A 28-year-old man presents with sudden onset gross hematuria 2 days after an upper respiratory tract infection. His blood pressure is 130/85 mmHg, creatinine 1.1 mg/dL. Urinalysis shows RBC casts. Renal biopsy immunofluorescence shows mesangial IgA deposits. What is the most important long-term prognostic predictor in this condition?

• A Macroscopic hematuria episodes
• B Age at onset
• C Serum IgA levels at diagnosis
• D Degree of proteinuria (>1 g/day) and hypertension ✓

Explanation

IgA nephropathy is the most common primary glomerulonephritis worldwide. The most important adverse prognostic factors are persistent proteinuria >1 g/day, hypertension, and impaired renal function at presentation. Macroscopic hematuria paradoxically correlates with a better prognosis. The Oxford MEST-C pathological classification also guides prognosis. Serum IgA levels do not predict prognosis. SGLT2 inhibitors (sparsentan) have recently shown benefit in reducing proteinuria in IgAN.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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