Chronic lithium nephropathy

Abstract

Fig. 1. Chronic tubulointerstitial nephritis with interstitial fibrosis and tubular atrophy. There are several tubular cysts (arrows) and focal lymphocytic infiltrations (arrowheads; hematoxylin and eosin stain, 40). A 49-year-oldman presented toTzu Chi General Hospital, Taipei, Taiwan, with cough, dyspnea, and general malaise. He had a history of bipolar disorder for > 20 years with regular follow-up at Taipei City Psychiatric Center (Taipei, Taiwan) and was under lithium therapy. He was admitted for antibiotic treatment under the impression of pneumonia and sepsis. Laboratory data revealed leukocytosis (white blood cells, 27.0 109/L), normocytic anemia (hemoglobin, 8.0 g/dL; mean cell volume, 88.5 fL), and azotemia (blood urea nitrogen, 111.6 mg/dL; creatinine, 3.69 mg/dL). In spite of aggressive management of respiratory failure and septic shock, the patient died 3 days later. At autopsy, the kidneys were grossly symmetrical. Several irregular, depressed scars were noted on the renal parenchyma. Microscopically, cortical and medullary interstitial fibrosis, interstitial lymphocytic infiltration, diffuse tubular atrophy, and tubular cysts with pericystic fibrosis (Fig. 1) indicated chronic tubulointerstitial nephritis accompanied by focal segmental (Fig. 2) and global glomerulosclerosis, diagnostic of chronic lithium nephropathy. The most common form of lithium nephropathy in patients on long-term lithium therapy is chronic tubulointerstitial nephritis, presenting most commonly as tubular atrophy, interstitial fibrosis, and lymphocytic infiltration. The presence of tubular cysts with pericystic fibrosis originating from the distal tubules and collecting ducts is highly characteristic of lithium nephropathy. Markowitz et al [1] reported global glomerulosclerosis in 24 of 24