Severe Chronic Lithium Intoxication Successfully Treated with Continuous Hemodiafiltration

Abstract

Hemodialysis is the usual recommended treatment for severe lithium intoxication when emergent extracorporeal lithium removal is necessary. Intermittent hemodialysis has been chosen most frequently, however it has disadvantages such as postdialysis rebound elevation in lithium concentration, hemodynamic instability, tendency to develop hypovolemia and deteriolate renal function. On the other hand continuous hemodiafiltration (CHDF) offers an advantage of slow sustained removal of lithium without the adverse effects of conventional hemodialysis. The following is a report of a case of severe chronic lithium intoxication successfully treated with CHDF. A 69-year old woman, who had been diagnosed with manicdepressive psychosis 18 years previously, was transferred to our ICU because of unconsciousness during lithium maintenance therapy (lithium carbonate 800mg/day). On arrival her consciousness level was Japan Coma Scale 100 and the pulse rate was 30beats/min. Since she had a past history of cardiac failure, we conducted CHDF to accelerate lithium elimination. CHDF was continued for 64 hours and thereafter her condition improved uneventfully.

Lithium Level in Cerebrospinal Fluid Cannot be a Reliable Indicator of Severity of Chronic Lithium Intoxication

“…As lithium has a narrow therapeutic level and is susceptible to chronic intoxication, regular measurement of the lithium level in blood is recommended for the prevention and early detection of chronic lithium intoxication. 1 Lithium is hardly taken up by the CNS cells; however, it is difficult for lithium once accumulated in the CNS cells to move out. As a result, lithium levels in blood do not correlate well with the severity of chronic lithium intoxication, as they do not accurately reflect the degree of lithium accumulation in the CNS cells.…”

“…As a result, lithium levels in blood do not correlate well with the severity of chronic lithium intoxication, as they do not accurately reflect the degree of lithium accumulation in the CNS cells. 1–3…”

“…As lithium has a narrow therapeutic level and is susceptible to chronic intoxication, regular measurement of the lithium level in blood is recommended for the prevention and early detection of chronic lithium intoxication. 1 Lithium is hardly taken up by the CNS cells; however, it is difficult for lithium once accumulated in the CNS cells to move out.…”

“…As a result, lithium levels in blood do not correlate well with the severity of chronic lithium intoxication, as they do not accurately reflect the degree of lithium accumulation in the CNS cells. [1][2][3] In this case, large amounts of lithium accumulated in the CNS cells because of the increased dose of lithium carbonate, enhanced lithium reabsorption through the renal tubules because of severe dehydration, and secondarily much lowered renal function, that is, acute renal failure (ARF) to eliminate lithium were considered to be the causes of chronic lithium intoxication. 1,2 Even after lithium levels in CSF as well as that in blood decreased enough, toxic neurologic symptoms persisted for a few more days.…”

“…[1][2][3] In this case, large amounts of lithium accumulated in the CNS cells because of the increased dose of lithium carbonate, enhanced lithium reabsorption through the renal tubules because of severe dehydration, and secondarily much lowered renal function, that is, acute renal failure (ARF) to eliminate lithium were considered to be the causes of chronic lithium intoxication. 1,2 Even after lithium levels in CSF as well as that in blood decreased enough, toxic neurologic symptoms persisted for a few more days. Surprisingly, lithium levels in the CSF were much lower than that in the blood.…”