Tolvaptan in Later-Stage Autosomal Dominant Polycystic Kidney Disease

Autosomal dominant polycystic kidney disease: an overview of recent genetic and clinical advances

Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most common inherited kidney disease, characterized by the progressive development of multiple kidney cysts, leading to a gradual decline in kidney function. ADPKD is also the fourth leading cause of kidney failure (KF) in adults. In addition to kidney manifestations, ADPKD is associated with various extrarenal features, including liver cysts, cardiovascular abnormalities, intracranial aneurysms, and chronic pain with significant impact on patients' quality of life. While several disease-modifying agents have been tested in ADPKD, tolvaptan remains the only approved drug by the US Food and Drug Administration. The Mayo Imaging Classification is currently the most practical tool for predicting rate of kidney disease progression in ADPKD. This review provides a comprehensive overview of ADPKD, focusing on its genetics, pathophysiology, clinical presentation, management, and prognostic tools. Advances in diagnostic imaging and genetic testing have improved the early detection of ADPKD, allowing better classification of patients and prediction of KF. The review also discusses current therapeutic approaches to ADPKD, including tolvaptan, a vasopressin V2-receptor antagonist. Additionally, we address specific issues in children and pregnant individuals with ADPKD. Despite substantial progress in understanding ADPKD, there is a large need for additional effective treatments and prognostic markers to provide a more personalized care for these patients.

Therapeutic opportunities in polycystic kidney and liver disease through extracellular matrix dynamics

Autosomal Dominant and Autosomal Recessive Polycystic Kidney Disease (ADPKD and ARPKD) are, respectively, common and rare forms of polycystic disorders, characterized by the formation and progressive growth of cysts from tubules in the kidneys and bile ducts in the liver. Alterations in the extracellular matrix (ECM) and in the activity of matrix metalloproteases (MMPs), both associated with fibrosis, have been shown to be important factors in cystic growth and progression of these diseases. We used tandem mass spectrometry (LC-MS/MS) to identify the most enriched proteins and pathways in an orthologous rapidly progressive mouse model of ADPKD: Pkd1flox/floxTamCre. This information was used to discover and validate novel therapeutic targets in orthologous models of ADPKD (Pkd1flox/floxTamCre) and ARPKD (Pkdh1del3-4/del3-4). ECM related pathways and expression levels of MMPs were among the most dysregulated cellular processes in polycystic kidney and liver. Selective inhibition of MMPs by marimastat (MTT) altered the ECM response and resulted in inhibition of collecting duct-derived cyst growth, delay of global kidney cyst progression and rescue of liver phenotype by normalized MMPs expression and significant reduction in fibrosis. This phenotypic improvement was further enhanced by treatment of MTT and tolvaptan, indicating an additive benefit to targeting the fibrotic and growth pathways in cysts. As conclusion, targeting of MMPs are important in ECM dysregulation and offers a new potential therapeutic strategy for both kidney and bile duct derived fibrocystic disease in ADPKD and ARPKD. Such approaches can have additive benefits with other treatment approaches, such as tolvaptan.

Effectiveness of Tolvaptan for Autosomal Dominant Polycystic Kidney Disease in US Clinical Practice With Comparison to Historical Control Data

Rationale & Objective

Data from clinical practice are needed to characterize the effectiveness of pharmacotherapy outside the controlled setting of clinical trials but lack an untreated placebo group for comparison. To assess the effectiveness of tolvaptan for autosomal dominant polycystic kidney disease (ADPKD) in nephrology practice, we performed a chart review of US patients and compared it with a historical matched control cohort.

Study Design

Patient data from charts were provided by US nephrologists who participated in an online survey. Historical control data for patients with ADPKD not treated with tolvaptan were extracted from a database of ADPKD clinical studies (Consortium for Radiologic Imaging Studies of Polycystic Kidney Disease, HALT Progression of Polycystic Kidney Disease, and OVERTURE).

Setting & Participants

Nephrologist respondents (n = 57) provided baseline data and up to 4 years of follow-up on estimated glomerular filtration rate (eGFR) for tolvaptan-treated adults (n = 149). Historical ADPKD-affected controls were adults in Mayo imaging risk classes 1C-1E (ie, at increased risk of rapid progression, consistent with the tolvaptan indication).

Exposure

Cases had to receive tolvaptan continuously for ≥2 years. Historical controls received nontolvaptan standard of care, including various antihypertensive regimens.

Outcome

Annual rate of eGFR change.

Analytical Approach

Cases and controls were matched on baseline clinical characteristics (matched set A: age, sex, and chronic kidney disease stage [110 matched pairs]; matched set B: age, sex, and eGFR [98 matched pairs]) and compared using a mixed model.

Results

The annual rate of eGFR decline was slower in tolvaptan-treated patients versus historical controls, by 1.40 mL/min/1.73 m2 (95% CI, 0.05-2.74; P = 0.04) in set A. Set B demonstrated a similar trend: 1.18 mL/min/1.73 m2 per year (95% CI, -0.22 to 2.58; P = 0.10).

Limitations

Risk of bias from convenience sampling and potential residual confounding after case/historical control matching.

Conclusions

Tolvaptan was associated with slower eGFR decline in routine clinical practice, consistent with the results of controlled trials.

Drug and siRNA screens identify ROCK2 as a therapeutic target for ciliopathies

BACKGROUND

Primary cilia mediate vertebrate development and growth factor signalling. Defects in primary cilia cause inherited developmental conditions termed ciliopathies. Ciliopathies often present with cystic kidney disease, a major cause of early renal failure. Currently, only one drug, Tolvaptan, is licensed to slow the decline of renal function for the ciliopathy polycystic kidney disease. Novel therapeutic interventions are needed.

METHODS

We screened clinical development compounds to identify those that reversed cilia loss due to siRNA knockdown. In parallel, we undertook a whole genome siRNA-based reverse genetics phenotypic screen to identify positive modulators of cilia formation.

RESULTS

Using a clinical development compound screen, we identify fasudil hydrochloride. Fasudil is a generic, off-patent drug that is a potent, broadly selective Rho-associated coiled-coil-containing protein kinase (ROCK) inhibitor. In parallel, the siRNA screen identifies ROCK2 and we demonstrate that ROCK2 is a key mediator of cilium formation and function through its possible effects on actin cytoskeleton remodelling.

CONCLUSIONS

Our results indicate that specific ROCK2 inhibitors (e.g. belumosudil) could be repurposed for cystic kidney disease treatment. We propose that ROCK2 inhibition represents a novel, disease-modifying therapeutic approach for heterogeneous ciliopathies.

The Role of Adiposity and Anthropometrics on Disease Progression in Autosomal Dominant Polycystic Kidney Disease: A Narrative Review

PURPOSE OF REVIEW

Autosomal dominant polycystic kidney disease (ADPKD) is a genetic disorder characterized by numerous cysts in kidneys and other organs which enlarge and cause organ dysfunction, with kidney involvement being the most common. Recently, increased body mass index, and adiposity have been associated with disease progression. In this review, we summarized the available literature on anthropometrics (body mass index, waist circumference, weight to hip ratio and visceral adipose tissue and their relationship with ADPKD progression.

RECENT FINDINGS

Although the mechanisms are not clear, various pathological processes and signaling pathways are aberrantly activated with increased adiposity in patients with ADPKD. These alterations may result in glomerular hyperfiltration, chronic inflammation, aberrant signaling, and metabolic alterations which cause disease progression in ADPKD. Although increased adiposity may be associated with ADPKD progression, the best anthropometric parameter related to disease progression is not known. Losing weight in overweight and obese individuals with ADPKD is probably beneficial but the type of diet (daily caloric restriction, intermittent fasting etc.) that is most effective needs to be clarified. Moreover, caution is warranted during weight loss, as caloric restriction may cause malnutrition.

The prospect of novel orphan therapeutic protocol for TSC2/PKD1 contiguous gene syndrome: a case report

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD, OMIM # 601313, # 173900) and tuberous sclerosis complex (TSC2, OMIM # 191092, #613254) are inherited multisystemic diseases that rarely associate. Large deletion on chromosome 16 can result in TSC2/PKD1 contiguous gene (deletion) syndrome (PKDTS, OMIM # 600273) presenting significant diagnostic and management challenges.

CASE PRESENTATION

A 50-year-old male presented clinical features consistent with autosomal dominant polycystic kidney disease (ADPKD) and signs of tuberous sclerosis complex (TSC), such as multiple facial angiofibroma, cortical tubers, cerebral hamartomas, and renal and hepatic angiomyolipomas, was investigated for the multisystemic disease pattern. Genetic testing confirmed the diagnosis of TSC2/PKD1 contiguous gene deletion syndrome (PKDTS), leading to the initiation of tolvaptan treatment to reduce the progression of ADPKD and considering everolimus as a potential therapeutic solution to decrease the size of angiomyolipomas, thereby minimizing the risk of spontaneous bleeding. Our report underlines for the first time, up to our knowledge, that the proposed therapy protocol for PKD1/TSC2 contiguous gene deletion syndrome could have potential.

CONCLUSIONS

This case illustrates the importance of recognizing overlapping genetic disorders, and providing insights into an innovative therapeutic approach. By integrating detailed clinical assessment with genetic testing, the diagnosis was clarified, and targeted therapies can be selected to address the dual impact of ADPKD and TSC; however, further studies are needed to evaluate the efficacy and safety of this approach. We also emphasize the need to recognize other cases of renal polycystic disease associated with angiomyolipomas and cutaneous manifestations.

