Effects Of Chronic Lithium Administration Research Articles

Effects of chronic lithium administration on renal acid excretion in humans and rats.

Lithium therapy's most common side effects affecting the kidney are nephrogenic diabetes insipidus (NDI) and chronic kidney disease. Lithium may also induce a distal renal tubular acidosis. This study investigated the effect of chronic lithium exposure on renal acid–base homeostasis, with emphasis on ammonia and citrate excretion. We compared 11 individuals on long‐term lithium therapy with six healthy individuals. Under basal conditions, lithium‐treated individuals excreted significantly more urinary ammonia than did control subjects. Following an acute acid load, urinary ammonia excretion increased approximately twofold above basal rates in both lithium‐treated and control humans. There were no significant differences between lithium‐treated and control subjects in urinary pH or urinary citrate excretion. To elucidate possible mechanisms, rats were randomized to diets containing lithium or regular diet for 6 months. Similar to humans, basal ammonia excretion was significantly higher in lithium‐treated rats; in addition, urinary citrate excretion was also significantly greater. There were no differences in urinary pH. Expression of the critical ammonia transporter, Rhesus C Glycoprotein (Rhcg), was substantially greater in lithium‐treated rats than in control rats. We conclude that chronic lithium exposure increases renal ammonia excretion through mechanisms independent of urinary pH and likely to involve increased collecting duct ammonia secretion via the ammonia transporter, Rhcg.

Chronic lithium treatment protects the rat kidney against ischemia/reperfusion injury: The role of nitric oxide and cyclooxygenase pathways

Ischemia/reperfusion injury is a major problem in renal transplantation. Several evidences represent lithium preconditioning effect against ischemia/reperfusion injury in various tissues. In this study our aim was to investigate the protective effect of chronic lithium administration on renal ischemia/reperfusion injury in rats. Ischemia/reperfusion injury was induced by clamping left renal pedicle for 60 min, 2 weeks after right nephrectomy. Lithium-treated animals received lithium-chloride in drinking water for 30 days. In order to investigate the role of nitric oxide (NO) and cyclooxygenase (COX) pathways in renoprotective effect of lithium, N ω-nitro-L-arginine methyl ester hydrochloride (L-NAME, NO synthase inhibitor) and indomethacin (COX inhibitor) were used, respectively. Serum creatinine, blood urea nitrogen and renal histology were assessed 24 h after inducing ischemia/reperfusion injury. Dimercaptosuccinic acid scan was also performed 48 h following operation. Chronic lithium treatment in ischemia/reperfusion injury groups significantly decreased creatinine (1.09 ± 0.16 mg/dl), blood urea nitrogen (59.0 ± 13.38 mg/dl), histological damage (7.83% ± 4.02%) and improved cortical function compared with non-lithium treated animals (4.45 ± 0.44, 176.66 ± 12.24 mg/dl and 83.5% ± 3.5%, respectively) (P < 0.001). Either L-NAME or indomethacin administration partially reversed the protective effect of lithium, while simultaneous blockade of NO and COX pathways completely abolished lithium renoprotective effect. Our results indicate that lithium ameliorates renal ischemia/reperfusion injury through NO and/or COX pathways. We propose that lithium pre-treatment as a simple and practical intervention to boost the renal viability and function after ischemia/reperfusion injury may be promising in the setting of transplantation.

Glycogen synthesis in brain and astrocytes is inhibited by chronic lithium treatment

Lithium is a drug widely used to treat bipolar disorder. It has been shown to inhibit the total activity of phosphoglucomutase (PGM) from rat brains. In this work, we show that lithium inhibits in vitro PGM activity in the cortex, hippocampus, striatum, brainstem and cerebellum. As a compensatory effect, chronic lithium treatment of Wistar rats for 6 weeks caused a 1.6-fold upregulation of cortex PGM activity. No difference was observed in the other areas tested. Another effect of chronic lithium administration was a drastic reduction of glycogen content in rat brains, as PGM activity is essential for its synthesis. In a primary culture of astrocytes, which are the main cellular components of the brain that produce glycogen, administration of 1 mM lithium for 3 days markedly reduced the steady state of glycogen content. In agreement with this result, lithium did not cause insulin-like effects as previously observed in hepatocytes where lithium activated glycogen synthesis. Reduction of glycogen content was due to inhibition of glycogen synthesis, as incorporation of [ 14U −C]-glucose into glycogen was impaired by lithium. Consistent with these results, incubation of glucose-starved astrocytes with lithium did not stimulate dephosphorylation of glycogen synthase, which normally occurs with re-feeding of glucose. Furthermore, in a chronically treated astrocyte culture, glycogen synthase was phosphorylated constitutively. Our results indicate that chronic lithium treatment can inhibit glycogen synthesis in brain suggesting that this effect might contribute to lithium's therapeutic effect.

