Abstract: FR-PO0710
When Rituximab Isn't Enough: A Case of Rituximab-Resistant Minimal Change Disease
Session Information
- Glomerular Diseases: Membranous Nephropathy, FSGS, and Podocytopathies
October 23, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Glomerular Diseases
- 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics
Authors
- Wekesa, Debra S.A, University of Nebraska System, Omaha, Nebraska, United States
- Trappett, Kevin Paul, University of Nebraska System, Omaha, Nebraska, United States
- Naranjo, Felipe Sebastian, University of Nebraska System, Omaha, Nebraska, United States
Introduction
Minimal change disease (MCD) is an uncommon nephrotic syndrome in the adult population. It is typically highly responsive to corticosteroids and other immunosuppressive therapies. Rituximab, an anti CD20 monoclonal antibody that leads to B cell depletion, is frequently used as a steroid sparing agent and is associated with high remission rates. However, for patients who are resistant or relapse despite therapy, additional medication options is critical. We present a case of relapsing MCD with failure of rituximab despite appropriate B cell depletion, followed by successful remission with obinutuzumab.
Case Description
A 48-year-old woman presented in 2022 with one month of worsening abdominal pain, edema, and shortness of breath. She had biopsy proven minimal change disease. She had a serum albumin of 1.9g/dL and a urine protein/creatine ratio (UPCR) of 13.7g. She started on a course of 17 weeks of a prednisone taper before starting tacrolimus maintenance therapy August 2022. She entered remission July 2022. In February 2024, she relapsed with UPCR 13.4g despite tacrolimus use and was treated with 19 week prednisone taper with remission by May 2024. She relapsed July 2024 with UPCR 10.3g despite steroids. She started rituximab with two doses in July and one dose in December 2024. She continued to have sub-nephrotic range proteinuria with normal serum albumin. CD19 and CD20 absolute counts were obtained February 2025 with appropriate depletion despite continued active disease. She relapsed in March 2025 with UPCR 3.5g and was started on a steroid taper. She had depleted CD19 and CD20 levels in June 2025. Due to concerns with chronic steroid use, she started on obinutuzumab June 2025. She quickly had resolution of her proteinuria after two doses and completed her 15 week steroid taper. Repeat CD19 and CD20 levels in March 2026 continued to show appropriate depletion. She has been in remission for almost one year.
Discussion
This case highlights a rare instance of rituximab-refractory MCD despite adequate B-cell depletion. Obinutuzumab, a newer anti-CD20 monoclonal antibody with higher antibody dependent cellular cytotoxicity and more sustained B cell depletion leading to prolonged medication effects. This case highlights the consideration of obinutuzumab as an alternative therapy in relapsing or treatment-resistant MCD, particularly in patients with contraindications to mainline therapies.