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Published: September 2010

Renal dangers associated with long term lithium use

Prescriber Update 31(3): 20
September 2010

Prescribers are reminded that long-term lithium therapy can cause renal failure along with other metabolic adverse effects including hypothyroidism, weight gain, and hyperparathyroidism. Renal function, including glomerular filtration rate (GFR) should be measured regularly even after 10 - 15 years of therapy. If renal impairment develops, advice from a nephrologist and/or psychiatrist should be sought as discontinuing lithium therapy may not possible for all patients.

Lithium is associated with a number of renal adverse effects including nephrogenic diabetes insipidus (which affects up to 40% of patients), chronic kidney disease (CKD) and renal failure.1

The Centre for Adverse Reactions Monitoring (CARM) has received a total of nine reports of renal failure in association with lithium use. Importantly, six of the reports were received in the last two years. The mean age of patients was 53 years (range 36-77 years) and the average duration of lithium therapy prior to development of CRF was 28 years (range 14-38 years). In at least one case, renal function continued to deteriorate despite lithium being discontinued.

The CARM reports are consistent with published literature1,2 in that renal failure developed slowly over several decades and discontinuation of lithium did not significantly reduce the rate of progression of disease in all cases. Possible risk factors identified include: increasing age; episodes of lithium toxicity; and other risk factors for CKD including diabetes, hypertension and concurrent use of long-term non-steroidal anti-inflammatory drugs.1,3

These cases highlight the need for continued monitoring of renal function to ensure early detection and management of renal impairment, although progression to renal failure may not be avoidable. Management options include the use of an alternative agent; however the psychiatric consequences of such action need to be carefully considered. Further information and advice has been published by BPAC in New Zealand and NICE in the United Kingdom, including a detailed list of monitoring requirements.3,4

Please report all serious reactions to medicines to CARM even if they are known. These reports can provide useful information on new risk factors or interactions with other medicines or foods.

References
  1. Grunfeld J-P and Rossier BC (2009). Lithium nephrotoxicity revisited. Nat. Rev Nephrol 5: 270-276 doi: 10.1038/ nrneph.2009.43
  2. Presne C et al (2003). Lithium-induced nephropathy: Rate of progression and prognostic factors. Kidney International 64: 585-592.
  3. BPAC (Feb 2007). Lithium in General Practice. Best Practice Issue 3: 16-27. Accessed online 17 August 2010
  4. National Institute for Health and Clinical Excellence (2006). The management of bipolar disorder in adults, children and adolescents, in primary and secondary care. (Clinical guideline 38, section 1.6.2.10) www.nice.org.uk/Guidance/CG38

 

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