Establishing Meaningful Patient-Centered Outcomes with Relevance for Patients with Polycystic Kidney Disease: Patient, Caregiver, and Researcher Priorities for Research in Polycystic Kidney Disease

Key Points

Background

Patient involvement in research can help to ensure that the evidence generated aligns with their needs and priorities. In the Establishing Meaningful Patient-Centered Outcomes with Relevance for Patients with Polycystic Kidney Disease (PKD) project, we aimed to identify patient-important outcomes and discuss the effect of PKD on patients.

Methods

Nine focus groups were held with adult patients with PKD, caregivers, and clinical or research experts in PKD. We used a nominal, multivote technique to rank patient-important outcomes to be prioritized by future PKD research. We conducted a thematic analysis of verbatim transcriptions to identify themes regarding the effect of PKD on their daily lives. Other focus group topics included insurability and patient engagement.

Results

Ninety patients and/or caregivers and eight clinicians and/or researchers participated in the focus groups. Nine focus groups yielded 35 outcomes important to patients that were grouped into six categories, ranked in order of importance: kidney health, comorbidities, lifestyle, psychological effect, family and awareness, and mortality. Regarding the effect of PKD on the patient's daily lives, we identified five themes, listed in order of importance: psychological effect, effect on daily living, issues affecting decision making, health care-related issues, and PKD-specific testing dilemmas.

Conclusions

This study of stakeholder engagement in patients with PKD revealed important priorities and values that should be considered for future research and when caring for patients with PKD. Future research should focus on kidney health and managing comorbidities in patients with PKD. This will help to bridge the knowledge gap and develop meaningful comparative effectiveness research in PKD.

Targeting Dysregulated Epigenetic Modifiers With Kidney-Targeted Nanotherapeutics for Polycystic Kidney Disease

Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic kidney disease worldwide. The one small molecule drug available to patients, tolvaptan, is associated with off-target side effects and high discontinuation rates, necessitating the development of new therapeutic strategies. Previous work has shown that the epigenome is altered in ADPKD; however, the identification and targeting of dysregulated epigenetic modulators has yet to be explored for human ADPKD therapy. Using cells derived from cysts of ADPKD patients, we tested the gene expression of several epigenetic modulators. We found Brd4 and BMi1 are upregulated and observed that their inhibition using small molecule drugs, AZD-5153 and PTC-209, significantly slowed the proliferation of ADPKD patient cells. To enhance the delivery of AZD-5153 and PTC-209 to renal cells, we loaded the drugs into kidney-targeting micelles (KM) and assessed their therapeutic effects in vitro. Combining AZD-5153 and PTC-209 in KMs had a synergistic effect on reducing the proliferation in ADPKD patient cells and in a 3D PKD cyst model. These findings were also consistent in murine in vitro models using Pkd1 null renal proximal tubule cells. In summary, we demonstrate Brd4 and BMi1 as novel targets in ADPKD and targeting the epigenome using kidney nanomedicine as a novel therapeutic strategy in ADPKD.

Treatment of Autosomal-Dominant Polycystic Kidney Disease

Autosomal-dominant polycystic kidney disease (ADPKD) is a chronic systemic disease that affects all races and ethnicities. It is the fourth leading cause of end-stage kidney disease, and it has a heterogenous phenotype ranging from mild to severe disease. Identifying patients with ADPKD who are at risk of rapid progression can guide therapeutic decisions. Several tools to predict disease severity are available, based on features such as total kidney volume assessed with magnetic resonance imaging, PKD genotype, estimated glomerular filtration rate (eGFR) trajectory, and the occurrence of hypertension and urologic complications early in life. During the past decade, more evidence has emerged regarding optimal ADPKD management. The HALT PKD (Halt Progression of Polycystic Kidney Disease) trial supported intensive blood pressure control in patients younger than 50 years of age with preserved kidney function. A healthy lifestyle, including maintaining a healthy weight, salt restriction, and smoking cessation, is likely to be beneficial. Tolvaptan, the only disease-modifying agent for patients with ADPKD at risk of rapid progression, is gaining wider use, but is still limited by its side effects. This is an exciting time for the ADPKD community because multiple promising interventions are in the pipeline and being investigated.

PKD1 mutation perturbs morphogenesis in tubular epithelial organoids derived from human pluripotent stem cells

Autosomal dominant polycystic kidney disease (ADPKD) is the most common renal genetic disease, with most patients carrying mutations in PKD1. The main feature is the formation of bilateral renal cysts, leading to end stage renal failure in a significant proportion of those affected. Despite recent advances made in understanding ADPKD, there are currently no effective curative therapies. The emergence of human induced pluripotent stem cell (hiPSC)-derived kidney disease models has led to renewed hope that more physiological systems will allow for the development of novel treatments. hiPSC-derived organoid models have been used to recapitulate ADPKD, however they present numerous limitations which remain to be addressed. In the present study, we report an efficient method for generating organoids containing a network of polarised and ciliated epithelial tubules. PKD1 null (PKD1-/-) organoids spontaneously develop dilated tubules, recapitulating early ADPKD cystogenesis. Furthermore, PKD1-/- tubules present primary cilia defects when dilated. Our model could therefore serve as a valuable tool to study early ADPKD cystogenesis and to develop novel therapies.

Longitudinal assessment of measured and estimated glomerular filtration-rate in autosomal dominant polycystic kidney disease: Real practice experience

BACKGROUND

Equations for estimation glomerular filtration rate (eGFR) have been associated with poor clinical performance and their clinical accuracy and reliability have been called into question.

AIM

To assess the longitudinal changes in measured glomerular filtration rate (mGFR) in patients with autosomal dominant polycystic kidney disease (ADPKD).

METHODS

Analysis of an ambispective data base conducted on consecutive patients diagnosed with ADPKD. The mGFR was assessed by iohexol clearance; while eGFR was calculated by three different formulas: (1) The chronic kidney disease epidemiology collaboration (CKD-EPI); (2) Modification of diet in renal disease (MDRD); and (3) The 24-hour urine creatinine clearance (CrCl). The primary end-points were the mean change in mGFR between the baseline and final visit, as well as the comparison of the mean change in mGFR with the change estimated by the different formulas.

RESULTS

Thirty-seven patients were included in the study. As compared to baseline, month-6 mGFR was significantly decrease by -4.4 mL/minute ± 10.3 mL/minute (P = 0.0132). However, the CKD-EPI, MDRD, and CrCl formulas underestimated this change by 48.3%, 89.0%, and 45.8% respectively, though none of these differences reached statistical significance (P = 0.3647; P = 0.0505; and P = 0.736, respectively). The discrepancies between measured and estimated glomerular filtration rate values, as evaluated by CKD-EPI (r = 0.29, P = 0.086); MDRD (r = 0.19, P = 0.272); and CrCl (r = 0.09, P = 0.683), were not correlated with baseline mGFR values.

CONCLUSION

This study indicated that eGFR inaccurately reflects the decline in mGFR and cannot reliably track changes over time. This poses significant challenges for clinical decision-making, particularly in treatment strategies.

Autosomal Dominant Polycystic Kidney Disease: A Review

Importance

Autosomal dominant polycystic kidney disease (ADPKD) is characterized by progressive development of kidney cysts and is the most common inherited kidney disorder worldwide. ADPKD accounts for 5% to 10% of kidney failure in the US and Europe, and its prevalence in the US is 9.3 per 10 000 individuals.

Observations

ADPKD is typically diagnosed in individuals aged 27 to 42 years and is primarily caused by pathogenic variants in the PKD1 (78%) or PKD2 (15%) genes. Most persons with ADPKD have an affected parent, but de novo disease is suggested in 10% to 25% of families. More than 90% of patients older than 35 years have hepatic cysts, which may cause abdominal discomfort and occasionally require medical or surgical intervention. Hypertension affects 70% to 80% of patients with ADPKD, and approximately 9% to 14% develop intracranial aneurysms, which have a rupture rate of 0.57 per 1000 patient-years. Approximately 50% of individuals with ADPKD require kidney replacement therapy by 62 years of age. The severity of kidney disease can be quantified using the Mayo Imaging Classification (MIC), which stratifies patients based on total kidney volume adjusted for height and age and ranges from 1A to 1E. Patients with MIC 1C to MIC 1E have larger kidneys because of more rapid growth (6%-10% per year) compared with those with MIC 1A and 1B (1%-5% per year) and have earlier progression to kidney replacement therapy, which occurs at a mean age of 58.4 years for MIC 1C, 52.5 years for MIC 1D, and 43.4 years for MIC 1E. Optimal management of ADPKD includes systolic blood pressure lower than 120 mm Hg for most patients, but lower than 110/75 mm Hg for patients with MIC 1C to 1E who have an estimated glomerular filtration rate (eGFR) greater than 60 mL/min/1.73 m2 and are younger than 50 years, dietary sodium restriction (<2000 mg/d), weight management, and adequate hydration (>2.5 L daily). The vasopressin type 2 receptor antagonist tolvaptan reduces the annual rate of eGFR decline by 0.98 to 1.27 mL/min/1.73 m2 and is indicated for patients with MIC 1C to 1E or an eGFR decline greater than 3 mL/min/1.73 m2 per year to slow disease progression and delay the onset of kidney failure.

