From the Research
I strongly advise against initiating any medication for depression and anxiety in patients with a glomerular filtration rate (GFR) of 15 without careful consideration and consultation with a nephrologist, due to the high risk of adverse effects and further kidney damage. For patients with this level of kidney dysfunction, medication selection and dosing requires careful consideration by a healthcare provider who can evaluate the individual's complete medical history. Many antidepressants and anti-anxiety medications require dose adjustments or may be contraindicated in severe kidney disease. Medications like SSRIs (such as sertraline or citalopram) or SNRIs (like duloxetine) often need significant dose reductions, as noted in a study published in 2020 1. Some medications, such as certain benzodiazepines, may accumulate in the body with kidney impairment and cause toxicity.
A study published in 2019 found that the addition of an antidepressant is an effective approach to treating residual symptoms for patients who do not achieve remission with cognitive behavioral therapy (CBT), as is adding CBT after antidepressant monotherapy 2. However, the study also noted that higher levels of anxiety predicted poorer outcomes for both treatment groups. Another study published in 2019 compared the efficacy of CBT versus sertraline for treating depression in patients receiving hemodialysis, and found that sertraline treatment resulted in lower depression scores at 12 weeks, but with more frequent adverse events 3.
Non-pharmacological approaches like cognitive behavioral therapy may be particularly important for these patients to minimize medication burden. A comprehensive treatment plan should prioritize minimizing medication burden while addressing mental health needs, and should be developed in consultation with a nephrologist and a mental health professional. Any medication regimen must balance mental health needs with the risks of further kidney damage or adverse effects.
Key considerations for treatment include:
- Careful selection and dosing of medications to minimize the risk of adverse effects and further kidney damage
- Consultation with a nephrologist to ensure that medication decisions take into account the patient's kidney function and overall health
- Consideration of non-pharmacological approaches like cognitive behavioral therapy to minimize medication burden
- Close monitoring of the patient's response to treatment and adjustment of the treatment plan as needed to ensure optimal outcomes.