Second-generation antipsychotics and the risk of chronic kidney disease: a population-based case-control study

The prevalence of chronic kidney disease in people with severe mental illness: A systematic review protocol

BACKGROUND

People with severe mental illness (SMI) are more likely to develop long-term physical health conditions, including type 2 diabetes and cardiovascular disease, compared to people without SMI. This contributes to an inequality in life expectancy known as the 'mortality gap'. Chronic kidney disease (CKD) is a growing global health concern set to be the 5th leading cause of life-years lost by 2040. However, there is limited research exploring the relationship between CKD and SMI. This systematic review will aim to examine the prevalence and incidence of CKD among people with SMI.

METHODS

We will search Medline, Embase, PsycINFO, CINAHL, Scopus and Web of Science for primary epidemiological research reporting the prevalence or incidence of CKD among people with SMI in any setting. Retrieved records will be managed in Covidence and screened by two independent reviewers. Data will be extracted from included studies using a piloted data extraction form, and the quality of studies will be evaluated using the appropriate JBI Critical Appraisal Checklist. The certainty of evidence will be assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. Data from the included studies will be narratively synthesised. Meta-analyses will be conducted using random effects models to examine the prevalence and incidence of CKD among people with SMI.

DISCUSSION

There is limited research exploring the relationship between CKD and SMI, and this proposed systematic review will be the first to examine the prevalence of CKD among people with SMI. This review will highlight the extent of the problem and provide a foundation for future research to improve health outcomes for people with SMI.

Risk of renal impairment in atypical antipsychotics: a systematic review and meta-analysis

PURPOSE

Atypical antipsychotics are associated with several adverse effects including metabolic syndrome, weight gain, QTc interval prolongation, and extrapyramidal effects. This study aims to investigate the risk of renal impairment in patients receiving atypical antipsychotics.

METHODS

A systematic literature search was conducted via PubMed and Ovid SP and Web of Science to retrieve studies reporting the risk of renal impairment in patients receiving atypical antipsychotic treatment. The pooled risk ratio (RR) of renal impairment and the subgroup analysis was calculated using the random-effects generic inverse variance method in Cochrane Review Manager.

RESULTS

A total of 4 studies involving 514,710 patients (221, 873 patients on atypical antipsychotics/CKD and 292, 837 controls) were included in this meta-analysis. Patients on atypical antipsychotics exhibited an increased risk of renal impairment, with a pooled risk ratio of 1.34 (95%CI 1.23-1.47). Subgroup analysis demonstrated that atypical antipsychotic use was associated with an increased risk of both acute kidney injury (AKI) (RR 1.51, 95%CI 1.34-1.71) and chronic kidney disease (CKD) (RR: 1.23, 95%CI 1.12-1.35).

CONCLUSION

Patients receiving atypical antipsychotics have an increased risk of renal impairment. Quetiapine carries the highest risk of renal impairment encompassing both AKI and CKD.

Chronic Kidney Disease in Patients with Hip Fracture: Prevalence and Outcomes

Objective. Although the association between chronic kidney disease (CKD) and osteoporotic fractures is well established, data on CKD combined with hip fracture (HF) are scarce and controversial. We aimed to assess in patients with HF the prevalence of CKD, its impact on hospital mortality and length of stay (LOS) and to determine the prognostic value of CKD to predict hospital outcomes. Methods. Prospectively collected clinical data were analysed in 3623 consecutive HF patients aged ≥65 years (mean age 83.4 ± 7.50 [standard deviation] years; 74.4% females). Results. CKD among older patients with HF is highly prevalent (39.9%), has different clinical characteristics, a 2.5-fold higher mortality rate, and 40% greater risk of prolonged LOS. The strongest risk for a poor outcome was advanced age (>80 years). The risk of death substantially increases in combination with chronic disorders, especially coronary artery disease, anaemia, hyperparathyroidism, and atrial fibrillation; models based only on three variables—CKD stage, age >80, and presence of a specific chronic condition—predicted in-hospital death with good discrimination capability (AUC ≥ 0.700) and reasonable accuracy, the number needed to predict ranged between 5.7 and 14.5. Only 12% of HF patients received osteoporotic drugs prefracture. Conclusion. In HF patients with CKD, the risk of adverse outcomes largely increases in parallel with worsening kidney function and, especially, in combination with comorbidities; models based on three admission variables predict a fatal outcome. Assessment of renal function is essential to preventing osteoporotic fractures.

