which psychotropic medications are metabolized through the kidnesy

The key distinction is renal excretion rather than renal metabolism: lithium is not meaningfully metabolised and is eliminated almost entirely by the kidneys, while paliperidone clearance also depends strongly on renal function SmPC Invega Rijavec & Rijavec B 2026.

• Lithium: the clearest example of a psychotropic dependent on renal elimination; reduced kidney function, dehydration and sodium depletion can cause accumulation and toxicity Rijavec & Rijavec B 2026.
• Paliperidone: an antipsychotic whose clearance falls as renal function declines; total clearance is reduced by approximately 32%, 64% and 71% in mild, moderate and severe renal impairment, respectively SmPC Invega.
• Midazolam — an important metabolite distinction: its active metabolite, alpha-hydroxymidazolam, relies heavily on renal excretion, so renal impairment can affect exposure to active drug metabolites even when the parent medicine is not described as renally metabolised Shimoyama et al. 2026.

Practical implication: check the individual medicine’s BNF entry or SmPC for renal dose adjustments rather than treating renal excretion and metabolism as interchangeable NICE CKS. For lithium, assess renal function, electrolytes and serum lithium concentrations, particularly during intercurrent illness or changes to interacting medicines such as ACE inhibitors, ARBs and diuretics Pilarski et al. 2026.