Glucocorticoid use in low-risk IgAN

Primary GNeasy

A 35-year-old woman with IgA nephropathy has stable kidney function (eGFR 90 mL/min/1.73 m2) and proteinuria of 0.5 g/day on a maximally tolerated ACE inhibitor. According to the KDIGO 2025 guideline, what is the recommended approach to systemic glucocorticoid therapy?

  1. A.Start high-dose systemic glucocorticoid therapy
  2. B.Start a reduced-dose systemic glucocorticoid course
  3. C.Continue optimized supportive care without glucocorticoidsCorrect
  4. D.Switch to a different antihypertensive drug class

Explanation

Systemic glucocorticoids in IgAN are reserved for patients who remain at high risk of progression—generally proteinuria persistently above ~0.75-1 g/day despite ~90 days of optimized supportive care—because of their infection and metabolic toxicity (TESTING trial). This patient has stable GFR and proteinuria of only 0.5 g/day (already at the guideline target of <0.5-0.3 g/day), so glucocorticoids are not indicated; the correct approach is to continue optimized supportive care (maximally tolerated RASi, BP/CV-risk control, SGLT2 inhibitor). Switching antihypertensive classes is unnecessary.

Why each option

A.
High-dose glucocorticoids are not indicated for low-risk, stable IgAN with proteinuria at target.
B.
Even reduced-dose steroids are reserved for persistent high-risk proteinuria despite optimized supportive care.
C.
Correct. With stable GFR and proteinuria ~0.5 g/day, continue optimized supportive care without glucocorticoids.
D.
There is no reason to switch away from the RASi, which is first-line therapy.

Reference: KDIGO 2025 IgAN/IgAV Guideline, Kidney International 2025; Lv J, et al. (TESTING) JAMA 2022.

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