Abstract:After an initial diagnosis of CKD, patients who are selected by their physicians to continue lithium treatment may not necessarily have an increased risk of developing end-stage CKD. Shifting to an anticonvulsant per se may not be associated with an advantage; however, this requires further investigation.
“…Furthermore, inclusion of both lithium treatment-naive (i. e., never exposed to lithium) patients and patients who have been treated with lithium previously could be of importance in the interpreta-tion of study results since previous tolerance or intolerance to a study drug may influence the subsequent study group allocation and thereby outcomes of the study [25]. Moreover, in some clinical samples, patients are followed for a brief period of time or data collection is cross-sectional by design [15,16], in contrast to other studies, primarily register-based, where patients are followed longterm or even lifelong, allowing for follow-up on development of renal impairment in patients exposed never, only previously, or still/ continuously [17][18][19][20]26]. Another advantage of register-based based studies is that all cases can more easily be identified (regardless of severity, course of illness, comorbidity, etc.)…”
The improved renal outcome found in the more recent lithium studies may be a result of improved monitoring and focus on recommended serum levels (preferentially 0.6-0.8 mmol/L) as compared to poorer renal outcome in studies with patients treated in the 1960s to 1980s.
“…Furthermore, inclusion of both lithium treatment-naive (i. e., never exposed to lithium) patients and patients who have been treated with lithium previously could be of importance in the interpreta-tion of study results since previous tolerance or intolerance to a study drug may influence the subsequent study group allocation and thereby outcomes of the study [25]. Moreover, in some clinical samples, patients are followed for a brief period of time or data collection is cross-sectional by design [15,16], in contrast to other studies, primarily register-based, where patients are followed longterm or even lifelong, allowing for follow-up on development of renal impairment in patients exposed never, only previously, or still/ continuously [17][18][19][20]26]. Another advantage of register-based based studies is that all cases can more easily be identified (regardless of severity, course of illness, comorbidity, etc.)…”
The improved renal outcome found in the more recent lithium studies may be a result of improved monitoring and focus on recommended serum levels (preferentially 0.6-0.8 mmol/L) as compared to poorer renal outcome in studies with patients treated in the 1960s to 1980s.
“…Interestingly, a large population‐based study suggested that maintenance treatment with lithium or anticonvulsants is associated with an increased rate of CKD while not necessarily increasing the rate of ESRD 4 . In a follow‐up study, Kessing et al showed that continued lithium treatment after an initial diagnosis of CKD may not necessarily increase the risk of developing ESRD 5 . However, the literature still remains controversial, hindering clinical evidence‐based decisions regarding the optimal time for clinicians to continue or discontinue lithium after a diagnosis of worsening CKD.…”
Section: Discussionmentioning
confidence: 99%
“…Nevertheless, reinitiating lithium treatment in our patient was successful in stabilizing her mood symptoms, ultimately reestablishing her illness remission. Furthermore, the clinical decision was supported by the evidence from Kessing and colleagues 5 who showed that continued lithium treatment after an initial diagnosis of CKD may not necessarily increase the risk of developing ESRD. Lithium can be used safely in patients with BD and CKD with careful monitoring of renal function.Risks/benefits of lithium treatment should always be weighed against the risk of illness decompensation.Restarting lithium treatment was possible without further decline in renal function.This case highlights the importance of patient‐education and team‐based individualized approach.…”
We present a 66-year-old female with a bipolar-I disorder diagnosis, euthymic on lithium for 41 years. Her past medical history included hypothyroidism (stable on levothyroxine), essential hypertension (controlled on carvedilol), hypercholesterolemia (on lovastatin), anemia, lumbar disc disease, osteopenia, and recurrent urinary tract infections. She gradually developed CKD stage IIIB (GFR 31-39 mL/ min/1.73 m 2 ). Her known risk factors for CKD were hypertension, hypothyroidism, and chronic lithium therapy. After an episode of acute renal failure, lithium was discontinued due to concerns regarding progression toward ESRD. Her treatment response assessment evaluated by the Alda scale prior to discontinuation was 9, but rapidly declined to 1-2. The Alda scale is a standardized scale used to measure longterm treatment response in subjects with BD. 1 Alda score is derived from the scores on two subscales, namely the A scale score (measures the change in illness severity following the introduction of treatment) minus the B scale score (this is used to establish whether there is a causal relationship between clinical improvement and the treatment). 1In the next 18 months, she tried different atypical antipsychotics (lurasidone, aripiprazole, and ziprasidone) with mild improvement (Alda A score = 3), but developed Parkinsonian symptoms. She had a poor response to antidepressants/anxiolytics (venlafaxine, bupropion, and buspirone). Lamotrigine and modafinil were tried but caused a skin rash. She had a mild response to a combination of valproate and desipramine (Alda A score = 3). The patient was not interested in other treatment modalities such as electroconvulsive therapy due to cognitive concerns. She continued weekly/bi-weekly cognitive behavioral therapy and regular exercise. Her depression remained refractory despite several trials of FDA-approved treatments for BD and poor/minimal response to the off-label use of several additional agents. Due to persistent depression and prior history of excellent response to lithium, it was decided to carefully reinitiate lithium while monitoring her renal function. At this time, she was on a combination of buspirone, valproate, and desipramine. Lithium carbonate was initiated at 150 mg daily and the dose was optimized to 300 mg daily. Desipramine and buspirone were gradually tapered.The patient experienced intention tremors and gait instability at a lithium level of 0.6 mEq/L. The valproate was tapered off and led to an improvement of her gait. Within 4-6 weeks of reinitiating lithium therapy, her depression improved significantly (Alda A score = 9).Self-assessment of the patient's mood via the mood scale (10 being the best mood she ever had [euthymia] and 0 the worst mood) found significant improvement after reinitiating lithium. Her mood change using the simple mood scale correlated well with the change in Alda A scores. The patient's renal function tests were checked monthly after reinitiating lithium, and her GFR remained stable between 37-40 mL/ml at 12 months.
| D ISCUSS ...
“…Recently, it was found that patients who continue lithium treatment after a diagnosis of CKD may not necessarily have an increased risk of developing end‐stage CKD. Shifting to an anticonvulsant per se may not be associated with an advantage …”
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