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Clinical Images in Nephrology and Dialysis

An Unexpected Imaging Finding in a CKD Patient on Lithium Therapy

Blaise Anthonissen, Etienne Danse and Eric Goffin
Kidney360 January 2021, 2 (1) 180-181; DOI: https://doi.org/10.34067/KID.0003642020
Blaise Anthonissen
1Department of Nephrology, University Hospital Saint-Luc, Brussels, Belgium
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Etienne Danse
2Department of Radiology, University Hospital Saint-Luc, Brussels, Belgium
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Eric Goffin
1Department of Nephrology, University Hospital Saint-Luc, Brussels, Belgium
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  • chronic kidney disease
  • lithium nephropathy
  • nephrogenic diabetes insipidus
  • renal micro-cysts
  • small cysts formation

Case Description

A 65-year-old woman, treated with lithium for 18 years for bipolar disorder, presented with CKD (serum creatinine level ranging between 1.6 and 2.0 mg/dl) and polyuria. There was no hematuria, aseptic leukocyturia or proteinuria, nor biologic signs of nephrogenic diabetes insipidus. Substitution of sodium valproate and olanzapine for lithium did not improve kidney function.

As part of the evaluation, an ultrasonography of the kidneys showed various cystic formations, including one with wall thickening (Figure 1). Magnetic resonance imaging (T2 sequence) demonstrates multiple, nonsuspect, disseminated, 1–2 mm diameter microcysts throughout the cortex and the medulla of both kidneys (Figure 2), highly suggestive of lithium nephropathy (1).

Figure 1.
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Figure 1.

Ultrasonography of the kidneys, demonstrating multiple cysts.

Figure 2.
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Figure 2.

MRI of the kidneys in a patient on lithium therapy. (A) Coronal and (B) axial T2 half-Fourier-acquired single-shot turbo spin echo magnetic resonance imaging demonstrates microcysts of 1–2 mm diameter within the cortex and medulla of both kidneys.

Lithium is a cation, not bound to proteins, not metabolized, and is eliminated completely by the kidneys. It is filtered by the glomeruli and then largely reabsorbed at the proximal level (2). Lithium is the standard treatment for bipolar mood disorders and requires regular kidney-function monitoring because of its narrow therapeutic index.

Chronic tubulointerstitial nephropathy with formation of small cysts within the renal cortex and medulla and nephrogenic diabetes insipidus (NDI) are the main nephrologic manifestations of lithium therapy. NDI is often, but not always, reversible when the drug is withdrawn. By contrast, the course of kidney disease after lithium withdrawal is unpredictable, but progressive kidney failure often occurs (3).

Risk factors for nephrotoxicity are both duration of lithium exposure and cumulative dose. The underlying pathophysiologic mechanism of renal toxicity remains ill defined (4). Magnetic resonance imaging is the most sensitive test to delineate the formation of small cysts.

Teaching Points

  • NDI and tubulointerstitial nephritis are the main kidney manifestations that may complicate lithium therapy.

  • The discovery of a progressive CKD with the presence of small cysts within the renal cortex and medulla in a patient treated with lithium are highly suggestive of lithium nephropathy.

Disclosures

All authors have nothing to disclose.

Funding

None.

Acknowledgments

Informed consent was obtained from the patient.

Author Contributions

B. Anthonissen wrote the original draft of the manuscript; and E. Danse and E. Goffin edited and reviewed the manuscript.

  • Received June 3, 2020.
  • Accepted August 12, 2020.
  • Copyright © 2021 by the American Society of Nephrology

References

  1. ↵
    1. Gong R,
    2. Wang P,
    3. Dworkin L
    : What we need to know about the effect of lithium on the kidney. Am J Physiol Renal Physiol 311: F1168–F1171, 2016 https://doi.org/10.1152/ajprenal.00145.2016
    OpenUrlCrossRefPubMed
  2. ↵
    1. Kishore BK,
    2. Ecelbarger CM
    : Lithium: A versatile tool for understanding renal physiology. Am J Physiol Renal Physiol 304: F1139–F1149, 2013 https://doi.org/10.1152/ajprenal.00718.2012
    OpenUrlCrossRefPubMed
  3. ↵
    1. McKnight RF,
    2. Adida M,
    3. Budge K,
    4. Stockton S,
    5. Goodwin GM,
    6. Geddes JR
    : Lithium toxicity profile: A systematic review and meta-analysis. Lancet 379: 721–728, 2012 https://doi.org/10.1016/S0140-6736(11)61516-X
    OpenUrlCrossRefPubMed
  4. ↵
    1. Davis J,
    2. Desmond M,
    3. Berk M
    : Lithium and nephrotoxicity: A literature review of approaches to clinical management and risk stratification. BMC Nephrol 19: 305, 2018 https://doi.org/10.1186/s12882-018-1101-4
    OpenUrl
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An Unexpected Imaging Finding in a CKD Patient on Lithium Therapy
Blaise Anthonissen, Etienne Danse, Eric Goffin
Kidney360 Jan 2021, 2 (1) 180-181; DOI: 10.34067/KID.0003642020

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An Unexpected Imaging Finding in a CKD Patient on Lithium Therapy
Blaise Anthonissen, Etienne Danse, Eric Goffin
Kidney360 Jan 2021, 2 (1) 180-181; DOI: 10.34067/KID.0003642020
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Keywords

  • Chronic kidney disease
  • lithium nephropathy
  • nephrogenic diabetes insipidus
  • renal micro-cysts
  • small cysts formation

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