Figure 1
Right kidney
Ultrasound (longitudinal section) of the right kidney/liver showing multiple hyperechoic foci within the right kidney (white arrows).
Lithium Nephropathy
SectionUroradiology & genital male imaging
Case TypeClinical Cases
AuthorsDr Sunit Davda, Dr Jann Yee Chin, Dr Anju Sahdev
Connected authors
49 years, male
Clinical History
49-year-old male patient with recent splenectomy and a background of hypogammaglobulinaemia, COPD, schizophrenia, hypertension and hypothyroidism. The patient was having a routine post-operative ultrasound when this characteristic appearance on ultrasound was noted incidentally on the kidneys. On review of the biochemistry the Creatinine has been persistently mildly elevated.
Imaging Findings
Figure 1 - Ultrasound (longitudinal section) of the right kidney/liver.
Figure 2 - Ultrasound (longitudinal section) of the left kidney.
Figures 1 and 2 demonstrate numerous punctate echogenic foci and microcysts, mainly within the cortex of the kidney
Figure 3 - 5mm axial CT slice through the level of the kidneys
Figure 4 - Coronal reformatted images of the Chest, Abdomen & Pelvis.
Figures 3 and 4 demonstrate the multiple microcysts bilaterally, predominantly within the cortex.
Figure 2 - Ultrasound (longitudinal section) of the left kidney.
Figures 1 and 2 demonstrate numerous punctate echogenic foci and microcysts, mainly within the cortex of the kidney
Figure 3 - 5mm axial CT slice through the level of the kidneys
Figure 4 - Coronal reformatted images of the Chest, Abdomen & Pelvis.
Figures 3 and 4 demonstrate the multiple microcysts bilaterally, predominantly within the cortex.
Discussion
Chronic lithium use in bipolar and other mental health disorders has been associated with various forms of renal toxicity, the most common being nephrogenic diabetes insipidus [1]. Rarely, lithium use can also result in nephrotic syndrome, renal tubular acidosis and nephropathies. The most common form of chronic nephropathy from lithium use is tubulointerstitial nephropathy. This is characterised by microcysts (1-2mm) and interstitial fibrosis on renal biopsy [2]. The degree of fibrosis is related to duration and cumulative dose of lithium [3].
The onset of renal impairment is usually gradual in patients on long term lithium. The degree of renal impairment is usually mild, however it slowly progresses onto end stage renal failure [3].
On ultrasound, there is a characteristic appearance of microcysts with punctate echogenic foci, which are classically uniform in size and found within both the cortex and medulla [4]. The imaging findings can also be appreciated on CT where they appear as hypodense microcysts occasionally displaying micro-calcification. On MRI, T2 weighted imaging shows small hyperintense round lesions within the medulla and cortex [5].
The treatment is cessation of lithium therapy, however, renal impairment may be progressive [2].
The onset of renal impairment is usually gradual in patients on long term lithium. The degree of renal impairment is usually mild, however it slowly progresses onto end stage renal failure [3].
On ultrasound, there is a characteristic appearance of microcysts with punctate echogenic foci, which are classically uniform in size and found within both the cortex and medulla [4]. The imaging findings can also be appreciated on CT where they appear as hypodense microcysts occasionally displaying micro-calcification. On MRI, T2 weighted imaging shows small hyperintense round lesions within the medulla and cortex [5].
The treatment is cessation of lithium therapy, however, renal impairment may be progressive [2].
Differential Diagnosis List
Lithium tubulointerstitial nephropathy
Autosomal dominant polycystic kidney disease
Glomerolcystic kidney disease
Final Diagnosis
Lithium tubulointerstitial nephropathy
References
[1] Boton R, Gaviria M, Batlle DC (1987) Prevalence, pathogenesis, and treatment of renal dysfunction associated with chronic lithium therapy. Am J Kidney Dis Nov;10(5):329-45 (PMID: 3314489)
[2] Markowitz GS, Radhakrishnan J, Kambham N, Valeri AM, Hines WH, D\'Agati VD (2000) Lithium nephrotoxicity: a progressive combined glomerular and tubulointerstitial nephropathy. J Am Soc Nephrol Aug;11(8):1439-48 (PMID: 10906157)
[3] Presne C, Fakhouri F, Noël LH, Stengel B, Even C, Kreis H, Mignon F, Grünfeld JP. (2003) Lithium-induced nephropathy: Rate of progression and prognostic factors. Kidney Int Aug;64(2):585-92 (PMID: 12846754)
[4] Di Salvo DN, Park J, Laing FC (2012) Lithium nephropathy: unique sonographic findings. J Ultrasound Med Apr;31(4):637-44 (PMID: 22441921)
[5] Farres MT, Ronco P, Saadoun D, Remy P, Vincent F, Khalil A, Le Blanche AF (2003) Chronic lithium nephropathy: MR imaging for diagnosis. Radiology Nov;229(2):570-4 (PMID: 14595154)
Case information
| URL: | https://eurorad.org/case/13087 |
| DOI: | 10.1594/EURORAD/CASE.13087 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Left kidney
Ultrasound (longitudinal section) of the left kidney demonstrating hyperechoic foci within the left kidney (white arrows).
Figure 3
Coronal CT
Coronal reformatted CT images of the chest, abdomen & pelvis. Hypodense microcysts demonstrated bilaterally (red arrows).
Figure 4
Axial CT
5mm Axial CT images at the level of both kidneys. Hypodense cysts demonstrated within both kidneys (red arrows).
Right kidney
Ultrasound (longitudinal section) of the right kidney/liver showing multiple hyperechoic foci within the right kidney (white arrows).
Barts Health NHS Trust
Barts Health NHS Trust
Left kidney
Ultrasound (longitudinal section) of the left kidney demonstrating hyperechoic foci within the left kidney (white arrows).
Barts Health NHS Trust
Barts Health NHS Trust
Coronal CT
Coronal reformatted CT images of the chest, abdomen & pelvis. Hypodense microcysts demonstrated bilaterally (red arrows).
Barts Health NHS Trust
Barts Health NHS Trust
Axial CT
5mm Axial CT images at the level of both kidneys. Hypodense cysts demonstrated within both kidneys (red arrows).
Barts Health NHS Trust
Barts Health NHS Trust