Table 1:
Therapeutic options currently in use for the treatment of IgAN by their mechanism of action
| Treatment by mechanism of action | Examples | Indicated population | Populations not recommended |
|---|---|---|---|
| Hemodynamic therapies | |||
| RAS blockade (ACE inhibitors and ARB) | ACE inhibitors: Captopril, ramipril, lisinopril, benazepril ARB: Losartan, valsartan, irbesartan | All patients with proteinuria >0.5 g/day, irrespective of the presence of hypertension (no combination therapy of ACE inhibitors and ARB) | Not recommended in patients who have rapidly changing GFR |
| SGLT-2 inhibitor | Dapagliflozin, canagliflozin | Patients with CKD who are at risk of progression | Contraindicated in patients with eGFR <30 mL/min/1.73 m2 49,50 |
| Glucocorticoids | |||
| Untargeted glucocorticoids | Prednisone, methylprednisolone | Patients at high risk of progressive CKDa and eGFR ≥30 mL/min/1.73 m2 should be considered for a 6-month course and counseled on the risk of treatment-emergent toxicity | Not recommended in patients with eGFR <30 mL/min/1.73 m2 and patients at high risk of steroid-related toxicity, particularly patients with eGFR <50 mL/min/m2 |
| Other immunomodulatory therapies | |||
| MMF | Suggested as a steroid-sparing agent for Chinese patients receiving glucocorticoids | Not suggested for non-Chinese patients owing to no evidence for the efficacy of MMF monotherapy in randomized controlled trials | |
| Cyclophosphamide | Patients with rapidly progressive IgAN, in combination with glucocorticoids | Not recommended in non-rapidly-progressive IgAN | |
Unless otherwise stated, source: KDIGO 2021 guidelines.47 Proteinuria >0.75–1 g/day despite ≥3 months of supportive care with RAS blockade. ACE: angiotensin-converting-enzyme; ARB: angiotensin receptor blocker; CKD: chronic kidney disease; eGFR: estimated GFR; GFR: glomerular filtration rate; IgAN: Immunoglobulin A nephropathy; MMF: mycophenolate mofetil; RAS: renin-angiotensin system; SGLT-2: sodium-glucose cotransporter-2.