اعتلال الكلية بـ IgA: العلاج التالي عند فشل تثبيط RAS وتثبيط SGLT2 في السيطرة على البروتينية

References

1. We suggest treatment with a 9-month course of Nefecon for patients who are at risk of progressive loss of kidney function with IgAN (2B).
2. In the NefIgArd study, 364 adult patients with IgAN, eGFR 35–90 ml/min per 1.73 m², and persistent proteinuria (urine protein-to-creatinine ratio [PCR] ≥0.8 g/g [80 mg/mmol] or proteinuria ≥1 g/24 h), despite physician-attested, optimized RASi use, were randomized (1:1) to receive 16 mg/d of Nefecon or placebo for 9 months, followed by a 15-month observational follow-up period off study drug.
3. In settings where Nefecon is not available, we suggest that patients who are at risk of progressive loss of kidney function with IgAN be treated with a reduced-dose systemic glucocorticoid regimen combined with antimicrobial prophylaxis (2B).
4. Treatment with systemic glucocorticoids should incorporate antimicrobial prophylaxis against Pneumocystis jirovecii and antiviral prophylaxis in hepatitis B carriers, along with gastroprotection and bone protection according to national guidelines.
5. The only validated early biomarker to help guide clinical decision-making is urine protein excretion, which should be maintained at a minimum of <0.5 g/d (or equivalent), and ideally at <0.3 g/d (or equivalent), accepting that in some patients with extensive kidney scarring, this may not be possible and that multiple treatment strategies, including nonpharmacologic interventions, may be needed to achieve this.