Hypothyroidism in children with steroid-resistant nephrotic syndrome

Overt Hypothyroidism and Severe Growth Retardation in a Preschool Girl with Poorly Controlled Nephrotic Syndrome: Case Report and Literature Review

Background

Nephrotic children may develop thyroid hormone dysfunction due to urinary excretion of thyroid hormones. In contrast to the subclinical hypothyroidism that affects around 30% of children with nephrotic syndrome (NS), the patient in this case had overt hypothyroidism and severe growth retardation.

Clinical case

A 5 years and 8 months old girl with steroid-dependent NS was referred from another center due to persistent edema and decreased diuresis, being treated with mycophenolate mofetil (MMF) 250 mg once a day and L-thyroxine 50 mcg daily since 4 months of NS onset because of hypothyroidism. Her albumin was 12.64 g/l, cholesterol 25.64 mmol/l and proteinuria 5 g/l. Severe growth retardation was observed: patient's height was 93.5 cm (-13 cm <3 percentile), weighted 17.2 kg (15-25 percentile). Her disease vintage was over 3 years. Girl's growth velocity has slowed down from 3.5 months. The patient received a high cumulative dose of prednisolone (approx. 7800 mg in 1 year and 8 months). Thyroid-stimulating hormone was higher (18.04 mU/L) with reduced FT4 11.43 pmol/l and IGF-1 < 15 µg/L. Kidney biopsy revealed minimal change disease, and genetic testing was negative. Intensive NS treatment with methylprednisolone pulse therapy, enlarged doses of MMF and albumin infusion were started and L-thyroxine dose was increased to 75 mcg. TPOAb was in normal range (12.65 IU/ml). After 3 weeks she was discharged with no edema and after stopping methylprednisolone treatment thyroid function normalized and L-thyroxin was discontinued. Two weeks later standard growth hormone stimulation test with clonidine showed partially insufficient growth hormone secretion. During NS remission with normalization of thyroid function (TSH 6.680 mU/l, FT4 13.85 pmol/l) and normalization of IGF-1 level (132 mcg/l) partial catch-up growth was observed (height velocity increased from 3.5 cm/year to 7.3 cm/year, based on 4-month calculation period).

Conclusions

Clinicians should be aware of a risk of developing hypothyroidism and consider thyroid function testing during the treatment of children with NS, as well as actively treat hypothyroidism and evaluate growth.

Association between albuminuria and thyroid function in patients with chronic kidney disease

PURPOSE

The relationship between proteinuria and thyroid function remains controversial in patients with chronic kidney disease (CKD). We prospectively investigated the association between kidney and thyroid function in thyroid antibody-negative patients through all CKD stages.

METHODS

We enrolled 184 nondialysis patients (mean age: 63.1 ± 16.9 years) without previous thyroid disease or thyroid-specific antibodies. Kidney function was assessed by estimating the glomerular filtration rate (eGFR) classified according KDIGO (CKD G1-5). Kidney damage was assessed by albuminuria (albumin-to-creatinine ratio, ACR) and classified as mild, moderate, or severe (ACR1: <300, ACR2: 300-3000, and ACR3: 3000 mg/g). To evaluate thyroid function, TSH, T4, fT4, T3, fT3, reverse T3 (rT3), and thyroxine-binding globulin (TBG) were measured.

RESULTS

rT3 concentrations correlated negatively with albuminuria (r = -0.286, p < 0.001) and were significantly lower in patients with severe albuminuria than in those with mild or moderate albuminuria (ACR3: 0.28 vs. ACR2: 0.32 vs. ACR1: 0.36 nmol/l, p < 0.001). The severity of albuminuria revealed no impact on TSH, fT4, T3, fT3, and TBG. EGFR correlated with increasing T4, fT4, T3, fT3, and TBG (T4: r = 0.289, p < 0.01; fT4: r = 0.196, p < 0.01; T3: r = 0.408, p < 0.01; fT3: r = 0.390, p < 0.01) but not with rT3.