Antinociceptive effect of chronic lithium on visceral hypersensitivity in a rat model of diarrhea‐predominant irritable bowel syndrome: The role of nitric oxide pathway

Lithium, a widely used drug in bipolar-affective disorders, plays gastro-protective roles. The effects of lithium on several tissues are mediated through nitric oxide (NO), which regulates gastrointestinal motility and mucosal integrity. The aim of this study was to investigate the protective effect of chronic lithium administration on visceral hypersensitivity and to investigate the role of NO as a potential mechanism of lithium in a rat model of irritable bowel syndrome. Colitis was induced by the intracolonic administration of acetic acid. After subsidence of inflammation on the seventh experimental day, nociception and defecation parameters were measured. A subgroup of animals had been pretreated with lithium carbonate (600 mg/L) for 35 days. Thereafter, either a non-selective NO synthase (NOS) inhibitor (N-nitro-L-arginine methyl ester [L-NAME], 10 mg/kg), a selective NOS inhibitor (aminoguanidine, 100 mg/kg), or saline were administered intraperitoneally 1 h before measurements. Chronic lithium attenuated the visceral hypersensitivity, increased the nociceptive threshold, and decreased stool frequency. L-NAME and aminoguanidine decreased the nociceptive threshold and reduced the protective effects of lithium on visceral hypersensitivity. Stool frequency was increased in both the lithium-treated and water-treated groups by L-NAME administration, but not aminoguanidine. The form of defecation in the lithium-treated rats shifted toward hard stools rather than being soft and formless, but NOS inhibitors did not change the stool consistency pattern. The results indicate the antinociceptive property of chronic lithium on visceral hypersensitivity. As this effect was lowered by NOS inhibitors, NO might play a role in the protective effect of lithium to some extent.

A role for nitrergic system in the antidepressant-like effects of chronic lithium treatment in the mouse forced swimming test

In the present study we evaluated the involvement of nitric oxide (NO) system in the antidepressant-like effects of chronic lithium administration in the mouse forced swimming test (FST). Administration of lithium chloride (300 mg/L in drinking water for 21 days) had no effect on the immobility of mice in the FST, whereas 600 mg/L lithium caused a significant ( P < 0.001) decrease in the immobility time compared with control animals. Administration of the NO synthase inhibitor N G-nitro-L-arginine methyl ester (L-NAME, 10 mg/kg, daily for a week, i.p.) had no significant effect on the immobility time of either control or lithium (300 mg/L)-treated mice, whereas acute administration of non-effective dose of L-NAME (30 mg/kg, i.p.) caused a robust decrease ( P < 0.01) in the immobility time of lithium (300 mg/L)-treated animals in the FST. Moreover, chronic administration of low dose of the NO precursor L-arginine (200 mg/kg, daily for a week, i.p.) prevented ( P < 0.001) the antidepressant-like effects of lithium treatment (600 mg/L) in the FST. Acute treatment with L-arginine (200 mg/kg, i.p.) increased ( P < 0.05) the immobility time of lithium (600 mg/L)-treated mice in the FST. Chronic lithium treatment (600 mg/L but not 300 mg/L) caused a significant ( P < 0.05) decrease in the serum NO X levels in mice compared with controls. Our data suggested that the NO system could be involved in the antidepressant-like effect of chronic lithium treatment in the FST.

