Psych · Consultation-liaison psychiatry
Renal and dialysis psychiatry
Also known as Dialysis psychiatry · CKD depression · ESRD mental health · Uraemic encephalopathy psychiatry · Haemodialysis anxiety · Renal consultation-liaison
Exam-exhaustive fellowship topic on renal and dialysis psychiatry for consultation-liaison practice — depression and anxiety in CKD/ESRD, CAST and ASCEND evidence, uraemic encephalopathy and cognitive impairment, psychotropic dosing and lithium–kidney interface, non-adherence, capacity and dialysis withdrawal, and shared nephrology–psychiatry care. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Uraemic encephalopathy (fluctuating confusion, asterixis, myoclonus, seizures) — urgent nephrology and dialysis optimisation; do not treat as primary psychosis alone
- Active suicide plan, access self-harm, or deliberate life-threatening dialysis non-attendance — secure environment and joint nephrology–psychiatry plan
- Lithium toxicity in CKD/AKI (coarse tremor, ataxia, confusion) — stop lithium, serial levels, volume support, escalate toward EXTRIP when criteria met
- Request to stop dialysis with delirium or untreated severe depression — treat reversible drivers before accepting refusal as capacitous
- Full-dose renally cleared psychotropics (lithium, amisulpride, paliperidone, gabapentinoids) without eGFR adjustment — accumulation risk
- Intradialytic agitation with line-pulling — protect vascular access first, then de-escalate
Meet the patient
A 64-year-old on maintenance haemodialysis is referred for "depression and non-compliance". She has missed her last two sessions, tells you life is not worth living, and her PHQ-9 came back at 19. The dialysis nurses add that she has been "vague and slow" mid-session this week.[1][7]
Two questions are live on this ward round, and the registrar will conflate them: is this depression, or uraemia, or both? and is she safe to drive home and to keep dialysing? A candidate who recites generic MDD criteria fails — the stem hides a medical differential, a dosing trap, a capacity question, and an adherence problem all at once.[4][5][11][13]
References16ShowHide
- [1]Palmer S, Vecchio M, Craig JC, et al. Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies Kidney Int, 2013.PMID 23486521
- [2]Palmer SC, Vecchio M, Craig JC, et al. Association between depression and death in people with CKD: a meta-analysis of cohort studies Am J Kidney Dis, 2013.PMID 23623139
- [3]Hedayati SS, Minhajuddin AT, Toto RD, et al. Prevalence of major depressive episode in CKD Am J Kidney Dis, 2009.PMID 19493599
- [4]Hedayati SS, Yalamanchili V, Finkelstein FO A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease Kidney Int, 2012.PMID 22012131
- [5]Hedayati SS, Gregg LP, Carmody T, et al. Effect of Sertraline on Depressive Symptoms in Patients With Chronic Kidney Disease Without Dialysis Dependence: The CAST Randomized Clinical Trial JAMA, 2017.PMID 29101402
- [6]Mehrotra R, Cukor D, Unruh M, et al. Comparative Efficacy of Therapies for Treatment of Depression for Patients Undergoing Maintenance Hemodialysis: A Randomized Clinical Trial Ann Intern Med, 2019.PMID 30802897
- [7]Cukor D, Coplan J, Brown C, et al. Depression and anxiety in urban hemodialysis patients Clin J Am Soc Nephrol, 2007.PMID 17699455
- [8]Cukor D, Rosenthal DS, Jindal RM, et al. Depression is an important contributor to low medication adherence in hemodialyzed patients and transplant recipients. Kidney Int, 2009.PMID 19242502
- [9]Kimmel PL Depression in patients with chronic renal disease: what we know and what we need to know J Psychosom Res, 2002.PMID 12377308
- [10]Cohen SD, Cukor D, Kimmel PL Anxiety in Patients Treated with Hemodialysis Clin J Am Soc Nephrol, 2016.PMID 27660303
- [11]Cohen LM, Germain MJ, Poppel DM Practical considerations in dialysis withdrawal: "to have that option is a blessing" JAMA, 2003.PMID 12709469
- [12]Kurella M, Chertow GM, Luan J, et al. Cognitive impairment in chronic kidney disease J Am Geriatr Soc, 2004.PMID 15507063
- [13]Baghdady NT, Banik S, Swartz SA, et al. Psychotropic drugs and renal failure: translating the evidence for clinical practice Adv Ther, 2009.PMID 19444657
- [14]Nagler EV, Webster AC, Vanholder R, et al. Antidepressants for depression in stage 3-5 chronic kidney disease: a systematic review of pharmacokinetics, efficacy and safety with recommendations by European Renal Best Practice (ERBP) Nephrol Dial Transplant, 2012.PMID 22859791
- [15]McKnight RF, Adida M, Budge K, et al. Lithium toxicity profile: a systematic review and meta-analysis Lancet, 2012.PMID 22265699
- [16]Decker BS, Goldfarb DS, Dargan PI, et al. Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup Clin J Am Soc Nephrol, 2015.PMID 25583292