This letter to the editor comments on a retrospective study by Zha et al. comparing obinutuzumab, rituximab retreatment, and no anti-CD20 therapy after rituximab failure in children with refractory nephrotic syndrome, arguing for more precise patient selection criteria before switching to obinutuzumab.
The authors' own single-center cohort (n=92 children with steroid-dependent nephrotic syndrome) found that 9 of 12 relapse episodes (75%) during B-cell depletion occurred within the first 4 weeks after rituximab, and none of these patients returned to a frequently relapsing or steroid-dependent course during the remaining depletion period — suggesting very early relapse may reflect delayed drug effect rather than true rituximab resistance.
This is a letter/commentary, not a primary study; the referenced cohort data are from a prior single-center publication and are not fully reproduced here. The call for patient-level data stratification has not yet been answered by the original authors.
Consider switching to obinutuzumab primarily in two scenarios: (1) absent or very short B-cell depletion after rituximab (especially with anti-rituximab antibodies), or (2) relapse more than 4 weeks post-rituximab despite persistent B-cell depletion — rather than broadly labeling all relapses during depletion as rituximab resistance.
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