Effect of chronic lithium administration on endothelium-dependent relaxation of rat mesenteric bed: role of nitric oxide

The mechanism of action of lithium, an effective treatment for bipolar disease, is still unknown. In this study, the mesenteric vascular beds of control rats and rats that were chronically treated with lithium were prepared by the McGregor method, and the mesenteric vascular bed vasorelaxation responses were examined. NADPH-diaphorase histochemistry was used to determine the activity of NOS (nitric oxide synthase) in mesenteric vascular beds. We demonstrated that ACh-induced vasorelaxation increased in the mesenteric vascular bed of rats treated with lithium. Acute No-nitro-L-arginine methyl ester (L-NAME) administration in the medium blocked ACh-induced vasorelaxation in the control group more effectively than in lithium-treated rats, while the vasorelaxant response to sodium nitroprusside, a NO donor, was not different between lithium-treated and control groups. Acute aminoguanidine administration blocked ACh-induced vasorelaxation of lithium-treated rats, but had no effect in the control rats. Furthermore, NOS activity, determined by NADPH-diaphorase staining, was significantly greater in the mesenteric vascular beds from chronic lithium-treated rats than in those from control rats. These data suggest that the enhanced ACh-induced endothelium-derived vasorelaxation in rat mesenteric bed from chronic lithium-treated rats might be associated with increased NOS activity, likely via iNOS. Simultaneous acute L-NAME and indomethacin administration suggests the possible upregulation of EDHF (endothelium-derived hyperpolarizing factor) in lithium-treated rats.

Protective Effects of Chronic Lithium Treatment against Spatial Memory Retention Deficits Induced by the Protein Kinase AII Inhibitor H-89 in Rats

We have previously shown that infusion of the PKAII inhibitor H-89 in the CA1 area of the hippocampus impaired spatial memory retention. There is some evidence suggesting the neuroprotective effects of chronic lithium administration including its ability to attenuate a deleterious effect of chronic stress on spatial memory in rats. In the present study, we investigated whether chronic administration of lithium can improve memory as well as influence the inhibitory effect of H-89 on spatial memory retention. Male albino rats were treated systemically with lithium (600 mg/l) for 4 weeks and then trained for 4 days in the Morris water maze. Testing the animals 48 h later showed a significant reduction in escape latency (p < 0.05) and travel distance (p < 0.05) compared to the controls. In separate experiments, the rats were similarly treated with lithium for 4 weeks, followed by similar training for 4 days and then immediately infused bilaterally with vehicle or 5 µmol/l H-89 into the CA1 region of the hippocampus. Animals were then tested 48 h after H-89 infusion in order to assess their spatial memory retention. The lithium treatment caused a significant reduction in escape latency (p < 0.001) and travel distance (p < 0.001) compared to H-89-treated animals. The data suggest that lithium treatment for 4 weeks improved spatial memory retention and that lithium pretreatment prevented or reversed the H-89-induced spatial memory deficits.

Effect of chronic lithium administration on endothelium‐dependent relaxation of rat corpus cavernosum: the role of nitric oxide and cyclooxygenase pathways

To verify the effect of chronic lithium administration on the endothelium-dependent relaxation of rat corpus cavernosum, as lithium is a major drug for treating bipolar disorder and some studies showed that lithium might cause erectile dysfunction in such patients, by a mechanism as yet unknown. LiCl (600 mg/L) was dissolved in drinking water and Sprague-Dawley rats received the solution for 30 days; control rats received tap water. After 30 days corporeal strips were prepared from both groups, mounted under tension in oxygenated organ baths, and pre-contracted with phenylephrine (7.5 microm). After equilibration, the strips were relaxed by acetylcholine (10 nm to 1 mm) in the presence or absence of indomethacin (a cyclooxygenase inhibitor; 20 microm). Furthermore, the relaxant responses to sodium nitroprusside (1 nm to 1 mm), a nitric oxide (NO) donor, were investigated in both groups. NADPH-diaphorase histochemistry was used to identify NO synthase within cavernosal tissue strips of both groups. The acetylcholine-dependent relaxation was significantly lower in lithium-treated rats than in controls. Although indomethacin decreased significantly the relaxant responses to acetylcholine in controls, it increased the relaxant responses in lithium-treated rats. NADPH-diaphorase staining was greater in the chronic lithium-treated than in control preparations. Sodium nitroprusside produced similar relaxation in both groups. Chronic lithium administration can impair the endothelium-dependent relaxation of rat corpus cavernosum; NO availability might decrease after lithium administration and the cyclooxygenase pathways might have a role in this effect.

