Outcomes and predictors of kidney failure in elderly patients with biopsy-proven IgA nephropathy

The clinical presentation and prognosis of immunoglobulin A nephropathy (IgAN) in older adults are poorly defined. We evaluated kidney and patient outcomes and predictors of progression in patients aged ≥60 years with biopsy-proven IgAN. We conducted a retrospective observational study in elderly patients diagnosed with primary IgAN between 2010 and 2024 at a tertiary center. Baseline clinical, laboratory, and histopathologic data were collected, and kidney biopsies were scored using the Oxford MEST-C (Mesangial hypercellularity, Endocapillary hypercellularity, Segmental glomerulosclerosis, Tubular atrophy/interstitial fibrosis, Crescents) classification. The primary outcome was a composite of end-stage kidney disease (ESKD) or death. Predictors of progression were assessed using Kaplan-Meier's analysis and Cox proportional hazards models. A total of 102 patients were included (median age 65 years; 73% male). Comorbidity burden was high (median Charlson Comorbidity Index 4), hypertension was prevalent (88%), and baseline kidney function was reduced (median estimated glomerular filtration rate (eGFR) 29.5 mL/min/1.73 m²). Chronic nephritic syndrome was the most frequent presentation (55%), and chronic histologic lesions predominated (T1/T2 in 52%, S1 in 32%). Over a median follow-up of 5 years, 49 patients (48%) reached the composite outcome, including 32 (31%) who progressed to ESKD. Older age, higher comorbidity burden, and greater proteinuria independently predicted progression, whereas baseline eGFR and individual MEST-C lesions did not. Renin-angiotensin system inhibitor use was associated with better outcomes, while no independent benefit of immunosuppression was observed after adjustment. Elderly patients with IgAN present with advanced chronic kidney disease and substantial comorbidity. Progression is driven mainly by age, comorbidity burden, and proteinuria, supporting optimized supportive care as the cornerstone of management.