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Qian E, Sud K, Lee V. Lithium-Associated Kidney Failure: Predictors and Outcomes. Kidney Int Rep 2024; 9:1276-1283. [PMID: 38707830 PMCID: PMC11068970 DOI: 10.1016/j.ekir.2024.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/12/2024] [Accepted: 01/22/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction Despite the widespread use of lithium for bipolar disorders and depression, little is known about the characteristics of patients with lithium-associated kidney failure receiving kidney replacement therapy (KRT). Methods We conducted a retrospective study using the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) to investigate the predictors and outcomes of patients with lithium-associated kidney failure receiving KRT. Results A total of 437 patients with lithium-associated kidney failure were compared to 1280 ANZDATA allocated controls of patients with kidney failure not associated with lithium. Patients with lithium-associated kidney failure commenced KRT at significantly older age (62 ± 10 vs. 58 ± 15 years; P < 0.001) and were more likely to be European (93% vs. 68%, P < 0.001), to be female (63% vs. 40%, P < 0.001), and to live in a postcode with a higher socioeconomic status (SES) (P < 0.001). In patients with lithium-associated kidney failure, there were lower rates of coronary artery disease (17% vs. 37%, P < 0.001), peripheral vascular disease (7% vs. 25%, P < 0.001), cerebrovascular disease (8% vs. 14%, P = 0.004) and diabetes mellitus (16% vs. 47%, P < 0.001). There were no differences between first KRT modality, although kidney transplantation and retransplantation rates were lower (21% vs. 27%, P = 0.008; 0.2% vs 3%, P = 0.001) with shorter wait-times to first transplantation (20 months vs. 29 months, P = 0.02) in the patients with lithium-associated kidney failure. Rates of at least 1 rejection episode was comparable (21% vs. 22%, P = 0.85) between the 2 groups. In addition, there were no survival differences regardless of KRT modality between the 2 groups. Conclusion Lithium-associated kidney failure represents a unique cohort which is predominantly older, female, European, with a higher SES and less comorbidities. Despite this, there are no differences in survival. Given the lower rate of transplantation, barriers to transplantation need further exploration.
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Affiliation(s)
- Emily Qian
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kamal Sud
- Nepean Kidney Research Centre, Department of Renal Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
- Faculty of Medicine and Health, Nepean Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Vincent Lee
- Department of Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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Erbaş E, Üstündağ H, Öztürk E, Parlak SN, Atcalı T. Astaxanthin treatment reduces kidney damage and facilitates antioxidant recovery in lithium-intoxicated rats. Toxicon 2024; 241:107664. [PMID: 38460603 DOI: 10.1016/j.toxicon.2024.107664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/16/2024] [Accepted: 02/27/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE This study aimed to evaluate the protective effects of astaxanthin against lithium-induced nephrotoxicity, focusing on histopathological changes, oxidative stress modulation, and alteration in the expression of key proteins related to apoptosis and inflammation. METHODS In this study, 56 male rats were utilized and divided into experimental groups subjected to lithium-induced nephrotoxicity, with and without astaxanthin treatment, over 14 and 28 days. The parameters assessed included oxidative stress markers (MDA, GSH, SOD), protein expression levels of BCL-2, BAX, TNF- α, PI3K, NF-κ B-p65, IL-1β, and comprehensive histopathological examinations to evaluate the integrity of renal tissue. RESULTS Lithium exposure led to significant renal damage, as evidenced by histological distortions in renal architecture, increased oxidative stress indicated by elevated MDA levels, and dysregulated expressions of apoptotic and inflammatory proteins. Notably, histopathological analysis revealed glomerular and tubular degeneration in lithium-treated groups. Astaxanthin treatment effectively mitigated these effects, demonstrating its efficacy in reducing lipid peroxidation, rebalancing apoptotic proteins, suppressing pro-inflammatory cytokines, and preserving renal histological structure. The concurrent use of lithium and astaxanthin showed a considerable amelioration of lithium-induced damage, suggesting astaxanthin's role in attenuating the nephrotoxic effects of lithium, both at a molecular and structural level. CONCLUSION Astaxanthin demonstrates significant renoprotective effects against lithium-induced nephrotoxicity, suggesting its utility as an effective adjunctive therapy. Through its potent antioxidative, anti-inflammatory, and anti-apoptotic actions, astaxanthin effectively reduces renal damage associated with lithium treatment, underscoring its potential for enhancing renal health in patients receiving lithium therapy.
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Affiliation(s)
- Elif Erbaş
- Atatürk University, Faculty of Veterinary, Department of Histology and Embryology, Erzurum, Turkiye.
| | - Hilal Üstündağ
- Erzincan Binali Yıldırım University, Faculty of Medicine, Department of Physiology, Erzincan, Turkiye.
| | - Emre Öztürk
- Erzurum Technical University, Faculty of Science, Department of Molecular Biology and Genetics, Erzurum, Turkiye
| | - Seçil Nazife Parlak
- Ağrı İbrahim Çeçen University, Faculty of Medicine, Department of Histology and Embryology, Ağrı, Turkiye
| | - Tuğçe Atcalı
- Bingöl University, Faculty of Veterinary, Department of Physiology, Erzurum, Turkiye
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3
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Cho Y, Lee D, Baek JH, Hong KS. Estimated glomerular filtration rate in Korean patients exposed to long-term lithium maintenance therapy. Int J Bipolar Disord 2022; 10:4. [PMID: 35128575 PMCID: PMC8818587 DOI: 10.1186/s40345-022-00249-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background Lithium-induced nephrotoxicity has long been debated. However, it has been rarely explored in Asian populations. The aim of the present study was to assess the effect of lithium maintenance therapy on estimated glomerular filtration rate (eGFR) in Korean patients diagnosed with a psychiatric illness. Methods This was a single-centered, retrospective study that included patients treated with lithium or comparator drug (valproate) in Samsung Seoul Medical Center between November 1994 and July 2020. Patients diagnosed with ICD codes F20-33 who had ≥ 6 months of exposure to lithium or valproate were included. Patients had to have ≥ 1 baseline and ≥ 2 post-baseline eGFR data with post-baseline data having an interval of at least 30 days. Chronic kidney disease (CKD) was defined as CKD stage 3 (eGFR < 60 mL/min/1.732). To be considered as CKD, the threshold had to be met at two consecutive post-baseline measurements. Those treated with both lithium and valproate, diagnosed with CKD stages 3–5, diagnosed with a renal disease, or received kidney transplantation were excluded. Results A total of 766 patients were included (242 treated with lithium and 524 with valproate). Two (0.8%) in the lithium group and 8 (1.5%) in the valproate group developed CKD stage 3. None developed CKD stages 4–5. Median yearly eGFR change was − 1.3 mL/min/1.732 (IQR: − 6.8, 1.7) for the lithium group and − 1.1 mL/min/1.732 (IQR: − 4.5, 1.5) for the valproate group, showing no significant difference between the two groups (p = 0.389). The rate of decline was more rapid for those with CKD in both groups. eGFR values of lithium and valproate groups did not show significant differences during a follow-up duration of 15 years or more. A significant negative correlation between baseline eGFR and yearly eGFR change was identified in a linear regression analysis. Conclusions In Korean patients, treatment with lithium did not increase the risk of developing CKD compared to treatment with valproate. Prevalence of CKD was lower than those previously reported in western populations. Low baseline eGFR showed significant correlation with changes in renal function. Supplementary Information The online version contains supplementary material available at 10.1186/s40345-022-00249-5.
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Parkin GM, McCarthy MJ, Thein SH, Piccerillo HL, Warikoo N, Granger DA, Thomas EA. Saliva testing as a means to monitor therapeutic lithium levels in patients with psychiatric disorders: Identification of clinical and environmental covariates, and their incorporation into a prediction model. Bipolar Disord 2021; 23:679-688. [PMID: 34536974 PMCID: PMC9291088 DOI: 10.1111/bdi.13128] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The narrow therapeutic window of lithium medications necessitates frequent serum monitoring, which can be expensive and inconvenient for the patient. Compared to blood, saliva collection is easier, non-invasive, requires less processing, and can be done without the need for trained personnel. This study investigated the utility of longitudinal salivary lithium level monitoring. METHODS We measured salivary lithium levels using ICP-OES in n = 169 passive drool samples, collected both as single observations and longitudinally for up to 18 months, from a multi-center cohort of n = 75 patients with bipolar disorder or other psychiatric conditions. RESULTS Saliva and serum lithium levels were highly correlated. Adjustment for daily lithium dose, diabetes, and smoking improved this relationship (r = 0.77). Using the adjusted intersubject equation and a patient's salivary lithium value, we observed a strong correlation between the predicted vs. observed serum lithium levels (r = 0.70). Most patients had highly stable saliva/serum ratios across multiple visits, with longitudinal variability significantly greater with age. Use of the intrasubject saliva/serum ratio from a single prior observation had similar predictive power to the use of the adjusted intersubject equation. However, the use of the mean intrasubject ratio from three prior observations could robustly predict serum lithium levels (predicted vs. observed r = 0.90). CONCLUSIONS These findings strongly suggest that saliva could be used for lithium monitoring, and open the door for the development and implementation of a point-of-care salivary lithium device for use at home or the clinic. We propose that the use of saliva will dramatically improve treatment opportunities for patients with mood disorders.
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Affiliation(s)
- Georgia M. Parkin
- Department of EpidemiologyUniversity of California IrvineIrvineCaliforniaUSA,Institute for Interdisciplinary Salivary Bioscience ResearchUniversity of California IrvineIrvineCaliforniaUSA
| | - Michael J. McCarthy
- Department of PsychiatryUniversity of California San DiegoSan DiegoCaliforniaUSA,VA San Diego Healthcare SystemSan DiegoCaliforniaUSA
| | - Soe H. Thein
- Department of Psychiatry and Behavioral SciencesUC Davis Health SystemSacramentoCaliforniaUSA
| | - Hillary L. Piccerillo
- Institute for Interdisciplinary Salivary Bioscience ResearchUniversity of California IrvineIrvineCaliforniaUSA
| | | | - Douglas A. Granger
- Institute for Interdisciplinary Salivary Bioscience ResearchUniversity of California IrvineIrvineCaliforniaUSA,Johns Hopkins University School of NursingBloomberg School of Public Health, and School of MedicineBaltimoreMarylandUSA
| | - Elizabeth A. Thomas
- Department of EpidemiologyUniversity of California IrvineIrvineCaliforniaUSA,Institute for Interdisciplinary Salivary Bioscience ResearchUniversity of California IrvineIrvineCaliforniaUSA
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Bgatova N, Taskaeva I, Makarova V. Influence of distant tumor growth and lithium treatment on ultrastructural organization of kidney proximal tubules. Ultrastruct Pathol 2021; 45:212-223. [PMID: 34304707 DOI: 10.1080/01913123.2021.1954735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Tumor growth causes significant metabolic disturbances, tissue damage and the accumulation of toxic metabolites in the blood. The kidney is an organ with highly developed capillary network and therefore can be exposed to toxic metabolites. Here, the proximal renal tubule cells were studied by immunohistochemistry and electron microscopy, on a model of hepatocellular carcinoma-29 growth in the thigh of CBA mice and lithium carbonate treatment. An increase of autophagy markers (LC3 and LAMP-1) expression was revealed under conditions of distant tumor growth and especially after lithium carbonate treatment. Under conditions of distant tumor we found decrease of numerical density of endosomes and dense apical tubules in the apical part of the cells. In the perinuclear cell compartment, there were swelling of mitochondria and a decrease in their cristae, a decrease of volume density of rough endoplasmic reticulum and the presence of autophagosomes and autolysosomes. The use of lithium carbonate led to an increase of autophagic structures volume density and of dense apical tubules numerical density in the proximal tubule cells. It is possible that the activation of autophagy by lithium can promote an increase in protein recycling in the proximal tubule cells.
