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Normotensive patients who excrete less than 500 mg of protein per day are not typically treated with angiotensin inhibition. However, because most patients progress slowly over time, monitoring of the serum creatinine and protein excretion at yearly intervals is recommended. Angiotensin inhibition should be started if there is evidence of progressive disease and protein excretion above 500 mg/day.

ACE inhibitor plus ARB — The addition of an ARB to an ACE inhibitor in patients with IgA nephropathy produces a further antiproteinuric effect that appears to be associated with a slower rate of loss of GFR [53,54] . This finding in consistent with a meta-analysis of trials in different glomerular diseases which found a significant 18 to 25 percent greater reduction in proteinuria with combined ACE inhibitors and ARBs compared to monotherapy [55] .
A more pronounced antiproteinuric effect is thought to be a marker for better outcomes but there are no trials that have confirmed this benefit of combination ARB/ACE inhibitor therapy. Questions have been raised about the reliability of the one trial (COOPERATE) that directly addressed the renoprotective effect of combination therapy. This issue is discussed separately. (See "Antihypertensive therapy and progression of nondiabetic chronic kidney disease", section on COOPERATE trial).

Treatment goals — The treatment goals with angiotensin inhibition are the same as those in other forms of proteinuric chronic kidney disease as described in the K/DOQI guidelines [56] . The data supporting the following recommendations are discussed in detail separately. (See "Antihypertensive therapy and progression of nondiabetic chronic kidney disease").
We recommend a minimum reduction in protein excretion of at least 60 percent from baseline values, and (preferably) to a goal protein excretion of less than 500 to 1000 mg/day [22,56] . Given simplicity and cost considerations, we initiate therapy with a single agent (either an ACE inhibitor or an ARB), and then proceed with combined ACE inhibitor and ARB therapy if the proteinuria goal is not reached with monotherapy alone.

The goal blood pressure is less than 130/80 mmHg, but even lower blood pressures may be beneficial in patients with persistent protein excretion above 1000 mg/day [56] . If the blood pressure goal is not reached with combined angiotensin inhibition alone, a diuretic should be added followed, if necessary, by diltiazem, verapamil, or a beta blocker.

Fish oil — The possible role of fish oil in IgA nephropathy, which might act by antiinflammatory mechanisms, is not well defined [57] . In addition to uncertain efficacy and consistency in regards to omega-3 fatty acid content, there is an associated fishy aftertaste and eructations with this treatment that often limit patient acceptance [58] .

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