Optimized Supportive Care in IgAN: Salt, Blood Pressure, and Proteinuria

This episode, "Optimized Supportive Care in IgAN: Salt, Blood Pressure, and Proteinuria," features Dr. Fervenza pressing on the fundamentals.

Dr. Fervenza opens by challenging the goal of driving proteinuria to zero. He calls that target faulty, arguing it derives from the RaDaR study population rather than all IgA nephropathy patients. He notes RaDaR enrolled patients already selected by GFR and proteinuria thresholds, biasing the outcome. He points out the study did not report blood pressure control, biopsy findings, or immunosuppression use. Dr. Fervenza then details his own supportive-care approach at Mayo. He measures 24-hour creatinine clearance, 24-hour proteinuria, and 24-hour urine sodium for every patient. He describes patients with 800 milligrams of proteinuria whose urine reveals 400 millimoles of sodium. In such cases, he argues, the intervention is cutting salt, not adding immunosuppression, and proteinuria falls dramatically. Dr. Fervenza then reframes the disease itself, praising industry for finally treating IgA nephropathy as inflammatory. He argues hematuria, not just proteinuria, deserves attention. He cites preliminary data that anti-APRIL and dual anti-APRIL/BAFF agents produce roughly 80% disappearance of hematuria. He asserts these are the only drugs shown so far to stabilize or improve GFR, while others merely slow decline. He cautions clinicians against escalating immunosuppression in a patient left with 500 milligrams of proteinuria and no hematuria. Doing so, he warns, risks overtreatment. Dr. Rovin agrees the RaDaR study is only one dataset, but notes other populations echo its concerns about proteinuria. He affirms that he too measures 24-hour urine sodium and finds salt intake astounding, along with the benefit of reducing it. He concludes the specialty has been proteinuria-centric for its entire history and must move beyond that single measure.

In "How You Lower Proteinuria in IgAN: Immunologic vs Hemodynamic," the panel will draw a sharp distinction between lowering proteinuria immunologically and lowering it by reducing hyperfiltration.