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Lithium's Effects on Kidneys

Q. I was diagnosed with bipolar disorder about 2 years ago and was put on lithium. I felt good on lithium but my current doctor believes that in time my kidneys will be damaged. He changed my medication to depakote and I am still somewhat depressed. Is this true about lithium? If my blood levels on lithium are always normal, could it still damage my kidneys in several years?

A. The issue of lithium's effects on the kidneys continues to be a matter of some controversy--though in my personal view, the risks have been overstated by many authorities. First, though, let's distinguish short-term effects on the kidneys' ability to put out urine, and the long-term effects on the kidneys' ability to remove waste products from the blood.

There's no question that for many patients, lithium increases the amount of urine they excrete, and this can occasionally become a serious problem. But this is often correctable and fully reversible with discontinuation of the lithium, or even dose reduction.

The more worrisome question is the one your doctor has raised--can long-term lithium use actually damage the kidneys' ability to filter out waste--so called "glomerular" damage? If you read a recent review by the "Father of Lithium Therapy", Mogen Schou [Arch Gen Psychiatry. 1997 Jan;54(1):9-13; discussion 14-5.], you will come away with the impression that such damage from lithium is exceedingly rare, and not a major concern, so long as lithium levels remain in the normal (non-toxic) range. But other researchers have come up with different conclusions (see, e.g., Bendz et al, : Nephrol Dial Transplant. 1994;9(9):1250-4.).

In my own experience, lithium has very rarely caused any serious problems with kidney function, and the benefits have far exceeded the risks. This is extremely important for the patient with bipolar disorder, since this is a potentially very serious condition. Many experts regard lithium as the best-studied, and overall most effective mood stabilizer we have, for the majority of patients with bipolar disorder. It is also the only one that has clear-cut evidence of reducing suicide risk in bipolar disorder. However, it is not for everybody, and newer mood stabilizers, such as lamotrigine, also have great promise.

I am very reluctant to stop lithium in a patient who has done well with it, and who has not shown any evidence of creeping kidney abnormalities over the years. But this is a risk-benefit decision that many doctors would weigh differently. If you have concerns, you may want to discuss with your doctor the option of a consultative second opinion with an expert in bipolar disorder.

December 2003

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