Antidepressants in Patients With CKD and Depression

Patients with CKD commonly experience depression, putting them at risk for a poor prognosis. The use of antidepressants in the population with CKD is widespread. However, according to Nanbo Zhu and colleagues, there are few data available on the safety of those agents in patients with CKD. 

Dr. Zhu et al conducted an analysis that included data on adults with stage 3-5 CKD (eGFR <60 mL/min/1.73 m² not treated with dialysis) and a diagnosis of incident depression from 2007 to 2019. The data were included in the Stockholm Creatinine Measurements project. The researchers compared three treatment strategies using the target trial emulation framework: (1) initiating versus not initiating antidepressants; (2) initiating mirtazapine versus selective serotonin reuptake inhibitors (SSRIs); and (3) initiating SSRIs with a lower dose versus a standard dose. 

The dataset included 7798 eligible individuals. Of those, 74% (n=5743) initiated treatment with an antidepressant. Compared with noninitiation, there was an association between initiation of antidepressants with higher hazards of short-term outcomes: hip fracture (hazard ratio [HR], 1.23; 95% CI, 0.88-1.74) and upper gastrointestinal bleeding (HR, 1.38; 95% CI, 0.82-2.31). The associations did not reach statistical significance. There was no association between initiation of anti-depressants and the long-term outcomes of all-cause mortality, major adverse cardiovascular events, progression of CKD, and suicidal behavior. 

Compared with SSRIs, there was an association between initiation of mirtazapine and lower hazard of upper gastrointestinal bleeding (HR, 0.52; 95% CI, 0.29-0.96). However, there was also an association between initiation of mirtazapine and a higher hazard of mortality (HR, 1.11; 95% CI, 1.00-1.22). Compared with the standard dose, there was a nonstatistically significant association between initiation of SSRIs at a lower dose and a lower hazard of upper gastrointestinal bleeding (HR, 0.68; 95% CI, 0.35-1.34) and progression of CKD (HR, 0.80; 95% CI, 0.63-1.02). There was also a nonstatistically significant association with a lower dose of SSRIs and a higher hazard of cardiac arrest (HR, 2.34; 95% CI, 1.02-5.40). 

“Antidepressant treatment was associated with short-term adverse outcomes but not long-term outcomes in people with CKD and depression,” the authors said. 

Source: Clinical Journal of the American Society of Nephrology