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Affiliation(s)
- Nataliya Bgatova
- Laboratory of Ultrastructural Research, Research Institute of Clinical and Experimental Lymphology - Branch of the Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - Iuliia Taskaeva
- Laboratory of Ultrastructural Research, Research Institute of Clinical and Experimental Lymphology - Branch of the Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - Viktoriia Makarova
- Laboratory of Ultrastructural Research, Research Institute of Clinical and Experimental Lymphology - Branch of the Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
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Abstract
Further understanding of older age bipolar disorder (OABD) may lead to more specific recommendations for treatment adjusted to the specific characteristics and needs caused by age-related somatic and cognitive changes. Late-onset mania has a broad differential diagnosis and requires full psychiatric and somatic work-up, including brain imaging. Research on pharmacotherapy in OABD is limited. First-line treatment of OABD is similar to that for adult bipolar disorder (BD), with specific attention to vulnerability to side effects and somatic comorbidity. Because findings in younger adults with BD cannot be extrapolated to OABD, more research in OABD is warranted.
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Affiliation(s)
- Annemiek Dols
- Department of Old Age Psychiatry, GGZinGeest and VUmc University Medical Center, Amstelveenseweg 589, 1081 JC, Amsterdam, The Netherlands; Mental Health Program, Amsterdam Public Health Research Institute, Van der Boechorstsstraat 7, 1081 BT, Amsterdam, The Netherlands; Mood, Anxiety and Psychosis Program, Amsterdam Neuroscience, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
| | - Aartjan Beekman
- Department of Old Age Psychiatry, GGZinGeest and VUmc University Medical Center, Amstelveenseweg 589, 1081 JC, Amsterdam, The Netherlands; Mental Health Program, Amsterdam Public Health Research Institute, Van der Boechorstsstraat 7, 1081 BT, Amsterdam, The Netherlands; Mood, Anxiety and Psychosis Program, Amsterdam Neuroscience, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands; Department of Psychiatry, GGZinGeest and VUmc University Medical Center, Amstelveenseweg 589, 1081 JC, Amsterdam, The Netherlands
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7
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Biomass of Arthrospira platensis enriched with lithium by bioaccumulation and biosorption process. FOOD BIOSCI 2021. [DOI: 10.1016/j.fbio.2021.100950] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Levenberg K, Edris W, Levine M, George DR. Considering a Potential Role of Linalool as a Mood Stabilizer for Bipolar Disorder. Curr Pharm Des 2020; 26:5128-5133. [PMID: 32713332 DOI: 10.2174/1381612826666200724160742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 07/28/2020] [Indexed: 12/18/2022]
Abstract
Epidemiologic studies suggest that the lifetime prevalence of bipolar spectrum disorders ranges from 2.8 to 6.5 percent of the population. To decrease morbidity and mortality associated with disease progression, pharmacologic intervention is indicated for the majority of these patients. While a number of effective treatment regimens exist, many conventional medications have significant side effect profiles that adversely impact patients' short and long-term well-being. It is thus important to continue advancing and improving therapeutic options available to patients. This paper reviews the limitations of current treatments and examines the chemical compound Linalool, an alcohol found in many plant species, that may serve as an effective mood stabilizer. While relatively little is known about Linalool and bipolar disorder, the compound has been shown to have antiepileptic, anti-inflammatory, anxiolytic, anti-depressive, and neurotrophic effects, with mechanisms that are comparable to current bipolar disorder treatment options.
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Affiliation(s)
- Kate Levenberg
- College of Medicine, Penn State University College of Medicine, State College, Hershey, United States
| | - Wade Edris
- Department of Medicine, Penn State University College of Medicine, State College, Hershey, United States
| | - Martha Levine
- Department of Pediatrics, Penn State University College of Medicine, Hershey, United States
| | - Daniel R George
- Department of Pediatrics, Penn State University College of Medicine, Hershey, United States
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9
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Ossani GP, Uceda AM, Lago NR, Martino DJ. Relationship between serum lithium concentration and kidney damage in a preclinical model. Bipolar Disord 2020; 22:281-285. [PMID: 31628694 DOI: 10.1111/bdi.12854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of the present study was to assess whether there is a relationship between serum lithium concentrations and the magnitude of kidney damage in a preclinical model. METHODS Thirty Wistar male rats were randomized into three groups: control group fed ad libitum powered standard diet for 3 months; and experimental groups fed ad libitum the same diet supplemented with 30 or 60 mmol/kg diet for 3 months (LowLi and HighLi groups respectively). Laboratory parameters were assessed at months 1 and 3 and histopathological changes were evaluated after 3 months. RESULTS Serum lithium levels in experimental rats were within therapeutic range used in humans throughout the entire experiment. After 3 months of treatment, lithium levels were statistically higher in HighLi group. Rats of the LowLi group showed dilation of cortical tubules although with similar clearance of creatinine. Rats from the HighLi group had greater histopathological damage in addition to lower creatinine clearance than the other two groups. CONCLUSIONS Our study suggests that during long-term treatments, even with serum lithium levels within the therapeutic range used in humans, the risk of kidney damage could increase proportionally to the serum lithium concentration.
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Affiliation(s)
- Georgina P Ossani
- Centre of Experimental and Applied Pathology, Department of Pathology, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina.,Laboratory of Experimental Medicine, Hospital Alemán, Buenos Aires, Argentina.,National Council of Scientific and Technical Research (CONICET), Buenos Aires, Argentina
| | - Ana M Uceda
- Centre of Experimental and Applied Pathology, Department of Pathology, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina.,Laboratory of Experimental Medicine, Hospital Alemán, Buenos Aires, Argentina
| | - Néstor R Lago
- Centre of Experimental and Applied Pathology, Department of Pathology, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Diego J Martino
- National Council of Scientific and Technical Research (CONICET), Buenos Aires, Argentina.,Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University, Buenos Aires, Argentina
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Ossani GP, Uceda AM, Acosta JM, Lago NR, Repetto MG, Martino DJ, Toblli JE. Role of Oxidative Stress in Lithium-Induced Nephropathy. Biol Trace Elem Res 2019; 191:412-418. [PMID: 30600502 DOI: 10.1007/s12011-018-1617-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 12/16/2018] [Indexed: 02/07/2023]
Abstract
Long-term lithium treatment was associated with chronic kidney disease and renal failure although the underlying pathogenic mechanisms are not certainty known. The aim of this study was to evaluate changes in oxidative stress measures as well as renal functional and structural alterations associated with chronic use of lithium in rats. Forty Wistar male rats were randomized into four groups: control groups fed ad libitum powered standard diet for 1 and 3 months and experimental groups fed ad libitum the same diet supplemented with 60 mmol/kg diet for 1 and 3 months. Histopathological changes, laboratory parameters, and oxidative stress measurements were assessed at months 1 and 3. The experimental animals showed alteration of the cortical tubules from the first month of lithium-treatment and a decrease in the glomerular filtration rate and in the glomerular area at the third month. There was an increase in thiobarbituric acid reactive substances and carbonyls, as well as an increase in reduced glutathione, in the kidney of rats exposed to lithium. These changes were evident from the first month of treatment and remained throughout the experiment. Our results suggest that, oxidative stress could be one of the pathogenic mechanisms involved in the structural and functional alterations of the kidney associated with prolonged use of lithium. The study of the pathogenic mechanisms involved in lithium-induced nephropathy is a critical issue for the development of new strategies for prevention and/or early detection.
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Affiliation(s)
- Georgina P Ossani
- School of Medicine, Department of Pathology, Centre of Experimental and Applied Pathology, University of Buenos Aires, Buenos Aires, Argentina.
- Laboratory of Experimental Medicine, Hospital Alemán, Buenos Aires, Argentina.
- National Council of Scientific and Technical Research (CONICET), Buenos Aires, Argentina.
| | - Ana M Uceda
- School of Medicine, Department of Pathology, Centre of Experimental and Applied Pathology, University of Buenos Aires, Buenos Aires, Argentina
- Laboratory of Experimental Medicine, Hospital Alemán, Buenos Aires, Argentina
| | - Juan M Acosta
- School of Pharmacy and Biochemistry, Department of Analytical Chemistry and Physicochemistry, Cathedra of General and Inorganic Chemistry, University of Buenos Aires, Buenos Aires, Argentina
| | - Néstor R Lago
- School of Medicine, Department of Pathology, Centre of Experimental and Applied Pathology, University of Buenos Aires, Buenos Aires, Argentina
| | - Marisa G Repetto
- National Council of Scientific and Technical Research (CONICET), Buenos Aires, Argentina
- School of Pharmacy and Biochemistry, Department of Analytical Chemistry and Physicochemistry, Cathedra of General and Inorganic Chemistry, University of Buenos Aires, Buenos Aires, Argentina
| | - Diego J Martino
- National Council of Scientific and Technical Research (CONICET), Buenos Aires, Argentina
- Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University, Buenos Aires, Argentina
| | - Jorge E Toblli
- Laboratory of Experimental Medicine, Hospital Alemán, Buenos Aires, Argentina
- National Council of Scientific and Technical Research (CONICET), Buenos Aires, Argentina
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
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Hanna RM, Hasnain H, Sangalang MD, Han J, Arasu A, Arman F, Barsoum M, Poa H, Rastogi A, Harari A. Three Patients with Lithium-Associated Hyperparathyroidism: Literature Review Regarding Medical and Surgical Management. Case Rep Nephrol Dial 2019; 9:108-118. [PMID: 31559266 PMCID: PMC6751439 DOI: 10.1159/000502399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 07/22/2019] [Indexed: 11/28/2022] Open
Abstract
Lithium (Li) carbonate has been established as a mood stabilizer and an efficacious treatment for bipolar disorder since its discovery by Dr. John Cade in 1948. Li interacts significantly with organ systems and endocrine pathways. One of the most challenging side effects of Li to manage is its effect on the parathyroid glands. Dysregulation of parathyroid signaling due to Li results in hypercalcemia due to increased vitamin D<sub>3</sub> generation, increased calcium absorption from the gut, and bone resorption, occasionally resulting in concomitant hypercalciuria. However, hypercalciuria is not a definitive feature for hyperparathyroidism, and normal calcium excretion might be seen in these patients. Hypercalcemia may also result from volume contraction and decreased renal clearance, which are commonly seen in these patients. Anatomically the parathyroid abnormalities can present as single or multiglandular disease. We report 3 cases where the patients developed multiple side effects of Li therapy as well as hypercalcemia due to hyperparathyroidism. The literature is reviewed with regard to medical and surgical management of Li-associated hyperparathyroidism in the context of these 3 presented cases.
