Pediatric IgA Nephropathy Medication
- Author: Mohammad Ilyas, MD, FAAP; Chief Editor: Craig B Langman, MD more...
The risks and benefits of immunoglobulin A (IgA) nephropathy (IgAN) treatment with steroids, fish oil, ACE inhibitors, or ARB and immunosuppressant (eg, mycophenolate mofetil) should be discussed with patients and parents. These agents theoretically may protect the kidney and prolong the interval between onset and renal failure.
Anti-inflammatory and immunosuppressive agents
These agents elicit anti-inflammatory and immunosuppressive properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli and reduce immune-mediated renal injury resulting from IgA deposition in the kidney.
Prednisone (Deltasone) or methylprednisolone (Solu-Medrol)
Potent anti-inflammatory and immunosuppressive therapy with corticosteroids has been reported to reduce the rate of progression of IgAN.
Several investigators have suggested that fish oil delays the progression of renal disease. The precise mechanism is not fully understood.
May be beneficial by decreasing mediators of glomerular injury and decreasing platelet aggregation. Omega-3 fatty acids may be used as nondrug dietary supplements in early high-risk coronary disease and IgAN.
Angiotensin-converting enzyme (ACE) inhibitors
In 1980, captopril became the first ACE inhibitor approved by the US Food and Drug Administration. Subsequently, at least 40 compounds have been identified. ACE inhibitors reduce the production of angiotensin II, thereby, lowering intraglomerular filtration pressure, reducing proteinuria, and slowing the decline of glomerular function in several chronic renal diseases. All ACE inhibitors probably have similar renal protective effects.
Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in increased levels of plasma renin and a reduction in aldosterone secretion.
Angiotensin Receptor Antagonist
Angiotensin II receptor antagonists may be considered if ACE inhibitors are not tolerated.
Angiotensin II receptor antagonist that blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II. May induce a more complete inhibition of the renin-angiotensin system than ACE inhibitors, does not affect the response to bradykinin, and is less likely to be associated with cough and angioedema. For patients unable to tolerate ACE inhibitors.
Angiotensin II receptor blockers reduce blood pressure and proteinuria, protecting renal function, and delaying onset of end-stage renal disease.
Limited data exist for use of mycophenolate mofetil (MMF). A short course (< 6 months) of MMF in patients with persistent proteinuria (>1.5 g/d) and well-maintained renal function (serum creatinine < 1.5 mg/dL) despite maximum ACE inhibitor/ARB therapy may be considered in patients with mild renal histopathology on biopsy.
Inhibits inosine monophosphate dehydrogenase (IMPDH) and suppresses de novo purine synthesis by lymphocytes, thereby inhibiting their proliferation. Inhibits antibody production.
Two formulations are available and are not interchangeable. The original formulation, mycophenolate mofetil (MMF, Cellcept) is a prodrug that once hydrolyzed in vivo, releases the active moiety mycophenolic acid. A newer formulation, mycophenolic acid (MPA, Myfortic) is an enteric-coated product that delivers the active moiety.
D'Amico G. Natural history of idiopathic IgA nephropathy and factors predictive of disease outcome. Semin Nephrol. 2004 May. 24(3):179-96. [Medline].
Li LS; Liu ZH. Epidemiologic data of renal diseases from a single unit in China: analysis based on 13,519 renal biopsies. Kidney Int. 2004 Sep. 66(3):920-3. [Medline].
Novak J, Julian BA, Mestecky J, Renfrow MB. Glycosylation of IgA1 and pathogenesis of IgA nephropathy. Semin Immunopathol. 2012 May. 34(3):365-82. [Medline].
Segarra A. [Progress in understanding the pathogenesis of IgA nephropathy: new perspectives for the near future?]. Nefrologia. 2010. 30(5):501-7. [Medline].
