predicted PH (OR 0.968 per year (95% CI 0.947 to 0.990); p=0.005). PH prevalence declined progressively with increasing age at first exposure (71% in 2–3.9 years vs 12% in ≥8 years; p=0.005). Overall, 12% required hospitalisation for severe infections; infection-related hospitalisation rates were higher among children with hypogammaglobulinaemia (0.41 vs 0.07 per year; p=0.002).
Conclusion: In this cross-sectional cohort, hypogammaglobulinaemia was detected in one-quarter of children ≥12 months after rituximab exposure and was independently associated with younger age at first exposure. Hypogammaglobulinaemia was also associated with higher infection-related hospitalisation rates, although this exploratory association cannot establish causality. Prospective longitudinal studies are needed to define IgG recovery and infection risk after rituximab.
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BibTeX
@article{saha2026persistent,
title = {{Persistent hypogammaglobulinaemia after rituximab in children with difficult-to-treat nephrotic syndrome: a multicentre cross-sectional observational study}},
author = {Suchismita Saha and Deepshikha Baranwal and Subhankar Sarkar and Sanjukta Poddar and Shakil Akhtar and Yincent Tse and Rajiv Sinha},
journal = {BMJ Paediatrics Open},
year = {2026},
month = nov,
doi = {10.1136/bmjpo-2026-005067},
url = {https://doi.org/10.1136/bmjpo-2026-005067},
note = {CC BY-NC 4.0},
}
RIS
TY - JOUR
TI - Persistent hypogammaglobulinaemia after rituximab in children with difficult-to-treat nephrotic syndrome: a multicentre cross-sectional observational study
AU - Suchismita Saha
AU - Deepshikha Baranwal
AU - Subhankar Sarkar
AU - Sanjukta Poddar
AU - Shakil Akhtar
AU - Yincent Tse
AU - Rajiv Sinha
PY - 2026
DA - 2026/11/02
JO - BMJ Paediatrics Open
DO - 10.1136/bmjpo-2026-005067
UR - https://doi.org/10.1136/bmjpo-2026-005067
AB - Background: Rituximab is widely used for difficult steroid-dependent and frequently relapsing nephrotic syndrome (SDNS/FRNS). Persistent hypogammaglobulinaemia (PH) after rituximab is increasingly recognised, but data from low- and middle-income settings remain limited. Methods: In this multicentre cross-sectional study, children <18 years with SDNS/FRNS who had received rituximab ≥12 months earlier were evaluated for serum immunoglobulin G (IgG) levels. PH was defined as IgG<2 SD below age-adjusted norms ≥12 months after the last rituximab dose. Logistic regression was performed to identify predictors of PH. Infection-related hospitalisation rates were compared between groups. Results: Among 109 children (median age 10.2 years; median 24 months since last rituximab), 27 (25%) had PH. Younger age at first rituximab independently predicted PH (OR 0.968 per year (95% CI 0.947 to 0.990); p=0.005). PH prevalence declined progressively with increasing age at first exposure (71% in 2–3.9 years vs 12% in ≥8 years; p=0.005). Overall, 12% required hospitalisation for severe infections; infection-related hospitalisation rates were higher among children with hypogammaglobulinaemia (0.41 vs 0.07 per year; p=0.002). Conclusion: In this cross-sectional cohort, hypogammaglobulinaemia was detected in one-quarter of children ≥12 months after rituximab exposure and was independently associated with younger age at first exposure. Hypogammaglobulinaemia was also associated with higher infection-related hospitalisation rates, although this exploratory association cannot establish causality. Prospective longitudinal studies are needed to define IgG recovery and infection risk after rituximab.
SN - 2399-9772
ER -