IgA Nephropathy Treatment Guidelines
Introduction to IgA Nephropathy Treatment
- The primary treatment for IgA nephropathy should be optimized supportive care, including RAS blockade, blood pressure control, and cardiovascular risk reduction, with glucocorticoids considered only in specific high-risk patients with persistent proteinuria despite supportive measures, as recommended by the Kidney International guidelines 1, 2
Diagnosis and Prognosis Assessment
- Diagnosis requires kidney biopsy with histologic scoring via the MEST-C system, and prognosis can be assessed using the International IgAN Prediction Tool, according to Kidney International 1, 3
Treatment Approach
- All patients should receive optimized supportive care, which includes RAS blockade (ACEi/ARB) for all patients with proteinuria >0.5 g/day, regardless of hypertension status (Grade 1B), as recommended by Kidney International 1, 4
- Blood pressure control to target 125/75 mmHg in patients with proteinuria >1 g/day is recommended by the American Journal of Kidney Diseases 5
- Cardiovascular risk reduction measures and weight control are also recommended by Kidney International 1
Second-Line Treatment
- Consider a 6-month course of glucocorticoids (Grade 2B) if proteinuria remains >0.75-1 g/day despite at least 90 days of optimized supportive care, and eGFR is ≥30 ml/min/1.73 m², as recommended by Kidney International 1, 2, 4
Special Populations and Considerations
- Chinese patients may consider mycophenolate mofetil (MMF) as a glucocorticoid-sparing agent, and Japanese patients may consider tonsillectomy, according to Kidney International 6, 7
- Rapidly progressive IgAN treatment with cyclophosphamide and glucocorticoids is recommended for patients with extensive crescent formation (>50% of glomeruli) and declining GFR, as recommended by Kidney International 7, 8
Therapies Not Recommended for General Use
- The following therapies are not recommended for routine use in IgAN: azathioprine, cyclophosphamide (except in rapidly progressive IgAN), calcineurin inhibitors, rituximab, mycophenolate mofetil (except in Chinese patients), and tonsillectomy (except in Japanese patients), according to Kidney International 2, 4
Emerging Therapies
- Enteric-coated budesonide has recently received FDA accelerated approval for primary IgA nephropathy with UPCR >1.5 g/g, as reported by the American Journal of Kidney Diseases 10