IgA nephropathy in adults - Treatment Standard.

Immunoglobulin A Nephropathy (IgAN) is the most common primary form of glomerular disease worldwide and carries a high life-time risk of kidney failure. The underlying pathogenesis of IgAN has been characterised to a sub-molecular level; immune-complexes containing specific O-glycoforms of IgA1 are central. Kidney biopsy remains the gold-standard diagnostic test for IgAN and histological features (i.e. MEST-C score) have also been shown to independently predict outcome. Proteinuria and blood-pressure are the main modifiable risk factors for disease progression. No IgAN-specific biomarker has yet been validated for diagnosis, prognosis or tracking response to therapy. There has been a recent resurgence of investigation into IgAN treatments. Optimised supportive care with lifestyle interventions and non-immunomodulatory drugs remains the backbone of IgAN management. The menu of available reno-protective medications is rapidly expanding beyond blockade of the renin angiotensin aldosterone system (RAAS) to include sodium glucose cotransporter 2 (SGLT2) and endothelin type A receptor antagonism. Systemic immunosuppression can further improve kidney outcomes, although recent randomised controlled trials have raised concerns regarding infectious and metabolic toxicity from systemic corticosteroids. Studies evaluating more refined approaches to immunomodulation in IgAN are ongoing: drugs targeting the mucosal immune-compartment, B-cell promoting cytokines, and the complement cascade are particularly promising. We review the current standards of treatment and discuss novel developments in pathophysiology, diagnosis, outcome prediction and management of IgAN.