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ASSESSMENT AND MANAGEMENT OF
IgA NEPHROPATHY
John Feehally
IgA NEPHROPATHY
The commonest pattern of
glomerulonephritis in the world
CLASSIFICATION OF GLOMERULONEPHRITIS
Histopathology
Clinical
Immune
mechanisms
CLASSIFICATION OF GLOMERULONEPHRITIS
Histopathology
Clinical
Immune
mechanisms
Patterns established on light microscopy
Membranous
Membranoproliferative
Focal segmental glomerulosclerosis
etc……
CLASSIFICATION OF GLOMERULONEPHRITIS
Histopathology
Clinical
Immune
mechanisms
Patterns established on light microscopy
Membranous
Membranoproliferative
Focal segmental glomerulosclerosis
‘Patterns’ not ‘diseases’
etc……
IgA1 deposition
In the glomerular
mesangium
IgA NEPHROPATHY
ASSESSMENT AND MANAGEMENT OF
IgA NEPHROPATHY
Is IgA nephropathy
a single ‘disease’ ?
IgA NEPHROPATHY
A pattern of glomerulonephritis
with many variations
Recurrent visible haematuria
Coincides with mucosal infection
Nephrotic syndrome
Asymptomatic
Haematuria / proteinuria
CKD
Proteinuria
Hypertension
Renal impairment
HENOCH-SCHȌNLEIN NEPHRITIS
Henoch-Schőnlein purpura
‘SECONDARY’ IgA NEPHROPATHY
COMMONLY REPORTED ASSOCIATIONS
Alcoholic liver disease
Celiac disease
Ankylosing spondylitis
Reiter’s syndrome
Uveitis
Dermatitis herpetiformis
RECURRENT IgA NEPHROPATHY
RECURRENT IgA NEPHROPATHY
Pooled published data – 5 year follow up
Recurrence
38-60%
Graft dysfunction
due to recurrence
Graft loss
due to recurrence
15%
7%
RECURRENT IgA NEPHROPATHY
Pooled published data – 5 year follow up
Recurrence
38-60%
Graft dysfunction
due to recurrence
Graft loss
due to recurrence
15%
7%
Why does IgA nephropathy
NOT always recur ?
15-21%
4.7%
<5%
Percentage of patients
with
primary glomerular disease
15-21%
Male > Female
4.7%
<5%
Male = Female
IgA NEPHROPATHY
Variations in:
Pathological pattern
Clinical pattern
Transplant recurrence
Epidemiological pattern
Pathogenesis
IgA NEPHROPATHY
No proof that IgAN is a single
Not expect
‘disease’
a single pathogenic mechanism
to lead to
mesangial IgA deposition
No proof that
IgAN
and
injuryis the same
‘disease’ in all parts of the world
ASSESSMENT AND MANAGEMENT OF
IgA NEPHROPATHY
Can you predict
which patients with IgA nephropathy
will get kidney failure?
ASSESSMENT AND MANAGEMENT OF
IgA NEPHROPATHY
Can you predict
which patients with IgA nephropathy
will get kidney failure?
CLINICAL evidence
PROGNOSIS IN IgA NEPHROPATHY
Rodicio 1982
PROGNOSIS IN IgA NEPHROPATHY
20% ESRD @ 20 years
Rodicio 1982
IgA NEPHROPATHY IN INDIA
CMC Vellore 1994-2003
Chacko B et al. Nephrology 2005; 10: 496
IgA NEPHROPATHY IN INDIA
CMC Vellore 1994-2003
478 adults
55% - Nephrotic syndrome at presentation
56% - Serum creatinine > 123 μmol/L at presentation
Chacko B et al. Nephrology 2005; 10: 496
MACROSCOPIC HAEMATURIA AND PROGNOSIS
IN IgA NEPHROPATHY
Beukhof 1983
LEAD TIME BIAS IN DIAGNOSIS OF IgA NEPHROPATHY
Geddes CC et al. NDT 2003; 18: 1541
ISOLATED NON-VISIBLE HAEMATURIA IN IgA NEPHROPATHY
How benign is it ?
Cohort study – Toronto – 286 patients
Non-visible
haematuria
Proteinuria < 0.2 g/24hr
plus
Normal BP
Bartosik et al. AJKD 2001; 38: 728
ISOLATED MICROSCOPIC HAEMATURIA IN IgA NEPHROPATHY
How benign is it ?