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Affiliation(s)
- Ramy M Hanna
- UCLA Department of Medicine, Division of Nephrology, Los Angeles, California, USA
| | - Huma Hasnain
- UCLA Department of Medicine, Division of Nephrology, Los Angeles, California, USA
| | | | - Jennifer Han
- UCLA Department of Medicine, Division of Endocrinology, Los Angeles, California, USA
| | - Aarthi Arasu
- UCLA Department of Medicine, Division of Endocrinology, Los Angeles, California, USA
| | - Farid Arman
- UCLA Department of Medicine, Division of Nephrology, Los Angeles, California, USA
| | - Marina Barsoum
- UCLA Department of Medicine, Division of Nephrology, Los Angeles, California, USA
| | - Hyunah Poa
- UCLA Department of Medicine, Los Angeles, California, USA
| | - Anjay Rastogi
- UCLA Department of Medicine, Division of Nephrology, Los Angeles, California, USA
| | - Avital Harari
- UCLA Department of Surgery, Division of Endocrine Surgery, Los Angeles, California, USA
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Impact of Long-Term Lithium Treatment on Renal Function in Patients With Bipolar Disorder Based on Novel Biomarkers. J Clin Psychopharmacol 2019; 39:238-242. [PMID: 30932947 DOI: 10.1097/jcp.0000000000001030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Lithium in the form of lithium carbonate (Li2CO3) has become one of the most effective and widely prescribed drugs for mood stabilization. However, lithium has adverse effects on renal tubular functions, such as decreased concentrating function of the kidneys, and even occasional symptoms of nephrogenous diabetes insipidus occur with additional evidence of glomerular disruption in lithium-treated patients. METHODS We assessed the kidney function of patients with bipolar disorder who are under long-term lithium treatment using novel markers of kidney damage such as plasma neutrophil gelatinase-associated lipocalin, cystatin C, albuminuria, estimated glomerular filtration rate, Chronic Kidney Disease-Epidemiology Investigation using creatinine and cystatin C, and serum and urinary osmolality, and compared the results with those of age-matched patients with bipolar disorder not treated with lithium. The study enrolled 120 patients with bipolar disorder, consisting of 80 (30 male and 50 female patients) who have been receiving lithium for 0.5 to 20 (mean, 7) years and 40 (10 male and 30 female patients) who had never been exposed to lithium treatment. RESULTS Patients treated with lithium had significantly decreased urine osmolality (mean ± SD, 405 ± 164 vs 667 ± 174 mmol/kg) and urine-to-serum osmolality ratio (1.35 ± 0.61 vs 2.25 ± 0.96). No significant difference was found in creatinine, estimated glomerular filtration rate values calculated using the Chronic Kidney Disease-Epidemiology Investigation using creatinine and cystatin C, neutrophil gelatinase-associated lipocalin, cystatin C, and albuminuria between both groups. We found no significant difference in renal biomarkers between patients treated with lithium for 6 to 24 months and those treated for 25 to 240 months. CONCLUSIONS We found significantly decreased kidney concentrating ability in the long-term lithium-treated patients compared with the control group. Other renal function markers did not indicate any significant signs of renal dysfunction.
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Nestsiarovich A, Kerner B, Mazurie AJ, Cannon DC, Hurwitz NG, Zhu Y, Nelson SJ, Oprea TI, Unruh ML, Crisanti AS, Tohen M, Perkins DJ, Lambert CG. Comparison of 71 bipolar disorder pharmacotherapies for kidney disorder risk: The potential hazards of polypharmacy. J Affect Disord 2019; 252:201-211. [PMID: 30986735 DOI: 10.1016/j.jad.2019.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/13/2019] [Accepted: 04/06/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study compared the largest set of bipolar disorder pharmacotherapies to date (71 drugs and drug combinations) for risk of kidney disorders (KDs). METHODS This retrospective observational study used the IBM MarketScan® database to analyze data on 591,052 adults with bipolar disorder without prior nephropathy, for onset of KDs (of "moderate" or "high" severity) following psychopharmacotherapy (lithium, mood stabilizing anticonvulsants [MSAs], antipsychotics, antidepressants), or "No drug". Cox regression models included fixed pre-treatment covariates and time-varying drug exposure covariates to estimate the hazard ratio (HR) of each treatment versus "No drug". RESULTS Newly observed KD occurred in 14,713 patients. No regimen had significantly lower risk of KDs than "No drug". The HR estimates ranged 0.86-2.66 for "all" KDs and 0.87-5.30 for "severe" KDs. As additional drugs were combined to compare more complex polypharmacies, higher HRs were consistently observed. Most regimens containing lithium, MSAs, or antipsychotics had a higher risk than "No drug" (p < 0.05). The risk for "all" and "severe" KDs was highest respectively on monoamine oxidase inhibitors (MAOIs) (HR = 2.66, p = 5.73 × 10-5), and a lithium-containing four-class combination (HR = 5.30, p = 2.46 × 10-9). The HR for lithium monotherapy was 1.82 (p = 4.73 × 10-17) for "severe" KDs. LIMITATIONS The limitations inherent for an observational study were non-randomized assignment of patients to treatment groups, non-standardization of diagnostic decisions, and non-uniform quality of data collection. No correction was made for medication dosage. CONCLUSIONS The findings support literature concerns about lithium nephrotoxicity and highlight the potential risks of MAOIs, MSAs, antipsychotics and psychotropic polypharmacy.
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Affiliation(s)
- Anastasiya Nestsiarovich
- Department of Internal Medicine, Center for Global Health, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Berit Kerner
- Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | | | | | | | - Yiliang Zhu
- Department of Internal Medicine, Division of Epidemiology, Biostatistics, and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Stuart J Nelson
- University of New Mexico Health Sciences Library and Informatics Center, Albuquerque, NM, USA; Department of Internal Medicine, Division of Translational Informatics, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Tudor I Oprea
- Department of Internal Medicine, Division of Translational Informatics, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Mark L Unruh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Annette S Crisanti
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Mauricio Tohen
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Douglas J Perkins
- Department of Internal Medicine, Center for Global Health, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Christophe G Lambert
- Department of Internal Medicine, Center for Global Health, University of New Mexico Health Sciences Center, Albuquerque, NM, USA; Department of Internal Medicine, Division of Translational Informatics, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
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14
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Davis J, Desmond M, Berk M. Lithium and nephrotoxicity: a literature review of approaches to clinical management and risk stratification. BMC Nephrol 2018; 19:305. [PMID: 30390660 PMCID: PMC6215627 DOI: 10.1186/s12882-018-1101-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 10/12/2018] [Indexed: 11/30/2022] Open
Abstract
Background Despite lithium being the most efficacious treatment for bipolar disorder, its use has been decreasing at least in part due to concerns about its potential to cause significant nephrotoxicity. Whilst the ability of lithium to cause nephrogenic diabetes insipidus is well established, its ability to cause chronic kidney disease is a much more vexing issue, with various studies suggesting both positive and negative causality. Despite these differences, the weight of evidence suggests that lithium has the potential to cause end stage kidney disease, albeit over a prolonged period. Methods A search strategy for this review was developed to identify appropriate studies, sourced from the electronic databases EMBASE, PubMed (NLM) and MEDLINE. Search terms included lithium with the AND operator to combine with nephrotoxicity or nephropathy or chronic kidney disease or nephrogenic diabetes insipidus or renal and pathophysiology. Results The risks for the development of lithium induced nephropathy are less well defined but appear to include the length of duration of therapy as well as increasing age, as well as episodes of over dosage/elevated lithium levels. Whilst guidelines exist for the routine monitoring of lithium levels and renal function, it remains unclear when nephrological evaluation should occur, as well as when cessation of lithium therapy is appropriate balancing the significant attendant mental health risks as well as the potential for progression to occur despite cessation of therapy against the risks and morbidity of bipolar disorder itself. Conclusion This paper will elucidate on the current evidence pertaining to the topic of the clinical management of lithium induced nephrotoxicity and provide a guide for clinicians who are faced with the long-term management of these patients.
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Affiliation(s)
- J Davis
- Department of Renal Medicine, University Hospital Geelong, Rotary House, 325 Ryrie St, Geelong, VIC, Australia.
| | - M Desmond
- Department of Renal Medicine, University Hospital Geelong, Rotary House, 325 Ryrie St, Geelong, VIC, Australia
| | - M Berk
- IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, 75 Pigdons Road, Geelong, Australia.,Orygen, The National Centre of Excellence in Youth Mental Health, the Department of Psychiatry, and the Florey Institute for Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
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15
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Roxanas MG, George C, Gallagher M. Comment on 'Continuation of lithium after a diagnosis of chronic kidney disease'. Acta Psychiatr Scand 2018; 138:275. [PMID: 30295936 DOI: 10.1111/acps.12908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- M G Roxanas
- University of Sydney Adventist Hospital Clinical School, Wahroonga, NSW, Australia
| | - C George
- Concord Repatriation General Hospital, Concord, NSW, Australia
| | - M Gallagher
- Concord Repatriation General Hospital, Concord, NSW, Australia
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16
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Lithium Treatment for Agitation in Alzheimer's disease (Lit-AD): Clinical rationale and study design. Contemp Clin Trials 2018; 71:33-39. [PMID: 29859917 DOI: 10.1016/j.cct.2018.05.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/23/2018] [Accepted: 05/25/2018] [Indexed: 11/22/2022]
Abstract
Symptoms of agitation, aggression, and psychosis frequently occur in patients with Alzheimer's disease (AD). These symptoms are distressing to patients and caregivers, often lead to institutionalization, are associated with increased mortality, and are very difficult to treat. Lithium is an established treatment for bipolar and other psychotic disorders in which agitation can occur. The Lit-AD study is the first randomized, double-blind, placebo-controlled trial to assess the efficacy of lithium treatment for symptoms of agitation or aggression, with or without psychosis, in older adults diagnosed with AD. Patients are randomly assigned to low dose (150-600 mg) lithium or placebo, targeting a blood level of 0.2-0.6 mmol/L, stratified by the presence/absence of psychotic symptoms. The study duration for each patient is 12 weeks. The primary study outcome is change in the agitation/aggression domain score on the Neuropsychiatric Inventory (NPI) over the study period. The secondary outcome is improvement in neuropsychiatric symptoms defined as a 30% decrease in a NPI core score that combines agitation/aggression and psychosis domain scores. The Treatment Emergent Symptom Scale (TESS) is used to assess somatic side effects. Other exploratory analyses examine the associations between improvement on lithium and indices shown to be associated with response to lithium in bipolar disorder: serum brain-derived neurotrophic factor (BDNF) levels, a SNP in intron 1 of the ACCN1 gene, and variation at the 7q11.2 gene locus. If lithium demonstrates efficacy in this Phase II pilot trial, a Phase III study will be developed to establish its clinical utility in these patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02129348.
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17
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Abstract
Further understanding of older age bipolar disorder (OABD) may lead to more specific recommendations for treatment adjusted to the specific characteristics and needs caused by age-related somatic and cognitive changes. Late-onset mania has a broad differential diagnosis and requires full psychiatric and somatic work-up, including brain imaging. Research on pharmacotherapy in OABD is limited. First-line treatment of OABD is similar to that for adult bipolar disorder (BD), with specific attention to vulnerability to side effects and somatic comorbidity. Because findings in younger adults with BD cannot be extrapolated to OABD, more research in OABD is warranted.
