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Table 2 Recommendations for health professionals regarding lithium therapy and potential renal complications

From: The perspectives of patients with lithium-induced end-stage renal disease

Stage 1: Start lithium therapy
(GFR > 60 ml/min/1.73 m2)
Relevant for all patients on lithium
Discuss symptoms/course of mental disorder and provide information on lithium and treatment options on a regular basis
Discuss lithium-related complications such as nephrogenic diabetes insipidus and renal failure (esp. in euthymic phase)
Discuss lifestyle factors (smoking, body weight)
Provide information about lithium use (dose/duration), prevention of intoxication, and how to act in case of dehydration
Initiate lithium and kidney monitoring in accordance with (inter)national guidelines
Attending health professional(s) should recognise and act on first signs of declining renal function at an early stage (i.e. increasing creatinine levels but also decreasing GFR)
Stage 2: First signs of renal dysfunction
(GFR 40-60 ml/min/1.73 m2)
Relevant for 12% of patients taking lithium
Attending health professional(s) should recognise and act on first signs of declining renal function at an early stage (i.e. increasing creatinine levels but also decreasing GFR)
Intensify monitoring
Obtain advice from or refer for treatment to experts in the field of lithium-induced nephropathy (preferably a nephrologist and psychiatrist)
Explain end-stage renal disorder, prognosis, and implications of haemodialysis
Discuss all pros and cons of all relevant treatment options with patient and family (e.g. continuing lithium therapy, tapering lithium, switching to another drug)
Take into consideration that renal dysfunction will progress at GFR < 40 (‘point of no return’).(5)
Stage 3: Severe renal insufficiency and renal failure
(GFR < 25 ml/min/1.73 m2)
Relevant for 12‰ to approx. 1% of lithium users
Treatment by psychiatrist and nephrologist
If lithium is discontinued: review regularly whether lithium should be restarted.