Anti-Inflammatory Effects of Peripheral Dopamine

Dopamine is synthesized in the nervous system where it acts as a neurotransmitter. Dopamine is also synthesized in a number of peripheral organs as well as in several types of cells and has organ-specific functions and, as demonstrated more recently, is involved in the regulation of the immune response and inflammatory reaction. In particular, the renal dopaminergic system is very important in the regulation of sodium transport and blood pressure and is particularly sensitive to stimuli that cause oxidative stress and inflammation. This review is focused on how dopamine is synthesized in organs and tissues and the mechanisms by which dopamine and its receptors exert their effects on the inflammatory response.

Chronic kidney disease and severe mental illness: a scoping review

BACKGROUND

People who have severe mental illness experience higher rates of long-term conditions and die on average 15-20 years earlier than people who do not have severe mental illness, a phenomenon known as the mortality gap. Long-term conditions, such as diabetes, impact health outcomes for people who have severe mental illness, however there is limited recognition of the relationship between chronic kidney disease and severe mental illness. Therefore, the aim of this scoping review was to explore the available evidence on the relationship between chronic kidney disease and severe mental illness.

METHODS

Electronic databases, including MEDLINE, Embase, CINAHL, and PsycINFO were searched. The database searches were limited to articles published between January 2000-January 2022, due to significant progress that has been made in the detection, diagnosis and treatment of both SMI and CKD. Articles were eligible for inclusion if they explored the relationship between SMI and CKD (Stages 1-5) in terms of prevalence, risk factors, clinical outcomes, and access to treatment and services. Severe mental illness was defined as conditions that can present with psychosis, including schizophrenia, schizoaffective disorder, bipolar disorder, and other psychotic disorders. Thirty articles were included in the review.

RESULTS

The included studies illustrated that there is an increased risk of chronic kidney disease amongst people who have severe mental illness, compared to those who do not. However, people who have severe mental illness and chronic kidney disease are less likely to receive specialist nephrology care, are less likely to be evaluated for a transplant, and have higher rates of mortality.

CONCLUSION

In conclusion, there is a dearth of literature in this area, but the available literature suggests there are significant health inequalities in kidney care amongst people who have severe mental illness. Further research is needed to understand the factors that contribute to this relationship, and to develop strategies to improve both clinical outcomes and access to kidney care.

Non-traditional risk factors of progression of chronic kidney disease in adult population: a scoping review

Chronic kidney disease (CKD) has become a public health concern over the last several years. Nowadays developed countries spend around 3% of their annual health-care budget on patients with CKD. According to the scientific community the most remarkable risk factors for CKD are diabetes and hypertension. Unknown CKD etiology has been reported as a global phenomenon including uncommon risk factors such as: dehydration, leptospirosis, heat stress, water quality, and others. This study aims to report non-traditional risk factors for ESRD based on a scoping review methodology. The scoping review methodology described by Arksey and O'Malley was used by performing an extensive review of the information. A total of 46 manuscripts were reviewed. The non-traditional ESRD risk factors are depicted based on six categories. Gender and ethnicity have been considered as risk factors for ESRD. Erythematous systemic lupus (ESL) is reported as an important risk factor for ESRD. Pesticide use has been an significant risk factor due to its effects on human and environmental health. Some compounds commonly used in homes against insects and plants are related to ESRD. Congenital and hereditary diseases in the urinary tract have been studied as a cause of ESRD in children and young adults. End-stage renal disease is a major concern for public health on a global level. As it can be seen, non-traditional risk factors are several and have different etiologies. It is necessary to put the issue on the table and add it to the public agenda in order to find multidisciplinary solutions.

Real-World Clinical Practice Among Patients With Bipolar Disorder and Chronic Kidney Disease on Long-term Lithium Therapy

PURPOSE

Long-term lithium therapy (LTLT) has been associated with chronic kidney disease (CKD). We investigated changes in clinical characteristics, pharmacotherapeutic treatments for medical/psychiatric disorders, and outcomes among patients with bipolar disorder (BD) and CKD on LTLT in a 2-year mirror-image study design.

METHODS

Adult BD patients on LTLT for ≥1 year who enrolled in the Mayo Clinic Bipolar Disorder Biobank and developed CKD (stage 3) were included, and our study was approved by the Mayo Clinic Institutional Review Board. The primary outcome was the time to the first mood episode after CKD diagnosis among the lithium (Li) continuers and discontinuers. Cox proportional hazards models were used to estimate the time to the first mood episode. We tested for differences in other medication changes between the Li continuers and discontinuers group using Mantel-Haenszel χ2 tests (linear associations).

