From the Guidelines
The management of IgA nephropathy should focus on optimized supportive care, including RAS blockade, blood pressure control, and lifestyle modifications, with consideration of immunosuppressive therapy for high-risk patients, as recommended by the KDIGO 2021 guidelines 1. The cornerstone of management includes optimal blood pressure control with ACE inhibitors or ARBs, targeting blood pressure below 130/80 mmHg to reduce proteinuria and slow disease progression. Lifestyle modifications are essential, including:
- Sodium restriction (<2g/day)
- Smoking cessation
- Weight management
- Regular exercise For patients with persistent proteinuria >0.75-1 g/d despite at least 90 days of optimized supportive care, a 6-month course of glucocorticoid therapy may be considered, with caution in patients with certain comorbidities, such as diabetes, obesity, or latent infections 1. Recent advances include targeted therapies such as SGLT2 inhibitors, which have shown renoprotective effects beyond glycemic control. Emerging therapies include targeted B-cell depletion, complement inhibition, and the endothelin receptor antagonist sparsentan, which has shown promise in reducing proteinuria. Regular monitoring of kidney function, proteinuria, and blood pressure is crucial, with follow-up every 3-6 months depending on disease severity and treatment response. Other immunosuppressive therapies, such as azathioprine, cyclophosphamide, and MMF, are not recommended in IgAN, except in specific situations, such as rapidly progressive IgAN or as a glucocorticoid-sparing agent in Chinese patients 1.
From the Research
Management of IgA Nephropathy
- The mainstay of therapy for IgA nephropathy is optimized supportive care, which includes measures to lower blood pressure, reduce proteinuria, and minimize lifestyle risk factors 2.
- Immunusuppression has become controversial, and systemic high-dose corticosteroid therapy should be considered for a few months, taking into account patient characteristics that would caution against or preclude such therapy 2.
- There is little evidence that any additional immunosuppression is helpful, with the exception of mycophenolate mofetil in patients of Asian descent 2.
Recent Advances in IgA Nephropathy
- A multitude of new therapies are being evaluated in IgA nephropathy, and several drugs, such as sodium-glucose transporter-2 inhibitors, sparsentan, nefecon, and iptacopan, have been approved, with more to come in the next few years 3.
- A new treatment paradigm that combines 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 has been proposed 3.
Treatment Options
- Mycophenolate mofetil/prednisone has been compared to cyclophosphamide/prednisone in the treatment of severe IgA nephropathy, and the results show that the combination of mycophenolate mofetil and prednisone achieved a higher remission rate and reduced adverse effects 4.
- Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have been shown to reduce proteinuria and preserve renal function in patients with IgA nephropathy, and dual therapy with both agents may be more effective than either agent alone 5.
Evidence-Based Recommendations
- Patients with proteinuria over 3 g/day, mild glomerular changes only, and preserved renal function should be treated with prednisone, which reduces proteinuria and stabilizes kidney function 6.
- Fish oil should be given to patients with progressive disease, and a tonsillectomy could reduce proteinuria and hematuria in those patients with recurrent tonsillitis 6.
- Angiotensin-converting enzyme inhibitors should be used to treat hypertension in patients with IgA nephropathy, as they preserve renal function and reduce proteinuria 6, 5.