Current treatment of IgA nephropathy

Abstract

IgA nephropathy (IgAN) is the most common type of glomerulonephritis in Asia and the Western world. In most patients, it follows an asymptomatic to oligosymptomatic course and GFR loss, if any, is slow. The mainstay of therapy therefore is optimized supportive care, i.e., measures that lower blood pressure, reduce proteinuria, minimize lifestyle risk factors, and otherwise help to reduce non-specific insults to the kidneys. The value of immunosuppression has become controversial and if at all, 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. In addition, adverse events related to corticosteroid therapy markedly increase as GFR declines. Beyond corticosteroids, there is little evidence that any additional immunosuppression is helpful, with the exception of mycophenolate mofetil in patients of Asian descent. A considerable number of clinical trials ranging from enteric coated budesonide to blockade of B-cell function to complement inhibitors are currently ongoing and will hopefully allow a more targeted therapy of high-risk patients with progressive IgAN in the future.

Keywords: Complement; Glucocorticoids; IgA nephropathy; Mesangioproliferative glomerulonephritis; Supportive therapy.

Fig. 1

Cornerstones of supportive therapy in IgA nephropathy adapted from [22,23]

Fig. 2

Patients and key study results from the long-term observation of the STOP-IgAN cohort [24,32]

Fig. 3

Treatment of primary IgAN (adapted from KDIGO 2021 CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF GLOMERULAR DISEASES. Kidney Int Suppl 2021 in press.). *Specific considerations apply to some ethnic groups: (1) if Japanese, consider tonsillectomy; (2) if Chinese consider mycophenolate mofetil as a corticosteroid-sparing agent