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Jelić Pranjić I, Orlić L, Carević A, Vrdoljak Margeta T, Šimić J, Bubić I. Exploring Thyroid Function after Kidney Transplantation: The Complex Interplay Unacknowledged in Post-Transplant Care. J Clin Med 2024; 13:3559. [PMID: 38930088 PMCID: PMC11204635 DOI: 10.3390/jcm13123559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/10/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Background/Objectives: The interplay between thyroid function and kidney graft function following kidney transplantation remains incompletely understood. Thyroid disorders are more prevalent in kidney transplant recipients than in the general population and are associated with poorer outcomes. Methods: This prospective, single-center study was designed to estimate thyroid function (thyroid-stimulating hormone (TSH), triiodothyronine (T3), free triiodothyronine (FT3), thyroxine (T4), free thyroxine (FT4), as well as anti-thyroid peroxidase antibody (anti-TPO), anti-thyroglobulin antibody (anti-Tg), and thyroid-stimulating immunoglobulin (TSI)) and its influence on kidney graft function among a cohort of 23 kidney transplant recipients during a follow-up period of 12 months. Results: Significantly increased levels of T4 and T3 were observed 12 months post-transplantation, with FT3 levels increasing significantly after 6 months. The prevalence of immeasurably low anti-Tg antibodies rose during follow-up. Initially, 8% of patients showed positive TSI, which turned negative for all after 6 months. A statistically significant correlation was found between the initial TSH and the estimated glomerular filtration rate (eGFR) value 6 months after transplantation (p = 0.023). The graft function was stable. Proteinuria was statistically significantly lower 12 months after transplantation. Conclusions: Identifying additional risk factors, understanding their impact on kidney graft function, and recognizing cardiovascular comorbidities could enhance patient care. Notably, this study marks the first prospective investigation into thyroid function after kidney transplantation in Croatia, contributing valuable insights to the global understanding of this complex interplay.
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Affiliation(s)
- Ita Jelić Pranjić
- Department of Nephrology, Dialysis and Kidney Transplantation, University Hospital Center Rijeka, Tome Strižića 3, 51000 Rijeka, Croatia; (L.O.); (A.C.); (T.V.M.); (J.Š.); (I.B.)
- Department of Internal Medicine, The Faculty of Medicine of the University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Lidija Orlić
- Department of Nephrology, Dialysis and Kidney Transplantation, University Hospital Center Rijeka, Tome Strižića 3, 51000 Rijeka, Croatia; (L.O.); (A.C.); (T.V.M.); (J.Š.); (I.B.)
- Department of Internal Medicine, The Faculty of Medicine of the University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Ana Carević
- Department of Nephrology, Dialysis and Kidney Transplantation, University Hospital Center Rijeka, Tome Strižića 3, 51000 Rijeka, Croatia; (L.O.); (A.C.); (T.V.M.); (J.Š.); (I.B.)
| | - Tea Vrdoljak Margeta
- Department of Nephrology, Dialysis and Kidney Transplantation, University Hospital Center Rijeka, Tome Strižića 3, 51000 Rijeka, Croatia; (L.O.); (A.C.); (T.V.M.); (J.Š.); (I.B.)
| | - Jelena Šimić
- Department of Nephrology, Dialysis and Kidney Transplantation, University Hospital Center Rijeka, Tome Strižića 3, 51000 Rijeka, Croatia; (L.O.); (A.C.); (T.V.M.); (J.Š.); (I.B.)
- Department of Internal Medicine, The Faculty of Medicine of the University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Ivan Bubić
- Department of Nephrology, Dialysis and Kidney Transplantation, University Hospital Center Rijeka, Tome Strižića 3, 51000 Rijeka, Croatia; (L.O.); (A.C.); (T.V.M.); (J.Š.); (I.B.)
- Department of Internal Medicine, The Faculty of Medicine of the University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
- Department of Clinical Sciences I, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 5, 51000 Rijeka, Croatia
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Tani H, Hirashio S, Tsuda A, Tachiyama Y, Hara S, Masaki T. Renal dysfunction caused by severe hypothyroidism diagnosed by renal biopsy: a case report. CEN Case Rep 2024:10.1007/s13730-024-00853-7. [PMID: 38416371 DOI: 10.1007/s13730-024-00853-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/17/2024] [Indexed: 02/29/2024] Open
Abstract
There is a close relationship between thyroid dysfunction and renal dysfunction. However, thyroid dysfunction can unfortunately result in inaccurate measurements of serum creatinine and cystatin C levels. The chronic decrease in cardiac output due to hypothyroidism can reduce renal plasma flow (RPF) resulting in renal dysfunction. We report the case of a 36-year-old male in whom renal dysfunction detected during a company health check-up was found to be caused by severe hypothyroidism. His serum creatinine levels showed poor results, but serum cystatin C levels were within the normal range. The physician thus prioritized serum cystatin C for assessing the patient's renal function, and concluded that his renal function was normal. He subsequently visited our hospital, aged 36 years, for a comprehensive examination. His serum creatinine level was 1.88 mg/dL and his serum cystatin C level was 0.75 mg/dL, indicating an unusual discrepancy between the two measurements. The patient also presented with fatigue, suggesting hypothyroidism, and we therefore evaluated his thyroid function. His free thyroxine level was below the sensitivity of the assay, while his thyroid-stimulating hormone level was > 100 μIU/mL. A renal biopsy was performed to further explore the underlying cause of his renal dysfunction, which suggested that reduced RPF could be the leading cause of his renal ischemia, with no indications of chronic glomerulonephritis or other abnormalities. His hypothyroidism and renal function improved after thyroid hormone replacement therapy. Given the limited reports of renal biopsy tissue examination during the acute phase of hypothyroidism, the current case provides important information regarding the diagnosis of renal dysfunction in patients with hypothyroidism.
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Affiliation(s)
- Hiroki Tani
- Department of Nephrology, National Hospital Organization Hiroshima-Nishi Medical Center, 4‑1‑1 Kuba, Ootake, Hiroshima, 739‑0696, Japan
| | - Shuma Hirashio
- Department of Nephrology, National Hospital Organization Hiroshima-Nishi Medical Center, 4‑1‑1 Kuba, Ootake, Hiroshima, 739‑0696, Japan
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Akihiro Tsuda
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yoshiro Tachiyama
- Department of Diagnostic Pathology, National Hospital Organization Hiroshima-Nishi Medical Center, 4‑1‑1 Kuba, Ootake, Hiroshima, 739‑0696, Japan
| | - Shigeo Hara
- Department of Diagnostic Pathology, Kobe City Medical Center General Hospital, 2-1-1 Minatojimaminamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
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You AS, Kalantar-Zadeh K, Brent GA, Narasaki Y, Daza A, Sim JJ, Kovesdy CP, Nguyen DV, Rhee CM. Impact of Thyroid Status on Incident Kidney Dysfunction and Chronic Kidney Disease Progression in a Nationally Representative Cohort. Mayo Clin Proc 2024; 99:39-56. [PMID: 38176833 PMCID: PMC10795379 DOI: 10.1016/j.mayocp.2023.08.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 08/12/2023] [Accepted: 08/29/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE To examine the relationship between thyroid status and incident kidney dysfunction/chronic kidney disease (CKD) progression. PATIENTS AND METHODS We examined incident thyroid status, ascertained by serum thyrotropin (TSH) levels measured from January 1, 2007, through December 31, 2018, among 4,152,830 patients from the Optum Labs Data Warehouse, containing deidentified retrospective administrative claims data from a large national health insurance plan and electronic health record data from a nationwide network of provider groups. Associations of thyroid status, categorized as hypothyroidism, euthyroidism, or hyperthyroidism (TSH levels >5.0, 0.5-5.0, and <0.5 mIU/L, respectively), with the composite end point of incident kidney dysfunction in patients without baseline kidney dysfunction and CKD progression in those with baseline CKD were examined using Cox models. RESULTS Patients with hypothyroidism and hyperthyroidism had higher risk of incident kidney dysfunction/CKD progression in expanded case-mix analyses (reference: euthyroidism): adjusted hazard ratios (aHRs) (95% CIs) were 1.37 (1.34 to 1.40) and 1.42 (1.39 to 1.45), respectively. Incrementally higher TSH levels in the upper reference range and TSH ranges for subclinical, mild overt, and overt hypothyroidism (≥3.0-5.0, >5.0-10.0, >10.0-20.0, and >20.0 mIU/L, respectively) were associated with increasingly higher risk of the composite end point (reference: TSH level, 0.5 to <3.0 mIU/L): aHRs (95% CIs) were 1.10 (1.09 to 1.11), 1.37 (1.34 to 1.40), 1.70 (1.59 to 1.83), and 1.70 (1.50 to 1.93), respectively. Incrementally lower TSH levels in the subclinical (<0.5 mIU/L) and overt (<0.1 mIU/L) hyperthyroid ranges were also associated with the composite end point: aHRs (95% CIs) were 1.44 (1.41 to 1.47) and 1.48 (1.39 to 1.59), respectively. CONCLUSION In a national cohort, TSH levels in the upper reference range or higher (≥3.0 mIU/L) and below the reference range (<0.5 mIU/L) were associated with incident kidney dysfunction/CKD progression.
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Affiliation(s)
- Amy S You
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Gregory A Brent
- Division of Endocrinology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA; Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Yoko Narasaki
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Andrea Daza
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Southern California, Los Angeles, CA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Danh V Nguyen
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA; Division of General Internal Medicine, University of California Irvine, Orange, CA
| | - Connie M Rhee
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA.
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Prasad N, Singh S, Kumar V, Sahay M, Chaudhury AR, Behera MR, Kushwaha RS, Yadav D, Gautam S, Jaiswal A. Protocol and Methods: Role of Levothyroxine on the Progression of Chronic Kidney Disease in Subclinical Hypothyroid Populations (LP-CKD) - A Multicenter Randomized Controlled Trial. Indian J Nephrol 2023; 33:449-455. [PMID: 38174306 PMCID: PMC10752393 DOI: 10.4103/ijn.ijn_188_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/05/2022] [Accepted: 11/09/2022] [Indexed: 07/19/2023] Open
Abstract
Introduction Subclinical hypothyroidism (SCH) is highly prevalent and associated with chronic kidney disease (CKD). However, it is still unanswered whether the restoration of euthyroid status in these patients will be beneficial in retarding a decline in glomerular filtration rate in early CKD patients. We aim to evaluate the efficacy of levothyroxine therapy versus placebo in slowing estimated glomerular filtration rate (eGFR) decline among CKD patients (stage 2-4) with SCH. Methods This study will be a multicentric, double-blind, randomized, parallel-group, placebo-controlled study. A total of 500 CKD patients, 250 patients in the treatment group and 250 patients in the placebo group, will be randomized. The randomization between the treatment arm and placebo arm will be performed as per the computer-generated random number table in a 1:1 ratio. The sample size was calculated based on the assumed reduction in eGFR after 1-year follow-up in the treatment and placebo groups of 10% and 25%, respectively, at a minimum two-sided 99% confidence interval and 90% power of the study and considering 20% loss on follow-up. Each patient will be followed every 3 months for at least 1 year after randomization. Individuals completing 1-year follow-up visits will be considered for analysis. The baseline and follow-up data will be compared between the treatment and placebo groups. The study will evaluate the efficacy and safety of levothyroxine therapy versus placebo in slowing eGFR decline among CKD patients (stage 2-4) with SCH. The primary endpoint will be the end of follow-up of the patients, reduction of eGFR by ≥50% from a baseline of that patient, or development of ESKD or death of the patients. The secondary endpoint will be any cardiovascular event or arrhythmia after the institution of the drug.
