Journal Article Annotations
2023, 4th Quarter
Annotations by Shivali Patel, MD and Sahil Munjal, MD
Although patients with chronic kidney disease also have clinical depression, many of these individuals (over 75% of this study’s sample) did not self-report depression or depressive symptoms. The study found that lower levels of education was the only predictor for greater depression severity despite other sociodemographic variable that were associated with depression.
Strength and weaknesses:
While the study made use of the PHQ-9, a reliable and valid tool to determine depressive severity, and aimed to capture important factors associated with depression on the screening instrument, there were several limitations. There was a relatively small sample size with limited generalizability, as most individuals included were male, over age 60, of Indo-Trinbagonian ethnicity, had family and/or social support, and were on government assistance. Moreover, this was a convenience sample, taken from individuals referred to the chronic kidney disease clinic. Apart from hypertension and diabetes mellitus, other potentially contributory medical conditions, substance use disorders, and use of medications were unknown.
C-L psychiatrists should be aware of the high prevalence of depression among patients with chronic kidney disease and the negative correlation between estimated glomerular filtration rate and PHQ-9 scores. Many patients with chronic kidney disease who have clinical depression may not voluntarily share their symptoms, so it is essential for psychiatrists to educate our nephrology colleagues on the importance of routinely screening patients for depression and referring for treatment when deemed clinically appropriate.
The study reviewed evidence of concurrent lithium and hemodialysis treatment (CLHT), using a conventional PubMed search along with a survey of current practices among nephrologists and psychiatrists to arrive at a practice guideline. The authors propose a calculation for target dose (mg), which can be determined as follows: 10 × body weight (kg) × target concentration (mmol/L). Per the evidence reviewed, lithium is taken on dialysis days only, immediately after dialysis. However, prescribing lithium on non-dialysis days may be necessary in cases with residual diuresis. It is important to note residual renal function is common in lithium-induced nephropathy leading to fluctuation of levels. The authors recommend trough levels to be assayed before each dialysis session until stable for at least three consecutive measurements, before reducing monitoring frequency to monthly. Using a flowchart, they highlight the steps in starting and/or continuing lithium in hemodialysis patients along with a proposed formula calculating lithium target dosing.
Strength and weaknesses:
Evidence was limited to case reports/series with a significant risk of publication bias. Also, there were only 16 respondents to the survey which was sent out to providers in Netherlands. It may not be generalizable to other places. Survey only included items pertaining to regimen chosen rather than the rationale.
The paper offers much needed practical guidance for CL psychiatrists on the safely of combining lithium and haemodialysis. Close multidisciplinary collaboration between psychiatrists and nephrologists are essential. Additional lithium measurements are advised in case of changes in dialysis schedule, residual diuresis, adverse effects, changes in co-medication, fluid intake, warm weather, and other potentially relevant events.
This review summarized recent literature regarding the long-term effects of lithium on kidneys. Risk factors for lithium-induced renal disease include length of exposure to lithium, previous episodes of lithium toxicity, elevated lithium levels, use of other psychotropic medications, comorbid medical disorders, female sex, and history of migraines. Individuals with higher serum creatinine before beginning lithium treatment are more likely to progress to chronic kidney disease stage IV or V compared to those with normal serum creatinine levels before beginning lithium treatment. Additionally, estimated glomerular filtration rate at the time of lithium discontinuation, serum creatinine >2.5 mg/dl, and a creatinine clearance cut-point of 40 ml/min may be important variables to consider when assessing the risk and trajectory of renal deterioration following lithium discontinuation.