Re: [Renaliste] Diabète insipide

Mar 23 Jan 18:07:39 CET 2007

Voici la veritable reponse a Hamid

"
1: J Am Soc Nephrol. 2000 Aug;11(8):1439-48.  Links 

Lithium nephrotoxicity: a progressive combined glomerular and tubulointerstitial nephropathy.
  a.. Markowitz GS, 
  b.. Radhakrishnan J, 
  c.. Kambham N, 
  d.. Valeri AM, 
  e.. Hines WH, 
  f.. D'Agati VD. 
Department of Pathology, Columbia Presbyterian Medical Center, New York, NY 10032, USA.

This study examines the clinical features, pathologic findings, and outcome of 24 patients with biopsy-proven lithium toxicity. 

The patient population was 50% male, 87.5% Caucasian, and had a mean age of 42.5 yr (range, 26 to 57). 

Mean duration of lithium therapy for bipolar disorder was 13.6 yr (range, 2 to 25). All patients were biopsied for renal insufficiency (mean serum creatinine 2.8 mg/dl; range, 1.3 to 8.0), with associated proteinuria >1.0 g/d in 41.7%. Nephrotic proteinuria (>3.0 g/d) was present in 25%. Other features included nephrogenic diabetes insipidus in 87% and hypertension in 33.3%. Renal biopsy revealed a chronic tubulointerstitial nephropathy in 100%, with associated cortical and medullary tubular cysts (62.5%) or dilatation (33.3%). All of the renal cysts stained for epithelial membrane antigen, while 51.4% stained with lectin Arachis hypogaea, and only 3.8% stained with Tetragonolobus purpureas, indicating they originated from distal and collecting tubules. The degree of tubular atrophy and interstitial fibrosis was graded as severe in 58.3%, moderate in 37.5%, and mild in 4.2% of cases. There was a surprisingly high prevalence of focal segmental glomerulosclerosis (50%) and global glomerulosclerosis (100%), sometimes of equivalent severity to the chronic tubulointerstitial disease.

 The significant degree of foot process effacement (mean 34%, five of 14 cases with >50%) suggests a potential direct glomerular toxicity.

 Focal segmental glomerulosclerosis correlated with proteinuria >1.0 g/d (P = 0.0014, Fisher exact test). Despite discontinuation of lithium, seven of nine patients with initial serum creatinine values >2.5 mg/dl progressed to end-stage renal disease (ESRD). Only three patients, all with initial serum creatinine <2.1 mg/dl, had subsequent improvement in renal function. By Kaplan-Meier survival analysis, the only significant predictor of progression to ESRD was serum creatinine >2.5 mg/dl at biopsy (P = 0. 008). In conclusion, lithium nephrotoxicity primarily targets distal and collecting tubules, with a higher incidence of proteinuria and associated glomerular pathology than recognized previously. 

Renal dysfunction is often irreversible despite lithium withdrawal, and early detection is essential to prevent progression to ESRD.

PMID: 10906157 [PubMed - indexed for MEDLINE]

Amicalement a toi Hamid

Jean-Marie

----- Original Message ----- 
From: "NEFTI Hamid" <hanefti at ch-macon.fr>
To: "Liste de discussion des néphrologues francophones" <renaliste at nephrodial.org>
Sent: Tuesday, January 23, 2007 3:43 PM
Subject: Re: [Renaliste] Diabète insipide

Message de la liste nephrologique francophone RENALISTE
----------------------------------
J'ai également la notion que le lithium entraîne un diabète insipide plutôt 
néphrogénique, donc pitressino-insensible. 

De plus, se pose la question de l'imputabilité au lithium de l'insuffisance 
rénale; je crois savoir qu'il existe desnéphropathies chroniques liées à la 
toxicité rénale au long cours des sels de lithium, en particulier des 
hyalinoses segmentaires et focales.

Se pose donc la question de rechercher, avec le psychiatre, une alternative 
au Lithium (type Dépamide ou autre), ce qui n'est pas toujours aisé à 
trouver...

Dr Hamid NEFTI
Néphrologue
CHG de Mâcon (71)
hanefti at ch-macon.fr

-----Original Message-----
From: "Jean-Claude Stolear" <Jean-Claude.Stolear at rhms.be>
To: renaliste at nephrodial.org
Date: Tue, 23 Jan 2007 10:02:26 +0100
Subject: [Renaliste] Diabète insipide

> Message de la liste nephrologique francophone RENALISTE
> ----------------------------------

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