1
|
Zhang H, Ren S, Hu J, Li G. Long-term renal survival in patients with IgA nephropathy: a systematic review. Ren Fail 2024; 46:2394636. [PMID: 39192601 PMCID: PMC11360644 DOI: 10.1080/0886022x.2024.2394636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 08/13/2024] [Accepted: 08/15/2024] [Indexed: 08/29/2024] Open
Abstract
The management strategy for IgA nephropathy (IgAN), has undergone constant improvements since the disease entity was first described 50 years ago. However, it is still unknown how these changes affected the long-term renal survival of IgAN patients. We systematically evaluate changes in IgAN renal survival by searching PubMed, Embase, and the Cochrane Library Database of Systematic Reviews from inception to 19 May 2024. We included a large sample of 103076 IgAN cases from 158 studies. Renal survival rates were 94.16% (95% CI: 94.02% to 94.31%), 88.68% (95% CI: 88.48% to 88.87%), and 78.13% (95% CI: 77.82% to 78.43%) at three, five, and ten-year, respectively. Over the past few decades, there haven't been any sound changes in the 3-year and 5-year renal survival rates. The kidney survival rate in developed countries is higher than in developing countries. Researchers consistently show that while proteinuria < 1.0 g/24 h, renal survival rates increase dramatically. In IgAN, long-term renal survival fluctuated rather than continuously improving over time. Our system review's findings indicate that supportive care-the most important recommendation for managing IgAN has shown promising results. The long-term outcomes of IgAN could be significantly improved by the latest developed treatment options.
Collapse
Affiliation(s)
- Huijian Zhang
- Renal Department, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Song Ren
- Renal Department, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Jieqiang Hu
- Renal Department, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Guisen Li
- Renal Department, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| |
Collapse
|
2
|
Oruc A, Sumnu A, Turkmen A, Basturk T, Cebeci E, Turgutalp K, Cetinkaya H, Uzerk Kibar M, Seyahi N, Tatar E, Ergul M, Derici Ü, Aylı MD, Pınar M, Bakar B, Kazancıoglu R, Yıldız A, Dirim AB, Yılmaz Z, Turkmen K, Tunca O, Koc M, Kutlay S, Micozkadıoglu H, Azak A, Boztepe B, Ustundag S, Şafak Ozturk S, Unsal A, Karadag S, Sahin G, Yenigun EC, Eren N, Gullulu M, Gursu M, Ozturk S. Immunosuppressive treatment results in patients with primary IgA nephropathy in Turkiye; the data from TSN-GOLD working group. Ren Fail 2024; 46:2341787. [PMID: 38637275 PMCID: PMC11028022 DOI: 10.1080/0886022x.2024.2341787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/06/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Immunoglobulin A (IgA) nephropathy (IgAN) treatment consists of maximal supportive care and, for high-risk individuals, immunosuppressive treatment (IST). There are conflicting results regarding IST. Therefore, we aimed to investigate IST results among IgAN patients in Turkiye. METHOD The data of 1656 IgAN patients in the Primary Glomerular Diseases Study of the Turkish Society of Nephrology Glomerular Diseases Study Group were analyzed. A total of 408 primary IgAN patients treated with IST (65.4% male, mean age 38.4 ± 12.5 years, follow-up 30 (3-218) months) were included and divided into two groups according to treatment protocols (isolated corticosteroid [CS] 70.6% and combined IST 29.4%). Treatment responses, associated factors were analyzed. RESULTS Remission (66.7% partial, 33.7% complete) was achieved in 74.7% of patients. Baseline systolic blood pressure, mean arterial pressure, and proteinuria levels were lower in responsives. Remission was achieved at significantly higher rates in the CS group (78% vs. 66.7%, p = 0.016). Partial remission was the prominent remission type. The remission rate was significantly higher among patients with segmental sclerosis compared to those without (60.4% vs. 49%, p = 0.047). In the multivariate analysis, MEST-C S1 (HR 1.43, 95% CI 1.08-1.89, p = 0.013), MEST-C T1 (HR 0.68, 95% CI 0.51-0.91, p = 0.008) and combined IST (HR 0.66, 95% CI 0.49-0.91, p = 0.009) were found to be significant regarding remission. CONCLUSION CS can significantly improve remission in high-risk Turkish IgAN patients, despite the reliance on non-quantitative endpoints for favorable renal outcomes. Key predictors of remission include baseline proteinuria and specific histological markers. It is crucial to carefully weigh the risks and benefits of immunosuppressive therapy for these patients.