Cohort study – Toronto – 286 patients
Microscopic
haematuria
Proteinuria < 0.2 g/24hr
plus
Normal BP
10 year risk
of deterioration in renal function
= ZERO
Bartosik et al. AJKD 2001; 38: 728
ISOLATED NON-VISIBLE HAEMATURIA IN IgA NEPHROPATHY
How benign is it ?
Cohort study – Hong Kong
Non-visible
haematuria
plus
Proteinuria < 0.4 g/24hr
During 7 years follow up, 44% had a ‘clinical event’
33% proteinuria
26% hypertension
7% renal impairment
Szeto C et al Am J Med 2001; 110:434
OUTCOME AND AVERAGE FOLLOW-UP PROTEINURIA
IN IgA NEPHROPATHY
REMISSION OF PROTEINURIA IMPROVES PROGNOSIS
IN IgA NEPHROPATHY
Time-average proteinuria
1 - < 1g/24h
2 – 1-2 g/24h
3 – 2-3g/24h
4 - >3g/24h
Reich H et al. JASN 2007; 18: 3177
ASSESSMENT AND MANAGEMENT OF
IgA NEPHROPATHY
Can you predict
which patients with IgA nephropathy
will get kidney failure?
PATHOLOGICAL evidence
A CLINICO-PATHOLOGICAL CLASSIFICATION
FOR IgA NEPHROPATHY
Does pathology add prognostic information
.. to clinical data at time of biopsy ?
.. to clinical data during follow up ?
A CLINICO-PATHOLOGICAL CLASSIFICATION
FOR IgA NEPHROPATHY
Does pathology add prognostic information
.. to clinical data at time of biopsy ?
Perhaps the biopsy is only useful
diagnosis
IgAN up
? ?
.. to
toestablish
clinical the
data
during of
follow
PATHOLOGICAL CLASSIFICATIONS
IN RENAL DISEASE
Are usually based on expert opinion
... and pre-conceived ideas of what
lesions are important
OXFORD CLASSIFICATION
OF IgA NEPHROPATHY
A different way
Approach the problem with an open mind
With an international consensus group
• Study all histological lesions
• Test reproducibility & independence
• Then test correlations with outcome
SCORING OF SELECTED PATHOLOGY FEATURES
Mesangial hypercellularity - in > or <50% of glomeruli
M0 or M1
Endocapillary hypercellularity – present/absent
E0 or E1
Segmental sclerosis/adhesions – present/absent
S0 or S1
Tubular atrophy/interstitial fibrosis – 0-25%, 26-50%, >50% T0 or T1 or T2
Each can be scored easily in routine clinical practice
PREDICTIVE SIGNIFICANCE OF
PATHOLOGY FEATURES IN IgA NEPHROPATHY
MEST
Each adds predictive value to ….
Initial clinical features
Follow up clinical features
In all ages and races studied
VALIDATION STUDIES
FOR THE OXFORD CLASSIFICATION OF IgAN
M
E
S
T
Macedonia
2010
98
+
+
+
+
USA
2011
54
+
+
-
+
Japan
2011
161 children
+
+
-
+
France
2011
183
-
+
+
+
USA, Canada
2011
187 adults &
children
+
+
+
+
China
2011
410
-
+
+
+
Japan
2011
702
-
-
+
+
Sweden
2012
99
+
+
-
+
Korea
2012
197
+
-
+
+
6/10
7/10
6/10
10/10
WHAT NEXT ?
Validation studies
Work towards combining pathology
and clinical elements
– to produce a single ‘risk score’
There is now the opportunity to design smaller,
shorter RCTs
ASSESSMENT AND MANAGEMENT OF
IgA NEPHROPATHY
How good is the evidence
to guide the treatment of
IgA nephropathy ?
KI Supplements 2012
2(2): 1-274
CLINICAL PRACTICE GUIDELINE FOR
GLOMERULONEPHRITIS
Examples of Rating Guideline Recommendations
QUALITY of Supporting Evidence is shown as A, B, C or D
Level 1
Level 2
We recommend….
1A
Most patients should receive the
recommended course of action
Supported by evidence from
high quality RCTs
We suggest …
2D
Different choices will be
appropriate for different patients.
Each patient needs help to arrive
at a management decision
appropriate for them
No RCTs
Supported by limited
observational data
Examples of Rating Guideline Recommendations
QUALITY of Supporting Evidence is shown as A, B, C or D
Level 1
We recommend….
