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Chen J. Is there a causal relationship between hypothyroidism and hyponatremia? Ther Adv Endocrinol Metab 2023; 14:20420188231180983. [PMID: 37435527 PMCID: PMC10331073 DOI: 10.1177/20420188231180983] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 05/19/2023] [Indexed: 07/13/2023] Open
Abstract
Hyponatremia is one of the most common lab abnormalities seen in clinical practice. It has become widely accepted that hypothyroidism is a cause of euvolemic hyponatremia. The primary mechanism is thought to be due to impaired free water excretion and changes in sodium handling in the kidney. However, the clinical studies are conflicting and do not definitively confirm the association between hypothyroidism and hyponatremia. Therefore, if severe hyponatremia occurs in a patient without myxedema coma, other potential etiologies should be sought.
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2
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Alqahtani HA, Almagsoodi AA, Alshamrani ND, Almalki TJ, Sumaili AM. Common Electrolyte and Metabolic Abnormalities Among Thyroid Patients. Cureus 2021; 13:e15338. [PMID: 34235017 PMCID: PMC8241464 DOI: 10.7759/cureus.15338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2021] [Indexed: 11/05/2022] Open
Abstract
The prevalence of thyroid diseases is high in the general population and causes serious abnormalities and disorders that can affect the quality of life. Many complications can result from poor or inappropriate management of the disease, leading to serious cardiovascular and metabolic complications. In the present review study, we aim to discuss the effect of thyroid diseases on metabolic and electrolyte abnormalities and the potential correlation with some common disorders. Evidence from previous studies has demonstrated that thyroid dysfunctions hugely affect the metabolism of glucose in the bodies of the affected patients, which can lead to the development of both type 1 and 2 diabetes mellitus (DM). Hyperthyroidism can lead to the development of impaired glucose tolerance and secondary diabetes mellitus. These include an increased glycogenolysis and gluconeogenesis process, increased intestinal absorption of glucose, and secondary ketogenesis and lipolysis, which will subsequently affect the functions of the insulin-secreting cells of the pancreas. Evidence showed that thyroid diseases are associated with the development of obesity and metabolic syndrome, and the management for these modalities should involve prior management of underlying thyroid diseases. Efforts should be made to adequately manage these cases with concomitant approaches to achieve the best clinical outcomes.
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Niri T, Horie I, Ando T, Kawahara H, Ueda M, Eto M, Sako A, Ikeuchi Y, Nakao T, Nakashima Y, Shigeno R, Ito A, Nozaki A, Haraguchi A, Natsuda S, Sagara I, Akazawa S, Kamada A, Imaizumi M, Abiru N, Usa T, Kawakami A. RENAL FUNCTION AND PLASMA RENIN ACTIVITY AS POTENTIAL FACTORS CAUSING HYPERKALEMIA IN PATIENTS WITH THYROID CARCINOMA UNDERGOING THYROID HORMONE WITHDRAWAL FOR RADIOACTIVE IODINE THERAPY. Endocr Pract 2020; 26:197-206. [PMID: 31652100 DOI: 10.4158/ep-2019-0374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Objective: Hypothyroidism is not commonly considered a cause of hyperkalemia. We previously reported that hyperkalemia was observed mainly in elderly patients treated with renin-angiotensin-aldosterone system (RAS) inhibitors when levothyroxine treatment was withdrawn for the thyroidectomized patients with thyroid carcinoma to undergo radioactive iodine treatment. Here, we investigated whether acute hypothyroidism causes hyperkalemia in patients who were not treated with RAS inhibitors. We also investigated factors influencing potassium metabolism in hypothyroid patients. Methods: We conducted a single-center, prospective cohort study of 46 Japanese patients with thyroid carcinoma undergoing levothyroxine withdrawal prior to radioiodine therapy. All patients were normokalemic before levothyroxine withdrawal. Blood samples were analyzed 3 times: before, and at 3 and 4 weeks after levothyroxine withdrawal. We investigated factors that may be associated with the elevation of serum potassium levels from a euthyroid state to a hypothyroid state. Results: None of the patients developed symptomatic hyperkalemia. The mean serum potassium level was significantly higher at 4 weeks after levothyroxine withdrawal compared to baseline. The serum sodium levels, the estimated glomerular filtration rate (eGFR), and the plasma renin activity (PRA) decreased significantly as hypothyroidism advanced. In contrast, the plasma levels of adrenocorticotropic hormone, cortisol, aldosterone, and antidiuretic hormone were not changed, while serum thyroid hormone decreased. At 4 weeks after their levothyroxine withdrawal, the patients' serum potassium values were significantly correlated with the eGFR and the PRA. Conclusion: Acute hypothyroidism can cause a significant increase in the serum potassium level, which may be associated with a decreased eGFR and decreased circulating RAS. Abbreviations: ACTH = adrenocorticotropic hormone; ADH = antidiuretic hormone; ATPase = adenosine triphosphatase; eGFR = estimated glomerular filtration rate; HbA1c = glycated hemoglobin; K+ = potassium; Na+ = sodium; PRA = plasma renin activity; RAS = renin-angiotensin-aldosterone system; T4 = thyroxine; TSH = thyroid-stimulating hormone.
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4
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Zhou N, Yang C. A case of extreme hyponatremia without neurologic symptoms. Clin Case Rep 2019; 7:1874-1879. [PMID: 31624600 PMCID: PMC6787862 DOI: 10.1002/ccr3.2383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/02/2019] [Accepted: 07/28/2019] [Indexed: 12/25/2022] Open
Abstract
Our case report highlights that profound hyponatremia with sodium level 101 mmol/L could have no CNS symptoms, and drugs and endocrine disorders are relatively common causes and should be considered in the differential diagnosis of hyponatremia. Standard dose trimethoprim-sulfamethoxazole-induced hyponatremia is rare but still worth close attention in clinical practice.
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Affiliation(s)
- Na Zhou
- Kidney Research ClinicUniversity of Utah School of MedicineSalt Lake CityUtah
| | - Chang Yang
- Apogee Hospital MedicinePassavant Area HospitalJacksonvilleIllinois
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5
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Abstract
Although removal of pituitary tumors yields excellent surgical outcomes, perturbations in the hypothalamic-pituitary axis are not uncommon. Careful assessment of postoperative hormone status with supplementation or further medical therapy is critical to successful outcomes. Although many centers routinely use perioperative steroids, they can be associated with worse outcomes in the absence of intact preoperative adrenal function or damage to the pituitary gland or stalk during surgery. Postoperative assessment of prolactin, cortisol, and growth hormone can be prognostic of surgical cure. Hormonal axes should be reevaluated routinely several weeks after surgery, because longitudinal monitoring is important for surgical and medical outcomes.
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Affiliation(s)
- Anshu Buttan
- Department of Medicine, Division of Endocrinology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Becker B-131, Los Angeles, CA 90048, USA
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, 127 S San Vicente Boulevard, A6600, Los Angeles, CA 90048, USA.
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Diker-Cohen T, Rozen-Zvi B, Yelin D, Akirov A, Robenshtok E, Gafter-Gvili A, Shepshelovich D. Endocrinopathy-induced euvolemic hyponatremia. Intern Emerg Med 2018; 13:679-688. [PMID: 29790126 DOI: 10.1007/s11739-018-1872-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 05/06/2018] [Indexed: 10/16/2022]
Abstract
Euvolemic hyponatremia results from either the syndrome of inappropriate antidiuretic hormone secretion (SIADH), hypothyroidism, or adrenal insufficiency. Furthermore, the criteria for diagnosis of SIADH entail the exclusion of hypothyroidism and hypoadrenalism. We aim to assess the yield of euvolemic hyponatremia workup focusing on underlying endocrinopathies in a real-world setting. A single-center retrospective study includes all patients diagnosed with euvolemic hyponatremia in a tertiary hospital between 1.1.2007 and 1.1.2013. Demographic, clinical, and laboratory data were collected from medical charts. Euvolemic hyponatremia was detected in 564 patients. Thyroid function was tested in 69% (391/564) and adrenal function was assessed in 29% (164/564) of cases. Endocrinopathy-induced euvolemic hyponatremia was diagnosed in nine (1.6%) patients: three patients were diagnosed with hypothyroidism-induced hyponatremia, three with adrenal insufficiency as an underlying cause, and three with central hypothyroidism and central hypoadrenalism. All nine had medical history and symptoms suggestive of endocrine deficiencies other than the hyponatremia, which resolved within 1-3 days after administration of hormone replacement therapy. Yield of performed workup for hypothyroidism and hypoadrenalism in euvolemic hyponatremia was low. However, in this real-world study, only a limited number of patients underwent a full ascertainment of hypoadrenalism and hypothyroidism, which was diagnosed only in patients with additional findings supportive of these endocrinopathies; a higher rate of undiagnosed endocrinopathies cannot be ruled out. As both hypoadrenalism and hypothyroidism are easily treatable, potentially life-threatening conditions, there are insufficient data to change current recommendation for their universal evaluation in patients with euvolemic hyponatremia.