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Affiliation(s)
- Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Shivendra Singh
- Institute of Medical Science, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Vivek Kumar
- Institute of Medical Education and Research, Chandigarh, India
| | - Manisha Sahay
- Osmania Medical College, Osmania General Hospital, Hyderabad, Telangana, India
| | | | - Manas Ranjan Behera
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Ravi Shankar Kushwaha
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Deependra Yadav
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Sonam Gautam
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Akhilesh Jaiswal
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Lo R, Narasaki Y, Lei S, Rhee CM. Management of traditional risk factors for the development and progression of chronic kidney disease. Clin Kidney J 2023; 16:1737-1750. [PMID: 37915906 PMCID: PMC10616454 DOI: 10.1093/ckj/sfad101] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Indexed: 11/03/2023] Open
Abstract
Chronic kidney disease (CKD) and its downstream complications (i.e. cardiovascular) are a major source of morbidity worldwide. Additionally, deaths due to CKD or CKD-attributable cardiovascular disease account for a sizeable proportion of global mortality. However, the advent of new pharmacotherapies, diagnostic tools, and global initiatives are directing greater attention to kidney health in the public health agenda, including the implementation of effective strategies that (i) prevent kidney disease, (ii) provide early CKD detection, and (iii) ameliorate CKD progression and its related complications. In this Review, we discuss major risk factors for incident CKD and CKD progression categorized across cardiovascular (i.e. hypertension, dyslipidemia, cardiorenal syndrome), endocrine (i.e. diabetes mellitus, hypothyroidism, testosterone), lifestyle (i.e. obesity, dietary factors, smoking), and genetic/environmental (i.e. CKDu/Mesoamerican nephropathy, APOL1, herbal nephropathy) domains, as well as scope, mechanistic underpinnings, and management.
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Affiliation(s)
- Robin Lo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Yoko Narasaki
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Sean Lei
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
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6
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Rhee CM, You AS, Narasaki Y, Brent GA, Sim JJ, Kovesdy CP, Kalantar-Zadeh K, Nguyen DV. Development and Validation of a Prediction Model for Incident Hypothyroidism in a National Chronic Kidney Disease Cohort. J Clin Endocrinol Metab 2023; 108:e1374-e1383. [PMID: 37186674 PMCID: PMC11009786 DOI: 10.1210/clinem/dgad261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 04/15/2023] [Accepted: 05/09/2023] [Indexed: 05/17/2023]
Abstract
CONTEXT Hypothyroidism is a common yet under-recognized condition in patients with chronic kidney disease (CKD), which may lead to end-organ complications if left untreated. OBJECTIVE We developed a prediction tool to identify CKD patients at risk for incident hypothyroidism. METHODS Among 15 642 patients with stages 4 to 5 CKD without evidence of pre-existing thyroid disease, we developed and validated a risk prediction tool for the development of incident hypothyroidism (defined as thyrotropin [TSH] > 5.0 mIU/L) using the Optum Labs Data Warehouse, which contains de-identified administrative claims, including medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees as well as electronic health record data. Patients were divided into a two-thirds development set and a one-third validation set. Prediction models were developed using Cox models to estimate probability of incident hypothyroidism. RESULTS There were 1650 (11%) cases of incident hypothyroidism during a median follow-up of 3.4 years. Characteristics associated with hypothyroidism included older age, White race, higher body mass index, low serum albumin, higher baseline TSH, hypertension, congestive heart failure, exposure to iodinated contrast via angiogram or computed tomography scan, and amiodarone use. Model discrimination was good with similar C-statistics in the development and validation datasets: 0.77 (95% CI 0.75-0.78) and 0.76 (95% CI 0.74-0.78), respectively. Model goodness-of-fit tests showed adequate fit in the overall cohort (P = .47) as well as in a subcohort of patients with stage 5 CKD (P = .33). CONCLUSION In a national cohort of CKD patients, we developed a clinical prediction tool identifying those at risk for incident hypothyroidism to inform prioritized screening, monitoring, and treatment in this population.
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Affiliation(s)
- Connie M Rhee
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
- Southern California Institute for Research and Education, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA 90822, USA
| | - Amy S You
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
- Southern California Institute for Research and Education, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA 90822, USA
| | - Yoko Narasaki
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
- Southern California Institute for Research and Education, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA 90822, USA
| | - Gregory A Brent
- Division of Endocrinology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
| | - John J Sim
- Division of Nephrology, Kaiser Permanente Southern California, Los Angeles, CA 90027, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN 38104, USA
- Section of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, TN 38104, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
- Southern California Institute for Research and Education, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA 90822, USA
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Danh V Nguyen
- Division of General Internal Medicine and Primary Care, University of California Irvine, Orange, CA 92868, USA
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Rusu CC, Kacso I, Moldovan D, Potra A, Tirinescu D, Ticala M, Rotar AM, Orasan R, Budurea C, Barar A, Anton F, Valea A, Bondor CI, Ticolea M. Triiodothyronine and Protein Malnutrition Could Influence Pulse Wave Velocity in Pre-Dialysis Chronic Kidney Disease Patients. Diagnostics (Basel) 2023; 13:2462. [PMID: 37510208 PMCID: PMC10377851 DOI: 10.3390/diagnostics13142462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/15/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
Cardiovascular diseases (CVD) are the first cause of chronic kidney disease (CKD) mortality. For personalized improved medicine, detecting correctable markers of CVD can be considered a priority. The aim of this study was the evaluation of the impact of nutritional, hormonal and inflammatory markers on brachial-ankle Pulse Wave Velocity (PWV) in pre-dialysis CKD patients. A cross-sectional observational study was conducted on 68 pre-dialysis CKD patients (median age of 69 years, 41.2% with diabetes mellitus, 52.9% male). Laboratory data were collected, including levels of prolactin, triiodothyronine, TGF α, IL-6, and IL-1β. The high values of brachial-ankle PWV were associated with reduced muscle mass (p = 0.001, r = -0.44), low levels of total cholesterol (p = 0.04, r = -0.26), triglycerides (p = 0.03, r = -0.31), triiodothyronine (p = 0.04, r = -0.24), and prolactin (p = 0.02, r = -0.27). High PWV was associated with advanced age (p < 0.001, r = 0.19). In the multivariate analysis, reduced muscle mass (p = 0.018), low levels of triiodothyronine (p = 0.002), and triglycerides (p = 0.049) were significant predictors of PWV, but age (p < 0.001) remained an important factor. In conclusion, reduced triiodothyronine together with markers of malnutrition and age were associated with PWV in pre-dialysis CKD patients.
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Affiliation(s)
- Crina Claudia Rusu
- Department of Nephrology, University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj, 8 Victor Babeș Street, 400012 Cluj-Napoca, Romania
- Department of Nephrology, County Emergency Clinical Hospital Cluj, 3-5 Clinicilor Street, 400006 Cluj-Napoca, Romania
| | - Ina Kacso
- Department of Nephrology, University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj, 8 Victor Babeș Street, 400012 Cluj-Napoca, Romania
- Department of Nephrology, County Emergency Clinical Hospital Cluj, 3-5 Clinicilor Street, 400006 Cluj-Napoca, Romania
| | - Diana Moldovan
- Department of Nephrology, University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj, 8 Victor Babeș Street, 400012 Cluj-Napoca, Romania
- Department of Nephrology, County Emergency Clinical Hospital Cluj, 3-5 Clinicilor Street, 400006 Cluj-Napoca, Romania
| | - Alina Potra
- Department of Nephrology, University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj, 8 Victor Babeș Street, 400012 Cluj-Napoca, Romania
- Department of Nephrology, County Emergency Clinical Hospital Cluj, 3-5 Clinicilor Street, 400006 Cluj-Napoca, Romania
| | - Dacian Tirinescu
- Department of Nephrology, University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj, 8 Victor Babeș Street, 400012 Cluj-Napoca, Romania
- Department of Nephrology, County Emergency Clinical Hospital Cluj, 3-5 Clinicilor Street, 400006 Cluj-Napoca, Romania
| | - Maria Ticala
- Department of Nephrology, University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj, 8 Victor Babeș Street, 400012 Cluj-Napoca, Romania
- Department of Nephrology, County Emergency Clinical Hospital Cluj, 3-5 Clinicilor Street, 400006 Cluj-Napoca, Romania
| | - Ancuta M Rotar
- Department of Food Science, Faculty of Food Science and Technology, University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca, Calea Manastur 3-5, 400372 Cluj-Napoca, Romania
| | - Remus Orasan
- Nefromed Dialysis Center, 40 Ana Aslan Street, 400528 Cluj-Napoca, Romania
| | - Cristian Budurea
- Nefromed Dialysis Center, 40 Ana Aslan Street, 400528 Cluj-Napoca, Romania
| | - Andrada Barar
- Department of Nephrology, County Emergency Clinical Hospital Cluj, 3-5 Clinicilor Street, 400006 Cluj-Napoca, Romania
| | - Florin Anton
- Department of Cardiology, University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj, 8 Victor Babeș Street, 400012 Cluj-Napoca, Romania
| | - Ana Valea
- Department of Endocrinology, University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj, 8 Victor Babeș Street, 400012 Cluj-Napoca, Romania
| | - Cosmina Ioana Bondor
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj, 6 Pasteur Street, 400349 Cluj-Napoca, Romania
| | - Madalina Ticolea
- Department of Nephrology, County Emergency Clinical Hospital Cluj, 3-5 Clinicilor Street, 400006 Cluj-Napoca, Romania
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Zhang C, Qian C, Wang W, Chen Z, Lin Y, Sun M. AIDS with obesity, hypothyroidism and elevated serum creatinine: A case report. Front Med (Lausanne) 2023; 10:1090659. [PMID: 36999076 PMCID: PMC10043362 DOI: 10.3389/fmed.2023.1090659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 02/24/2023] [Indexed: 03/15/2023] Open
Abstract
Hypothyroidism is a prevalent endocrine illness with a variety of clinical symptoms, but among which elevated serum creatinine is uncommon. Hypothyroidism is also common in acquired immunodeficiency syndrome (AIDS) patients, especially those receiving highly active antiretroviral treatment (HAART). Here we present a case of a young AIDS patient with hypothyroidism, increased serum creatinine, and obesity. Despite the lack of a kidney biopsy, following levothyroxine (LT4) therapy, his serum creatinine recovered to normal levels, and weight loss, edema, weakness, rough skin and other clinical symptoms obtained notable improvement. This highlights the need of clinicians paying attention to whether thyroid function is aberrant in human immunodeficiency virus (HIV) patients with increased creatinine, edema and significant weight gain since prompt thyroid hormone therapy can restore the alterations in renal function and avoid invasive renal biopsy.
