title: A decision analysis of long-term lithium treatment and the risk of renal failure.
abstract: OBJECTIVE
  To establish whether lithium or anticonvulsant should be used for maintenance treatment for bipolar affective disorder (BPAD) if the risks of suicide and relapse were traded off against the risk of end-stage renal disease (ESRD).
  
  
  METHODS
  Decision analysis based on a systematic literature review with two main decisions: (1) use of lithium or at treatment initiation and (2) the potential discontinuation of lithium in patients with chronic kidney disease (CKD) after 20 years of lithium treatment. The final endpoint was 30 years of treatment with five outcomes to consider: death from suicide, alive with stable or unstable BPAD, alive with or without ESRD.
  
  
  RESULTS
  At the start of treatment, the model identified lithium as the treatment of choice. The risks of developing CKD or ESRD were not relevant at the starting point. Twenty years into treatment, lithium still remained treatment of choice. If CKD had occurred at this point, stopping lithium would only be an option if the likelihood of progression to ESRD exceeded 41.3% or if anticonvulsants always outperformed lithium regarding relapse prevention.
  
  
  CONCLUSIONS
  At the current state of knowledge, lithium initiation and continuation even in the presence of long-term adverse renal effects should be recommended in most cases.
authors.affiliation: Division of Psychiatry, Department of Clinical Sciences, Umeå University, Sweden. uwerneke@gmail.com
authors.forename: U
authors.initials: U
authors.lastname: Werneke
authors.forename: M
authors.initials: M
authors.lastname: Ott
authors.forename: E Salander
authors.initials: ES
authors.lastname: Renberg
authors.forename: D
authors.initials: D
authors.lastname: Taylor
authors.forename: B
authors.initials: B
authors.lastname: Stegmayr
mesh_terms: D000928:Antidepressive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D018692:Antimanic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001714:Bipolar Disorder / Q000188:drug therapy*; D004305:Dose-Response Relationship, Drug; D006801:Humans; D007676:Kidney Failure, Chronic / Q000139:chemically induced* / Q000453:epidemiology; D007677:Kidney Function Tests; D016651:Lithium Carbonate / Q000009:adverse effects / Q000627:therapeutic use*; D055502:Secondary Prevention; D013405:Suicide / Q000706:statistics & numerical data; D013997:Time Factors; D016896:Treatment Outcome; D000092864:Suicide Prevention
chemical_list: D000928:Antidepressive Agents; D018692:Antimanic Agents; D016651:Lithium Carbonate