Lithium Nephropathy Clinical Presentation

  • Author: Eleanor Lederer, MD; Chief Editor: Vecihi Batuman, MD, FACP, FASN   more...
 
Updated: Jan 12, 2012
 

History

Generally, lithium nephrotoxicity will occur within a month of onset of use of the drug, manifested predominantly by polyuria and polydipsia. The onset of these symptoms may also occur in the presence of accelerating dose regimens. Initially, these symptoms are reversible but may become permanent with long-term use and/or chronically high serum lithium levels. When acute renal failure occurs in the setting of lithium toxicity, the patients generally will exhibit other signs of lithium toxicity, such as obtundation.

Polyuria

  • Polyuria, defined as a 24-hour urine output of greater than 3 L, is the most common complication in an otherwise asymptomatic patient who has a plasma lithium level consistent with therapeutic dosing.[15] Patients may develop polydipsia. In a case report of persistent lithium-induced nephrogenic diabetes insipidus, the patient drank 20-40 glasses of water per day.
  • Nocturia can be a useful marker of polyuria. Up to 68% of patients report at least 1 urination episode per night.
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Physical

Patients with lithium nephrotoxicity may exhibit signs of modest volume depletion, including orthostatic hypotension, tachycardia, and dry mouth. With severe dehydration, patients will show evidence of hypernatremia, including altered mental status.

  • Signs of volume depletion - Hypotension, orthostasis, tachycardia, and dry mouth
  • Altered mental status.
  • Occasional signs of hypothyroidism, including impaired reflexes and bradycardia
  • Signs of cardiotoxicity, including cardiac conduction blockade, SA node dysfunction, T wave flattening and inversion, and cardiovascular collapse
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Causes

Lithium toxicity tends to occur in the context of suicide attempts or an intervening illness in an otherwise stable patient leading to poor intake, volume depletion, and subsequent increase in lithium levels. Alternatively, if the patient does not have elevated lithium level, then the practitioner should look for other causes of diabetes insipidus.

Central diabetes insipidus

  • Familial disorder
  • Trauma-induced
  • Postsurgical
  • Neoplastic
  • Ischemic
  • Infectious
  • Autoimmune
  • Granulomatous
  • Idiopathic

Other causes of nephrogenic diabetes insipidus

  • Renal causes include chronic renal failure, the diuretic phase of acute renal failure, and obstructive uropathy.
  • Systemic disorders include familial X-linked syndrome, electrolyte disturbances (hypokalemia, hypercalcemia), sickle cell anemia (trait or disease), Sjögren syndrome, amyloidosis, or sarcoidosis.
  • Drugs include demeclocycline, loop diuretics, angiographic dyes, or anticancer agents.
  • Dietary abnormalities include polydipsia, low-protein diet, or low-sodium diet.
  • Pregnancy
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Contributor Information and Disclosures
Author

Eleanor Lederer, MD  Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa

Disclosure: Dept of Veterans Affairs Grant/research funds Research

Coauthor(s)

Clifford C Dacso, MD, MPH, MBA  John S Dunn Sr Research Chair, The Methodist Hospital Research Institute; Distinguished Research Professor, University of Houston

Clifford C Dacso, MD, MPH, MBA is a member of the following medical societies: American College of Physicians, American Medical Association, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Mark DT Tran, MD  Staff Physician, Department of Internal Medicine, Baylor College of Medicine

Mark DT Tran, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Anil Kumar Mandal, MD  Clinical Professor, Department of Internal Medicine, Division of Nephrology, University of Florida School of Medicine

Anil Kumar Mandal, MD is a member of the following medical societies: American College of Clinical Pharmacology, American College of Physicians, American Society of Nephrology, and Central Society for Clinical Research

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

George R Aronoff, MD  Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, and National Kidney Foundation

Disclosure: Nothing to disclose.

Rebecca J Schmidt, DO, FACP, FASN  Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine

Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association

Disclosure: Renal Ventures Ownership interest Other

Chief Editor

Vecihi Batuman, MD, FACP, FASN  Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

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