Lithium Use in a Patient With Bipolar Disorder and End-Stage Kidney Disease on Hemodialysis: A Case Report

Abstract

Lithium has been implicated in causing chronic tubulointerstitial nephritis and decline in renal function. However, lithium still plays a role in stabilizing patients with bipolar disorder. We illustrated a case of a bipolar I disorder patient approaching end-stage kidney disease (ESKD) with other medical comorbidities. As her mental state was affecting her compliance with medical treatment, she was mentally and medically unwell. Our patient was hospitalized on two separate occasions, for 5 and 4 months respectively, and failed adequate trials of different psychotropics due to inefficacy or intolerable side effects. A decision was made between the psychiatrist, nephrologist, and cardiologist to use lithium with hemodialysis support, with good treatment response and improved mental state. This case has shown that lithium carbonate can still be prescribed in ESKD patients on hemodialysis. Daily monitoring of lithium levels in the initial phase of lithium and hemodialysis commencement for at least 2 weeks is imperative, reducing to three times per week pre-hemodialysis towards the end of discharge after three consecutive daily serum lithium levels have stabilized. Clinicians can also consider a target serum level of less than 0.6 mEq/L in maintenance treatment for bipolar disorder in patients on hemodialysis.

Mental Health Status of the Elderly Chinese Population During COVID-19: An Online Cross-Sectional Study

“…However, among the copious amount of empirical studies that focus on the mental health of the general population ( 29 ), medical staff ( 30 ), patients ( 31 ), college students ( 32 ), and adolescents ( 33 ) during the outbreak of COVID-19, studies on the specific mental situation of the elderly population under the pandemic can hardly be found. Therefore, this study aimed to assess the psychological status among the elderly Chinese population during COVID-19 pandemic by quantifying their degree of depression, neurasthenia, fear, anxiety, and hypochondria and to analyze the potential risk factors associated with these symptoms.…”

Lithium therapy in patients on dialysis: A systematic review

“…6,13,18 Two patients received lithium through the dialysate solution, one via peritoneal dialysis and the other via hemodialysis; the dialysate administration route was used due to poor adherence and difficulty reaching stable therapeutic serum levels with oral dosing. 8,13 In patients with major depression or bipolar disorder, therapeutic pre-dialysis lithium concentrations ranged from 0.3–1.3 mmol/L in patients under 60 years of age 3,4,8–10,13–15 and 0.5–0.9 mmol/L in patients age 60 years and greater. 6,7,11,12,16 Adverse effects were reported included uncomfortable thirst (n = 1), elevated serum parathyroid hormone and decreased serum calcium (n = 1), somnolence and slurred speech (n = 1), vomiting and myoclonic twitching (n = 1), and broad-based gait, unsteadiness, and ataxia which led to lithium discontinuation (n = 1).…”

“…2,3 Additionally, lithium has been shown to decrease the risk of suicide in patients with bipolar disorder. 4 General adverse event monitoring with lithium should include nausea, increased body weight, increased thirst and urination, QT-interval prolongation, hypothyroidism, reduced cognitive processing, sedation, tremor, and dermatologic reactions (e.g. acne, rash, hair loss, psoriasis).…”

“…7,16 Lithium distributes via total body water, first into the extracellular fluid, and then into the intracellular fluid within 5-10 days. 4 It is suggested that approximately 80% of lithium is removed from the extracellular fluid during a dialysis treatment. 6 Lithium slowly re-equilibrates back into the serum following dialysis, but ingestion of the next dose is required to achieve therapeutic serum concentrations following dialysis.…”

“…These challenges are not insurmountable, as multiple case reports demonstrated safety and efficacy of lithium treatment in dialysis. 3,4,[6][7][8][9][10][11][12][13][14][15][16][17][18] Pharmacokinetically, lithium remains as a metal cation in the body with over 90% bioavailability, has minimal protein binding, follows a two-compartment model of distribution, and is almost entirely renally eliminated; the goal for dialysis patients is to maintain therapeutic serum concentrations between dialysis sessions. 7,16 Lithium distributes via total body water, first into the extracellular fluid, and then into the intracellular fluid within 5-10 days.…”