Haemodialysis for lithium poisoning: Translating EXTRIP recommendations into practical guidelines

Abstract

Objectives: This study aimed to determine the impact on practice of applying the Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup criteria to lithium toxicity. Method:We retrospectively examined the medical records of patients from three hospitals who presented with chronic or acute on chronic lithium poisoning with a lithium concentration ≥1.3 mmol/L (2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018). We determined which criteria were met by patients and their subsequent course. We developed and validated a method to predict if lithium concentration would be >1mmol/L at 36 hours.Results: There were 111 acute on chronic and 250 chronic lithium toxic patients.Nine patients (2.5%) were treated with haemodialysis. Six chronic patients had neurological sequelae. The "estimated lithium concentration at 36 hours > 1 mmol/L" criterion required pharmacokinetic calculations. A simple nomogram was developed using Estimated Glomerular Filtration Rate (eGFR) and lithium concentration. For chronic toxicity, the nomogram would have correctly predicted lithium concentration >1.4 mmol/L at 36 hours in all except two patients. If EXTRIP criteria were followed, dialysis would have been instituted for 211 patients (58%). However, only 51 patients with chronic toxicity fulfilled both a concentration and a clinical criterion. Late neurological sequelae were observed in five out of six patients who fulfilled a concentration and a clinical criterion on admission, with the sixth meeting these criteria shortly after admission. Conclusions:The EXTRIP criteria are too broad, but minor modifications allow haemodialysis to be targeted to those most at risk of sequelae. Most acute on chronic poisonings do not need haemodialysis, but it might shorten hospital stay in those with very high concentrations. The nomogram accurately predicts the fall in lithium concentration for chronic poisoning. K E Y W O R D S acute on chronic lithium poisoning, chronic lithium toxicity, EXTRIP, haemodialysis, nomogram

Lithium Poisoning Update in Diagnosis and Treatment

“…High-efficiency hemodialysis leads to a lithium clearance up to ten times higher than endogenous clearance, reaching up to 100-120 ml / min [42] and its indications, although they are still controversial because they are based on consensus of experts and small cohort studies were summarized by EXTRIP (Extracorporeal Treaments in Poisoning) in 2015 as shown in Table 3 [43].…”

The desperate searching for reliable and convenient criteria of haemodialysis in the lithium‐poisoned patient

“…The pattern of lithium poisoning was only provided in the four nondialysed patients with discordant haemodialysis indications when using EXTRIP versus Paris criteria. Yet relevance of EXTRIP criteria likely depends on the pattern of lithium poisoning, 2 and the criterion "serum lithium concentration greater than 5.2 mmol/L" in Paris criteria is limited to patients with acute or acute-on-chronic lithium intoxication. 3 Moreover, Table 2 of the article highly suggested that only initial lithium and creatinine values were mostly available.…”

Evidence‐based recommendations for haemodialysis in lithium‐poisoned patients: Getting from where we are to where we want to be

“…They derived a simple set of clinical criteria and suggest that these new criteria outperform the EXTRIP criteria. Similarly, Buckley retrospectively analysed patients from three local hospitals and performed a toxicokinetic evaluation to identify patients whose lithium concentrations were likely to remain elevated for a prolonged period of time . Both groups address parameters (the peak serum lithium concentration, prolonged lithium elimination, and individual patient factors) that were recognized decades ago as likely markers of morbidity and were evaluated and included in the EXTRIP recommendations …”