# ADPKD: recognize risk early and plan ahead

At diagnosis, document family history, BP, kidney imaging, kidney-function trend and proteinuria. Assess progression risk before advanced CKD develops. Mayo classification and serial eGFR inform a discussion of tolvaptan with the specialist. KDIGO recommends initiation in eligible adults at risk of rapid progression with eGFR at least 25 mL/min/1.73 m²; the FDA indication is not written as that numerical cutoff. At eGFR 22, individualized KRT and transplant planning are essential, and starting tolvaptan is outside the standard KDIGO initiation recommendation. This is not a blanket FDA contraindication or an automatic stop rule for someone already taking it.

[KDIGO 2025 ADPKD, corrected April 2026](https://kdigo.org/wp-content/uploads/2026/04/KDIGO-2025-ADPKD-Guideline.pdf) · [FDA JYNARQUE label, 2026](https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/204441s016lbl.pdf) · [REPRISE — PubMed](https://pubmed.ncbi.nlm.nih.gov/29105594/)

Andrew Bland, MD, FACP, FAAP