RESULTS

Of 38 BD patients who developed CKD, 18 (47%) discontinued Li, and the remainder continued (n = 20). The median age of the cohort was 56 years (interquartile range [IQR], 48-67 years), 63.2% were female, and 97.4% were White. As compared with continuers, discontinuers had more psychotropic medication trials (6 [IQR, 4-6] vs 3 [IQR, 2-5], P = 0.02), a higher rate of 1 or more mood episodes (61% vs 10%, P = 0.002), and a higher risk of a mood episode after CKD diagnoses (Hazard Ratio, 8.38; 95% confidence interval, 1.85-38.0 [log-rank P = 0.001]].

CONCLUSIONS

Bipolar disorder patients on LTLT who discontinued Li had a higher risk for relapse and a shorter time to the first mood episode, suggesting a need for more thorough discussion before Li discontinuation after the CKD diagnosis.

National trends in metabolic risk of psychiatric inpatients in the United States during the atypical antipsychotic era

Although the cardiometabolic effects of atypical antipsychotics have been well-described in clinical samples, less is known about the longer-term impacts of these treatments. We report rates of metabolic syndrome in a nationally representative sample of U.S. adult inpatients 1993-2018 admitted for schizophrenia-spectrum disorders (n = 1,785,314), any mental health disorder (n = 8,378,773), or neither (n = 14,458,616) during a period of widespread atypical antipsychotic use. Metabolic syndrome, derived from additional diagnoses, was defined as three or more of hypertension, dyslipidemia, type II diabetes, hyperglycemia, and overweight or obese. Using an ecological age and period design, a 4-level period variable was constructed to proxy for atypical antipsychotic exposure as the minimum of age minus 20 years or the calendar year minus 1997 in accord with the disease course for schizophrenia-spectrum illness and the market share of atypical antipsychotics in the U.S. Logistic regression models, adjusted for age, year, and exposure main effects, estimated odds ratios (ORs) of metabolic syndrome. Relative to other mental health or other discharges, schizophrenia-spectrum discharges had an elevated risk for metabolic syndrome regardless of potential atypical antipsychotic exposure (OR = 1.46; 95 % CI, 1.30-1.64). For schizophrenia-spectrum discharges, periods of potential atypical antipsychotic exposure conferred additional metabolic syndrome risk OR = 1.21; 95 % CI, 1.04-1.41 for exposures of 1-2 years, OR = 1.29; 95 % CI, 1.13-1.46 for 3-7 years, OR = 1.27; 95 % CI, 1.12-1.44 for 8-12 years, and OR = 1.10; 95 % CI 0.98-1.24 for >12 years. In summary, cardiometabolic disease and related risks were elevated among a nationally representative sample of adult inpatients with schizophrenia-spectrum disorders during a period of pervasive atypical antipsychotic use.

Psychotropic Drugs and Adverse Kidney Effects: A Systematic Review of the Past Decade of Research

BACKGROUND AND OBJECTIVE

Psychotropic drugs are a heterogenous group of treatments prescribed for many psychiatric disorders, often for long periods. Their effects on the kidney and its functioning are complex and a source of significant research and debate. This article aims to review recent evidence of the acute and chronic kidney adverse events of diverse psychotropes.

METHODS

A systematic search of randomized controlled trials and large observational studies (n ≥ 100) reporting the effects of psychotropic drugs on the kidney was conducted. The MEDLINE, PsycInfo, and EMBASE databases from 2011 to 2021, inclusive, were broadly searched with few restrictions and no prespecified outcomes. Two or more independent reviewers assessed and summarized all eligible studies, including risks of bias and levels of evidence.

RESULTS

In all, 1999 abstracts were screened for eligibility and 47 articles were included, which examined lithium (33), antiepileptics (10), antipsychotics (13), and antidepressants (9). No studies examining kidney adverse effects of other psychotropes, such as benzodiazepines, met inclusion criteria. Study populations were adult (8), geriatric (9), and mixed (30). Lithium was almost unanimously associated with (1) chronic kidney disease and (2) nephrogenic diabetes insipidus in methodologically diverse studies. The most supported risk factors for declining kidney functioning with lithium were advanced age, duration of lithium treatment, acute lithium toxicity, female sex, medications with known renal interactions, diabetes mellitus/hyperglycemia, and overall medical comorbidity. Supratherapeutic lithium concentrations are both the causes and consequences of acute kidney injury. Once significant chronic kidney disease has developed, four studies found that replacing lithium with other mood stabilizers does not slow progression, and the evolution to end-stage kidney disease is rare overall with modern practices. Compared to lithium, fewer studies examined antipsychotics and antiepileptics but found relatively less direct kidney harms. Antidepressants were not associated with acute or chronic kidney harms.

