Severe Hypernatraemia Due to Nephrogenic Diabetes Insipidus - a Life-Threatening Side Effect of Chronic Lithium Therapy

Abstract

Renal toxicity of long-term lithium therapy is a common problem. Nephrogenic diabetes insipidus is the most frequently encountered complication, but often remains unrecognised because of the rather benign symptoms. We present a patient with long-term lithium therapy who developed life-threatening hypernatraemia due to insufficient oral fluid intake after elective spinal surgery. Careful daily substitution of up to 25 l of hypotonic fluids led to full recovery within 9 days. Nephrogenic diabetes insipidus should always be considered in lithium-treated patients undergoing elective surgery in order to avoid severe hypernatraemia.

Key words

Lithium - nephrogenic diabetes insipidus - hypernatraemia

References

• 1 Adrogue HJ, Madias NE. Hypernatremia.  N Engl J Med. 2000;  342 1493-1499
• 2 Awad SS, Miskulin J, Thompson N. Parathyroid adenomas versus four-gland hyperplasia as the cause of primary hyperparathyroidism in patients with prolonged lithium therapy.  World J Surg. 2003;  27 486-488
• 3 Battle DC, von Riotte AB, Gaviria M, Grupp M. Amelioration of polyuria by amiloride in patients receiving long-term lithium therapy.  N Engl J Med. 1985;  312 408-414
• 4 Bendz H, Aurell M, Balldin J, Mathe AA, Sjodin I. Kidney damage in long-term lithium patients: a cross-sectional study of patients with 15 years or more on lithium.  Nephrol Dial Transplant. 1994;  9 1250-1254
• 5 Christensen S, Kusano E, Yusufi AN, Murayama N, Dousa TP. Pathogenesis of nephrogenic diabetes insipidus due to chronic administration of lithium in rats.  J Clin Invest. 1985;  75 1869-1879
• 6 Garofeanu CH, Weir M, Rosas-Arellano MP, Henson G, Garg AX, Clark WF. Causes of reversible nephrogenic diabetes insipidus: a systematic review.  Am J Kidney Dis. 2005;  45 626-637
• 7 Hensen J, Haenelt M, Gross P. Lithium induced polyuria and renal vasopressin receptor density.  Nephrol Dial Transplant. 1996;  11 622-627
• 8 Holtzman EJ, Ausiello DA. Nephrogenic diabetes insipidus: causes revealed.  Hosp Pract (Off Ed). 1994;  29 89-104
• 9 Libber S, Harrison H, Spector D. Treatment of nephrogenic diabetes insipidus with prostaglandin synthesis inhibitors.  J Pediatr. 1986;  108 305-311
• 10 Markowitz GS, Radhakrishnan J, Kambham N, Anthony M, Valeri AM, Hines WH, D'Agati VD. Lithium nephrotoxicity: a progressive combined glomerular and tubulointerstitial nephropathy.  J Am Soc Nephrol. 2000;  11 1439-1448
• 11 Marples D, Christensen S, Christensen EI, Ottosen PD, Nielsen S. Lithium-induced downregulation of aquaporin-2 water channel expression in rat kidney medulla.  J Clin Invest. 1995;  95 1838-1845
• 12 McHenry CR, Lee K. Lithium therapy and disorders of the parathyroid glands.  Endocr Pract. 1996;  2 103-109
• 13 Monnens L, Jonkman A, Thomas C. Response to indomethacin and hydrochlorothiazide in nephrogenic diabetes insipidus.  Clin Sci. 1984;  66 709-715
• 14 Robertson GL. Diabetes insipidus.  Endocrinol Metab Clin North Am. 1995;  24 549-572
• 15 Seely EW, Moore TJ, LeBoff MS, Brown EM. A single dose of lithium carbonate acutely elevates intact parathyroid hormone levels in humans.  Acta Endocrinol. 1989;  121 174-176
• 16 Waise A, Fisken RA. Unsuspected nephrogenic diabetes insipidus.  BMJ. 2001;  323 96-97

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