Monoclonal antibodies in nephrology: a delicate balance between curative potential, evidence of effectiveness, and toxicity

Rituximab is a chimeric human-murine anti-CD20 monoclonal antibody able to obtain the depletion of B lymphocytes. In recent years significant clinical experience has been gained and literature studies have been carried out investigating the possible role of this drug in autoimmune conditions such as immune-mediated glomerulonephritis and transplant rejection. It must be stressed that at present the drug is not registered for any type of kidney disease and its use in nephrology is to be considered off-label. A recent report showed that rituximab is generously administered in clinical settings where the support of the literature is still debated and inconclusive; in a significant number of cases the drug is used in contexts where the scientific support can be considered substantially inconsistent. This brief report will address the principal findings on the use of rituximab in nephrology. It will also briefly evaluate the role of eculizumab, a novel biological drug active on the complement cascade. Experimental evidence points to a central role for these two new drugs in many immune-mediated conditions of nephrologic interest. This exciting field of research is still in its infancy with regard to the scientific assessment of the clinical applications. In view of the ethical considerations concerning the toxicity of therapeutic interventions and the need to give patients the best available treatment, a great collaborative effort is required by the nephrology community to address these clinical issues in the context of multicenter randomized controlled studies.