CONCLUSIONS

In thyroid antibody-negative patients presenting advanced CKD (stages 4 and 5), even severe kidney protein loss failed to influence thyroid hormone status. However, albuminuria severity correlated negatively with rT3, which was significantly lower in patients with albuminuria in the nephrotic range.

Severity of Proteinuria Is Directly Associated With Risk of Hypothyroidism in Adults

CONTEXT

Proteinuria can cause or exacerbate hypothyroidism, possibly due to urinary loss of protein-bound thyroid hormone. However, the precise relationship between proteinuria and hypothyroidism remains unclear.

OBJECTIVE

This work aimed to determine the prevalence of hypothyroidism in patients with proteinuria and the relationship between hypothyroidism and degree of proteinuria.

DESIGN

A retrospective cohort study was conducted from December 1979 to March 2015.

SETTING

This study was conducted at a large academic hospital.

PATIENTS

All paired samples of urine protein and serum thyrotropin (TSH), measured within 24 hours, were obtained from adults (age > 18 years) with at least one instance of urine protein greater than 0.2 g/day or mg/mg creatinine.

MAIN OUTCOME MEASURES

Samples were stratified by urine protein tertile. Mean TSH and risk of TSH elevation were compared among tertiles using analysis of covariance and generalized estimating equations controlled for age, sex, samples per patient, and levothyroxine treatment.

RESULTS

A total of 2676 samples were identified from 2136 patients. Mean ± SE TSH (mIU/L) was increased in the highest tertile of urine protein (> 1.75g/day) compared to the lower 2 tertiles (2.09 ± 0.07 vs 1.59 ± 0.07, 1.59 ± 0.06, P < .001). The highest tertile had a greater prevalence of TSH greater than 5 mIU/L (17.2% vs 10.5%, 11.9%, P < .001) but a similar risk of TSH greater than 5 mIU/L (odds ratio [OR] 1.44; 95% CI, 0.67-3.09, P = .35). The highest tertile also had a higher prevalence (6.2% vs 3.4%, 2.6%, P = .003) and risk (OR 1.72; 95% CI, 1.05-2.84, P = .008) of TSH greater than 10 mIU/L. Similar results were observed when comparing samples with nephrotic-range proteinuria (> 3.5g/day) to those with lesser proteinuria.

CONCLUSION

Hypothyroidism is common among adults with proteinuria, and the risk of hypothyroidism is directly related to the severity of proteinuria.

Thyroid Dysfunction in Children with Idiopathic Nephrotic Syndrome Attending a Paediatric Hospital in Qazvin, Iran

Objectives

Nephrotic syndrome is a glomerular disease characterised by a loss of albumin and high-molecular-weight proteins such as thyroxine-binding globulin and thyroid hormones, potentially resulting in subclinical or even overt hypothyroidism. This study aimed to compare thyroid hormone levels between nephrotic children and healthy controls as well as between nephrotic children in the active phase of the disease and those in remission.

Methods

This case-control study was conducted between March 2016 and 2018 at a paediatric hospital in Qazvin, Iran. A total of 73 nephrotic children comprised the case group—including 49 with active disease and 24 in remission—while the control group included 74 healthy children. Thyroid function was assessed according to levels of thyroid-stimulating hormone (TSH), free triiodothyronine (T3), free thyroxine (T4), total T4, total T3 and anti-thyroid peroxidase.

Results

All of the controls had normal total T4 levels. Elevated TSH levels were more frequent in nephrotic children compared to controls (34.2% versus 10.8%; P = 0.001). A significantly lower number of patients with active disease were euthyroid compared to those in remission (51% versus 95.8%; P = 0.001). Moreover, 7 (9.5%) of patients in the active and no patient in remission phase had abnormal total T4 levels (P <0.001), while 14.3% and 0% had highly elevated TSH levels (P = 0.002).

Conclusion

Due to the prevalence of subclinical and even overt hypothyroidism, thyroid screening tests may be required for nephrotic children. However, further research is needed to confirm these findings.

