Update on the management of IgA nephropathy

IgA nephropathy is the commonest primary glomerular disease worldwide. A high prevalence has been noted in Asia including India. The clinical course has a wide spectrum of presentation varies from isolated microscopic hematuria to crescentic glomerulonephritis. The approach of the treatment has to be decided as per the clinical and histopathological manifestation of the disease. Risk assessment is important to determine management and also to balance between the risks of therapy by the selection of patients. Clinical features appear to be the stronger prognostic indicators however certain renal histopathological findings have been associated with an increased risk of progressive disease. There is no definitive therapeutic approach despite of better understanding of pathogenic mechanism of the disease. The expected outcome of therapy is slowing the deterioration in kidney function as well as a reduction in proteinuria and control of blood pressure by suppression of angiotensin II with ACE inhibitors or angiotensin II-receptor blockers (ARBs). The indications for the use of corticosteroid alone or in combination with other immunosuppressive agents e.g. Azathioprine or cyclophosphamide are not well defined. Different regimens have been used, consisting of corticosteroids alone or in combination with other immunosuppressive agents.

Despite retrospective studies in IgA nephropathy supporting the use of immunosuppressive therapy other than corticosteroid, few randomized control trials have demonstrated a benefit. Corticosteroid combined with cyclophosphamide or azathioprine can be considered in patients with rapidly progressive disease with crescentic IgA nephropathy. Fish oil can be used in the treatment of IgA nephropathy with proteinuria above 1 g/day despite 3–6 months of optimized therapy with ACE inhibitors or ARBs and blood pressure control.