Renal dysfunction lithium

Extensive literature has accumulated concerning other forms of renal dysfunction during long-term lithium therapy, including chronic interstitial nephritis and minimal-change glomerulopathy with nephrotic syndrome. Some instances of decreased glomerular filtration rate have been encountered but no instances of marked azotemia or renal failure. 

Lithium Mechanism of action uncertain suppresses inositol signaling and inhibits glycogen synthase kinase-3 (GSK-3), a multifunctional protein kinase No significant antagonistic actions on autonomic nervous system receptors or specific CNS receptors no sedative effects Bipolar affective disorder-prophylactic use can prevent mood swings between mania and depression Oral absorption, renal elimination half-life 20 h. narrow therapeutic window (monitor blood levels) Toxicity Tremor, edema, hypothyroidism, renal dysfunction, dysrhythmias pregnancy category D Interactions Clearance decreased by thiazides and some NSAIDs... 

A 78-year-old woman taking lithium had hyperamyla-semia and hyperlipasemia in the absence of gastrointestinal symptoms. Ultrasound examination showed the pancreas and liver to be normal. She also had hyperparathyroidism and renal dysfunction (306). 

The possibility of renal dysfunction as a rare adverse effect should be considered. The patient had a history of allergic reactions to lithium, carbamazepine, clozapine, haloperidol, and lamotrigine. 

Boron R, Gavirla M, Batlle DC. Prevalence, pathogenesis, and treatment of renal dysfunction associated with chronic lithium therapy. Am J Kidney Dis 1987 10(5) 329-345. 

Lehmann K, Ritz E. Angiotensin-converting enzyme inhibitors may cause renal dysfunction in patients on long-term lithium treatment. Am J Kidney Dis. 1995 25 82-87. 

Urinary tract The association of lithium with renal dysfunction has again been confirmed in a retrospective record review of 59 out-patients [74 ]. There was a positive association between duration of lithium treatment and serum creatinine concentration, but the duration of treatment was also greater in older patients (14.2 years for those over 65 years of age and 6.9 years for those under 65 years of age). 

A 54-year-old woman with bipolar disorder who had taken lithium for 6 years (600-900 mg/day with serum, concentrations of 0.8-1.5 mmol/1) stopped taking lithium because of renal dysfunction. About 1 month after withdrawal she began to have nocturnal headaches about 4 hours after going to sleep. They were of mild to moderate intensity, lasted for 3-4 hours, and resolved spontaneously. The headaches persisted for 1 month and then ended without treatment. 

In clinical use, the major concern regarding lithium use is not efficacy, but rather toxicity. Clinicians and patients are particularly concerned about the potential for renal dysfunction [39 ]. To address this conundrum, a decision analysis based on a systematic review of the literature was performed, and found that lithium initiation and continuation, even in the presence of long-term adverse renal effects, should be recommended in most cases [40 " ]. This appears to also apply to elder subjects after prolonged lithium treatment [4i iiu a> study 42review]... 

Lithium should not be administered to patients with fluctuating or unstable renal function. Because hthium may affect functioning of the cardiac sinus node, patients with sinus node dysfunction (e.g., sick sinus syndrome) should not receive hthium. Although hthium also has acute and chronic effects on the thyroid, patients with hypothyroidism may receive hthium if the thyroid disease is adequately treated and monitored. Laboratory tests that should be performed before initiation of hthium are listed in Table 5-1. 

Lithium Neurological tremor, ataxia, seizures Endocrine hypothyroidism Cardiovascular T wave changes, sinus node dysfunction Renal polyuria, nephrogenic diabetic insipidus Dermatological hair loss, acne, psoriasis, rash Gastrointestinal nausea, diarrhea Miscellaneous fluid retention, weight gain, weakness... 

Although the combined use of lithium and carbamazepine is beneficial in many patients, it may increase the risk of neurotoxicity. Sinus node dysfunction has also occurred in a few patients. An isolated report describes a patient who had a marked rise in lithium levels and lithium toxicity, which was apparently caused by carbamazepine-induced renal impairment. 

---