From the Guidelines
IGA nephropathy management should prioritize multifaceted, optimized supportive care, including RAS blockade, blood pressure control, and lifestyle modifications, with consideration of glucocorticoid therapy for high-risk patients with persistent proteinuria above 0.75-1 g/d despite optimized supportive care. The primary focus of IGA nephropathy management should be on optimized supportive care, including RAS blockade with ACE inhibitors or ARBs, such as lisinopril 10-40mg daily or losartan 50-100mg daily, to reduce protein leakage and slow kidney damage 1. Lifestyle modifications, including limiting dietary salt, maintaining a healthy weight, avoiding smoking, and moderating alcohol consumption, are also essential.
For patients with significant proteinuria (>1g/day) and declining kidney function, a 6-month course of corticosteroids like prednisone (0.5-1mg/kg/day) may be recommended, but with caution in patients with certain comorbidities, such as diabetes, obesity, or latent infections 1. The use of glucocorticoids in IGA nephropathy is supported by recent studies, including the TESTING trial, which showed a significant reduction in composite outcome with steroid treatment over a median 4.2-year follow-up 1. However, the risk of serious adverse events, including infections, must be carefully considered.
Recent evidence also suggests that targeted-release glucocorticoids, such as budesonide, may be a promising treatment option for IGA nephropathy, with preliminary results showing a statistically significant reduction in proteinuria from baseline at 9 months 1. Key considerations in IGA nephropathy management include:
- Optimized supportive care, including RAS blockade and lifestyle modifications
- Glucocorticoid therapy for high-risk patients with persistent proteinuria
- Careful consideration of comorbidities and potential adverse events
- Regular monitoring of kidney function, blood pressure, and proteinuria
- Emerging treatment options, such as targeted-release glucocorticoids, which may offer improved efficacy and safety profiles.
From the Research
Overview of IgA Nephropathy
- IgA nephropathy (IgAN) is the world's most common primary glomerular disease, carrying a significant lifetime risk for kidney failure and an enormous socioeconomic burden 2.
- The mainstay of therapy for IgAN is optimized supportive care, including measures that lower blood pressure, reduce proteinuria, minimize lifestyle risk factors, and otherwise help to reduce non-specific insults to the kidneys 3.
Treatment Approaches
- The effectiveness of immunosuppressive measures, particularly high-dose corticosteroid therapy, has been reported variably, but there is considerable evidence for an increase in serious adverse effects with such therapies 2, 3.
- A new treatment paradigm has been proposed, combining therapies with different mechanisms of action to target the immune components and the chronic kidney disease components of IgAN in parallel to preserve long-term kidney survival 2.
- The KDIGO Clinical Practice Guideline for Glomerulonephritis recommends long-term ACE-I or ARB treatment when proteinuria is more than 1 g/day, with up-titration of the drug, and a 6-month course of corticosteroid therapy for patients with GFR >50 ml/min and proteinuria persistently higher than 1 g/day 4.
Specific Treatment Options
- Steroids, such as prednisone, have been shown to reduce proteinuria and stabilize kidney function in patients with IgAN 5, 6.
- The combination of cyclophosphamide, dipyridamole, and warfarin should not be used, nor should cyclosporine A 5.
- Fish oil may be beneficial in patients with progressive disease (creatinine clearance of less than 70 ml/min) 5.
- Azathioprine may be effective in reducing the severity of proteinuria and stabilizing renal function in IgAN, particularly in combination with steroids 6.