CONCLUSIONS

Despite the heterogeneity of findings, owing to varying methodologies and research challenges, recent studies strongly suggest that lithium is associated with an increased risk of chronic kidney disease and nephrogenic diabetes insipidus, especially in older adults and long-term lithium users. Clinicians should balance the harms of lithium against its established benefits, and ensure adequate monitoring and management of comorbidities in all patients. Weaker evidence suggests that antiepileptics such as valproate and antipsychotics result in comparatively less harm to the kidney than lithium, but warrant monitoring because of multiple direct and indirect mechanisms for potential kidney adverse events. Antidepressants do not have clear kidney adverse effects and appear safe (though potentially less effective) in the setting of kidney disease. Other classes of psychotropic drugs have received little research interest. Further research is warranted, particularly into specific antiepileptics and antipsychotics, and careful attention should be paid to mitigating important sources of bias such as confounding by indication.

The Effects of Use of Long-Term Second-Generation Antipsychotics on Liver and Kidney Function: A Prospective Study

(1) Background: The second-generation antipsychotics (SGAPs) induce metabolic and inflammatory side effects, but documentation of their effects on the liver and kidneys is scarce. Aim: To study the three-year fluctuation of selected markers of renal and hepatic function in forensic psychiatric patients receiving SGAPs for more than five years. (2) Methods: Thirty-five forensic psychiatric patients (N = 35) were classified into two groups according to the type of SGAPs used for their treatment and the relevant risk of weight gain and metabolic complications. The three-year medication history, anthropometric data and biochemical data relevant to renal and hepatic function were retrieved from the individual medical files, specifically: serum levels of urea, uric acid, creatinine, alkaline phosphatase and amylase; the liver function enzymes, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT) and gamma-glutamyl transpeptidase(γ-GT), and also the inflammatory index C-reactive protein (CRP). (3) Results: The patients receiving the SGAPs with a low risk for weight gain showed no significant fluctuation in the biochemical markers over the three-year period. The patients receiving the SGAPs with a high risk for weight gain showed significant differences between at least two measurements of uric acid (p = 0.015), SGOT (p = 0.018) and SGPT (p = 0.051). They showed significantly higher levels of creatinine in the third year compared to the second year (p = 0.029), and SGOT in the second year compared to the first (p = 0.038), and lower levels of SGPT in the third year compared to the second (p = 0.024). (4) Conclusion:In addition to consideration of possible metabolic and inflammatory complications, the choice of an antipsychotic drug for long-term treatment should also take into account the risk of hepatotoxicity and kidney damage.

New Insight Concerning Therapeutic Drug Monitoring-The Importance of the Concept of Psychonephrology

Recently, the concept of psychonephrology was developed and has been recognized as a field of study that focuses on nephrology and mental health fields, such as psychiatry and psychosomatic medicine. Indeed, patients with chronic kidney disease frequently suffer from mental problems as the disease stage progresses. Most psychotropic drugs are hepatically metabolized, but some are unmetabolized and eliminated renally. However, renal disease may affect the pharmacokinetics of many psychotropic drugs, as the decreased renal function not only delays the urinary excretion of the drug and its metabolites but also alters various pharmacokinetic factors, such as protein-binding, enterohepatic circulation, and activity of drug-metabolizing enzymes. Therefore, when prescribing drug therapy for patients with both renal disease and mental issues, we should consider reducing the dosage of psychotropic drugs that are eliminated mainly via the kidney and also carefully monitor the blood drug concentrations of other drugs with a high extrarenal clearance, such as those that are largely metabolized in the liver. Furthermore, we should carefully consider the dialyzability of each psychotropic drug, as the dialyzability impacts the drug clearance in patients with end-stage renal failure undergoing dialysis. Therapeutic drug monitoring (TDM) may be a useful tool for adjusting the dosage of psychotropic drugs appropriately in patients with renal disease. We herein review the pharmacokinetic considerations for psychotropic drugs in patients with renal disease as well as those undergoing dialysis and offer new insight concerning TDM in the field of psychonephrology.

Incidence of hospital contacts with acute kidney injury after initiation of second-generation antipsychotics in older adults: a Danish population-based cohort study

Purpose

To investigate the association between acute kidney injury (AKI) and use of second-generation antipsychotics (SGA) in older adults.