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Kidney disease and thyroid dysfunction: the chicken or egg problem. Pediatr Nephrol 2022; 37:3031-3042. [PMID: 35737115 DOI: 10.1007/s00467-022-05640-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/04/2022] [Accepted: 05/19/2022] [Indexed: 01/10/2023]
Abstract
Patients with non-dialysis-dependant chronic kidney disease (NDD-CKD) and dialysis-dependant chronic kidney disease (DD-CKD) frequently also suffer from thyroid disorders, especially hypothyroidism which is found two to five times more often among them compared to the general population. Emerging research has illustrated the potential prognostic implications of this association as NDD-CKD and DD-CKD patients with hypothyroidism have been shown to have higher mortality rates, and treatment of subclinical hypothyroidism in NDD-CKD patients has been reported to attenuate the decline of glomerular filtration rate over time. This review illustrates the bidirectional, multi-layered interplay between the kidneys and the thyroid gland explaining how pathologies in one organ will affect the other and vice versa. Additionally, it outlines the impact of thyroid disorders on routine parameters of kidney function (especially serum creatinine and serum cystatin C) that nephrologists should be aware of in their clinical practice. Lastly, it summarizes the emerging evidence from clinical studies on how treatment of subclinical hypothyroidism in NDD-CKD and DD-CKD patients may potentially have beneficial effects on kidney function as well as mortality. While most of the research in this area has been performed on adult patients, we specifically discuss what is currently known about thyroid dysfunctions in paediatric CKD patients as well and provide management suggestions. The evidence accumulated so far clearly indicates that further, prospective studies with meticulous methodology are warranted to refine our understanding of thyroid disorders in paediatric and adult CKD patients and establish optimal treatment pathways.
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Locatelli F, Del Vecchio L. Hypoxia-Inducible Factor-Prolyl Hydroxyl Domain Inhibitors: From Theoretical Superiority to Clinical Noninferiority Compared with Current ESAs? J Am Soc Nephrol 2022; 33:1966-1979. [PMID: 36041790 PMCID: PMC9678041 DOI: 10.1681/asn.2022040413] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Anemia is a common complication of chronic kidney disease; it is mainly treated with erythropoiesis-stimulating agents (ESAs) and iron. Experimental studies extensively investigated the mechanisms involved in the body's response to hypoxia and led to the discovery of the hypoxia-inducible factor (HIF) pathway and the enzymes regulating its function. HIF-prolyl-hydroxyl domain (PHD) inhibitors are a new class of oral drugs developed to treat anemia in chronic kidney disease. By inhibiting the function of PHD enzymes, they mimic the exposure to moderate hypoxia and stimulate the production of endogenous erythropoietin and very likely increase iron availability. Some data also suggest that their efficacy and, consequently, dose needs are less influenced by inflammation than ESAs. Overall, data from phases 2 and 3 clinical development showed efficacy in anemia correction and maintenance for all of the class molecules compared with placebo (superiority) or erythropoiesis-stimulating agents (noninferiority). Three molecules, roxadustat, vadadustat, and daprodustat, underwent extensive clinical investigation to assess their safety on hard cardiovascular end points, mortality, and special interest events (including cancer and thrombosis). Aside from vadadustat in the nondialysis population, at the prespecified primary analyses, all three molecules met the noninferiority margin for the risk of major cardiovascular events compared with erythropoiesis-stimulating agents or placebo. The reason for this discrepancy is difficult to explain. Other safety signals came from secondary analyses of some of the other randomized clinical trials, including a higher incidence of thrombosis. A more extensive clinical experience with post-marketing data on hard safety issues is needed to define better when and how to use HIF-PHD inhibitors compared with already available ESAs.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital (past Director) ASST Lecco, Lecco, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant’Anna Hospital, ASST Lariana, Como, Italy
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Konishi T, Fujiogi M, Michihata N, Matsui H, Tanabe M, Seto Y, Yasunaga H. Association between body mass index and incidence of breast cancer in premenopausal women: a Japanese nationwide database study. Breast Cancer Res Treat 2022; 194:315-325. [DOI: 10.1007/s10549-022-06638-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/16/2022] [Indexed: 11/02/2022]
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Ettleson MD, Papaleontiou M. Evaluating health outcomes in the treatment of hypothyroidism. Front Endocrinol (Lausanne) 2022; 13:1026262. [PMID: 36329885 PMCID: PMC9623066 DOI: 10.3389/fendo.2022.1026262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
Clinical hypothyroidism is defined by the inadequate production of thyroid hormone from the thyroid gland to maintain normal organ system functions. For nearly all patients with clinical hypothyroidism, lifelong treatment with thyroid hormone replacement is required. The primary goal of treatment is to provide the appropriate daily dose of thyroid hormone to restore normal thyroid function for each individual patient. In current clinical practice, normalization of thyrotropin (TSH) level is the primary measure of effectiveness of treatment, however the use of a single biomarker to define adequate thyroid hormone replacement is being reevaluated. The assessment of clinical health outcomes and patient-reported outcomes (PROs), often within the context of intensity of treatment as defined by thyroid function tests (i.e., undertreatment, appropriate treatment, or overtreatment), may play a role in evaluating the effectiveness of treatment. The purpose of this narrative review is to summarize the prominent health outcomes literature in patients with treated hypothyroidism. To date, overall mortality, cardiovascular morbidity and mortality, bone health and cognitive function have been evaluated as endpoints in clinical outcomes studies in patients with treated hypothyroidism. More recent investigations have sought to establish the relationships between these end results and thyroid function during the treatment course. In addition to clinical event outcomes, patient-reported quality of life (QoL) has also been considered in the assessment of adequacy of hypothyroidism treatment. From a health care quality perspective, treatment of hypothyroidism should be evaluated not just on its effectiveness for the individual patients but also to the extent to which patients of different sociodemographic groups are treated equally. Ultimately, more research is needed to explore differences in health outcomes between different sociodemographic groups with hypothyroidism. Future prospective studies of treated hypothyroidism that integrate biochemical testing, PROs, and end result clinical outcomes could provide a more complete picture into the effectiveness of treatment of hypothyroidism.
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Affiliation(s)
- Matthew D. Ettleson
- Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL, United States
- *Correspondence: Matthew D. Ettleson,
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes and Institute of Gerontology, University of Michigan, Ann Arbor, MI, United States
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You AS, Budoff M, Zeb I, Ahmadi N, Novoa A, Flores F, Hamal S, Kinninger A, Dailing C, Nakata T, Kovesdy CP, Nguyen DV, Brent GA, Kalantar-Zadeh K, Rhee CM. Elevated serum thyrotropin levels and endothelial dysfunction in a prospective hemodialysis cohort. Hemodial Int 2022; 26:57-65. [PMID: 34231302 PMCID: PMC10753993 DOI: 10.1111/hdi.12964] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/13/2021] [Accepted: 06/19/2021] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Thyroid dysfunction is a highly prevalent yet under-recognized complication in hemodialysis patients. In the general population, hypothyroidism has been associated with endothelial dysfunction due to impaired vasodilator synthesis and activity. Little is known about the association of serum thyrotropin (TSH), the most sensitive and specific single biochemical metric of thyroid function, with endothelial function in hemodialysis patients. METHODS In a secondary analysis of 99 patients from the Anti-inflammatory and anti-oxidative nutrition in hypoalbuminemic dialysis patients (AIONID) trial, we examined measurements of serum TSH and endothelial function ascertained by fingertip digital thermal monitoring (DTM), a novel method used to measure micro-vascular reactivity, collected within a 90-day period. DTM was used to measure changes in fingertip temperature during and after an ischemic stimulus (blood pressure cuff occlusion) as an indicator of changes in blood flow, and two DTM indices were assessed, namely adjusted (a) Temperature Rebound (TR), defined as the maximum temperature rebound post-cuff deflation, and adjusted (b) Area Under the Temperature Curve (TMP-AUC), defined as area under the curve between the maximum and minimum temperatures. We examined the relationship between serum TSH with impaired TR (separately) and TMP-AUC (both defined as less than the median level of observed values) using multivariable logistic regression. FINDINGS In unadjusted and case-mix analyses, higher serum TSH levels (defined as the three highest quartiles) were associated with lower (worse) TR (ref: lowest TSH quartile): ORs (95% CI) 2.64 (1.01-6.88) and 2.85 (1.08-7.57), respectively. In unadjusted and case-mix analyses, higher TSH levels were associated with lower (worse) TMP-AUC: ORs (95% CI) 2.64 (1.01-6.88) and 2.79 (1.06-7.38), respectively. DISCUSSION In HD patients, higher serum TSH levels were associated with worse micro-vascular reactivity measured by DTM. Further studies are needed to determine if thyroid hormone supplementation improves endothelial function in hemodialysis patients with lower levels of thyroid function.
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Affiliation(s)
- Amy S. You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California, USA
| | - Matthew Budoff
- Lundquist Institute, Harbor UCLA Medical Center, Torrance, California, USA
| | - Irfan Zeb
- Division of Cardiology, West Virginia University, Morgantown, West Virginia, USA
| | - Naser Ahmadi
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Alejandra Novoa
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California, USA
| | - Ferdinand Flores
- Lundquist Institute, Harbor UCLA Medical Center, Torrance, California, USA
| | - Sajad Hamal
- Lundquist Institute, Harbor UCLA Medical Center, Torrance, California, USA
| | - April Kinninger
- Lundquist Institute, Harbor UCLA Medical Center, Torrance, California, USA
| | | | - Tracy Nakata
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Danh V. Nguyen
- Division of General Internal Medicine, University of California Irvine School of Medicine, Orange, California, USA
| | - Gregory A. Brent
- Division of Endocrinology, Diabetes and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Connie M. Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California, USA
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Pappa T, Heydarpour M, Williams J, Hopkins PN, Adler GK, Alexander EK, Williams G. The Role of Thyroid in Renovascular Function: Independent Association of Serum TSH With Renal Plasma Flow. J Clin Endocrinol Metab 2021; 106:e3327-e3334. [PMID: 34061954 PMCID: PMC8372660 DOI: 10.1210/clinem/dgab390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT There are well-established interactions between the thyroid and the kidney. Thyroid hypofunction is associated with reduced renal plasma flow (RPF), and hypothyroidism is highly prevalent in chronic kidney disease; however, less is known about the thyroid-kidney axis in the euthyroid state. OBJECTIVE This work aimed to study the association of thyroid function with renovascular parameters in a well-phenotyped cohort of euthyroid normotensive and hypertensive individuals. METHODS This cross-sectional, multicenter study of the HyperPATH Consortium took place in 5 US and European academic institutions. A total of 789 individuals, aged 18 to 65 years, with serum thyrotropin (TSH) 0.4 to 5.5 mIU/L, participated; individuals with uncontrolled or secondary hypertension or on medication affecting the hypothalamus-pituitary-thyroid axis were excluded. Hemodynamic parameters including RPF, thyroid function testing, and the Thr92Ala deiodinase 2 (D2) polymorphism were assessed in the setting of a liberal and restricted salt diet. We searched for associations between thyroid function and renovascular parameters and accounted for confounding factors, such as older age, hypertension, and diabetes. RESULTS Serum TSH was inversely associated with RPF assessed in the setting both of liberal and restricted salt diets. This association remained significant and independent when accounting for confounding factors, whereas free thyroxine index (fTI) and the Thr92Ala polymorphism, associated with lower D2 catalytic activity and disrupted thyroid hormone tissue availability, were not independently associated with RPF. Serum TSH remained an independent predictor of RPF on a liberal salt diet when the analysis was restricted to healthy young individuals. CONCLUSION Serum TSH levels, but not fTI nor the Thr92Ala D2 polymorphism, were independently inversely associated with RPF in individuals of the HyperPATH Consortium. These findings suggest a direct interconnection between TSH and renovascular dynamics even with TSH within reference range, warranting further investigation.
