The perspectives of patients with lithium-induced end-stage renal disease

Concurrent lithium and haemodialysis treatment: Clinical recommendations based on the literature and a multicentre survey

INTRODUCTION

Lithium has an irreplaceable role in the treatment of severe mood disorders, but declining renal function associated with its use leads to clinical dilemmas. Although not often applied, and requiring close monitoring and multidisciplinary actions, concurrent lithium and haemodialysis treatment (CLHT) is a feasible option. To our knowledge, however, there are no detailed consensus- or evidence-based treatment guidelines or directives on its delivery.

METHODS

To fill this gap, we reviewed the literature and surveyed psychiatrists and nephrologists with experience in CLHT using a self-designed questionnaire. Our goal was to form an integrated picture of the current knowledge and clinical practices of CLHT and formulate practical recommendations for colleagues being confronted with patients with renal dysfunction requiring lithium to help manage their mood disorder.

RESULTS

We identified 14 case reports and case series describing CLHT and one systematic review concluding CLHT to be effective. Ten nephrologists and six psychiatrists practising in the Netherlands completed our questionnaire, providing details on collaboration, lithium dosing regimens, serum level evaluations and additional amenities and services they deemed necessary during CLHT delivery.

DISCUSSION

We found that CLHT appears to be safe and effective and argue that delivery is a shared responsibility and needs continuous multidisciplinary finetuning. To facilitate delivery, we provide a flowchart for the initiation or reinstatement of lithium therapy in haemodialysis patients and a practical guide for CLHT, including an easy-to-use rule of thumb for calculating the lithium target dose.

Lithium-Associated Kidney Failure: Predictors and Outcomes

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.

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

OBJECTIVES

In order to improve the degree of shared decision making (SDM) experienced by patients, it is necessary to gain insight into the explanations for the differences in these degrees.

METHODS

A scoping review of the literature on the explanations for differences in the degree of SDM experienced by patients was conducted. We assessed 21,329 references. Ultimately, 308 studies were included. The explanations were divided into micro, meso, and macro levels.

RESULTS

The explanations are mainly related to the micro level. They include explanations related to the patient and healthcare professionals, the relationship between the patient and the physician, and the involvement of the patient's relatives. On the macro level, explanations are related to restrictions within the healthcare system such as time constraints, and adequate information about treatment options. On the meso level, explanations are related to the continuity of care and the involvement of other healthcare professionals.

CONCLUSIONS

SDM is not an isolated process between the physician and patient. Explanations are connected to the macro, meso, and micro levels.

PRACTICE IMPLICATIONS

This scoping review suggests that there could be more focus on explanations related to the macro and meso levels, and on how explanations at different levels are interrelated.

A Review for Lithium: Pharmacokinetics, Drug Design, and Toxicity

Lithium as a mood stabilizer has been used as the standard pharmacological treatment for Bipolar Disorder (BD) for more than 60 years. Recent studies have also shown that it has the potential for the treatment of many other neurodegenerative disorders, including Alzheimer's, Parkinson's and Huntington's disease, through its neurotrophic, neuroprotective, antioxidant and anti-inflammatory actions. Therefore, exploring its pharmacokinetic features and designing better lithium preparations are becoming important research topics. We reviewed many studies on the pharmacokinetics, drug design and toxicity of lithium based on recent relevant research from PubMed, Web of Science, Elsevier and Springer databases. Keywords used for searching references were lithium, pharmacology, pharmacokinetics, drug design and toxicity. Lithium is rapidly and completely absorbed from the gastrointestinal tract after oral administration. Its level is initially highest in serum and then is evidently redistributed to various tissue compartments. It is not metabolized and over 95% of lithium is excreted unchanged through the kidney, but different lithium preparations may have different pharmacokinetic features. Lithium has a narrow therapeutic window limited by various adverse effects, but some novel drugs of lithium may overcome these problems. Various formulations of lithium have the potential for treating neurodegenerative brain diseases but further study on their pharmacokinetics will be required in order to determine the optimal formulation, dosage and route of administration.

Systematic review and practical guideline for the prevention and management of the renal side effects of lithium therapy

Lithium is the first line therapy of bipolar mood disorder. Lithium-induced nephrogenic diabetes insipidus (Li-NDI) and lithium nephropathy (Li-NP, i.e., renal insufficiency) are prevalent side effects of lithium therapy, with significant morbidity. The objective of this systematic review is to provide an overview of preventive and management strategies for Li-NDI and Li-NP. For this, the PRISMA guideline for systematic reviews was used. Papers on the prevention and/or treatment of Li-NDI or Li-NP, and (influenceable) risk factors for development of Li-NDI or Li-NP were included. We found that the amount of evidence on prevention and treatment of Li-NDI and Li-NP is scarce. To prevent Li-NDI and Li-NP we advise to use a once-daily dosing schedule, target the lowest serum lithium level that is effective and prevent lithium intoxication. We emphasize the importance of monitoring for Li-NDI and Li-NP, as early diagnosis and treatment can prevent further progression and permanent damage. Collaboration between psychiatrist, nephrologist and patients themselves is essential. In patients with Li-NDI and/or Li-NP cessation of lithium therapy and/or switch to another mood stabilizer should be considered. In patients with Li-NDI, off label therapy with amiloride can be useful.

Lithium Use in a Patient With Bipolar Disorder and End-Stage Kidney Disease on Hemodialysis: A Case Report

Lithium has been implicated in causing chronic tubulointerstitial nephritis and decline in renal function. However, lithium still plays a role in stabilizing patients with bipolar disorder. We illustrated a case of a bipolar I disorder patient approaching end-stage kidney disease (ESKD) with other medical comorbidities. As her mental state was affecting her compliance with medical treatment, she was mentally and medically unwell. Our patient was hospitalized on two separate occasions, for 5 and 4 months respectively, and failed adequate trials of different psychotropics due to inefficacy or intolerable side effects. A decision was made between the psychiatrist, nephrologist, and cardiologist to use lithium with hemodialysis support, with good treatment response and improved mental state. This case has shown that lithium carbonate can still be prescribed in ESKD patients on hemodialysis. Daily monitoring of lithium levels in the initial phase of lithium and hemodialysis commencement for at least 2 weeks is imperative, reducing to three times per week pre-hemodialysis towards the end of discharge after three consecutive daily serum lithium levels have stabilized. Clinicians can also consider a target serum level of less than 0.6 mEq/L in maintenance treatment for bipolar disorder in patients on hemodialysis.