1A
Most patients should receive the
recommended course of action
Supported by evidence from
high quality RCTs
Of 10 recommendations or suggestions
in the IgA Nephropathy guideline
Level 2
We suggest …
Only 2 (20%) are 1A or2D
1B
Different choices will be
appropriate for different patients.
Each patient needs help to arrive
at a management decision
appropriate for them
No RCTs
Supported by limited
observational data
Clinical Practice Guideline for
Glomerulonephritis
…. will not tell you what to do for every
difficult patient in every situation
Clinical Practice Guideline for
Glomerulonephritis
…. will not tell you what to do for every
difficult patient in every situation
The Guideline is not there to give you expert
advice about an individual problem case
Clinical Practice Guideline for
Glomerulonephritis
…. will not tell us what to do for every
difficult patient in every situation
….will remind us what we know
Clinical Practice Guideline for
Glomerulonephritis
…. will not tell us what to do for every
difficult patient in every situation
….will remind us what we know
….will remind us what we do not know
ASSESSMENT AND MANAGEMENT OF
IgA NEPHROPATHY
“Should I treat this patient with
IgA nephropathy ?”
TREATMENT DECISIONS IN IgA NEPHROPATHY
Non-visible haematuria
Visible haematuria
Acute kidney injury
Crescentic IgA nephropathy
Proteinuria > 1g/day
Nephrotic syndrome
Hypertension
Progressive fall in GFR
TREATMENT DECISIONS IN IgA NEPHROPATHY
Microscopic haematuria
Macroscopic haematuria
Acute kidney injury
Crescentic IgA nephropathy
Proteinuria > 1g/day
Nephrotic syndrome
Hypertension
Progressive fall in GFR
TREATMENT RECOMMENDATIONS FOR IgA NEPHROPATHY
Recurrent Macroscopic Haematuria
No role for antibiotics
No role for tonsillectomy
TREATMENT DECISIONS IN IgA NEPHROPATHY
Microscopic haematuria
Macroscopic haematuria
Acute kidney injury
Proteinuria > 1g/day
Nephrotic syndrome
Hypertension
Progressive renal insufficiency
TREATMENT RECOMMENDATIONS FOR IgA NEPHROPATHY
Macroscopic Haematuria with acute renal failure
Renal biopsy is mandatory
if not improve in 2-3 days with supportive measures
AKI WITH VISIBLE HAEMATURIA
IN IgA NEPHROPATHY
9 published reports – 84 patients
How common ?
AKI in 38% (4/11) of visible haematuria episodes (Praga 1985)
Much less common in most other reports
How important are crescents ?
Crescents often seen, but in <20% of glomeruli
and usually not the cause of AKI
Moreno J et al. CJASN 2012; 7: 175
AKI WITH VISIBLE HAEMATURIA
IN IgA NEPHROPATHY
9 published reports – 84 patients
Recovery of renal function ?
Most reports (29 patients) …
100% have complete recovery of renal function
Two reports (55 patients) – only 73% full recovery
Moreno J et al. CJASN 2012; 7: 175
AKI WITH VISIBLE HAEMATURIA
IN IgA NEPHROPATHY
Recovery of renal function ?
One centreFull
in Spain
recov(52 patients)
Full recovery less likely:
Older age
Duration of visible haematuria (mean 15 vs 36 days)
Peak sCr (7.1 vs 309 mg/dL)
Tubular necrosis
Tubular red cell casts
Interstitial; fibrosis
Moreno J et al. CJASN 2012; 7: 175
TREATMENT RECOMMENDATIONS FOR IgA NEPHROPATHY
Macroscopic Haematuria with acute renal failure
Renal biopsy is mandatory
if not improve in 2-3 days with supportive measures
Acute Tubular Necrosis
Crescentic IgA nephropathy
Supportive measures
only
Immunosuppression may
be appropriate
TREATMENT DECISIONS IN IgA NEPHROPATHY
Microscopic haematuria
Macroscopic haematuria
Acute renal failure
Crescentic IgA nephropathy
Proteinuria > 1g/day
Nephrotic syndrome
Hypertension
Progressive renal insufficiency
CRESCENTIC GLOMERULONEPHRITIS
Renal outcome with best known treatment
Renal survival
1 year
5 years
Systemic vasculitis
80%
75%
Goodpasture’s
70%
50%
Crescentic IgA nephropathy
50%
20%
TREATMENT FOR
CRESCENTIC IgA NEPHROPATHY
A number of recent optimistic reports Corticosteroids + Cyclophosphamide
Small : < 20 patients
Selection criteria variable
All are anecdotal
TREATMENT FOR CRESCENTIC IgA NEPHROPATHY
Definition?
