Effective therapeutic use of rituximab in refractory Wegener's granulomatosis

1Queen Elizabeth Hospital, Department of Nephrology, Birmingham, 2Birmingham University, Division of Immunity and Infection, Birmingham, UK Wegener's granulomatosis (WG) is a chronic, multisystem disease, characterized by a small vessel vasculitis. Whilst it previously carried a high early mortality (80% in 2 years) [1], the advent of cyclophosphamide therapy for the induction of remission has reduced this greatly. Despite the use of other immunosuppressive agents, including methotrexate, azathioprine and mycophenolate mofetil, to maintain remission, relapse often occurs – with many patients requiring further courses of cyclophosphamide over many years. Despite its success at remission induction, cyclophosphamide therapy comes at a heavy price, with increased rates of infection resulting in significant morbidity and mortality, and dose-related increases in rates of haematological and solid organ malignancies [2]. As a result, alternative therapeutic strategies, for example directed against cytokines such as tumour necrosis factor (TNF), are also being tested with some success [3], but these also carry significant risks of opportunistic infection, especially with mycobacteria.