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Affiliation(s)
- Talia Diker-Cohen
- Medicine A, Beilinson Hospital, Rabin Medical Center, 39 Jabotinski St, 49100, Petah-Tikva, Israel.
| | - Benaya Rozen-Zvi
- Department of Nephrology, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dana Yelin
- Medicine A, Beilinson Hospital, Rabin Medical Center, 39 Jabotinski St, 49100, Petah-Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Akirov
- Institute of Endocrinology, Diabetes and Metabolism, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Robenshtok
- Institute of Endocrinology, Diabetes and Metabolism, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Gafter-Gvili
- Medicine A, Beilinson Hospital, Rabin Medical Center, 39 Jabotinski St, 49100, Petah-Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Shepshelovich
- Medicine A, Beilinson Hospital, Rabin Medical Center, 39 Jabotinski St, 49100, Petah-Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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Wolf P, Beiglböck H, Smaijs S, Wrba T, Rasoul-Rockenschaub S, Marculescu R, Gessl A, Luger A, Winhofer Y, Krebs M. Hypothyroidism and Hyponatremia: Rather Coincidence Than Causality. Thyroid 2017; 27:611-615. [PMID: 28351291 DOI: 10.1089/thy.2016.0597] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hypothyroidism is referred to be a rare but possible cause of hyponatremia. However, there is only poor evidence supporting this association. Since hyponatremia and hypothyroidism are both common conditions themselves, co-occurrence does not have to be causal. METHODS To address a potential relationship, a retrospective analysis of data from the Division of Endocrinology of the Medical University of Vienna from April 2004 to February 2016 was performed. A total of 8053 hypothyroid patients (48 ± 18 years of age; 71% female) with thyrotropin >4.0 μIU/mL and available blood tests for free thyroxine and sodium (Na+) within maximal ± seven days were included and screened for hyponatremia. Patients' records were searched for concomitant disease and medication when Na+ concentration was <135 mmol/L. RESULTS Hyponatremia was present in 448/8053 (5.56%) patients. Analysis of medical history revealed potential alternative causes of hyponatremia in 442/448 (98.88%) patients (i.e., side effects of medication, concomitant underlying disease, or other endocrine disorders). This distribution did not differ between patients suffering from clinical or subclinical hypothyroidism. No case of clinically relevant hyponatremia (Na+ < 130 mmol/L), present in 111/448 (24.78%) patients could be attributed only to hypothyroidism. There was a very weak but statistically significant trend toward a positive association between thyroid function and serum Na+ levels (Na+/thyrotropin: R = 0.022, p = 0.046; Na+/free thyroxine: R = -0.047, p < 0.001). CONCLUSION The results suggest that hypothyroid patients with moderate to severe hyponatremia often have other potential explanations for their low serum Na+ concentrations in routine care.
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Affiliation(s)
- Peter Wolf
- 1 Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna , Vienna, Austria
| | - Hannes Beiglböck
- 1 Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna , Vienna, Austria
| | - Sabina Smaijs
- 1 Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna , Vienna, Austria
| | - Thomas Wrba
- 2 IT Systems and Communications, Medical University of Vienna , Vienna, Austria
| | | | - Rodrig Marculescu
- 3 Department of Laboratory Medicine, Medical University of Vienna , Vienna, Austria
| | - Alois Gessl
- 1 Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna , Vienna, Austria
| | - Anton Luger
- 1 Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna , Vienna, Austria
| | - Yvonne Winhofer
- 1 Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna , Vienna, Austria
| | - Michael Krebs
- 1 Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna , Vienna, Austria
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8
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Takamura A, Sangen R, Furumura Y, Usuda D, Kasamaki Y, Kanda T. Diagnosis of myxedema coma complicated by renal failure: a case report. Clin Case Rep 2017; 5:399-402. [PMID: 28396755 PMCID: PMC5378864 DOI: 10.1002/ccr3.850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 01/10/2017] [Accepted: 01/14/2017] [Indexed: 02/05/2023] Open
Abstract
Myxedema coma, caused by severe lack of thyroid hormone, is characterized by deterioration of mental status, hypothermia, hypotension, hyponatremia, and hypoventilation. We describe an 84-year-old woman who presented with renal failure and new onset severe hypothyroidism leading to challenges in the recognition of myxedema coma.
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Affiliation(s)
- Akiteru Takamura
- Department of General Medicine CenterKanazawa Medical University Hospital1‐1 UchinadaKahoku‐gunIshikawaJapan
- Department of Medical EducationKanazawa Medical University1‐1 UchinadaKahoku‐gunIshikawaJapan
- Department of Family MedicineMie University Graduate School of Medicine2‐174 Edo‐bashiTsuMieJapan
| | - Ryusho Sangen
- Department of General MedicineHimi Municipal HospitalKanazawa Medical University31‐9 Saiwai‐choHimiToyamaJapan
| | - Yoshiki Furumura
- Department of General MedicineHimi Municipal HospitalKanazawa Medical University31‐9 Saiwai‐choHimiToyamaJapan
| | - Daisuke Usuda
- Department of General MedicineHimi Municipal HospitalKanazawa Medical University31‐9 Saiwai‐choHimiToyamaJapan
| | - Yuji Kasamaki
- Department of General MedicineHimi Municipal HospitalKanazawa Medical University31‐9 Saiwai‐choHimiToyamaJapan
| | - Tsugiyasu Kanda
- Department of General MedicineHimi Municipal HospitalKanazawa Medical University31‐9 Saiwai‐choHimiToyamaJapan
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Kim J, Cho SG, Kang SR, Kwon SY, Cho DH, Cho JS, Song HC. Preparation for radioactive iodine therapy is not a risk factor for the development of hyponatremia in thyroid cancer patients. Medicine (Baltimore) 2017; 96:e6004. [PMID: 28151897 PMCID: PMC5293460 DOI: 10.1097/md.0000000000006004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The aim of this study was to evaluate whether the preparation for radioactive iodine (RAI) therapy by thyroid hormone withdrawal (THW) or a low-iodine diet (LID) can be risk factors for the development of hyponatremia in patients with differentiated thyroid cancer after thyroidectomy.We retrospectively reviewed the medical records and laboratory findings of 326 patients who underwent preparation for RAI therapy after thyroidectomy from 2012 to 2014. Demographic and clinical variables including the method of thyrotropin stimulation and duration of LID were assessed. Serum sodium was measured twice, before operation and before RAI therapy.Hyponatremia was detected in only 3 patients (0.9%) before operation, but in 15 patients (4.6%) before RAI therapy. None of the patients had severe hyponatremia after preparation for RAI therapy. Pre-RAI therapy serum sodium was correlated with the method of thyrotropin stimulation (TWH vs recombinant human thyroid stimulating hormone, P = 0.014) and duration of LID (r = -0.131, P = 0.018); however, the preparation of RAI therapy, THW and LID, did not affect the development of hyponatremia in logistic regression analysis. Preoperative serum sodium was a significant risk factor for hyponatremia during preparation for RAI therapy.Preparation for RAI therapy by THW or LID is not a risk factor for the development of hyponatremia in patients with thyroid cancer. The development of hyponatremia was neither frequent nor severe during preparation for RAI therapy. Physicians should not be greatly concerned about rare life-threatening hyponatremia during preparation for RAI therapy.
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Affiliation(s)
- Jahae Kim
- Department of Nuclear Medicine, Chonnam National University Hospital
| | - Sang-Geon Cho
- Department of Nuclear Medicine, Chonnam National University Hospital
| | - Sae-Ryung Kang
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital
| | - Seong Young Kwon
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital
| | - Dong-Hyeok Cho
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Hospital
| | - Jin-Seong Cho
- Department of Surgery, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Ho-Chun Song
- Department of Nuclear Medicine, Chonnam National University Hospital
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Vannucci L, Parenti G, Simontacchi G, Rastrelli G, Giuliani C, Ognibene A, Peri A. Hypothyroidism and hyponatremia: data from a series of patients with iatrogenic acute hypothyroidism undergoing radioactive iodine therapy after total thyroidectomy for thyroid cancer. J Endocrinol Invest 2017; 40:49-54. [PMID: 27507082 DOI: 10.1007/s40618-016-0525-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 07/24/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE The aim of the present study was to evaluate the role of hypothyroidism as a cause of hyponatremia in a clinical model of iatrogenic acute hypothyroidism due to thyroid hormone withdrawal prior to ablative radioactive iodine (RAI) therapy after total thyroidectomy. METHODS The study group consisted of 101 differentiated thyroid cancer (DTC) patients (77 women and 24 men). Plasma concentration of thyroid-stimulating hormone ([TSH]) and sodium ([Na+]) was evaluated before total thyroidectomy (pre[TSH] and pre[Na+]) and on the day of RAI therapy (post[TSH] and post[Na+]). RESULTS The frequency of hypothyroidism-associated hyponatremia was 4 % (4/101). Pre[Na+] was significantly higher than post[Na+] (140.7 ± 1.6 vs 138.7 ± 2.3 mEq/L, p = 0.012). Moreover, a linear correlation was identified between pre[Na+] and post[Na+]. CONCLUSIONS Iatrogenic acute hypothyroidism-related hyponatremia is uncommon. However, because of the significant reduction of [Na+] in the transition from euthyroidism to iatrogenic hypothyroidism, the value of pre[Na+] should be viewed as a parameter to be considered. Since it acts as an independent risk factor for the development of hyponatremia, patients with a pre[Na+] close to the lower limit of normal range may deserve a closer monitoring of [Na+].