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Affiliation(s)
- Theodora Pappa
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Correspondence: Theodora Pappa, MD, PhD, Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women’s Hospital, 221 Longwood Ave, Boston, MA 02115, USA.
| | - Mahyar Heydarpour
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jonathan Williams
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Paul N Hopkins
- Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Gail K Adler
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Erik K Alexander
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Gordon Williams
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Deng B, Yuan Y, Zhong M, Ren R, Deng W, Duan X. The Relationship Between Metabolic Parameters, Age, and Thyroid Status: A Cross-Sectional Study-Based National Survey of Iodine Nutrition, Thyroid Disease. Risk Manag Healthc Policy 2021; 14:1723-1730. [PMID: 33935526 PMCID: PMC8079349 DOI: 10.2147/rmhp.s306122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/31/2021] [Indexed: 01/07/2023] Open
Abstract
Aim The relationship between thyroid status and metabolic factors was investigated as well as iodine nutrition in the general population and among the elderly population. Methods We performed a cross-sectional survey of 2483 subjects to assess the status of national iodine nutrition and incidence of thyroid disease. The general and elderly populations were divided into normal thyroid function (NTF) and subclinical hypothyroidism (SCH) groups. The anthropometric parameters and biochemical indicators were then analyzed. Results Overall, 327 participants were diagnosed with thyroid diseases, 73 (22.32%) of whom were 65 years or older. For the general population, compared with the NTF group, individuals in the SCH group were older, presented with higher systolic blood pressure, fasting blood glucose, serum cholesterol, and urinary iodine concentration (all p<0.05) but lower blood uric acid (UA) (p<0.05). Linear regression analysis further revealed that age and triglyceride (TG) serum levels positively correlated with serum thyroid-stimulating hormone (TSH) levels. Multiple regression analyses revealed that age, TG, waist circumference (WC), and body mass index were independent predictors for abnormal TSH serum levels. For the elderly population, compared with NTF group, individuals in the SCH group were substantially older (p<0.05) but presented with lower UA (p<0.05). Pearson linear regression analysis revealed a positive correlation between age (p=0.003) as well as TG levels (p<0.001) and serum TSH levels. In contrast, WC (p=0.003) was negatively related to TSH serum levels. Further multiple regression analysis revealed that age, TG, WC and heart rate were independent predictors of blood TSH. Conclusion The large-scale national study of iodine nutrition, thyroid disease has shown a vital relationship between metabolic indicators and serum TSH levels. Age and metabolic diseases increase the likelihood of developing thyroid diseases, both the general population and among the elderly.
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Affiliation(s)
- Bo Deng
- Department of Endocrinology, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, People's Republic of China
| | - Yi Yuan
- Department of Endocrinology, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, People's Republic of China
| | - Miao Zhong
- Department of Endocrinology, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, People's Republic of China
| | - Rui Ren
- Department of Endocrinology, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, People's Republic of China
| | - Wuquan Deng
- Department of Endocrinology, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, People's Republic of China
| | - Xiaodong Duan
- Department of Rehabilitation, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, 646000, People's Republic of China
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Jing W, Long G, Yan Z, Ping Y, Mingsheng T. Subclinical Hypothyroidism Affects Postoperative Outcome of Patients Undergoing Total Knee Arthroplasty. Orthop Surg 2021; 13:932-941. [PMID: 33817980 PMCID: PMC8126938 DOI: 10.1111/os.12934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/10/2020] [Accepted: 12/27/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate whether subclinical hypothyroidism could increase the risk of postoperative complications in patients undergoing primary total knee arthroplasty (TKA). METHODS A prospective case-control study of 796 patients undergoing primary TKA between January 2015 and January 2020 was performed. A total of 700 patients (87.9%) were female and the average age of included patients was 65.0 years, with a standard deviation of 5.6. The participants who had subclinical hypothyroidism were referred to as the case group, while those without abnormal thyrotropin (TSH) were included in the control group (matched for age and gender). The fasting plasma levels of TSH were tested in the morning in all patients. The diagnosis of subclinical hypothyroidism was completed by a senior endocrinologist based on laboratory tests; namely, a serum TSH ≥ 5 mu/L and normal free thyroxine (FT4). Subclinical hypothyroidism was further described as mild (TSH < 10 mu/L) or severe (TSH ≥ 10 mu/L). The incidence of 90-day postoperative complications was compared between two cohorts. Logistic regression analysis was used for the risk factors of 90-day postoperative complications following TKA. RESULTS A total of 398 patients had a diagnosis of subclinical hypothyroidism. Among them, 275 cases (69.1%) were described as mild (79 patients [19.8%] with low FT4 and 196 patients [49.2%] with normal FT4 in the repeated test) and 123 cases (30.9%) as severe subclinical hypothyroidism. Of the 196 patients (49.2%) with mild subclinical hypothyroidism and normal FT4, 63 patients (15.8%) had symptoms before surgery. Patients were followed up for an average duration of 25.4 months (6 to 43 months). A total of 265 patients (66.6%) received preoperative treatment for subclinical hypothyroidism, with an average therapy time of 9.2 months. There were 162 patients (40.7%) with positive autoantibodies to thyroid peroxidase (anti-TPO). There were no statistically significant differences in baseline data between cohorts (all P > 0.05). As for the cumulative 90-day outcomes, subclinical hypothyroidism increased the incidences of both medical and surgical complications following primary TKA compared to those without this condition (11.6% vs 7.2%, OR = 1.55, 95% confidence interval [CI] = 1.47-1.62, P < 0.05). Subclinical hypothyroidism caused patients to suffer increased total incidence of readmission within the first 90 days after discharge when compared to those without this condition (20.61% vs 14.15%, OR = 1.45, 95% CI = 1.41-1.49, P < 0.001). Controlling for preoperative and intraoperative variables, the patients with TSH ≥ 10 mu/L and positive anti-TPO and those without corrected subclinical hypothyroid and thyroid hormone supplementation were more likely to experience postoperative complications within 90 days of TKA. CONCLUSION Subclinical hypothyroidism might increase the risk of postoperative complications within 90 days of TKA, especially for the patients with TSH ≥ 10 mu/L and positive anti-TPO and those without corrected subclinical hypothyroid and thyroid hormone supplementation.
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Affiliation(s)
- Wen Jing
- Department of Endocrinology and Metabolism, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, No. 99, Longcheng Street, Taiyuan City, Shanxi Province, 030032, China
| | - Gong Long
- Department of Orthopedic, China-Japan Friendship Hospital, China-Japan Friendship Hospital, Peking Union Medica College, Chinese Academy of Medical College, No.2 Yin Hua East Street, Beijing, 100029, China
| | - Zhao Yan
- Department of Orthopaedic Surgery, the 980th Hospital of Joint Logistic Support Force of PLA., Shijiazhuang, He Bei Province, 050000, China
| | - Yi Ping
- Department of Orthopedic, China-Japan Friendship Hospital, China-Japan Friendship Hospital, Peking Union Medica College, Chinese Academy of Medical College, No.2 Yin Hua East Street, Beijing, 100029, China
| | - Tan Mingsheng
- Department of Orthopedic, China-Japan Friendship Hospital, China-Japan Friendship Hospital, Peking Union Medica College, Chinese Academy of Medical College, No.2 Yin Hua East Street, Beijing, 100029, China
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Abstract
Hypothyroidism is a highly prevalent endocrine complication in chronic kidney disease (CKD) patients. A large body of evidence has shown that there is a bidirectional relationship between thyroid dysfunction and kidney disease, yet there are many remaining gaps in knowledge in regards to the clinical management of CKD patients with hypothyroidism, including those receiving hemodialysis and peritoneal dialysis. Given that hypothyroidism has been associated with many deleterious outcomes including a higher risk of (1) mortality, (2) cardiovascular disease, (3) impaired health-related quality of life, and (4) altered body composition in both non-CKD and CKD patients, future research is needed to establish the appropriate screening, diagnosis, and treatment approaches in these populations.
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Affiliation(s)
- Yoko Narasaki
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, CA
| | - Peter Sohn
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, CA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, CA.
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Bidirectional Interaction of Thyroid-Kidney Organs in Disease States. Int J Nephrol 2020; 2020:5248365. [PMID: 33343938 PMCID: PMC7728481 DOI: 10.1155/2020/5248365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/17/2020] [Accepted: 11/16/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose Thyroid hormones play an important role in growth, development, and physiology of the kidney. The kidney plays a key role in the metabolism, degradation, and excretion of thyroid hormones and its metabolites. The aim of this study is to investigate the prevalence of disease states of thyroid-kidney organs and detecting the correlation between thyroid and kidney function abnormalities. Materials and Methods In this retrospective study, a total of forty-five patients with thyroid and kidney dysfunction were investigated. Clinical features, laboratory data at initial presentation, management, and outcomes were collected. The paper has been written based on searching PubMed and Google Scholar to identify potentially relevant articles or abstracts. Median, percentage, mean ± standard deviation (SD), and the two-tailed t-test were used for statistical analyses. The correlation between variables was assessed by Pearson's, Spearman's correlation tests and regression analyses. Results The mean ± SD of age of study patients was 48.2 ± 22.93 years (ranging from 1 to 90 years). There was no correlation between serum thyroid-stimulating hormone, free thyroxine levels with estimated glomerular filtration rate, and proteinuria. No association between antimicrosomal antibodies with estimated glomerular filtration rate was seen. Cardiovascular disease was the most common complication of overt hypothyroidism in kidney dysfunction patients. Conclusion The present study showed more prevalence of primary hypothyroidism in comparison with other thyroid dysfunctions in patients with kidney dysfunction. Reduced mean values of thyroid function profiles after treatment suggest that this thyroid disease should be considered and ameliorated with thyroid hormone replacement therapy in patients with kidney disease.
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Liu T, Guan Y, Li J, Mao H, Zhan Y. Thyroid dysfunction and cardiovascular events in patients with chronic kidney disease: A protocol of systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23218. [PMID: 33217834 PMCID: PMC7676516 DOI: 10.1097/md.0000000000023218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cardiovascular disease is the main cause of death in patients with chronic kidney disease (CKD). Studies have found that hypothyroidism can significantly increase cardiovascular risk. Meanwhile, hypothyroidism is a common complication of CKD, but the correlation between hypothyroidism and cardiovascular risk in CKD patients has not been verified and paid enough attention. We therefore plan to conduct a systematic review and meta-analysis to explore whether hypothyroidism was independently predictive for the cardiovascular risk in patients with CKD. METHODS We will search in PubMed, Embase Database, Web of Science, China National Knowledge Infrastructure (CNKI), China Biology Medicine Database (CBM), and Wanfang Database, and include the cross-sectional studies, case--control studies, and cohort studies that explore the association between hypothyroidism and cardiovascular risk in CKD patients. According to the eligibility criteria, two researchers will independently screen the retrieved literature, evaluate the methodological quality, and extract data. We will combine the extracted data based on STATA and TSA software. RESULTS This systematic review will assess the association between hypothyroidism and cardiovascular risk in CKD patients based on the incidence of cardiovascular events in CKD people with hypothyroidism. CONCLUSIONS This study will provide more evidence for the correlation between hypothyroidism and cardiovascular risk in CKD patients, which will contribute to the management and clinical practice of CKD population. ETHICS AND DISSEMINATION This protocol is based on available literatures so that the ethical approval and informed consent are not applicable. The results of this study will be published in a peer-reviewed journals or relevant conferences. PROTOCOL REGISTRATION NUMBER INPLASY2020100022.