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Affiliation(s)
- Annemiek Dols
- Department of Old Age Psychiatry, GGZinGeest and VUmc University Medical Center, Amstelveenseweg 589, 1081 JC, Amsterdam, The Netherlands; Mental Health Program, Amsterdam Public Health Research Institute, Van der Boechorstsstraat 7, 1081 BT, Amsterdam, The Netherlands; Mood, Anxiety and Psychosis Program, Amsterdam Neuroscience, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
| | - Aartjan Beekman
- Department of Old Age Psychiatry, GGZinGeest and VUmc University Medical Center, Amstelveenseweg 589, 1081 JC, Amsterdam, The Netherlands; Mental Health Program, Amsterdam Public Health Research Institute, Van der Boechorstsstraat 7, 1081 BT, Amsterdam, The Netherlands; Mood, Anxiety and Psychosis Program, Amsterdam Neuroscience, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands; Department of Psychiatry, GGZinGeest and VUmc University Medical Center, Amstelveenseweg 589, 1081 JC, Amsterdam, The Netherlands
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18
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Grunze H, Vieta E, Goodwin GM, Bowden C, Licht RW, Azorin JM, Yatham L, Mosolov S, Möller HJ, Kasper S. The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Acute and long-term treatment of mixed states in bipolar disorder. World J Biol Psychiatry 2018; 19:2-58. [PMID: 29098925 DOI: 10.1080/15622975.2017.1384850] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Although clinically highly relevant, the recognition and treatment of bipolar mixed states has played only an underpart in recent guidelines. This WFSBP guideline has been developed to supply a systematic overview of all scientific evidence pertaining to the acute and long-term treatment of bipolar mixed states in adults. METHODS Material used for these guidelines is based on a systematic literature search using various data bases. Their scientific rigour was categorised into six levels of evidence (A-F), and different grades of recommendation to ensure practicability were assigned. We examined data pertaining to the acute treatment of manic and depressive symptoms in bipolar mixed patients, as well as data pertaining to the prevention of mixed recurrences after an index episode of any type, or recurrence of any type after a mixed index episode. RESULTS Manic symptoms in bipolar mixed states appeared responsive to treatment with several atypical antipsychotics, the best evidence resting with olanzapine. For depressive symptoms, addition of ziprasidone to treatment as usual may be beneficial; however, the evidence base is much more limited than for the treatment of manic symptoms. Besides olanzapine and quetiapine, valproate and lithium should also be considered for recurrence prevention. LIMITATIONS The concept of mixed states changed over time, and recently became much more comprehensive with the release of DSM-5. As a consequence, studies in bipolar mixed patients targeted slightly different bipolar subpopulations. In addition, trial designs in acute and maintenance treatment also advanced in recent years in response to regulatory demands. CONCLUSIONS Current treatment recommendations are still based on limited evidence, and there is a clear demand for confirmative studies adopting the DSM-5 specifier with mixed features concept.
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Affiliation(s)
- Heinz Grunze
- a Institute of Neuroscience , Newcastle University , Newcastle upon Tyne , UK
- b Paracelsus Medical University , Nuremberg , Germany
- c Zentrum für Psychiatrie Weinsberg , Klinikum am Weissenhof , Weinsberg , Germany
| | - Eduard Vieta
- d Bipolar Disorders Programme, Institute of Neuroscience , Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM , Barcelona , Catalonia , Spain
| | - Guy M Goodwin
- e Department of Psychiatry , University of Oxford, Warneford Hospital , Oxford , UK
| | - Charles Bowden
- f Dept. of Psychiatry , University of Texas Health Science Center , San Antonio , TX , USA
| | - Rasmus W Licht
- g Psychiatric Research Unit, Psychiatry , Aalborg University Hospital , Aalborg , Denmark
- h Clinical Department of Medicine , Aalborg University , Aalborg , Denmark
| | - Jean-Michel Azorin
- i Department of Psychiatry , Hospital Ste. Marguerite , Marseille , France
| | - Lakshmi Yatham
- j Department of Psychiatry , University of British Columbia , Vancouver , BC , Canada
| | - Sergey Mosolov
- k Department for Therapy of Mental Disorders , Moscow Research Institute of Psychiatry , Moscow , Russia
| | - Hans-Jürgen Möller
- l Department of Psychiatry and Psychotherapy , Ludwigs-Maximilian University , Munich , Germany
| | - Siegfried Kasper
- m Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
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Hallab B, Hallab S, Battas O, Agoub M. Syndrome de neurotoxicité irréversible de lithium-effectuated ou SILENT : à propos d’un cas. Therapie 2017; 72:403-407. [DOI: 10.1016/j.therap.2016.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 10/20/2016] [Accepted: 10/25/2016] [Indexed: 11/16/2022]
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20
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De Fazio P, Gaetano R, Caroleo M, Pavia M, De Sarro G, Fagiolini A, Segura-Garcia C. Lithium in late-life mania: a systematic review. Neuropsychiatr Dis Treat 2017; 13:755-766. [PMID: 28331326 PMCID: PMC5352229 DOI: 10.2147/ndt.s126708] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The prevalence of mania among >65-year-olds ranges from 0.1% to 0.4% and its treatment is a particular challenge for clinicians. Although lithium is the treatment of choice for bipolar disorder (BD), its use in elderly population was recently questioned. This study provides a comprehensive review of literature on the efficacy and tolerability of lithium as a pharmacologic treatment for mania in elderly BD patients. We conducted a systematic review, based on PRISMA guidelines, of articles published between 1970 and August 2016 and indexed in the following databases: EMBASE, MEDLINE, Cochrane Library Databases and PsycINFO. The key words "age", "late-life", "geriatric", "elderly", and "older" were combined with words indicating pharmacologic treatments, such as lithium and other mood stabilizers and with the diagnostic terms "bipolar disorder" and "mania". Fifteen out of 196 retrieved studies met our inclusion criteria. Seven studies evaluated both the efficacy and tolerability of lithium treatment in elderly BD patients; a further three evaluated only the efficacy and five assessed tolerability. Only limited data on the treatment of elderly BD patients are available, but evidence suggests that lithium is effective and tolerated in this subgroup of patients and thus should remain a first-line drug. It seems to be more effective at lower doses and close monitoring of plasma concentrations is necessary.
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Affiliation(s)
- Pasquale De Fazio
- Department of Health Sciences, Psychiatric Unit, University Magna Græcia of Catanzaro
| | - Raffaele Gaetano
- Department of Health Sciences, Psychiatric Unit, University Magna Græcia of Catanzaro
| | - Mariarita Caroleo
- Department of Health Sciences, Psychiatric Unit, University Magna Græcia of Catanzaro
| | - Maria Pavia
- Department of Health Science, University Magna Græcia
| | - Giovanbattista De Sarro
- Department of Health Sciences, Institute of Pharmacology, University Magna Græcia, Catanzaro
| | - Andrea Fagiolini
- Department of Molecular Medicine, Division of Psychiatry, University of Siena, Siena, Italy
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21
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Beasley AK, Larson CC, Garcia-Pittman EC. Lithium rechallenge after renal transplant. Ment Health Clin 2017; 7:46-50. [PMID: 29955497 PMCID: PMC6007664 DOI: 10.9740/mhc.2017.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Mrs B is a 65-year-old, married, white woman with long-standing history of bipolar disorder type I who achieved mood stability with chronic lithium treatment. She developed end-stage renal disease, which was suspected to be the result of chronic lithium exposure in the context of medical comorbidity, and subsequently required renal transplantation. Following transplantation and discontinuation of lithium, Mrs B was unable to achieve mood stability with multiple medication trials and required more than 40 medical and psychiatric hospitalizations with eventual transition to skilled nursing care. After much discussion among the psychiatric treatment team, the patient, and her husband, primary care provider, nephrologist, and renal transplant surgeon, the decision was made to restart the patient on lithium given her previous treatment success. The purpose of this case report is to discuss the use of lithium following renal transplantation. In this case, a multidisciplinary approach was used to assist the patient in carefully weighing the risks and benefits of her treatment decisions. The consensus of the patient, her husband, and her providers was that the benefit of mood stabilization outweighed the potential risks of renal toxicity. Although treatment with lithium after renal transplant is not a first-line treatment option, this case illustrates that lithium could be considered in certain cases.
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Affiliation(s)
- Anna K. Beasley
- (Corresponding author) Psychosomatic Medicine Fellow PGY-5, The University of Texas at Austin Dell Medical School, Austin, Texas
| | - Catherine C. Larson
- Child and Adolescent Psychiatry Fellow PGY-5, The University of Texas at Austin Dell Medical School, Austin, Texas
| | - Erica C. Garcia-Pittman
- Assistant Professor, The University of Texas at Austin Dell Medical School at Seton Family of Hospitals - Psychiatry Residency Program, Austin, Texas
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Abstract
OBJECTIVE To review the relationship between lithium-related renal dysfunction and microcysts. METHOD Electronic databases (PubMed and Google Scholar) were queried. RESULTS From a total of 12,425 publications, 76 were reviewed. DISCUSSION Glomerular renal dysfunction occurs after an average of 20 years of continuous lithium treatment, and the severity is related to the total lithium load as measured by dose and duration. Recently, several reports have highlighted the relationship between renal microcyst formation and significant reductions in glomerular filtration rate. Radiologically visible lithium-related microcysts are usually 1-2 mm and occasionally 3 mm. Smaller cysts, which are impossible to resolve, are probably more common than the visible cysts, based on observations of renal needle biopsies. Increases in the number of microcysts and the space they occupy within kidney volume appear to be related to both the duration of lithium treatment and the reduction in kidney function. The proposed mechanism of microcyst formation is related to the antiapoptotic effect of lithium. Specifically, by preventing renal tubular epithelial cells from undergoing apoptosis as part of the process of normal renal maintenance, lithium may be allowing the inappropriate growth of the surface area of tubules to form invaginations and ultimately cysts. It is proposed that the physical space occupied by these cysts in the limited volume within the renal capsule compromises the function of otherwise healthy renal tissue. Monitoring of kidneys utilizing radiographic imaging may be more sensitive than monitoring laboratory values. Additional research is required to optimize this new monitoring tool.