Conclusion

ADPKD is the most common genetic kidney disease worldwide and is characterized by progressive development of kidney cysts. Patients typically have hypertension and liver cysts, and 9% to 14% develop intracranial aneurysms. First-line treatment includes blood pressure control, dietary and weight management, and adequate hydration. Tolvaptan reduces the rate of eGFR decline for those at high risk of rapid progression to kidney failure.

Predicting Kidney Outcomes in Autosomal Dominant Polycystic Kidney Disease: A Comprehensive Biomarker Analysis

Background:

Risk stratification tools for Autosomal Dominant Polycystic Kidney Disease (ADPKD) predict kidney outcomes on a group level but lack precision in individuals.

Methods:

We assessed the value of adding 13 prognostic biomarkers to established risk factors (sex, age, estimated glomerular filtration rate (eGFR), systolic blood pressure, Mayo Imaging Class (MIC), and mutation type) for predicting disease progression. We included 596 patients from the DIPAK (Developing Intervention strategies to halt Progression of Autosomal Dominant Polycystic Kidney Disease) cohorts with ≥2 eGFR measurements and ≥1 year follow-up.

Results:

During a mean±SD follow-up of 5.0±2.3 years, the mean±SD eGFR slope was -3.46±2.5 mL/min/1.73m2/year. Rapid disease progression (eGFR loss ≥3 mL/min/1.73m2/year) occurred in 303 patients (50.8%), and 279 patients (46.8%) reached the combined endpoint of kidney failure or 30% eGFR decline. Urinary albumin/creatinine, urinary monocyte chemotactic protein-1 (MCP-1)/creatinine, and serum copeptin consistently and independently predicted eGFR slope (all P <0.001), rapid disease progression (AUC increasing from 0.79 [95% CI: 0.76, 0.85] for a baseline model to 0.83 [95% CI: 0.81, 0.88] when MCP-1/creatinine and copeptin were included, P=0.006) and reaching the combined kidney endpoint (C-index improving from 0.806 [95% CI: 0.78, 0.84] for a baseline model to 0.82 [95% CI: 0.79, 0.85] for a model also containing albumin/creatinine and copeptin, P <0.001). These results were confirmed in an independent external validation cohort (N=144), and were robust in early disease stages and in patients with moderately increased kidney volumes (MIC 1C).

Conclusion:

Our findings suggest that incorporating these biomarkers into ADPKD risk stratification tools will improve risk prediction, even in subgroups where prognostication is most challenging and relevant.

Integrated Use of Autosomal Dominant Polycystic Kidney Disease Prediction Tools for Risk Prognostication

Key Points

The Mayo clinic imaging classification and the predicting renal outcome in polycystic kidney disease score are used to assess the risk of progression to kidney failure in autosomal dominant polycystic kidney disease. Mayo imaging classification and predicting renal outcome in polycystic kidney disease show little concordance; combined use increased the ability to identify rapid progression especially among intermediate risk patients. Accurate risk prediction is key for determining indication for specific treatment.

Background

Autosomal dominant polycystic kidney disease is the most common genetic cause of kidney failure. Specific treatment is indicated on observed or predicted rapid progression. For the latter, risk stratification tools have been developed independently based on either total kidney volume or genotyping as well as clinical variables. This study aimed to improve risk prediction by combining both imaging and clinical-genetic scores.

Methods

We conducted a retrospective multicenter cohort study of 468 patients diagnosed with autosomal dominant polycystic kidney disease. Clinical, imaging, and genetic data were analyzed for risk prediction. We defined rapid disease progression as an eGFR slope ≥3 ml/min per 1.73 m2 per year over 2 years, Mayo imaging classification (MIC) 1D–1E, or a predicting renal outcome in polycystic kidney disease (PROPKD) score of ≥7 points. Using MIC, PROPKD, and rare exome variant ensemble learner scores, several combined models were designed to develop a new classification with improved risk stratification. Primary endpoints were the development of advanced CKD stages G4–G5, longitudinal changes in eGFR, and clinical variables such as hypertension or urological events. Statistically, logistic regression, survival, receiver operating characteristic analyses, linear mixed models, and Cox proportional hazards models were used.

Results

PKD1 -genotype (P < 0.001), MIC class 1E (P < 0.001), early-onset hypertension (P < 0.001), and early-onset urological events (P = 0.003) correlated best with rapid progression in multivariable analysis. While the MIC showed satisfactory specificity (77%), the PROPKD was more sensitive (59%). Among individuals with an intermediate risk in one of the scores, integration of the other score (combined scoring) allowed for more accurate stratification.

Conclusions

The combined use of both risk scores was associated with higher ability to identify rapid progressors and resulted in a better stratification, notably among intermediate risk patients.

Spot Versus 24-Hour Urine Osmolality Measurement in Autosomal Dominant Polycystic Kidney Disease: A Diagnostic Test Study

Rationale & Objective

Arginine vasopressin (AVP) is an established driver of cyst growth in autosomal dominant polycystic kidney disease (ADPKD). Urine osmolality (osm) measures are surrogate markers of AVP activity. Both 24-hour and spot urine samples are used as indicators of AVP suppression. The agreement between these 2 measurements remains unclear.

Study Design

A retrospective cohort study.

Setting & Study Population

Three hundred and forty-nine patients with ADPKD with 839 urine samples from a tertiary care center.

Selection Criteria for Study

Patients with ADPKD with records of spot and 24-hour urine measurements.

Data Extraction

Consecutive patients' data from January 2018 to March 2023 were extracted from the quality assurance database of The Ottawa Hospital Cystic Kidney Disease Clinic.

Analytical Approach

Discordance assessed at target urine osmolality of 250 and 270 mmol/kg. Agreement assessed by Bland-Altman plots. The percentage of patients with difference in osmolality between the 2 measures for cutoff points of > 50, > 100, >150, and > 200 mmol/kg was calculated.

Results

The mean 24-hour urine osm was 364 mmol/kg, and the mean spot urine osm was 424 mosm/kg. Mean age of 46 years, 52% females, and 47 (13.5%) were on tolvaptan. Overall, in comparing spot urine osm to 24-hour urine osm, the discordance at 250 and 270 mmol/kg was 24% with poor agreement on Bland-Altman plots. The differences between the 2 measures at varying cutoff points were 53.9% at 50 mmol/kg, 35.8% at 100 mmol/kg, 24.1% at 150 mmol/kg, and 16.1% at 200 mmol/kg. Results were similar when only a single measurement from each patient was used for analysis.

Limitations

Total of 29% of patients did not have concurrent spot urine osmolality and 24-hour urine osmolality. The study was conducted at a single center. Limited number of patients were on tolvaptan.

Conclusions

In adults with ADPKD, important differences exist between the 24-hour urine osmolality and spot urine osmolality that preclude interchangeable use. The method employed may impact clinical decision-making. More research is needed to determine, which urine osm should be used when assessing AVP suppression.

Citrate in autosomal dominant polycystic kidney disease: biomarker or therapeutic agent?

PURPOSE OF REVIEW

This review highlights the latest findings regarding hypocitraturia in autosomal dominant polycystic kidney disease (ADPKD), from both experimental and clinical studies, exploring the underlying pathophysiology and potential therapeutic approach.

RECENT FINDINGS

Experimental studies have shown that the lodging of microcrystals in the tubules can trigger cyst formation and growth in polycystic kidney disease (PKD). ADPKD patients are prone to developing hypocitraturia in early stages, which could predispose to calcium microcrystal formation. Low urinary citrate excretion has been associated with a more rapid decline in eGFR and poorer renal survival in ADPKD patients. Animal studies employing citrate supplementation have shown promising effects on preserving the decline in estimated glomerular filtration rate (eGFR) and cyst growth.

SUMMARY

Current knowledge suggests that urinary citrate could be incorporated into existing prognostic markers for disease progression and potential adjuvant therapy in ADPKD, but further clinical studies to support such hypothesis must be undertaken.

The Role of Baseline Total Kidney Volume Growth Rate in Predicting Tolvaptan Efficacy for ADPKD Patients: A Feasibility Study

Background/Objectives: Although tolvaptan efficacy in ADPKD has been demonstrated in randomized clinical trials, there is no definitive method for assessing its efficacy in the individual patient in the clinical setting. In this exploratory feasibility study, we report a method to quantify the change in total kidney volume (TKV) growth rate to retrospectively evaluate tolvaptan efficacy for individual patients. Treatment-related changes in estimated glomerular filtration rate (eGFR) are also assessed. Methods: MRI scans covering at least 1 year prior to and during treatment with tolvaptan were performed, with deep learning facilitated kidney segmentation and fitting multiple imaging timepoints to exponential growth in 32 ADPKD patients. Clustering analysis differentiated tolvaptan treatment "responders" and "non-responders" based upon the magnitude of change in TKV growth rate. Differences in rate of eGFR decline, urine osmolality, and other parameters were compared between responders and non-responders. Results: Eighteen (56%) tolvaptan responders (mean age 42 ± 8 years) were identified by k-means clustering, with an absolute reduction in annual TKV growth rate of >2% (mean = -5.1% ± 2.5% per year). Thirteen (44%) non-responders were identified, with <1% absolute reduction in annual TKV growth rate (mean = +2.4% ± 2.7% per year) during tolvaptan treatment. Compared to non-responders, tolvaptan responders had significantly higher mean TKV growth rates prior to tolvaptan treatment (7.1% ± 3.6% per year vs. 3.7% ± 2.4% per year; p = 0.003) and higher median pretreatment spot urine osmolality (Uosm, 393 mOsm/kg vs. 194 mOsm/kg, p = 0.03), confirmed by multivariate analysis. Mean annual rate of eGFR decline was less in responders than in non-responders (-0.25 ± 0.04, CI: [-0.27, -0.23] mL/min/1.73 m2 per year vs. -0.40 ± 0.06, CI: [-0.43, -0.37] mL/min/1.73 m2 per year, p = 0.036). Conclusions: In this feasibility study designed to assess predictors of tolvaptan treatment efficacy in individual patients with ADPKD, we found that high pretreatment levels of annual TKV growth rate and higher pretreatment spot urine osmolality were associated with a responder phenotype.

