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Crescentic IgA Nephropathy — RACP Adult Medicine MCQ

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HardNephrologyCrescentic IgA NephropathyRACP Adult Medicine

A 45-year-old Aboriginal man from the Torres Strait Islands presents with a rapidly progressive glomerulonephritis. Renal biopsy shows IgA nephropathy with crescentic change. His eGFR is 25 mL/min/1.73 m² and proteinuria is 5 g/day. He is on maximum-dose ACEi. What treatment regimen is indicated for rapidly progressive IgA nephropathy with crescents?

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Correct answer: B — Plasma exchange

Rapidly progressive (crescentic) IgA nephropathy with declining eGFR requires immunosuppression beyond supportive care alone. Corticosteroids (as per the TESTING trial protocol) are indicated. For crescentic IgAN (>50% crescents), treatment is often intensified to resemble ANCA vasculitis protocols: pulsed IV methylprednisolone followed by oral prednisolone ± cyclophosphamide. Aboriginal and Torres Strait Islander peoples have disproportionately high rates of kidney disease and may present with more aggressive IgAN phenotypes. SGLT2i and ACEi are important adjuncts but insufficient alone for crescentic disease.

Reference: KDIGO – 2024 – IgA Nephropathy; KHA-CARI – 2024 – Indigenous Kidney Health