Narita I, Gejyo F. Pathogenetic significance of aberrant glycosylation of IgA1 in IgA nephropathy. Clin Exp Nephrol. 2008 Oct. 12(5):332-8. [Medline].
Suzuki H, Kiryluk K, Novak J, et al. The pathophysiology of IgA nephropathy. J Am Soc Nephrol. 2011 Oct. 22(10):1795-803. [Medline].
Yu HH, Chu KH, Yang YH, et al. Genetics and immunopathogenesis of IgA nephropathy. Clin Rev Allergy Immunol. 2011 Oct. 41(2):198-213. [Medline].
Novak J, Moldoveanu Z, Julian BA, et al. Aberrant glycosylation of IgA1 and anti-glycan antibodies in IgA nephropathy: role of mucosal immune system. Adv Otorhinolaryngol. 2011. 72:60-3. [Medline].
[Guideline] Cattran DC, Coppo R, Cook HT, et al. The Oxford classification of IgA nephropathy: rationale, clinicopathological correlations, and classification. Kidney Int. 2009 Sep. 76(5):534-45. [Medline].
Lai FM, Szeto CC, Choi PC, et al. Characterization of early IgA nephropathy. Am J Kidney Dis. 2000 Oct. 36(4):703-8. [Medline].
Hasbargen JA, Copley JB. Utility of skin biopsy in the diagnosis of IgA nephropathy. Am J Kidney Dis. 1985 Aug. 6(2):100-2. [Medline].
Reich HN, Troyanov S, Scholey JW, Cattran DC. Remission of proteinuria improves prognosis in IgA nephropathy. J Am Soc Nephrol. 2007 Dec. 18(12):3177-83. [Medline].
Kunz R, Friedrich C, Wolbers M, Mann JF. Meta-analysis: effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease. Ann Intern Med. 2008 Jan 1. 148(1):30-48. [Medline].
Donadio JV Jr, Larson TS, Bergstralh EJ, Grande JP. A randomized trial of high-dose compared with low-dose omega-3 fatty acids in severe IgA nephropathy. J Am Soc Nephrol. 2001 Apr. 12(4):791-9. [Medline]. [Full Text].
Appel GB, Waldman M. The IgA nephropathy treatment dilemma. Kidney Int. 2006 Jun. 69(11):1939-44. [Medline].
Floege J, Eitner F. Present and future therapy options in IgA-nephropathy. J Nephrol. 2005 Jul-Aug. 18(4):354-61. [Medline].
Manno C, Torres DD, Rossini M, Pesce F, Schena FP. Randomized controlled clinical trial of corticosteroids plus ACE-inhibitors with long-term follow-up in proteinuric IgA nephropathy. Nephrol Dial Transplant. 2009 Dec. 24(12):3694-701. [Medline].
Ballardie FW, Roberts IS. Controlled prospective trial of prednisolone and cytotoxics in progressive IgA nephropathy. J Am Soc Nephrol. 2002 Jan. 13(1):142-8. [Medline].
Tumlin JA, Lohavichan V, Hennigar R. Crescentic, proliferative IgA nephropathy: clinical and histological response to methylprednisolone and intravenous cyclophosphamide. Nephrol Dial Transplant. 2003 Jul. 18(7):1321-9. [Medline].
Maes BD, Oyen R, Claes K, et al. Mycophenolate mofetil in IgA nephropathy: results of a 3-year prospective placebo-controlled randomized study. Kidney Int. 2004 May. 65(5):1842-9. [Medline].
Tang SC, Tang AW, Wong SS, Leung JC, Ho YW, Lai KN. Long-term study of mycophenolate mofetil treatment in IgA nephropathy. Kidney Int. 2010 Mar. 77(6):543-9. [Medline].
Frisch G, Lin J, Rosenstock J, Markowitz G, et al. Mycophenolate mofetil (MMF) vs placebo in patients with moderately advanced IgA nephropathy: a double-blind randomized controlled trial. Nephrol Dial Transplant. 2005 Oct. 20(10):2139-45. [Medline].
