Lithium Intoxication: Pharmacokinetics During and After Terminated Hemodialysis in Acute Intoxications

Jacobsen, Dag; Aasen, Gunnar; Frederichsen, Per; Eisenga, Bernard H.

doi:10.3109/15563658708992615

Cited by 31 publications

(13 citation statements)

References 10 publications

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“…Because impairment of kidney function often accompanies lithium toxicity and because lithium itself has long-term effects on kidney function, lower lithium clearances are usually reported, reaching an average of 10.6 mL/min for our cohort (14,204). The reported lithium half-life during HD was always shorter than that before and/or after dialysis, when it was calculated (18,70,71,97,110,111,149,193,202). Exact lithium removal by ECTR was quantified in several reports (usually using older dialysis technology) (56,62, 71,107,126,172,183,192,202) and shown to be significant, sometimes even in excess of 25 mEq/h (71).…”

Section: Dialyzabilitymentioning

confidence: 99%

“…This phenomenon may be caused by either a redistribution of lithium from deeper compartments/red blood cells to the plasma or by ongoing absorption from the gastrointestinal tract. Postredistribution lithium rebound characteristically occurs after high-efficiency techniques; the rise in [Li + ] is maximal after 6-12 hours (reaching 0.5-1.0 mEq/L) (18,47,64,70,79,89,110,111,207) and not associated with recurrent symptoms as lithium moves away from the toxic compartment (56). By contrast, rebound from ongoing absorption can occur in poisonings from extended-release formulations or patients with decreased gastrointestinal motility; they can be noticeably much greater in extent (16,68,71,72,87,91,152,178) and may be associated with recurrence of symptoms or clinical deterioration, because the absorbed drug will ultimately distribute into the CNS and other tissues.…”

Section: Lithium Reboundmentioning

confidence: 99%

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Extracorporeal Treatment for Lithium Poisoning

Decker¹,

Goldfarb²,

Dargan³

et al. 2015

Clinical Journal of the American Society of Nephrology

150

139

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on behalf of the EXTRIP Workgroup Abstract The Extracorporeal Treatments in Poisoning Workgroup was created to provide evidence-based recommendations on the use of extracorporeal treatments in poisoning. Here, the EXTRIP workgroup presents its recommendations for lithium poisoning. After a systematic literature search, clinical and toxicokinetic data were extracted and summarized following a predetermined format. The entire workgroup voted through a two-round modified Delphi method to reach a consensus on voting statements. A RAND/UCLA Appropriateness Method was used to quantify disagreement, and anonymous votes were compiled and discussed in person. A second vote was conducted to determine the final workgroup recommendations. In total, 166 articles met inclusion criteria, which were mostly case reports, yielding a very low quality of evidence for all recommendations. A total of 418 patients were reviewed, 228 of which allowed extraction of patient-level data. The workgroup concluded that lithium is dialyzable (Level of evidence=A) and made the following recommendations: Extracorporeal treatment is recommended in severe lithium poisoning (1D).

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Section: Dialyzabilitymentioning

confidence: 99%

Section: Lithium Reboundmentioning

confidence: 99%

Extracorporeal Treatment for Lithium Poisoning

Decker¹,

Goldfarb²,

Dargan³

et al. 2015

Clinical Journal of the American Society of Nephrology

150

139

View full text Add to dashboard Cite

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“…Usually one session of hemodialysis or 24 hours of CVVH is sufficient, although some experts advise to continue dialysis after normal (,1 mmol/L) levels of lithium have been achieved to prevent a rebound effect. 2 In our patient, treatment was initiated with rehydration as well as CVVH and the patient was admitted to our intensive care unit (ICU). CVVH was continued for 24 hours, which resulted in a decrease of lithium levels toward therapeutic levels.…”

Section: Questions For Considerationmentioning

confidence: 99%

Clinical Reasoning: Heart to swallow

et al. 2016

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A 55-year-old woman was admitted to our intensive care department after intoxication with lithium. Her medical history was relevant for bipolar disorder for which she received medical treatment with lithium, haloperidol, and citalopram. In the week before admission, she had developed a clinical picture of gastroenteritis with diarrhea and vomiting, which resulted in dehydration and a marked deterioration in kidney function. During the last days before admission, she had become progressively lethargic and had developed dysarthria as well as postural tremors of the extremities. The tremors were coarse and irregular, most clearly present in the hands with a frequency of approximately 8 Hz. At admission, she opened her eyes spontaneously, localized pain, and showed normal verbal responses (E4M5V5). Physical examination showed severe dysarthria, ataxia, and no focal neurologic deficits. Reflexes were normal. Laboratory investigation revealed a de novo elevated creatinine level (220 mmol/L, normal 49-90) corresponding to an estimated glomerular filtration rate of 22 mL/min/1.73 m 2 (normal .60) and a lithium level that was 5.8 mmol/L (target value 0.6-0.8 mmol/L). ECG at admission was normal except for a prolonged QTc interval of 533 milliseconds (normal ,450).Questions for consideration:

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“…However, there are different methods of estimating this removed amount, and most methods ignore tissue-binding and drug rebound after hemodialysis, which is seen with many drugs, e.g. gentamicin [4], vancomycin [5], ganciclovir [6], digoxin [7], and lithium [8].…”

Section: Introductionmentioning

confidence: 99%

New AUC-Based Method to Estimate Drug Fraction Removed by Hemodialysis

Czock

Rasche²

2004

Kidney Blood Press Res

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Background: A supplemental dose is often necessary after hemodialysis depending on the amount of drug removed by hemodialysis. However, there are different methods of estimating this amount, and most methods ignore drug rebound after hemodialysis. In this report we present a new area under the concentration curve (AUC)-based method that provides an estimate of the drug fraction removed by hemodialysis including drug rebound. Methods: Valganciclovir, the oral prodrug of ganciclovir, was administered to 6 patients with end-stage renal disease. Hemodialysis was performed after 32 h. The fraction of ganciclovir removed by hemodialysis was estimated using the new AUC-based method, a classical method (using the slope on and off hemodialysis), the back-extrapolation method, and a reference model (a two-compartment model with zero-order input and first-order elimination). Results: The AUC-based method and the back-extrapolation method provided accurate estimates of the fraction of ganciclovir removed by hemodialysis (47 ± 6 and 46 ± 5%, respectively) compared to the reference model (49 ± 3%). The classical method, which does not account for the rebound of ganciclovir concentrations after hemodialysis, overestimated the removed fraction by 9% (58 ± 3%). Conclusions: The new AUC-based method and the back-extrapolation method accurately estimate the drug fraction removed by hemodialysis for drugs with a rebound after hemodialysis. The AUC-based method is more robust and as efficient compared to the back-extrapolation method.

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Lithium Intoxication: Pharmacokinetics During and After Terminated Hemodialysis in Acute Intoxications

Cited by 31 publications

References 10 publications

Extracorporeal Treatment for Lithium Poisoning

Extracorporeal Treatment for Lithium Poisoning

Clinical Reasoning: Heart to swallow

New AUC-Based Method to Estimate Drug Fraction Removed by Hemodialysis

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