Chronic lithium chloride administration to rats elevates glucose metabolism in wide areas of brain, while potentiating negative effects on metabolism of dopamine D2-like receptor stimulation

The regional cerebral metabolic rate for glucose (rCMRglc) can be imaged in vivo as a marker of brain functional activity. The effects of chronic lithium administration on baseline values of rCMRglc and values in response to administration of dopamine D2-like receptor agonists have not been examined in humans or rats. Knowing these effects may elucidate and localize the therapeutic action of lithium in bipolar disorder. In unanesthetized rats, we used the 2-deoxy-D-glucose (2-DG) technique to image the effects of a 6-week control diet or LiCl diet sufficient to produce a plasma lithium concentration therapeutically relevant to bipolar disorder, on rCMRglc at baseline and in response to the dopaminergic D2-like receptor agonist, quinpirole (1 mg/kg i.v.), or to i.v. saline. Baseline rCMRglc was significantly elevated in 30 of 81 brain regions examined, in LiCl diet compared with control diet rats. Affected were visual and auditory structures, frontal cortex, amygdala, hippocampus, nucleus accumbens, caudate-putamen, interpeduncular nucleus, and substantia nigra. Acute quinpirole significantly decreased rCMRglc in four areas of the caudate-putamen in control diet rats, and in these and 19 additional brain areas in LiCl-fed rats. In unanesthetized rats, chronic lithium administration widely upregulates baseline rCMRglc and potentiates the negative effects on rCMRglc of D2-like receptor stimulation. The baseline elevation may relate to lithium's reported ability to increase auditory and visual evoked responses in humans, whereas lithium's potentiation of quinpirole's negative effects on rCMRglc may be related to its therapeutic efficacy in bipolar disorder.

Chronic Lithium Administration to Rats Selectively Modifies 5-HT2A/2C Receptor-Mediated Brain Signaling Via Arachidonic Acid

The effects of chronic lithium administration on regional brain incorporation coefficients k* of arachidonic acid (AA), a marker of phospholipase A2 (PLA2) activation, were determined in unanesthetized rats administered i.p. saline or 1 mg/kg i.p. (+/-)-1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane hydrochloride (DOI), a 5-HT2A/2C receptor agonist. After injecting [1-(14)C]AA intravenously, k* (brain radioactivity/integrated plasma radioactivity) was measured in each of 94 brain regions by quantitative autoradiography. Studies were performed in rats fed a LiCl or a control diet for 6 weeks. In the control diet rats, DOI significantly increased k* in widespread brain areas containing 5-HT2A/2C receptors. In the LiCl-fed rats, the significant positive k* response to DOI did not differ from that in control diet rats in most brain regions, except in auditory and visual areas, where the response was absent. LiCl did not change the head turning response to DOI seen in control rats. In summary, LiCl feeding blocked PLA2-mediated signal involving AA in response to DOI in visual and auditory regions, but not generally elsewhere. These selective effects may be related to lithium's therapeutic efficacy in patients with bipolar disorder, particularly its ability to ameliorate hallucinations in that disease.

Effects of chronic lithium administration on rat brain phosphatidylinositol cycle constituents, membrane phospholipids and amino acids

There is evidence linking affective disorders and their treatment to alterations in membrane phospholipid metabolism, the phosphatidylinositol (PtdIns) second messenger cycle and brain excitatory and inhibitory amino acids. This study examines lithium effects on rat brain metabolites associated with the above systems and their reversal by myo-inositol. Thirty rats were treated for 14 days with i.p. lithium, saline or lithium plus myo-inositol. 1H, 31P and 7Li NMR were used to measure brain metabolites. Lithium, administered alone or with myo-inositol, resulted in brain lithium concentrations of approximately 0.6 microM/gram brain tissue. Brain myo-inositol was unchanged when lithium was co-administered with myo-inositol. Lithium increased brain inositol-1-phosphate (I1P) by 98% compared with saline and this effect was not attenuated by the addition of myo-inositol. Lithium treatment decreased phosphatidylserine (PtdSer) and PtdIns by 3% and 8%, respectively. Lithium also decreased taurine levels by 8% and increased aspartate levels by 9%. The above effects of lithium on PtdSer, PtdIns and taurine were attenuated or abolished by the co-administration of myo-inositol. Lithium alters levels of key membrane phospholipids and appears to affect the balance between inhibitory and excitatory amino acids in rat brain. Co-administration of myo-inositol attenuates some of these lithium effects on brain metabolites.