More than just a few crescents
Rapidly progressive renal failure
TREATMENT FOR CRESCENTIC IgA NEPHROPATHY
Definition?
More than just a few crescents
Rapidly progressive renal failure
Which patients respond ?
Treat if crescents + other active glomerular damage
AND no chronic or irreversible changes
TREATMENT FOR CRESCENTIC IgA NEPHROPATHY
If immunosuppression is indicated…
INDUCTION:
Prednisolone 0.5-1mg/kg/day
Cyclophosphamide 2mg/kg/day
MAINTENANCE:
Prednisolone in reducing dosage
Azathioprine 2mg/kg/day
[plasma exchange unproven]
TREATMENT FOR CRESCENTIC IgA NEPHROPATHY
If immunosuppression is indicated…
INDUCTION:
Prednisolone 0.5-1mg/kg/day
Cyclophosphamide 2mg/kg/day
MAINTENANCE:
Prednisolone in reducing dosage
Azathioprine 2mg/kg/day
[plasma exchange unproven]
An RCT is badly needed
…. and will be difficult to achieve
TREATMENT DECISIONS IN IgA NEPHROPATHY
Microscopic haematuria
Macroscopic haematuria
Acute renal failure
Crescentic IgA nephropathy
Proteinuria > 1g/day
Nephrotic syndrome
Hypertension
Progressive renal insufficiency
NEPHROTIC-RANGE PROTEINURIA IN
IgA NEPHROPATHY
IgAN and nephrotic range proteinuria
N = 233
More likely to have normoalbuminaemia
than minimal change, FSGS, or membranous
Nephrotic-range proteinuria and serum albumin > 35 g/l
95.8% specificity for IgAN
Chen M et al. NDT 2011; 26: 1247
NEPHROTIC SYNDROME IN IgA
NEPHROPATHY
n = 100 – mean follow up 45 months
Complete remission 48%
Partial remission 32%
No remission 20%
Spontaneous remission 24%
PRIMARY END POINT - DOUBLE SERUM CREATININE
24%
More likely if partial or no remission
Kim J-K et al. CJASN 2012; 7: 247
NEPHROTIC SYNDROME IN IgA
NEPHROPATHY
n = 100
Mean follow
up 45 months
p<0.001
Kim J-K et al. CJASN 2012; 7: 247
NEPHROTIC SYNDROME IN IgA
NEPHROPATHY
100
885
P<0.001
Kim J-K et al. CJASN 2012; 7: 247
NEPHROTIC SYNDROME + MICROSCOPIC HAEMATURIA
NEPHROTIC SYNDROME + MICROSCOPIC HAEMATURIA
Corticosteroids: complete remission of nephrotic syndrome
Microscopic haematuria persists
Two common glomerular diseases coincide……
Minimal change
nephrotic syndrome
IgA nephropathy
NEPHROTIC SYNDROME IN IgA NEPHROPATHY
Minimal change
Mesangial hypercellularity
Glomerulosclerosis
NEPHROTIC SYNDROME IN IgA NEPHROPATHY
Randomised controlled trial
n = 34
Prednisolone for 4 months: 40-60 mg daily halved after 8 weeks
Follow up 38 months
Response of proteinuria
only in those with minor histological changes
Lai - Clin Neph 1986; 26:174
NEPHROTIC SYNDROME IN IgA NEPHROPATHY
Minimal change
Mesangial hypercellularity
Glomerulosclerosis
The response to corticosteroids in minimal change
does not justify their use
in all IgAN with nephrotic syndrome
TREATMENT DECISIONS IN IgA NEPHROPATHY
Microscopic haematuria
Macroscopic haematuria
Acute kidney injury
Crescentic IgA nephropathy
Proteinuria > 1g/day
Nephrotic syndrome
Hypertension
Progressive fall in GFR
TREATMENT DECISIONS IN IgA NEPHROPATHY
Non-visible haematuria
Visible haematuria
Acute kidney injury
Crescentic IgA nephropathy
Proteinuria > 1g/day
Nephrotic syndrome
Hypertension
Progressive fall in GFR
PUBLISHED TREATMENT TRIALS
IN IgA NEPHROPATHY
Often underpowered
Often insufficient follow up for ‘hard’ endpoints
Most use clinical entry criteria
Some have patients beyond ‘the point of no return’
TREATMENT OPTIONS FOR
PROGRESSIVE IgA NEPHROPATHY
Blood pressure control
Renin-angiotensin blockade
Corticosteroids
Other immunosuppressives
TREATMENT OPTIONS FOR
PROGRESSIVE IgA NEPHROPATHY
Blood pressure control
Renin-angiotensin blockade
Corticosteroids
Other immunosuppression
TREATMENT RECOMMENDATIONS FOR
IgA NEPHROPATHY
Target Blood Pressure
Proteinuria < 1g/24hr 130/80
Proteinuria > 1g/24hr 125/75
RAS Blockade
Proteinuria > 1g/24hr 125/75
Combination therapy ?