Collapse
Affiliation(s)
- Aysegul Oruc
- Department of Nephrology, Bursa Uludag University Faculty of Medicine, Bursa, Turkiye
| | - Abdullah Sumnu
- Department of Nephrology, Medipol University Faculty of Medicine, Istanbul, Turkiye
| | - Aydın Turkmen
- Department of Nephrology, Istanbul University Faculty of Medicine, Istanbul, Turkiye
| | - Taner Basturk
- Department of Nephrology, University of Health Sciences, Etfal Hamidiye Training and Research Hospital, Istanbul, Turkiye
| | - Egemen Cebeci
- Department of Nephrology, Istanbul Provincial Directorate of Health Istanbul Haseki Training and Research Hospital, Istanbul, Turkiye
| | - Kenan Turgutalp
- Department of Nephrology, Mersin University Faculty of Medicine, Training and Educational Hospital, Mersin, Turkiye
| | - Hakkı Cetinkaya
- Department of Nephrology, University of Health Sciences, Sultan 2. Abdülhamid Han Training and Research Hospital, Istanbul, Turkiye
| | - Müge Uzerk Kibar
- Department of Nephrology, Health Ministry of Turkiye Republic Ankara Bilkent City Hospital, Ankara, Turkiye
| | - Nurhan Seyahi
- Department of Nephrology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkiye
| | - Erhan Tatar
- Department of Nephrology, Izmir Provincial Directorate of Health Bozyaka Education and Research Hospital, Izmir, Turkiye
| | - Metin Ergul
- Department of Nephrology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkiye
| | - Ülver Derici
- Department of Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkiye
| | - Mehmet Deniz Aylı
- Department of Nephrology, Mınıstry Of Health Dıskapı Yıldırım Beyazıt Traınıng And Research Hospıtal, Ankara, Turkiye
| | - Musa Pınar
- Department of Nephrology, Faculty of Medicine, Sakarya University, Sakarya, Turkiye
| | - Betül Bakar
- Department of Nephrology, Ankara Provincial Health Directorate Ankara Training and Research Hospital, Ankara, Turkiye
| | - Rümeyza Kazancıoglu
- Department of Nephrology, Faculty of Medicine, Bezmialem Vakif Univeristy, Istanbul, Turkiye
| | - Abdülmecit Yıldız
- Department of Nephrology, Bursa Uludag University Faculty of Medicine, Bursa, Turkiye
| | - Ahmet Burak Dirim
- Department of Nephrology, Istanbul Provincial Health Directorate ˙Istanbul Bakirköy Dr. Sadi Konuk Education And Research Hospital, Istanbul, Turkiye
| | - Zülfükar Yılmaz
- Department of Nephrology, Dicle University Faculty of Medicine, Diyarbakır, Turkiye
| | - Kültigin Turkmen
- Department of Nephrology, Faculty of Medicine Hospital, Necmettin Erbakan University Meram, Konya, Turkiye
| | - Onur Tunca
- Department of Nephrology, Faculty of Medicine, Afyonkarahisar University of Health Sciences, Afyonkarahisar, Turkiye
| | - Mehmet Koc
- Department of Nephrology, Faculty of Medicine, Marmara University, Istanbul, Turkiye
| | - Sim Kutlay
- Department of Nephrology, Faculty of Medicine, Ankara University, Ankara, Turkiye
| | - Hasan Micozkadıoglu
- Department of Nephrology, Baskent University Faculty of Medicine, Dr. Turgut Noyan Adana Application and Research Hospital, Adana, Turkiye
| | - Alper Azak
- Department of Nephrology, Balikesir Provincial Health Directorate Atatürk City Hospital, Balıkesir, Turkiye
| | - Burcu Boztepe
- Department of Nephrology, Istanbul Provincial Health Directorate Haydarpasa Numune Traınıng And Research Hospıtal, Istanbul, Turkiye
| | - Sedat Ustundag
- Department of Nephrology, Faculty of Medicine, Trakya University, Edirne, Turkiye
