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Rituximab Pause Hypogammaglobulinaemia Infections — ESENeph MCQ

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ModerateRenal VasculitisRituximab Pause Hypogammaglobulinaemia InfectionsESENeph

A 60-year-old man with ANCA vasculitis on Rituximab maintenance for 3 years has CD19 B-cell count of 0 cells/uL and IgG of 3.2 g/L. He has had 3 chest infections in 6 months. Should Rituximab be continued?

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Correct answer: A — The benefit-risk balance should be reassessed – prolonged B-cell depletion with hypogammaglobulinaemia and recurrent infections may warrant pausing Rituximab, considering IgG replacement therapy, and closely monitoring for vasculitis relapse; shared decision-making is essential

After prolonged Rituximab therapy, cumulative B-cell depletion can cause sustained hypogammaglobulinaemia (IgG <4 g/L) with clinically significant immunodeficiency. KDIGO 2024 AAV guideline practice point acknowledges this complication. Management options: (1) extend Rituximab dosing intervals (e.g. from 6-monthly to 9-12 monthly) allowing partial B-cell reconstitution; (2) pause Rituximab and monitor for relapse; (3) start IgG replacement (IVIg or subcutaneous Ig) if IgG <4 g/L with recurrent infections; (4) switch maintenance to Azathioprine (though less effective for relapse prevention). The decision requires balancing infection risk against relapse risk.

Reference: KDIGO 2024 – AAV; Roberts et al 2015 – Rituximab Immunodeficiency