From the Research
Hemodialysis (HD) is typically recommended for lithium levels exceeding 4.0 mEq/L (or 4.0 mmol/L), regardless of symptoms, or for lower levels (>2.5 mEq/L) when accompanied by severe clinical toxicity that doesn't respond to supportive care. For patients with significant kidney injury or those who remain symptomatic despite conventional treatment, HD may be initiated at even lower levels. The decision to initiate HD should be based on the severity of clinical symptoms and the patient's overall condition, rather than solely on the lithium level 1. Key considerations in managing lithium toxicity include:
- The standard HD session for lithium toxicity should last 4-6 hours, with extended or repeated sessions often necessary due to lithium's post-dialysis rebound effect from tissue redistribution 2.
- Continuous renal replacement therapy (CRRT) may be considered as an alternative in hemodynamically unstable patients.
- Hemodialysis effectively removes lithium because the ion is small, not protein-bound, and has a low volume of distribution, making it readily dialyzable when present in the bloodstream.
- Monitoring of lithium levels 6-8 hours after dialysis completion is crucial to assess for the post-dialysis rebound effect 3, 4, 5. In clinical practice, the management of lithium toxicity requires a comprehensive approach, taking into account the patient's clinical presentation, laboratory results, and overall condition, with the goal of minimizing morbidity, mortality, and improving quality of life.