Which antidepressive-substance could be used in a patient with poor kidney-function?/nThe patient i

Fråga: Which antidepressive-substance could be used in a patient with poor kidney-function? The patient is a 47-year-old man with hypertension, hyperlipaemi, depression, and 25% remaining kidney-function.

Sammanfattning: Sertraline and citalopram are used in depressed patient with renal impairment. The lowest effective dose should be used and plasma concentration followed. Close observation should be paid to adverse effects as the symptoms of renal impairment often overlap SSRI side effects.

Svar: The nephrology-clinic at Huddinge University Hospital has treated a number of patients with decreased kidney-function and depression with citalopram or sertraline with good result (1). Citlaopram is metabolised in the liver to less active substances. After an oral dose only 15% of the substance is excreted through the kidneys (2). Sertraline is mainly eliminated through liver-metabolism although gastrointestinal metabolism may also be of importance. After an oral dose 45% is excreted in the faeces and 44% through the kidneys (2). There are no significant differences in the kinetics of sertraline in patients with renal impairment or old age compared to young, healthy female volunteers (3). Sertraline has also been successfully used in treating depression in patients with hemodialysis (4). There are also reports that sertraline can be used to treat hemodialysis-induced hypotension (5).

There are no reports on aggravation of renal impairment after treatment with selective serotonin re-uptake inhibitors (SSRI) in the Swedish register of adverse effects (6). Some cases of urinary retention are spontaneously reported as possible adverse effect of citalopram or sertraline (6). These side effects are likely to be due to effects on bladder and sphincter innervation. It could aggravate the condition though. There is one case each reported with hypertensive adverse effects after treatment with citalopram and sertraline respectively (6). Close observation has to be paid to eventual adverse effect of SSRI and it should be remembered that symptoms of renal insufficiency are similar to adverse effects often seen (4). It would be advisable to follow plasma-concentrations to ensure that the patient does not accumulate the drug.