IPNA clinical practice recommendations for the diagnosis and management of children with steroid-resistant nephrotic syndrome

Idiopathic nephrotic syndrome newly affects 1-3 per 100,000 children per year. Approximately 85% of cases show complete remission of proteinuria following glucocorticoid treatment. Patients who do not achieve complete remission within 4-6 weeks of glucocorticoid treatment have steroid-resistant nephrotic syndrome (SRNS). In 10-30% of steroid-resistant patients, mutations in podocyte-associated genes can be detected, whereas an undefined circulating factor of immune origin is assumed in the remaining ones. Diagnosis and management of SRNS is a great challenge due to its heterogeneous etiology, frequent lack of remission by further immunosuppressive treatment, and severe complications including the development of end-stage kidney disease and recurrence after renal transplantation. A team of experts including pediatric nephrologists and renal geneticists from the International Pediatric Nephrology Association (IPNA), a renal pathologist, and an adult nephrologist have now developed comprehensive clinical practice recommendations on the diagnosis and management of SRNS in children. The team performed a systematic literature review on 9 clinically relevant PICO (Patient or Population covered, Intervention, Comparator, Outcome) questions, formulated recommendations and formally graded them at a consensus meeting, with input from patient representatives and a dietician acting as external advisors and a voting panel of pediatric nephrologists. Research recommendations are also given.

The relationship between thyroid dysfunction and nephrotic syndrome: a clinicopathological study

Abnormalities of thyroid function are common in patients with nephrotic syndrome (NS). However, a limited number of studies have reported on the association between clinicopathologic features and thyroid dysfunction in patients with NS. We retrospectively studied 317 patients who had been definitively diagnosed with NS. The NS patients with thyroid dysfunction showed higher urine protein, creatinine and lipid levels and lower albumin and hemoglobin than those with normal thyroid function, with no significant differences of pathological types. After dividing thyroid dysfunction groups into five subgroups, interestingly, membranous nephropathy was the most common pathologic type, both in normal thyroid group and in subclinical hypothyroidism group (40.4% and 46.7%, respectively), followed by minimal change disease (28.1% and 21.7%, respectively); while in the hypothyroid, low T3, and low T3T4 groups minimal change disease is now the leading type (48.8%, 33.3% and 38.6%, respectively). High levels of urinary protein, creatinine, cholesterol, and platelets were independent risk factors predicting thyroid dysfunction, while higher albumin and hemoglobin were protective factors. We demonstrated that the type of renal pathology was different among NS patients in different thyroid dysfunction subgroups. Interpretation of the interactions between thyroid and renal function is a challenge for clinicians involved in the treatment of patients with NS.

Changes in the thyroid hormone profiles in children with nephrotic syndrome

Purpose

We compared thyroid hormone profiles in children with nephrotic syndrome (NS) during the nephrotic phase and after remission.

Methods

This study included 31 pediatric NS patients. The thyroid hormone profiles included serum levels of triiodothyronine (T3), thyroxine (T4), thyroid-stimulating hormone (TSH), and free T4.

Results

Of the 31 patients, 16 (51.6%) showed abnormal thyroid hormone profiles: 6 had overt hypothyroidism, 8 had subclinical hypothyroidism, and 2 had low T3 syndrome. The mean serum T3, T4, and free T4 levels in the nephrotic phase and after remission were 82.37±23.64 and 117.88±29.49 ng/dL, 5.47±1.14 and 7.91±1.56 µg/dL, and 1.02±0.26 and 1.38±0.23 ng/dL, respectively; the levels were significantly lower in the NS nephrotic phase (P=0.0007, P<0.0001, and P=0.0002). The mean serum TSH levels during the nephrotic phase and after remission were 8.05±3.53 and 4.08±2.05 µIU/ mL, respectively; they were significantly higher in the nephrotic phase (P=0.0005). The urinary protein/ creatinine ratio during the nephrotic phase was significantly correlated with serum T3, T4, and free T4 levels (r=-0.5995, P=0.0032; r=-0.5797, P=0.0047; r=-0.5513, P=0.0078) as well as with TSH levels (r=0.5022, P=0.0172). A significant correlation was found between serum albumin and serum T3 levels during the nephrotic phase (r=0.5385, P=0.0018) but not between serum albumin and T4, TSH, or free T4 levels. These significant correlations all disappeared after remission.

