From the Guidelines
Implications of Immunoglobulin A (IgA) Nephropathy in an 80-year-old Patient with Impaired Renal Function
In an 80-year-old patient diagnosed with IgA nephropathy and impaired renal function, treatment should focus on controlling symptoms and slowing disease progression, with a primary emphasis on multifaceted, optimized supportive care 1. This approach includes the use of RAS blockade, such as angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB), to reduce proteinuria and blood pressure, alongside blood pressure control, cardiovascular risk minimization, and adherence to lifestyle advice including dietary counseling, smoking cessation, weight control, and exercise as appropriate.
Key considerations in managing IgA nephropathy in this patient population include:
- Proteinuria reduction: Targeting a reduction in proteinuria to under 1 g/d, which is a surrogate marker of improved kidney outcome in IgAN 1.
- Glucocorticoid therapy: May be considered for patients with persistent proteinuria above 0.75-1 g/d despite optimized supportive care, but its use should be approached with caution, especially in patients with eGFR <30 ml/min per 1.73 m², diabetes, obesity, latent infections, or other conditions that may increase the risk of adverse effects 1, 2.
- Immunosuppressive therapies: Generally not recommended for IgAN, except in specific cases such as rapidly progressive IgAN, and the use of mycophenolate mofetil in Chinese patients as a glucocorticoid-sparing agent 1, 3.
- New therapies: Emerging treatments like SGLT2 inhibitors, sparsentan, atrasentan, and hydroxychloroquine are being evaluated for their potential to augment supportive care or offer more specific approaches to managing IgAN 1.
Given the patient's age and impaired renal function, it is crucial to weigh the risk/benefit profile of any treatment, including glucocorticoids, carefully and consider the patient's overall health status, potential for adverse effects, and the presence of any comorbid conditions 2, 3. The decision to initiate any therapy should be made on an individual basis, taking into account the latest evidence and guidelines, such as those outlined by KDIGO 1 and commentary from the American Journal of Kidney Diseases 2.
Treatment Approach
- Initial Therapy: Focus on RAS blockade with ACEi or ARB to reduce proteinuria and blood pressure.
- Lifestyle Modifications: Encourage dietary counseling, smoking cessation, weight control, and appropriate exercise.
- Monitoring: Close monitoring of renal function, proteinuria, and blood pressure, with adjustments to therapy as needed.
- Consideration of Glucocorticoids: In selected cases with persistent proteinuria, under close monitoring for potential adverse effects, considering the patient's age and comorbidities.
From the Research
Implications of Immunoglobulin A (IgA) Nephropathy
- IgA nephropathy is a type of kidney disease that can lead to impaired renal function, especially in elderly patients 4.
- The relationship between IgA nephropathy and other conditions, such as chronic replicative Epstein-Barr virus infection, is not fully understood, but it may affect the clinical course of the disease 4.
- Elderly patients with IgA nephropathy and impaired renal function may be at risk of developing other complications, such as acute kidney injury or chronic kidney disease 5, 6.
Management and Treatment
- The management of IgA nephropathy in elderly patients with impaired renal function typically involves controlling blood pressure, reducing proteinuria, and slowing the progression of kidney disease 5.
- The use of certain medications, such as immunosuppressants, may be necessary to treat IgA nephropathy, but they can also increase the risk of adverse effects, such as Fanconi syndrome 7.
- Elderly patients with IgA nephropathy and impaired renal function may require close monitoring and adjustment of their treatment plan to minimize the risk of complications and slow the progression of kidney disease 5, 6.
Complications and Risks
- Elderly patients with IgA nephropathy and impaired renal function are at risk of developing other complications, such as acute kidney injury, chronic kidney disease, and cardiovascular disease 5, 6.
- The use of certain medications, such as clopidogrel, may increase the risk of adverse effects, such as neutropenia, in elderly patients with impaired renal function 8.
- The risk of developing Fanconi syndrome, a rare complication of immunosuppressant treatment, should be considered in elderly patients with IgA nephropathy and impaired renal function 7.