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Affiliation(s)
- Tongtong Liu
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences
| | - Yingjie Guan
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Juan Li
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences
| | - Huimin Mao
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences
| | - Yongli Zhan
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences
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You AS, Sim JJ, Kovesdy CP, Streja E, Nguyen DV, Brent GA, Kalantar-Zadeh K, Rhee CM. Association of thyroid status prior to transition to end-stage renal disease with early dialysis mortality. Nephrol Dial Transplant 2020; 34:2095-2104. [PMID: 30299498 DOI: 10.1093/ndt/gfy289] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/13/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Advanced chronic kidney disease (CKD) patients, including those receiving dialysis, have a high prevalence of thyroid dysfunction. Although hypothyroidism is associated with higher death risk in end-stage renal disease (ESRD) patients, no studies have examined whether thyroid status in the pre-ESRD period impacts mortality after dialysis initiation. METHODS Among US veterans with CKD identified from the national Veterans Affairs database that transitioned to dialysis over the period from October 2007 to September 2011, we examined the association of pre-ESRD serum thyrotropin (TSH) levels averaged over the 1-year pre-dialysis ('prelude') period with all-cause mortality in the first year following dialysis initiation. RESULTS Among 15 335 patients in the 1-year prelude cohort, TSH levels >5.0 mIU/L were associated with higher mortality in expanded case-mix Cox models (reference: TSH 0.5-5.0 mIU/L): adjusted hazard ratio (aHR) [95% confidence interval (CI) 1.20 (1.07-1.33). Similar findings were observed for TSH >5.0 mIU/L and mortality in the 2- and 5-year cohorts: aHRs (95% CI) 1.11 (1.02-1.21) and 1.15 (1.07-1.24), respectively. Analyses of finer gradations of TSH in the 1-year prelude cohort demonstrated that incrementally higher levels >5.0 mIU/L were associated with increasingly higher mortality in expanded case-mix models (reference: TSH 0.5-3.0 mIU/L): aHRs (95% CI) 1.18 (1.04-1.33) and 1.28 (1.03-1.59) for TSH levels >5.0-10.0 mIU/L and >10.0 mIU/L, respectively. In the 2- and 5-year cohorts, mortality associations persisted most strongly for those with TSH >10.0 mIU/L, particularly after laboratory covariate adjustment. CONCLUSIONS Among new ESRD patients, there is a dose-dependent relationship between higher pre-ESRD TSH levels >5.0 mIU/L and post-ESRD mortality. Further studies are needed to determine the impact of TSH reduction with thyroid hormone supplementation in this population.
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Affiliation(s)
- Amy S You
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, USA
| | - John J Sim
- Kaiser Permanente Southern California, Department of Nephrology, Los Angeles, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, USA.,Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Danh V Nguyen
- Division of General Internal Medicine, University of California Irvine, Orange, CA, USA
| | - Gregory A Brent
- Division of Endocrinology, Diabetes and Hypertension, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, USA.,Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, USA
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21
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Thyroid Pathology in End-Stage Renal Disease Patients on Hemodialysis. Diagnostics (Basel) 2020; 10:diagnostics10040245. [PMID: 32340182 PMCID: PMC7236006 DOI: 10.3390/diagnostics10040245] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/17/2020] [Accepted: 04/20/2020] [Indexed: 12/14/2022] Open
Abstract
Objectives: Chronic kidney disease is a rising cause of morbidity and mortality in developed countries, including end-stage renal disease (ESRD). The prevalence of thyroid comorbidities in persons with chronic kidney disease is documented higher than in normal population. The study aims to investigate the prevalence of morphological and functional thyroid disorders in patients with chronic kidney disease, with renal replacement therapy (hemodialysis). Methods: A cross-sectional study was performed on 123 consecutive patients with chronic kidney disease stage 5, on hemodialysis during a period of one month (May 2019–June 2020). All patients were enrolled for maintenance hemodialysis in B Braun Hemodialysis Center Timisoara and were examined on conventional 2B ultrasound. Thyroid blood tests were done, including serum free thyroxin (FT4), free triiodothyronine (FT3) and thyroid-stimulating hormone (TSH) at the time of starting hemodialysis. Results: We evaluated 123 patients (male to female ratio 70/53) mean age 62.2 ± 11.01, mostly above 65 years old, enrolled in the end-stage renal disease program, on renal replacement therapy. From the cohort, 76/123 presented thyroid disease, including autoimmune hypothyroidism, nodular goiter or thyroid cancer. Among them, 63 patients presented nodular goiter, including 3 thyroid cancers, confirmed by surgery and histopathological result, 22 patients had thyroid autoimmune disease. The serum thyroid-stimulating hormone levels found in the cohort was 3.36 ± 2.313 mUI/mL, which was in the normal laboratory reference range. The thyroid volume was 13 ± 7.18 mL. A single patient in the cohort presented Graves Basedow disease, under treatment and three patients present subclinical hyperthyroidism. We have found that thyroid disease risk is increased by 3.4-fold for the female gender and also the increase of body mass index (BMI) with one unit raises the risk of developing thyroid disease with 1.083 times (p = 0.018). Conclusion: To conclude, this study aimed to quantify the prevalence of thyroid disease in end-stage kidney disease population, especially nodular goiter, important for differential diagnosis in cases with secondary hyperparathyroidism. Thyroid autoimmune disease can be prevalent among these patients, as symptoms can overlap those of chronic disease and decrease the quality of life. We have found that thyroid disease has a high prevalence among patients with end-stage renal disease on hemodialysis. Thyroid goiter and nodules in ESRD patients were more prevalent than in the general population. Clinical surveillance and routine screening for thyroid disorders can improve the quality of life in these patients.
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22
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Zijlstra LE, van Velzen DM, Simsek S, Mooijaart SP, van Buren M, Stott DJ, Ford I, Jukema JW, Trompet S. The kidney, subclinical thyroid disease and cardiovascular outcomes in older patients. Endocr Connect 2020; 9:55-62. [PMID: 31846431 PMCID: PMC6993270 DOI: 10.1530/ec-19-0502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/17/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Thyroid hormones have been implicated to play a role in cardiovascular disease, along with studies linking thyroid hormone to kidney function. The aim of this study is to investigate whether kidney function modifies the association of subclinical thyroid dysfunction and the risk of cardiovascular outcomes. METHODS In total, 5804 patients were included in the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER). For the current analysis, 426 were excluded because of overt thyroid disease at baseline or 6 months, 266 because of inconsistent thyroid function at baseline and 6 months, 294 because of medication use that could influence thyroid function, and 16 because of missing kidney or thyroid values. Participants with normal fT4 were classified, based on TSH both at inclusion and 6 months, into three groups: subclinical hypothyroidism (TSH >4.5 mIU/L); euthyroidism (TSH = 0.45-4.5 mIU/L); and subclinical hyperthyroidism (TSH <0.45 mIU/L). Strata of kidney function were made based on estimated glomerular filtration rate into three clinically relevant groups: <45, 45-60, and >60 mL/min/1.73 m2. The primary endpoint consists of death from coronary heart disease, non-fatal myocardial infarction and (non)fatal stroke. RESULTS Mean age was 75.3 years, and 49.0% patients were male. Mean follow-up was 3.2 years. Of all participants, 109 subjects (2.2%) had subclinical hypothyroidism, 4573 (94.0%) had euthyroidism, and 182 (3.7%) subclinical hyperthyroidism. For patients with subclinical hypothyroidism, euthyroidism, and subclinical hyperthyroidism, primary outcome occurred in 9 (8.3%), 712 (15.6%), and 23 (12.6%) patients, respectively. No statistically significant relationship was found between subclinical thyroid dysfunction and primary endpoint with adjusted hazard ratios of 0.51 (0.24-1.07) comparing subclinical hyperthyroidism and 0.90 (0.58-1.39) comparing subclinical hypothyroidism with euthyroidism. Neither was this relationship present in any of the strata of kidney function, nor did kidney function interact with subclinical thyroid dysfunction in the association with primary endpoint (P interaction = 0.602 for subclinical hyperthyroidism and 0.388 for subclinical hypothyroidism). CONCLUSIONS In this secondary analysis from PROSPER, we found no evidence that the potential association between thyroid hormones and cardiovascular disease is modified by kidney function in older patients with subclinical thyroid dysfunction.
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Affiliation(s)
- L E Zijlstra
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Correspondence should be addressed to L E Zijlstra:
| | - D M van Velzen
- Department of Internal Medicine, Section of Endocrinology, Northwest Clinics, Alkmaar, The Netherlands
| | - S Simsek
- Department of Internal Medicine, Section of Endocrinology, Northwest Clinics, Alkmaar, The Netherlands
| | - S P Mooijaart
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M van Buren
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, HagaHospital, The Hague, The Netherlands
| | - D J Stott
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - I Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - J W Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - S Trompet
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
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23
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Abstract
PURPOSE OF REVIEW Hypothyroidism is a highly prevalent endocrine disorder in the end-stage renal disease (ESRD) population, yet many cases may remain latent and undiagnosed. RECENT FINDINGS Epidemiologic data show that there is a nearly five-fold higher prevalence of hypothyroidism in advanced chronic kidney disease (CKD) patients vs. those without CKD. Given that the metabolism, degradation, and excretion of thyroid hormone and its metabolites, as well as the regulation of the hypothalamic-pituitary-thyroid axis may be altered in ESRD, certain considerations should be made when interpreting thyroid functional tests in these patients. Growing evidence shows that hypothyroidism and other thyroid functional test derangements are associated with higher risk of cardiovascular disease, worse patient-centered outcomes, and survival in the advanced CKD population, including those with ESRD. Although limited data examining treatment of hypothyroidism suggests benefit, further studies of the efficacy and safety of thyroid hormone supplementation, including clinical trials and rigorous longitudinal observational studies are needed to inform the management of thyroid dysfunction in CKD. SUMMARY Given the high burden of hypothyroidism in ESRD patients, and potential ill effects on their cardiovascular health, patient-centered outcomes, and survival, further research is needed to inform the optimal management of thyroid dysfunction in this population.
