Lithium Acetate Therapy in a Maintenance Hemodialysis Patient

Abstract

Background/Aims: Single cases of lithium carbonate dosing in hemodialysis patients have been published. We investigate the dose-serum level relationship after single and multiple lithium acetate dosing in a hemodialysis patient and review the literature. Methods: Lithium acetate was administered orally over a period of 11 months in a patient with major depressive episodes after being placed on hemodialysis three times a week. The serum trough levels of lithium before and after hemodialysis were analyzed. The data were compared with those reported in the literature, and potential drug interactions and the importance of the residual renal function are discussed. Results: No adverse events due to the lithium therapy were documented. Steady state levels of between 0.6 and 0.8 mmol/l of lithium acetate were achieved 17 days after initiating the therapy, using 24 mmol/l of lithium three times a week, in a patient with a residual diuresis of about 400 ml/day. In contrast, data reported in the literature implicate that only 9.6–14.4 mmol/l of lithium (450–600 mg of lithium carbonate) is sufficient to achieve adequate serum levels. Conclusions: The residual renal function can be important for lithium clearance. The creatinine clearance does not reflect this point.

Optimizing Lithium Dosing in Hemodialysis

“…1 Our final regimen is in accordance with that of patients with no residual kidney function but lower than that for a patient with residual kidney function. 1 We have not observed prior publication of an algorithm for plasma concentration during 2-compartment distribution without elimination.…”

“…1 Our final regimen is in accordance with that of patients with no residual kidney function but lower than that for a patient with residual kidney function. 1 We have not observed prior publication of an algorithm for plasma concentration during 2-compartment distribution without elimination. The comparability of the maintenance dose estimates based on this algorithm and on volume of distribution suggests that these estimates are preferable to an estimate based on GFR, which leads to concentrations well below the therapeutic level.…”

“…However, lithium dosing in patients without renal function is only rarely described. 1 In such patients, central nervous system toxicity still remains as a potential major drug-induced adverse effect. We aimed to identify a drug regimen in accordance with changes in excretion during and after hemodialysis in a patient with chronic renal insufficiency and severe depression.…”

Lithium therapy in patients on dialysis: A systematic review

“…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). 7,9,11,13,14 The other patients were successfully managed with close serum level monitoring and dose adjustment.…”

“…Reports which obtained post-dialysis concentrations assessed patient-specific pharmacokinetic parameters, determined the specific amount of lithium cleared during dialysis, and investigated signs of lithium toxicity. 6,11,14,16…”