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Given that the majority of patients with IgA nephropathy are asymptomatic, current guidelines suggest initial management measures aimed at reducing proteinuria and disease progression. Some guidelines recommend the use of sodium-glucose cotransporter-2 inhibitors (iSGLT-2). Although factors such as proteinuria > 0.7 g/24 hrs, hypertension, and decreased glomerular filtration rate at the time of diagnosis are considered high risk, the use of immunosuppressive therapy in these situations is still controversial. The 2022 KDIGO guidelines suggest steroid treatment for 6 months with proteinuria > 1 g/24 hrs. There is no evidence of the efficacy of other immunosuppressants, except for mycophenolate, which has been shown to be useful only in patients of Asian descent. The aim of this study is to demonstrate the management provided to patients diagnosed with IgA nephropathy in a cohort of Mexican patients.
A cohort study was conducted, including 12 patients with a confirmed diagnosis of IgA nephropathy by renal biopsy. The treatment instituted from the diagnosis, the response to it, and the quarterly modifications made during the first year of diagnosis were determined. Qualitative variables are described with frequencies.
At the time of diagnosis, all patients received an aldosterone receptor blocker (100% losartan). Calcitriol was added to 33% of patients, iSGLT2 (dapagliflozin) to 42%, and both to 67%. Five patients received three doses of methylprednisolone, two of them due to their association with vasculitis, and the other due to acute kidney injury (median creatinine of 4, IQR 2-6 mg/dl). Four patients received oral steroids (average creatinine 1.5±0.7 mg/dl). At three months, of the patients managed with methylprednisolone pulses, two continued to have deteriorating renal function (creatinine of 1.5±0.5 mg/dl, hematuria, and proteinuria), and another required renal replacement therapy. Patients who used oral steroids all reduced urinary protein levels from an initial average of 2.4±1 g/24 hrs to 1.7±0.9 g/2 hrs but maintained the same creatinine levels. At six months of treatment, the patients continued antiproteinuric management with ARBs, calcitriol, and SGLT2, without modifications. After one year, one patient (without initial steroid management) no longer showed signs of the disease. Three patients who had received steroids had mycophenolate mofetil added due to persistent proteinuria. Two of these, at 7 and 10 years, respectively, progressed to chronic renal failure requiring renal replacement therapy.
This study demonstrates that the use of measures to delay disease progression remains the treatment of choice for over 20 years. The use of steroids and mycophenolic acid in our center is still performed according to the physician's discretion. This highlights the need for safe and effective therapies for high-risk IgA nephropathy patients.