Kidney functioning during lithium treatment: a prospective study of patients treated with lithium for up to ten years

Drug information update. Lithium and chronic kidney disease: debates and dilemmas

Lithium is an established treatment for bipolar disorder and an augmenting agent for treatment-resistant depression. Despite awareness of renal adverse effects, including chronic kidney disease, for the past five decades, there has been a lack of research evidence. This has led to debates around the existence and magnitude of the risk. This article discusses the current evidence base regarding the link between lithium and chronic kidney disease, monitoring of renal functions and its clinical implications.

The effects of lithium on renal function in older adults--a systematic review

Chronic renal failure (CRF) and nephrogenic diabetes insipidus (NDI) are potential consequences of chronic lithium use, while acute renal failure (ARF) has been described in lithium intoxication. We performed a systematic review of all studies pertaining to the effects of lithium on the kidney in older adults. The ARF incidence was 1.5% per person-year and concurrent loop diuretic and angiotensin-converting enzyme inhibitor use with lithium increased the risk. The CRF prevalence estimates varied from 1.2% to 34%, with risk factors including age, previous lithium intoxication, polyuria, previously impaired renal function, and decreased maximal urine osmolality. The prevalence of NDI varied widely from 1.8%  to 85%. Risk factors included lithium duration, dose, level, slow-release formulation, and clinical nonresponse. Except for amiloride use in NDI, there is little evidence for treatment of other lithium-induced adverse renal effects. Currently, there is no compelling evidence to suggest that lithium should be avoided in elderly patients for fear of renal side effects.

Effects of chronic lithium treatment on renal function

INTRODUCTION

Lithium treatment is associated with renal side effects which vary from mild nephrogenic diabetes insipidus to end stage renal disease (ESRD). A review of the literature suggests that ESRD is a very rare side effect, caused after very long-term lithium treatment, and that it might be preventable if lithium is stopped early.

METHODS

Sixty-one patients were treated with lithium for a mean of 15.6 years (range 3-32, SD=6.4). Their kidney function was monitored at an Affective Disorders Clinic for a mean of 11.5 years (range 2-29, SD=5.4). We estimated their glomerular filtration rate (eGFR) at the end of monitoring. As a control group we used 53 patients who received ECT at our hospital, and had not taken lithium, and nine patients from the same clinic who were taking other mood-stabilisers.

RESULTS

Lithium patients had lower eGFR compared to controls: 66.1 vs. 75.0 mL/min/1.73 m2, p=0.0006 after controlling for age and gender. The percentage of patients with an eGFR<60 ml/min/1.73 m2 (grade 3 chronic kidney disease) was 34.4%, vs. 13.1% in the controls, and was much increased compared to the general population in the respective age ranges. There was a modest but non-significant correlation between the number of years that patients had taken lithium and their eGFR, (beta=-0.177, B=-0.43, p=0.1). One patient reached an eGFR of 28 mL/min/1.73 m2 and her lithium was stopped. One patient required dialysis 6 years after leaving the clinic.

CONCLUSIONS

Lithium causes a modest decline in renal function. However the available research suggests that ESRD is a very rare complication of long-term lithium treatment, affecting ∼1% of patients who have taken lithium for over 15 years.

Meta-analysis of the effects of lithium usage on serum creatinine levels

There is conflicting evidence concerning lithium's effect on renal function. The aim is to clarify whether lithium affects kidney function and at what stage of treatment any effect may occur. Systematic review identified 23 studies split into three groups on which meta-analysis was performed to identify the following: A) lithium's effect on renal function in cross-sectional case-control studies, B) studies of renal function before and after commencement on lithium, C) studies of longer term effect in those already established on lithium therapy. Group A showed a statistically significant increase of 5.7 μmol/L in creatinine in the study population compared with controls. Group B showed a non-statistically significant rise in creatinine (2.9 μmol/L) after a mean follow-up of 86 months. Group C showed a statistically significant increase in creatinine of 7.0 μmol/L over a mean duration of 64 months. An increase in creatinine of an average of 1.6 μmol/L/year on lithium was also identified in this group. Any lithium-associated increase in serum creatinine is quantitatively small and of questionable clinical significance. However, routine renal function monitoring of patients on lithium is essential.

[Chronic renal complications induced by lithium]

INTRODUCTION

After 40 years of use of lithium in the treatment of mood disorders, the renal risks associated with the long-term exposure to lithium are better known.

OBJECTIVE

This review is aimed at summarizing the information available in the literature regarding the impact of lithium on renal structure and function, the prevalence of renal abnormalities, the associated risk-factors and the strategy for their identification and management.

METHOD

Articles were selected using a Medline search. The keywords were lithium, renal function, kidney, nephrotoxicity, renal insufficiency, side-effects, polyuria, diabetes insipidus and drug monitoring.

RESULT

A well-recognized adverse effect of lithium exposure is the occurrence of nephrotic diabetes insipidus (NDI) resulting in polyuria and polydipsia, which occurs in 20% of the patients on long-term lithium treatment. This side-effect is linked to a deficit in urine concentrating ability. Its occurrence is associated with the duration of lithium therapy. Although this effect of lithium is initially functional and may disappear if the treatment is rapidly stopped, it may become structural and permanent over time. The decision to stop lithium or to treat the NDI with amiloride is mainly based upon its functional impact.

