Lupus nephritis (LN) is a frequent and severe complication of systemic lupus erythematosus, with important mortality and morbidity. International 2024 guidelines recommend immunosuppressive therapy (MMF, cyclophosphamide, calcineurin inhibitors, rituximab, azathioprine) in patients with heavy or uncontrolled proteinuria, but none of these therapies has been evaluated in robust multicenter prospective. Therefore, no treatment has regulatory approval for pure class V LN.
Obinutuzumab, a 2nd-generation B-cell targeting therapy, is more efficient than rituximab in inducing B-cell depletion and complete renal response in patient with class III or IV lupus nephritis.
This study aims to assess the efficacy and safety of an obinutuzumab monotherapy in patients with pure class V LN. The primary endpoint is complete renal response at week 52 according to 2024 KDIGO criteria (UPCR < 0.5 g/g, eGFR ≥ 85% of baseline, and no intercurrent event: treatment failure, rescue therapy, long-term dialysis, renal transplantation, death or early trial withdrawal)
Inclusion Criteria:
Diagnosis of SLE fulfilling the 2019 EULAR/ACR classification criteria (score > 10)
Age from 18 to 75 years old included
Pure class V lupus nephritis, defined on a renal biopsy sample following the ISN/RPS 2003 criteria AND
For women of childbearing age, agreement to remain abstinent (refrain from heterosexual intercourse) or willingness to use appropriate and effective contraception, as recommended when using obinutuzumab (18 months after last infusion)
Signature of informed consent
French social security affiliation (beneficiary or legal)
Time interval between kidney biopsy showing pure class V LN and baseline visit of no more than 12 months
Exclusion Criteria:
Ongoing treatment (induction or maintenance) for proliferative LN (class III-A or IV-A)
Negativity for anti-nuclear antibodies (< 1/80) on immunofluorescence assay
Severe extra-renal (i.e but not limited to : cardiac, central nervous system, pulmonary, enteric) lupus flare requiring high dose (> 1 mg/kg/day) corticosteroids.
Receipt of any of the following excluded therapies:
Contraindication to the use of obinutuzumab, its premedication drugs or hypersensitivity to its excipients.
Fewer than 10 non-sclerosed glomeruli analyzable on renal biopsy
Ongoing pregnancy or breastfeeding women
CKD stage 4 or 5, defined as eGFR <30 ml/min/1.73m2 according to CKD-EPI creatinine equation measured two times in an interval of 3 months (to be dissociated from acute kidney injury).
Obsolescence of more than 60% of glomeruli or tubulo-interstitial scarring of more than 60% on kidney biopsy.
Patients already included in an interventional study (RIPH1, clinical investigation or clinical trial)
Patient under legal protection measure (tutorship or curatorship) and patient deprived of freedom
Patients with a previously documented kidney disease causing proteinuria (> 3 g/g or > 3 g/day) more than 1 year prior to the diagnosis of pure class V LN.
Exclusion of primary membranous nephropathy, defined by positive anti-PLA2R antibodies on serum and/or glomerular PLA2R staining on kidney biopsy
romain.brousse@aphp.fr+33 1 56 01 70 43
jean-jacques.boffa@aphp.fr+33 1 56 01 69 99
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