Practice Practice Pointer

Lithium and chronic kidney disease

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2452 (Published 03 July 2009) Cite this as: BMJ 2009;339:b2452
  1. Mukesh Kripalani, specialist registrar1,
  2. James Shawcross, speciality registrar2,
  3. Joe Reilly, professor of mental health3,
  4. John Main, consultant renal physician2
  1. 1Tees, Esk and Wear Valleys NHS Foundation Trust, St Luke’s Hospital, Middlesbrough TS4 3AF
  2. 2South Tees Acute Hospitals NHS Trust, James Cook University Hospital, Middlesbrough TS4 3BW
  3. 3Durham University, School for Medicine and Health, Wolfson Research Institute, Stockton on Tees TS17 6BH
  1. Correspondence to: J Reilly j.g.reilly{at}durham.ac.uk
  • Accepted 16 March 2009

Lithium use is associated with renal disorder and renal failure; this article offers guidance on monitoring, drug interactions, and when to consider stopping the drug

Lithium remains a key drug in the treatment of bipolar disorder1 and recurrent depressive disorder, and renal monitoring is essential for safe prescribing. The recent guidance from the National Institute for Health and Clinical Excellence (NICE) on early identification and management of chronic kidney disease mentions lithium as a nephrotoxin and emphasises active management of hypertension and other cardiovascular risk factors.2 Lithium prescribers in the United Kingdom already receive estimated glomerular filtration rate results when monitoring renal function in lithium users,3 and the inclusion of lithium monitoring in the primary care quality and outcomes framework has raised awareness about its importance. This article discusses the effects of lithium on the kidney and looks at existing evidence to guide treatment when incidental chronic kidney disease is detected in those in whom lithium is being considered or when long term lithium users develop chronic kidney disease.

What do we know about the effect of lithium on the kidney?

Lithium use is associated with a range of glomerular and tubular disorders resulting in chronic kidney disease and more rarely established renal failure.4 5 (see the web table on bmj.com) Nephrogenic diabetes insipidus is commonly observed and may predispose to acute lithium toxicity, but it does not directly lead to progressive renal impairment. In clinical practice some lithium users have a stable reduction in glomerular filtration rate or a slowly progressive decline, for which a biopsy is rarely carried out; hence the histopathology is poorly characterised. The existing evidence from a small cohort study shows a “creeping creatinine” phenomenon (a progressive increase in the serum creatinine concentration over time), with some evidence of improvement on discontinuation.6 It remains uncertain who is at risk of either milder …

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