opioid analgesics are considered; if pain continues, then surgical interventions can target renal or hepatic cysts to directly address the cause of pain, with surgical options including renal cyst decortication, renal denervation, and nephrectomy. renal cyst aspiration aspiration with ethanol sclerotherapy can be performed for the treatment of symptomatic simple renal cysts, but can be impractical in advanced patients with multiple cysts. the procedure itself consists in the percutaneous insertion of a needle into the identified cyst, under ultrasound guidance, with subsequent draining the contained liquid; the sclerotherapy is used to avoid liquid reaccumulation that can occur in the cyst, which can result in symptom recurrence. laparoscopic cyst decortication laparoscopic cyst decortication (also referred to as marsupialization) consists in the removal of one or more kidney cysts through laparoscopic surgery, during which cysts are punctured, and the outer wall of the larger cysts is excised with care not to incise the renal parenchyma. this procedure can be useful for pain relief in patients with adpkd, and is usually indicated after earlier cyst aspiration has confirmed that the cyst to be decorticated is responsible for pain. nonrandomised controlled trials conducted in the '90s showed that patients with symptomatic simple renal cysts who had recurrence of symptoms after initial response to simple aspiration could be safely submitted to cyst decortication, with a mean pain-free life between 17 and 24 months after surgery. laparoscopic decortication presents a 5% recurrence rate of renal cysts compared to an 82% recurrence rate obtained with sclerotherapy. neurolysis a novel treatment of specifically the chronic pain experienced by many with adpkd is celiac plexus neurolysis. this involves the chemical ablation of the celiac plexus, to cause a temporary degeneration of targeted nerve fibers. when the nerve fibers degenerate, it causes an interruption in the transmission of nerve signals. this treatment, when successful, provides significant pain relief for a period ranging from a few days to over a year. the procedure may be repeated when the affected nerves have healed and the pain returns. nephrectomy many adpkd patients experience symptomatic sequelae in consequence of the disease, such as cyst hemorrhage, flank pain, recurrent infections, nephrolithiasis, and symptoms of mass effect (i.e., early satiety, nausea and vomiting, and abdominal discomfort), from their enlarged kidneys. in such cases, nephrectomy can be required due to intractable symptoms or when in the course of preparing for kidney transplantation, the native kidneys are found to impinge upon the true pelvis and preclude the placement of a donor allograft. additionally, native nephrectomy may be undertaken in the presence of suspected malignancy, as renal cell carcinoma (rcc) is two to three times more likely in the adpkd population in end-stage kidney disease (eskd) than in the eskd patients without adpkd. although the indications for nephrectomy in adpkd may be related to kidney size, the decision to proceed with native nephrectomy is often undertaken on an individual basis, without specific reference to kidney size measurements. dialysis two modalities of dialysis can be used in the treatment of adpkd patients: peritoneal dialysis and hemodialysis. epidemiological data shows that adpkd affects 5–13.4% of patients undergoing hemodialysis in europe and in the united states, and about 3% in japan. peritoneal dialysis has usually been contra-indicated in adpkd patients with large kidney and liver volumes, due to expected physical difficulties in the procedure and possible complications; however, no difference is seen in long-term morbidity between hemodialysis and peritoneal dialysis in adpkd. kidney transplant kidney transplantation is accepted as the preferred treatment for adpkd patients with esrd. among american patients on the kidney-transplant waiting list (as of december 2011), 7256 (8.4%) were listed due to cystic kidney disease and of the 16,055 renal transplants performed in 2011, 2057 (12.8%) were done for patients with cystic kidney disease, with 1,189 from deceased donors and 868 from living donors. prognosis in adpkd patients, gradual cyst development and expansion result in kidney enlargement, and during the course of the disease, glomerular filtration rate remains normal for decades before kidney function starts to progressively deteriorate, making early prediction of renal outcome difficult. the crisp study, mentioned in the treatment section above, contributed to build a strong rationale supporting the prognostic value of total kidney volume (tkv) in adpkd; tkv (evaluated by mri) increases steadily and a higher rate of kidney enlargement correlated with accelerated decline of gfr, while patient height-adjusted tkv (httkv) ≥600 ml/m predicts the development of stage 3 chronic kidney disease within 8 years. besides tkv and httkv, the estimated glomerular filtration rate (egfr) has also been tentatively used to predict the progression of adpkd. after the analysis of ct or mri scans of 590 patients with adpkd treated at the mayo translational polycystic kidney disease center, irazabal and colleagues developed an imaging-based classification system to predict the rate of egfr decline in patients with adpkd. in this prognostic method, patients are divided into five subclasses of estimated kidney growth rates according to age-specific httkv ranges (1a, <1.5%; 1b, 1.5–3.0%; 1c, 3.0–4.5%; 1d, 4.5–6.0%; and 1e, >6.0%) as delineated in the crisp study. the decline in egfr over the years following initial tkv measurement is significantly different between all five patient subclasses, with those in subclass 1e having the most rapid decline. some of the most common causes of death in patients with adpkd are various infections (25%), a ruptured berry aneurysm (15%), or coronary/hypertensive heart disease (40%).