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Affiliation(s)
- Mashal Khan
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, KY, USA
| | - Rif S El-Mallakh
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, KY, USA
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23
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Bulteau S, Vigneau C, Bronnec M, Etcheverrigaray F, Maulaz B, Guitteny M, Masson M, Vanelle JM, Sauvaget A. Modalités de surveillance des sels de lithium en psychiatrie : des guidelines à la pratique. ANNALES MEDICO-PSYCHOLOGIQUES 2016. [DOI: 10.1016/j.amp.2015.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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24
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Preventative strategies may reduce the risk of chronic kidney disease in elderly patients receiving lithium. DRUGS & THERAPY PERSPECTIVES 2015. [DOI: 10.1007/s40267-015-0250-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Shine B, McKnight RF, Leaver L, Geddes JR. Long-term effects of lithium on renal, thyroid, and parathyroid function: a retrospective analysis of laboratory data. Lancet 2015; 386:461-8. [PMID: 26003379 DOI: 10.1016/s0140-6736(14)61842-0] [Citation(s) in RCA: 146] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Lithium is a widely used and highly effective treatment for mood disorders, but causes poorly characterised adverse effects in kidney and endocrine systems. We aimed to analyse laboratory information system data to determine the incidence of renal, thyroid, and parathyroid dysfunction associated with lithium use. METHODS In a retrospective analysis of laboratory data from Oxford University Hospitals National Health Service Trust (Oxfordshire, UK), we investigated the incidence of renal, thyroid, and parathyroid dysfunction in patients (aged ≥18 years) who had at least two creatinine, thyrotropin, calcium, glycated haemoglobin, or lithium measurements between Oct 1, 1982, and March 31, 2014, compared with controls who had not had lithium measurements taken. We used survival analysis and Cox regression to estimate the hazard ratio (HR) for each event with lithium use, age, sex, and diabetes as covariates. FINDINGS Adjusting for age, sex, and diabetes, presence of lithium in serum was associated with an increased risk of stage three chronic kidney disease (HR 1·93, 95% CI 1·76-2·12; p<0·0001), hypothyroidism (2·31, 2·05-2·60; p<0·0001), and raised total serum calcium concentration (1·43, 1·21-1·69; p<0·0001), but not with hyperthyroidism (1·22, 0·96-1·55; p=0·1010) or raised adjusted calcium concentration (1·08, 0·88-1·34; p=0·4602). Women were at greater risk of development of renal and thyroid disorders than were men, with younger women at higher risk than older women. The adverse effects occurred early in treatment (HR <1 for length of treatment with lithium). Higher than median lithium concentrations were associated with increased risk of all adverse outcomes. INTERPRETATION Lithium treatment is associated with a decline in renal function, hypothyroidism, and hypercalcaemia. Women younger than 60 years and people with lithium concentrations higher than median are at greatest risk. Because lithium remains a treatment of choice for bipolar disorder, patients need baseline measures of renal, thyroid, and parathyroid function and regular long-term monitoring. FUNDING None.
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Affiliation(s)
| | - Rebecca F McKnight
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK.
| | | | - John R Geddes
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
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Murru A, Popovic D, Pacchiarotti I, Hidalgo D, León-Caballero J, Vieta E. Management of adverse effects of mood stabilizers. Curr Psychiatry Rep 2015; 17:603. [PMID: 26084665 DOI: 10.1007/s11920-015-0603-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Mood stabilizers such as lithium and anticonvulsants are still standard-of-care for the acute and long-term treatment of bipolar disorder (BD). This systematic review aimed to assess the prevalence of their adverse effects (AEs) and to provide recommendations on their clinical management. We performed a systematic research for studies reporting the prevalence of AEs with lithium, valproate, lamotrigine, and carbamazepine/oxcarbazepine. Management recommendations were then developed. Mood stabilizers have different tolerability profiles and are eventually associated to cognitive, dermatological, endocrine, gastrointestinal, immunological, metabolic, nephrogenic, neurologic, sexual, and teratogenic AEs. Most of those can be transient or dose-related and can be managed by optimizing drug doses to the lowest effective dose. Some rare AEs can be serious and potentially lethal, and require abrupt discontinuation of medication. Integrated medical attention is warranted for complex somatic AEs. Functional remediation and psychoeducation may help to promote awareness on BD and better medication management.
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Affiliation(s)
- Andrea Murru
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain,
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27
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Correll CU, Detraux J, De Lepeleire J, De Hert M. Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World Psychiatry 2015; 14:119-36. [PMID: 26043321 PMCID: PMC4471960 DOI: 10.1002/wps.20204] [Citation(s) in RCA: 515] [Impact Index Per Article: 57.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
People with severe mental illness have a considerably shorter lifespan than the general population. This excess mortality is mainly due to physical illness. Next to mental illness-related factors, unhealthy lifestyle, and disparities in health care access and utilization, psychotropic medications can contribute to the risk of physical morbidity and mortality. We systematically reviewed the effects of antipsychotics, antidepressants and mood stabilizers on physical health outcomes in people with schizophrenia, depression and bipolar disorder. Updating and expanding our prior systematic review published in this journal, we searched MEDLINE (November 2009 - November 2014), combining the MeSH terms of major physical disease categories (and/or relevant diseases within these categories) with schizophrenia, major depressive disorder and bipolar disorder, and the three major psychotropic classes which received regulatory approval for these disorders, i.e., antipsychotics, antidepressants and mood stabilizers. We gave precedence to results from (systematic) reviews and meta-analyses wherever possible. Antipsychotics, and to a more restricted degree antidepressants and mood stabilizers, are associated with an increased risk for several physical diseases, including obesity, dyslipidemia, diabetes mellitus, thyroid disorders, hyponatremia; cardiovascular, respiratory tract, gastrointestinal, haematological, musculoskeletal and renal diseases, as well as movement and seizure disorders. Higher dosages, polypharmacy, and treatment of vulnerable (e.g., old or young) individuals are associated with greater absolute (elderly) and relative (youth) risk for most of these physical diseases. To what degree medication-specific and patient-specific risk factors interact, and how adverse outcomes can be minimized, allowing patients to derive maximum benefits from these medications, requires adequate clinical attention and further research.
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Affiliation(s)
- Christoph U Correll
- Department of Psychiatry, Zucker Hillside Hospital, North Shore - Long Island Jewish Health SystemGlen Oaks, New York, NY, USA,Department of Psychiatry and Molecular Medicine, Hofstra North Shore LIJ School of MedicineHempstead, New York, NY, USA,Psychiatric Neuroscience Center of Excellence, Feinstein Institute for Medical ResearchManhasset, New York, NY, USA,Department of Psychiatry and Behavioral Sciences, Albert Einstein College of MedicineBronx, New York, NY, USA
| | - Johan Detraux
- Department of Neurosciences, Catholic University LeuvenB-3070 Kortenberg, Belgium
| | - Jan De Lepeleire
- Department of Public Health and Primary Care, University of LeuvenB-3000 Leuven, Belgium
| | - Marc De Hert
- Department of Neurosciences, Catholic University LeuvenB-3070 Kortenberg, Belgium
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Aiff H, Attman PO, Aurell M, Bendz H, Ramsauer B, Schön S, Svedlund J. Effects of 10 to 30 years of lithium treatment on kidney function. J Psychopharmacol 2015; 29:608-14. [PMID: 25735990 DOI: 10.1177/0269881115573808] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Long-term lithium treatment is associated with end-stage renal disease, but there is little evidence of a clinically significant reduction in renal function in most patients. We previously found that 1.5% of people who took lithium from the 1960s and 1970s developed end-stage renal disease; however, none of the patients who started after 1980 had end-stage renal disease. Here we aimed to study the prevalence and extent of kidney damage during the course of long-term lithium treatment since 1980. We retrieved serum lithium and creatinine levels from 4879 patients examined between 1 January 1981 and 31 December 2010. Only patients who started their lithium treatment during the study period and had at least 10 years of cumulative treatment were included. The study group comprised 630 adult patients (402 women and 228 men) with normal creatinine levels at the start of lithium treatment. There was a yearly increase in median serum creatinine levels already from the first year of treatment. About one-third of the patients who had taken lithium for 10-29 years had evidence of chronic renal failure but only 5% were in the severe or very severe category. The results indicate that a substantial proportion of adult patients who are treated with lithium for more than a decade develop signs of renal functional impairment, also when treated according to modern therapeutic principles. Our results emphasise that lithium treatment requires continuous monitoring of kidney function.
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Affiliation(s)
- Harald Aiff
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per-Ola Attman
- Department of Nephrology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mattias Aurell
- Department of Nephrology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Bendz
- Department of Clinical Sciences, Psychiatry, Lund University, Lund, Sweden
| | - Bernd Ramsauer
- Department of Nephrology, Skaraborg Hospital, Skövde, Sweden
| | - Staffan Schön
- Diaverum Renal Services Group, Lund & Swedish Renal Registry, Jönköping, Sweden
| | - Jan Svedlund
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Bocchetta A, Ardau R, Fanni T, Sardu C, Piras D, Pani A, Del Zompo M. Renal function during long-term lithium treatment: a cross-sectional and longitudinal study. BMC Med 2015; 13:12. [PMID: 25604586 PMCID: PMC4300557 DOI: 10.1186/s12916-014-0249-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 12/09/2014] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The effects of lithium treatment on renal function have been previously shown, albeit with discrepancies regarding their relevance. In this study, we examined glomerular filtration rate in patients treated with lithium for up to 33 years. METHODS All lithium patients registered from 1980 to 2012 at a Lithium Clinic were screened. Estimated glomerular filtration rate (eGFR) was calculated from serum creatinine concentration using the Modification of Diet in Renal Disease Study Group equation. A cross-sectional evaluation of the last available eGFR of 953 patients was carried out using multivariate regression analysis for gender, current age, and duration of lithium treatment. Survival analysis was subsequently applied to calculate the time on lithium needed to enter the eGFR ranges 45 to 59 mL/min/1.73 m² (G3a) or 30 to 44 mL/min/1.73 m² (G3b). Finally, 4-year follow-up of eGFR was examined in subgroups of patients who, after reduction to an eGFR lower than 45 mL/min/1.73 m² either i) continued lithium at the same therapeutic range or ii) discontinued lithium or continued at concentrations below the therapeutic range (0.5 mmol/L). RESULTS In the cross-sectional evaluation, eGFR was found to be lower in women (by 3.47 mL/min/1.73 m²), in older patients (0.73 mL/min/1.73 m² per year of age), and in patients with longer lithium treatment (0.73 mL/min/1.73 m² per year). Half of the patients treated for longer than 20 years had an eGFR lower than 60 mL/min/1.73 m². The median time on lithium taken to enter G3a or G3b was 25 years (95% CI, 23.2-26.9) and 31 years (95% CI, 26.6-35.4), respectively. Progression of renal failure throughout the 4-year follow-up after a reduction to an eGFR lower than 45 mL/min/1.73 m² did not differ between the subgroup who continued lithium as before and the subgroup who either discontinued lithium or continued at concentrations below the therapeutic range. CONCLUSIONS Duration of lithium treatment is to be added to advancing age as a risk factor for reduced glomerular filtration rate. However, renal dysfunction tends to appear after decades of treatment and to progress slowly and irrespective of lithium continuation.
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Affiliation(s)
- Alberto Bocchetta
- Section of Neuroscience and Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Via Ospedale 54, Cagliari 09124, Italy.