Safety and efficacy of tolvaptan in real‑world Japanese patients with autosomal dominant polycystic kidney disease: final results of SLOW‑PKD surveillance

BACKGROUND

Tolvaptan, a vasopressin type 2 receptor antagonist, has been used to treat autosomal dominant polycystic kidney disease in Japan since 2014.

METHODS

This long-term, real-world, post-marketing surveillance (PMS) was conducted in Japan from March 2014 to March 2022. Safety was assessed based on adverse drug reactions (ADRs). For efficacy, changes in the slope of total kidney volume (TKV) and estimated glomerular filtration rate (eGFR) were assessed before and during the administration of tolvaptan.

RESULTS

A total of 1676 patients were enrolled, with mean TKV (n = 1000) of 2149 ± 1339 mL and eGFR (n = 1641) of 44.4 ± 21.7 mL/min/1.73 m2. Frequent ADRs were hepatic function abnormal (9.6%), hyperuricaemia (8.3%), and thirst (8.1%). Most of the increased alanine aminotransferase exceeding 3 times the upper limit of the reference level occurred from 3  to  14 months after the start of treatment, but about 20% was observed after 15 months. There was no increase in ADRs over 36 months, suggesting that no other safety concerns need to be monitored during administration over 3-7 years. The mean slope of the estimated TKV increase before and during tolvaptan treatment was 6.58 and 3.71%/year, respectively (P = 0.0020). The mean slope of eGFR decline was - 3.63 and - 3.26 mL/min/1.73 m2/year, respectively (P = 0.2728).

CONCLUSION

There were no major problems with the safety of tolvaptan treatment, and efficacy in limiting TKV increase in this PMS was comparable to the previous, pivotal randomized control trials. Trial registration ClinicalTrials.gov; NCT02847624.

Commentary: Tolvaptan for Autosomal Dominant Polycystic Kidney Disease (ADPKD) - an update

Autosomal Dominant Polycystic Kidney Disease (ADPKD) affects up to 70 000 people in the UK and the most common inherited cause of end-stage kidney disease (ESKD). It is generally a late-onset multisystem disorder characterised by bilateral kidney cysts, liver cysts and an increased risk of intracranial aneurysms. Approximately 50% of people with ADPKD reach ESKD by age 60. Disease-associated pain, discomfort, fatigue, emotional distress and, impaired mobility can impact health-related quality of life. The approval of tolvaptan, a vasopressin V2 receptor antagonist, has greatly advanced the care for people with ADPKD, shifting the focus from general chronic kidney disease management to targeted therapeutic approaches. While guidance from NICE and SMC provides a foundational framework, this is not clear or comprehensive enough to offer practical guidance for healthcare professionals in real-world settings. This commentary expands on the previous United Kingdom Kidney Association (UKKA) commentary in 2016 with an updated evidence base, the incorporation of real-world data and expert opinion to provide practical guidance to healthcare professionals. Through co-development with people affected by ADPKD, it now incorporates valuable patient perspectives and offers practical recommendations for the UK kidney community seeking to harmonise the quality of care of all people with ADPKD.

Development of dual V1a/V2 antagonists containing triazolobenzazepine scaffold

The development of a dual V1a/V2 antagonist compound is a complex and challenging task. Conivaptan is up to now the only known V1a/V2 antagonist which was approved for the treatment of euvolemic hyponatremia. Previously, we reported RGH-122, a novel selective V1a antagonist compound. Herein, we describe several promising dual antagonist compounds, which are derived from RGH-122 by using modifications in its tail region. These modifications can result in excellent binding affinity on both V1a and V2 receptors.

Novel PKD1 Mutation (c.G10086T) Drives High Intracranial Aneurysm Risk in Autosomal Dominant Polycystic Kidney Disease

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is frequently complicated by intracranial aneurysms (IAs). However, the genetic factors driving the elevated IA risk in ADPKD remain poorly understood. In this study, we identified a novel PKD1 mutation associated with a remarkably high IA incidence in a large Chinese ADPKD family.

METHODS

We conducted whole-exome sequencing in a three-generation Chinese ADPKD family (n = 24) characterized by an unusually high IA prevalence. The pathogenicity of the identified PKD1 variant was validated through comprehensive functional studies, including protein localization, calcium signaling, and endothelial cell behavior analyses.

RESULTS

We discovered a novel PKD1 mutation (c.G10086T) that co-segregated with disease in all affected family members. Notably, 38.1% (8/21) of the mutation carriers developed IAs, a significantly higher rate than reported in general ADPKD populations (4%-11.5%). Functional studies revealed that this mutation disrupted polycystin-1 trafficking and impaired calcium signaling, leading to endothelial dysfunction. In vitro experiments demonstrated enhanced angiogenic potential and compromised vascular integrity in cells expressing mutant PKD1.

CONCLUSIONS

The newly identified PKD1:c.G10086T mutation represents a high-risk genetic variant for IA development in ADPKD. Our findings provide new insights into the vascular complications of ADPKD and suggest that PKD1 genotyping may help identify patients requiring intensive IA surveillance. This study supports the development of mutation-specific screening strategies for ADPKD-associated vascular complications.

Altered bile acid and coproporphyrin-I disposition in patients with autosomal dominant polycystic kidney disease

AIMS

Serum, liver and urinary bile acids are increased, and hepatic transport protein levels are decreased in a non-clinical model of polycystic kidney disease. Similar changes in patients with autosomal dominant polycystic kidney disease (ADPKD) may predispose them to drug-induced liver injury (DILI) and hepatic drug-drug interactions (DDIs). Systemic coproporphyrin-I (CP-I), an endogenous biomarker for hepatic OATP1B function and MRP2 substrate, is used to evaluate OATP1B-mediated DDI risk in humans. In this clinical observational cohort-comparison study, bile acid profiles and CP-I concentrations in healthy volunteers and patients with ADPKD were compared.

METHODS

Serum and urine samples from healthy volunteers (n = 16) and patients with ADPKD (n = 8) were collected. Serum bile acids, and serum and urine CP-I concentrations, were quantified by ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS).

RESULTS

Patients with ADPKD exhibited increased serum concentrations of total (1.3-fold) and taurine-conjugated (2.8-fold) bile acids compared to healthy volunteers. Specifically, serum concentrations of six bile acids known to be more hydrophobic/hepatotoxic (glycochenodeoxycholate, taurochenodeoxycholate, taurodeoxycholate, lithocholate, glycolithocholate and taurolithocholate) were increased (1.5-, 2.9-, 2.8-, 1.6-, 1.7- and 2.7-fold, respectively) in patients with ADPKD. Furthermore, serum CP-I concentrations were elevated and the renal clearance of CP-I was reduced in patients with ADPKD compared to healthy volunteers.

CONCLUSIONS

Increased exposure to bile acids may increase susceptibility to DILI in some patients with ADPKD. Furthermore, the observed increase in serum CP-I concentrations could be attributed, in part, to impaired OATP1B function in patients with ADPKD, which could increase the risk of DDIs involving OATP1B substrates compared to healthy volunteers.

A guide to gene-disease relationships in nephrology

The use of next-generation sequencing technologies such as exome and genome sequencing in research and clinical care has transformed our understanding of the molecular architecture of genetic kidney diseases. Although the capability to identify and rigorously assess genetic variants and their relationship to disease has advanced considerably in the past decade, the curation of clinically relevant relationships between genes and specific phenotypes has received less attention, despite it underpinning accurate interpretation of genomic tests. Here, we discuss the need to accurately define gene-disease relationships in nephrology and provide a framework for appraising genetic and experimental evidence critically. We describe existing international programmes that provide expert curation of gene-disease relationships and discuss sources of discrepancy as well as efforts at harmonization. Further, we highlight the need for alignment of disease and phenotype terminology to ensure robust and reproducible curation of knowledge. These collective efforts to support evidence-based translation of genomic sequencing into practice across clinical, diagnostic and research settings are crucial for delivering the promise of precision medicine in nephrology, providing more patients with timely diagnoses, accurate prognostic information and access to targeted treatments.

Autosomal Dominant Polycystic Kidney Disease Inflammation Biomarkers in the Tolvaptan Era

With the approval of tolvaptan as the first specific medicine for the treatment of rapidly progressive Autosomal Dominant Polycystic Kidney Disease (ADPKD), biomarker discovery has gained renewed interest as it is widely recognized that these will be crucial in clinical decision-making, serving as either prognostic or predictive tools. Since the marketing authorization was first issued in 2015 for ADPKD, tolvaptan has remained the sole pharmacological compound specifically targeting the disease. For ADPKD patients it is an invaluable medicine for retarding disease progression. Although the field of overall biomarker discovery and validation has been detailed in several publications, the role of inflammation remains largely overlooked in ADPKD. The current work aims to provide the reader with an updated review of inflammation biomarkers research in ADPKD, highlighting the role of urinary MCP-1 (monocyte chemoattractant protein-1) as the most promising tool.