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Affiliation(s)
- L Vannucci
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - G Parenti
- Endocrine Unit, Careggi Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - G Simontacchi
- Radiotherapy Unit, Careggi Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - G Rastrelli
- Andrologyy and Sexual Medicine Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - C Giuliani
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - A Ognibene
- Central Laboratory, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - A Peri
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy.
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Liamis G, Filippatos TD, Liontos A, Elisaf MS. MANAGEMENT OF ENDOCRINE DISEASE: Hypothyroidism-associated hyponatremia: mechanisms, implications and treatment. Eur J Endocrinol 2017; 176:R15-R20. [PMID: 27484454 DOI: 10.1530/eje-16-0493] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 07/06/2016] [Accepted: 08/01/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with moderate to severe hypothyroidism and mainly patients with myxedema may exhibit reduced sodium levels (<135 mmol/L). SUMMARY The aim of this short review is the presentation of the mechanisms of hyponatremia and of the available data regarding its implications and treatment in patients with hypothyroidism. Hypothyroidism is one of the causes of hyponatremia, thus thyroid-stimulating hormone determination is mandatory during the evaluation of patients with reduced serum sodium levels. The main mechanism for the development of hyponatremia in patients with chronic hypothyroidism is the decreased capacity of free water excretion due to elevated antidiuretic hormone levels, which are mainly attributed to the hypothyroidism-induced decrease in cardiac output. However, recent data suggest that the hypothyroidism-induced hyponatremia is rather rare and probably occurs only in severe hypothyroidism and myxedema. Other possible causes and superimposed factors of hyponatremia (e.g. drugs, infections, adrenal insufficiency) should be considered in patients with mild/moderate hypothyroidism. Treatment of hypothyroidism and fluid restriction are usually adequate for the management of mild hyponatremia in patients with hypothyroidism. Patients with possible hyponatremic encephalopathy should be urgently treated according to current guidelines. CONCLUSIONS Severe hypothyroidism may be the cause of hyponatremia. All hypothyroid patients with low serum sodium levels should be evaluated for other causes and superimposed factors of hyponatremia and treated accordingly.
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Affiliation(s)
- G Liamis
- Department of Internal MedicineSchool of Medicine, University of Ioannina, Ioannina, Greece
| | - T D Filippatos
- Department of Internal MedicineSchool of Medicine, University of Ioannina, Ioannina, Greece
| | - A Liontos
- Department of Internal MedicineSchool of Medicine, University of Ioannina, Ioannina, Greece
| | - M S Elisaf
- Department of Internal MedicineSchool of Medicine, University of Ioannina, Ioannina, Greece
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12
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Curtò L, Trimarchi F. Hypopituitarism in the elderly: a narrative review on clinical management of hypothalamic-pituitary-gonadal, hypothalamic-pituitary-thyroid and hypothalamic-pituitary-adrenal axes dysfunction. J Endocrinol Invest 2016; 39:1115-24. [PMID: 27209187 DOI: 10.1007/s40618-016-0487-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 05/10/2016] [Indexed: 10/21/2022]
Abstract
Hypopituitarism is an uncommon and under-investigated endocrine disorder in old age since signs and symptoms are unspecific and, at least in part, can be attributed to the physiological effects of aging and related co-morbidities. Clinical presentation is often insidious being characterized by non-specific manifestations, such as weight gain, fatigue, low muscle strength, bradipsychism, hypotension or intolerance to cold. In these circumstances, hypopituitarism is a rarely life-threatening condition, but evolution may be more dramatic as a result of pituitary apoplexy, or when a serious condition of adrenal insufficiency suddenly occurs. Clinical presentation depends on the effects that each pituitary deficit can cause, and on their mutual relationship, but also, inevitably, it depends on the severity and duration of the deficit itself, as well as on the general condition of the patient. Indeed, indications and methods of hormone replacement therapy must include the need to normalize the endocrine profile without contributing to the worsening of intercurrent diseases, such as those of glucose and bone metabolism, and the cardiovascular system, or to the increasing cancer risk. Hormonal requirements of elderly patients are reduced compared to young adults, but a prompt diagnosis and appropriate treatment of pituitary deficiencies are strongly recommended, also in this age range.
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Affiliation(s)
- L Curtò
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Messina, AOU Policlinico "G. Martino" (Block H, Floor 4), Via Consolare Valeria, 1, 98125, Messina, Italy.
| | - F Trimarchi
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Messina, AOU Policlinico "G. Martino" (Block H, Floor 4), Via Consolare Valeria, 1, 98125, Messina, Italy
- Accademia Peloritana dei Pericolanti, University of Messina, Messina, Italy
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13
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Dayrit JCP, Cunanan EC, Kho SA. Prevalence of Hyponatremia in Hypothyroid Patients during Radioactive ¹³¹I Ablation for Differentiated Thyroid Cancer: Single Institution Experience. Endocrinol Metab (Seoul) 2016; 31:410-415. [PMID: 27546873 PMCID: PMC5053053 DOI: 10.3803/enm.2016.31.3.410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/31/2016] [Accepted: 07/18/2016] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Hyponatremia developing in hypothyroid patients has been encountered in clinical practice; however, its prevalence has not been well established. METHODS Thirty patients diagnosed with differentiated thyroid cancer, rendered hypothyroid after surgery and levothyroxine withdrawal, and who are for radioactive iodine (RAI) ablation were included. Serum sodium concentrations were measured twice, at the time of admission for RAI ablation, and before discharge after increased oral fluid intake. The outcome measures were to determine the prevalence of hyponatremia among hypothyroid patients prior to RAI ablation and after oral hydration post-RAI, and to correlate the serum sodium levels pre-RAI and post-RAI with thyroid-stimulating hormone (TSH) concentration and age. RESULTS Thirty patients were included, with ages from 23 to 65 years old (median, 40). Two patients (6.7%) were hyponatremic prior to RAI ablation, and eight patients (26.7%) had mild hyponatremia (130 to 134 mEq/L) after RAI and hydration. There was no significant correlation between TSH levels and serum sodium levels prior to or after RAI. There was also no significant correlation between pre- and post-RAI sodium concentration and age. CONCLUSIONS The prevalence of hyponatremia pre-RAI was 6.7%, and 26.7% post-RAI. No significant correlation was noted between TSH concentration and age on pre- or post-RAI sodium concentrations. Routine measurement of serum sodium post-RAI/isolation is still not advised. Measurement of sodium post-RAI may be considered in patients who are elderly, with comorbid conditions or on medications.
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Affiliation(s)
- Juan Carlo P Dayrit
- Section of Endocrinology and Metabolism, Department of Medicine, University of Santo Tomas Hospital, Manila, Philippines.
| | - Elaine C Cunanan
- Section of Endocrinology and Metabolism, Department of Medicine, University of Santo Tomas Hospital, Manila, Philippines
| | - Sjoberg A Kho
- Section of Endocrinology and Metabolism, Department of Medicine, University of Santo Tomas Hospital, Manila, Philippines
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Abuzaid AS, Birch N. The Controversies of Hyponatraemia in Hypothyroidism: Weighing the evidence. Sultan Qaboos Univ Med J 2015; 15:e207-e212. [PMID: 26052453 PMCID: PMC4450783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 08/13/2014] [Accepted: 10/23/2014] [Indexed: 06/04/2023] Open
Abstract
Hyponatraemia is a common electrolyte disturbance, with moderate (serum sodium: 125-129 mmol/L) to severe (serum sodium: ≤125 mmol/L) forms of the disease occurring in 4-15% of hospitalised patients. While it is relatively common, determining the underlying cause of this condition can be challenging and may require extensive laboratory investigations. To this end, it is important to ascertain the efficacy of laboratory tests in determining the cause of hyponatraemia. Up to 10% of patients with hypothyroidism also have hyponatraemia. Routine evaluation of thyroid function is often advocated in cases of low serum sodium. A review and discussion of the available literature is presented here to examine this recommendation.