Cattran DC. Current status of cyclosporin A in the treatment of membranous, IgA and membranoproliferative glomerulonephritis. Clin Nephrol. 1991. 35 Suppl 1:S43-7. [Medline].
Béné MC, Faure GC, Hurault de Ligny B, de March AK. Clinical involvement of the tonsillar immune system in IgA nephropathy. Acta Otolaryngol Suppl. 2004 Dec. 10-4. [Medline].
Xie Y, Chen X, Nishi S, Narita I, Gejyo F. Relationship between tonsils and IgA nephropathy as well as indications of tonsillectomy. Kidney Int. 2004 Apr. 65(4):1135-44. [Medline].
Rasche FM, Schwarz A, Keller F. Tonsillectomy does not prevent a progressive course in IgA nephropathy. Clin Nephrol. 1999 Mar. 51(3):147-52. [Medline].
Coppo R, Roccatello D, Amore A, et al. Effects of a gluten-free diet in primary IgA nephropathy. Clin Nephrol. 1990 Feb. 33(2):72-86. [Medline].
Rostoker G, Desvaux-Belghiti D, Pilatte Y, et al. High-dose immunoglobulin therapy for severe IgA nephropathy and Henoch-Schönlein purpura. Ann Intern Med. 1994 Mar 15. 120(6):476-84. [Medline].
Krebs S, Omer B, Omer TN, Fliser D. Wormwood (Artemisia absinthium) for poorly responsive early-stage IgA nephropathy: a pilot uncontrolled trial. Am J Kidney Dis. 2010 Dec. 56(6):1095-9. [Medline].
Abe S. Pregnancy in IgA nephropathy. Kidney Int. 1991 Dec. 40(6):1098-102. [Medline].
Choy BY, Chan TM, Lai KN. Recurrent glomerulonephritis after kidney transplantation. Am J Transplant. 2006 Nov. 6(11):2535-42. [Medline].
Odum J, Peh CA, Clarkson AR, et al. Recurrent mesangial IgA nephritis following renal transplantation. Nephrol Dial Transplant. 1994. 9(3):309-12. [Medline].
Ponticelli C, Traversi L, Feliciani A, Cesana BM, Banfi G, Tarantino A. Kidney transplantation in patients with IgA mesangial glomerulonephritis. Kidney Int. 2001 Nov. 60(5):1948-54. [Medline].
Geddes CC, Rauta V, Gronhagen-Riska C, Bartosik LP, Jardine AG, Ibels LS. A tricontinental view of IgA nephropathy. Nephrol Dial Transplant. 2003 Aug. 18(8):1541-8. [Medline].
Szeto CC, Lai FM, To KF, et al. The natural history of immunoglobulin a nephropathy among patients with hematuria and minimal proteinuria. Am J Med. 2001 Apr 15. 110(6):434-7. [Medline].
Wakai K, Kawamura T, Endoh M, et al. A scoring system to predict renal outcome in IgA nephropathy: from a nationwide prospective study. Nephrol Dial Transplant. 2006 Oct. 21(10):2800-8. [Medline].
Alamartine E, Sabatier JC, Berthoux FC. Comparison of pathological lesions on repeated renal biopsies in 73 patients with primary IgA glomerulonephritis: value of quantitative scoring and approach to final prognosis. Clin Nephrol. 1990 Aug. 34(2):45-51. [Medline].
Rekola S, Bergstrand A, Bucht H. Deterioration of GFR in IgA nephropathy as measured by 51Cr-EDTA clearance. Kidney Int. 1991 Dec. 40(6):1050-4. [Medline].
Donadio JV, Bergstralh EJ, Grande JP, Rademcher DM. Proteinuria patterns and their association with subsequent end-stage renal disease in IgA nephropathy. Nephrol Dial Transplant. 2002 Jul. 17(7):1197-203. [Medline].