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AAV Renal Relapse — SCE Rheumatology MCQ

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HardVasculitisAAV Renal RelapseSCE Rheumatology

A 50-year-old man with GPA on maintenance Rituximab develops persistent microscopic haematuria with rising creatinine. ANCA has become positive again. Renal biopsy shows active crescentic glomerulonephritis. What treatment is indicated?

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Correct answer: C — Re-induction with Rituximab at induction dosing (375 mg/m2 weekly x4 or 1 g x2) plus glucocorticoids

Active renal relapse during Rituximab maintenance requires re-induction therapy not simply continuing the maintenance dose. BSR 2025 AAV guidelines recommend re-induction with Rituximab at full induction dosing (either 375 mg/m2 weekly for 4 weeks or 1 g two weeks apart) combined with glucocorticoids. The maintenance dose (500 mg every 6 months) is insufficient for active vasculitis. Cyclophosphamide is an alternative for re-induction. After achieving remission maintenance therapy should be intensified (shorter intervals or higher doses).

Reference: BSR 2025 AAV guidelines; Stone JH et al 2010 RAVE trial