What is the recommended management of IgA nephropathy in a pregnant woman?

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Last updated: April 14, 2026 • View editorial policy

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Management of IgA Nephropathy in Pregnancy

Women with IgA nephropathy who are pregnant or planning pregnancy must discontinue RAS inhibitors, SGLT2 inhibitors, sparsentan, and Nefecon before conception, and should optimize blood pressure control with pregnancy-compatible antihypertensives while focusing on supportive care during pregnancy 1.

Preconception Management

The 2025 KDIGO guidelines explicitly address childbearing in IgAN patients 1:

  • Discontinue nephrotoxic medications: Stop RASi, SGLT2i, sparsentan, and Nefecon before attempting conception
  • Optimize blood pressure control: Transition to pregnancy-compatible antihypertensives (e.g., methyldopa, labetalol, nifedipine) prior to conception
  • Consider disease control: For women at risk of progressive kidney function loss, a trial of immunopathogenesis-targeted treatments before conception may be desirable to achieve optimal disease control

Pre-conception blood pressure control is critical - women requiring antihypertensive medications (beyond RASi alone) before pregnancy have significantly higher risks of severe hypertensive disorders requiring IV nicardipine (aOR 5.01) and preterm delivery (aOR 6.45) 2.

During Pregnancy

Blood Pressure Management

  • Maintain strict blood pressure control with pregnancy-safe agents
  • Target BP <120/70 mm Hg when feasible (though this specific target may need adjustment during pregnancy)
  • Monitor closely for hypertensive disorders of pregnancy and preeclampsia

Proteinuria and Kidney Function Monitoring

  • Regular monitoring of proteinuria and kidney function throughout pregnancy
  • Women with higher baseline proteinuria are at increased risk but can have successful outcomes with careful management 3

Medication Options During Pregnancy

Systemic glucocorticoids may be used during pregnancy 1, though this should be reserved for specific indications:

  • Rapidly progressive IgAN with crescentic formation may require cyclophosphamide and glucocorticoids even during pregnancy 4
  • Standard immunosuppression for stable disease is generally avoided

Hydroxychloroquine appears safe and effective during pregnancy for IgAN patients 3:

  • Reduces proteinuria effectively
  • No significant adverse pregnancy outcomes compared to untreated patients
  • May be particularly helpful in patients with history of spontaneous abortion
  • This represents an important pregnancy-compatible treatment option

Nefecon (targeted-release budesonide) is currently not advised during pregnancy 1.

Special Considerations

Risk Stratification

Women with IgAN face higher risks of:

  • Hypertensive disorders of pregnancy
  • Preeclampsia
  • Preterm delivery
  • Fetal loss

The strongest predictor of obstetrical complications is baseline eGFR 3 - lower kidney function correlates with worse outcomes.

Rapidly Progressive Disease

If rapid kidney function decline occurs during pregnancy (≥50% eGFR decline over ≤3 months with crescentic formation), aggressive treatment with cyclophosphamide and systemic glucocorticoids may be necessary despite pregnancy 1, 4. This represents a rare but critical scenario where maternal kidney preservation takes priority.

Supportive Measures

  • Low-protein diet may be beneficial 5
  • Dietary sodium restriction (<2 g/day when applicable)
  • Close monitoring for disease flares, particularly with visible hematuria

Delivery Planning

  • Timing of delivery depends on maternal kidney function, blood pressure control, and fetal well-being
  • Successful pregnancies have been achieved even with active disease, reaching 34-36 weeks gestation with appropriate management 5
  • Intensive hemodialysis (if needed for advanced CKD) can support pregnancy to term 6

Common Pitfalls

  • Failing to discontinue RASi/ARBs before conception - these are teratogenic and must be stopped
  • Inadequate pre-conception counseling - all women of childbearing potential with IgAN need this discussion
  • Underestimating the importance of pre-pregnancy disease control - achieving remission before conception significantly improves outcomes
  • Not transitioning to pregnancy-safe antihypertensives early enough - this should occur during pregnancy planning, not after conception

References

6
Research

Antiangiogenic factors and maternal hemodynamics during intensive hemodialysis in pregnancy.

Hemodialysis international. International Symposium on Home Hemodialysis, 2013

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