Table 2.
Summary of the KDIGO treatment recommendations for IgAN.
| Intervention | Recommendation | Grade | Comments and areas of uncertainty |
|---|---|---|---|
| Blood pressure control and use of ACE inhibitors or ARBs | Long-term use of ACE inhibitors or ARBs is recommended for patients with proteinuria > 1g/day, with up-titration of the drug depending on blood pressure to achieve proteinuria <1g/day. | 1B | It is not clear at what level of proteinuria one should start ACE inhibitors or ARBs. Combined ACE inhibition and ARB use is generally not advised given potential risks of side effects of hyperkalemia and hypertension, especially in elderly. |
| A target blood pressure of <130/80 mm Hg is recommended for patients with proteinuria <1 g daily, and <125/75 for patients with proteinuria >1 g daily. | Not graded | ||
| Corticosteroids | A 6-month trial of corticosteroids is recommended in patients with persistent proteinuria of >1g/day despite 3–6 months of optimal supportive care and GFR > 50 ml/min per 1.73m2 | 2C | Presently, it is unclear at what level of reduced GFR this therapy becomes futile (i.e. “the point of no return”), and whether patients with lower levels of proteinuria should also be treated. |
| Other immunosuppressive agents | Patients with crescentic IgAN involving over 50% of glomeruli and rapidly progressive course should be treated with steroids and cyclophosphamide. | 2D | The definition of crescentic IgAN remains controversial. Rituximab has not yet been used in a significant enough number of patients to be recommended, however, data from studies on other crescentic diseases suggest a potential benefit. |
| Not treating with corticosteroids combined with cyclophosphamide or azathioprine (unless crescentic forms with rapidly progressive course). | 2D | There is no convincing evidence for the use of combined immunosuppression in IgAN, except for crescentic forms. | |
| Not using immunosuppressive therapy in patients with GFR < 30 ml/min per 1.73 m2 (unless crescentic forms with rapidly progressive course). | 2C | There is no convincing evidence for the use of immunosuppressive treatments in advanced stages of CKD due to IgAN. | |
| Not using MMF | 2C | The data for MMF in IgAN is generally of poor quality | |
| Fish oils | Fish oils may be potentially useful in patients with persistent proteinuria ≥ 1g/d, despite 3–6-months of optimized supportive care. | 2D | RCTs give equivocal results on the benefit of fish oils. Given low side effect profile and over-the-counter availability, the use of fish oils can probably be left to the choice of individual patients. However, this treatment should not replace corticosteroids, for which the evidence is stronger. |
| Tonsillectomy | Not recommended | 2C | No convincing evidence of benefit. Generally not recommended, unless specifically indicated by recurrent episodes of tonsillitis with synpharyngitic disease flares. |
Recommendation grading: Level 1 = “Recommended”, Level 2 = “Suggested”. Quality of evidence grading: A = “High”, B = “Moderate”, C = “Low”, D = “Very Low”.