Understanding the Support Needs of People with Autosomal Dominant Polycystic Kidney Disease: A Qualitative Phenomenological Descriptive Study

INTRODUCTION

Autosomal dominant polycystic kidney disease (ADPKD) is a prevalent hereditary kidney disease and the fourth most common cause of kidney failure. Patients may be aware of their condition from an early age or discover it unexpectedly, with varying levels of familial knowledge about the disease. This chronic condition presents significant challenges for healthcare professionals. The study aimed to investigate how people with ADPKD experience their participation in a dedicated ADPKD clinic and to investigate their support needs in managing their disease in everyday life.

METHODS

A qualitative phenomenological descriptive study was conducted, involving semi-structured telephone interviews with patients who attended a newly established dedicated ADPKD clinic between March and April 2023. The data were analyzed using Malterud's principles of systematic text condensation.

RESULTS

In total, 18 out of 22 patients agreed to participate in the interviews. Six themes emerged from the interviews. Participants expressed feelings of uncertainty about their future and highlighted the necessity for personalized care tailored to their individual circumstances. They reported challenges in coping with emotions associated with the disease and sought assistance in making difficult decisions. Maintaining control over their health and illness was a significant theme, alongside a desire for increased knowledge about their condition.

CONCLUSION

Our study supports existing knowledge in this area. In this study, the participants experienced satisfaction with the dedicated ADPKD clinic, feeling well informed, listened to, and more at ease after the check-up. Investing in a dedicated ADPKD clinic could help alleviate the uncertainty that many people with ADPKD experience.

Change in kidney volume growth rate and renal outcomes of tolvaptan treatment in autosomal dominant polycystic kidney disease: post-hoc analysis of TEMPO 3:4 trial

BACKGROUND

Despite of long-lasting tolvaptan treatment, individual renal outcomes are unclear in autosomal dominant polycystic kidney disease (ADPKD). This post-hoc analysis of the TEMPO 3:4 trial aimed to evaluate the predictability of estimated height-adjusted total kidney volume growth rate (eHTKV-α) on renal outcomes.

METHODS

In TEMPO 3:4, 1445 patients with ADPKD were randomised to tolvaptan or placebo for 3 years. The present analysis included patients with total kidney volume (TKV) data available at baseline and month 12 (tolvaptan, n = 812; placebo, n = 453); tolvaptan-assigned patients were grouped into quartiles based on percent change in eHTKV-α from baseline at 1 year. Clinical parameters were compared between quartiles, and regression analyses evaluated the predictive value of 1-year percent change in eHTKV-α and other factors on annual changes in TKV and estimated GFR (eGFR) over 3 years.

RESULTS

Trend tests identified significant differences between quartiles for several baseline parameters. Multivariate regression models confirmed that 1-year percent change in eHTKV-α was a significant predictor of annual changes in both TKV and eGFR over 3 years. Other significant predictors of annual changes in TKV and eGFR over 3 years were sex, age and body mass index, and first-year change in eGFR, race and baseline eGFR, respectively. Predicting factors using urine osmolality and plasma copeptin levels were not significant by backward stepwise selection analysis.

CONCLUSIONS

1-year percent change in eHTKV-α is useful biomarker to identify treatment good responders and may be utilized for early estimate of trial outcomes of new drugs in ADPKD.

Tolvaptan safety in autosomal-dominant polycystic kidney disease; a focus on idiosyncratic drug-induced liver injury liabilities

Tolvaptan is a vasopressin V2 receptor antagonist which has proven to be an effective and mostly well-tolerated agent for the treatment of autosomal-dominant polycystic kidney disease. However, its administration is associated with rare but serious idiosyncratic liver injury, which has warranted a black box warning on the drug labels and frequent monitoring of liver blood tests in the clinic. This review outlines mechanistic investigations that have been conducted to date and constructs a working narrative as an explanation for the idiosyncratic drug-induced liver injury (IDILI) events that have occurred thus far. Potential risk factors which may contribute to individual susceptibility to DILI reactions are addressed, and key areas for future investigative/clinical development are highlighted.

Tolvaptan and Autosomal Dominant Polycystic Kidney Disease Progression in Individuals Aged 18-35 Years: A Pooled Database Analysis

Rational & Objective

Data are limited regarding the long-term efficacy of tolvaptan in adults aged 18-35 years with autosomal dominant polycystic kidney disease (ADPKD) at increased risk of rapid progression. We assessed the effects of tolvaptan within a larger population of younger adults and over longer follow-up than individual clinical trials could provide.

Study Design

Pooled database study.

Setting & Study Populations

A consolidated clinical study database with ADPKD patients aged 18-35 years.

Selection Criteria for Studies

Studies that enrolled patients who received either tolvaptan or standard-of-care treatment not including tolvaptan.

Data Extraction

Annual rate of change in estimated glomerular filtration rate (eGFR) and time to kidney failure.

Analytical Approach

For individuals participating in multiple studies, their data were longitudinally linked to extend the follow-up period. We matched tolvaptan-treated patients with controls based on age, sex, chronic kidney disease stage, eGFR, and, where possible, Mayo Imaging Classification. We compared eGFR decline between groups using mixed-effects modeling.

Results

The matched analysis set encompassed 204 tolvaptan-treated individuals and 204 controls. Median follow-up was 4.6 years for the tolvaptan group and 1.7 years for controls. In the mixed-effects model, the eGFR decline rate (in mL/min/1.73 m2/year) was -2.58 for the tolvaptan cohort and -4.28 for controls. This indicates reduction in the eGFR decline rate by 1.69 mL/min/1.73 m2/year (95% confidence interval: 0.87-2.52; P < 0.001) with tolvaptan, a 40% improvement. Extrapolating eGFR over 35 years, tolvaptan could delay kidney failure onset by approximately 11 years.

Limitations

Median follow-up was shorter in the control cohort than the tolvaptan cohort. The projection of time to kidney failure assumed a linear model of eGFR decline.

Conclusions

This analysis offers insights into the anticipated treatment benefits of tolvaptan for young adults with ADPKD. These findings are crucial for weighing treatment benefits against any associated risks.

Effectiveness of tolvaptan on renal replacement therapy in patients with autosomal dominant polycystic kidney disease: a retrospective cohort study from the TriNetX global collaborative network

BACKGROUND AND HYPOTHESIS

Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a major genetic contributor to end-stage kidney disease (ESKD). Current evidence on tolvaptan primarily focuses on slowing estimated glomerular filtration rate (eGFR) decline and kidney volume growth. However, direct confirmation of its effectiveness in reducing the need for hemodialysis in ESKD remains limited.

METHODS

We included ADPKD patients aged ≥18 years using TriNetx data from Sep 2, 2018, to Sep 3, 2023. Propensity score matching (PSM) ensured baseline comparability (standardized mean difference (SMD) <0.1). Hazard ratios (HRs) with 95% confidence intervals (CIs) evaluated outcomes, and subgroup analyses were performed.

RESULTS

After 1:1 PSM, both groups comprised 673 patients. The average age was 45, with generally good health (3-5% diabetes, 2-3% ischemic heart disease). Baseline eGFR averaged ∼55 ml/min/1.732m2. Post-matching, all SMDs were <0.1, indicating successful matching. Tolvaptan users exhibited lower eGFR (51.45 ± 30.09 vs. 57.37 ± 33.65, p < 0.001) and higher risk of stage 4-CKD (HR: 2.436, 95% CI:1.649, 3.599) compared to non-users. However, tolvaptan users showed significantly reduced chances of initiating hemodialysis (HR:0.362, 95%CI:0.176, 0.745), experiencing urinary tract infections (HR:0.581, 95%CI:0.354, 0.956), and all-cause mortality (HR:0.355, 95% CI:0.180, 0.700). Kaplan-Meier curves for hemodialysis initiation indicated higher survival rates among tolvaptan users across age and number of medication refill subgroups.

CONCLUSIONS

This real-world study, employing precise matching, reveals tolvaptan's role in reducing hemodialysis initiation risk in ADPKD, despite initial hemodynamic-induced lower eGFR.

Ciliopathy organoid models: a comprehensive review

Cilia are membrane-bound organelles found on the surface of most mammalian cell types and play numerous roles in human physiology and development, including osmo- and mechanosensation, as well as signal transduction. Ciliopathies are a large group of, usually rare, genetic disorders resulting from abnormal ciliary structure or ciliary dysfunction that have a high collective prevalence. Autosomal dominant or recessive polycystic kidney disease (ADPKD/ARPKD), Bardet-Biedl-Syndrome, and primary ciliary dyskinesia (PCD) are the most frequent etiologies. Rodent and zebrafish models have improved the understanding of ciliopathy pathophysiology. Yet, the limitations of these genetically modified animal strains include the inability to fully replicate the phenotypic heterogeneity found in humans, including variable multiorgan involvement. Organoids, self-assembled three-dimensional cell-based models derived from human induced pluripotent stem cells (iPSCs) or primary tissues, can recapitulate certain aspects of the development, architecture, and function of the target organ "in the dish." The potential of organoids to model patient-specific genotype-phenotype correlations has increased their popularity in ciliopathy research and led to the first preclinical organoid-based ciliopathy drug screens. This review comprehensively summarizes and evaluates current ciliopathy organoid models, focusing on kidney, airway, liver, and retinal organoids, as well as the specific methodologies used for their cultivation and for interrogating ciliary dysfunction.

