Renal replacement therapy associated with lithium nephrotoxicity in Australia

In reply: We welcome valuable comments in response to our article on lithium and end-stage renal disease (ESRD).1 This is an area that warrants further discussion and additional data. Our study, the first comprehensive epidemiological analysis of the link between lithium nephropathy and ESRD in any country, indicated a progressive increase in the problem in Australia between 1991 and 2011.

We have had difficulty determining whether this increase was due to increased lithium use, given that ESRD is usually associated with prolonged exposure (typically 20 years or more) and that complete data on lithium use in Australia are only readily available since 1995.

We accept that lithium is often an effective mood stabiliser that only sometimes causes toxicity. However, we believe that prescription of a drug that can propel people toward permanent dialysis or transplantation requires caution. We therefore applaud Saboisky's practice as a psychiatrist of conjointly managing patients with a nephrologist. We do similarly.

We also endorse the call for more accurate diagnosis of renal disease, especially as bipolar disorder is often associated with risk factors such as smoking, obesity and poor diet. Our study showed that few patients with suspected lithium-induced kidney disease undergo renal biopsy, and we suggest that nephrologists could consider modifying this deficiency.