Journal Article Annotations
2022, 4th Quarter
Annotations by Sahil Munjal, MD
This systematic review looks at 10 years of literature on the potential kidney adverse effects (AE) of psychotropic drugs. Lithium is strongly associated with CKD and nephrogenic diabetes insipidus (NDI). The strength of association and causal relationship to acute kidney insufficiency (AKI) was less clear. Antidepressants, in general, are associated with fewer kidney AE. Limited evidence exists on the renal risks of antiepileptics and antipsychotics. The authors share a helpful table with recommended kidney-related monitoring frequency in bipolar disorder on lithium, valproate, and antipsychotics.
Strength and weaknesses:
Authors included largest and methodologically sound studies with systematic evaluations of bias and levels of evidence. Majority of included studies were observational with significant heterogeneity. Most studies focused on lithium, with fewer studies examining antiepileptics, antipsychotics, and antidepressants. No studies evaluated the risks of psychostimulants and benzodiazepines. There may be multiple confounding variables including indication/severity of the illness, comorbidities, additional interacting medications, and dosage differences resulting in inconsistent results.
The findings pertaining to lithium and its association with CKD, AKI, and NDI are not surprising. Risk factors include advanced age, lithium duration, female sex, overall comorbidities, toxic lithium concentrations, and low eGFR when initiating lithium. Neither lithium nor antiepileptics were not observed to increase the risk of progression or the eventual development of end stage renal disease relative to discontinuing them. Evidence strongly supports the importance of regular monitoring, managing medical comorbidities, and avoiding drugs with potentially nephrotoxic lithium interactions such as thiazide diuretics and NSAIDs. Clinicians should keep this in mind while engaging in shared decision making.