Treatment of IgA Nephropathy: A Rapidly Evolving Field.
The treatment landscape for IgA nephropathy is evolving rapidly, with goal-directed supportive care plus SGLT2 inhibitors and sparsentan now integral, and immunosuppression reserved for higher-risk patients identified by clinical and histologic parameters.
Background
The pivotal event in IgA nephropathy is binding of circulating IgA-containing immune complexes to mesangial cells, triggering secondary glomerular and tubulointerstitial inflammation and fibrosis. Management is challenging because of heterogeneity in clinical presentation and prognosis, requiring an individualized treatment approach.
Key recommendations
Goal-directed supportive care remains the foundation of therapy for all patients regardless of progression risk. SGLT2 inhibitors and sparsentan are described as integral to contemporary supportive care, particularly in patients with chronic kidney damage. Systemic glucocorticoids are indicated in high-risk patients, but their benefits wane after withdrawal and carry substantial treatment-associated toxicity.
Clinical implications
Pending reliable biomarkers, identifying patients with active disease most likely to benefit from immunosuppression remains a challenge. Clinical parameters such as degree of proteinuria, persistent microscopic hematuria, and rate of eGFR loss, combined with histologic MEST-C scoring, currently offer the best approach. Therapies with direct effects on disease pathogenesis, including targeted-release budesonide, anti-B-cell strategies, and selective complement inhibition, are increasingly available and can be combined to target distinct steps in pathophysiology.
Category
Research
Source
J Am Soc Nephrol
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