Current perspectives and trends of the research on hypertensive nephropathy: a bibliometric analysis from 2000 to 2023

Hypertensive nephropathy continues to be a major cause of end-stage renal disease and poses a significant global health burden. Despite the staggering development of research in hypertensive nephropathy, scientists and clinicians can only seek out useful information through articles and reviews, it remains a hurdle for them to quickly track the trend in this field. This study uses the bibliometric method to identify the evolutionary development and recent hotspots of hypertensive nephropathy. The Web of Science Core Collection database was used to extract publications on hypertensive nephropathy from January 2000 to November 2023. CiteSpace was used to capture the patterns and trends from multi-perspectives, including countries/regions, institutions, keywords, and references. In total, 557 publications on hypertensive nephropathy were eligible for inclusion. China (n = 208, 37.34%) was the most influential contributor among all the countries. Veterans Health Administration (n = 19, 3.41%) was found to be the most productive institution. Keyword bursting till now are renal fibrosis, outcomes, and mechanisms which are predicted to be the potential frontiers and hotspots in the future. The top seven references were listed, and their burst strength was shown. A comprehensive overview of the current status and research frontiers of hypertensive nephropathy has been provided through the bibliometric perspective. Recent advancements and challenges in hypertensive nephropathy have been discussed. These findings can offer informative instructions for researchers and scholars.

Clinical characteristics and outcomes of kidney transplantation in autosomal dominant polycystic kidney disease patients

BACKGROUND

Kidney transplantation (KT) is the best kidney replacement treatment for autosomal dominant polycystic kidney disease (ADPKD). We aimed to investigate the clinical characteristics and outcomes of KT in ADPKD patients compared to those in non-ADPKD patients.

METHODS

We retrospectively analyzed KT recipients in two Korean transplantation centers from 2005 to 2020. Propensity score-matching and Cox regression analysis were used to assess the clinical outcomes of ADPKD compared to non-ADPKD and identify prognostic factors influencing outcomes in ADPKD.

RESULTS

Among a total of 4452 KT patients, 189 (4.2%) were ADPKD patients. Median age at transplantation was 53.0 and 47.0 in ADPKD and non-ADPKD patients, respectively. In both groups, living-donor KT was more common than deceased-donor KT. The ADPKD group had a 4.09-fold higher risk of post-transplant diabetes mellitus and a 1.65-fold higher risk of post-transplant infection compared to the non-ADPKD group; however, subjects with ADPKD had similar risk of rejection, graft failure, and mortality. In the ADPKD group, kidney volume decreased after KT, irrespective of kidney volume status (Mayo classification), while the size of hepatic cysts increased. Neither kidney volume nor nephrectomy of native kidneys were associated with risk of infection, graft failure, or mortality in the ADPKD group.

CONCLUSIONS

ADPKD patients have a higher risk of post-transplant diabetes mellitus and infection than non-ADPKD patients, with no significant impact of kidney volume or nephrectomy on post-transplant outcomes.

Early treatment with 2-deoxy-d-glucose reduces proliferative proteins in the kidney and slows cyst growth in a hypomorphic Pkd1 mouse model of autosomal dominant polycystic kidney disease (PKD)

In autosomal dominant polycystic kidney disease (ADPKD) there is cyst growth in the kidneys that leads to chronic kidney disease often requiring dialysis or kidney transplantation. There is enhanced aerobic glycolysis (Warburg effect) in the cyst lining epithelial cells that contributes to cyst growth. The glucose mimetic, 2-Deoxy-d-glucose (2-DG) inhibits glycolysis. The effect of early and late administration of 2-DG on cyst growth and kidney function was determined in Pkd1RC/RC mice, a hypomorphic PKD model orthologous to human disease. Early administration of 2-DG resulted in decreased kidney weight, cyst index, cyst number and cyst size, but no change in kidney function. 2-DG decreased proliferation. a major mediator of cyst growth, of cells lining the cyst. Late administration of 2-DG did not have an effect on cyst growth or kidney function. To determine mechanisms of decreased proliferation, an array of mTOR and autophagy proteins was measured in the kidney. 2-DG suppressed autophagic flux in Pkd1RC/RC kidneys and decreased autophagy proteins, ATG3, ATG5 and ATG12-5. 2-DG had no effect on p-mTOR or p-S6 (mTORC1) and decreased p-AMPK. 2-DG decreased p-4E-BP1, p-c-Myc and p-ERK that are known to promote proliferation and cyst growth in PKD. 2-DG decreased p-AKTS473, a marker of mTORC2. So the role of mTORC2 in cyst growth was determined. Knockout of Rictor (mTORC2) in Pkd1 knockout mice did not change the PKD phenotype. In summary, 2-DG decreases proliferation in cells lining the cyst and decreases cyst growth by decreasing proteins that are known to promote proliferation. In conclusion, the present study reinforces the therapeutic potential of 2-DG for use in patients with ADPKD.

Structural basis of tolvaptan binding to the vasopressin V2 receptor

The vasopressin V2 receptor (V2R) is a validated therapeutic target for autosomal dominant polycystic kidney disease (ADPKD), with tolvaptan being the first FDA-approved antagonist. Herein, we used Gaussian accelerated molecular dynamics simulations to investigate the spontaneous binding of tolvaptan to both active and inactive V2R conformations at the atomic-level. Overall, the binding process consists of two stages. Tolvaptan binds initially to extracellular loops 2 and 3 (ECL2/3) before overcoming an energy barrier to enter the pocket. Our simulations result highlighted key residues (e.g., R181, Y205, F287, F178) involved in this process, which were experimentally confirmed by site-directed mutagenesis. This work provides structural insights into tolvaptan-V2R interactions, potentially aiding the design of novel antagonists for V2R and other G protein-coupled receptors.

Liver safety of tolvaptan in patients with autosomal dominant polycystic kidney disease: interim data from a post-authorization safety study

Background

After the risk of drug-induced liver injury was detected during tolvaptan clinical development for the treatment of autosomal dominant polycystic kidney disease (ADPKD), a post-marketing pharmacovigilance study was required for European Union regulatory approval.

Methods

This is an interim analysis from a prospective, observational study enrolling patients prescribed tolvaptan for ADPKD in routine clinical practice. Data were obtained through physician records collected during regular care. Per the prescribing label, liver transaminases were to be monitored monthly for the first 18 months of treatment and once every 3 months thereafter. Patients and physicians were required to report adverse events suggestive of serious and potentially fatal liver injury. Data collection was from October 2016 to April 2022.

Results

Of 2074 patients (median follow-up 528 days), alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels ≥3 times the upper limit of normal (ULN) were reported in 75 (3.6%) patients. At data cut-off, the enzyme elevations were confirmed for 65 patients. Among the 65 confirmed patients, in addition to transaminase elevations, there were 69 adverse events suggestive of liver injury. Tolvaptan was interrupted or withdrawn in 59/65 (90.8%) participants with confirmed ALT or AST ≥3 times the ULN, with most transaminase elevations and adverse events resolved or resolving at data cut-off. No liver enzyme elevations met laboratory criteria for Hy's law cases.

Conclusions

Transaminase elevations occurred post-marketing in a similar proportion of patients as reported in clinical trials (4.4-5.6%). Regular monitoring per label facilitates prompt detection of liver adverse events and intervention to mitigate the risk of severe injury.

Autosomal Dominant Polycystic Kidney Disease

Over 50% of people affected with autosomal dominant polycystic kidney disease (ADPKD) will develop kidney failure, making ADPKD the 4th most common cause of end-stage kidney disease. ADPKD is a systemic condition affecting the kidneys, liver, heart, vasculature, and other organ systems. A minority of patients may have severe complications such as massive hepatomegaly from a polycystic liver or rupture of an intracranial aneurysm. Recent advances in the understanding of genetics, prognosis, and treatment of this condition have allowed delivery of personalized treatment capable of changing the natural history of the disease. This review focuses on diagnosis, determining risk of kidney failure, treatment, blood pressure management, and preimplantation genetic testing related to ADPKD.

Evaluation of tolvaptan-associated hepatic disorder using different national pharmacovigilance databases

Tolvaptan-associated hepatic disorder is a rare, but lethal adverse event; however, the precise risk and time of onset remain unclear. This study aimed to characterize the severity, time‑to‑onset, and outcomes of hepatic disorder based on patient age and sex. Patient data were acquired from the Japanese Adverse Drug Event Report database (JADER) and the JAPIC AERS database, which consists of the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) processed by the Japan Pharmaceutical Information Center. Hepatic disorder was classified as severe or nonsevere. Tolvaptan use was associated with hepatic disorder in analyses using the FAERS [Severe hepatic disorder: reporting odds ratio (ROR) 4.93, 95% confidence interval (CI) 4.33‒5.61; information component (IC) 2.11, 95% CI 1.92‒2.29; nonsevere hepatic disorder: ROR 6.78, 95% CI 6.01‒7.65; IC 2.51, 95% CI 2.33‒2.68] and the JADER (severe hepatic disorder: ROR 4.21, 95% CI 3.57‒4.97; IC 1.86, 95% CI 1.63‒2.10; nonsevere hepatic disorder: ROR 4.27, 95% CI 3.68‒4.95; IC 1.83, 95% CI 1.62‒2.04). A time‑to‑onset analysis revealed that the median onset time was significantly longer in patients aged < 60 years compared with patients aged ≥ 60, regardless of the severity (FAERS: severe hepatic disorder 7 vs. 58 days, p < 0.0001; nonsevere hepatic disorder 8 vs. 52.5 days, p < 0.0001; JADER: severe hepatic disorder 9.5 vs. 32 days, p = 0.0017; nonsevere hepatic disorder 9 vs. 89 days, p < 0.0001). Severe outcomes were observed, regardless of the severity of hepatic disorder. Patients should be monitored for liver function based on age to prevent fatal outcomes.

