From the FDA Drug Label
Hemodialysis is an effective and rapid means of removing the ion from the severely toxic patient The indications for hemodialysis in patients with lithium toxicity are:
- Severe cases of lithium poisoning
- Severely toxic patients Hemodialysis is used when the goal is to rapidly eliminate the lithium ion from the patient 1.
From the Research
Hemodialysis is indicated for patients with severe lithium toxicity, specifically when serum lithium levels exceed 4.0 mEq/L regardless of symptoms, or when levels are above 2.5 mEq/L with severe clinical manifestations, as supported by the most recent and highest quality study available 2.
Indications for Hemodialysis
The decision to initiate hemodialysis in patients with lithium toxicity should be based on the severity of symptoms, serum lithium levels, and the presence of significant kidney injury or life-threatening complications. Key indications include:
- Serum lithium levels exceeding 4.0 mEq/L, regardless of symptoms
- Serum lithium levels above 2.5 mEq/L with severe clinical manifestations such as altered mental status, seizures, or life-threatening cardiac arrhythmias
- Significant kidney injury
- Respiratory failure
Rationale for Hemodialysis
Hemodialysis is effective for lithium toxicity due to lithium's small molecular size and minimal protein binding, making it readily dialyzable 3. However, the post-dialysis rebound effect, where lithium levels rise again after treatment, may necessitate multiple dialysis sessions 4, 5.
Treatment Approach
Treatment should continue until clinical improvement occurs and lithium levels remain below 1.0 mEq/L. Supportive care, including IV fluids, airway management, and treatment of seizures or arrhythmias, should be provided while awaiting dialysis. Early nephrology consultation is crucial to coordinate appropriate dialysis timing and duration 6, 2.
Choice of Dialysis Modality
Conventional hemodialysis is generally preferred over continuous renal replacement therapy due to its superior lithium clearance. However, sustained low-efficiency dialysis (SLED) and continuous venovenous hemodialysis (CVVHD) may also be effective in certain cases, particularly in hemodynamically unstable patients 3, 5.