Conclusion

Abnormal thyroid hormone profile findings were observed in 51.6% of pediatric patients with NS. Thyroid hormone levels normalized after remission, regardless of levothyroxine therapy.

Non-Autoimmune Subclinical and Overt Hypothyroidism in Idiopathic Steroid-resistant Nephrotic Syndrome in Children

OBJECTIVE

To evaluate the frequency of non-autoimmune subclinical and overt hypothyroidism in children with idiopathic steroid-resistant nephrotic syndrome (SRNS).

METHODS

This cross-sectional study recruited 30 children (age 1-18 y) with idiopathic SRNS; and 30 healthy controls. Serum T3, T4 and TSH were performed in cases as well as controls. Anti-thyroid peroxidase and anti-thyroglobulin antibody tests were performed in all cases.

RESULTS

Non-autoimmune subclinical or overt hypothyroidism was detected in 10 out of 30 children with idiopathic SRNS; 2 had overt hypothyroidism, while 8 patients had subclinical hypothyroidism. Children with SRNS had a mean (SD) TSH value 4.55 (4.64) mIU/L that was higher as compared to controls (1.88 (1.04) mIU/L) (P<0.01). Focal segmental glomerulosclerosis (FSGS) was the commonest histopathological condition, seen in 13 (43.3%). Children with overt hypothyroidism (2 cases) and grade III subclinical hypothyroidism (1 case) were subsequently started on levothyroxine therapy.

CONCLUSION

The prevalence of subclinical and overt hypothyroidism seems to be high in idiopathic SRNS, with almost one-third of children having overt or subclinical non-autoimmune hypothyroidism.

Renal Biopsy Findings in Patients with Hypothyroidism: Report of 16 cases

INTRODUCTION

Hypothyroidism is prevalent in India. Its association with renal diseases though not very common but have been described in many studies. Here we are reporting renal biopsy findings in 16 cases, all of whom were already diagnosed cases of hypothyroidism.

AIM

To study renal parenchymal diseases associated in patients with hypothyroidism.

MATERIALS AND METHODS

Formalin fixed paraffin embedded sections of renal biopsy were examined after staining with H&E, PAS and Acid Fuschin Orange G (AFOG) stain. Serum urea/creatinine measurements done by semi-autoanalysers and urine analysis were done by using urine strips and light microscopy.

RESULTS

In 16 cases, M:F ratio was 9:7. Duration of disease varied from 6 months to 14 years. Blood urea and serum creatinine were raised in 10 cases (62.5%) and nephrotic range proteinuria was present in 13 cases (81.25%). Two of the patients had co existing systemic lupus erythaematous. Renal pathology revealed membranous glomerulonephritis (GN) in both cases. In renal biopsy seven cases (43.75%) had pure Membranous Glomerulonephritis (MGN), 4 cases (25%) had mixture of Mesan-gial cell proliferation and membranous Glomerulonephritis(GN) also called MembranoProliferative GN (MPGN). Another four cases (25%) had Focal Segmental Glomerulosclerosis (FSGS) with chronic interstitial nephritis and one case was having minimal change disease.

CONCLUSION

Thus present study concludes that hypothyroidism can cause renal parenchymal disease like membranous GN, mesangiocapillary GN which is also called as membranoproliferative GN and FSGS.

The non-immunosuppressive management of childhood nephrotic syndrome

Idiopathic nephrotic syndrome (INS) is one of the most common renal diseases found in the paediatric population and is associated with significant complications, including infection and thrombosis. A high proportion of children enter sustained remission before adulthood, and therapy must therefore mitigate the childhood complications, while minimising the long-term risk to health. Here we address the main complications of INS and summarise the available evidence and guidance to aid the clinician in determining the appropriate treatment for children with INS under their care. Additionally, we highlight areas where no consensus regarding appropriate management has been reached. In this review, we detail the reasons why routine prophylactic antimicrobial and antithrombotic therapy are not warranted in INS and emphasise the conservative management of oedema. When pharmacological intervention is required for the treatment of oedema, we provide guidance to aid the clinician in determining the appropriate therapy. Additionally, we discuss obesity and growth, fracture risk, dyslipidaemia and thyroid dysfunction associated with INS. Where appropriate, we describe how recent developments in research have identified potential novel therapeutic targets.

