Who Gets What, When? Navigating Therapy Selection in IgA Nephropathy, With Corey Cavanaugh, DO

While the treatment landscape for IgA nephropathy (IgAN) has considerably expanded recently, clinicians continue to navigate how best to select and sequence these emerging therapies for their patients.

New breakthrough developments have brought treatment options well beyond traditional approaches, such as corticosteroids and supportive care, now encompassing complement inhibitors and APRIL/BAFF-targeting agents.

“On the immunosuppressive side, we still have corticosteroids, we still have targeted release… sort of the newer kids on the block, if you will, are the complement inhibitor… and then our anti April therapies that are numerous and rolling out. Those are the major ones we're fixating on,” ​​said Corey Cavanaugh, DO, an academic nephrologist at the Cleveland Clinic, in an interview with HCPLive. “The major question is, who gets what and when, and that still is… this is a matter of, just to be clear right off the bat, this is not necessarily evidence-based. This is all just opinion-based.”

The 2025 Kidney Disease: Improving Global Outcomes (KDIGO) updated IgAN guidelines marked a conceptual shift, recommending clinicians to initiate therapies targeting pathogenic IgA production simultaneously with those addressing the consequences of existing nephron loss, a dual-track approach departing from the traditional stepwise model. The guidelines also introduced a more stringent proteinuria target, with the goal of achieving <0.3 g/d.¹

For diagnosis and prognosis in IgAN, proteinuria and eGFR remain the only validated biomarkers to guide therapy selection in the continuously expanding therapeutic landscape. Combination regimens may offer additive benefits, but supporting evidence is still emerging, and there is no existing evidence-based framework for sequencing decisions yet.

Meaningful progress toward personalized therapy in IgAN will depend on identifying biomarkers which can guide which patients are most likely to benefit from complement inhibition, APRIL blockade, or targeted intestinal therapy with Nefecon.

“My personal preference is to avoid steroids as much as I can, whether it be targeted release or oral systemic corticosteroids. That's just my personal preference. When we have a steroid-sparing option, I'm going to choose it. Young people don't like steroids… like anyone else.”

Current evidence supports guideline recommendations to avoid corticosteroid therapy in those with an eGFR <30 mL/min/1.73 m² and the suggestion to exercise cautiously in individuals at high risk of developing corticosteroid-related side effects, such as those with diabetes mellitus, obesity, latent infections, active peptic ulceration, uncontrolled psychiatric illness, and severe osteoporosis.²

Editor’s Note: Cavanaugh reports relevant disclosures with Otsuka Pharmaceutical Co, Novartis Pharmaceutical Corporation, Travere Therapeutics, and Vera Therapeutics.

References

1. Floege J, Barratt J, Cook HT, et al. Executive summary of the KDIGO 2025 Clinical Practice Guideline for the Management of Immunoglobulin A Nephropathy (IgAN) and Immunoglobulin A Vasculitis (IgAV). Kidney international. 2025;108(4):548-554. doi:https://doi.org/10.1016/j.kint.2025.04.003

2. Floege J, Barratt J, Cook HT, et al. Executive summary of the KDIGO 2025 Clinical Practice Guideline for the Management of Immunoglobulin A Nephropathy (IgAN) and Immunoglobulin A Vasculitis (IgAV). Kidney international. 2025;108(4):548-554. doi:https://doi.org/10.1016/j.kint.2025.04.003