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Abstract Background and Aims Immunoglobulin A nephropathy (IgAN) is the most common form of primary glomerulonephritis worldwide. Due to the often progressive nature of IgAN, patients generally face a poor prognosis if the condition is not appropriately controlled. Current treatment recommendations focus on disease management through the use of optimised supportive care, including use of an angiotensin-converting enzyme inhibitor (ACEi) and/or angiotensin receptor blocker (ARB). A physician questionnaire and patient chart review was conducted to investigate the real-world management of IgAN in five European countries. Method Between 21 December 2022 and 6 February 2023, physicians from France, Germany, Italy, Spain and the UK completed a questionnaire on IgAN management, and patient charts from their centres were analysed. Physicians included had to spend 40% of their time in a clinical setting, and have been in practice between 2 and 40 years. Physicians had to have ≥50 CKD stage 1–4 patients under their management, including ≥4 non-dialysis IgAN patients. Patient charts included in the analysis were required to be from patients ≥12 years of age, diagnosed with IgAN and not on dialysis, with an estimated glomerular filtration rate (eGFR) ≥15 mL/min/1.73 m2. Results A total of 261 physicians answered the questionnaire on IgAN management and completed chart audits on 473 of their most recently seen patients. Charts included in the audit were predominantly from male (71%), Caucasian (78%) patients. The mean age of patients was 47 years and 76% were in CKD stage 3 or later. At referral, 66% of patients were receiving an ACEi and/or ARB, 21% were receiving another antihypertensive agent and 6% were taking a sodium-glucose cotransporter 2 inhibitor (SGLT2i). Most patients (88%) had undergone ≥1 kidney biopsy. At the time of initial biopsy, average eGFR was 51.0 mL/min/1.73 m2 and proteinuria was 2.7 g/day. Of patients who had a biopsy, 73% had a mesangial hypercellularity (M), endocapillary hypercellularity (E), segmental glomerulosclerosis (S), tubular atrophy/interstitial fibrosis (T) and crescents (C) (MEST-C) score available. Due to biopsy results, 29% of patients initiated systemic steroids and 10% started an SGLT2i. On average, IgAN patients are prescribed five medications, with the number of medications increasing with age. The large majority of patients (92%) were taking an ACEi and/or ARB at the time of the most current visit; prescriptions with an ACEi and/or ARB included combination with an SGLT2i only (36%), with a systemic steroid only (10%), and with both an SGLT2i and a systemic steroid (5%). Less than half (41%) of patients were prescribed an ACEi and/or ARB alone. An ACEi and/or ARB were considered first-line therapy by 81% of physicians. Systemic steroids and SGLT2is were largely thought of as later line treatment options. The majority of physicians (66%) believed that their patients were completely adherent to their treatment regimen. Notably, over one-third (35%) of patients were on second-line therapy or later, with drivers of treatment change including increased proteinuria (31%), decreased eGFR (26%) and side effect management (15%). Over half (54%) of physicians were not completely satisfied with their patients’ overall response to treatment. Physicians anticipated that 74% of their patients would eventually progress to dialysis. Conclusion Many treating physicians are not satisfied with current treatment options for IgAN, with increasing levels of proteinuria, eGFR decline and side effects driving treatment change. Overall, this study indicates that there is a need for more effective and safe treatments for IgAN to prevent disease progression and improve prognosis.
Csomor et al. (Wed,) studied this question.