| | - Seda Şafak Ozturk
- Department of Nephrology, Istanbul University Faculty of Medicine, Istanbul, Turkiye
| | - Abdulkadir Unsal
- Department of Nephrology, University of Health Sciences, Etfal Hamidiye Training and Research Hospital, Istanbul, Turkiye
| | - Serhat Karadag
- Department of Nephrology, Istanbul Provincial Directorate of Health Istanbul Haseki Training and Research Hospital, Istanbul, Turkiye
| | - Gülizar Sahin
- Department of Nephrology, University of Health Sciences, Sultan 2. Abdülhamid Han Training and Research Hospital, Istanbul, Turkiye
| | - Ezgi Coşgun Yenigun
- Department of Nephrology, Ankara Provincial Health Directorate Ankara Training and Research Hospital, Ankara, Turkiye
| | - Necmi Eren
- Department of Nephrology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkiye
| | - Mustafa Gullulu
- Department of Nephrology, Bursa Uludag University Faculty of Medicine, Bursa, Turkiye
| | - Meltem Gursu
- Department of Nephrology, Faculty of Medicine, Bezmialem Vakif Univeristy, Istanbul, Turkiye
| | - Savaş Ozturk
- Department of Nephrology, Istanbul University Faculty of Medicine, Istanbul, Turkiye
| |
Collapse
|
3
|
Filippone EJ, Gulati R, Farber JL. Contemporary review of IgA nephropathy. Front Immunol 2024; 15:1436923. [PMID: 39188719 PMCID: PMC11345586 DOI: 10.3389/fimmu.2024.1436923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 07/02/2024] [Indexed: 08/28/2024] Open
Abstract
IgA nephropathy (IgAN) is considered the most common primary glomerulonephritis worldwide with a predilection for Asian-Pacific populations and relative rarity in those of African descent. Perhaps 20%-50% of patients progress to kidney failure. The pathogenesis is incompletely understood. Mesangial deposition of immune complexes containing galactose-deficient IgA1 complexed with anti-glycan IgG or IgA antibodies results in mesangial cell activation and proliferation, inflammatory cell recruitment, complement activation, and podocyte damage. Diagnosis requires a biopsy interpreted by the Oxford criteria. Additional pathologic features include podocytopathy, thrombotic microangiopathy, and C4d staining. Biomarkers predicting adverse outcomes include proteinuria, reduced GFR, hypertension, and pathology. Acceptable surrogate endpoints for therapeutic trials include ongoing proteinuria and rate of eGFR decline. The significance of persisting hematuria remains uncertain. The mainstay of therapy is supportive, consisting of lifestyle modifications, renin-angiotensin inhibition (if hypertensive or proteinuric), sodium-glucose-transporter 2 inhibition (if GFR reduced or proteinuric), and endothelin-receptor antagonism (if proteinuric). Immunosuppression should be considered for those at high risk after maximal supportive care. Corticosteroids are controversial with the most positive results observed in Chinese. They carry a high risk of serious side effects. Similarly, mycophenolate may be most effective in Chinese. Other immunosuppressants are of uncertain benefit. Tonsillectomy appears efficacious in Japanese. Active areas of investigation include B-cell inhibition with agents targeting the survival factors BAFF and APRIL and complement inhibition with agents targeting the alternate pathway (Factors B and D), the lectin pathway (MASP-2), and the common pathway (C3 and C5). Hopefully soon, the who and the how of immunosuppression will be clarified, and kidney failure can be forestalled.
