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Abstract: TH-PO074

A Rare and Serious Reaction to Frequently Used Rituximab

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials


  • Torres-Rivera, Gabriel J., VA Caribbean Healthcare System, San Juan, San Juan, Puerto Rico
  • Cortes, Carlos, VA Caribbean Healthcare System, San Juan, San Juan, Puerto Rico
  • Rosado-Rodriguez, Carlos S., VA Caribbean Healthcare System, San Juan, San Juan, Puerto Rico
  • Rivera-Bobe, Nicole, VA Caribbean Healthcare System, San Juan, San Juan, Puerto Rico

Rituximab is an anti-CD20 monoclonal antibody used in malignancies, and rheumatologic and kidney diseases. Rituximab is seldom associated with life threatening complications. Cytokine Release Syndrome (CRS) is a systemic response following an extensive release of inflammatory cytokines due to activation of myeloid cells and lymphocytes. Depending on its severity, it can present with rash, fever, abdominal pain, mental status changes, and respiratory failure. Few cases are reported in the literature, most leading to a catastrophic cascade of events. We herein present a man with B-Cell lymphoma who became critically ill with severe lactic acidosis, altered mental status, and renal failure within minutes of receiving his first rituximab dose.

Case Description

A 68 y/o man with hypertension went to the ER complaining of chills at night and weight loss. Normal vital signs but found with bilateral cervical and axillary lymphadenopathy. Labs with increased creatinine: 0.9>1.31mg/dL and Ca+: 11mg/dL. He was admitted to Oncology due to symptomatic hypercalcemia, AKI, and lymphadenopathy with suspected malignancy. Lymph node biopsy yielded B-cell lymphoma diagnosis and he was started on rituximab. Minutes after starting the infusion, he presented with chills, tachypnea, tachycardia, hypertension, and altered mental status. No edema or skin rash but presented abdominal discomfort. Infusion was stopped and he was given IV diphenhydramine and solumedrol. Lactic acid: 21.2mmol/L, blood pH: 7.2, Anion Gap: 34, K+: 5.0mEq/L, and PO4-: 5.9mg/dL, LDH 2212 U/L, CPK 55 U/L. Elevated lactic acid without evidence of hypoperfusion and his electrolytic disturbances suggest rapid destruction of tumor cells by rituximab leading to CRS. Initially provided with supportive therapy, but became anuric 2 days later for which a trial of hemodialysis was started. There was no improvement with worsening pancytopenia, the family opted for comfort measures and the patient was discharged home under hospice care.


Because of its efficacy, Rituximab is widely and frequently used. Rituximab-associated CRS is very rare but carries a high morbidity and mortality risk. This case is important for the community since it highlights a very rare and overlooked reaction of rituximab which is being used more frequently.