Background <p>The use of steroids glucocorticoids in combination with supportive therapy for reducing proteinuria and the risk of end-stage kidney disease (ESRD) in patients with IgA nephropathy (IgA N) remains controversial. The purpose of this meta-analysis was to evaluate the efficacy and safety of glucocorticoids compared to supportive therapy in the treatment of IgA N, providing guidance for clinical practice.</p> Methods <p>We conducted an online search of PubMed, Embase, Cochrane Library, and Web of Science databases for relevant literature published from the inception of each database to March 28, 2024. Randomized controlled trials (RCTs) assessing the efficacy and safety of steroids versus supportive therapy in the treatment of IgA N were included. The Cochrane risk of bias tool was used to assess the risk of bias in the included studies, and statistical analysis was performed using Stata 15.0 software.</p> Results <p>A total of 9,889 articles were identified, and after screening, twenty-one RCTs were included with a total sample size of 4,704. The primary outcome measures favored glucocorticoid treatment over supportive therapy: 24-hour urinary protein was significantly reduced [WMD = -0.66, 95% CI (-0.98, -0.34),<i>P</i> = 0.001], serum creatinine was significantly improved [SMD = -0.64, 95% CI (-1.04, -0.23) ,<i>p</i> = 0.036], and there was no statistically significant difference in eGFR [SMD = 0.32, 95% CI (-0.05, 0.7),<i>P</i>&lt;0.001]. Secondary outcomes showed a significant difference in the incidence of adverse events [RR = 1.44, 95% CI (1.14, 1.81) ,<i>P</i>&lt;0.001].</p> Discussion <p>Current evidence indicates that low-dose glucocorticoids offer certain benefits in reducing the risk of proteinuria and end-stage renal disease (ESRD) in patients with IgA nephropathy. Several studies included in this review evaluated emerging immunosuppressive agents, such as targeted-release budesonide, which may provide similar therapeutic effects with fewer systemic adverse reactions and better overall tolerability compared with systemic glucocorticoids. Nevertheless, their use should still be approached with caution, particularly in high-risk patients. The findings of this study also reaffirm that changes in proteinuria and serum creatinine remain key biomarkers for the early assessment of IgA nephropathy progression. In addition, multiple included studies reported the urinary protein–creatinine ratio (UPCR) and ESRD as potentially valuable indicators for early disease evaluation. Further high-quality, well-designed studies are warranted to validate these observations.</p> Clinical trial number <p>Not applicable.</p>