Collapse
Affiliation(s)
- Edward J. Filippone
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Rakesh Gulati
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - John L. Farber
- Department of Pathology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| |
Collapse
|
4
|
Yan Q, Liu M, Xie Y, Lin Y, Fu P, Pu Y, Wang B. Kidney-brain axis in the pathogenesis of cognitive impairment. Neurobiol Dis 2024; 200:106626. [PMID: 39122123 DOI: 10.1016/j.nbd.2024.106626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/31/2024] [Accepted: 08/02/2024] [Indexed: 08/12/2024] Open
Abstract
The kidney-brain axis is a bidirectional communication network connecting the kidneys and the brain, potentially affected by inflammation, uremic toxin, vascular injury, neuronal degeneration, and so on, leading to a range of diseases. Numerous studies emphasize the disruptions of the kidney-brain axis may contribute to the high morbidity of neurological disorders, such as cognitive impairment (CI) in the natural course of chronic kidney disease (CKD). Although the pathophysiology of the kidney-brain axis has not been fully elucidated, epidemiological data indicate that patients at all stages of CKD have a higher risk of developing CI compared with the general population. In contrast to other reviews, we mentioned some commonly used medicines in CKD that may play a pivotal role in the pathogenesis of CI. Revealing the pathophysiology interactions between kidney damage and brain function can reduce the potential risk of future CI. This review will deeply explore the characteristics, indicators, and potential pathophysiological mechanisms of CKD-related CI. It will provide a theoretical basis for identifying CI that progresses during CKD and ultimately prevents and treats CKD-related CI.
Collapse
Affiliation(s)
- Qianqian Yan
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Mengyuan Liu
- Department of Anesthesiology, Air Force Hospital of Western Theater Command, PLA, Chengdu 610011, China
| | - Yiling Xie
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yimi Lin
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Ping Fu
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yaoyu Pu
- Department of Rheumatology and Immunology, West China Hospital of Sichuan University, Chengdu 610041, China.
| | - Bo Wang
- Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu 610041, China.
| |
Collapse
|
5
|
Xu R, Gao Q, Zhang Y, Lin Y, Li Y, Su L, Zhou S, Cao Y, Gao P, Li P, Luo F, Chen R, Zhang X, Nie S, Xu X. Associations between Different Antivirals and Hospital-Acquired Acute Kidney Injury in Adults with Herpes Zoster. Clin J Am Soc Nephrol 2024; 19:694-703. [PMID: 38527975 PMCID: PMC11168829 DOI: 10.2215/cjn.0000000000000452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
Key Points Among intravenous antivirals, acyclovir was associated with the highest risk of hospital-acquired AKI, followed by penciclovir/ganciclovir and foscarnet. The risk of hospital-acquired AKI was dose dependent for intravenous nucleoside analogs. Background To examine the association of use of different antivirals with hospital-acquired AKI among Chinese adults with herpes zoster. Methods This study selected 3273 adult patients who received antiviral therapy for herpes zoster during hospitalization from the China Renal Data System. We identified and staged AKI using patient-level serum creatinine data according to the Kidney Disease Improving Global Outcomes criteria. We compared the relative risks of hospital-acquired AKI among patients treated with different antivirals using Cox proportional hazards models. Results Among 3273 patients, 1480 (45%), 681 (21%), 489 (15%), and 623 (19%) were treated with acyclovir/valacyclovir, ganciclovir, penciclovir/famciclovir, and foscarnet, respectively. During the follow-up period, a total of 111 cases of hospital-acquired AKI occurred, predominantly classified as AKI stage 1. The cumulative incidences of hospital-acquired AKI were 5%, 3%, 3%, and 1% in the patients receiving acyclovir/valacyclovir, ganciclovir, penciclovir/famciclovir, and foscarnet, respectively. Compared with acyclovir/valacyclovir, penciclovir/famciclovir/ganciclovir and foscarnet were associated with a lower risk of hospital-acquired AKI, with an adjusted hazard ratio of 0.59 (95% confidence interval [CI], 0.37 to 0.94) and 0.27 (95% CI, 0.11 to 0.63), respectively. Compared with intravenous acyclovir, intravenous penciclovir/ganciclovir and foscarnet were associated with a lower risk of hospital-acquired AKI with an adjusted hazard ratio of 0.53 (95% CI, 0.29 to 0.98) and 0.31 (95% CI, 0.12 to 0.76), respectively. The associations were consistent across various subgroups and sensitivity analyses. Conclusions Among antiviral therapies for herpes zoster, we found different risks of hospital-acquired AKI among the patients receiving different antivirals, in particular, those administered intravenously. Among intravenous antivirals, acyclovir was associated with the highest risk of hospital-acquired AKI, followed by penciclovir/ganciclovir and foscarnet. Confirmation studies with large samples from other populations are warranted.
