Navigating Novel Pathways and Treatment Decisions in IgA Nephropathy - Episode 4
2025 KDIGO Guidelines in IgAN: Treatment Selection and Overcoming Inertia
The 2025 KDIGO guidelines endorse treating both the IgA pathway and supportive care from the start. Dr. Geara and Dr. Cheung discuss treatment inertia, early diagnosis, and matching each agent to patient risk and preferences.
Dr. Geara explains that the major change in the 2025 KDIGO guidelines is simultaneous treatment of the IgA pathway and supportive care. In his clinic, patients now start targeted therapy and supportive care together from the outset. The guidelines also give him leverage with insurers and reassure patients that they receive the current standard of care. Choosing an agent from each pathway is harder, and he emphasizes an individual approach based on risk factors, demographic profile, and each drug's adverse effects.
Dr. Cheung names access as the key barrier, then points to familiarity with immune-targeting therapies and the need to educate patients and colleagues about monitoring. Treatment inertia persists in the UK, partly from a perception that IgAN progresses slowly. Registry data from the UK, US, Europe, and Asia show otherwise, and Dr. Cheung urges earlier diagnosis. Dr. Wadhwani adds that time of diagnosis is not time of onset, and many patients have already lost half their kidney function.
For selection, Dr. Geara says all six approved agents reduce proteinuria and separate from placebo on eGFR, though the degree differs. He credits sibeprenlimab and atacicept with the most durable eGFR stability, sparsentan with strong proteinuria effects, and targeted-release budesonide with less suppression. Complement inhibitors act quickly on inflammation.
He favors an APRIL or BAFF/APRIL agent for maintenance. For a highly inflammatory presentation, he might start a complement inhibitor and transition later. Dr. Wadhwani adds that patient preferences matter, including willingness to inject, accept immunosuppression, or take steroids again. Dr. Wadhwani agrees that the expanding menu of options is a welcome challenge, but one that demands an individualized conversation with each patient.
The next episode in this series, "Targeting BAFF and APRIL in IgAN: Mechanisms and VISIONARY eGFR Data," features Dr. Cheung explaining the rationale for B-cell modulation, followed by Dr. Geara's read of the VISIONARY results.