Interventions for preventing the progression of autosomal dominant polycystic kidney disease

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is the leading inherited cause of kidney disease. Clinical management has historically focused on symptom control and reducing associated complications. Improved understanding of the molecular and cellular mechanisms involved in kidney cyst growth and disease progression has resulted in new pharmaceutical agents targeting disease pathogenesis and preventing disease progression. However, the role of disease-modifying agents for all people with ADPKD is unclear. This is an update of a review first published in 2015.

OBJECTIVES

We aimed to evaluate the benefits and harms of interventions to prevent the progression of ADPKD and the safety based on patient-important endpoints, defined by the Standardised Outcomes in NephroloGy-Polycystic Kidney Disease (SONG-PKD) core outcome set, and general and specific adverse effects.

SEARCH METHODS

We searched the Cochrane Kidney and Transplants Register of Studies up to 13 August 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any interventions for preventing the progression of ADPKD with other interventions, placebo, or standard care were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study risks of bias and extracted data. Summary estimates of effects were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We included 57 studies (8016 participants) that investigated 18 pharmacological interventions (vasopressin 2 receptor (V2R) antagonists, antihypertensive therapy, mammalian target of rapamycin (mTOR) inhibitors, somatostatin analogues, antiplatelet agents, eicosapentaenoic acids, statins, kinase inhibitors, diuretics, anti-diabetic agents, water intake, dietary intervention, and supplements) in this review. Compared to placebo, the V2R antagonist tolvaptan probably preserves eGFR (3 studies, 2758 participants: MD 1.26 mL/min/1.73 m2, 95% CI 0.73 to 1.78; I2 = 0%) and probably slows total kidney volume (TKV) growth in adults (1 study, 1307 participants: MD -2.70 mL/cm, 95% CI -3.24 to -2.16) (moderate certainty evidence). However, there was insufficient evidence to determine tolvaptan's impact on kidney failure and death. There may be no difference in serious adverse events; however, treatment probably increases nocturia, fatigue and liver enzymes, may increase dry mouth and thirst, and may decrease hypertension and urinary and upper respiratory tract infections. Data on the impact of other therapeutic interventions were largely inconclusive. Compared to placebo, somatostatin analogues probably decrease TKV (6 studies, 500 participants: SMD -0.33, 95% CI -0.51 to -0.16; I2 = 11%), probably have little or no effect on eGFR (4 studies, 180 participants: MD 4.11 mL/min/1.73 m3, 95% CI -3.19 to 11.41; I2 = 0%) (moderate certainty evidence), and may have little or no effect on kidney failure (2 studies, 405 participants: RR 0.64, 95% CI 0.16 to 2.49; I2 = 39%; low certainty evidence). Serious adverse events may increase (2 studies, 405 participants: RR 1.81, 95% CI 1.01 to 3.25; low certainty evidence). Somatostatin analogues probably increase alopecia, diarrhoea or abnormal faeces, dizziness and fatigue but may have little or no effect on anaemia or infection. The effect on death is unclear. Targeted low blood pressure probably results in a smaller per cent annual increase in TKV (1 study, 558 participants: MD -1.00, 95% CI -1.67 to -0.33; moderate certainty evidence) compared to standard blood pressure targets, had uncertain effects on death, but probably do not impact other outcomes such as change in eGFR or adverse events. Kidney failure was not reported. Data comparing antihypertensive agents, mTOR inhibitors, eicosapentaenoic acids, statins, vitamin D compounds, metformin, trichlormethiazide, spironolactone, bosutinib, curcumin, niacinamide, prescribed water intake and antiplatelet agents were sparse and inconclusive. An additional 23 ongoing studies were also identified, including larger phase III RCTs, which will be assessed in a future update of this review.

AUTHORS' CONCLUSIONS

Although many interventions have been investigated in patients with ADPKD, at present, there is little evidence that they improve patient outcomes. Tolvaptan is the only therapeutic intervention that has demonstrated the ability to slow disease progression, as assessed by eGFR and TKV change. However, it has not demonstrated benefits for death or kidney failure. In order to confirm the role of other therapeutic interventions in ADPKD management, large RCTs focused on patient-centred outcomes are needed. The search identified 23 ongoing studies, which may provide more insight into the role of specific interventions.

Applying a Deep Learning Model for Total Kidney Volume Measurement in Autosomal Dominant Polycystic Kidney Disease

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary renal disease leading to end-stage renal disease. Total kidney volume (TKV) measurement has been considered as a surrogate in the evaluation of disease severity and prognostic predictor of ADPKD. However, the traditional manual measurement of TKV by medical professionals is labor-intensive, time-consuming, and human error prone.

MATERIALS AND METHODS

In this investigation, we conducted TKV measurements utilizing magnetic resonance imaging (MRI) data. The dataset consisted of 30 patients with ADPKD and 10 healthy individuals. To calculate TKV, we trained models using both coronal- and axial-section MRI images. The process involved extracting images in Digital Imaging and Communications in Medicine (DICOM) format, followed by augmentation and labeling. We employed a U-net model for image segmentation, generating mask images of the target areas. Subsequent post-processing steps and TKV estimation were performed based on the outputs obtained from these mask images.

RESULTS

The average TKV, as assessed by medical professionals from the testing dataset, was 1501.84 ± 965.85 mL with axial-section images and 1740.31 ± 1172.21 mL with coronal-section images, respectively (p = 0.73). Utilizing the deep learning model, the mean TKV derived from axial- and coronal-section images was 1536.33 ± 958.68 mL and 1636.25 ± 964.67 mL, respectively (p = 0.85). The discrepancy in mean TKV between medical professionals and the deep learning model was 44.23 ± 58.69 mL with axial-section images (p = 0.8) and 329.12 ± 352.56 mL with coronal-section images (p = 0.9), respectively. The average variability in TKV measurement was 21.6% with the coronal-section model and 3.95% with the axial-section model. The axial-section model demonstrated a mean Dice Similarity Coefficient (DSC) of 0.89 ± 0.27 and an average patient-wise Jaccard coefficient of 0.86 ± 0.27, while the mean DSC and Jaccard coefficient of the coronal-section model were 0.82 ± 0.29 and 0.77 ± 0.31, respectively.

CONCLUSION

The integration of deep learning into image processing and interpretation is becoming increasingly prevalent in clinical practice. In our pilot study, we conducted a comparative analysis of the performance of a deep learning model alongside corresponding axial- and coronal-section models, a comparison that has been less explored in prior research. Our findings suggest that our deep learning model for TKV measurement performs comparably to medical professionals. However, we observed that varying image orientations could introduce measurement bias. Specifically, our AI model exhibited superior performance with axial-section images compared to coronal-section images.

Ketogenic Interventions in Autosomal Dominant Polycystic Kidney Disease: A Comprehensive Review of Current Evidence

Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a genetic disorder characterized by the development and enlargement of multiple kidney cysts, leading to progressive kidney function decline. To date, Tolvaptan, the only approved treatment for this condition, is able to slow down the loss of annual kidney function without stopping the progression of the disease. Furthermore, this therapy is approved only for patients with rapid disease progression and its compliance is problematic because of the drug's impact on quality of life. The recent literature suggests that cystic cells are subject to several metabolic dysregulations, particularly in the glucose pathway, and mitochondrial abnormalities, leading to decreased oxidative phosphorylation and impaired fatty acid oxidation. This finding paved the way for new lines of research targeting potential therapeutic interventions for ADPKD. In particular, this review highlights the latest studies on the use of ketosis, through ketogenic dietary interventions (daily calorie restriction, intermittent fasting, time-restricted feeding, ketogenic diets, and exogenous ketosis), as a potential strategy for patients with ADPKD, and the possible involvement of microbiota in the ketogenic interventions' effect.

The Impact of Autosomal Dominant Polycystic Kidney Disease in Children: A Nephrological, Nutritional, and Psychological Point of View

Autosomal dominant polycystic kidney disease (ADPKD) is a hereditary disorder characterized by the formation of numerous fluid-filled cysts in the kidneys, leading to progressive renal failure and various extrarenal complications, including hypertension. This review explores the genetic basis of ADPKD, including emerging evidence of epigenetic mechanisms in modulating gene expression and disease progression in ADPKD. Furthermore, it proposes to examine the pathological characteristics of this condition at the nephrological, cardiovascular, nutritional, and psychological levels, emphasizing that the follow-up of patients with ADPKD should be multidisciplinary from a young pediatric age.

