Standard of Care for Patients With IgAN

Chee Kay Cheung, MBCHB, MRCP, PhD: For standard of care, we follow the latest KDIGO [Kidney Disease Improving Global Outcomes] guidelines, which were published in 2021, and they’re due to be updated very soon as well. In the first line of standard of care, [we] use optimized supportive care. This consists of good control of blood pressure, addressing lifestyle and cardiovascular risk factors such as optimizing weight and smoking cessation, a healthy diet that’s low in salt, and lipid management. In those with proteinuria that’s above 0.5 g per day, treatment with a renin-angiotensin system inhibitor, or RASI, such as an ACE [angiotensin-converting enzyme] inhibitor or angiotensin receptor blocker, should be used. That’s regardless of the starting blood pressure. Evidence for this optimized supportive care came from the STOP-IgAN trial, which was a multicenter trial that took place in Germany, showing that if you instituted a comprehensive, supportive care program like this, then around one-third of patients at high risk of disease progression will respond. These measures are very safe and well validated as well. There’s no robust or…consistent evidence for the use of other therapies, including immunosuppression or dietary approaches. There’s limited evidence for the use of mycophenolate that comes from Chinese populations [or] the use of tonsillectomy in Japanese patients. But these studies were relatively small, and findings have not been replicated in other populations as well. So if proteinuria remains above 0.75 g per day, despite 3 months of optimized care, then patients are considered to be at high risk of kidney disease progression.

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