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Affiliation(s)
- Ahmed S. Abuzaid
- Department of Internal Medicine, Creighton University, Omaha, Nebraska, USA
| | - Nathan Birch
- Department of Internal Medicine, Nebraska-Western Iowa Health Care System, Omaha, Nebraska, USA
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Horie I, Ando T, Imaizumi M, Usa T, Kawakami A. Hyperkalemia develops in some thyroidectomized patients undergoing thyroid hormone withdrawal in preparation for radioactive iodine ablation for thyroid carcinoma. Endocr Pract 2015; 21:488-94. [PMID: 25667379 DOI: 10.4158/ep14532.or] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Hyponatremia is observed in hypothyroidism, but it is not known if hypo- or hyperkalemia is associated with hypothyroidism. To study these questions, we determined serum potassium (K(+)) levels in thyroidectomized patients undergoing levothyroxine withdrawal before radioactive iodine (RAI) therapy for thyroid carcinoma. METHODS We retrospectively studied the records of 108 patients who had undergone total thyroidectomy for thyroid carcinoma followed by levothyroxine withdrawal and then ablation with RAI at Nagasaki University Hospital from 2009-2013. Blood samples were analyzed for serum K(+) concentrations when patients were euthyroid just before levothyroxine withdrawal and hypothyroid 21 days after levothyroxine withdrawal. We determined the proportion of patients who developed hyperkalemia (K(+) ≥5 mEq/L) and hypokalemia (K(+) ≤3.5 mEq/L). RESULTS Five (4.6%) patients developed hyperkalemia and 2 (1.9%) patients developed hypokalemia after levothyroxine withdrawal. The mean serum K(+) level after levothyroxine withdrawal was significantly higher than before levothyroxine withdrawal (4.23 ± 0.50 mEq/L vs. 4.09 ± 0.34 mEq/L; P<.001). After levothyroxine withdrawal, serum K(+) values were significantly correlated with age, serum sodium and creatinine levels, and the estimated glomerular filtration rate but not with serum free thyroxine or thyroid-stimulating hormone concentrations. The finding of an elevated serum K(+) of >0.5 mEq/L after levothyroxine withdrawal was more prevalent with age >60 years (odds ratio [OR], 4.66; P = .026) and with the use of angiotensin-II receptor blockers or angiotensin-converting enzyme inhibitors (OR, 3.53; P = .033) in a multivariate analysis. CONCLUSION Hyperkalemia develops in a small percentage of hypothyroid patients after thyroid hormone withdrawal, especially in patients over 60 years of age who are using antihypertensive agents that inhibit the reninangiotensin-aldosterone system.
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Pantalone KM, Hatipoglu BA. Hyponatremia and the Thyroid: Causality or Association? J Clin Med 2014; 4:32-6. [PMID: 26237016 PMCID: PMC4470237 DOI: 10.3390/jcm4010032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 12/05/2014] [Indexed: 12/18/2022] Open
Abstract
Thyroid disorders, particularly hypothyroidism, have historically been implicated in the development of serum hyponatremia. However, in more recent years, this paradigm has been challenged, and it has been suggested that the link between hypothyroidism and hyponatremia may merely be an association. This review will focus on the thyroid and its link with serum hyponatremia, and review the available literature on the topic.
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Affiliation(s)
| | - Betul A. Hatipoglu
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-216-445-6709
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Lee JE, Kim SK, Han KH, Cho MO, Yun GY, Kim KH, Choi HY, Ryu YH, Ha SK, Park HC. Risk factors for developing hyponatremia in thyroid cancer patients undergoing radioactive iodine therapy. PLoS One 2014; 9:e106840. [PMID: 25170831 PMCID: PMC4149575 DOI: 10.1371/journal.pone.0106840] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 08/02/2014] [Indexed: 12/28/2022] Open
Abstract
Background Due to the alarming increase in the incidence of thyroid cancer worldwide, more patients are receiving postoperative radioactive iodine (RAI) therapy and these patients are given a low-iodine diet along with levothyroxine withdrawal to induce a hypothyroid state to maximize the uptake of RAI by thyroid tissues. Recently, the reported cases of patients suffering from life-threatening severe hyponatremia following postoperative RAI therapy have increased. This study aimed to systematically assess risk factors for developing hyponatremia following RAI therapy in post-thyroidectomy patients. Methods We reviewed the medical records of all thyroid cancer patients who underwent thyroidectomy and postoperative RAI therapy from July 2009 to February 2012. Demographic and biochemical parameters including serum sodium and thyroid function tests were assessed along with medication history. Results A total of 2229 patients (47.0±11.0 years, female 76.3%) were enrolled in the analysis. Three hundred seven patients (13.8%) of all patients developed hyponatremia; 44 patients (2.0%) developed moderate to severe hyponatremia (serum Na+≤130 mEq/L) and another 263 (11.8%) patients showed mild hyponatremia (130 mEq/L<serum Na+≤135 mEq/L). In univariate analysis, old age, female sex, presence of hypertension, presence of diabetes, use of thiazide diuretics, use of angiotensin receptor blocker or angiotensin-converting enzyme inhibitors, lung metastasis, and hyponatremia and lower estimated glomerular filtration rate at the start of RAI therapy were significantly associated with hyponatremia in patients undergoing RAI therapy after total thyroidectomy. Multivariate analysis showed that old age, female sex, use of thiazide diuretics, and hyponatremia at the initiation of RAI therapy were independent risk factors for the development of hyponatremia. Conclusion Our data suggest that age greater than 60 years, female sex, use of thiazide, and hyponatremia at the initiation of RAI therapy are important risk factors for developing hyponatremia following RAI therapy in post-thyroidectomy patients.
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Affiliation(s)
- Jung Eun Lee
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Kyu Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung Hwa Han
- Biostatistics Collaboration Unit, Gangnam Medical Research Center, Seoul, Republic of Korea
| | - Mi Ok Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gi Young Yun
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ki Hyun Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hoon Young Choi
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Hoon Ryu
- Department of Nuclear Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Kyu Ha
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyeong Cheon Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- * E-mail:
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Colombero C, Venara M, Gonzalez D, Roman RJ, Nowicki S. Cytochrome P4504A inhibitors attenuate the exaggerated natriuretic response to volume expansion in thyroidectomized rats. Physiol Rep 2014; 2:2/6/e12040. [PMID: 24920124 PMCID: PMC4208633 DOI: 10.14814/phy2.12040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Cecilia Colombero
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE); CONICET - FEI - División de Endocrinología; Hospital de Niños Ricardo Gutiérrez; Buenos Aires Argentina
| | - Marcela Venara
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE); CONICET - FEI - División de Endocrinología; Hospital de Niños Ricardo Gutiérrez; Buenos Aires Argentina
| | - Daniel Gonzalez
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE); CONICET - FEI - División de Endocrinología; Hospital de Niños Ricardo Gutiérrez; Buenos Aires Argentina
| | - Richard J. Roman
- Department of Pharmacology and Toxicology; The University of Mississippi Medical Center; Jackson Mississippi
| | - Susana Nowicki
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE); CONICET - FEI - División de Endocrinología; Hospital de Niños Ricardo Gutiérrez; Buenos Aires Argentina
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Kim SK, Yun GY, Kim KH, Park SK, Choi HY, Ha SK, Park HC. Severe hyponatremia following radioactive iodine therapy in patients with differentiated thyroid cancer. Thyroid 2014; 24:773-7. [PMID: 24093878 DOI: 10.1089/thy.2013.0110] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Symptomatic hyponatremia in association with radioactive iodine (RAI) therapy for differentiated thyroid cancer has rarely been reported. Due to the increasing incidence of thyroid cancer worldwide, more patients are now receiving postoperative RAI therapy. We report two cases of life-threatening severe hyponatremia in association with RAI therapy. SUMMARY Two elderly female patients who had bilateral thyroidectomies for their thyroid cancer underwent a low-iodine diet and levothyroxine withdrawal for two weeks prior to RAI therapy. Upon admission, the patients were given 130 mCi (4810 MBq) and 150 mCi (5550 MBq) of (131)I respectively, and oral hydration (two to three liters of water daily) to increase the frequency of emptying the bladder of RAI. Both patients completed their RAI therapy without significant complications and were discharged from hospital. Two days after discharge, both patients were admitted to the emergency room with complaints of severe nausea and dizziness. Initial laboratory tests revealed that they were in a hypothyroid state and had severe hyponatremia with a serum sodium level of 108 mEq/L. The symptomatic hyponatremia responded to intravenous hypertonic saline infusion and thyroid hormone replacement, and the patients made a full recovery. The low-iodine diet and hypothyroid state with overzealous hydration in the setting of RAI therapy may have provoked severe hypotonic hyponatremia. CONCLUSION Hypothyroid patients after undergoing RAI therapy, especially the elderly, are at an increased risk for serious hyponatremia and should be monitored closely.