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Affiliation(s)
- Connie M. Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
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24
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Lin HJ, Lin CC, Lin HM, Chen HJ, Lin CC, Chang CT, Chou CY, Huang CC. Hypothyroidism is associated with all-cause mortality in a national cohort of chronic haemodialysis patients. Nephrology (Carlton) 2018; 23:559-564. [PMID: 28346975 DOI: 10.1111/nep.13049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 03/20/2017] [Accepted: 03/21/2017] [Indexed: 12/27/2022]
Abstract
AIM The prevalence of hypothyroidism is high in haemodialysis (HD) patients and hypothyroidism increases all-cause mortality in HD patients. Comorbidities are common in HD patients and are associated with both mortality and hypothyroidism. The aim of the study is to explore the effect of the interactions of comorbidities and hypothyroidism on all-cause mortality in HD patients. METHOD Patients with hypothyroidism (ICD-9-CM 244.0, 244.1, and 244.9) and matched patients without hypothyroidism in the Registry for Catastrophic Illness Patient Database of Taiwan Health Insurance from 2000 to 2010 were analyzed. The association of hypothyroidism and risk of all-cause mortality was analyzed using Cox proportional hazard regression. RESULT Nine hundred and eight HD patients with hypothyroidism and 3632 sex-, age-, gender- matched HD patients without hypothyroidism were analyzed. Hypothyroidism was associated with increased all-cause mortality with an adjusted hazard ratio of 1.22 [95% confidence interval (CI): 1.10-1.36, P < 0.001]. TRT may decrease mortality associated with hypothyroidism (P < 0.001). There was a significant interaction (P = 0.04) between diabetes and hypothyroidism. There was no significant interaction found in hypothyroidism and the following comorbidities: hyperlipidaemia, hypertension, chronic obstructive pulmonary disease, coronary artery disease, stroke, peripheral arterial disease, asthma, congestive heart failure and cancer. CONCLUSION Hypothyroidism is associated with increased all-cause mortality in chronic HD patients. The interaction of hypothyroidism and diabetes, but not other common comorbidities in HD patients, has an effect on mortality risks.
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Affiliation(s)
- Hsuan-Jen Lin
- Division of Nephrology, Department of Internal Medicine, Asia University Hospital, Wufeng, Taichung, Taiwan.,Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Wufeng, Taichung, Taiwan
| | - Chung-Chih Lin
- Division of Nephrology, Department of Internal Medicine, Asia University Hospital, Wufeng, Taichung, Taiwan
| | - Hsuan Ming Lin
- Division of Nephrology, Department of Internal Medicine, Tainan Municipal Annan Hospital- China Medical University, Wufeng, Taichung, Taiwan
| | - Hsuan-Ju Chen
- Management Office for Health Data, China Medical University Hospital, Wufeng, Taichung, Taiwan.,College of Medicine, China Medical University, Wufeng, Taichung, Taiwan
| | - Che-Chen Lin
- Management Office for Health Data, China Medical University Hospital, Wufeng, Taichung, Taiwan.,College of Medicine, China Medical University, Wufeng, Taichung, Taiwan.,Healthcare Service Research Center (HSRC), Taichung Veterans General Hospital, Wufeng, Taichung, Taiwan
| | - Chiz-Tzung Chang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Wufeng, Taichung, Taiwan.,College of Medicine, China Medical University, Wufeng, Taichung, Taiwan
| | - Che-Yi Chou
- Division of Nephrology, Department of Internal Medicine, Asia University Hospital, Wufeng, Taichung, Taiwan.,Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Wufeng, Taichung, Taiwan.,College of Medicine, China Medical University, Wufeng, Taichung, Taiwan.,Department of Biotechnology, Asia University, Wufeng, Taichung, Taiwan
| | - Chiu-Ching Huang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Wufeng, Taichung, Taiwan.,College of Medicine, China Medical University, Wufeng, Taichung, Taiwan
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25
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Ro K, Yuen AD, Du L, Ro CC, Seger C, Yeh MW, Leung AM, Rhee CM. Impact of Hypothyroidism and Heart Failure on Hospitalization Risk. Thyroid 2018; 28:1094-1100. [PMID: 29897016 PMCID: PMC6154446 DOI: 10.1089/thy.2017.0362] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prior studies suggest that the relationship between hypothyroidism and mortality is dependent on underlying cardiovascular risk. Little is known about the association of hypothyroidism with hospitalization risk, and how these associations are modified by cardiovascular status. METHODS This study examined the association of thyroid status, defined by serum thyrotropin (TSH), with hospitalization risk among patients who received care at a large university-based tertiary care center between 1990 and 2015. Thyroid status was categorized as hypothyroidism versus euthyroidism (TSH >4.7 vs. 0.3-4.7 mIU/L, respectively). The relationship between thyroid status and hospitalization risk stratified by cardiovascular status was examined using multivariable Cox models. RESULTS Among 52,856 patients who met eligibility criteria, 49,791 (94.2%) had euthyroidism and 3065 (5.8%) had hypothyroidism. In analyses stratified by congestive heart failure (CHF) status, compared to euthyroidism, hypothyroidism was associated with higher risk of hospitalization in those with CHF but slightly lower risk in those without CHF (adjusted hazard ratio [aHRs] = 1.86 [confidence interval (CI) 1.17-2.94] and HR = 0.95 [CI 0.92-0.99], respectively; p = 0.006). In sensitivity analyses accounting for death as a competing event, underlying coronary artery disease modified the hypothyroidism-hospitalization relationship, such that stronger associations were observed among those with versus without coronary artery disease. In competing risk analyses, hypothyroidism was associated with higher versus lower risk of hospitalization among those with versus without cerebrovascular disease, respectively. CONCLUSIONS Hypothyroidism is associated with higher hospitalization risk among patients with underlying cardiovascular disease. Future studies are needed to determine whether correction of thyroid status with replacement therapy ameliorates hospitalization risk in this population.
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Affiliation(s)
- Kevin Ro
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Alexander D. Yuen
- Section of Endocrine Surgery, Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Lin Du
- Department of Biostatistics, University of California Los Angeles, Los Angeles, California
| | - Clarissa C. Ro
- Section of Endocrine Surgery, Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Christian Seger
- Section of Endocrine Surgery, Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Michael W. Yeh
- Section of Endocrine Surgery, Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Angela M. Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Connie M. Rhee
- Division of Nephrology and Hypertension, Department of Medicine, University of California Irvine School of Medicine, Orange, California
- Address correspondence to:Connie M. Rhee, MD, MScHarold Simmons Center for Kidney Disease Research and EpidemiologyDivision of Nephrology and HypertensionUniversity of California Irvine School of Medicine101 The City Drive South, City TowerOrange, CA 92868
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26
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Affiliation(s)
- Marius N Stan
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN.
| | - Matthew T Drake
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
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27
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Rhee CM, Kalantar-Zadeh K, Ravel V, Streja E, You AS, Brunelli SM, Nguyen DV, Brent GA, Kovesdy CP. Thyroid Status and Death Risk in US Veterans With Chronic Kidney Disease. Mayo Clin Proc 2018; 93:573-585. [PMID: 29728200 PMCID: PMC6049829 DOI: 10.1016/j.mayocp.2018.01.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/25/2018] [Accepted: 01/30/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Given that patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) have a disproportionately higher prevalence of hypothyroidism compared with their non-CKD counterparts, we sought to determine the association between thyroid status, defined by serum thyrotropin (TSH) levels, and mortality among a national cohort of patients with NDD-CKD. PATIENTS AND METHODS Among 227,422 US veterans with stage 3 NDD-CKD with 1 or more TSH measurements during the period October 1, 2004, to September 30, 2012, we first examined the association of thyroid status, defined by TSH categories of less than 0.5, 0.5 to 5.0 (euthyroidism), and more than 5.0 mIU/L, with all-cause mortality. We then evaluated 6 granular TSH categories: less than 0.1, 0.1 to less than 0.5, 0.5 to less than 3.0, 3.0 to 5.0, more than 5.0 to 10.0, and more than 10.0 mIU/L. We concurrently examined thyroid status, thyroid-modulating therapy, and mortality in sensitivity analyses. RESULTS In expanded case-mix adjusted Cox analyses, compared with euthyroidism, baseline and time-dependent TSH levels of more than 5.0 mIU/L were associated with higher mortality (adjusted hazard ratios [aHRs] [95% CI], 1.19 [1.15-1.24] and 1.23 [1.19-1.28], respectively), as were baseline and time-dependent TSH levels of less than 0.5 mIU/L (aHRs [95% CI], 1.18 [1.15-1.22] and 1.41 [1.37-1.45], respectively). Granular examination of thyroid status showed that incrementally higher TSH levels of 3.0 mIU/L or more were associated with increasingly higher mortality in baseline and time-dependent analyses, and TSH categories of less than 0.5 mIU/L were associated with higher mortality (reference, 0.5-<3.0 mIU/L) in baseline analyses. In time-dependent analyses, untreated and undertreated hypothyroidism and untreated hyperthyroidism were associated with higher mortality (reference, spontaneous euthyroidism), whereas hypothyroidism treated-to-target showed lower mortality. CONCLUSION Among US veterans with NDD-CKD, high-normal TSH (≥3.0 mIU/L) and lower TSH (<0.5 mIU/L) levels were associated with higher death risk. Interventional studies identifying the target TSH range associated with the greatest survival in patients with NDD-CKD are warranted.
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Affiliation(s)
- Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Vanessa Ravel
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Amy S You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | | | - Danh V Nguyen
- Division of General Internal Medicine, University of California Irvine School of Medicine, Orange, CA
| | - Gregory A Brent
- Division of Endocrinology, Diabetes and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Csaba P Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN; Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN.
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28
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Rosario PWS, Calsolari MR. Impact of subclinical hypothyroidism with TSH ≤10 mIU/L on glomerular filtration rate in adult women without known kidney disease. Endocrine 2018; 59:694-697. [PMID: 29327299 DOI: 10.1007/s12020-017-1496-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
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29
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Molfino A, Beck GJ, Li M, Lo JC, Kaysen GA. Association between change in serum bicarbonate and change in thyroid hormone levels in patients receiving conventional or more frequent maintenance haemodialysis. Nephrology (Carlton) 2017; 24:81-87. [PMID: 29064128 DOI: 10.1111/nep.13187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2017] [Indexed: 11/30/2022]
Abstract
AIM Correction of metabolic acidosis in patients with chronic kidney disease has been associated with improvement in thyroid function. We examined whether changes in bicarbonate were associated with changes in thyroid function in patients with end-stage renal disease receiving conventional or more frequent haemodialysis. METHODS In the Frequent Hemodialysis Network Trials, the relationship between changes in serum bicarbonate, free triiodothyronine (FT3) and free thyroxine (FT4) was examined among 147 and 48 patients with endogenous thyroid function who received conventional (3×/week) or more frequent (6×/week) haemodialysis (Daily Trial) or who received conventional or more frequent nocturnal haemodialysis (Nocturnal Trial). Equilibrated normalized protein catabolic rate (enPCR) was examined to account for nutritional factors affecting both acid load and thyroid function. RESULTS Increasing dialysis frequency was associated with increased bicarbonate level. Baseline bicarbonate level was not associated with baseline FT3 and FT4. Change in bicarbonate level was not associated with changes in FT3 and FT4 in the Daily Trial nor for FT4 in the Nocturnal Trial (r ≤ 0.14, P > 0.21). While, a significant correlation between change in serum bicarbonate and change in FT3 (r = 0.44, P = 0.02) was observed in the Nocturnal Trial; findings were no longer significant after adjusting for change in enPCR (r = 0.37, P = 0.08). For participants with baseline bicarbonate <23 mmol/L, no association between change in bicarbonate and change in thyroid indices were seen in the Daily Trial; for the Nocturnal Trial, findings were also not significant for change in FT3 and the association between change in bicarbonate and change in FT4 (r = 0.54, P = 0.03) was no longer significant after adjusting for enPCR (r = 0.45, P = 0.11). CONCLUSION Changes in bicarbonate were not associated with changes in thyroid hormone levels after adjusting for enPCR, as a marker of nutritional status. Future studies should examine whether improvement in acid base status improves thyroid function in haemodialysis patients with evidence of thyroid hypofunction.
