Samih H. Nasr, MD, Glen S. Markowitz, MD, and Vivette D. D’Agati, MD. Department of Pathology, Columbia University, New York, NY, USA. The patient s father had a history of bipolar disorder and renal insufficiency, reportedly due to chronic lithium toxicity. The patient s medications included lithium 300 mg TID and venlafaxine hydrochloride 150 mg QD. Serum lithium levels were repeatedly within the therapeutic range. Physical examination revealed a BP of 170/80 and 2+ edema. Eight patients had acute renal failure that was attributed to acute tubular necrosis in 2, pre-renal azotemia in 5, and concurrent acute lithium intoxication in 1. Of the 18 patients who underwent diagnostic renal biopsy, 13 had minimal change disease, 2 membranous glomerulopathy, 2 focal segmental glomerulosclerosis, and 1 diffuse glomerulosclerosis and interstitial fibrosis. Sixteen patients had complete remission of nephrotic syndrome after lithium discontinuation, generally within 2-6 weeks, and only 4 of the 16 patients were treated with steroids. Importantly, nephrotic syndrome recurred in all 4 patients in whom lithium was re-introduced as a result of worsening of symptoms of bipolar disorder (4). The pathogenesis of lithium-induced minimal change disease is unknown but may involve enhanced permeability factor release by T cells through amplification of second messenger pathways (5).
