IgA Nephropathy: What to Do When Disease-Modifying Therapy Has Not Achieved Proteinuria Goals
This protocol applies to patients with IgA nephropathy who remain at high risk of progression after completing a course of disease-modifying therapy that did not achieve the intended proteinuria and kidney-function targets.
Prior Treatment Line — Failure Condition
The preceding line involved Nefecon or a systemic glucocorticoid regimen (methylprednisolone or equivalent). Escalation to this protocol is indicated when that treatment did not sustain urine protein excretion below 0.5 g/d and did not stabilise eGFR.
Clinical Goals at This Stage
Partial or complete remission of haematuria and proteinuria; meaningful reduction in proteinuria.
Treatment Approach (Partial Overview)
For patients who remain at high risk despite prior disease-modifying therapy, population-specific add-on options are considered. These include an immunosuppressive agent used in a glucocorticoid-sparing role in certain patient groups, and a surgical intervention evaluated in a distinct patient population. The full selection criteria, approach, and clinical context are available in the complete protocol.
References
- In those patients in whom glucocorticoids are being considered MMF may be used as a glucocorticoid-sparing agent
- The first from Hong Kong (n=40, eGFR ~51 ml/min/1.73 m2) showed a significant reduction in time-averaged proteinuria after MMF (1.5 to 2.0 g/day for 6 months) was added to SC in patients with proteinuria >1 g/d.
- In a small, short-term RCT conducted in China, hydroxychloroquine introduced to patients with proteinuria of 0.75-3.5 g/d despite optimized ACEi/ARB reduced proteinuria by 48% versus 10% in the placebo group at 6 months.
- Tonsillectomy alone or with pulsed glucocorticoids may extend kidney survival and increase the likelihoods of partial or complete remission of hematuria and proteinuria based on multiple, mostly retrospective studies from Japan.
- Tonsillectomy should not be performed as a treatment of IgAN in non-Japanese patients.
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