Sustained low-efficiency dialysis (SLED) for acute lithium intoxication

Acute lithium intoxication may cause serious neurologic and cardiac manifestations, up to the patient's death. Owing to its low molecular weight, relatively small volume of distribution close to that of total body water, and its negligible protein binding, lithium can be efficiently removed by any extracorporeal modality of renal replacement therapy (RRT). However, the shift from the intracellular to the extracellular compartment, with the inherent rebound phenomenon after the end of RRT, might limit the efficacy of the conventional, short-lasting haemodialysis. There have been no published studies up to now concerning the use of sustained low-efficiency dialysis (SLED) in lithium intoxication. This report describes a woman with a voluntary acute lithium ingestion of 40 tablets of lithium carbonate (8.12 mEq lithium each). The lithium concentration increased up to 4.18 mEq/l about 24 h after admission, notwithstanding treatment with intravenous crystalloids and gastric lavage. She developed mental status changes, oliguria, hypotension and bradycardia. We started SLED (8 h) with a blood flow of 200 ml/min and countercurrent dialysate flow of 300 ml/min. Lithium serum levels decreased by 86% during treatment, and the patient fully awoke recovering a normal mental status within the first 4 h of treatment. SLED was completed safely within the prescribed time. After the end of treatment, the rebound of lithium concentration was unremarkable. Renal function fully recovered, and the patient was transferred into a psychiatric facility 3 days after admission.