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Affiliation(s)
- Alessio Molfino
- Division of Nephrology, Department of Internal Medicine, University of California, Davis, California, USA.,Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Minwei Li
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joan C Lo
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - George A Kaysen
- Division of Nephrology, Department of Internal Medicine, University of California, Davis, California, USA.,Department of Biochemistry and Molecular Medicine, University of California, Davis, California, USA
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30
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Rhee CM, Chen Y, You AS, Brunelli SM, Kovesdy CP, Budoff MJ, Brent GA, Kalantar-Zadeh K, Nguyen DV. Thyroid Status, Quality of Life, and Mental Health in Patients on Hemodialysis. Clin J Am Soc Nephrol 2017; 12:1274-1283. [PMID: 28705886 PMCID: PMC5544520 DOI: 10.2215/cjn.13211216] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 04/17/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES In the general population, there is increasing recognition of the effect of thyroid function on patient-centered outcomes, including health-related quality of life and depression. Although hypothyroidism is highly prevalent in hemodialysis patients, it is unknown whether thyroid status is a risk factor for impaired health-related quality of life or mental health in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined the association of thyroid status, defined by serum thyrotropin, with health-related quality of life and depressive symptoms over time in a prospective cohort of 450 patients on hemodialysis from 17 outpatient dialysis facilities from May of 2013 to May of 2015 who underwent protocolized thyrotropin testing, Short-Form 36 surveys, and Beck Depression Inventory-II questionnaires every 6 months. We examined the association of baseline and time-dependent thyrotropin categorized as tertiles and continuous variables with eight Short-Form 36 domains and Beck Depression Inventory-II scores using expanded case mix plus laboratory adjusted linear mixed effects models. RESULTS In categorical analyses, the highest baseline thyrotropin tertile was associated with a five-point lower Short-Form 36 domain score for energy/fatigue (P=0.04); the highest time-dependent tertile was associated with a five-point lower physical function score (P=0.03; reference: lowest tertile). In continuous analyses, higher baseline serum thyrotropin levels (+Δ1 mIU/L) were associated with lower role limitations due to physical health (β=-1.3; P=0.04), energy/fatigue (β=-0.8; P=0.03), and pain scores (β=-1.4; P=0.002), equivalent to five-, three-, and five-point lower scores, respectively, for every 1-SD higher thyrotropin. Higher time-dependent thyrotropin levels were associated with lower role limitations due to physical health scores (β=-1.0; P=0.03), equivalent to a three-point decline for every 1-SD higher thyrotropin. Baseline and time-dependent thyrotropin were not associated with Beck Depression Inventory-II scores. CONCLUSIONS In patients on hemodialysis, higher serum thyrotropin levels are associated with impaired health-related quality of life across energy/fatigue, physical function, and pain domains. Studies are needed to determine if thyroid-modulating therapy improves the health-related quality of life of hemodialysis patients with thyroid dysfunction.
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Affiliation(s)
| | - Yanjun Chen
- Institute for Clinical and Translational Science, University of California, Irvine, California
| | - Amy S. You
- Division of Nephrology and Hypertension and
| | | | - Csaba P. Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Gregory A. Brent
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; and
- Departments of Medicine and
- Physiology, David Geffen School of Medicine at the University of California, Los Angeles, California
| | | | - Danh V. Nguyen
- Department of Medicine, University of California Irvine, Orange, California
- Institute for Clinical and Translational Science, University of California, Irvine, California
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Rhee CM, You AS, Nguyen DV, Brunelli SM, Budoff MJ, Streja E, Nakata T, Kovesdy CP, Brent GA, Kalantar-Zadeh K. Thyroid Status and Mortality in a Prospective Hemodialysis Cohort. J Clin Endocrinol Metab 2017; 102:1568-1577. [PMID: 28324018 PMCID: PMC5443328 DOI: 10.1210/jc.2016-3616] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/23/2017] [Indexed: 12/19/2022]
Abstract
CONTEXT AND OBJECTIVE Compared with the general population, hemodialysis patients have a substantially higher risk of hypothyroidism, as defined by an elevated serum thyrotropin (TSH) level, and cardiovascular mortality. Whereas an elevated TSH is associated with cardiovascular disease and death in the general population, associations among dialysis patients have been inconsistent. DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOME We examined 541 hemodialysis patients from 17 southern California dialysis centers in the prospective Hypothyroidism, Cardiovascular Health, and Survival study who underwent protocolized measurement of repeated serum TSH levels every 6 months from 2013 to 2015. Associations between TSH tertiles (<1.28, 1.28 to <2.14, and 2.14 to 86.7 mIU/L) and mortality were estimated using time-dependent Cox models with four adjustment levels. In sensitivity analyses, we excluded patients receiving thyroid hormone supplementation. RESULTS Compared with the lowest TSH tertile, the highest TSH tertile was associated with a 2.2- to 2.5-fold higher mortality risk in unadjusted, case-mix, expanded case-mix+laboratory, and expanded case-mix+laboratory+medication models [hazard ratios (95% confidence interval), 2.54 (1.32 to 4.89), 2.53 (1.30 to 4.93), 2.19 (1.11 to 4.32), and 2.28 (1.45 to 3.58), respectively]. We observed a consistent trend between higher TSH tertiles and numerically higher mortality risk across all models. Similar findings were observed in analyses excluding patients receiving thyroid hormone supplementation. CONCLUSION In time-dependent analyses, TSH levels in the high-normal to high range were independently associated with higher death risk in hemodialysis patients. Further studies are indicated to determine whether normalization of TSH levels with thyroid hormone supplementation improves survival in this population.
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Affiliation(s)
- Connie M. Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, Orange, California 92868
| | - Amy S. You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, Orange, California 92868
| | - Danh V. Nguyen
- Division of General Internal Medicine, University of California Irvine, Orange, California 92868
| | | | - Matthew J. Budoff
- Los Angeles BioMedical Research Institute, Torrance, California 90502
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, Orange, California 92868
- Veterans Affairs Long Beach Healthcare System, Long Beach, California 90822
| | - Tracy Nakata
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, Orange, California 92868
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee 38163
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee 38104
| | - Gregory A. Brent
- Department of Medicine, VA Greater Los Angeles Healthcare System 90073
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California 90095
- Department of Physiology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, Orange, California 92868
- Los Angeles BioMedical Research Institute, Torrance, California 90502
- Veterans Affairs Long Beach Healthcare System, Long Beach, California 90822
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Lo JC, Beck GJ, Kaysen GA, Chan CT, Kliger AS, Rocco MV, Li M, Chertow GM. Thyroid function in end stage renal disease and effects of frequent hemodialysis. Hemodial Int 2017; 21:534-541. [PMID: 28301073 DOI: 10.1111/hdi.12527] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION End-stage renal disease (ESRD) is associated with perturbations in thyroid hormone concentrations and an increased prevalence of hypothyroidism. Few studies have examined the effects of hemodialysis dose or frequency on endogenous thyroid function. METHODS Within the Frequent Hemodialysis Network (FHN) trials, we examined the prevalence of hypothyroidism in patients with ESRD. Among those with endogenous thyroid function (without overt hyper/hypothyroidism or thyroid hormone supplementation), we examined the association of thyroid hormone concentration with multiple parameters of self-reported health status, and physical and cognitive performance, and the effects of hemodialysis frequency on serum thyroid stimulating hormone (TSH), free thyroxine (FT4), and free tri-iodothyronine (FT3) levels. Conventional thrice-weekly hemodialysis was compared to in-center (6 d/wk) hemodialysis (Daily Trial) and Nocturnal (6 nights/wk) home hemodialysis (Nocturnal Trial) over 12 months. FINDINGS Among 226 FHN Trial participants, the prevalence of hypothyroidism was 11% based on thyroid hormone treatment and/or serum TSH ≥8 mIU/mL. Among the remaining 195 participants (147 Daily, 48 Nocturnal) with endogenous thyroid function, TSH concentrations were modestly (directly) correlated with age (r = 0.16, P = 0.03) but not dialysis vintage. Circulating thyroid hormone levels were not associated with parameters of health status or physical and cognitive performance. Furthermore, frequent in-center and nocturnal hemodialysis did not significantly change (baseline to month 12) TSH, FT4, or FT3 concentrations in patients with endogenous thyroid function. DISCUSSION Among patients receiving hemodialysis without overt hyper/hypothyroidism or thyroid hormone treatment, thyroid indices were not associated with multiple measures of health status and were not significantly altered with increased dialysis frequency.
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Affiliation(s)
- Joan C Lo
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - George A Kaysen
- Division of Nephrology, Department of Medicine, University of California Davis, Davis, California, USA
| | - Christopher T Chan
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Alan S Kliger
- Division of Nephrology, Department of Medicine, Yale School of Medicine and Yale New Haven Health System, New Haven, Connecticut, USA
| | - Michael V Rocco
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Minwei Li
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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Abstract
Thyroid hormones influence renal development, kidney hemodynamics, glomerular filtration rate and sodium and water homeostasis. Hypothyroidism and hyperthyroidism affect renal function by direct renal effects as well as systemic hemodynamic, metabolic and cardiovascular effects. Hypothyroidism has been associated with increased serum creatinine and decreased glomerular filtration rate. The reverse effects have been reported in thyrotoxicosis. Most of renal manifestations of thyroid dysfunction are reversible with treatment. Kidney disease may also cause thyroid dysfunction by several mechanisms. Nephrotic syndrome has been associated to changes in serum thyroid hormone concentrations. Different forms of glomerulonephritis and tubulointerstitial disease may be linked to thyroid derangements. A high prevalence of thyroid hormone alteration has been reported in acute kidney injury. Thyroid dysfunction is highly prevalent in chronic kidney disease patients. Subclinical hypothyroidism and low triiodothyronine syndrome are common features in patients with chronic kidney disease. Patients treated by both hemodialysis and peritoneal dialysis, and renal transplantation recipients, exhibit thyroid hormone alterations and thyroid disease with higher frequency than that found in the general population. Drugs used in the therapy of thyroid disease may lead to renal complications and, similarly, drugs used in kidney disorders may be associated to thyroid alterations. Lastly, low thyroid hormones, especially low triiodothyronine levels, in patients with chronic kidney disease have been related to a higher risk of cardiovascular disease and all-cause mortality. Interpretation of the interactions between thyroid and renal function is a challenge for clinicians involved in the treatment of patients with thyroid and kidney disease.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology, Hospital Ramón y Cajal, Ctra. De Colmenar, Km 9,100, 28034, Madrid, Spain.