Collapse
Affiliation(s)
- Ruqi Xu
- Division of Nephrology, State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Renal Failure Research, National Clinical Research Center for Kidney Disease, Guangdong Provincial Institute of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Del Vecchio L, Allinovi M, Comolli S, Peiti S, Rimoldi C, Locatelli F. Drugs in Development to Treat IgA Nephropathy. Drugs 2024; 84:503-525. [PMID: 38777962 DOI: 10.1007/s40265-024-02036-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/25/2024]
Abstract
IgA nephropathy is a common glomerulonephritis consequent to the autoimmune response to aberrant glycosylated immunoglobulin (Ig) A antibodies. Although it has historically been considered a benign disease, it has since become clear that a substantial percentage of patients reach end-stage kidney failure over the years. Several therapeutic attempts have been proposed, with systemic steroids being the most prevalent, albeit burdened by possible serious adverse events. Thanks to the more in-depth knowledge of the pathogenesis of IgA nephropathy, new treatment targets have been identified and new drugs developed. In this narrative review, we summarise the molecules under clinical development for the treatment of IgA nephropathy. As a search strategy, we used PubMed, Google, ClinicalTrials.gov and abstracts from recent international congresses. TRF budesonide and sparsentan are the two molecules at a more advanced stage, just entering the market. Other promising agents are undergoing phase III clinical development. These include anti-APRIL and anti-BLyS/BAFF antibodies and some complement inhibitors. Other new possible strategies include spleen tyrosine kinase inhibitors, anti-CD40 ligands and anti-CD38 antibodies. In an era increasingly characterised by 'personalised medicine' and 'precision therapy' approaches and considering that the potential therapeutic armamentarium for IgA nephropathy will be very broad in the near future, the identification of biomarkers capable of helping the nephrologist to select the right drug for the right patient should be the focus of future studies.
Collapse
Affiliation(s)
| | - Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy
| | - Stefania Comolli
- Department of Nephrology and Dialysis, ASST Sette Laghi, Varese, Italy
| | - Silvia Peiti
- Department of Nephrology and Dialysis, ASST Lariana, Como, Italy
| | | | - Francesco Locatelli
- Past Director of the Department of Nephrology and Dialysis, ASST Lecco, Lecco, Italy
| |
Collapse
|
7
|
Trimarchi H, Fervenza FC, Coppo R. Points of view in nephrology: personalized management of IgA nephropathy, beyond KDIGO. J Nephrol 2024; 37:739-745. [PMID: 38236471 DOI: 10.1007/s40620-023-01833-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/18/2023] [Indexed: 01/19/2024]
Abstract
IgA nephropathy is the most common primary glomerulonephritis worldwide, and an important cause of kidney failure, as 20-40% of patients progress to renal replacement therapy 20-30 years after diagnosis. Its clinical presentation ranges from isolated microscopic hematuria to nephrotic syndrome, and even to a rapidly progressive course. Ethnicity and epigenetics play a key role in its clinical aggressiveness. Selection of patients at risk needing immunosuppressive treatment is a challenge for the nephrologist. Some active and chronic kidney lesions detected on kidney biopsy have been demonstrated to have prognostic value according to the Oxford Classification of IgA nephropathy, later validated by numerous studies. However, KDIGO 2021 guidelines still consider persistent proteinuria > 1 g/24 h to be the most relevant risk factor for the progression of IgA nephropathy and the only one requiring immunosuppressive treatment. KDIGO guidelines have proposed a therapeutic algorithm, but many patients present peculiar characteristics that are not addressed by the current guidelines, pointing to the need for alternative approaches. In these cases, a tailored approach to each patient should be followed in which clinical, histological, laboratory, social and ethical aspects must be considered. In this manuscript we present three cases of IgA nephropathy from different countries, highlighting many of the aspects encountered in clinical practice that illustrate an individualized approach to the treatment of these patients.
