What are your criteria for starting tolvaptan in adult patients diagnosed with autosomal dominant polycystic kidney disease?

This question is probably a bit too broad to answer in detail here, but in broad strokes, depending on the age, imaging criteria (Mayo class / total kidney volume), and kidney function of the patient, as well as other clinical factors, you assess the patient's risk of rapid disease progression to make a determination and discuss with the patient. The barriers to initiation (REMS, concern about symptoms, cost, etc) should not be used as a reason not to initiate because Jynarque brand exclusivity ends in April 2025 and in my experience, patients tend to be under-treated. It is not yet clear how REMS will be regulated for a generic option but regardless nephrologists should familiarize themselves with the use of this medication ASAP as it rema...