IgA nephropathy: a disease in search of a large-scale clinical trial to reliably inform practice.

ue to its frequency, IgA nephropathy has attracted significant scientific interest. Reearch has mainly covered the natural history of isease, predictive factors, and pathogenesis. lthough IgA nephropathy was first identified as he pathological correlate of “benign recurrent ematuria,” it is now recognized that it is not enign, with about 15% to 40% of patients eveloping kidney failure within 20 years of idney biopsy. Identification of effective treatments for IgA ephropathy has posed challenges for the renal ommunity, and randomized trials like the one escribed by Lv et al in this issue of the Amerian Journal of Kidney Diseases are welcome dditions to a sparse evidence base. Lv et al provide the results of a trial of the ombined effects of the glucocorticosteroid predisone and the angiotensin-converting enzyme ACE) inhibitor cilazapril versus an ACE inhibior alone in patients with IgA nephropathy. A otal of 63 patients (33 to combination therapy nd 30 to ACE inhibitor alone) were randomized n the study. Key results were that the risk of a 0% increase of serum creatinine (what they eferred to as kidney “death”) was significantly ower with combination therapy than with ACE nhibition alone (1 out of 33 events in the combiation group versus 7 out of 30 in the ACE nhibitor alone group; relative risk [RR], 0.13; 5% confidence interval [CI], 0.02 to 0.99). At 4 months from trial initiation, kidney survival as 96.6% in the combination therapy group ersus 75.7% in the ACE inhibition alone group. hose in the combination therapy group also had more rapid and stable reduction in proteinuria han those in the ACE inhibition alone group. he authors suggested that the addition of gluocorticosteroids to ACE inhibitors provided aditional benefit compared to ACE inhibition lone, although they pointed out that their study as a pilot only and a much larger study needs to e conducted. Strengths of the trial include random allocaion of patients and the reporting of results in the