Reviews

IgA nephropathy: Challenges and opportunities

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The role of more aggressive immunosuppression

At present, the evidence for using mycophenolate mofetil (CellCept) or calcineurin inhibitors (such as cyclosporin or tacrolimus) is fragmentary or contradictory.3,19,23 Similarly, the benefits of long-term azathioprine therapy are based on observational data only and so it cannot be recommended as evidence-based.24 Opportunities exist for combined therapy (eg, an ACE inhibitor or an ARB or both, combined with omega-3 fatty acids and azathioprine or mycophenolate mofetil), but at present, controlled trials are lacking. Crescentic disease and rapidly progressive glomerulonephritis should probably be treated with combined cyclophosphamide and parental and oral corticosteroids, based on observational data. Patients with IgA nephropathy and minimal change disease with nephrotic syndrome should be treated with oral steroids, but the only data available are observational. Low-protein diets could be tried in the presence of slowly progressive renal disease with estimated GFR less than 30 mL/min/1.73 m2, but there are no controlled trials demonstrating efficacy for this approach in IgA neph-ropathy.

Renal transplantation is very successful

Renal transplantation is a very suitable alternative for patients with IgA nephropathy that progresses to ESRD. Overall success rates are as good or better than those in other primary glomerular diseases. Unfortunately, the disease recurs in the majority of renal grafts and may in some cases lead to loss of the graft.25,26 We need much more information on the factors that predict such recurrences and their undesirable effects on transplantation outcomes.

MUCH WORK TO BE DONE

Much work needs to be done in the field of therapeutics in IgA nephropathy. Much of this effort will hinge on the interests of the pharmaceutical industry in IgA nephropathy as a potential therapeutic market. At present, the prospects for the development of a safe and effective novel therapy for IgA nephropathy (eg, approvable by the US Food and Drug Administration) do not appear great, but this may be overly pessimistic. The nature of the disease mandates long-term observation, agents that are very safe (with low rates of ESRD, death, and transplantation), and dependency on surrogate markers of efficacy. Therefore, designing and executing studies will not be easy.

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