A case of minimal change nephrotic syndrome with hypothyroidism deterioration

A 73-year-old woman with Graves' disease underwent total thyroidectomy and was being treated with levothyroxine. She developed edema in the lower region of both legs 1 month before hospitalization. She had a high concentration of urine protein and was hospitalized for further assessment. A urine protein concentration of 4.4 g/day was observed, and she was diagnosed with minimal change nephrotic syndrome (MCNS) after kidney biopsy. The patient's thyroid function had declined, as indicated by a thyroid-stimulating hormone (TSH) level of 139.0 μIU/mL and a free thyroxine (fT4) level of 0.66 ng/dL. She was prescribed 40 mg/day of prednisolone (PSL) and achieved remission. fT4 level normalized on the 36th hospital day. She was in remission subsequently. However, MCNS recurred when PSL was tapered to 10 mg/day. When she was rehospitalized, thyroid function decline was noted once more, with a TSH level of 29.8 μIU/mL and an fT4 level of 0.74 ng/dL. Her oral PSL dose was increased to 30 mg/day, but she did not achieve remission. However, she achieved remission after steroid pulse therapy. After remission, the thyroid function normalized. During the course of her treatment, the levothyroxine dose was maintained at 87.5 μg/day. Therefore, we predicted that the loss of thyroid hormone in urine due to nephrotic syndrome may have led to the aggravation of hypothyroidism. We have reported this case because of its rarity.

Do Not Forget Nephrotic Syndrome as a Cause of Increased Requirement of Levothyroxine Replacement Therapy

Nephrotic syndrome increases L-thyroxine requirements because of urinary loss of free and protein-bound thyroid hormones. We report 2 hypothyroid patients referred to us because of high serum TSH, even though the L-thyroxine daily dose was maintained at appropriate levels or was increased. The cause of nephrotic syndrome was multiple myeloma in one patient and diabetic glomerulosclerosis in the other patient. As part of the periodic controls for diabetes, urinalysis was requested only in the second patient so that proteinuria could be detected. However, as in the first patient, facial puffiness and body weight increase were initially attributed to hypothyroidism, which was poorly compensated by L-thyroxine therapy. In the first patient, the pitting nature of the pedal edema was missed at the initial examination. An endocrinologist consulted over the phone by the practitioner hypothesized some causes of intestinal malabsorption of L-thyroxine. This diagnosis would have been accepted had the patient continued taking a known sequestrant of L-thyroxine, i.e. calcium carbonate. The diagnostic workup of patients with increasing requirements of L-thyroxine replacement therapy should not be concentrated on the digestive system alone. Careful history taking and physical examination need to be thorough. Endocrinologists should not forget nephrotic syndrome that, in turn, can be secondary to serious diseases.

The nephrotic syndrome: pathogenesis and treatment of edema formation and secondary complications

Nephrotic syndrome is an important clinical condition affecting both children and adults. Studies suggest that the pathogenesis of edema in individual patients may occur via widely variable mechanisms, i.e., intravascular volume underfilling versus overfilling. Managing edema should therefore be directed to the underlying pathophysiology. Nephrotic syndrome is also associated with clinically important complications related to urinary loss of proteins other than albumin. This educational review focuses on the pathophysiology and management of edema and secondary complications in patients with nephrotic syndrome.

Steroids combined with levothyroxine to treat children with idiopathic nephrotic syndrome: a retrospective single-center study

BACKGROUND

The clinical efficacy and safety of low-dose levothyroxine in the treatment of idiopathic nephritic syndrome accompanied by thyroid dysfunction have not been established.