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Chronic Kidney Disease in Lithium-Treated Older Adults: A Review of Epidemiology, Mechanisms, and Implications for the Treatment of Late-Life Mood Disorders. Drugs Aging 2014; 32:31-42. [DOI: 10.1007/s40266-014-0234-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Kirkham E, Skinner J, Anderson T, Bazire S, Twigg MJ, Desborough JA. One lithium level >1.0 mmol/L causes an acute decline in eGFR: findings from a retrospective analysis of a monitoring database. BMJ Open 2014; 4:e006020. [PMID: 25380811 PMCID: PMC4225230 DOI: 10.1136/bmjopen-2014-006020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES Lithium is a mainstay of bipolar disorder treatment, however, there are still differences in opinion on the effects of lithium use on renal function. The aim of this analysis was to determine if there is an association between short-term exposure to various elevated lithium levels and estimated-glomerular filtration rate (eGFR) at ≤3 months, 6 months (±3 months) and 1 year (±3 months) follow-up. SETTING Norfolk-wide (UK) lithium register and database. PARTICIPANTS 699 patients from the Norfolk database. PRIMARY OUTCOME MEASURES eGFR change from baseline at ≤3 months, 6 months (±3 months) and 1 year (±3 months) after exposure to a lithium level within these ranges: 0.81-1.0 mmol/L (group 2), 1.01-1.2 mmol/L (group 3) and 1.21-2.0 mmol/L (group 4). The reference group was patients whose lithium levels never exceeded 0.8 mmol/L. RESULTS Compared to the reference group, groups 3 and 4 showed a significant decrease in eGFR in the first 3 months after exposure (p=0.047 and p=0.040). At 6 months (±3 months) postexposure group 4 still showed a decline in eGFR, however, this result was not significant (p=0.298). CONCLUSIONS These results show for the first time that a single incident of a lithium level >1.0 mmol/L is associated with a significant decrease in eGFR in the following 3 months when compared to patients whose lithium levels never exceeded 0.8 mmol/L. It is still not known whether the kidneys can recover this lost function and the impact that more than a single exposure to a level within these ranges can have on renal function. These results suggest that lithium level monitoring should be undertaken at least every 3 months, in line with current UK guidelines and not be reduced further until the impact of more than one exposure to these lithium levels has been fully established.
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Affiliation(s)
- E Kirkham
- School of Pharmacy, University of East Anglia, Norwich, UK
- Norfolk and Suffolk NHS Foundation Trust, Hellesdon Hospital, Norwich, UK
| | - J Skinner
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - T Anderson
- Norfolk and Suffolk NHS Foundation Trust, Hellesdon Hospital, Norwich, UK
| | - S Bazire
- School of Pharmacy, University of East Anglia, Norwich, UK
- Norfolk and Suffolk NHS Foundation Trust, Hellesdon Hospital, Norwich, UK
| | - M J Twigg
- School of Pharmacy, University of East Anglia, Norwich, UK
| | - J A Desborough
- School of Pharmacy, University of East Anglia, Norwich, UK
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Amitai M, Zivony A, Kronenberg S, Nagar L, Saar S, Sever J, Apter A, Shoval G, Golubchik P, Hermesh H, Weizman A, Zalsman G. Short-term effects of lithium on white blood cell counts and on levels of serum thyroid-stimulating hormone and creatinine in adolescent inpatients: a retrospective naturalistic study. J Child Adolesc Psychopharmacol 2014; 24:494-500. [PMID: 24828326 DOI: 10.1089/cap.2013.0046] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The purpose of this study was to determine if the known side effects of lithium in adults may be generalized to younger patients with psychiatric disorders. METHODS A retrospective naturalistic study design was used. Data were collected from the database of a tertiary pediatric medical center covering the years 1994-2010. Included were patients hospitalized for bipolar and non-bipolar disorders and treated with lithium, alone or in combination with other medications. The electronic medical files were reviewed for changes in thyroid and kidney function and for hematological parameters during the course of treatment. RESULTS Sixty-one patients 12.5-20.4 years of age (mean 16.94±1.66) met the study criteria: 33 with bipolar disorder and 28 with a non-bipolar disorder. Mean duration of lithium treatment (mean lithium blood level, 0.73±0.24 mEq/L) was 193.68±254.35 days. Mean levels of thyroid-stimulating hormones (TSH) rose significantly from baseline to last measurement (3.16±2.68 vs. 1.52±0.92 mU/L; paired t=-5.19, df=50, p<0.001); in 25% of patients, TSH levels at the last measurement were above normal (≥4 mU/L). Only one patient developed TSH values >10 mU/L (the threshold considered clinically significant). Positive correlation was found between pre- and posttreatment TSH levels (Pearson's r=0.60; n=51, p<0.05). White blood cell count (WBC) also increased significantly following lithium treatment (7195±2151 vs. 7944±2096 cells/mm(3); t=2.83, df=60, p=0.006). No significant changes were noted in serum creatinine levels. There was no difference in these parameters between patients treated with lithium alone or in combination with other medications. CONCLUSIONS Lithium treatment in adolescents with bipolar or non-bipolar disorders is associated with a significant increase in blood TSH levels and WBC count. Lithium-treated adolescent inpatients with a high basal TSH level may be at risk of developing pituitary-thyroid axis dysregulation. Therefore, baseline measurement of thyroid functions and serial monitoring throughout treatment are recommended.
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Affiliation(s)
- Maya Amitai
- 1 Geha Mental Health Center , Petach Tikva, Israel
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Abstract
Primary care providers (PCPs) are frequently responsible for the pharmacologic management of mood disorders, and the PCP is often an important member of the clinical team in the management of bipolar disorder and schizophrenia. Not only is a good understanding of psychopharmacology important for the effective treatment of psychiatric disease, it is also necessary for patient safety. Clinicians should understand the side effects and the medication interactions associated with psychotropic medications. This article reviews mechanisms of action, indications, dosing, side effects, medication interactions, and general management considerations for common medications used to treat psychiatric conditions encountered in the primary care setting.
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Affiliation(s)
- L Renata Thronson
- Division of General Internal Medicine, Department of Medicine, Adult Medicine Clinic, Harborview Medical Center, University of Washington School of Medicine, 325 9th Avenue, Seattle, WA 98104, USA.
| | - Genevieve L Pagalilauan
- Department of Medicine, Division of General Internal Medicine, Roosevelt General Internal Medicine Clinic, University of Washington Medical Center, 4245 Roosevelt Way North East, Seattle, WA 98105
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Plotnikov EY, Silachev DN, Zorova LD, Pevzner IB, Jankauskas SS, Zorov SD, Babenko VA, Skulachev MV, Zorov DB. Lithium salts — Simple but magic. BIOCHEMISTRY (MOSCOW) 2014; 79:740-9. [DOI: 10.1134/s0006297914080021] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Roxanas M, Grace BS, George CRP. Renal replacement therapy associated with lithium nephrotoxicity in Australia. Med J Aust 2014; 200:226-8. [DOI: 10.5694/mja13.10435] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 10/10/2013] [Indexed: 11/17/2022]
Affiliation(s)
| | - Blair S Grace
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA
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Lithium toxicity in the setting of nonsteroidal anti-inflammatory medications. Case Rep Nephrol 2014; 2013:839796. [PMID: 24558630 PMCID: PMC3914168 DOI: 10.1155/2013/839796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 03/17/2013] [Indexed: 11/25/2022] Open
Abstract
Lithium toxicity is known to affect multiple organ systems, including the central nervous system. Lithium levels have been used in the diagnosis of toxicity and in assessing response to management. There is evidence that nonsteroidal anti-inflammatory medications (NSAIDs) can increase lithium levels and decrease renal lithium clearance. We present a case of lithium toxicity, which demonstrates this effect and also highlights the fact that lithium levels do not correlate with clinical improvement, especially the neurological deficit.
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Aiff H, Attman PO, Aurell M, Bendz H, Schön S, Svedlund J. The impact of modern treatment principles may have eliminated lithium-induced renal failure. J Psychopharmacol 2014; 28:151-4. [PMID: 24346809 DOI: 10.1177/0269881113516202] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We have previously shown that lithium can cause end-stage renal disease (ESRD): however, this serious side-effect of lithium in prophylactic treatment of mood disorders may reflect the treatment regime of the 1960s and 1970s. Today's modern treatment routines, intended to reduce or eliminate lithium-induced ESRD (Li-ESRD), were introduced in Sweden in the early 1980s. The aim of the present study was to test the hypothesis that these routines have eliminated the risk of Li-ESRD. We used the Swedish Renal Registry to identify patients on renal replacement therapy (RRT), treated with dialysis or renal transplantation, with suspected Li-ESRD in two regions of Sweden with altogether about three million inhabitants. We reviewed their medical records to verify the exposure to lithium treatment, the diagnosis of Li-ESRD and the date of starting the lithium treatment. We found 32 RRT patients in whom lithium treatment was the sole or main contributing cause of ESRD. The starting year of their lithium treatment was between 1965-1980 in all patients. No patient started lithium treatment later than 1980. Modern lithium treatment may have eliminated the risk of Li-ESRD. Our findings support the continued use of lithium as a safe drug for the long-term treatment of mood disorders.
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Affiliation(s)
- Harald Aiff
- 1Department of Psychiatry and Neurochemistry, University of Gothenburg, Gothenburg, Sweden
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Rodrigo C, de Silva NL, Gunaratne R, Rajapakse S, De Silva VA, Hanwella R. Lower estimated glomerular filtration rates in patients on long term lithium: a comparative study and a meta-analysis of literature. BMC Psychiatry 2014; 14:4. [PMID: 24400671 PMCID: PMC3893601 DOI: 10.1186/1471-244x-14-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 01/06/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Several studies have shown that long-term lithium use is associated with a subtle decline in estimated glomerular filtration rate. This study compared mean estimated glomerular filtration rates (eGFR) in patients on long term lithium, against matched controls. METHODS Patients with bipolar affective disorder, who are on lithium (for at least a year), were compared against controls that were matched (1:1) for age, gender and presence or absence of diabetes or hypertension. The eGFR was calculated from creatinine values according to the 'modification of diet in renal disease study' (MDRD) formula and was compared between cases and controls. A meta-analysis was performed to compare our findings with similar studies in literature. RESULTS Forty seven patients met the inclusion criteria. They were matched with 47 controls. The eGFR values of lithium users were significantly lower (p = 0.04) compared to controls. This difference persisted between the subgroup of lithium users without comorbidities (diabetes and hypertension) and their controls but disappeared for lithium users with comorbidities and their controls. Nonetheless, lithium users had lower eGFR values in both subgroups. A meta-analysis of 9 studies showed a significant lowering in the glomerular filtration rate in lithium users compared to controls [mean difference -10.3 ml/min (95% confidence interval: -15.13 to -5.55, p < 0.0001)]. CONCLUSIONS Lithium causes a subtle decline in glomerular filtration rate; renal function needs to be monitored in patients on lithium treatment.
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Affiliation(s)
- Chaturaka Rodrigo
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | - Ravindi Gunaratne
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Senaka Rajapakse
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Varuni Asanka De Silva
- Department of Psychological Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Raveen Hanwella
- Department of Psychological Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Kemp DE, Sylvia LG, Calabrese JR, Nierenberg AA, Thase ME, Reilly-Harrington NA, Ostacher MJ, Leon AC, Ketter TA, Friedman ES, Bowden CL, Pencina M, Iosifescu DV. General medical burden in bipolar disorder: findings from the LiTMUS comparative effectiveness trial. Acta Psychiatr Scand 2014; 129:24-34. [PMID: 23465084 PMCID: PMC3789858 DOI: 10.1111/acps.12101] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This study examined general medical illnesses and their association with clinical features of bipolar disorder. METHOD Data were cross-sectional and derived from the Lithium Treatment - Moderate Dose Use Study (LiTMUS), which randomized symptomatic adults (n = 264 with available medical comorbidity scores) with bipolar disorder to moderate doses of lithium plus optimized treatment (OPT) or to OPT alone. Clinically significant high and low medical comorbidity burden were defined as a Cumulative Illness Rating Scale (CIRS) score ≥4 and <4 respectively. RESULTS The baseline prevalence of significant medical comorbidity was 53% (n = 139). Patients with high medical burden were more likely to present in a major depressive episode (P = .04), meet criteria for obsessive-compulsive disorder (P = .02), and experience a greater number of lifetime mood episodes (P = 0.02). They were also more likely to be prescribed a greater number of psychotropic medications (P = .002). Sixty-nine per cent of the sample was overweight or obese as defined by body mass index (BMI), with African Americans representing the racial group with the highest proportion of stage II obesity (BMI ≥35; 31%, n = 14). CONCLUSION The burden of comorbid medical illnesses was high in this generalizable sample of treatment-seeking patients and appears associated with worsened course of illness and psychotropic medication patterns.
