Early Therapy with Nefecon in IgAN: Two Case Reports Demonstrating Improved Clinical Outcomes

Introduction: The 2024 draft KDIGO guidelines endorse Nefecon, a targeted-release budesonide, as the first disease-modifying therapy for high-risk IgA nephropathy (IgAN), signaling a shift from traditional supportive care. Though trials confirm its efficacy, real-world data remain limited. We present two cases where early Nefecon use with optimized supportive measures led to significant improvement. Case Description: Case 1: Rapid Response in a Young Adult A 23-year-old male with elevated blood pressure presented with headaches, elevated serum creatinine (148 μmol/L), and proteinuria (1.073 g/24 h). Renal biopsy confirmed focal proliferative IgAN (Oxford: M1E1S1T1-C1). Initial treatment with hydroxychloroquine and an angiotensin II receptor blocker showed minimal benefit. At referral, serum creatinine was 141 μmol/L with proteinuria of 0.86 g/24 h. Starting targeted-release oral budesonide (Nefecon, 16 mg/d) alongside optimized renin–angiotensin–aldosterone blockade led to significant improvement over six months: serum creatinine decreased to 97 μmol/L (-31%) and proteinuria to 0.52 g/24 h (-40%) (Figure 1A). Case 2: Advanced Disease in a Diabetic Patient A 48-year-old male with type 2 diabetes mellitus presented with progressive renal dysfunction (serum creatinine 241 μmol/L, proteinuria 2.67 g/24 h). Biopsy revealed focal sclerosing IgAN with glomerular tuft necrosis (Oxford: M1E1S1T1-C1). Renal function deteriorated despite strict glycemic control, optimized antihypertensive therapy, and urate-lowering treatment. Introducing Nefecon (16 mg/d) resulted in marked improvement: after seven months, serum creatinine decreased to 161 μmol/L (-33%) and proteinuria to 0.65 g/24 h (-76%) (Figure 1B). Discussion: These cases highlight the potential of early Nefecon use with optimized supportive care to stabilize renal function and slow progression to end-stage kidney disease. This proactive approach contrasts with traditional reactive strategies and warrants further study on timing, duration, and biomarker-guided management to improve long-term outcomes.Figure 1 Proteinuria and Urinary Creatinine Levels during Follow-up Visits