IgA nephropathy (IgAN) is a very common glomerulonephritis worldwide. In this review, we discuss therapeutic options in four clinical scenarios encountered in patients with IgAN: first is the patient with minor urinary abnormalities where the mainstay of treatment is long-term, regular follow-up to detect renal progression and hypertension. Second is the typical patient presenting with microhematuria, significant but non-nephrotic proteinuria, hypertension, and variable degrees of renal failure. Here the mainstay of treatment is optimized supportive care. If this does not lower proteinuria below 1 g/d, corticosteroid monotherapy may be effective, as long as the GFR is above 50 ml/min. There is insufficient data to advocate the use of other immunosuppressive drugs or even combination therapy in such patients. Third is the atypical patient with overt nephrotic syndrome, or acute or rapidly progressive kidney injury where a possible vasculitic form of IgAN should be sought and, if present, treated with immunosuppression. In other atypical patients with secondary IgAN, treatment should target the underlying primary disease. And fourth is the transplanted patient with recurrent IgAN where the mainstay of treatment is optimized supportive care.