Progressive Polycystic Kidney Disease in an Infant Girl With TSC2/PKD1 Contiguous Gene Syndrome

TSC2/PKD1 contiguous gene syndrome is caused by deletions involving the TSC2 and PKD1 genes that lead to tuberous sclerosis complex and autosomal dominant polycystic kidney disease. It is characterized by early-onset severe cystic kidney disease with progressive enlargement of the kidneys and the cysts. As it can lead to early hypertension and an accelerated decline of kidney function, early genetic testing is needed for early diagnosis of this syndrome, and more frequent imaging-based examinations are necessary to assess disease progression and determine appropriate management. We report the case of an infant girl with TSC2/PKD1 contiguous gene syndrome who presented with epileptic seizures. Brain magnetic resonance imaging (MRI) revealed subependymal nodules and cortical tubers, and abdominal MRI revealed polycystic kidney lesions and enlargement of both kidneys. TSC2/PKD1 contiguous gene syndrome was suspected from her radiological features, and we confirmed the presence of a deletion in the girl's genome, which included the TSC2 and PKD1 genes, via microarray analysis. Thereafter, we evaluated the change in kidney size via repeated abdominal MRI. The polycystic kidney lesions enlarged, and the patient developed hypertension in early childhood, for which we administered an angiotensin-converting enzyme inhibitor. We emphasize the importance of evaluation with longitudinal abdominal imaging because renal cysts tend to enlarge rapidly and induce hypertension, as demonstrated in our case.

The Vasopressin Receptor Antagonist Tolvaptan Counteracts Tumor Growth in a Murine Xenograft Model of Small Cell Lung Cancer

We have previously demonstrated that the vasopressin type 2 receptor (AVPR2) antagonist tolvaptan reduces cell proliferation and invasion and triggers apoptosis in different human cancer cell lines. To study this effect in vivo, a xenograft model of small cell lung cancer was developed in Fox1nu/nu nude mice through the subcutaneous inoculation of H69 cells, which express AVPR2. One group of mice (n = 5) was treated with tolvaptan for 60 days, whereas one group (n = 5) served as the control. A reduced growth was observed in the tolvaptan group in which the mean tumor volume was significantly smaller on day 60 compared to the control group. In the latter group, a significantly lower survival was observed. The analysis of excised tumors revealed that tolvaptan effectively inhibited the cAMP/PKA and PI3K/AKT signaling pathways. The expression of the proliferative marker proliferating cell nuclear antigen (PCNA) was significantly lower in tumors excised from tolvaptan-treated mice, whereas the expression levels of the apoptotic marker caspase-3 were higher than those in control animals. Furthermore, tumor vascularization was significantly lower in the tolvaptan group. Overall, these findings suggest that tolvaptan counteracts tumor progression in vivo and, if confirmed, might indicate a possible role of this molecule as an adjuvant in anticancer strategies.

Renal ultrasonography predicts worsening renal function in patients with heart failure under tolvaptan administration

AIMS

Renal dysfunction in patients with chronic heart failure predicts a poor prognosis. Tolvaptan has a diuretic effect in patients with chronic kidney disease and heart failure without adverse effects on renal function. We aimed to determine the effects of tolvaptan and predictors of worsening renal function in patients with heart failure.

METHODS AND RESULTS

This post hoc analysis was a sub-analysis of a single-centre prospectively randomized trial on the early and short-term tolvaptan administration. We enrolled 201 participants with decompensated heart failure between January 2014 and March 2019 (early group, n = 104; age: 79.0 ± 12.8 years; late group, n = 97; age: 80.3 ± 10.8 years). Renal ultrasonography was performed before and after the administration of tolvaptan. Urine output and oral water intake significantly increased during tolvaptan administration. The difference between water intake and urine volume increased during tolvaptan administration. Changes in body weight, blood pressure, heart rate, and estimated glomerular filtration rate (eGFR) in both groups were comparable. The changes in peak-systolic velocity (PSV), acceleration time (AT) of the renal arteries, and resistance index were comparable. The changes in PSV and end-diastolic velocity (EDV) of the interlobar arteries increased following tolvaptan administration (Δmax PSV: 0.0 ± 14.8 cm/s before tolvaptan vs. 5.6 ± 15.7 cm/s after tolvaptan, P = 0.002; Δmean PSV: 0.4 ± 12.3 vs. 4.9 ± 12.7 cm/s, P = 0.002; Δmax EDV: -0.2 ± 3.5 vs. 1.4 ± 4.0 cm/s, P = 0.001; Δmean EDV: -0.0 ± 3.1 vs. 1.1 ± 3.4 cm/s, P = 0.003). The renal artery AT was negatively correlated with the eGFR (Δmax AT: beta = -0.2354, P = 0.044; Δmean AT: beta = -0.2477, P = 0.035).

CONCLUSIONS

Tolvaptan increased the PSV and EDV of the interlobar artery, which may mean tolvaptan increased renal blood flow. The renal artery AT may be a surrogate for worsening renal function.

HL156A, an AMP-Activated Protein Kinase Activator, Inhibits Cyst Growth in Autosomal Dominant Polycystic Kidney Disease

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is the most prevalent genetic kidney disorder. While metformin has demonstrated the ability to inhibit cyst growth in animal models of ADPKD via activation of adenosine monophosphate-activated protein kinase (AMPK), its effectiveness in humans is limited due to its low potency. This study explored the impact of HL156A, a new and more potent AMPK activator, in a mouse model of ADPKD.

METHODS

To investigate whether HL156A inhibits the proliferation of renal cyst cells in ADPKD in vitro, exogenous human telomerase reverse transcriptase (hTERT)-immortalized renal cyst cells from ADPKD patients were treated with HL156A, and an MTT (dimethylthiazol-diphenyltetrazolium bromide) assay was performed. To assess the cyst-inhibitory effect of HL156A in vivo, we generated Pkd1 conditional knockout (KO) mice with aquaporin 2 (AQP2)-Cre, which selectively expresses Cre recombinase in the collecting duct. The effectiveness of HL156A in inhibiting cyst growth and improving renal function was confirmed by measuring the number of cysts and blood urea nitrogen (BUN) levels in the collecting duct-specific Pkd1 KO mice.

RESULTS

When cyst cells were treated with up to 20 µM of metformin or HL156A, HL156A reduced cell viability by 25% starting at a concentration of 5 µM, whereas metformin showed no effect. When AQP2-Cre male mice were crossed with Pkd1flox/flox female mice, and when AQP2-Cre female mice were crossed with Pkd1flox/flox male mice, the number of litters produced by both groups was comparable. In collecting duct-specific Pkd1 KO mice, HL156A was found to inhibit cyst growth, reducing both the number and size of cysts. Furthermore, it was confirmed that kidney function improved as HL156A treatment led to a reduction in elevated BUN levels. Lastly, it was observed that the increase in AMPK phosphorylation induced by HL156A decreased ERK phosphorylation and α-SMA expression.

CONCLUSION

HL156A has potential as a drug that can restore kidney function in ADPKD patients by inhibiting cyst growth.

Rapamycin-encapsulated nanoparticle delivery in polycystic kidney disease mice

Rapamycin slows cystogenesis in murine models of polycystic kidney disease (PKD) but failed in clinical trials, potentially due to insufficient drug dosing. To improve drug efficiency without increasing dose, kidney-specific drug delivery may be used. Mesoscale nanoparticles (MNP) selectively target the proximal tubules in rodents. We explored whether MNPs can target cystic kidney tubules and whether rapamycin-encapsulated-MNPs (RapaMNPs) can slow cyst growth in Pkd1 knockout (KO) mice. MNP was intravenously administered in adult Pkd1KO mice. Serum and organs were harvested after 8, 24, 48 or 72 h to measure MNP localization, mTOR levels, and rapamycin concentration. Pkd1KO mice were then injected bi-weekly for 6 weeks with RapaMNP, rapamycin, or vehicle to determine drug efficacy on kidney cyst growth. Single MNP injections lead to kidney-preferential accumulation over other organs, specifically in tubules and cysts. Likewise, one RapaMNP injection resulted in higher drug delivery to the kidney compared to the liver, and displayed sustained mTOR inhibition. Bi-weekly injections with RapaMNP, rapamycin or vehicle for 6 weeks resulted in inconsistent mTOR inhibition and little change in cyst index, however. MNPs serve as an effective short-term, kidney-specific delivery system, but long-term RapaMNP failed to slow cyst progression in Pkd1KO mice.

Data driven approach to characterize rapid decline in autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is a genetic kidney disease with high phenotypic variability. Furthering insights into patients' ADPKD progression could lead to earlier detection, management, and alter the course to end stage kidney disease (ESKD). We sought to identify patients with rapid decline (RD) in kidney function and to determine clinical factors associated with RD using a data-driven approach. A retrospective cohort study was performed among patients with incident ADPKD (1/1/2002-12/31/2018). Latent class mixed models were used to identify RD patients using differences in eGFR trajectories over time. Predictors of RD were selected based on agreements among feature selection methods, including logistic, regularized, and random forest modeling. The final model was built on the selected predictors and clinically relevant covariates. Among 1,744 patients with incident ADPKD, 125 (7%) were identified as RD. Feature selection included 42 clinical measurements for adaptation with multiple imputations; mean (SD) eGFR was 85.2 (47.3) and 72.9 (34.4) in the RD and non-RD groups, respectively. Multiple imputed datasets identified variables as important features to distinguish RD and non-RD groups with the final prediction model determined as a balance between area under the curve (AUC) and clinical relevance which included 6 predictors: age, sex, hypertension, cerebrovascular disease, hemoglobin, and proteinuria. Results showed 72%-sensitivity, 70%-specificity, 70%-accuracy, and 0.77-AUC in identifying RD. 5-year ESKD rates were 38% and 7% among RD and non-RD groups, respectively. Using real-world routine clinical data among patients with incident ADPKD, we observed that six variables highly predicted RD in kidney function.