Collapse
Affiliation(s)
- Hernán Trimarchi
- Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | | | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy.
| |
Collapse
|
8
|
Di Leo V, Annese F, Papadia F, Russo MS, Giliberti M, Sallustio F, Gesualdo L. Refractory IgA Nephropathy: A Challenge for Future Nephrologists. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:274. [PMID: 38399561 PMCID: PMC10890070 DOI: 10.3390/medicina60020274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024]
Abstract
IgA nephropathy (IgAN) represents the most prevalent form of primary glomerulonephritis, and, on a global scale, it ranks among the leading culprits behind end-stage kidney disease (ESKD). Presently, the primary strategy for managing IgAN revolves around optimizing blood pressure and mitigating proteinuria. This is achieved through the utilization of renin-angiotensin system (RAS) inhibitors, namely, angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs). As outlined by the KDIGO guidelines, individuals who continue to show a persistent high risk of progressive ESKD, even with comprehensive supportive care, are candidates for glucocorticoid therapy. Despite these therapies, some patients have a disease refractory to treatment, defined as individuals that present a 24 h urinary protein persistently >1 g after at least two rounds of regular steroids (methylprednisolone or prednisone) and/or immunosuppressant therapy (e.g., mycophenolate mofetil), or who do not tolerate regular steroids and/or immunosuppressant therapy. The aim of this Systematic Review is to revise the current literature, using the biomedical database PubMed, to investigate possible therapeutic strategies, including SGLT2 inhibitors, endothelin receptor blockers, targeted-release budesonide, B cell proliferation and differentiation inhibitors, fecal microbiota transplantation, as well as blockade of complement components.
Collapse
|
9
|
El Karoui K, Fervenza FC, De Vriese AS. Treatment of IgA Nephropathy: A Rapidly Evolving Field. J Am Soc Nephrol 2024; 35:103-116. [PMID: 37772889 PMCID: PMC10786616 DOI: 10.1681/asn.0000000000000242] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/19/2023] [Indexed: 09/30/2023] Open
Abstract
The pivotal event in the pathophysiology of IgA nephropathy is the binding of circulating IgA-containing immune complexes to mesangial cells, with secondary glomerular and tubulointerstitial inflammation and fibrosis. The paramount difficulty in the management of IgA nephropathy is the heterogeneity in its clinical presentation and prognosis, requiring an individualized treatment approach. Goal-directed supportive care remains the bedrock of therapy for all patients, regardless of risk of progression. Sodium-glucose transporter 2 inhibitors and sparsentan should be integral to contemporary supportive care, particularly in patients with chronic kidney damage. Pending the development of reliable biomarkers, it remains a challenge to identify patients prone to progression due to active disease and most likely to derive a net benefit from immunosuppression. The use of clinical parameters, including the degree of proteinuria, the presence of persistent microscopic hematuria, and the rate of eGFR loss, combined with the mesangial hypercellularity, endocapillary hypercellularity, segmental glomerulosclerosis, tubular atrophy/interstitial fibrosis, crescents score, is currently the best approach. Systemic glucocorticoids are indicated in high-risk patients, but the beneficial effects wane after withdrawal and come at the price of substantial treatment-associated toxicity. Therapies with direct effect on disease pathogenesis are increasingly becoming available. While targeted-release budesonide has garnered the most attention, anti-B-cell strategies and selective complement inhibition will most likely prove their added value. We propose a comprehensive approach that tackles the different targets in the pathophysiology of IgA nephropathy according to their relevance in the individual patient.
Collapse
Affiliation(s)
- Khalil El Karoui
- Department of Nephrology, Hôpital Tenon, Sorbonne Université, Paris, France
| | | | - An S. De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
| |
Collapse
|
10
|
McGuire M. Selecting Treatment for IgA Nephropathy. Clin J Am Soc Nephrol 2023; 18:1109-1110. [PMID: 37553878 PMCID: PMC10564356 DOI: 10.2215/cjn.0000000000000263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
|
11
|
Lafayette RA, Kamal FS. Considering the Treatment of IgA Nephropathy. Clin J Am Soc Nephrol 2023; 18:1113-1115. [PMID: 37533148 PMCID: PMC10564336 DOI: 10.2215/cjn.0000000000000261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Affiliation(s)
- Richard A Lafayette
- Division of Nephrology , Stanford University Medical Center , Stanford , California
| | | |
Collapse
|