Toxicokinetics of Lithium Intoxication Treated by Hemodialysis

Unrecognized acute lithium toxicity: a case report

“…There is some correlation between Li serum levels and the severity of symptoms of intoxication [1]. There are various recommendations which refer to usage of hemodialysis in cases of various levels of drug in blood [13,25,26]. Certain number of authors does not recommend use of hemodialysis in cases when lithium concentration is above 4 mmol/L [27,28].…”

“…Unfortunately, due to fast redistribution, after hemodialysis, plasma values almost reach the level before dialysis and often require re-dialysis. It is also determined that the rebound-effect and sudden leaps of lithium concentration occur after hemodialysis [1,12,13]. Hemodialysis is the treatment of choice for rapid removal of lithium from the body, especially in cases of toxicity with higher lithium levels [14].…”

Extracorporeal Treatment for Lithium Poisoning

“…The effect of ECTR on lithium elimination from other body compartments is less often reported, but the decrease of lithium concentration in red blood cells (71,167,172) and cerebrospinal fluid (111,149,193) seems to parallel that from the serum. In one report, ECTR did not seem to reduce endogenous renal elimination (18).…”

“…Because impairment of kidney function often accompanies lithium toxicity and because lithium itself has long-term effects on kidney function, lower lithium clearances are usually reported, reaching an average of 10.6 mL/min for our cohort (14,204). The reported lithium half-life during HD was always shorter than that before and/or after dialysis, when it was calculated (18,70,71,97,110,111,149,193,202). Exact lithium removal by ECTR was quantified in several reports (usually using older dialysis technology) (56,62, 71,107,126,172,183,192,202) and shown to be significant, sometimes even in excess of 25 mEq/h (71).…”

“…This phenomenon may be caused by either a redistribution of lithium from deeper compartments/red blood cells to the plasma or by ongoing absorption from the gastrointestinal tract. Postredistribution lithium rebound characteristically occurs after high-efficiency techniques; the rise in [Li + ] is maximal after 6-12 hours (reaching 0.5-1.0 mEq/L) (18,47,64,70,79,89,110,111,207) and not associated with recurrent symptoms as lithium moves away from the toxic compartment (56). By contrast, rebound from ongoing absorption can occur in poisonings from extended-release formulations or patients with decreased gastrointestinal motility; they can be noticeably much greater in extent (16,68,71,72,87,91,152,178) and may be associated with recurrence of symptoms or clinical deterioration, because the absorbed drug will ultimately distribute into the CNS and other tissues.…”