Molecular markers or clinical end points? What is the optimal monitoring tool for low-dose rituximab in membranous nephropathy in resource-limited settings?

Rituximab has been advocated for as the first treatment choice for idiopathic membranous nephropathy. Currently, low-dose rituximab protocols are being implemented for the treatment of primary membranous nephropathy with CD19 B-cell monitoring in resource-limited settings. CD19 monitoring is a recently established monitoring tool for determining the optimal response to rituximab treatment, especially when using low-dose rituximab. This manuscript identifies the problems encountered with rituximab treatment, pitfalls in CD19 monitoring and its performance in relation to conventional monitoring tools like anti-PLA2R levels, level of proteinuria, and estimated glomerular filtration rate (eGFR). This article highlights the utility of low-dose, tailor-made regimens of rituximab in the Indian subcontinent with CD19 B cell monitoring to verify appropriate clinical response, along with the economic benefits of such modified regimens in resource-limited settings, based on current scientific evidence.