SGLT2 inhibitors in CKD with IgAN

Primary GNmedium

A 45-year-old man with IgA nephropathy and CKD stage 3a (eGFR 55 mL/min/1.73 m2) has persistent proteinuria of 1.0 g/day on a maximally tolerated ACE inhibitor. According to the KDIGO 2025 guideline, which add-on therapy best reduces proteinuria and slows CKD progression?

  1. A.Add an SGLT2 inhibitor to current therapyCorrect
  2. B.Start cyclophosphamide-based immunosuppression
  3. C.Start high-dose systemic glucocorticoid therapy
  4. D.Restrict dietary protein to 0.4 g/kg/day

Explanation

KDIGO 2025 recommends adding an SGLT2 inhibitor to maximally tolerated RAS inhibition in IgAN with CKD and residual proteinuria to lower proteinuria and slow GFR decline (DAPA-CKD, EMPA-KIDNEY). Cyclophosphamide is only for rapidly progressive/crescentic disease, high-dose glucocorticoids are not indicated for stable moderate proteinuria (and reduced-dose regimens are reserved for persistent high-risk proteinuria after optimized supportive care), and very-low-protein diets are not recommended and risk malnutrition.

Why each option

A.
Correct. SGLT2 inhibitors are guideline-recommended add-on therapy for IgAN with CKD and residual proteinuria.
B.
Cyclophosphamide is reserved for rapidly progressive/crescentic IgAN.
C.
High-dose glucocorticoids are not appropriate for stable moderate proteinuria.
D.
Severe protein restriction is not recommended and risks malnutrition.

Reference: KDIGO 2025 IgAN/IgAV Guideline, Kidney International 2025; DAPA-CKD (N Engl J Med 2020); EMPA-KIDNEY (N Engl J Med 2023).

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