DISCUSSION

A debate has been ongoing for decades regarding whether or not the long-term use of lithium may cause slowly progressive renal failure. According to the recent literature, progressive renal failure occurs in approximately 20% of the patients on long-term lithium treatment, among whom a few develop severe renal insufficiency due to lithium (possibly in conjunction with other somatic factors) in the form of interstitial nephritis. However, there is an increasing number of reports of patients requiring dialysis after long-term exposure to lithium.

CONCLUSION

Current recommended strategies for minimising the renal side effects of lithium include: avoiding acute episodes of renal toxicity; monitoring serum lithium concentrations in order to achieve optimal efficacy at the lowest possible concentrations; monitoring serum creatinine levels at least on a yearly basis, with discontinuation of lithium use, discussion with a nephrologist if creatinine clearance decreases below 60 ml/mn; and the possible application of lithium into single daily dose.

Effects of short- and long-term lithium treatment on kidney functioning in patients with bipolar mood disorder

Lithium (Li) carbonate has been reported to be able to cause some reversible functional changes in the kidney. In this study, the authors aimed to investigate whether the duration of Li treatment is the primary determinant of the changes in renal functioning due to the Li treatment. For this purpose, 10 Li-naïve (mean age+/-S.D.: 34.50+/-4.85), 10 short-term (mean age+/-S.D.: 31.77+/-7.61) and 10 long-term (mean age+/-S.D.: 36.60+/-10.15) Li-treated bipolar patients were included in the study. Serum blood urea nitrogen (BUN) and creatinine, urine creatinine levels, creatinine clearance, urine osmolality before and after 8-h water deprivation and urine osmolality after desmopressin injection were measured in all patients. Serum BUN and creatinine levels were within the normal limits and not statistically different among the groups. Creatinine clearance of the long-term Li-treated group was significantly lower than both that of the Li-naïve group and that of the short-term Li-treated group. After 8-h water deprivation and also after desmopressin injection, no difference was found among the groups in terms of urine osmolality. However, when each patient was evaluated individually in terms of their renal concentrating ability, partial nephrogenic diabetes insipidus was diagnosed in four patients on long-term and in two patients on short-term Li treatment. To our surprise, hypothalamic diabetes insipidus was also diagnosed in other two patients on long-term Li treatment. These results demonstrate that long-term Li treatment may cause impairment in renal concentrating ability, some of which may originate from the effects of Li on vasopressin on hypothalamic level, and a decrease in glomerular filtration rate (GFR). In the light of these data, we can conclude that long-term administration of Li may be a risk factor for Li-induced renal impairment, which is a progressive effect in nature.

Lithium treatment at 52

The paper reviews briefly and comments in detail on selected events in the history of lithium treatment. The events include Cade's discovery of lithium's antimanic action, the discovery and establishment of its prophylactic action, the ensuing debate, amelioration and prevention of side effects and risks, use during pregnancy, non-compliance, selection of patients, information and instruction, the question whether new and better prophylactic agents are about to oust lithium, the use of combination treatment, the effect of lithium on suicidal behavior, the benefits of prophylactic lithium treatment, and the design of future comparative trials.

Lithium in the over-65s: who is taking it and who is monitoring it? A survey of older adults on lithium in the Cambridge Mental Health Services catchment area

OBJECTIVES

To determine the prevalence of lithium therapy in the over-65s in the Cambridge Mental Health Services catchment area, to obtain a profile of this group and to find out how well and by whom lithium treatment is being monitored.

METHODS

A census was carried out of patients over the age of 65 in the Cambridge Mental Health Services catchment area who were on lithium therapy on 1 February 1995. The records of these patients were examined retrospectively for demographic details, details of lithium therapy, information about lithium monitoring and risk factors associated with lithium treatment.

RESULTS

One hundred and forty-eight patients were identified representing a point prevalence of 0.27%. GPs carried out lithium monitoring for the majority of this group and 47% had not been seen by a psychiatrist in the 12 months leading up to the census date. Thirty-two per cent of the group were on thyroxine treatment or had raised TSH levels.

CONCLUSIONS

The prevalence of lithium therapy in this study was greater than the prevalences reported in studies of patients of all ages. Standards of monitoring varied widely and were not always better where psychiatrists monitored the treatment, although psychiatrists were more likely than GPs to monitor renal function. There was a high rate of thyroid dysfunction in the study group.

A cross-sectional study of glomerular function in 740 unselected lithium patients

Creatinine clearance was estimated using a formulaic method from serum creatinine, age and sex in 740 unselected lithium-treated patients in southeastern Scotland. Psychiatric history and details of prescribing and monitoring of lithium treatment were obtained from existing case registers. Lithium treatment duration and glomerular filtration, controlling for the effects of age, were weakly related, but only in males. Cases who had been exposed to higher serum lithium concentrations had lower creatinine clearance than those maintained within therapeutic range. Of cases within the lowest quartile of renal function, proportionally more were supervised in general practice rather than at hospital clinics. Suggestions are made for the clinical practice of monitoring serum lithium concentrations and serum creatinine.