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Affiliation(s)
- David E. Kemp
- Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH USA
| | | | - Joseph R. Calabrese
- Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH USA
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Mir SA, Wani AI, Masoodi SR, Bashir MI, Ahmad N. Lithium toxicity and myxedema crisis in an elderly patient. Indian J Endocrinol Metab 2013; 17:S654-S656. [PMID: 24910829 PMCID: PMC4046609 DOI: 10.4103/2230-8210.123558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
UNLABELLED While thyroid dysfunction is a frequent complication of lithium treatment, myxedema crisis is a rare occurrence with a handful of cases described. Here, we describe a patient receiving lithium for about a decade for bipolar disorder, who presented with myxedema crisis and lithium toxicity. In this patient, myxedema crisis was likely precipitated by lithium toxicity and community acquired pneumonia. The effects of lithium on thyroid are briefly reviewed. OBJECTIVE To describe an elderly male who was diagnosed with myxedema crisis and lithium toxicity. CASE REPORT A 70-year-old male was admitted in our hospital with history of gradual onset progressive decrease in level of consciousness and altered behavior for last 1 month. Patient also had history of respiratory tract symptoms for 1 week. Patient was a known case of diabetes and bipolar affective disorder for which he had been receiving insulin and lithium for 10 years. One year earlier, patient was admitted in our ward for glycemic control and evaluation of complications and was found to be clinically and biochemically euthyroid; he never returned for follow up until the present admission. On examination patient had incoherent speech, hypothermia, and bradycardia. Thyroid function showed thyroid-stimulating hormone >150 IU/ml, Tetraiodothyronine (T4) <1 μg/dl, anti-thyroid peroxidase titer of 60 IU/ml. The serum lithium level was 2.9 nmol/L (therapeutic level 0.2-1.2 nmol/L). He was managed with levothyroxine, starting with a loading oral dose of 500 μg through ryles tube followed by 100 μg daily, IV antibiotics and fluids; lithium was stopped after consultation with a psychiatrist. From day 5, patient started showing progressive improvement and by day 10, he had a Glasgow Coma Scale of 15/15, normal electrolyte, serum creatinine of 1.8 mg/dl and serum lithium level of 0.5 nmol/L. CONCLUSION Lithium-induced hypothyroidism may be life-threatening, thyroid function should be monitored before and during lithium therapy and drug should be discontinued and appropriate therapy instituted if hypothyroidism develops.
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Affiliation(s)
- Shahnaz Ahmad Mir
- Department of Endocrinology, Sheri-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Arshad Iqbal Wani
- Department of Endocrinology, Sheri-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Shariq Rashid Masoodi
- Department of Endocrinology, Sheri-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Mir Iftikhar Bashir
- Department of Endocrinology, Sheri-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Nadeem Ahmad
- Department of Endocrinology, Sheri-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
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Rybakowski JK, Abramowicz M, Chłopocka-Wozniak M, Czekalski S. Novel markers of kidney injury in bipolar patients on long-term lithium treatment. Hum Psychopharmacol 2013; 28:615-8. [PMID: 24519695 DOI: 10.1002/hup.2362] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 09/19/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We assessed kidney function in long-term lithium-treated bipolar patients compared with age-matched patients not taking lithium, including novel markers of kidney injury such as plasma neutrophil gelatinase-associated lipocalin (NGAL) and urinary beta-2 microglobulin (β2-MG) METHODS: The study comprised 120 patients with bipolar disorder of which 90 (30 males and 60 females) have been receiving lithium for 5-38 (mean 16) years, and 30 (10 males and 20 females) have never been exposed to lithium. RESULTS Lithium-treated patients, both men and women, showed significantly higher plasma NGAL and urinary β2-MG and lower urine specific gravity and estimated glomerular filtration rate (eGFR), compared with patients not taking lithium. In these patients, serum NGAL did not correlate with any clinical feature or other parameter of kidney function. Urinary β2-MG correlated with serum creatinine and eGFR in the whole group of lithium-treated patients and in addition, in males, with duration of illness, duration of lithium treatment, and urine specific gravity. CONCLUSIONS Lithium treatment causes an impairment of kidney function reflected also by abnormal levels of novel markers of kidney injury. Of these, urinary β2-MG, as a marker of tubular function seems to be better predictor than serum NGAL in lithium-treated patients because it shows multiple clinical and biochemical correlations, especially in men.
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Affiliation(s)
- Janusz K Rybakowski
- Department of Adult Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
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Kirkham E, Bazire S, Anderson T, Wood J, Grassby P, Desborough JA. Impact of active monitoring on lithium management in Norfolk. Ther Adv Psychopharmacol 2013; 3:260-5. [PMID: 24167700 PMCID: PMC3805386 DOI: 10.1177/2045125313486510] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Lithium has been used in the fields of rheumatology and psychiatry since the 1800s and it is now generally considered to be a gold standard treatment for bipolar disorders. However, lithium is known to have significant side effects and requires close serum level monitoring to ensure levels remain within the therapeutic range to minimize the risk of serious adverse effects or toxicity. This article reviews the monitoring of lithium and reports on the implementation of a regional lithium register and database within Norfolk. METHODS Recorded blood results from the Norfolk lithium database were extracted for the first full year of operation across the region, 2005/6, and from the most recent full year 2011/12. The number of lithium monitoring tests, U&Es and thyroid function tests conducted on all people registered on the database were compared between the two sample years. RESULTS In 2005/6 there were a significant number of people not receiving the recommended number of four or more serum lithium test per year (68.3%) and the majority of people had two or three tests (62%). By 2011/12 this had noticeably increased with the majority of patients having four or more tests per year (68.5%) and the number having only two or three tests reducing dramatically (26.4%). CONCLUSION Improved rates of lithium testing and monitoring have been demonstrated since the introduction of the Norfolk database helping to achieve national targets. Consequently, the chances of adverse events from insufficient monitoring have been minimized.
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Affiliation(s)
- Emma Kirkham
- School of Pharmacy, University of East Anglia, Norwich Research Park, Norfolk NR4 7TJ, UK
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Grunze H, Vieta E, Goodwin GM, Bowden C, Licht RW, Möller HJ, Kasper S. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2012 on the long-term treatment of bipolar disorder. World J Biol Psychiatry 2013; 14:154-219. [PMID: 23480132 DOI: 10.3109/15622975.2013.770551] [Citation(s) in RCA: 265] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES These guidelines are based on a first edition that was published in 2004, and have been edited and updated with the available scientific evidence up to October 2012. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the long-term treatment of bipolar disorder in adults. METHODS Material used for these guidelines are based on a systematic literature search using various data bases. Their scientific rigor was categorised into six levels of evidence (A-F) and different grades of recommendation to ensure practicability were assigned. RESULTS Maintenance trial designs are complex and changed fundamentally over time; thus, it is not possible to give an overall recommendation for long-term treatment. Different scenarios have to be examined separately: Prevention of mania, depression, or an episode of any polarity, both in acute responders and in patients treated de novo. Treatment might differ in Bipolar II patients or Rapid cyclers, as well as in special subpopulations. We identified several medications preventive against new manic episodes, whereas the current state of research into the prevention of new depressive episodes is less satisfactory. Lithium continues to be the substance with the broadest base of evidence across treatment scenarios. CONCLUSIONS Although major advances have been made since the first edition of this guideline in 2004, there are still areas of uncertainty, especially the prevention of depressive episodes and optimal long-term treatment of Bipolar II patients.
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Affiliation(s)
- Heinz Grunze
- Newcastle University, Institute of Neuroscience, Newcastle upon Tyne, UK.
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44
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Findling RL, Kafantaris V, Pavuluri M, McNamara NK, Frazier JA, Sikich L, Kowatch R, Rowles BM, Clemons TE, Taylor-Zapata P. Post-acute effectiveness of lithium in pediatric bipolar I disorder. J Child Adolesc Psychopharmacol 2013; 23:80-90. [PMID: 23510444 PMCID: PMC3609605 DOI: 10.1089/cap.2012.0063] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study examined the long-term effectiveness of lithium for the treatment of pediatric bipolar disorder within the context of combination mood stabilizer therapy for refractory mania and pharmacological treatment of comorbid psychiatric conditions. METHODS Outpatients, ages 7-17 years, meeting American Psychiatric Association, diagnostic and statistical manual of mental disorders, 4th ed. (DSM-IV) diagnostic criteria for bipolar disorder I (BP-I) (manic or mixed) who demonstrated at least a partial response to 8 weeks of open-label treatment with lithium (phase I) were eligible to receive open-label lithium for an additional 16 weeks (phase II). Up to two adjunctive medications could be prescribed to patients experiencing residual symptoms of mania or comorbid psychiatric conditions, following a standardized algorithm. RESULTS Forty-one patients received continued open-label long-term treatment with lithium for a mean of 14.9 (3.0) weeks during phase II. The mean weight-adjusted total daily dose at end of phase II was 27.8 (6.7) mg/kg/day, with an average lithium concentration of 1.0 (0.3) mEq/L. Twenty-five of the 41 patients (60.9%) were prescribed adjunctive psychotropic medications for residual symptoms. The most frequent indications for adjunctive medications were refractory mania (n=13; 31.7%) and attention-deficit/hyperactivity disorder (ADHD) (n=15; 36.6%). At the end of this phase 28 (68.3%) patients met a priori criteria for response (≥50% reduction from phase I baseline in young mania rating scale [YMRS] summary score and a clinical global impressions-improvement [CGI-I] score of 1 or 2), with 22 (53.7%) considered to be in remission (YMRS summary score≤12 and CGI-severity score of 1 or 2). These data suggest that patients who initially responded to lithium maintained mood stabilization during continuation treatment, but partial responders did not experience further improvement during Phase II, despite the opportunity to receive adjunctive medications. The most commonly reported (≥20%) adverse events associated with lithium treatment were vomiting, headache, abdominal pain, and tremor. CONCLUSIONS Lithium may be a safe and effective longer-term treatment for patients with pediatric bipolar disorder who respond to acute treatment with lithium. Partial responders to acute lithium did not appear to experience substantial symptom improvement during the continuation phase, despite the possibility that adjunctive medications could be prescribed.