Methods

In a population-based cohort study using Danish national registries, new users of SGAs (aged ≥ 65) were identified during 2005–2015. Each SGA user was matched to 10 population controls on age, sex, and the SGA initiation date. The outcome was incident AKI within 90 days after the index date. Cox regression was used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs), adjusting for potential confounders.

Results

In the study, 36,581 new SGA users and 365,810 controls were included. The 90-day incidence rate of AKI was 4.38 and 1.70 per 1000 person-years among SGA users and controls, respectively, corresponding to a crude HR of 2.57 (1.79–3.68). The fully adjusted HR (aHR) was 1.43 (0.89–2.27) for all SGAs. The risk differed among individual drugs with aHRs for olanzapine 3.50 (1.20–10.23), quetiapine 1.62 (0.81–3.26), and risperidone 0.68 (0.28–1.64). In sensitivity analyses, the aHR declined to 1.24 (0.95–1.61) at 1-year follow-up.

Conclusions

Olanzapine use was associated with a significantly increased 90-day AKI risk. For quetiapine, the risk was elevated but not significant, and risperidone had no association. CIs were wide and confounder adjustment largely impacted the estimates. Main limitations included residual confounding and incomplete recording of AKI diagnoses.

Supplementary information

The online version contains supplementary material available at 10.1007/s00228-022-03339-6.

Risperidone Exacerbates Glucose Intolerance, Nonalcoholic Fatty Liver Disease, and Renal Impairment in Obese Mice

Risperidone, a second-generation antipsychotic drug used for schizophrenia treatment with less-severe side effects, has recently been applied in major depressive disorder treatment. The mechanism underlying risperidone-associated metabolic disturbances and liver and renal adverse effects warrants further exploration. This research explores how risperidone influences weight, glucose homeostasis, fatty liver scores, liver damage, and renal impairment in high-fat diet (HFD)-administered C57BL6/J mice. Compared with HFD control mice, risperidone-treated obese mice exhibited increases in body, liver, kidney, and retroperitoneal and epididymal fat pad weights, daily food efficiency, serum triglyceride, blood urea nitrogen, creatinine, hepatic triglyceride, and aspartate aminotransferase, and alanine aminotransferase levels, and hepatic fatty acid regulation marker expression. They also exhibited increased insulin resistance and glucose intolerance but decreased serum insulin levels, Akt phosphorylation, and glucose transporter 4 expression. Moreover, their fatty liver score and liver damage demonstrated considerable increases, corresponding to increases in sterol regulatory element-binding protein 1 mRNA, fatty acid-binding protein 4 mRNA, and patatin-like phospholipid domain containing protein 3 expression. Finally, these mice demonstrated renal impairment, associated with decreases in glutathione peroxidase, superoxide dismutase, and catalase levels. In conclusion, long-term administration of risperidone may exacerbate diabetes syndrome, nonalcoholic fatty liver disease, and kidney injury.

Physical health examination in outpatients with schizophrenia: the cost effectiveness of laboratory screening tests

BACKGROUND

Guidelines on laboratory screening in schizophrenia recommend annual monitoring of fasting lipids and glucose. The utility and the cost effectiveness of more extensive laboratory screening have not been studied.

METHODS

The Living Conditions and the Physical Health of Outpatients with Schizophrenia Study provided a comprehensive health examination, including a laboratory test panel for 275 participants. We calculated the prevalence of the results outside the reference range for each laboratory test, and estimated the cost effectiveness to find an aberrant test result using the number needed to screen to find one abnormal result (NNSAR) and the direct cost spent to find one abnormal result (DCSAR, NNSAR x direct cost per test) formulas. In addition, we studied whether patients who were obese or used clozapine had more often abnormal results.

RESULTS

A half of the sample had 25-hydroxyvitamin D below, and almost one-fourth cholesterol, triglycerides or glucose above the reference range. One-fifth had sodium below and gamma glutamyltransferase above the reference range. NNSAR was highest for potassium (137) and lowest for 25-hydroxyvitamin D (2). DCSAR was below 5€ for glucose, all lipids and sodium, and below 10€ for creatinine and gamma glutamyltransferase. Potassium (130€), pH-adjusted ionized calcium (33 €) and thyroid stimulating hormone (33€) had highest DCSARs. Several abnormal results were more common in obese and clozapine using patients.

CONCLUSIONS

An annual laboratory screening panel for an outpatient with schizophrenia should include fasting glucose, lipids, sodium, creatinine, a liver function test and complete blood count, and preferably 25-hydroxyvitamin D.