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Affiliation(s)
- Seung Kyu Kim
- Gangnam Severance Hospital, Yonsei University College of Medicine , Seoul, Korea
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Jo HJ, Kim YH, Shin DH, Kim MJ, Lee SJ, Jeon DO, Im SG, Jang SK, Choi JY. Hyponatremia after thyroid hormone withdrawal in a patient with papillary thyroid carcinoma. Endocrinol Metab (Seoul) 2014; 29:77-82. [PMID: 24741458 PMCID: PMC3970286 DOI: 10.3803/enm.2014.29.1.77] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 03/12/2013] [Indexed: 01/20/2023] Open
Abstract
Hyponatremia is an electrolyte abnormality commonly found in clinical practice. It is important to diagnose the underlying etiology of the hyponatremia and correct it appropriately because severe hyponatremia can cause serious complications and substantially increase the risk of mortality. Although hypothyroidism is known to be a cause of hyponatremia, it is rare that hyponatremia occurs in relation to hypothyroidism induced by thyroid hormone withdrawal in patients with differentiated thyroid cancer. We report a case of a 76-year-old woman with papillary thyroid carcinoma presenting with severe hyponatremia related to hypothyroidism induced by thyroid hormone withdrawal for radio-active iodine whole-body scanning, who was treated by thyroid hormone replacement and hydration. Considering that the incidence of differentiated thyroid cancer is rapidly increasing, physicians should be aware that, although uncommon, hyponatremia can occur in patients undergoing radioiodine therapy or diagnostic testing.
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Affiliation(s)
- Hyo Jin Jo
- Department of Internal Medicine, Bundang Jesaeng Hospital, Kwandong University College of Medicine, Seongnam, Korea
| | - Yong Hyun Kim
- Department of Internal Medicine, Bundang Jesaeng Hospital, Kwandong University College of Medicine, Seongnam, Korea
| | - Dong Hyun Shin
- Department of Internal Medicine, Bundang Jesaeng Hospital, Kwandong University College of Medicine, Seongnam, Korea
| | - Mi Jeoung Kim
- Department of Internal Medicine, Bundang Jesaeng Hospital, Kwandong University College of Medicine, Seongnam, Korea
| | - Sang Jin Lee
- Department of Internal Medicine, Bundang Jesaeng Hospital, Kwandong University College of Medicine, Seongnam, Korea
| | - Dong Ok Jeon
- Department of Internal Medicine, Bundang Jesaeng Hospital, Kwandong University College of Medicine, Seongnam, Korea
| | - Sung Gyu Im
- Department of Internal Medicine, Bundang Jesaeng Hospital, Kwandong University College of Medicine, Seongnam, Korea
| | - Sun Kyung Jang
- Department of Internal Medicine, Bundang Jesaeng Hospital, Kwandong University College of Medicine, Seongnam, Korea
| | - Jin Young Choi
- Department of Internal Medicine, Bundang Jesaeng Hospital, Kwandong University College of Medicine, Seongnam, Korea
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Hunze J, IJsselstijn L, Wulkan RW, van Alphen AM. Does Hypothyroidism Cause Hyponatremia? Health (London) 2014. [DOI: 10.4236/health.2014.612179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Hammami MM, Almogbel F, Hammami S, Faifi J, Alqahtani A, Hashem W. Acute severe hypothyroidism is not associated with hyponatremia even with increased water intake: a prospective study in thyroid cancer patients. BMC Endocr Disord 2013; 13:27. [PMID: 23902827 PMCID: PMC3735475 DOI: 10.1186/1472-6823-13-27] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 07/23/2013] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Hypothyroidism, commonly induced in preparation for radioiodine treatment of differentiated thyroid cancer, is a text-book cause for hyponatremia. Nausea, stress, and increased fluid intake associated with the treatment are expected to exacerbate hyponatremia. METHODS We prospectively studied 212 (80% females) consecutive thyroid cancer patients for the incidence of hypothyroidism-induced hyponatremia and associated risk factors. RESULTS Mean(SD) age was 39.7(14.1) year, creatinine 82.0(20.8) μmol/l, TSH 141.6(92.0) mU/l, pre- and post-isolation sodium 139.5(2.3) and 137.8(3.0) mEq/l, respectively, and estimated fluid intake during isolation 9.7(6.2) L. Mild hyponatremia (≥130 mEq/l) was present in 18 patients (8.5%) and moderate hyponatremia (≥120 mEq/l) in 4(1.9%), 3 of the latter had elevated creatinine concentration and 2 were on diuretics. There was no significant correlation between post-isolation sodium concentration and TSH concentration (r = 0.03, p = 0.69) or estimated fluid intake (r = 0.10, p =0.17). There was significant correlation between post-isolation sodium concentration and age (r = -0.24, p < 0.0001) and creatinine concentration (r = -0.22, p = 0.001). Pre-post-isolation drop in sodium concentration was more in females (mean difference 1.21, p = 0.02). Compared to eunatremic patients, hyponatremic patients were more likely to have pre-isolation hyponatremia (9% vs. 0.5%, p = 0.03), elevated creatinine concentration (36% vs. 13%, p = 0.008), and to be on diuretics (23% vs. 1%, p = 0.0001). CONCLUSIONS In the setting of acute severe hypothyroidism: 1) clinically-important hyponatremia is uncommon; sodium concentration may not need to be monitored unless patients have impaired renal function or are on diuretics, 2) age and female gender are associated with lower sodium concentration. Uncomplicated acute severe hypothyroidism didn't cause clinically-important hyponatremia/SIADH in this cohort of patients.
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Affiliation(s)
- Muhammad M Hammami
- Department of Clinical Studies & Empirical Ethics, King Faisal Specialist Hospital and Research Centre, PO Box # 3354, Riyadh 11211, (MBC 03), Saudi Arabia
- Department of Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Fahad Almogbel
- Department of Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Sumaya Hammami
- Department of Clinical Studies & Empirical Ethics, King Faisal Specialist Hospital and Research Centre, PO Box # 3354, Riyadh 11211, (MBC 03), Saudi Arabia
| | - Jaber Faifi
- Department of Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Awad Alqahtani
- Department of Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Walid Hashem
- Department of Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
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Abstract
PURPOSE Acute kidney injury (AKI) caused by hypothyroidism-induced rhabdomyolysis is a rare and potentially life-threatening syndrome. The aim of this study was to investigate the clinical characteristics of such patients. MATERIALS AND METHODS We retrospectively analyzed five patients treated at the Second Affiliated Hospital of Chongqing Medical University with AKI secondary to hypothyroidism- induced rhabdomyolysis from January 2006 to December 2010. RESULTS Of the five cases reviewed (4 males, age range of 37 to 62 years), adult primary hypothyroidism was caused by amiodarone (1 case), chronic autoimmune thyroiditis (1 case), and by uncertain etiologies (3 cases). All patients presented with facial and lower extremity edema. Three patients presented with weakness, while two presented with blunted facies and oliguria. Only one patient reported experiencing myalgia and proximal muscle weakness, in addition to fatigue and chills. Creatine kinase, lactate dehydrogenase, and renal function normalized after thyroid hormone replacement, except in two patients who improved through blood purification. CONCLUSION Hypothyroidism should be considered in patients presenting with renal impairment associated with rhabdomyolysis. Moreover, further investigation into the etiology of the hypothyroidism is warranted.
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Affiliation(s)
- Ying Cai
- Department of Nephrology, the Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Lin Tang
- Department of Nephrology, the Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Persistence of mortality risk in patients with acute cardiac diseases and mild thyroid dysfunction. Am J Med Sci 2012; 343:65-70. [PMID: 21876429 DOI: 10.1097/maj.0b013e31822846bd] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION There are no studies on the long-term prognostic role of abnormal thyrotropin value in patients with acute cardiac diseases. Aim of the study was to assess the incidence and persistence of risk of cardiac and overall deaths in patients with acute cardiac diseases. METHODS A total of 1026 patients (mean age: 67.7 years) were divided into 4 groups: (1) euthyroid (EU, n=579); (2) subclinical-like hypothyroidism (SLHYPO, n=68); (3) subclinical-like hyperthyroidism (SLHYPER, n=23) and (4) low-triiodothyronine syndrome (LowT3, n=356). Follow-up started from the day of thyroid hormone evaluation (mean follow-up: 30 months). The events considered were cardiac and overall deaths. RESULTS Survival rate for cardiac death was lower in SLHYPO and in LT3 than in EU (log rank test; χ(2)=33.6; P < 0.001). Survival rate for overall death was lower in SLHYPO, SLHYPER and LowT3 than in EU (48.3; P < 0.001). After adjustment for several risk factors, the hazard ratio for cardiac death was higher in SLHYPO (3.65; P=0.004) in LowT3 (1.88; P=0.032) and in SLHYPER (4.73; P=0.047). Hazard ratio for overall death was higher in SLHYPO (2.30; P=0.009), in LowT3 (1.63; P=0.017) and in SLHYPER than in EU (3.71; P=0.004). Hazards for SLHYPO, SLHYPER and LowT3 with respect to EU were proportional over the follow-up period. CONCLUSION In patients with acute cardiac disease, a mildly altered thyroid status was associated with increased risk of mortality that remains constant during all the follow-up.
