From the Guidelines
The initial treatment for IgA Nephropathy should focus on optimized supportive care, including RAS blockade, blood pressure control, and lifestyle modifications, as recommended by the 2021 KDIGO guideline 1.
Key Components of Initial Treatment
- RAS blockade should be instituted irrespective of hypertension if the patient has proteinuria >0.5 g/d, as it reduces proteinuria and slows disease progression 1.
- Blood pressure control is crucial, and lifestyle modifications such as dietary counseling, smoking cessation, weight control, and exercise should be encouraged 1.
- The primary goal of treatment is to reduce proteinuria to under 1 g/d, which is a surrogate marker of improved kidney outcome in IgA Nephropathy 1.
Considerations for Additional Therapies
- If proteinuria stays above 0.75–1 g/d despite at least 90 days of optimized supportive care, a 6-month course of glucocorticoid therapy may be considered, but with caution in patients with certain comorbidities or risk factors 1.
- Other immunosuppressive therapies, such as azathioprine, cyclophosphamide, and rituximab, are not recommended in IgA Nephropathy, except in specific situations like rapidly progressive disease 1.
Ongoing Evaluation and Monitoring
- Regular monitoring of kidney function, proteinuria, and blood pressure is essential to assess treatment response and disease progression 1.
- The International IgAN Prediction Tool can be used to assess disease prognosis, but it should not be used to determine the likely impact of any particular treatment regimen 1.
From the Research
Initial Treatment for IgA Nephropathy
The initial treatment for IgA Nephropathy depends on various factors, including the presence of hypertension, proteinuria, and reduced glomerular filtration rate.
- For patients with recurrent macroscopic hematuria or isolated microscopic hematuria and proteinuria <1 g/24 h, no specific treatment is required 2.
- For patients with nephrotic syndrome and minimal change on renal biopsy, treatment should be managed as for minimal change nephropathy 2.
- For patients presenting with acute renal failure, evaluation is necessary to distinguish acute tubular necrosis, which requires supportive therapy only, from crescentic IgAN, for which treatment with cyclophosphamide and corticosteroids is indicated 2.
- Patients at greatest risk of progressive renal impairment are those with hypertension, proteinuria >1 g/24 h, and reduced glomerular filtration rate at diagnosis, and should be treated to a blood pressure of 125/75 mm Hg with dual blockade of the renin-angiotensin system with angiotensin-converting enzyme inhibition and angiotensin receptor blockade 2.
Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers
- Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are effective in reducing proteinuria in patients with IgA nephropathy 3, 4.
- The combination therapy of olmesartan+temocapril had the highest probability of being the most effective treatment to reduce proteinuria in normotensive CKD patients, including those with IgA nephropathy 3.
- Dual ACE inhibitor-ARB therapy reduces proteinuria by 54% to 73% and is more effective than either agent alone 4.
Use of Immunosuppressive Agents
- There is insufficient evidence for the additional use of immunosuppressive agents in the treatment of IgA nephropathy 2.
- A short course of therapy with prednisone and cyclophosphamide has been effective in a subset of IgA nephropathy patients with florid glomerular changes and major urinary abnormalities 5.
Treatment of Early IgA Nephropathy
- For early IgA nephropathy patients with minimal proteinuria, normal blood pressure, and normal renal function, treatment with 2.5 mg/daily of ramipril for 5 years does not offer any benefit 6.