Chee Kay Cheung MBChB PhD, is a consultant nephrologist and honorary senior lecturer at the University of Leicester.

Chee Kay Cheung, MBChB, PhD

IgAN Risk, Proteinuria Targets, and KDIGO Updates, With Chee Kay Cheung, MBChB, PhD

The management of IgA nephropathy (IgAN) is undergoing a rapid transformation, driven by a wave of emerging therapies and a deeper understanding of disease progression.

Historically, treatment strategies were constrained by limited options and an imprecise ability to identify which patients were most at risk for kidney decline. The latest update from Kidney Disease: Improving Global Outcomes (KDIGO) reflects a significant shift that moves the field toward more nuanced risk stratification, lower treatment targets, and a growing emphasis on targeted and combination therapies.

 at the World Congress of Nephrology (WCN) Conference in Yokohama, Japan, Chee Kay Cheung, MBChB, PhD, a consultant nephrologist and honorary associate professor at the University of Leicester, noted that one of the most important gaps in prior guidance was the lack of clarity around high-risk patients, with earlier definitions relying heavily on persistent proteinuria despite renin-angiotensin system inhibition.

“Now we have very much an expanding treatment landscape with the development of new targeted therapies for IgA nephropathy… which has meant that the guidelines have had to be revised and continue to be revised to accommodate these exciting developments,” he said.

Risk assessment has also evolved. Cheung points to the IgAN prediction tool as a valuable resource for estimating short- to medium-term risk—up to 7 years—based on large patient cohorts. However, he emphasizes that this falls short of capturing the lifelong trajectory of a disease often diagnosed in patients in their 30s or 40s. As a result, he highlights the need for improved tools that can better predict long-term outcomes and guide therapeutic decision-making.

One of the most notable changes in the updated guidance is a shift in proteinuria targets. Drawing on data from international registries, Cheung notes that even patients with proteinuria between 0.5 and 1 gram per day face a meaningful risk of progression, with approximately 30% advancing to kidney failure within a decade. In response, the guidelines now advocate for reducing proteinuria as much as possible, ideally < 0.3 grams per day.

Cheung also underscores the guideline’s new framework, which categorizes therapies into those targeting upstream immune mechanisms and those addressing downstream consequences of kidney injury. Despite this progress, he stresses that evidence supporting combination approaches remains limited. Determining how best to combine or sequence therapies and ensuring access to these treatments represents a critical unmet need.

Looking ahead, Cheung describes an increasingly complex but promising therapeutic landscape. With additional agents entering clinical use and evolving guidance on their placement, he emphasizes that optimizing treatment strategies will be central to improving long-term outcomes for patients with IgAN.

“I think it's a very exciting time in IgA nephropathy, and there are more treatments coming. These all look very promising in terms of tolerability, in terms of efficacy, and where we place these treatments is going to be a key question in the future as well.”

include Travere Therapeutics, Alexion, Alpine Immune Sciences, Calliditas Therapeutics, CSL Vifor, Novartis, Otsuka Pharmaceutical, Roche, Vera Therapeutics, and others.

Brooks A. KDIGO Releases Updated IgA Nephropathy, IgA Vasculitis Clinical Practice Guideline. HCPLive. September 18, 2025. Accessed March 28, 2026. 

https://www.hcplive.com/view/kdigo-releases-updated-iga-nephropathy-iga-vasculitis-clinical-practice-guideline

Videos

KDIGO updates in IgA nephropathy highlight lower proteinuria targets, improved risk tools, and an expanding landscape of targeted and combination therapies.

Future Directions in IgAN

In the closing discussion, the panel looks ahead to how IgA nephropathy treatment may continue to evolve. They highlight growing momentum toward earlier, mechanism-based intervention, particularly with B-cell pathway modulators that reduce production of galactose-deficient IgA1 at its origin. The group emphasizes the need for long-term data to understand durability of proteinuria response, immunoglobulin stability, and overall kidney function trajectories with extended use of these therapies. They also discuss the future role of biomarkers—including serum Gd-IgA1 levels, complement activation markers, and genetic signatures—which may eventually help match the right therapy to the right patient rather than relying primarily on proteinuria thresholds. Combination strategies are noted as an emerging research priority, especially pairing supportive care with targeted immunomodulation. The panel closes by expressing optimism that continued collaboration among clinicians, researchers, and patients will meaningfully improve outcomes and reduce progression to kidney failure over time.

In the closing discussion, the panel looks ahead to how IgA nephropathy treatment may continue to evolve.

Evolving Therapeutic Strategies and Real-World Application in IgAN

This episode focuses on translating clinical evidence into everyday treatment decisions. The panel emphasizes that the expanding therapeutic landscape requires individualized care, balancing disease severity, patient comorbidities, and willingness to engage in ongoing monitoring. They discuss how clinicians might choose between targeted-release budesonide, dual endothelin/angiotensin receptor blockade (e.g., sparsentan), and B-cell modulators, depending on proteinuria level, risk of progression, and tolerance profiles. Real-world considerations such as clinic workflow, infusion vs. injection preferences, and patient adherence are highlighted. The group stresses the importance of shared decision-making, noting that treatment choices are not solely algorithmic but influenced by patient goals and lifestyle. They conclude that as more agents become available, clinicians must be prepared to sequence and adjust therapy over time, rather than relying on a single long-term intervention.

This episode focuses on translating clinical evidence into everyday treatment decisions.

2025 KDIGO Guideline Update for IgAN

The KDIGO 2025 guidelines update emphasizes a more aggressive approach to treating IgA Nephropathy. The experts highlight key changes, including recognizing a broader range of patients as high-risk and lowering the proteinuria threshold for intervention to 500 milligrams. The guidelines now advocate for earlier biopsy and more comprehensive treatment strategies.

The panelists stress the importance of ambitious treatment goals, including reducing eGFR decline to less than one milliliter per minute per year and targeting proteinuria below 0.5 grams daily, ideally below 0.3 grams. The panel agrees that these goals were unimaginable just five years ago.

The guidelines recommend simultaneous treatment approaches, moving away from sequential therapies. They encourage targeting multiple disease mechanisms, including supportive care and immunological interventions. The experts emphasize the need to treat IgA Nephropathy as a lifelong condition, with the ultimate goal of protecting kidney function and avoiding dialysis.

The KDIGO 2025 guidelines update emphasizes a more aggressive approach to treating IgA Nephropathy.

Chee Kay Cheung, MBChB, PhD

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