A patient with end-stage renal disease on haemodialysis is found to have significant depressive symptoms. The MOST appropriate antidepressant choice, considering renal clearance and safety?
- A Venlafaxine
- B Duloxetine
- C Sertraline (SSRI with hepatic metabolism and minimal renal clearance) ✓
- D Lithium
Explanation
Sertraline is the preferred antidepressant in patients with chronic kidney disease and ESRD because it is predominantly hepatically metabolised with minimal renal excretion of active drug. It has a well-established safety profile, manageable drug interactions, and is dialysable in overdose. Venlafaxine has a renally cleared active metabolite (O-desmethylvenlafaxine) requiring dose adjustment. Duloxetine is contraindicated in severe CKD (eGFR <30) due to accumulation of toxic metabolites. Lithium is absolutely contraindicated in ESRD due to its narrow therapeutic index and complete renal elimination; haemodialysis removes it but inter-dialysis accumulation creates dangerous variability.
Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.
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