From the Guidelines
Pulse Dose Corticosteroids in IgA Nephropathy
Pulse dose corticosteroids are recommended in IgA nephropathy patients with persistent proteinuria above 0.75-1 g/d despite at least 90 days of optimized supportive care, indicating a high risk of progressive loss of kidney function 1.
- The primary focus of IgA nephropathy management should be multifaceted, optimized supportive care, including RAS blockade, blood pressure control, cardiovascular risk minimization, and lifestyle advice 1.
- A 6-month course of glucocorticoid therapy may be considered for patients with high-risk features, but should be given with extreme caution or avoided entirely in patients with certain conditions, such as eGFR <30 ml/min per 1.73 m2, diabetes, obesity, latent infections, secondary disease, active peptic ulceration, uncontrolled psychiatric disease, or severe osteoporosis 1.
- The use of pulse dose corticosteroids, such as methylprednisolone or dexamethasone, may be considered in patients with rapidly progressive glomerulonephritis or those with persistent proteinuria and impaired renal function, despite optimal supportive care 1.
- A typical regimen consists of methylprednisolone 1 gram intravenously daily for 3 consecutive days, repeated at 2-3 month intervals for a total of 6-12 months, in conjunction with oral prednisone 0.5-1 mg/kg/day for 6-12 months, although the optimal regimen is not well established 1.
- Alternatively, dexamethasone 20-30 mg/day orally for 2-3 days, repeated every 2-4 weeks for 6-12 months, may be considered in patients who cannot tolerate intravenous therapy, but the evidence for this approach is limited 1.
- Targeted-release glucocorticoids, such as budesonide, may also be considered, as they have shown potential to reduce proteinuria with fewer adverse events, but long-term kidney survival outcomes are still uncertain 1.
From the Research
Indications for Pulse Dose Corticosteroids in IgA Nephropathy
Pulse dose corticosteroids, also known as steroids, are used in the treatment of Immunoglobulin A (IgA) nephropathy, a common type of primary glomerulonephritis. The following are indications for their use:
- Patients with IgA nephropathy and a glomerular filtration rate (GFR) >50ml/min and proteinuria >1g/day 2
- Patients with high-risk IgA nephropathy, defined as those with proteinuria between 1 and 3.5 g/24 h after ACEI/ARB for at least 90 days 3
- Patients with established renal dysfunction, as evidenced by a serum creatinine concentration of 2.76 +/- 1.32 mg/dl 4
- Patients with crescentic, proliferative IgA nephropathy and clinically progressive disease 5
- Patients with histologically active IgAN and established renal impairment at the time of treatment 6
Treatment Regimens
Different treatment regimens have been studied, including:
- Methylprednisolone pulses (1g/day for 3 consecutive days at the beginning of months 1,3, and 5, followed by 0.5mg/kg prednisolone on alternate days) 2
- Pulsed intravenous methylprednisolone combined with alternative low-dose prednisone (MCALP) 3
- Methylprednisolone pulse therapy (500 mg intravenous every 2 weeks for 6 months) 6
- Pulse steroids and intravenous cyclophosphamide 5
Efficacy and Safety
The efficacy and safety of pulse dose corticosteroids in IgA nephropathy have been demonstrated in several studies:
- Reduced relapse risk and longer relapse-free period in patients treated with steroid pulses compared to oral steroids 2
- Similar complete remission rates at 12 and 18 months in patients treated with MCALP and full-dose prednisone regimens, with fewer side effects in the MCALP group 3
- Attenuation of progression of renal failure and delay in the need for dialysis in patients with established renal dysfunction 4
- Reduction in proteinuria and stabilization of renal function in patients with crescentic, proliferative IgA nephropathy 5
- Improvement in renal function and dialysis-free renal survival in patients with histologically active IgAN and established renal impairment 6