A decision analysis of long-term lithium treatment and the risk of renal failure

Division of Psychiatry, Department of Clinical Sciences, Umeå University, Sweden.
Acta Psychiatrica Scandinavica (Impact Factor: 5.61). 03/2012; 126(3):186-97. DOI: 10.1111/j.1600-0447.2012.01847.x
Source: PubMed


To establish whether lithium or anticonvulsant should be used for maintenance treatment for bipolar affective disorder (BPAD) if the risks of suicide and relapse were traded off against the risk of end-stage renal disease (ESRD).
Decision analysis based on a systematic literature review with two main decisions: (1) use of lithium or at treatment initiation and (2) the potential discontinuation of lithium in patients with chronic kidney disease (CKD) after 20 years of lithium treatment. The final endpoint was 30 years of treatment with five outcomes to consider: death from suicide, alive with stable or unstable BPAD, alive with or without ESRD.
At the start of treatment, the model identified lithium as the treatment of choice. The risks of developing CKD or ESRD were not relevant at the starting point. Twenty years into treatment, lithium still remained treatment of choice. If CKD had occurred at this point, stopping lithium would only be an option if the likelihood of progression to ESRD exceeded 41.3% or if anticonvulsants always outperformed lithium regarding relapse prevention.
At the current state of knowledge, lithium initiation and continuation even in the presence of long-term adverse renal effects should be recommended in most cases.

Download full-text


Available from: Ursula Werneke,
1 Follower
64 Reads
  • Source
    • "A critical question (Werneke et al. 2010) is when to stop lithium in a patient who develops impairment in kidney function. Such a decision should not be based exclusively on whether a patient has a slowly increasing creatinine. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Reports of toxic effects on the kidney of lithium treatment emerged very soon after lithium therapy was introduced. Lithium-induced nephrogenic diabetes insipidus is usually self-limiting or not clinically dangerous. Some reports of irreversible chronic kidney disease and renal failure were difficult to attribute to lithium treatment since chronic kidney disease and renal failure exist in the population at large. In recent years, large-scale epidemiological studies have convincingly shown that lithium treatment elevates the risk of chronic kidney disease and renal failure. Most patients do not experience renal side effects. The most common side effect of polyuria only weakly predicts increasing creatinine or reduced kidney function. Among those patients who do experience decrease in creatinine clearance, some may require continuation of lithium treatment even as their creatinine increases. Other patients may be able to switch to a different mood stabilizer medication, but kidney function may continue to deteriorate even after lithium cessation. Most, but not all, evidence today recommends using a lower lithium plasma level target for long-term maintenance and thereby reducing risks of severe nephrotoxicity.
  • Source
    • "Lithium is the most widely used medication for treating bipolar disorder [4] and, although, it is highly effective at reducing the frequency and intensity of mood swings, it can be potentially dangerous. Lithium prescribed in the form of carbonate (Li2CO3) or citrate has a very narrow therapeutic range (concentrations ranging from 0.4 to 1.0 mM) with the upper limit being uncomfortably close to toxic levels [5]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Lithium medication is the gold standard of treatment in Bipolar Disorder patients, preventing and reducing mood swings and suicidality. However, despite its effectiveness, it is a potentially hazardous drug requiring regular monitoring of blood levels to ensure toxic levels are not reached. This paper describes the first steps towards developing a new portable device that can be used by Bipolar Disorder patients to facilitate the analysis of lithium blood levels at home. Solutions of lithium carbonate have been optically fingerprinted using a high-end spectrophotometer. Preliminary measurements indicate that while the visible to near infrared region of the absorption spectra fall heavily within the water band, measurements in the Ultraviolet region show a strong distinction between different lithium concentrations. The optical spectra of Lithium in the 220 nm to 230 nm region demonstrated the ability to differentiate between concentrations representing those found in patients.
  • Source
    • "Since CKD 5 is not a common outcome even for people at CKD stages 1–3, in most cases risk–benefit analysis would favour continuation of lithium (Gitlin 1999). Gitlin's position has more recently been supported by Werneke et al (2012), who applied a mathematical model based on the existing evidence to analyse the risks and benefits of continuing or discontinuing lithium in people with chronic kidney disease. They suggest that lithium should be continued in the majority of patients even if they develop long-term renal adverse effects, unless the likelihood of progression to end-stage renal disease exceeds 41.3% or anticonvulsant medication is found to outperform lithium in relapse prevention. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Lithium is one of the most effective psychotropic drugs we have, but it is underused because of its low therapeutic index, the need for regular blood tests and perceptions about its adverse effects, including renal problems. The last include urinary concentration deficits and diabetes insipidus, chronic kidney disease (including renal failure), nephrotic syndrome, hypercalcaemia, hyperparathyroidism and distal tubular acidosis. This article reviews these adverse effects with special emphasis on their management.
    Advances in Psychiatric Treatment 11/2013; 19(6):457-466. DOI:10.1192/apt.bp.112.010306
Show more