Effects of chronic lithium administration on rat brain phosphatidylinositol cycle constituents, membrane phospholipids and amino acids

Effects of chronic lithium administration on rat brain phosphatidylinositol cycle constituents, membrane phospholipids and amino acids

Effect of chronic lithium administration on endothelium-dependent relaxation in rat aorta.

1. The effects of chronic lithium administration on the relaxant responses of rat thoracic aortic rings in the presence of indomethacin (a cyclo-oxygenase inhibitor) and/or NG-nitro-L-arginine (L-NOARG; a nitric oxide synthase inhibitor) to acetylcholine (ACh) or sodium nitroprusside were investigated in the present study. 2. Acetylcholine produced a concentration-dependent relaxation in vessels precontracted by phenylephrine (PE), while in lithium-treated rats the maximal relaxation was significantly increased. 3. Indomethacin (20 mumol/L) significantly potentiated the ACh-induced relaxation in lithium-treated and control rats. 4. NG-Nitro-L-arginine (1 mumol/L) decreased the ACh-induced relaxation in both control and lithium-treated rats. In contrast, indomethacin (20 mumol/L) reversed the inhibitory effect of L-NOARG. 5. Sodium nitroprusside produced similar concentration-dependent relaxations of vessels from both control and lithium-treated rats, which was not affected by indomethacin. In endothelium-denuded rings, indomethacin (20 mumol/L) caused a rightward shift in the concentration-contraction curve to PE. 6. These data support evidence for a possible increase in endothelium-dependent relaxation induced by ACh during long-term administration of lithium in rat aortic rings.

85 kDa cytosolic phospholipase A2 is a target for chronic lithium in rat brain.

The mechanism by which chronic lithium exerts its therapeutic effect in brains of bipolar patients is not known. One possibility, suggested by our demonstration in the rat brain, is that chronic lithium inhibits turnover of arachidonic acid (AA) by reducing the activity of an AA-specific phospholipase A2 (PLA2). To test this further, mRNA levels of two AA-specific PLA2s, cytosolic PLA2 (cPLA2) type IV and intracellular PLA2 (iPLA2) type VIII, and protein level of cPLA2 were quantified in the brain of rats given lithium for 6 weeks. Chronic lithium markedly reduced brain mRNA and protein level of cPLA2, but had no effect on mRNA level of iPLA2. These results suggest that the final common path effect of chronic lithium administration is to reduce turnover of AA in brain by down-regulating cPLA2.

The effect of lithium on methamphetamine-induced regional Fos protein expression in the rat brain.

Lithium has been used widely for the treatment of manic states. Since amphetamines produce effects in humans similar to the symptoms of idiopathic mania, amphetamine administration to animals has been proposed as a model of this condition. To investigate the neurobiologic substrates of the antimanic effects of chronic lithium administration, we investigated its effects on methamphetamine-induced regional Fos protein expression in the rat brain. Chronic lithium administration (14 days; serum lithium concentration, 0.41+/-0.02 mEq/l) significantly reduced the number of neuronal nuclei showing immunoreactivity induced by methamphetamine (2mg/kg) in the prefrontal cortex, caudate/putamen, nucleus accumbens, and central nucleus of the amygdala. These results indicate the structural basis in CNS which is responsible for the antimanic effect of lithium.

Region-specific effects of chronic lithium administration on neuropeptide Y and somatostatin mRNA expression in the rat brain

The aim of this study was to examine the effects of 4-week lithium (Li +) food supplementation on neuropeptide mRNA expression in the rat brain. In situ hybridisation was used to determine the effects on the expression of neuropeptide Y (NPY) and somatostatin (SS) mRNA. Increases in NPY mRNA levels were seen in the hippocampus, layers II–III of the entorhinal cortex, nucleus accumbens shell and in the medial caudate-putamen. Increases in SS mRNA expression were seen in the layers IV–VI of the entorhinal cortex and in the lateral caudate putamen. Thus, Li + appears to affect discrete populations of NPY and SS mRNA expressing neurons, with possible relevance to beneficial effects of Li + in affective disorders.

Regulation of endogenous ADP-ribosylation by acute and chronic lithium in rat brain.

