What is your recommended sequence of therapies for achieving optimal proteinuria reduction in IgA nephropathy, especially in light of the recent approvals of sparsentan, delayed-release budesonide, and iptacopan?

I am actually quite persistent with conservative therapies first - I push an ARB or ACE inhibitor in an effort to get the proteinuria under 1 gram per day, or ideally 0.75 gram per day. I favor stronger ARBs such as olmesartan or azilsartan over weaker ones such as losartan or valsartan, and really ...

When approaching treatment for a new diagnosis of IgAN, it is important to look at the presentation and the biopsy findings before considering treatment. If the patient has the classical presentation of proteinuria with hematuria (with/without low GFR) and kidney biopsy with mesangial hypercellulari...

This question depends a great deal on the patient's trajectory and clinical features. I always start with ACEI or ARB, and uptitrate as rapidly as tolerated. I then add an SGLT2i, though I may delay this if we plan to add immunosuppression. In a patient with aggressive/active disease (based on biops...