How is glomerulonephritis managed in immunoglobulin A (IgA) nephropathy?

Updated: May 19, 2020
  • Author: Sohail Abdul Salim, MD, FASN, FACP; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Answer

IgA nephropathy is a common cause of glomerulonephritis. Although it is a benign disease in most patients, chronic kidney disease and end-stage kidney disease (ESKD) occur in about 20-40% of patients within 20 years of presentation. Currently, multiple treatment options are available; no one therapy is appropriate for all patients. No randomized controlled trial has verified the value of the MEST-C score (see Overview/Prognosis) in making treatment decisions, but proteinuria seems to be the biggest prognostic factor. There are no trials in patients with a urinary protein-to-creatinine ratio (UPCR) of < 0.5 g/day.

General recommendations include the following:

  • In patients with isolated hematuria (ie, without proteinuria or hypertension) monitor with urinalysis, renal function testing, and blood pressure measurement.

  • Treat hypertension early and aggressively with renin-angiotensin blockade; a reasonable goal is a blood pressure of 130/80 mm Hg if proteinuria is < 1g/day. [23]  If proteinuria is > 1 g/day, then 125/75 mm Hg should be the goal.

  • Steroids are most beneficial if more than 1 g of proteinuria is present in a 24-hour urine specimen. [24]

  • Goal UPCR is < 0.5-0.75 g/day with renin-angiotensin blockade.

  • If UPCR is > 1.5 g/day despite maximum renin-angiotensin blockade for 4-6 months, steroids can be added, but not if the GFR is < 25 mL/min/1.73m2. [25]

  •  If UPCR is persistently 0.75-1.5 g/day, the short-term benefits of steroid ues remain uncertain.

  • The presence of crescents on biopsy in a sample with more than 10 glomeruli is an indication for treatment with cyclophosphamide.

  • The role of direct renin inhibitors and mineralocorticoid receptor antagonists have not been evaluated in a randopmize controlled trial.

  • If GFR > 25 mL/min/1.73 mand UPCR is > 0.6 g/day there is a benefit to treatment. [26]


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