In the present study, we investigated the effects of lithium on endogenous ADP-ribosylation in rat brain. It was found that addition of lithium in vitro inhibits endogenous ADP-ribosylation activity in extracts of frontal cortex at therapeutically relevant concentrations. Inhibition is observed at concentrations as low as 0.3 mM and is maximal at 1 mM when 50% inhibition is obtained. A similar degree of inhibition of endogenous ADP-ribosylation was observed for all substrate proteins identified, including Gs alpha, suggesting that lithium's effect may be achieved at the level of ADP-ribosyltransferases and not specific substrate proteins. In contrast to lithium, chloride salts of sodium and potassium do not alter endogenous ADP-ribosylation activity in frontal cortex. To assess the possible in vivo relevance of this in vitro action of lithium, we studied the effect of chronic lithium administration on levels of endogenous ADP-ribosylation in frontal cortex. It was found that chronic lithium treatment, in contrast to the inhibitory effect of the drug in vitro, produced a > 35% increase in endogenous ADP-ribosylation activity. A similar degree of increase was observed for all of the substrate proteins identified. These novel findings raise the possibility that certain endogenous ADP-ribosyltransferases are among the acute targets of lithium in the brain and that adaptations in these enzymes may be part of the mechanisms underlying lithium's long-term effects on brain function.

Regional and subcellular localization of Li+ and other cations in the rat brain following long-term lithium administration.

Rats were given LiCl in their diet (40 mmol/kg dry weight) for at least 3 months to elucidate the regional and subcellular localization of Li+ in the brain as well as the effect of chronic lithium administration on the distribution of other cations. At steady-state the mean concentrations of Li+ were 0.66 mmol/kg wet weight in the whole brain and 0.52 mM in plasma. The tissue/plasma concentration ratio exceeded unity in all anatomical regions. No region showed excessive accumulation of Li+. Whole brain or regional contents of Na+ or K+ were unaffected by lithium treatment. Subcellular Li+ localization was demonstrated in nuclear, crude mitochondrial, and microsomal fractions of whole brain homogenate. Subfractionation of the crude mitochondrial fraction revealed energy-independent intrasynaptosomal and intramitochondrial Li+ and K+ localization at 0-4 degrees C. Li+ administered in vivo disappeared within 10 min from synaptosomes incubated at 37 degrees C. Li+ added in vitro at 1 mM attained a synaptosomal steady-state concentration within 30 min at 37 degrees C. In control rats, synaptosomal concentrations and synaptosomal/medium concentration gradients of cations paralleled their respective in vivo concentrations and gradients. Lithium treatment caused synaptosomal depletion of K+ and Mg2+ and hence probably partial membrane depolarization. Addition of 1 mM Li+ in vitro also caused synaptosomal Mg2+ depletion. The results indicate that Li+ is "accumulated" in brain sediments and synaptosomes following its long-term treatment. The estimated intracellular and intrasynaptosomal Li+ concentrations are lower than predicted by passive distribution according to the Nernst equation, evidencing active extrusion of Li+.

Hypoproteinemia Related with Chronic Lithium Therapy in Two Patients

We present here two cases of reversible hypoproteinemia which could have occurred as an adverse effect of chronic lithium administration. In the present cases, protein losing a renal dysfunction, liver dysfunction and malabsorption syndrome were not observed, and the relationship between their dietary volume and serum protein levels was poor. The mechanism of hypoproteinemia in these cases was not identified from previously obtained data. We suggested that this type of hypoproteinemia might be a new adverse effect of lithium.

Effects of chronic lithium administration on brain weights, acetylcholinesterase activity and learning ability in rats

In order to test the effects of chronic lithium (Li) administration on learning and memory, 21 day old rats were subjected to different degrees of environmental stimulation (enriched condition, EC and impoverished condition, IC) with and without Li for 144 days. Li was administered with food (2.18 mEq/Kg weight/day). Average plasma Li concentration at the end of the experiment was 0.41 ± 0.04 μEq/ml. Both Li treatment and the environmental condition showed an overall significant effect on the cortex/subcortex weight ratio and learning ability index, but not on AChE activity in occipital cortex. A similar pattern of brain Li distribution was observed in both EC-Li and IC-Li, with occipital cortex having the highest levels. Li tissue/protein/plasma ratio was higher in EC than in IC, in all the brain areas studied. Other organs (liver and kidney) did not show EC-IC differences in the tissue/protein/plasma Li ratio.