Unexpected Late Response to Ofatumumab in Adult Post-Transplantation Recurrent Focal Segmental Glomerulosclerosis, Case Report

Effective treatment of immune mediated peripheral neuropathy with Ofatumumab - A case report

Recurrent immune-mediated peripheral neuropathy is a rare immune disorder that presents significant therapeutic challenges. Ofatumumab (OFA) is a fully humanized anti-CD20 monoclonal antibody with low immunogenicity. We report a patient with recurrent immune-mediated peripheral neuropathy who achieved sustained remission following OFA treatment after multiple relapses. Over a two-year period, the patient experienced over 20 episodes of bilateral upper and lower limb weakness. Furthermore, the patient was unresponsive to intravenous immunoglobulin, plasma exchange, corticosteroids, mycophenolate mofetil, and Telitacicept. Subcutaneous OFA administration resulted in marked reductions in CD19+ and CD20+ B-cell counts and a relapse-free period exceeding 20 months, with no adverse events observed. This case provides early evidence supporting OFA as a safe and effective alternative for recurrent immune-mediated peripheral neuropathy.

Use of rituximab and plasma exchange in treatment and prophylaxis of recurrent FSGS

Background

Focal segmental glomerulosclerosis (FSGS) is a common cause of nephrotic syndrome and renal failure, requiring transplantation. However, FSGS can often recur after transplantation resulting in graft failure. The most used therapeutic intervention for rFSGS is plasma exchange (PE), with variable success. Recently, rituximab has found increasing use in both treatment and prevention of recurrent FSGS.

Methods

We undertook a systematic review of therapeutic ± preventative plasma exchange, rituximab or a combination of both for recurrent FSGS. Studies published between 2017 and 2024 were included, to reflect the most contemporary clinical practice.

Results

Twenty-seven studies with a total of 475 patients received treatment for recurrence post-transplantation and/or for prevention of recurrent FSGS. Of 221 patients who received plasma exchange on its own as therapy, 156 (71%) achieved either complete or partial remission. Rituximab alone was used in only four patients (75% remission rate), while 67% achieved remission with a combination of both. One hundred and forty-two patients received pre/peri-transplantation treatment to prevent recurrence in the graft. Fifty-one patients (36%) experienced recurrence despite prophylaxis. Recurrence rates were 35% with plasma exchange alone and 38% with rituximab alone.

Conclusion

We conclude that rituximab did not add significant benefit to plasma exchange when used as initial therapeutic intervention in post-transplant recurrent FSGS. The modest benefit of prophylactic therapies highlights the need for risk stratification to identify patients most likely to benefit from such interventions. Larger prospective studies with standardized approaches to treatment are essential in improving outcomes in rFSGS.