IMMUNOSUPPRESSIVE THERAPY IN IgA NEPHROPATHY ASSOCIATED WITH CHRONIC LIVER DISEASE

IgA nephropathy (IgAN) associated with chronic liver disease (CLD), considered a secondary form of IgAN, is a poorly characterized condition with limited treatment guidance. While immunosuppressive therapy (IMM) is actively being studied in primary IgAN, patients with secondary IgAN are often excluded from clinical trials due to concerns about worsening hepatic dysfunction. 

We analyzed 60 patients with biopsy-confirmed IgAN and concurrent CLD between January 2021 and December 2023. Thirty-seven patients received immunosuppression (IV solumedrol, oral steroids, and mycophenolate mofetil), while 23 received conservative management. Treatment decisions were made at physician discretion. Renal function (ΔeGFR) and proteinuria (ΔUPCR) were evaluated at baseline, 3, 6, and 9 months. Missing data were handled via multiple imputation, and mixed-effects models adjusted for MELD-Na and hypertension.

Baseline characteristics were comparable, except for higher hypertension prevalence in the IMM group. At 9 months, the IMM group showed significantly greater improvement in eGFR (+10.3 vs. +2.4 mL/min; p<0.001) and greater proteinuria reduction (−1.6 vs. −0.4 g/g; p<0.001). MELD-Na scores were higher in the IMM group (18.2 vs. 15.4; p=0.03), yet renal benefit persisted after adjustment. Infections occurred in 27% vs. 13% (p=0.20), and hepatic decompensation in 19% vs. 9% (p=0.27) of IMM and No-IMM groups, respectively. In the IMM group, one patient died of sepsis with hepatic encephalopathy, and another had recurrent SBP requiring early IMM termination.

Immunosuppression in CLD-associated IgAN significantly improves renal outcomes without accelerating liver dysfunction. While infections and decompensation risks require close monitoring, these findings challenge the conventional wisdom of avoiding immunosuppression and excluding these patients from clinical trials