A 50-year-old man with IgA nephropathy (confirmed by biopsy showing mesangial IgA deposits) has proteinuria 2.8 g/day despite 3 months of maximal RAS blockade (ACE inhibitor + ARB optimization), eGFR 48 mL/min/1.73m², BP 128/78. Per 2023 KDIGO guidelines, what is the next recommended therapy?
- A Add immunosuppression with prednisolone
- B Add sparsentan (dual endothelin/angiotensin receptor antagonist)
- C Start cyclophosphamide + steroids (Oxford protocol)
- D Add SGLT2 inhibitor (dapagliflozin) ✓
Explanation
Per 2023 KDIGO IgA Nephropathy guidelines update, SGLT2 inhibitors (specifically dapagliflozin in DAPA-CKD trial, and canagliflozin in CREDENCE for CKD) are now recommended as adjunctive therapy for IgAN with eGFR ≥20 and proteinuria despite RAS blockade, given their renoprotective effects independent of glycemia. SGLT2 inhibitors reduce intraglomerular hypertension and proteinuria. Steroids carry significant risks and are reserved for high-risk patients (rapid progression). Sparsentan showed proteinuria reduction in PROTECT trial and received FDA approval for IgAN in 2023. However, SGLT2 inhibitors are the more accessible, guideline-endorsed first step in this scenario.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.