Rethinking KDIGO Guidance and Payer Models in the Era of Targeted IgA Nephropathy Therapies

Led by the moderator, the panelist examined targeted therapies for IgA nephropathy, which have gained regulatory approval, will result in future KDIGO updates shifting from a predominantly supportive-care and steroid-centric framework toward a risk-stratified, mechanism-based treatment algorithm. Proteinuria and eGFR thresholds may be refined to trigger earlier use of disease-modifying agents, particularly for patients with persistent proteinuria despite optimized RAAS blockade and SGLT2 inhibition. Guidance will also need to address sequencing and potential combination strategies across endothelin receptor antagonists, complement inhibitors, and mucosal-targeted steroids, with clearer definitions of treatment response and stopping rules. Incorporation of safety monitoring pathways and steroid-sparing approaches will be essential to reflect the improved tolerability profiles of newer agents.

For payers and health systems, IgA nephropathy should be viewed as a progressive, high-cost chronic disease where early intervention can reduce downstream expenditures related to dialysis, transplantation, and hospitalizations. Value assessments may need to emphasize long-term kidney survival and total cost of care rather than short-term drug spend. Coverage policies that remove mandatory steroid step edits and align with risk-based treatment pathways could improve outcomes while reducing cumulative toxicity. Investment in care coordination, pharmacist-led access programs, and registry participation will help generate real-world effectiveness data that supports sustainable reimbursement models.

Throughout the conversation, the experts provide a comprehensive reflection on the field and the factors that may shape how clinicians approach care moving forward.

In the next episode, Near-Term Priorities for Transforming Clinical Practice in IgA Nephropathy, panelists will continue their discussion on IgA nephropathy.