A 28-year-old man develops nephrotic syndrome: proteinuria 8 g/day, serum albumin 1.8 g/dL, oedema. Renal biopsy shows diffuse mesangial IgA deposits with crescents in 40% of glomeruli, fibronectin staining, and segmental endocapillary proliferation. MEST-C Oxford score is M1E1S1T1C2. He has serum creatinine 2.4 mg/dL. Current KDIGO 2021 guidelines suggest which induction therapy?
- A ACE inhibitor alone is sufficient
- B Cyclophosphamide and corticosteroids (like for ANCA vasculitis)
- C Tonsillectomy is the recommended treatment for IgA nephropathy with crescents
- D Immunosuppression with corticosteroids is warranted given high-risk features and crescents; SGLT2 inhibitor should also be added ✓
Explanation
This is high-risk IgA nephropathy with crescents (C2 = ≥25% crescents in Oxford MEST-C) and nephrotic-range proteinuria — significant predictors of renal function decline. KDIGO 2021 Glomerulonephritis guidelines recommend optimised supportive care (RAAS blockade, BP <130/80) as first-line, but add that corticosteroids (6-month course) may be considered in patients at high risk of progression (proteinuria >1 g/day despite 3 months of optimised supportive care). SGLT2 inhibitors (e.g., dapagliflozin — DAPA-CKD trial) are now recommended for CKD with proteinuria to reduce progression. Crescent IgAN with rapid progression may warrant IV methylprednisolone.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.