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Chou KM, Chiu SYH, Chen CH, Yang NI, Huang BY, Sun CY. Correlation of clinical changes with regard to thyroxine replacement therapy in hypothyroid patients: focusing on the change of renal function. Kidney Blood Press Res 2011; 34:365-72. [PMID: 21646817 DOI: 10.1159/000328324] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 04/02/2011] [Indexed: 12/17/2022] Open
Abstract
Thyroid dysfunction has an important role in renal insufficiency. The aim of the study was to correlate the change of renal function with other clinical factors after thyroxine therapy in hypothyroid patients. A prospective study was designed and 30 hypothyroid patients were included. All study subjects received 0.15-0.2 mg/day thyroxine for 12 weeks. Diastolic blood pressure and serum levels of creatine phosphokinase (CPK) and myoglobulin decreased significantly after thyroxine therapy. Serum creatinine decreased (0.87 ± 0.22 vs. 0.70 ± 0.17 mg/dl, p < 0.001) and estimated glomerular filtration rate (eGFR) increased significantly (82.06 ± 31.08 vs. 100.31 ± 31.79 ml/min/1.73 m(2); p < 0.001) after thyroxine replacement. Left ventricular ejection fraction (LVEF) was significantly increased after thyroxine replacement (64.47 ± 11.94 vs. 72.40 ± 13.89%, p = 0.026). No significant vascular functional changes of peripheral (pulse wave velocity) and renal interlobar arteries (pulsatility index and resistance index) were noted. The change of eGFR significantly correlated with the changes of serum-free T(4) (fT(4)), CPK, myoglobulin and LVEF. The correlation between the change of eGFR and thyroid-stimulating hormone (TSH) level was not significant. In conclusion, the GFR of hypothyroid patients increased significantly after thyroxine replacement. The change of GFR was significantly correlated with the changes of fT(4), CPK, myoglobulin and LVEF, but not with TSH.
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Affiliation(s)
- Kuei-Mei Chou
- Department of Health Care Management, Chang Gung University, Tao-Yuan, Taiwan, ROC
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Rachoin JS, Cerceo EA. Four nephrology myths debunked. J Hosp Med 2011; 6:E1-5. [PMID: 21661096 DOI: 10.1002/jhm.703] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2009] [Revised: 02/25/2010] [Accepted: 03/02/2010] [Indexed: 11/08/2022]
Abstract
There are many controversial topics relating to renal disease in hospitalized patients. The aim of this review is to shed light on some important and often debated issues. Hypothyroidism, unlike myxedema, is not a cause of hyponatremia (although it can be sometimes seen in conjunction with the latter) and additional investigations should be done to determine its etiology. Sodium bicarbonate is effective for treatment of hyperkalemia primarily by enhancing renal potassium elimination rather than by translocating potassium into cells. Acetaminophen can be a cause of metabolic acidosis by causing 5-oxoprolinuria. Furosemide (and sulfa containing diuretics) can safely be used in patients with an allergy to sulfa-containing antibiotics (SCA).
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Affiliation(s)
- Jean-Sebastien Rachoin
- Department of Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, Cooper University Hospital, Camden, New Jersey, USA.
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da Silva MA, Calil Cury Guimarães MI, Yoriyaz H, Carvalho Pinto Ribela MT, Buchpiguel CA, Bartolini P, Okazaki K. Evaluation of the cytogenetic effects of (131)I preceded by recombinant human thyrotropin (rhTSH) in peripheral lymphocytes of Wistar rats. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2008; 47:453-461. [PMID: 18712404 DOI: 10.1007/s00411-008-0189-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Accepted: 07/24/2008] [Indexed: 05/26/2023]
Abstract
The present study was carried out to investigate the cytogenetic effects of therapeutic exposure to radioiodine preceded by rhTSH in an animal model. Three groups of Wistar rats (n = 6) were used: one group was treated only with (131)I (11.1 MBq/animal); the other two groups received rhTSH (1.2 mug/rat of either Thyrogen or rhTSH-IPEN, respectively) 24 h before administration of radioiodine. The percentage of lymphocytes with chromosome aberrations and the average number of aberrations and of dicentrics per cell were determined on blood samples collected 24 h, 7 and 30 days after administration of (131)I. The data show that the treatment with radioiodine alone or associated with rhTSH resulted in a greater quantity of chromosome alterations in relation to basal values after 24 h, with a gradual decline after 7 and 30 days of treatment. An increase in chromosome alterations was also seen after rhTSH treatment alone. Neither of the treatments, i.e., with (131)I alone or associated with hormone, resulted in an aneugenic effect or influenced the kinetics of cellular proliferation in rat blood lymphocytes. There was no significant difference between the cytogenetic effects of Thyrogen and rhTSH-IPEN treatment. These data suggest that the treatment with radioiodine, associated or not with rhTSH, affects to a limited extent a relatively small number of cells although the occurrence of late stochastic effects could not be discarded.
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Affiliation(s)
- Márcia Augusta da Silva
- Centro de Biotecnologia, Instituto de Pesquisas Energéticas e Nucleares, IPEN-CNEN/SP, Cidade Universitária, Av. Prof. Lineu Prestes, 2242, Caixa Postal 11049, CEP 05508-900 São Paulo, Brazil
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Braithwaite SS. Thyroid Disorders. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50063-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Munger MA. New agents for managing hyponatremia in hospitalized patients. Am J Health Syst Pharm 2007; 64:253-65. [PMID: 17244874 DOI: 10.2146/060101] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
PURPOSE An overview of hyponatremia is provided, including its pathophysiology, clinical manifestations, signs and symptoms, and treatment, particularly with arginine vasopressin (AVP)-receptor antagonists. SUMMARY Hyponatremia (generally defined as a serum sodium concentration of <135 meq/L) is one of the most common electrolyte disorders in hospitalized and clinic patients. It may be caused by a number of conditions, including infections, heart disease, surgery, malignancy, and medication use. Clinical signs and symptoms such as hallucinations, lethargy, weakness, bradycardia, respiratory depression, seizures, coma, and death have been reported. Conventional treatment consists of fluid restriction and administration of hypertonic saline and pharmacologic agents, such as demeclocycline, lithium carbonate, and urea. These treatment options are often of limited effectiveness or difficult for patients to tolerate. AVP promotes the reabsorption of water in the renal collecting ducts by activation of V(2) receptors, resulting in water retention and dilution of serum solutes. The AVP-receptor antagonists, conivaptan, lixivaptan, and tolvaptan, are being studied for the treatment of hyponatremia. Conivaptan has been shown in clinical trials to increase free-water excretion and safely normalize serum sodium concentrations in patients with hyponatremia and is well tolerated. Also in clinical trials, lixivaptan and tolvaptan have safely improved serum sodium concentrations in patients with hyponatremia. CONCLUSION Hyponatremia is a serious health condition for which treatment should be carefully performed. As new agents for treating hyponatremia, AVP-receptor antagonists have demonstrated efficacy and safety in clinical trials and may serve as significant improvements in the current treatment options for managing this disorder.
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Affiliation(s)
- Mark A Munger
- College of Pharmacy, University of Utah, 30 South 2000 East, Room 201, Salt Lake City, UT 84112-5820, USA.
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Warner MH, Holding S, Kilpatrick ES. The effect of newly diagnosed hypothyroidism on serum sodium concentrations: a retrospective study. Clin Endocrinol (Oxf) 2006; 64:598-9. [PMID: 16649984 DOI: 10.1111/j.1365-2265.2006.02489.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Luster M, Felbinger R, Dietlein M, Reiners C. Thyroid hormone withdrawal in patients with differentiated thyroid carcinoma: a one hundred thirty-patient pilot survey on consequences of hypothyroidism and a pharmacoeconomic comparison to recombinant thyrotropin administration. Thyroid 2005; 15:1147-55. [PMID: 16279848 DOI: 10.1089/thy.2005.15.1147] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The study objective was to elucidate clinical, quality-of-life, and pharmacoeconomic effects of hypothyroidism secondary to thyroid hormone withdrawal (withdrawal) in athyroid patients with differentiated thyroid cancer (DTC). We also intended to compare societal costs of withdrawal and recombinant human thyroid-stimulating hormone administration (rhTSH) in this population. We mailed a 13-item pilot survey to patients with DTC who had undergone withdrawal before diagnostic whole-body scan (dxWBS). Using survey results and actual and estimated cost data, we retrospectively constructed a societal cost model comparing withdrawal versus rhTSH and performed a sensitivity analysis by increasing the conservatism of 8 assumptions about withdrawal costs. One hundred thirty (55%) of 236 patients answered the questionnaire. Among respondents, 92% had symptomatic and 85% multisymptomatic hypothyroidism. Almost half sought medical attention for hypothyroid complaints. Approximately one third drove motor vehicles while hypothyroid. Median absence from salaried work was 11 days per withdrawal. In the pharmacoeconomic model, societal costs per dxWBS were approximately 326 euro (25%) greater for withdrawal than for rhTSH. In the sensitivity analysis, societal costs of rhTSH exceeded those of withdrawal by approximately 307 euro (30%). In conclusion, hypothyroidism secondary to withdrawal causes important morbidity, safety risks, and productivity impairment. rhTSH avoids these drawbacks at roughly equivalent societal cost to that of withdrawal.