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Affiliation(s)
- Robert L Findling
- Johns Hopkins University and the Kennedy Krieger Institute, Baltimore, Maryland, USA.
| | - Vivian Kafantaris
- Zucker Hillside Hospital and Feinstein Institute for Medical Research of the North Shore—Long Island Jewish Health System, Glen Oaks, New York
| | - Mani Pavuluri
- Department of Psychiatry, University of Illinois, Chicago, Illinois
| | - Nora K McNamara
- University Hospitals Case Medical Center/ Case Western Reserve University, Cleveland, Ohio
| | - Jean A Frazier
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Linmarie Sikich
- Department of Psychiatry, University of North Carolina, Chapel Hill, North Carolina
| | - Robert Kowatch
- Center for Innovation for Pediatric Practice, Nationwide Children's Hospital, Cincinnati, Ohio
| | - Brieana M Rowles
- University Hospitals Case Medical Center/ Case Western Reserve University, Cleveland, Ohio
| | | | - Perdita Taylor-Zapata
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland
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Rej S, Senouci SI, Looper K, Segal M. Using hypernatraemic events to predict reduced renal function in elderly lithium patients: a brief report. Psychogeriatrics 2013; 13:25-8. [PMID: 23551408 DOI: 10.1111/j.1479-8301.2012.00433.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 05/10/2012] [Accepted: 09/03/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Diabetes insipidus (DI) is a recognized adverse effect of lithium use, and studies have shown an association between decreased renal function and DI in patients using lithium. We hypothesize that hypernatraemic events that occur in DI predict decreased renal function in elderly patients on lithium. METHODS We conducted a retrospective cohort study involving 55 geriatric psychiatry patients using lithium between 1985 and 2010. Patients who always had sodium levels ≤146 mmol/L were compared to patients with one or more episodes of hypernatraemia (serum sodium level ≥147 mmol/L) for estimated glomerular filtration rate (eGFR) levels and prevalence of severe chronic renal failure (eGFR ≤30 mL/min/1.73 m(2)). RESULTS eGFR was found to be less in the hypernatraemic group than in the non-hypernatraemic controls (41 vs 56 mL/min/1.73 m(2); P = 0.0074). Severe chronic renal failure appeared more prevalent in hypernatraemic patients (4/14 (28.6%) vs. 3/41 (7.3%)), but this did not achieve statistical significance (P = 0.061). The two groups did not differ for age, sex, medical comorbidities or other clinical variables, except antidepressant use. Hypernatraemic patients appeared less likely to use antidepressants than non-hypernatraemic patients, odds ratio = 0.69 (P = 0.020). However, in multivariate analysis, hypernatraemia correlated with decreased eGFR (β = -0.39, P = 0.004), while antidepressant use did not (P = 0.81). CONCLUSIONS These results suggest that hypernatraemic events may predict reduced renal function in geriatric patients using lithium. The role of hypernatraemia and DI in renal failure in this population requires further study. Health professionals should be aware of the risks of renal failure in older patients treated with lithium, especially in the context of sodium level abnormalities.
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Affiliation(s)
- Soham Rej
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada.
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Leo JR, Farrell HM, Friedman R. Lithium-Induced Nephrogenic Diabetes Insipidus After Gastric Banding. PSYCHOSOMATICS 2013; 54:200-4. [DOI: 10.1016/j.psym.2012.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Revised: 02/07/2012] [Accepted: 02/08/2012] [Indexed: 11/26/2022]
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Kishore BK, Ecelbarger CM. Lithium: a versatile tool for understanding renal physiology. Am J Physiol Renal Physiol 2013; 304:F1139-49. [PMID: 23408166 DOI: 10.1152/ajprenal.00718.2012] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
By virtue of its unique interactions with kidney cells, lithium became an important research tool in renal physiology and pathophysiology. Investigators have uncovered the intricate relationships of lithium with the vasopressin and aldosterone systems, and the membrane channels or transporters regulated by them. While doing so, their work has also led to 1) questioning the role of adenylyl cyclase activity and prostaglandins in lithium-induced suppression of aquaporin-2 gene transcription; 2) unraveling the role of purinergic signaling in lithium-induced polyuria; and 3) highlighting the importance of the epithelial sodium channel (ENaC) in lithium-induced nephrogenic diabetes insipidus (NDI). Lithium-induced remodeling of the collecting duct has the potential to shed new light on collecting duct remodeling in disease conditions, such as diabetes insipidus. The finding that lithium inhibits glycogen synthase kinase-3β (GSK3β) has opened an avenue for studies on the role of GSK3β in urinary concentration, and GSK isoforms in renal development. Finally, proteomic and metabolomic profiling of the kidney and urine in rats treated with lithium is providing insights into how the kidney adapts its metabolism in conditions such as acquired NDI and the multifactorial nature of lithium-induced NDI. This review provides state-of-the-art knowledge of lithium as a versatile tool for understanding the molecular physiology of the kidney, and a comprehensive view of how this tool is challenging some of our long-standing concepts in renal physiology, often with paradigm shifts, and presenting paradoxical situations in renal pathophysiology. In addition, this review points to future directions in research where lithium can lead the renal community.
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Affiliation(s)
- Bellamkonda K Kishore
- Nephrology Research (151M) VA SLC Health Care System, 500 Foothill Dr, Salt Lake City, UT 84148, USA.
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Severus E, Bauer M. Managing the risk of lithium-induced nephropathy in the long-term treatment of patients with recurrent affective disorders. BMC Med 2013; 11:34. [PMID: 23399409 PMCID: PMC3606445 DOI: 10.1186/1741-7015-11-34] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/11/2013] [Indexed: 11/20/2022] Open
Abstract
Lithium has been the most effective psychopharmacological drug in the long-term treatment of patients with recurrent unipolar and bipolar affective illness. As a result of its widespread and longtime use in patients with recurrent affective disorders, psychiatrists have become increasingly aware of the whole spectrum of lithium's potential side effects. One of the side effects associated with its chronic use is lithium-induced nephropathy. In a recent cross-sectional study published in BMC Medicine, Alberto Bocchetta et al. add further information to this topic, demonstrating that duration of lithium treatment is associated with impaired glomerular function in patients with recurrent or chronic affective disorders. The present paper will discuss the implications of this and other related recent research on our management of patients with recurrent affective disorders. In this context the importance of shared decision making and close monitoring of kidney function is highlighted, including the regular assessment of the glomerular filtration rate, to provide best possible care to our patients maintained on lithium treatment.See related research article here http://www.biomedcentral.com/1741-7015/11/33.
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Affiliation(s)
- Emanuel Severus
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr, 74, D-01307 Dresden, Germany.
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Bocchetta A, Ardau R, Carta P, Ligas F, Sardu C, Pani A, Del Zompo M. Duration of lithium treatment is a risk factor for reduced glomerular function: a cross-sectional study. BMC Med 2013; 11:33. [PMID: 23399351 PMCID: PMC3606463 DOI: 10.1186/1741-7015-11-33] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 02/11/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The adverse renal effects of lithium have long been known, but glomerular insufficiency had been considered an unlikely event until recently, when new studies have raised concern regarding very long-term treatment. In this cross-sectional study, we examined glomerular function in a cohort of patients treated with lithium for up to 33 years and a control group of lithium-naïve patients treated with other mood-stabilizers. METHODS Patients with a diagnosis of recurrent or persistent affective disorders, examined between 1 October 2007 and 31 December 2009, were screened. Demographic and clinical data were extracted from clinical charts regarding two study groups: one for patients treated with lithium for at least 12 months and the other for patients never exposed to lithium. Multivariate regression analysis was applied: the dependent variable was the estimated glomerular filtration rate (eGFR) calculated from the last available serum creatinine value using the Modification of Diet in Renal Disease Study Group equation; the following independent variables, potentially associated with renal dysfunction, were included: gender, current age, duration of lithium treatment, cigarette smoking, hypertension, diabetes and dyslipidemia. RESULTS eGFRs lower than 60 ml/min were significantly more frequent in the group treated with lithium (38/139 = 27.3%) compared to lithium-naïve patients (4/70 = 5.7%) (P = 0.0002; Fisher's test). Regression analysis showed a significant effect on eGFR of age, gender and duration of lithium treatment but no effect of cigarette smoking, hypertension, diabetes or dyslipidemia. eGFR was estimated to decrease by 0.64 ml/min (95% confidence interval = 0.38 to 0.90; P = 0.00) for each year of lithium treatment. CONCLUSIONS The duration of lithium treatment is a risk factor for glomerular failure, in addition to advancing age. For example, all patients aged 60 years or older may be estimated to undergo Stage 3 or more severe chronic kidney disease (namely an eGFR less than 60 ml/min) if treated with lithium for 30 years. These data may be added to the current debate on the balance between the protective effects of lithium on recurrent affective disorders and suicide and the risk of renal disease.See related commentary article here http://www.biomedcentral.com/1741-7015/11/34.
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Affiliation(s)
- Alberto Bocchetta
- Section of Neuroscience and Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Via Ospedale 54, Cagliari, 09124 Italy.
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Kibirige D, Luzinda K, Ssekitoleko R. Spectrum of lithium induced thyroid abnormalities: a current perspective. Thyroid Res 2013; 6:3. [PMID: 23391071 PMCID: PMC3568739 DOI: 10.1186/1756-6614-6-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 02/04/2013] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED BACKGROUND Lithium is an integral drug used in the management of acute mania, unipolar and bipolar depression and prophylaxis of bipolar disorders. Thyroid abnormalities associated with treatment with lithium have been widely reported in medical literature to date. These include goitre, hypothyroidism, hyperthyroidism and autoimmune thyroiditis. This current review explores the varied thyroid abnormalities frequently encountered among patients on lithium therapy and their management, since lithium is still a fundamental and widely drug used in psychiatry and Internal Medicine. METHODS PubMed database and Google scholar were used to search for relevant English language articles relating to lithium therapy and thyroid abnormalities up to December 2012. The search terms used were lithium treatment, thyroid abnormalities, thyroid dysfunction, goitre, hypothyroidism, hyperthyroidism, thyrotoxicosis, autoimmune thyroiditis, lithium toxicity, treatment of affective disorders and depression and side effects of antipsychotic drugs. Reference lists of the identified articles were further used to identify other studies. RESULTS Lithium affects normal thyroid functioning through multiple mechanisms. At the cellular level, it decreases thyroid hormone synthesis and release. It also decreases peripheral deiodination of tetraiodothyronine (T4) or thyroxine by decreasing the activity of type I 5' de-iodinase enzyme. Hypothyroidism and goitre (clinically and/ultrasonographically detected) are the most prevalent thyroid abnormalities among patients on long term lithium therapy. Lithium induced hyperthyroidism is very infrequent. Lithium increases the propensity to thyroid autoimmunity in susceptible individuals due to its effect of augmenting the activity of B lymphocytes and reducing the ratio of circulating suppressor to cytotoxic T cells. CONCLUSIONS Thyroid function tests (serum thyroid stimulating hormone, free thyroid hormones-T4 and triiodothyronine [T3] concentrations and thyroid auto-antibodies) and assessment of thyroid size clinically and by thyroid ultrasonography ought to be performed among patients initiating lithium therapy at baseline and later annually. More frequent assessment of thyroid function status and size during the course of therapy is recommended among middle aged females (≥50 years), patients with a family history of thyroid disease and those positive for thyroid auto-antibodies (anti-thyroid peroxidase and TSH receptor antibodies).
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Affiliation(s)
- Davis Kibirige
- Department of Medicine, Uganda Martyrs Hospital Lubaga, Kampala, Uganda.
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