Calliditas IgAN Pocket Guide

Practice Point 2.3.1.1 Considerations for treatment of patients with IgAN who are at high risk of progressive CKD despite maximal supportive care • High risk of progression in IgAN is currently defined as proteinuria >0.75–1 g/d despite ≥90 days of optimized supportive care. • Immunosuppressive drugs should be considered only in patients with IgAN who remain at high risk of progressive CKD despite maximal supportive care (the patients enrolled in the only large randomized controlled trial [RCT] suggesting benefit of immunosuppression had an average of 2.4 g/d of proteinuria). • In view of the current uncertainty over the safety and efficacy of existing immunosuppressive treatment choices, all patients who remain at high risk of progressive CKD despite maximal supportive care should be offered the opportunity to take part in a clinical trial. • In all patients in whom immunosuppression is being considered, a detailed discussion of the risks and benefits of each drug should be undertaken with the patient recognizing that adverse treatment effects are more likely in patients with an eGFR <50 ml/min per 1.73 m 2 . • Dynamic assessment of patient risk over time should be performed, as decisions regarding immunosuppression may change. Recommendation 2.3.1.1 We suggest that patients who remain at high risk of progressive CKD despite maximal supportive care be considered for a 6-month course of glucocorticoid therapy. The important risk of treatment-emergent toxicity must be discussed with patients, particularly those who have an eGFR <50 ml/min per 1.73 m 2 (Recommendation Grading 2B — Moderate Suggestion). Recommendation 2.3.2 We recommend that all patients with proteinuria >0.5 g/d irrespective of whether they have hypertension be treated with either an ACEi or ARB (Recommendation Grading 1B — Moderate Recommendation). Practice Point 2.3.1.2 Proteinuria reduction to under 1 g/d is a surrogate marker of improved kidney outcome in IgAN, and reduction to under 1 g/d is a reasonable treatment target. Practice Point 2.3.1.4 Management of patients with IgAN who remain at high risk for progression after maximal supportive care. (Figure 4)

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