Hemodialysis for lithium poisoning. Lavonas EJ, Buchanan J. Cochrane Database Sys Rev 2015 Sep 16 [Epub ahead of print]
At a session at the ACEP Scientific Assembly last year, Jerry remarked: “Guidelines should regularly conclude that there is no evidence. Full stop.”
I really like this Cochrane review of hemodialysis in lithium poisoning because [SPOILER ALERT] that is exactly what the authors conclude. They note that although hemodialysis undoubtedly increases clearance of lithium, there is no agreement as to whether this enhanced elimination actually improves clinical outcome.
In an attempt to answer that question, they used explicit criteria to review the literature, looking for randomized controlled trials that studied the effect of extracorporeal techniques (hemodialysis, hemofiltration, and continuous renal replacement methods) on outcomes in patients with lithium toxicity.
[T]here is no evidence from randomized controlled trials to support nor refute the use of hemodialysis in the management of patients with lithium poisoning.
This seems right on, and is useful counterpoint to the recent ExTRIP review that, based on no logic or evidence that was apparent to this reader, came up with precise lithium levels for which to recommend extracorporeal treatment.
Although this Cochrane review included no studies, the paper is worth reading for the general discussion of lithium toxicity and the logical (if not evidentiary) basis for hemodialysis.