Nephrol Dial Transplant (2004) 19: 1041-1046
Nephrol Dial Transplant Vol. 19 No. 5 © ERA-EDTA 2004; all rights reserved
Editorial Comment
IgA nephropathy treatment 25 years on: can we halt progression? The evidence base
Department of Nephrology, Manchester Royal Infirmary, Manchester, UK
Correspondence and offprint requests to: F. W. Ballardie, Consultant Physician and Nephrologist, Department of Nephrology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. Email: francis.ballardie@cmmc.nhs.uk
Keywords: evidence-based medicine; evidence-base standards; IgA nephropathy treatment; trial design
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Introduction |
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Berger's disease, considered benign in the classic descriptions and for a decade, is perhaps the most challenging primary glomerulonephritis in which to evaluate pathogenesis, its impact on renal services and to discover effective treatments for progressive forms, yet these remain inchoate 25 years after the first trial constructs [1]. A wide variety of treatments has been attempted [2] and most facets of immune perturbations, blood rheology, glomerular inflammation and haemodynamics addressed. Three reasons suggest why we remain perplexed: (i) the timescale of progression of commoner forms (a decade or more) means studies have addressed parameters, notably proteinuria, rather than loss of glomerular filtration rate (GFR) using ‘soft’ end-points (those subject to haemodynamic variables modifying residual function); (ii) studies in a disease as heterogeneous merit careful design, incorporating probability modelling to address pivotal questions, most importantly, retarding progression ‘primum non nocere’ [3] ;
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Trial strategies and evidence-base standards |
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Trial design in IgA nephropathy: small can be beautiful |
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Treatments: immunomodulatory |
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Corticosteroids
Cytotoxics
Tonsillectomy
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Modifying glomerular microdynamics |
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ACE inhibitors and angiotensin-II receptor blockers
Fish oils
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Treating cause, and consequences, of IgA nephropathy: balancing the issues |
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Recommendations for progressive IgA nephropathy |
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Moderate progressive disease
Slowly progressive disease
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Future trials: short-term therapy, long-term benefit? |
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