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Affiliation(s)
- Markus Luster
- Department of Nuclear Medicine, University of Würzburg, Germany.
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Huang CH, Chou KJ, Lee PT, Chen CL, Chung HM, Fang HC. A case of lymphocytic hypophysitis with masked diabetes insipidus unveiled by glucocorticoid replacement. Am J Kidney Dis 2005; 45:197-200. [PMID: 15696461 DOI: 10.1053/j.ajkd.2004.09.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Lymphocytic hypophysitis may involve the pituitary gland and various hormonal abnormalities. A 72-year-old man presented with euvolemic hyponatremia caused by glucocorticoid deficiency. After glucocorticoid replacement, hypernatremia in the presence of dilute urine was found. Central diabetes insipidus (DI) was confirmed later by a significant increase in urine osmolality after vasopressin administration. Brain magnetic resonance imaging showed a pituitary mass and loss of hyperintense signal in the posterior pituitary gland on T1-weighted imaging. The patient underwent a transsphenoidal adenectomy, and pathological examination of dissected tissues showed a typical finding of lymphocytic hypophysitis. Two months after surgery, the patient's central DI had resolved sufficiently that 1-desamino-8- d -arginine vasopressin therapy was discontinued without polyuria. However, he was kept on glucocorticoid and levothyroxine therapy. In conclusion, lymphocytic hypophysitis may feature a concealed central DI caused by glucocorticoid deficiency-associated hyponatremia.
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Affiliation(s)
- Chun-Hao Huang
- Department of Medicine, Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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Gonc EN, Kandemir N, Sen Y, Yordam N. Hyponatremia can be a presenting finding of multiple pituitary hormone deficiency in children: report of a case and review of literature. Clin Pediatr (Phila) 2005; 44:623-8. [PMID: 16151569 DOI: 10.1177/000992280504400711] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- E Nazli Gonc
- Hacettepe University Faculty of Medicine, Division of Pediatric Endocrinology, Ankara, Turkey
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Taskapan C, Sahin I, Taskapan H, Kaya B, Kosar F. Possible malignant neuroleptic syndrome that associated with hypothyroidism. Prog Neuropsychopharmacol Biol Psychiatry 2005; 29:745-8. [PMID: 15927337 DOI: 10.1016/j.pnpbp.2005.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2005] [Indexed: 11/30/2022]
Abstract
A 54-year-old woman with schizophrenia presented to hospital with unconsciousness, fever and marked muscle rigidity. She had been given fluphenazine decanoete 20 mg intramuscularly 15 days before the admission and she had continued taking haloperidol 20 mg daily and oral biperiden 2-4 mg. She was extremely rigid and unresponsive. On laboratory investigations revealed: serum sodium 120 mEq/l, creatinine phosphokinase 12,980 IU/l (normal up to 170), lactate dehydrogenase 1544 IU/l (150-500), free trioidothyronine < 1.00 pg/ml (1.5-4.5), free throxyine 0.76 ng/dl (0.8-1.9), thyroid stimulating hormone 1.14 microU/ml (0.4-4), cortisol (at 8.00 a.m.) 9 microg/dl (5-25). Antipsychotic drugs were withdrawn after admission. A diagnosis of secondary adrenal insufficiency and secondary hypothyroidism was made. Hormonal substitution with hydrocortisone and levothyroxine and correction of hyponatremia with intravenous hypertonic saline solution resulted in rapid improvement of symptoms and signs. It seems that the symptoms and signs of hypothyroidism and hyponatremia were attributed to acute psychosis in this patient. As a conclusion failure to recognize the endocrinopathy may not only produce recovery difficulties but also psychiatric and endocrine repercussions if psychotropic medications are given in such masked cases.
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Affiliation(s)
- Cagatay Taskapan
- Department of Biochemistry, Inonu University Faculty of Medicine, Turgut Ozal Medical Center, 44069 Malatya, Turkey.
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Kohlfuerst S, Igerc I, Lind P. Recombinant human thyrotropin is helpful in the follow-up and 131I therapy of patients with thyroid cancer: a report of the results and benefits using recombinant human thyrotropin in clinical routine. Thyroid 2005; 15:371-6. [PMID: 15876162 DOI: 10.1089/thy.2005.15.371] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
There is no doubt that the availability of recombinant human thyrotropin (rhTSH) is one of the milestones in the management of patients with differentiated thyroid cancer (DTC). It offers the opportunity to obtain representative serum thyroglobulin (Tg) levels and diagnostic whole-body scanning (Dx WBS) with 131I under adequate TSH elevation, while the patient continues to receive thyroid hormone. But rhTSH is also used with success in the treatment of local recurrences and distant metastases. In this retrospective analysis we were able to show that our excellent clinical experiences with the use of rhTSH (rare side effects and high compliance) could also be demonstrated by sufficiently elevated TSH levels and representative stimulated Tg measurements. Since April 2001 most of the patients with thyroid cancer in our hospital have undergone diagnostic examination (205 patients underwent 319 examinations) and 131I therapy (a total of 68 treatments) with rhTSH stimulation excluding the first radioiodine ablation of remnants after initial thyroidectomy. Our results show that under rhTSH stimulation 83.5% (diagnostic group) and 88% (therapy group) of our patients with DTC obtained a TSH level of greater than 80 mU/L after two injections of rhTSH (Thyrogen, Genzyme Corp., Cambridge, MA) 0.9 mg intramuscularly 24 hours and 48 hours before the administration of 131I. Only 2.3% (diagnostic group) and 0% (therapy group) demonstrated TSH levels less than 50 mU/L. Serum Tg levels under rhTSH-stimulated conditions showed that in 81.2% the serum Tg maximum was obtained on day 5. Because of the costs associated with periodically rhTSH-assisted Tg testing and based on the data of other studies we are now testing mainly on day 5 to identify residual tumor mass and to compare these Tg levels in the follow-up. Our experience demonstrates that the administration of rhTSH is a safe, effective, and-from an economic point of view- valuable tool in the management of patients with DTC.
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Affiliation(s)
- Susanne Kohlfuerst
- Department of Nuclear Medicine and Endocrinology, PET Center, LKH Klagenfurt, St. Veiterstrase 47, 9020 Klagenfurt, Austria.
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Woodrum DT, Gauger PG. Role of131I in the treatment of well differentiated thyroid cancer. J Surg Oncol 2005; 89:114-21. [PMID: 15719384 DOI: 10.1002/jso.20185] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
(131)I is an integral component in postsurgical management of well-differentiated thyroid cancer (WDTC), which includes papillary and follicular types. (131)I is used postsurgically to either destroy remaining thyroid tissue (thyroid ablation) or to treat recurrence and metastases (radioiodine therapy). (131)I is no longer a routine diagnostic modality, but it is widely used for remnant ablation after thyroidectomy for WDTC > 1 cm, under conditions of thyroxine withdrawal. It is generally-though not unanimously-accepted that postsurgical radioiodine is the most powerful method by which to lengthen disease-free survival. (131)I cannot be used if the residual thyroid remnant is large; many surgeons therefore perform near-total or total thyroidectomy for all WDTC > 1 cm. Since 1997, radioiodine treatment has been performed in outpatient settings, where side effects are common, but mild and transient. Secondary screening is by physical exam, thyroglobulin measurements, and (131)I diagnostic whole-body scans. This is performed under conditions of thyrotropin stimulation, which is accomplished either by thyroxine withdrawal or administration of recombinant human thyrotropin. While most cancers are well treated with radioiodine, some advanced cancers may no longer take up radioiodine, rendering them resistant to treatment. For these cancers, redifferentiation therapy and molecular target-specific medicines hold future promise for improved treatment.
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Affiliation(s)
- Derek T Woodrum
- Division of Endocrine Surgery, University of Michigan Department of Surgery, Ann Arbor, Michigan, USA
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Abstract
OBJECTIVE To review clinical information on the incidence and causes of hyponatremia (defined as a serum sodium level <130 mEq/L), the most common electrolyte abnormality seen in general hospital patients, and to discuss the diagnosis and treatment of hyponatremia in relation to these factors. DATA SOURCES Primary sources and review articles were identified via MEDLINE (1981-July 2003) for entries on hyponatremia. We limited the search to specific topics including incidence, risk factors, diagnosis, treatment, and clinical disorders and medications associated with hypotonic hyponatremia. STUDY SELECTION AND DATA EXTRACTION All of the articles identified were evaluated, and relevant and representative information was included in this review. DATA SYNTHESIS Hyponatremia can result from several disease states, injury, surgery, physical exercise, or the administration of certain drugs (e.g., antidepressants, antiepileptics) and is associated with advanced age. Drug-induced hyponatremia is often asymptomatic and usually resolves following water restriction and monitoring of medication. Symptoms of hyponatremia are primarily neurologic; the principal danger of hyponatremia relates to effects on central nervous system function due to changes in brain size. CONCLUSIONS Although hyponatremia can be a serious condition, appropriate measures for the management of at-risk and affected patients will lead to full recovery in most cases.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390-8856, USA.
