Introduction
What is the treatment dilemma for Japanese nephrologists?
Are the annual urinary screening system (kenshin) and kidney biopsies useful?
The desire of patients and their families versus insufficient clinical evidence
A risk of overtreatment versus a lost ‘golden period’
Preservation of kidney function versus induction of clinical remission
What is the overall natural history of IgA nephropathy?
Chauveau and Droz | |
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Observation period | 20 years |
Number of patients | 74 |
Spontaneous remission | 29.7% |
Persistent urinary abnormalities without aggravation of kidney function | 32.4% |
End-stage renal failure | 37.8% |
Do patients with mild or early-stage IgA nephropathy recover or progress?
Shen et al. | Szeto et al. | |||
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Daily proteinuria | <0.03 g | >0.03, <0.3 g | Total (<0.3 g) | <0.4 g |
Observation period | 92 ± 28 months | 84 (14–180) months | ||
Number of patients | 50 | 85 | 135 | 72 |
Disappearance of hematuria | 22% | 6% | 12% | 14% |
Increased proteinuria (>1.0 g) | 6% | 42% | 29% | 33% |
Hypertension | 12% | 44% | 32% | 19% |
Decreased kidney function | 4% | 29% | 20% | 7% |
Does oral prednisolone therapy improve the outcome of IgA nephropathy?
Kobayashi et al. | Pozzi et al. | |
---|---|---|
Study design | Retrospective cohort study | Randomized controlled trial |
Treatment groups | Oral steroid versus control | Steroid pulse versus control |
Daily proteinuria | 1.0–2.0 g | 1.0–3.5 g |
CCr | 85 ± 14 versus 88 ± 13 | 70–111 ml/min (mean 91) |
CCr (≥70 ml/min) | Renal survival rate: 100 versus 80% at 5 years (ns) 80 versus 34% at 10 years (p < 0.001) | Non-progression rate: 97 versus 53% at 10 years (p = 0.0003) Urinary complete remission rate: ~10% in the steroid pulse group |
Does methylprednisolone pulse therapy preserve kidney function?
Does tonsillectomy stop the progression of renal failure?
Rasche et al. | Xie et al. | Chen et al. | |
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Treatment groups | Tonsillectomy versus control | Tonsillectomy versus control | Tonsillectomy versus control |
Daily proteinuria | (>1.5 g) 9/16 versus 25/39 | 0.91 ± 1.12 versus 1.09 ± 1.43 | 0.973 ± 0.924 versus 1.17 ± 1.02 (>1.0 g) 19/54 versus 23/58 |
sCr | 2.4 ± 2.8 versus 1.6 ± 0.9 | 1.07 ± 0.27 versus 1.07 ± 0.31 | 1.08 ± 0.33 versus 1.07 ± 0.275 |
CCr (≥70 ml/min) | Not available | Renal survival rate: 98 versus 89% at 10 years (ns) 90 versus 63.8% at 20 years (efficacy at 20 years; p < 0.05) | CR rate: 46.3 versus 27.5% (p = 0.04) Relapse rate: 38.9 versus 48.3% (p = 0.317) Not improved rate: 16.7 versus 34.5% (p = 0.031) ESRD at less than 15 years: 3.7 versus 12.1% (p = 0.059) |
CCr (<70 ml/min) | Renal survival rate: 40% and 60% at 10 years (ns) | Not available | Not available |
Does TSP induce CR?
Hotta et al. | Miura et al. | |
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Study design | Retrospective cohort study | Multicenter retrospective study |
Patients’ background | Daily proteinuria: mean ± SD: 1.38 ± 1.17 g sCr: 0.96 ± 0.22 mg/dl | |
CCr (>70 ml/min) | TSP versus steroid: CR rate: 59.7 versus 35.3%; p < 0.01 | CR rate: 54.1% CR versus non-CR: Years from diagnosis until TSP therapy: mean ± SD 5.3 ± 5.2 versus 6.9 ± 6.8 (p = 0.02) Daily proteinuria 0.8 ± 0.8 versus 1.5 ± 1.6 (p < 0.0001) sCr 0.87 ± 0.34 versus 0.99 ± 0.40 (p = 0.006) |
CCr (<70 ml/min) | Sato et al. Retrospective cohort study TSP versus steroid versus control Daily proteinuria: mean ± SD: 2.2 ± 1.9 versus 1.9 ± 0.9 versus 0.9 ± 0.6 CCr: 45.0 ± 15.1 versus 44.4 ± 14.9 versus 48.6 ± 19.7 Renal survival rate at 8 years: 82.8 versus 51.0 versus 45.1%: p = 0.017 (No significant difference in patients with sCr >2.0 mg/dl) | Not available |
Do all patients with IgA nephropathy respond to TSP?
Do prospective controlled studies confirm the efficacy of TSP?
Komatsu et al. | Miyazaki et al. | |
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Study design | Prospective controlled trial | Randomized controlled trial |
Treatment groups | TSP versus steroid pulse | TSP (40 patients) versus steroid pulse (40 patients) |
Daily proteinuria (mean ± SD) | 1.06 ± 1.01 versus 1.41 ± 1.05 | Between 1.0 and 3.5 g |
sCr | 0.72 ± 0.29 versus 0.84 ± 0.30 | sCr <1.5 mg/dl |
CCr (>70 ml/min) | CR rate: 21/34 (61.8%) versus 3/17 (17.6%) (p < 0.001) | Forthcoming |