Psychiatric Pharmacy Essentials: Psychotropic Medication and Renal Impairment

The prevalence of psychiatric disorders has been well documented in individuals with renal disease. Although not robust, data exists to guide medication choices and dosing strategies in patients with renal insufficiency, including those on dialysis.

  • What are some of the pharmacokinetic, pharmacodynamic, and physiologic considerations for psychotropic medication use in patients with renal disease?1-3
  • Do psychotropic medications require dose adjustments for patients with renal disease?4-7
  • How should depression be managed in patients with renal disease?8-14
  • Can lithium be used in patients with renal disease?15-17

Reviewer 1: Roisin Sabol, PharmD
Reviewer 2: Austin Smith, PharmD, BCPP
2024-2025 AAPP Resident and New Practitioner Committee

Essential Questions and References

  1. Damba JJ, Bodenstein K, Lavin P, Drury J, Sekhon H, Renoux C, Trinh E, Rej S, Greenway KT. Psychotropic Drugs and Adverse Kidney Effects: A Systematic Review of the Past Decade of Research. CNS Drugs. 2022 Oct;36(10):1049-1077. [PubMed]
  2. Hashimoto M, Maeda H, Oniki K, Yasui-Furukori N, Watanabe H, Saruwatari J, Kadowaki D. New Insight Concerning Therapeutic Drug Monitoring-The Importance of the Concept of Psychonephrology. Biol Pharm Bull. 2022;45(7):834-842. [PubMed]
  3. Eyler RF, Unruh ML, Quinn DK, Vilay AM. Psychotherapeutic Agents in End-Stage Renal Disease. Semin Dial. 2015;28(4):417-26. DOI: 10.1111/sdi.12370. PubMed PMID: 25857865.
  4. Baghdady NT, Banik S, Swartz SA, McIntyre RS. Psychotropic drugs and renal failure: translating the evidence for clinical practice. Adv Ther. 2009;26(4):404-24. DOI: 10.1007/s12325-009-0021-x. PubMed PMID: 19444657.
  5. Ward S, Roberts JP, Resch WJ, Thomas C. When to adjust the dosing of psychotropics in patients with renal impairment. Current Psychiatry 2016;15(8):60-66. [Weblink]
  6. Mathew RO, Bettinger JJ, Wegrzyn EL, Fudin J. Pharmacotherapeutic considerations for chronic pain in chronic kidney and end-stage renal disease. JPR. 2016;9:1191-1195. DOI: 10.2147/JPR.S125270. PubMed PMID: 27994481; PubMed Central PMCID: PMC5153274.
  7. Whittaker CF, Miklich MA, Patel RS, Fink JC. Medication Safety Principles and Practice in CKD. CJASN. 2018;13(11):1738-1746. DOI: 10.2215/CJN.00580118. PubMed PMID: 29915131; PubMed Central PMCID: PMC6237057.
  8. Palmer SC, Natale P, Ruospo M, Saglimbene VM, Rabindranath KS, Craig JC, Strippoli GF. Antidepressants for treating depression in adults with end-stage kidney disease treated with dialysis. Cochrane Database Syst Rev. 2016 May 23;2016(5):CD004541. [PubMed]
  9. Nagler EV, Webster AC, Vanholder R, Zoccali C. 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 Transpl. 4th ednth ed. 2012;27(10):3736-45. DOI: 10.1093/ndt/gfs295. PubMed PMID: 22859791.
  10. Bautovich A, Katz I, Smith M, Loo CK, Harvey SB. Depression and chronic kidney disease: A review for clinicians. Aust N Z J Psychiatry. 11th ed. 2014;48(6):530-41. DOI: 10.1177/0004867414528589. PubMed PMID: 24658294.
  11. 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 Reports. 2017;2(1):94-107. DOI: 10.1016/j.ekir.2016.09.005. PubMed PMID: 29318209; PubMed Central PMCID: PMC5720531.
  12. Hedayati SS, Gregg LP, Carmody T, Jain N, Toups M, Rush AJ, et al. Effect of Sertraline on Depressive Symptoms in Patients With Chronic Kidney Disease Without Dialysis Dependence: The CAST Randomized Clinical Trial. JAMA. 2017;318(19):1876-1890. DOI: 10.1001/jama.2017.17131. PubMed PMID: 29101402; PubMed Central PMCID: PMC5710375.
  13. Assimon MM, Brookhart MA, Flythe JE. Comparative cardiac safety of selective serotonin reuptake inhibitors among individuals receiving maintenance hemodialysis. J Am Soc Nephrol 2019;30(4):611-23. [PubMed]
  14. Mehrotra R, Cukor D, Unruh M, Rue T, Heagerty P, Cohen SD, et al. Comparative Efficacy of Therapies for Treatment of Depression for Patients Undergoing Maintenance Hemodialysis: A Randomized Clinical Trial. Ann Intern Med. 2019;170(6):369-379. DOI: 10.7326/M18-2229. PubMed PMID: 30802897.
  15. McGrane IR, Omar FA, Morgan NF, Shuman MD. Lithium therapy in patients on dialysis: A systematic review. Int J Psychiatry Med. 2022 May;57(3):187-201. [PubMed]
  16. Gitlin M, Bauer M. Key questions on the long term renal effects of lithium: a review of pertinent data. Int J Bipolar Disord. 2023 Nov 16;11(1):35. [PubMed]
  17. Kuiper WJ, Grootens KP, Kerckhoffs APM. Concurrent lithium and haemodialysis treatment: Clinical recommendations based on the literature and a multicentre survey. Bipolar Disord. 2024 Jun;26(4):335-347. [PubMed]