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Kaufman KR, Gerner R. Adjunctive oxcarbazepine in comorbid anxiety and affective disorder with hyponatremic seizure: case analysis and literature review. Epilepsy Behav 2003; 4:766-70. [PMID: 14698716 DOI: 10.1016/j.yebeh.2003.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Rational polypharmacy is required for management of refractory psychiatric disorders. Antiepileptic drugs are increasingly used as primary or adjunctive agents in the treatment of affective, schizoaffective, anxiety, and impulse control disorders. In this case report, the authors present the first case of hyponatremic seizure associated with oxcarbazepine in adjunctive treatment of comorbid affective/anxiety disorders.
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Affiliation(s)
- Kenneth R Kaufman
- Department of Psychiatry, UMDNJ-Robert Wood Johnson Medical School, 125 Paterson Street, Suite 2200, 08901, New Brunswick, NJ, USA.
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Emerson CH, Torres MST. Recombinant human thyroid-stimulating hormone: pharmacology, clinical applications and potential uses. BioDrugs 2003; 17:19-38. [PMID: 12534318 DOI: 10.2165/00063030-200317010-00003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The major functions of pituitary thyroid-stimulating hormone (TSH) are to maintain the biosynthesis and secretion of the thyroid hormones L-thyroxine (T4) and L-3,5,3'triidothyronine (T3). The TSH core contains two apoproteins, the alpha and beta subunits. The alpha subunit is identical to that of pituitary follitropin, pituitary lutropin and placental chorionic gonadotropin, whereas the beta subunit is unique. TSH is a glycoprotein; the glycoprotein components of the alpha and beta subunits account for more than 10% of their mass and are essential for normal thyrotropic action and intravascular kinetics. The hypothalamic tripeptide, TSH-releasing hormone (TRH) is required for optimum TSH biosynthesis, particularly as far as addition of the glycoprotein components is concerned. TRH deficiency is associated with secretion of TSH molecules that are appropriately measured in most assays but have reduced bioactivity. In previous years the TSH used in clinical practice was obtained and purified from bovine pituitaries. Bovine TSH was used to test thyroid function and to augment the uptake of radioiodine in patients with thyroid cancer. Bovine TSH has been largely abandoned as a clinical agent because of adverse immune reactions. A recombinant human TSH (rhTSH; Thyrogen), has been approved by the US FDA for diagnostic use in patients with thyroid cancer. The alpha and beta subunits of Thyrogen are identical to those of human pituitary TSH. Thyrogen has a specific activity of approximately 4 IU/mg and is a potent stimulator of T4, T3 and thyroglobulin (Tg) secretion in healthy volunteers. It also increases thyroid iodide uptake in patients with thyroid cancer or multinodular goitre and in volunteers, even those exposed to large amounts of stable iodide. Thyroid cancer patients who have been treated by thyroidectomy and radioiodine ablation but are at risk of harbouring residual thyroid cancer are candidates for Thyrogen administration to prepare them for whole body iodide scans and serum Tg measurements. In thyroidectomised thyroid cancer patients who are unable to secrete pituitary TSH upon thyroid hormone withdrawal, Thyrogen is the only acceptable method to prepare them for these procedures. Thyrogen has been used on a compassionate basis to prepare patients for radioiodine ablation. rhTSH, in addition to being useful in the management of patients with thyroid cancer, is potentially useful to test thyroid reserve and to aid in thyroid-related nuclear medicine procedures. In the future, TSH analogues that have superagonist or antagonist properties may become available as therapeutic agents.
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Affiliation(s)
- Charles H Emerson
- Department of Medicine, University of Massachusetts School of Medicine, Worcester, Massachusetts 01655, USA.
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del-Río Camacho G, Tapia Ceballos L, Picazo Angelín B, Ruiz Moreno JA, Hortas Nieto ML, Romero González J. Renal failure and acquired hypothyroidism. Pediatr Nephrol 2003; 18:290-2. [PMID: 12644927 DOI: 10.1007/s00467-002-1033-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2002] [Revised: 09/26/2002] [Accepted: 09/30/2002] [Indexed: 11/27/2022]
Abstract
The effects of thyroid metabolism on renal function in children are barely referred to in the literature. Primary hypothyroidism is known to be associated with a consistent elevation in serum creatinine levels. This is essentially because of the hypodynamic state that occurs in hypothyroidism, leading to a reduced glomerular filtration rate and hypercreatinemia. A teenager who developed renal failure due to primary hypothyroidism is reported. He displayed diverse serum biochemistry anomalies with an unremarkable physical examination. Thyroxine replacement therapy completely restored the euthyroid state and renal function. We propose, in accordance with other authors, measurement of thyrotropin levels in patients with hypercreatinemia.
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Affiliation(s)
- Genoveva del-Río Camacho
- Department of Pediatrics, Hospital Costa del Sol, Carretera nacional 340, Km 187, Marbella, Málaga, Spain.
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Pellegriti G, Scollo C, Giuffrida D, Vigneri R, Squatrito S, Pezzino V. Usefulness of recombinant human thyrotropin in the radiometabolic treatment of selected patients with thyroid cancer. Thyroid 2001; 11:1025-30. [PMID: 11762711 DOI: 10.1089/105072501753271707] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Treatment of persistent/recurrent differentiated thyroid cancer is based on surgery, when feasible, and malignant tissue ablation by 131I administration. This procedure requires levothyroxine withdrawal to obtain high levels of endogenous thyrotropin (TSH) to stimulate radioactive iodine uptake by the malignant tissue. Levothyroxine withdrawal may cause severe adverse effects and complications in patients with concomitant illness or advanced metastatic disease. The recent availability of recombinant human thyrotropin (rhTSH) allows diagnostic whole-body scan (WBS) and thyroglobulin testing without levothyroxine withdrawal. We describe six patients with metastatic differentiated thyroid cancer (DTC) and concomitant illness in whom the use of rhTSH was effective in preventing the complications that patients had previously experienced during hypothyroidism consequent to levothyroxine withdrawal. Our results indicate that rhTSH can be particularly advantageous to avoid signs and symptoms of hypothyroidism and complications because of associated diseases in view of 131I treatment of DTC metastases in selected cases in which levothyroxine withdrawal may be dangerous. Its efficacy to treat advanced metastatic disease should be further investigated.
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Affiliation(s)
- G Pellegriti
- Istituto di Medicina Interna e Malattie Endocrine e del Metabolismo, University of Catania Medical School, Ospedale Garibaldi, Catania, Italy.
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Burke MP, Opeskin K. Sudden death from hyponatremia and hypokalemia in a woman with Gardner syndrome. Am J Forensic Med Pathol 2001; 22:84-7. [PMID: 11444670 DOI: 10.1097/00000433-200103000-00017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The authors present the case of a 39-year-old woman with Gardner syndrome who died from marked hyponatremia and hypokalemia. Gardner syndrome is a rare variant of the familial adenomatous polyposis syndrome in which the affected individual develops thousands of polyps within the gastrointestinal tract, with a 100% risk of eventual malignant change. Individuals with Gardner syndrome also develop a variety of extra gastrointestinal abnormalities. In the case presented, a woman with a clinical history of Gardner syndrome who had previously undergone a total colectomy with ileorectal anastomosis presented to the hospital with a recent history of sore throat, fever, diarrhea, and abdominal pain. The symptoms were considered clinically to be due to a viral gastroenteritis. She was admitted to the hospital, where she had episodes of collapse believed to be vasovagal in origin. She suffered a cardiorespiratory arrest and died 24 hours after admission. After her death, electrolyte estimation performed on blood taken shortly before death revealed severe hyponatremia and hypokalemia. Postmortem examination showed the gastric mucosa to be virtually covered by innumerable adenomatous and hyperplastic polyps. Fewer polyps were seen within the small bowel. There was no evidence of malignancy. The features were consistent with Gardner syndrome. Hyponatremia and hypokalemia have been described in patients with villous adenomas and in familial adenomatous polyposis syndromes associated with numerous colonic polyps. The cause of death in this case was considered to be hyponatremia and hypokalemia associated with florid gastric polyps in a woman with Gardner syndrome. Viral gastroenteritis contributed to the death by causing further electrolyte depletion. To the best of the authors' knowledge, death in Gardner syndrome has not been described as attributable to such metabolic disturbance, in particular in those who have only gastric, small bowel, and rectal polyps remaining after total colectomy.
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Affiliation(s)
- M P Burke
- Victorian Institute of Forensic Medicine, Southbank Victoria, Australia
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