Corticosteroids in IgA Nephropathy

Abstract

Current guidelines suggest treatment with corticosteroids (CS) in IgA nephropathy (IgAN) when proteinuria is persistently $1 g/d despite 3-6 months of supportive care and when eGFR is .50 ml/min per 1.73 m 2 . Whether the benefits of this treatment extend to patients with an eGFR#50 ml/min per 1.73 m 2 , other levels of proteinuria, or different renal pathologic lesions remains unknown. We retrospectively studied 1147 patients with IgAN from the European Validation Study of the Oxford Classification of IgAN (VALIGA) cohort classified according to the Oxford-MEST classification and medication used, with details of duration but not dosing. Overall, 46% of patients received immunosuppression, of which 98% received CS. Treated individuals presented with greater clinical and pathologic risk factors of progression. They also received more antihypertensive medication, and a greater proportion received renin angiotensin system blockade (RASB) compared with individuals without immunosuppressive therapy. Immunosuppression was associated with a significant reduction in proteinuria, a slower rate of renal function decline, and greater renal survival. Using a propensity score, we matched 184 subjects who received CS and RASB to 184 patients with a similar risk profile of progression who received only RASB. Within this group, CS reduced proteinuria and the rate of renal function decline and increased renal survival. These benefits extended to those with an eGFR#50 ml/min per 1.73 m 2 , and the benefits increased proportionally with the level of proteinuria. Thus, CS reduced the risk of progression regardless of initial eGFR and in direct proportion to the extent of proteinuria in this cohort.

Role of corticosteroid therapy in IgA nephropathy; where do we stand?

“…It does not recommend use of steroids in subset of patients with eGFR <50 mL/min/1.73 m 2 (3). The use of steroids in patients with eGFR <50 mL/ min/1.73 m 2 has been addressed in the VALIGA study which examined the benefit of steroids in this subset of patients in addition to renin angiotensin system blockers (RASBs) compared with RASBs alone, (particularly in patients with proteinuria >1 g/d), suggesting a value in patients with eGFR <50 mL/min/1.73 m2 as well (11). In our study, group 1 did not benefit in terms of progression of CKD compared to group 2.…”

“…The KDIGO guidelines make no recommendations for use of corticosteroids (CS) in individuals with an initial eGFR ≤50 mL/min/1.73 m 2 , who are under-represented in majority of the trials (3)(4)(5)(6)(7)(8)(9)(10). The recent analysis from VALIGA study showed that steroids may be of benefit even in this group (11).…”

Mycophenolate mofetil therapy in immunoglobulin A nephropathy: histological changes after treatment

“…Analysis from the VALIGA study showed that 7/184 (3.8%) patients who had received any form of immunosuppression developed ESRD compared to 20/184 (10.8%) of propensity matched patients receiving RAAS blockade alone after mean follow up of 4.7 years [20]. Acknowledging the limitations of a small sample size, observed rates of development of ESRD (5%) in our study could suggest that MMF provides some long-term renal protection.…”

“…A large retrospective review of 1147 patients who were part of the European Validation Study of the Oxford Classification of IgAN (VALIGA) cohort identified 184 subjects with greater risk of progression, and propensity matched them to 184 subjects who received RAAS blockade alone. They found that immunosuppression (corticosteroids) in this targeted cohort of patients reduced proteinuria and the rate of renal function decline, and increased renal survival [20]. This suggests that for certain patients at greater risk of progression, immunosuppressive therapy may in fact be indicated.…”

Crescentic IgA nephropathy following bone fracture

“…The current management of patients with acute crescentic rapidly progressive IgA nephropathy includes steroids [29][30][31] and cytotoxic drugs [32,33], though overall renal survival in crescentic IgA nephropathy is significantly inferior to that in other forms of crescentic glomerulonephritis, including systemic vasculitis and Good pasture's disease [7,34]. The use of high dose of intravenous methylprednisolone followed by oral prednisolone and mycophenolate mofetil, in this reported case, was very effective in ameliorating the renal function deterioration and in inducing rapid recovery without dialysis support despite the presence of crescentic glomeruli together with interstitial inflammation and tubular atrophy.…”