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.

  • 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.
    Full-text · Article · Jan 2015
    • "Although data are limited, two RCTs suggest that amiloride (5–20 mg/day) may be helpful in treating NDI[71,72]. Weighing the psychiatric benefits and renal risks in long-term lithium users, decisional analyses of the literature suggest that lithium continuation may be recommended in most cases where patients experience renal dysfunction[128]. Why? "
    [Show abstract] [Hide abstract]
    ABSTRACT: Lithium is an important medication in the treatment of mood disorders. However, clinicians are hesitant to use lithium in older adults for fear of its medical effects, particularly kidney disease. This review describes the current understanding of the epidemiology and mechanisms underlying chronic kidney disease (CKD) in older lithium users, with recommendations for using lithium safely in late life. Prevalence estimates of CKD in older lithium users range from 42-50 %, which does not differ greatly from the 37.8 % rates seen in community-dwelling non-lithium using, non-psychiatric populations. Clinical and pre-clinical data suggest a variety of synergistic mechanisms contributing to CKD in older lithium users, including aging, cardiovascular factors, oxidative stress, inflammation, nephrogenic diabetes insipidus, acute kidney injury, and medication interactions. With regards to CKD, lithium can be used safely in many older adults with mood disorders. Compared to patients with pre-existing CKD, those with an estimated glomerular filtration rate >60 mL/min/1.73 m(2) are probably not as susceptible to lithium-associated renal decline. Using lithium concentrations <0.8 mmol/L; monitoring lithium concentrations and renal function every 3-6 months; being vigilant about concurrent medication use (e.g., diuretics, anti-inflammatories); as well as preventing/treating acute kidney injury, nephrogenic diabetes insipidus, diabetes mellitus, hypertension, smoking, and coronary artery disease can all help prevent CKD and further renal decline in older lithium users.
    No preview · Article · Dec 2014 · Drugs & Aging
  • 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.
    Full-text · Article · Aug 2014
Show more