EFFECT OF ACE INHIBITOR PLUS ARB ON PROTEINURIA
IN IgA NEPHROPATHY: META-ANALYSIS
6 studies – 109 patients
Cheng J et al. Int J Clin Pract 2012; 66: 917
EFFECT OF ACE INHIBITOR PLUS ARB ON PROTEINURIA
IN IgA NEPHROPATHY: META-ANALYSIS
6 studies – 109 patients
No effect on GFR
but
Study duration:
2-12 months
Cheng J et al. Int J Clin Pract 2012; 66: 917
TREATMENT RECOMMENDATIONS FOR
IgA NEPHROPATHY
Target Blood Pressure
Proteinuria < 1g/24hr 130/80
SALT
Proteinuria > 1g/24hr 125/75
RESTRICTION
RAS Blockade
Proteinuria > 1g/24hr 125/75
Combination therapy ?
DIETARY SODIUM RESTRICTION AMPLIFIES EFFECTS OF
RAS BLOCKADE ON PROTEINURIA
Lisinopril
40mg/day
Valsartan
320mg/day
Sodium intake
50 or 200 mmol/day
Slagman M et al. BMJ 2011
DIETARY SODIUM RESTRICTION AMPLIFIES EFFECTS OF
RAS BLOCKADE ON PROTEINURIA
Lisinopril
40mg/day
Systolic BP
Valsartan
320mg/day
Sodium intake
50 or 200 mmol/day
Diastolic BP
Slagman M et al. BMJ 2011
TREATMENT RECOMMENDATIONS
FOR IgA NEPHROPATHY
Proteinuria > 1g/day + hypertension
Only if
BP target achieved…
and proteinuria still >1g/24 hr
consider corticosteroids, immunosuppressive regimens …
What is the evidence these regimens are effective
in these circumstances ?
TREATMENT OPTIONS FOR
PROGRESSIVE IgA NEPHROPATHY
Blood pressure control
Renin-angiotensin blockade
Corticosteroids
Other immunosuppression
CORTICOSTEROID TREATMENT FOR IgA NEPHROPATHY
Randomised controlled trial – serum creatinine < 130 µmol/L
Survival without end point - doubling of serum creatinine
Pozzi C et al
Lancet 1999; 353; 883 - JASN 2004; 15: 157
CORTICOSTEROID TREATMENT IN IgA NEPHROPATHY
Randomised controlled trial – serum creatinine < 133 µmol/L
n = 86
creatinine < 133 µmol/l - proteinuria 1-3.5g/24hr
Regimen
methylprednisolone 1g iv x3 at 1,3,5 months
plus
prednisolone 0.5 mg/kg/alt days for 6 months
No important side effects - no study ‘drop outs’
Pozzi C et al
Lancet 1999; 353; 883 - JASN 2004; 15: 157
CORTICOSTEROID TREATMENT IN IgA NEPHROPATHY
Randomised controlled trial – serum creatinine < 133 µmol/L
n= 103
2 year treatment regimen
Prednisolone 20mg od reducing to 5mg by 6 months
Antiproteinuric effect but no effect on renal function
Katafuchi AJKD 2003; 41:972
BLOOD PRESSURE CONTROL IN IgA NEPHROPATHY TRIALS
Corticosteroids
BP (mm Hg)
Pozzi
160
150
140
130
120
110
100
90
80
70
60
NKF
Recommendation
125/75
Katafuchi
CORTICOSTEROIDS PLUS ACE INHIBITOR IN
PROTEINURIC IgA NEPHROPATHY
TWO SIMILAR STUDIES
Proteinuria > 1g/24h - GFR > 50 ml/min
Continuous ACE inhibitor
+ oral CORTICOSTEROIDS
for 6-8 months
Follow up: 2 years (China), 5 years (Italy)
Well maintained BP
Lv J et al. 2009 AJKD; 53: 26
Manno C et al. NDT 2009; 24: 3694
