HelixTalk Episode #83 - Flow and Fluoxetine - Evaluating Antidepressant Selection in Chronic Kidney Disease

Date posted: August 28, 2018, 6:00 am

In this episode, we discuss the importance of accurately recognizing depressive symptoms in patients with kidney disease and provide review the limited available literature regarding treatment in this population. We then discuss guidelines to determine some of the best treatment options for this unique subgroup of patients.

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Key Concepts

1. Depressive symptoms are common in kidney disease, both as a response to stressors as well as potentially to physiologic changes. Recognition is important as most studies show poorer outcomes if depression is left untreated.
2. There is a lack of data, particularly with larger studies, regarding the effects of impaired renal function on antidepressant serum concentrations.
3. If an antidepressant is to be used, the SSRI fluoxetine does not require any dose adjustments even in ESRD. Other agents in the class may need adjustments especially in ESRD. For the SNRIs, venlafaxine lacks efficacy studies but can be used with a 50% dose reduction to account for drug accumulation. Duloxetine does not need dose adjustment as long as eGFR >30.
4. Don’t forget about psychotherapy. A lot of the depressive symptoms may be in response to the stress of dialysis and its perceived impact on quality of life.

References

1. Shirazian S, Grant CD, Aina O, Mattana J, Khorassani F, Ricardo AC. Depression in chronic kidney disease and end-stage renal disease: Similarities and differences in diagnosis, epidemiology, and management. Kidney Int Rep. 2016. Sep 20; 2(1): 94-107.
2. Nagler EV, Webster AC, Vanholder R, et al. Antidepressants for depression in stage 3-5 chronic kidney disease: a systematic review of pharmacokinetics, efficacy and safety with recommendations by European Renal Best Practice (ERBP). Nephrol Dial Transplant. 2012; 27: 3736-45.