Lithium, an old and invaluable psychiatric therapy, is still the best treatment option in several clinical circumstances, including acute mania, bipolar and unipolar recurrent mood disorders, suicidal ideation and behavior, recurrent or chronic unipolar depression that has not responded to other treatments, aggressive or impulsive behavior and alcoholism, especially when an affective component is manifest. However, lithium has a narrow therapeutic index and is associated with many serious acute and long-term side effects. Furthermore, monitoring requirements, i.e., frequent blood draws and frequent visits, discourage lithium use. Therefore, the drug is underused. Full awareness of lithium side effects and competence to minimize them is the only contrast to this ominous trend. Renal side effects are frequent in the course of lithium treatment. Although not serious in the large majority of cases, they may seldom become severe and result in chronic renal failure and end stage renal disease. The aim of the paper is reviewing the renal safety profile of lithium and the suggested strategies in the management of the lithium associated renal side effects.