|Year : 2015 | Volume
| Issue : 3 | Page : 646
Safety of rituximab in a patient with chronic renal failure and low-grade non-Hodgkin lymphoma
Ralph Chebib1, Claude Ghorra2, Joseph Kattan1
1 Department of Hematology - Oncology, Hotel Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
2 Department of Histology Pathology, Hotel Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
|Date of Web Publication||9-Oct-2015|
Adib Ishac St., Sahnaoui Bld, sixth floor, Beirut
Source of Support: None, Conflict of Interest: None
An 82-year-old man, with known chronic renal failure and a creatinine clearance (CrCl) of 18 mL/min, was diagnosed with low-grade marginal zone non-Hodgkinlymphoma (NHL) of his right orbit. He received rituximab as single treatment (375 mg/m 2 every 3 weeks). After eight cycles, almost complete response was obtained, rituximab was extremely well-tolerated, and his creatinine levels remained stable throughout the whole treatment.
Keywords: Chronic renal failure, low-grade lymphoma, rituximab
|How to cite this article:|
Chebib R, Ghorra C, Kattan J. Safety of rituximab in a patient with chronic renal failure and low-grade non-Hodgkin lymphoma. J Can Res Ther 2015;11:646
| > Introduction|| |
Rituximab (MabThera; Roche Pharma, Basel, Switzerland) is used frequently in combination with chemotherapy or alone in the treatment of patients with CD20-positive lymphoproliferative malignancies. The majority of published trials excluded patients with creatinine higher than 2.0mg/dL, and there are no specific available recommendations regarding rituximab dosage adjustment for patients with renal failure. Moreover, pharmacokinetic data of the drug in patients with renal failure is not available. We present the case of a patient with non-Hodgkin lymphoma (NHL) marginal zone type, and chronic renal failure successfully treated with full-dosage rituximab without any complication or side effect.
| > Case report|| |
An 82-year-old man is followed regularly in the nephrology department for a chronic renal failure secondary to arterial hypertension since 20 years. His creatinine clearance (CrCl) was maintained around 18 mL/min during the last 2 years. Glomerular filtration rate (GFR) was estimated using Modification of Diet in Renal Disease (MDRD) formula and results were further confirmed by measurement of CrCl on 24 h urine collection. In February 2013, he had a right exophthalmia. Physical examination and laboratory findings were otherwise unremarkable. A magnetic resonance imaging (MRI) of the orbits showed a dumbbell-shaped mass occupying the roof and lateral aspect of the right orbital cavity, protruding into the subcutaneous space. It measured 40 × 35 × 10 mm, compressing and displacing downward and forward the eyeball, exerting mass effect over the superior rectus muscle, and displacing it downward. Surgical resection was almost complete. Histology assessment showed diffuse expansion and infiltration of abnormal lymphoid cells. Flow cytometry and immunohistochemistry staining revealed CD20, CD5, and CD43 positive; while CD10, CD23, and cyclin D1 were negative. Diagnosis of marginal low-grade B-cell NHL was made. Extension work-up was limited to diffusion-weighted whole body MRI with background body signal suppression (DWIBS) using metabolic MRI. It showed diffuse infiltration of the bone marrow, a 3cm lesion of the left transverse process of L5 and multiples enlarged lymph nodes in the paravertebral, inguinal, and pelvic region. A monotherapy with rituximab alone was administered, preceded by a 1 g infusion of paracetamol. Full dosage with 375 mg/m 2 rituximab every 3 weeks were given for a total of eight cycles. Treatment was well tolerated without any treatment-related adverse events. Disease assessment by the same metabolic MRI method was almost normal, and renal function remained stable during the whole treatment period.
| > Discussion|| |
Orbital space is a rare localization of NHL. NHL occurs primarily in the lymph nodes, although involvement of additional extranodal sites is common. The orbit is involved in 10% of all lymphomas, 5-8% of all extranodal lymphomas and 1.3-2% of all primary orbital extranodal tumors. Such lesions usually present as gradually increasing painless mass in the orbit or subconjunctival space.  Only a minority of orbital lymphomas are intermediate or high-grade, while most of them have a low-grade histology.  There are no formal studies that have examined the effects of renal impairment on the pharmacokinetics of rituximab. The safety and efficacy of rituximab, as well as the optimal dose of rituximab in patients with renal impairment have not been established because data on the use of Rituximab in patients with hematological disorders and impaired renal function are limited to few case reports. In the pivotal phase 3 trials for rituximab, patients with serum creatinine >2 mg/dL or a CrCl <60 mL/min were excluded.  Abdelkefi et al., reported a case of a 47-year-old patient with chronic renal failure treated with 4 weekly doses of rituximab as initial treatment for follicular lymphoma followed with maintenance therapy with rituximab. The patient achieved a complete remission and rituximab was well tolerated and his renal function remained stable.  Rituximab was also reported by Tokar et al., to induce a complete remission in a 34-year-old man with acute renal failure due to bilateral kidney infiltration by NHL.  Bartel and colleagues reported use of rituximab and bendamustine to treat a patient with membranoproliferative glomerulonephritis type 1 secondary to chronic lymphocytic leukemia (CLL). His renal function progressed on first line chemotherapy and rituximab was administered alone subsequently. During the course of rituximab therapy, renal function improved and no other complications were reported.  Rituximab was also reported to improve renal function in a 68-year-old female with membranous nephropathy that developed post-allogenic hematopoietic stem cell transplantation for stage 3 follicular NHL.  Mandreoli et al., reported a case of chronic renal failure and pure red cell aplasia treated with rituximab. One week following the last rituximab dose, endogenous erythropoietin (EPO) levels had increased and anti-EPO antibodies had decreased.  In 2002, Pham et al., reported a case of a 25-year-old male who had undergone a living related donor renal transplant from his mother for an end-stage renal disease; the patient subsequently developed a hepatic mass that turned out to be a malignant large B-cell lymphoma posttransplant lymphoproliferative disease (PTLD). Although his serum creatinine was in the range of 1.2-1.5 mg/dL, he received 5 weekly injections of rituximab with a good response. His renal function remained stable.  Another similar case was reported by Kaposztas et al., where the use of rituximab was safe in a PTLD in a patient with a serum creatinine in the range of 1.5-2 mg/dL.  Our case report along with few other reported cases in the literature, confirmed that rituximab could be administered safely to patients with chronic renal failure without any dose reduction and without harming its efficacy.
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