Lithium-Induced Minimal Change Disease and Acute Kidney Injury

Abstract

Context: Lithium carbonate is a psychiatric medication commonly used in the treatment of bipolar disorder. It has been implicated in inducing nephrogenic diabetes inspidus, chronic tubulointerstitial nephropathy, and acute tubular necrosis. We describe a case of lithium-induced minimal change disease (MCD) and acute kidney injury (AKI).

Case report: A 32-year-old female with a medical history of bipolar disorder treated with chronic lithium therapy presented with anasarca, fatigue, and tremors. Work-up revealed supra-therapeutic lithium levels, hypoalbuminemia, and significant proteinuria. The patient was treated conservatively with fluids and discontinuation of lithium therapy. Subsequently, she developed significant AKI and persistent proteinuria. She underwent a renal biopsy that demonstrated effacement of podocyte foot processes consistent with lithium-induced MCD. This was treated with corticosteroids, which decreased the proteinuria and resolved all the patient's symptoms.

Conclusion: Lithium-induced MCD is a rare disease that affects patients of all ages. It is often associated with therapeutic lithium and is typically resolved with discontinuation of lithium. In some cases, concurrent AKI may result due to vascular obstruction from hyperalbuminuria and associated renal interstitial edema. Corticosteroids may be needed to reduce the proteinuria and prevent progression to chronic kidney disease. As such, patients on lithium therapy may benefit from monitoring of glomerular function via urinalysis to prevent the onset of nephrotic syndrome.

Keywords: Lithium; minimal change disease; nephrotic syndrome; proteinuria; renal insufficiency.

Figure 1

Light and electron microscopic evidence of minimal change disease. (a) Light microscopy identifying focal interstitial fibrosis and cellular mesangial expansion (black arrows). No evidence of ischemic injury to tubular structures. Developed with periodic acid-Schiff stain. (b) Electron microscopic demonstration of widespread podocyte effacement (red arrows). Magnification, ×12,000

Figure 2

Serum creatinine and albumin/creatinine ratio throughout the hospitalization and post-hospitalization follow-up. Progression of serum creatinine and albumin/creatinine ratio from first day of hospitalization to current follow-up. The start of prednisone is marked. * Indicates the day of lithium discontinuation. ▪ indicates albumin/creatinine levels. • Indicates serum creatinine levels