B-cell-targeting therapies in podocytopathies

Podocytopathies, including minimal change disease and focal segmental glomerulosclerosis, represent the leading causes of nephrotic syndrome in children and adolescents. Although traditionally considered T-cell-mediated disorders, growing evidence over the last decade has reshaped this paradigm, highlighting a central role for B-cells, plasma cells, and humoral immune mechanisms in podocyte injury. The identification of pathogenic autoantibodies, particularly anti-nephrin IgG, and the involvement of complement activation have provided a strong mechanistic rationale for B-cell-targeted therapies. Rituximab, an anti-CD20 monoclonal antibody, has become an established steroid-sparing agent in steroid-dependent and frequently relapsing nephrotic syndrome, significantly reducing relapse rates and cumulative steroid exposure in pediatric patients. However, its efficacy is limited in steroid-resistant disease and in settings characterized by persistent autoantibody production or post-transplant recurrence. These limitations have prompted the exploration of next-generation anti-CD20 agents, such as obinutuzumab, which achieve deeper and more sustained B-cell depletion, as well as therapies targeting long-lived plasma cells, including anti-CD38 monoclonal antibodies. Emerging clinical data suggest that combined B-cell and plasma cell targeting may induce durable remission in refractory podocytopathies and recurrent post-transplant focal segmental glomerulosclerosis, while maintaining an acceptable safety profile. In parallel, novel strategies targeting the BAFF/APRIL axis and cellular therapies such as CAR-T cells are under investigation. This review summarizes current evidence on B-cell-directed therapies in podocytopathies, mostly in pediatrics, discusses unmet clinical needs, and outlines future perspectives toward precision, mechanism-based immunotherapy.