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Dr. DeVries:
This is CE with the GLC, and I'm Dr. An DeVries. Joining me today, we have Dr. Jörg Latus and Dr. Chee Kay Cheung.

Now that we have the updated KDIGO guidelines and a broad range of the emerging therapies, I thought perhaps that in this episode we could focus a little bit on what the future holds for IgAN care.

Jörg, let's begin with you.

Dr. Latus:
Yeah, thanks a lot, An. I think the future of IgA nephropathy is incredibly exciting because we are moving beyond simply slowing disease progression to targeting the disease through multiple complementary mechanisms.

And I would like to start very easy. Let's talk about the FIND-CKD trial, very recently published and presented at the ERA in Glasgow, where they could show that finerenone reduces proteinuria and preserves eGFR, even in patients with IgA nephropathy.

Looking to the future, maybe the CD38 antibodies coming up. Of course, in the future, IgA-degrading enzymes that could rapidly remove pathogenic IgA-containing immune complexes.

So that's the future. But I believe it's very important now to make an early diagnosis of our patients. We are very often too late. Then, of course, we should use combination therapy, as were recommend by the guideline.

Dr. DeVries:
And what about you, Chee Kay?

Dr. Cheung:
So I think that the future for IgA nephropathy care is very exciting, and we now have a number of very promising therapies that are emerging or newly approved for the treatment of IgA nephropathy.

The goal of our treatment has to be to prevent kidney failure in all of our patients. And in order to do so, we're going to need a much better idea of how to individualize our treatment approach, how to detect our patients much earlier in their disease course, and determine what part of the pathogenesis is active at a particular time in order to best individualize treatments.

And I think over the course of our patients' lifetime, it's likely that we're going to have to cycle through different treatment approaches. And in order to better do that, we need better biomarkers that are beyond proteinuria and eGFR, so biomarkers that really truly reflect the underlying disease pathway and activity at that moment in time.

So I think with the emergence of all these clinical trials, new therapies, we're going to be able to better understand the underlying disease process and which patients may respond and which may not. And hopefully with these new tools that we have, we're going to be able to prevent kidney failure in the lifetime of our patients and be able to much better treat our patients in the near future.

Dr. DeVries:
Well, if we look forward in IgAN care, I think the real challenge for us clinicians is not the lack of options, but exactly the opposite. We are entering an era where multiple targeted therapies are becoming available, each acting on different parts of the disease pathway. And that sounds promising, but at the bedside it actually makes decision-making much more complex. So in my view, the key message is not every patient should receive every drug.

And the first question is then what is really driving the disease in this specific patient that is sitting in front of me? Is it predominantly active inflammation, ongoing immune activation with potentially reversible injury, or are we dealing mainly with chronic established damage, where the window for modifying the trajectory may already be limited?

And another important issue is, I think, the dynamics of the disease. Is this a smoldering course, slowly progressing over years, or is this a rapidly evolving disease, where early and decisive intervention is crucial?

So those are very different clinical scenarios, and I think they should lead to different therapeutic strategies.

Now, it's easy for me to say it, but in practice I think it's not always that straightforward. And the current tools that we have available to assess activity versus chronicity or to predict the trajectory, they are imperfect. Biomarkers are emerging, but as you know, they are not yet fully integrated into routine care, and even histology provides only a snapshot in time.

So ultimately, the future of IgAN care will depend not just on having more drugs, but on becoming better at choosing the right drug for the right patient at the right moment in the disease course.

And that's all the time we have today. So thank you for joining us.

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