Membranous nephropathy (MN) is the most common cause of primary nephrotic syndrome among adults. The identification of phospholipase A2 receptor (PLA2R) as target antigen in most patients changed the management of MN dramatically, and provided a rationale for B-cell depleting agents such as rituximab. The efficacy of rituximab in inducing remission has been investigated in several studies, including 3 randomized controlled trials, in which complete and partial remission of proteinuria was achieved in approximately two-thirds of treated patients. Due to its favorable safety profile, rituximab is now considered a first-line treatment option for MN, especially in patients at moderate and high risk of deterioration in kidney function. However, questions remain about how to best use rituximab, including the optimal dosing regimen, a potential need for maintenance therapy, and assessment of long-term safety and efficacy outcomes. In this review, we provide an overview of the current literature and discuss both strengths and limitations of "the new standard."

Clinical Division of Nephrology Department of Internal Medicine Medical University of Graz Graz Austria

Département de Néphrologie et Transplantation d'Organes Centre de Référence des Maladies Rénales Rares Centre Hospitalier Universitaire de Toulouse Toulouse France

Department of Cardiovascular Sciences University of Leicester Leicester United Kingdom

Department of Clinical Sciences Lund University Skane University Hospital Nephrology Lund Lund Sweden

Department of Health Medicine and Caring Sciences Linköping University Linköping Sweden

Department of Internal Medicine 3 University Hospital Jena Friedrich Schiller University Jena Germany

Department of Internal Medicine 4 Medical University Innsbruck Innsbruck Austria

Department of Internal Medicine 4 Section of Nephrology Klinikum Wels Grieskirchen Wels Austria

Department of Internal Medicine Erasmus MC University Medical Centre Rotterdam Rotterdam Netherlands

Department of Medical and Surgical Specialities Radiological Sciences and Public Health University of Brescia Brescia Italy

Department of Nephrology 1st Faculty of Medicine Charles University and General University Hospital Prague Czech Republic

Department of Nephrology and Dialysis Dubrava University Hospital Zagreb Croatia

Department of Nephrology and Renal Transplantation Hospital Clínic Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud Department of Medicine University of Barcelona IDIBAPS Barcelona Spain

Department of Nephrology and Transplantation Rare French Disease Centre Idiopathic Nephrotic syndrome Henri Mondor Albert Chenevier Hospital Assistance Publique Hôpitaux de Paris Inserm U955 Team 21 Paris East University Créteil France

Department of Nephrology and Transplantation University Hospital of Wales Cardiff UK

Department of Nephrology Juntendo University Faculty of Medicine Tokyo Japan

Department of Nephrology Radboud University Medical Center Nijmegen Netherlands

Department of Pediatrics Yonsei University College of Medicine Seoul Korea

Department of Renal Medicine CLINTEC Karolinska Institutet at Karolinska University Hospital Stockholm Sweden

Department of Renal Medicine Queen Elizabeth Hospital University Hospitals Birmingham Edgbaston Birmingham UK

Department of Renal Medicine Vasculitis and Lupus Clinic Addenbrooke's Hospital Cambridge University Hospitals Cambridge UK

Division of Nephrology and Hypertension Mayo Clinic Rochester Minnesota USA

Division of Nephrology Columbia University Medical Center New York New York USA

Division of Nephrology Department of Medicine 4 University Hospital LMU Munich Munich Germany

Division of Nephrology Vasculitis and Glomerulonephritis Center Massachusetts General Hospital Boston Massachusetts USA

Division of Pediatric Nephrology Severance Children's Hospital Seoul Korea

Institut National de la Santé et de la Recherche Médicale U1048 Toulouse France

Institute of Kidney Disease Research Yonsei University College of Medicine Seoul Korea

John Walls Renal Unit University Hospitals of Leicester NHS Trust Leicester UK

Medical Faculty Johannes Kepler University Linz Linz Austria

Nephrology Post Graduate Institute of Medical Education and Research Chandigarh India

Nephrology Unit ASST Spedali Civili di Brescia Brescia Italy

Service de Néphrologie Hôpital Européen Georges Pompidou Assistance Publique des Hôpitaux de Paris Paris France

Tareev Clinic of Internal Diseases Sechenov 1st Moscow State Medical University Moscow Russia

The Cambridge Centre for Sport and Exercise Science Anglia Ruskin University Cambridge UK

University College London Department of Renal Medicine Royal Free Hospital London UK

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Implications of rituximab pharmacokinetic and pharmacodynamic alterations in various immune-mediated glomerulopathies and potential anti-CD20 therapy alternatives