[Between efficiency and toxicity: the case of a patient improved by lithium who developed iatrogenic nephropathy]

Although almost fifteen cases have been reported since 1970, renal failure during a long term lithium therapy remains in the epidemiologic studies a rare pathology. Lithium treatment side effects can be considered in term of morphologic damages or in terms of kidney physiology impairments in filtration or concentration. For example it has long been known that lithium generates polyuria which results from an induced nephrotic diabetes insipidus (NDI). Fortunately most of these common impairments are reversible without any alarming or starting consequences. Moreover histological injures may also occur such as interstitial fibrosis, sclerotic glomeruli, tubular atrophy or dilatation ... whose evidence still raises some controversy concerning their incidence and specificity. We report here the case of a Bipolar I patient stabilized for at least fifteen years with lithium at a high level of social and professional life, in whom renal failure was found with tubular damage. This injury correlated to the lithium therapy even if always controlled at a normal rate during fifteen years, forced us to withdraw this treatment and switch to valproate. Is our goal to protect the renal function against the patient wishes totally justified since he relapsed in hypomania 63 days after the drop out? We had to choose between renal preservation and mental health.

[Schizophrenia, affective symptoms and clozapine]

Clozapine has been shown to be effective in treating schizophrenic patients. In this study we compare the efficacy of clozapine in two groups of treatment resistant psychotics (among the most severe inpatients). 5 chronic schizophrenics (CS). Age 49.6 +/- 12 (paranoid, disorganized residuals). 14 "mixed" patients (MP). Age 34.6 +/- 13, between: major affective disorders (MAD) with mood incongruent psychotic features; schizo affective disorders (SAD). 19 patients (11 females -8 males) have been involved in our trial. They receive 400 up to 800 mg/day of clozapine for a minimum of 12 months and a maximum of 38 months. Treatment responders were defined on the evaluation of the following criteria: scores PANSS-CGI-MADRS (not for the first patients); number of relapses; response to socialisation (exit); quality of life. The results even if based on small sample sizes were classified as: Improvement -->reduction of all major symptoms: patient exit. CS:2/5 (40%); MP:5/14 (35%). Improvement++-->decrease of most major symptoms. CS:1/5 (20%); MP:5/14 (35%). Improvement+-->decrease of one or few major symptoms. CS:2/5 (40%); MP: 1/14 (8%). Failure-->3 from the MP subgroup (16%), 1 leucopenia, 1 worsening, 1 non responder). These finding show that affective disorders and schizoaffective patients are as likely to respond to clozapine as the schizophrenic patients: 60% of the CS and 70% of the MP were very much ( ) and much improved (++). The data also suggest that in the subtype of MP high scores of response occur with the youngest and most recently ill patients (< 30 years, < 18 months).(ABSTRACT TRUNCATED AT 250 WORDS)