BLOOD PRESSURE CONTROL IN IgA NEPHROPATHY TRIALS
Corticosteroids
Pozzi
BP (mm Hg)
160
Katafuchi
Manno
Lv
150
140
130
120
110
100
90
80
70
60
JNC
Recommendation
125/75
CORTICOSTEROIDS PLUS ACE INHIBITOR IN
PROTEINURIC IgA NEPHROPATHY
ESRD
STEROIDS
ITALY
CONTROL
1/48
8/49
Statistically
significant
CHINA
1/30
7/33
Lv J et al. 2009 AJKD; 53: 26
Manno C et al. NDT 2009; 24: 3694
CORTICOSTEROIDS PLUS ACE INHIBITOR IN
PROTEINURIC IgA NEPHROPATHY
STEROIDS
ITALY
CONTROL
1/48
8/49
Statistically
significant
CHINA
1/30
7/33
But.. achieved ACE inhibitor dose rather low
Lv J et al. 2009 AJKD; 53: 26
Manno C et al. NDT 2009; 24: 3694
CORTICOSTEROIDS PLUS ACE INHIBITOR IN
PROTEINURIC IgA NEPHROPATHY
STEROIDS
ITALY
CONTROL
1/48
8/49
Statistically
significant
CHINA
1/30
7/33
But.. neither study had a ‘run-in‘ period
Lv J et al. 2009 AJKD; 53: 26
Manno C et al. NDT 2009; 24: 3694
TREATMENT OPTIONS FOR
PROGRESSIVE IgA NEPHROPATHY
Blood pressure control
Renin-angiotensin blockade
Corticosteroids
Other immunosuppression
IMMUNOSUPPRESSIVE TREATMENT FOR
PROGRESSIVE IgA NEPHROPATHY
NO ROLE FOR
Cyclophosphamide
BLOOD PRESSURE CONTROL IN IgA NEPHROPATHY TRIALS
Corticosteroids
Pozzi
BP (mm Hg)
160
Katafuchi
Manno
Lv
150
140
130
120
110
100
90
80
70
Ballardie
60
JNC
Recommendation
125/75
Corticosteroids
+
Cyclophosphamide
IMMUNOSUPPRESSIVE TREATMENT FOR
PROGRESSIVE IgA NEPHROPATHY
NO ROLE FOR
Cyclophosphamide
What about Mycophenolate
BLOOD PRESSURE CONTROL IN IgA NEPHROPATHY TRIALS
Corticosteroids
Mycophenolate
Pozzi
Maes
BP (mm Hg)
160
Katafuchi
Manno
Tang
Lv
150
140
130
120
110
100
90
80
70
Ballardie
60
JNC
Recommendation
125/75
Corticosteroids
+
Cyclophosphamide
MYCOPHENOLATE IN IgA NEPHROPATHY
Benefit
BP achieved
ACE inhibitors
None
125/73
100%
salt restricted
ESRD
reduced
122/71
100%
[number of patients]
BELGIUM
Maes 2004 [34]
HONG KONG
Tang 2005 [40]
TREATMENT RECOMMENDATIONS FOR IgA NEPHROPATHY
Uncertainty
• The role of corticosteroids and immunosuppressives
after tight BP control and maximal RAS blockade ?
• The effect of ancestry on treatment responses
Run-in Phase
(6 Months)
Study Design
Optimal supportive therapy for 6 months
(ACEi, ARB, target BP < 125/75 mm Hg, Statin, etc.)
Responder
Drop-Out
Study-Phase
(3 Years)
Non-Responder
Proteinuria >0.75 g/d
RANDOMISATION
Optimal supportive
Optimal supportive +
Immunosuppression
Recruitment-Update STOP IgAN
- Status 28.2.2011 -
Study patients
n=356
400
IgAN patients
350
300
250
200
Randomised
n=127
150
100
50
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TREATMENT RECOMMENDATIONS FOR IgA NEPHROPATHY
We are still short of evidence …..
So there is room for your own opinion …..