Hemodialysis for lithium poisoning

Abstract

BackgroundLithium salts, particularly lithium carbonate, are frequently used to treat bipolar disorder and mania. Lithium poisoning, which can occur as a result of reduced renal elimination, prescribing error, drug-drug interactions, or deliberate overdosage, produces neurologic injury that can be permanent. Hemodialysis is o en recommended to treat lithium poisoning. Although hemodialysis clearly enhances the elimination of lithium, it is unclear whether this translates into improved patient outcomes. Evidence from observational studies, generally of low methodological quality, shows similar outcomes in patients managed with or without the use of hemodialysis. ObjectivesTo determine whether hemodialysis, applied in addition to standard therapy, reduces the likelihood, severity, or duration of neurological sequelae following lithium poisoning. Search methodsWe ran the search on 15 May 2015. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), Embase Classic+Embase (OvidSP), CINAHL Plus, clinical trials registers and four other databases. We screened the reference lists of relevant studies, textbook chapters, and review articles, and performed a Google search to identify grey literature. Selection criteriaIn the context of this review, hemodialysis was defined as any extracorporeal technique to filter and extract toxicants from the serum, including all forms of hemodialysis, hemofiltration, and continuous renal replacement techniques, but not peritoneal dialysis. We included any clinical trials in which patients were randomly allocated to receive, or not receive, hemodialysis in addition to standard care for lithium poisoning. Data collection and analysisTwo authors reviewed the abstracts of all identified articles. If either author identified an article as potentially meeting the inclusion criteria, both authors reviewed the full text of the article. Main resultsNo randomized controlled trials of hemodialysis therapy for lithium poisoning were identified.

Use of the anion gap and intermittent hemodialysis following continuous hemodiafiltration in extremely high dose acute‐on‐chronic lithium poisoning: A case report

“…Although no robust evidence from clinical trial has been reported so far, several clinical reviews have described the rationale of RRT for lithium poisoning according to the serum lithium concentration; the threshold is 4.0–5.0 mEq/L for acute poisoning and 2.5 mEq/L for chronic poisoning. However, no clear cut‐off value and standard therapy for acute‐on‐chronic poisoning has been established.…”

Assessment of Extracorporeal Treatments in Poisoning criteria for the decision of extracorporeal toxin removal in lithium poisoning

“…no protein binding, limited volume of distribution, absence of metabolism, and exclusive renal elimination), extracorporeal toxin removal (ECTR) represents the method of choice for enhancing lithium elimination in poisoning, if lithium elimination is compromised despite optimal fluid management . However, ECTR indications and benefits in lithium poisoning are still controversial …”

“…1 However, ECTR indications and benefits in lithium poisoning are still controversial. [2][3][4][5] The EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup, an international workgroup including clinical toxicologists, nephrologists, epidemiologists and pharmacologists, 6 provided recommendations on ECTR use in lithium poisoning, based on a systematic literature review and considered to date as the most up-to-date international guideline. 1 Using the GRADE system, all recommendations were grade D (i.e.…”

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

“…Though Cochrane correctly concluded that there are no randomized controlled human trials to inform the decision to perform haemodialysis in lithium-poisoned patients, their focused methodology prevented them for offering any clinical decision support. 10 In contrast, the Extracorporeal Treatments In Poisoning (EXTRIP) workgroup (https://www.extrip-workgroup.org) assembled a multidisciplinary team of international experts (including toxicologists, pharmacologists, nephrologists, intensivists, and methodologists) who reviewed the entirety of the existing literature and used a sound, transparent, and reproducible evidence and consensus-based methodology to offer their best recommendations for ECTR in lithium-poisoned patients. 11 Despite achieving consensus on many items, the low level of available evidence created the significant likelihood of imprecision around the clinical conditions and laboratory values used as criteria to either suggest or recommend ECTR for a given patient.…”