Polycystic Kidney Disease and Dialysis: Treatment Options for ESRD
Primary Treatment Recommendation
Kidney transplantation should be considered the preferred treatment option for PKD patients progressing to ESRD, as it offers superior outcomes in terms of mortality and quality of life compared to dialysis. 1
Timing of Renal Replacement Therapy
Dialysis initiation should be based on clinical symptoms rather than GFR alone. The decision to start dialysis should occur when one or more of the following are present: 2, 1
- Symptoms or signs attributable to kidney failure (serositis, acid-base or electrolyte abnormalities, pruritus)
- Inability to control volume status or blood pressure
- Progressive deterioration in nutritional status refractory to dietary intervention
- Cognitive impairment
This typically occurs when GFR is between 5-10 mL/min/1.73 m², though symptoms should drive the decision, not the number alone. 2
Transplantation as First-Line Therapy
Living donor preemptive kidney transplantation should be considered when GFR falls below 20 mL/min/1.73 m² with evidence of progressive and irreversible CKD over 6-12 months. 2, 1 This approach avoids dialysis entirely and provides the best long-term outcomes.
Dialysis Modality Selection
Hemodialysis
Hemodialysis is a highly effective option for PKD patients, with outcomes that actually surpass the general dialysis population. 3 PKD patients on dialysis demonstrate:
- Lower total mortality compared to non-diabetic ESRD controls (relative risk of death = 0.57) 3
- Higher rates of transplant listing (11.7 vs 8.4 per 100 person-years) 4
- Higher transplantation rates (9.8 vs 4.8 per 100 person-years) 4
- Lower mortality rates (5.6 vs 15.5 per 100 person-years) 4
For hemodialysis, target a Kt/V of 1.4 per session (minimum 1.2) with sessions lasting at least 3 hours for patients with minimal residual renal function. 1
Peritoneal Dialysis
Peritoneal dialysis is an equally suitable and safe option for PKD patients despite historical concerns about limited intra-abdominal space. 5, 6 Evidence demonstrates:
- Similar technique survival rates compared to non-PKD patients 5
- Comparable peritonitis rates (1 episode per 84.5 months) 6
- Similar rates of hernias and leaks as non-PKD patients 5
- Equivalent dialysis adequacy (Kt/V and creatinine clearance) at all time points 6
- Lower mortality in PKD-PD patients compared to general PD population 5
The concern that massive polycystic kidneys preclude peritoneal dialysis is not supported by contemporary evidence. 5, 6
Multidisciplinary Management Approach
PKD patients with progressive CKD should be managed in a multidisciplinary care setting that includes or has access to: 2
- Dietary counseling
- Education about all RRT modalities (hemodialysis, peritoneal dialysis, transplantation)
- Vascular access surgery planning
- Psychological and social support
- Advance care planning discussions
Conservative Management Option
Conservative management without dialysis is an appropriate option for patients who choose not to pursue RRT, particularly those with: 2
- Age ≥75 years with multiple comorbidities
- Frailty or significant functional impairment
- Cognitive impairment
- Limited life expectancy where dialysis may not extend survival
This approach should include comprehensive symptom management, advance care planning, and coordinated end-of-life care. 2
Critical Pitfalls to Avoid
Do not initiate dialysis based solely on GFR level without uremic symptoms present. 2, 1 Early dialysis initiation without symptoms does not improve outcomes and may reduce quality of life.
Do not exclude peritoneal dialysis as an option based solely on kidney size. 5, 6 Contemporary evidence shows PKD is not a contraindication to PD.
Do not offer only one dialysis modality without discussing all options, including transplantation and conservative management. 2 Shared decision-making requires full disclosure of all treatment paths.
Ensure vascular access preservation in stage III-V CKD patients by avoiding unnecessary peripheral venipuncture. 7 This is critical for future hemodialysis access creation.
Prognostic Considerations
PKD patients have distinct advantages on dialysis compared to other ESRD causes, with mortality from extrarenal PKD complications (except polycystic liver disease) being similar or lower than non-diabetic controls. 3 However, only 48% of PKD patients receive adequate predialysis nephrology care (>12 months), suggesting opportunities for earlier intervention and preparation. 4