METHODS

One hundred and sixty-four patients were divided into three groups according to the levels of thyroid hormone and treatment. The thyroid status, efficacy and adverse reactions of thyroid treatment were observed in each group.

RESULTS

Thyroid dysfunction was found in 73 patients. 40 cases were treated with steroids combined with levothyroxine. Proteinuria, cholesterol and thyroid-stimulating hormone (TSH) levels were significantly higher in patients with thyroid dysfunction, whereas serum albumin and free and total T3 and T4 levels were lower than those of euthyroid patients. The time for proteinuria remission in patients receiving levothyroxine therapy was shorter and their serum albumin higher than for patients without levothyroxine treatment.

CONCLUSIONS

Thyroid hormonal changes are related to the degree of both proteinuria and serum albumin in patients with INS. Combined treatment with low-dose levothyroxine supplementation and steroids in children with INS and thyroid dysfunction is associated with reduced proteinuria and increased plasma albumin compared with patients treated with steroids only.

The thyroid and the kidney: a complex interplay in health and disease

Thyroid hormones may directly affect the kidney and altered kidney function may also contribute to thyroid disorders. The renal manifestations of thyroid disorders are based on hemodynamic alterations or/and to direct effects of thyroid hormones. The renin-angiotensin system plays a crucial role in the cross-talk between the thyroid and the kidney. Hypothyroidism may be accompanied by an increase of serum creatinine and reduction of glomerular filtration rate (GFR), whereas hyperthyroidism may increase GFR. Treatment of thyroid disorders may lead to normalization of GFR. Primary and subclinical hypothyroidism and low triiodothyronine (T3) syndrome are common features in patients with chronic kidney disease (CKD). In addition low levels of thyroid hormones may predict a higher risk of cardiovascular and overall mortality in patients with end-stage renal disease. The causal nature of this correlation remains uncertain. In this review, special emphasis is given to the thyroid pathophysiology, its impact on kidney function and CKD and the interpretation of laboratorial findings of thyroid dysfunction in CKD.

When thyroid hormone replacement is ineffective?

PURPOSE OF REVIEW

In this article, we will consider the failure of thyroid hormone replacement therapy to normalize serum thyroid stimulating hormone concentrations. We will review circumstances and causes for failures, discuss pertinent unpublished personal cases of didactical value, and provide practical suggestions for providers encountering patients with similar presentations.

RECENT FINDINGS

Recent data are available on the benefit of novel formulations of levothyroxine therapy on malabsorption.

SUMMARY

Most frequently, reasons for ineffectiveness are noncompliance, inappropriate administration of levothyroxine, gastrointestinal disorders, and drug interactions. The diagnostic work-up should include careful history to elucidate the potential reasons for the ineffective therapy.

Subclinical non-autoimmune hypothyroidism in children with steroid resistant nephrotic syndrome

BACKGROUND

Thyroid status has not been studied well in children with steroid resistant nephrotic syndrome (SRNS).

METHODS

In this cross sectional study we recruited 20 children aged 1-16 years with SRNS and similar number of controls. Serum levels of FT3, FT4 and TSH were measured in all the subjects. Overt hypothyroidism was defined as low FT4 (normal values: 0.7-2.0 ng/mL) and elevated serum TSH above reference values (0.45-4.5 mIU/L). Subclinical hypothyroidism (SH) was defined as an elevation in serum TSH with a normal serum FT4 concentration. The primary outcome measure was serum levels of FT3, FT4 and TSH in children with SRNS.

RESULTS

Thirty per cent of the children (n = 6) with SRNS had non-autoimmune subclinical hypothyroidism (2 children each with grade I, II and III). Children with SRNS had a median TSH value [3.9 mIU/L (0.5-13)] within normal range, but levels were high as compared to controls. Out of 6 children with SH, 3 were in partial remission, 3 were in complete remission. The TSH levels normalized on thyroxine supplementation in grades II and III subclinical hypothyroidism.

CONCLUSION

Subclinical non-autoimmune hypothyroidism is present in a significant proportion of children with SRNS despite partial or complete remission. Thyroid profile should be evaluated routinely in this subset of patients.