Lithium and chronic kidney disease: to stop or not to stop?
In a recent paper this question has been debated again (Velani, 2023). Two cases are discussed.
Lithium is the first-line treatment as a mood stabiliser in bipolar affective disorder and can prevent suicide in mood disorder.
However, lithium therapy in this patient group is associated with a two-and-a-half-fold increased risk of developing chronic kidney disease (CKD). This is because it can cause a chronic tubulo-interstitial nephritis. As a result, consideration of ongoing lithium therapy in patients with CKD is a relatively common clinical scenario for a psychiatrist.
In 2012, Werneke et al carried out a decision analysis of long-term lithium treatment and the risk of kidney failure (CKD5), which suggested that lithium continuation, even in the presence of long-term adverse renal effects, should be recommended in most cases, with these caveats:
- Broadly speaking, lithium should be continued for patients presenting with CKD stages 1, 2 or 3B (without heavy proteinuria)
- Lithium should normally be stopped in CKD stage 4 and 5, unless there is significant risk of harm to self or others. If past consequences of relapse have been severe and/or trials on other medication have failed, monitored continuation may be appropriate.
Also. Central to the decision making process is involvement of the patient and relevant friends or family. Education and discussion around the relevant risks of the decision is likely to increase patient buy-in with the plan and reduce risk of adverse outcomes.
A guide to management
If lithium is continued, drugs known to affect kidney function should be avoided or their dosage reduced where possible. These include diuretics, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs and non-steroidal anti-inflammatory drugs (NSAIDs). Additionally, it is important to ensure minimum effective dosing, once daily dosing and more frequent monitoring of lithium levels and kidney function.
If lithium is stopped, it should be done gradually over one to three months. Patients should be monitored closely for relapse during reduction and for three months after stopping.
If the patient’s GP or psychiatrist is unsure what to do, renal referral is recommended.
Last Reviewed on 29 September 2023