| | - María Auxiliadora Bajo
- Department of Nephrology, Hospital La Paz, Madrid, Spain
- Department of Health Sciences, Universidad Autónoma de Madrid, Madrid, Spain
| | - Rafael Selgas
- Department of Nephrology, Hospital La Paz, Madrid, Spain
- Department of Health Sciences, Universidad Autónoma de Madrid, Madrid, Spain
| | - Juan José Díez
- Department of Endocrinology, Hospital Ramón y Cajal, Ctra. De Colmenar, Km 9,100, 28034, Madrid, Spain
- Department of Medicine, University de Alcalá de Henares, Madrid, Spain
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Chuang MH, Liao KM, Hung YM, Chou YC, Chou P. Association of TSH Elevation with All-Cause Mortality in Elderly Patients with Chronic Kidney Disease. PLoS One 2017; 12:e0168611. [PMID: 28045962 PMCID: PMC5207752 DOI: 10.1371/journal.pone.0168611] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 12/02/2016] [Indexed: 12/12/2022] Open
Abstract
Chronic kidney disease (CKD) is a widespread condition in the global population and is more common in the elderly. Thyroid-stimulating hormone (TSH) level increases with aging, and hypothyroidism is highly prevalent in CKD patients. However, the relationship between low thyroid function and mortality in CKD patients is unclear. Therefore, we conducted a retrospective cohort study to examine the relationship between TSH elevation and all-cause mortality in elderly patients with CKD. This retrospective cohort study included individuals ≥65 years old with CKD (n = 23,786) in Taipei City. Health examination data from 2005 to 2010 were provided by the Taipei Databank for Public Health Analysis. Subjects were categorized according to thyroid-stimulating hormone (TSH) level as follows: low normal (0.34<TSH<1.074 mIU/L), middle normal (1.074≤TSH≤2.46 mIU/L), high normal (2.46<TSH<5.2 mIU/L), elevated I (5.2≤TSH<10 mIU/L), and elevated II (TSH≥10 mIU/L). Risk of mortality was evaluated using a Cox proportional hazard regression model adjusted for sex, age, hypertension, diabetes mellitus, CKD stage, serum albumin, high-density lipoprotein cholesterol, uric acid, hemoglobin, body mass index, glutamic-pyruvic transaminase, smoking, alcohol consumption, and history of cardiovascular disease (coronary artery disease, congestive heart failure, cerebral vascular disease), history of cancer, and history of chronic obstructive pulmonary disease. Our results showed that compared to the reference group (middle normal TSH), the risk of all-cause mortality was increased in the elevated I group (hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.02–1.45) and elevated II group (HR, 1.30; 95% CI, 1.00–1.69). We found a significant association between TSH elevation and all-cause mortality in this cohort of elderly persons with CKD. However, determining the benefit of treatment for moderately elevated TSH level (5.2–10 mIU/L) in elderly patients with CKD will require a well-designed randomized controlled trial.
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Affiliation(s)
- Mei-hsing Chuang
- Division of Family Medicine, Department of Community Medicine, Taipei City Hospital, Taipei, Taiwan
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Kuo-Meng Liao
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei City Hospital, Taipei, Taiwan
| | - Yao-Min Hung
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yi-Chang Chou
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan
- Department of Education and Research, Taipei City Hospital, Taipei, Taiwan
| | - Pesus Chou
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan
- * E-mail:
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Rhee CM, Ravel VA, Streja E, Mehrotra R, Kim S, Wang J, Nguyen DV, Kovesdy CP, Brent GA, Kalantar-Zadeh K. Thyroid Functional Disease and Mortality in a National Peritoneal Dialysis Cohort. J Clin Endocrinol Metab 2016; 101:4054-4061. [PMID: 27525529 PMCID: PMC5095247 DOI: 10.1210/jc.2016-1691] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
CONTEXT AND OBJECTIVE End-stage renal disease patients have a higher risk of thyroid disease compared with those without kidney disease. Although thyroid dysfunction is associated with higher death risk in the general population and those undergoing hemodialysis, little is known about the effect of thyroid disease upon mortality in patients treated with peritoneal dialysis (PD). DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOME We examined the association of thyroid status, assessed by serum TSH, with all-cause mortality among PD patients from a large national dialysis organization who underwent one or more TSH measurements over 5 years (January 2007 to December 2011). Thyroid status was categorized as overt-hyperthyroid, subclinical-hyperthyroid, low-normal, high-normal, subclinical-hypothyroid, and overt-hypothyroid range (TSH < 0.1, 0.1–<0.5, 0.5–<3.0, 3.0–<5.0, 5.0–<10.0, and ≥10.0 mIU/L, respectively). We examined the association between TSH and mortality using case mix–adjusted time-dependent Cox models to assess short-term thyroid function–mortality associations and to account for changes in thyroid function over time. RESULTS Among 1484 patients, 7 and 18% had hyperthyroidism and hypothyroidism, respectively, at baseline. We found that both lower and higher time-dependent TSH levels were associated with higher mortality (reference: TSH, 0.5-<3.0 mIU/L): adjusted hazard ratios (95% confidence intervals) 2.09 (1.08-4.06), 1.53 (0.87-2.70), 1.05 (0.75-1.46), 1.63 (1.11-2.40), and 3.11 (2.08-4.63) for TSH levels, <0.1, 0.1-<0.5, 0.5-<3.0, 3.0-<5.0, 5.0-<10.0, and ≥10.0 mIU/L, respectively. CONCLUSION Time-dependent TSH levels < 0.1 mIU/L and ≥ 5.0 mIU/L were associated with higher mortality, suggesting hyper- and hypothyroidism carry short-term risk in PD patients. Additional studies are needed to determine mechanisms underlying the thyroid dysfunction-mortality association, and whether normalization of TSH with treatment ameliorates mortality in this population.
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Affiliation(s)
- Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Vanessa A Ravel
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Rajnish Mehrotra
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Steven Kim
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Jiaxi Wang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Danh V Nguyen
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Csaba P Kovesdy
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Gregory A Brent
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
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Abstract
PURPOSE OF REVIEW Hypothyroidism is highly prevalent in chronic kidney disease (CKD) patients, including those receiving dialysis. This review examines potential mechanistic links between thyroid and kidney disease; current evidence for hypothyroidism as a risk factor for de novo CKD and CKD progression; and studies of thyroid functional disorders, cardiovascular disease, and death in the CKD population. RECENT FINDINGS Epidemiologic data have demonstrated an incrementally higher prevalence of hypothyroidism with increasing severity of kidney dysfunction. Various thyroid functional test abnormalities are also commonly observed in CKD due to alterations in thyroid hormone synthesis, metabolism, and regulation. Although the mechanistic link between thyroid and kidney disease remains unclear, observational studies suggest that hypothyroidism is associated with abnormal kidney structure and function. Previously thought to be a physiologic adaptation, recent studies show that hypothyroidism is associated with higher risk of cardiovascular disease and death in CKD. SUMMARY A growing body of evidence suggests that hypothyroidism is a risk factor for incident CKD, CKD progression, and higher death risk in kidney disease patients. Rigorous studies are needed to determine the impact of thyroid hormone replacement upon kidney disease progression, cardiovascular disease, and mortality, which may shed light onto the causal implications of hypothyroidism in CKD.
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Affiliation(s)
- Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine School of Medicine, Orange, California, United States
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Xu H, Brusselaers N, Lindholm B, Zoccali C, Carrero JJ. Thyroid Function Test Derangements and Mortality in Dialysis Patients: A Systematic Review and Meta-analysis. Am J Kidney Dis 2016; 68:923-932. [PMID: 27596516 DOI: 10.1053/j.ajkd.2016.06.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 06/29/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND We evaluated current evidence associating thyroid function test result derangements with risk for mortality in patients with chronic kidney failure treated by long-term dialysis. STUDY DESIGN Systematic review and meta-analysis of cohort studies. SETTING & POPULATION Dialysis patients. SELECTION CRITERIA FOR STUDIES We searched PubMed, Web of Science, Science Citation Index, Cochrane Library, and Embase databases from inception through December 2015. PREDICTORS Hypothyroidism (thyrotropin level greater than reference range) and low triiodothyronine (T3) and thyroxine (T4) levels. OUTCOMES All-cause and cardiovascular mortality. RESULTS 12 studies involving 14,766 participants (4,450 deaths) were identified. Of those, 6 studies provided data for cardiovascular mortality (2,772 participants with 327 cardiovascular deaths). Overall, confidence in the available evidence was moderate. Pooled adjusted HRs for all-cause mortality associated with hypothyroidism, low T3 level, and low T4 level were 1.24 (95% CI, 1.14-1.34), 1.67 (95% CI, 1.23-2.27), and 2.40 (95% CI, 1.47-3.93), respectively. Pooled adjusted HRs for cardiovascular mortality associated with low T3 and T4 levels were 1.84 (95% CI, 1.24-2.74) and 3.06 (95% CI, 1.29-7.24), respectively. LIMITATIONS Fewer studies reporting on T4 and thyrotropin outcomes. CONCLUSIONS In patients treated with long-term dialysis, (cardiovascular) mortality is consistently higher in the presence of thyroid function test result derangements.
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Affiliation(s)
- Hong Xu
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Division of Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Nele Brusselaers
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Division of Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Carmine Zoccali
- Division of Nephrology, Dialysis and Kidney Transplantation, CNR Hospital, Reggio Calabria, Italy
| | - Juan Jesús Carrero
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Division of Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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El Ters M, Patel SM, Norby SM. Hypothyroidism and reversible kidney dysfunction: an essential relationship to recognize. Endocr Pract 2016; 20:490-9. [PMID: 24325990 DOI: 10.4158/ep12084.ra] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report 3 cases of reversible hypothyroidism-induced kidney dysfunction and review the interaction between these commonly encountered, yet seemingly disparate, conditions. METHODS We describe the clinical course and laboratory and physical findings of 3 patients who presented with kidney dysfunction that improved after initiating thyroid hormone replacement therapy. We also review similar cases in the literature and discuss the pathophysiologic mechanisms. RESULTS A 68-year-old male presented with classical signs and symptoms of hypothyroidism, including fatigue, confusion, and gait imbalance. Physical exam showed bradycardia, thyromegaly, slow mentation, and cracked, thin skin; he was found to have decreased kidney function. Second, a 42-year-old previously healthy female presented with bilateral hand swelling and elevated serum creatinine with an otherwise unremarkable physical exam. The third patient was a 72-year-old male with advanced heart failure on amiodarone and stage 3 chronic kidney disease who presented with fatigue, acute kidney injury, and lower extremity edema. In all cases, serum creatinine and thyroid-stimulating hormone (TSH) were elevated at presentation (1.4-3.0 mg/dL and 94.1-184 mIU/L respectively), and free thyroxine (T4) was low (undetectable-0.4 ng/dL). The initiation or increased dose of levothyroxine normalized serum creatinine to baseline within 2 to 10 months. CONCLUSION Hypothyroidism and kidney dysfunction are both commonly encountered clinical entities, but the interplay between the thyroid gland and kidneys may be infrequently recalled, causing the reversible relationship between these 2 disorders to be missed.
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Affiliation(s)
- Mireille El Ters
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Sandeep M Patel
- The Heart and Vascular Institute, University of Pittsburgh, Pennsylvania
| | - Suzanne M Norby
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
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Afsar B, Yilmaz MI, Siriopol D, Unal HU, Saglam M, Karaman M, Gezer M, Sonmez A, Eyileten T, Aydin I, Hamcan S, Oguz Y, Covic A, Kanbay M. Thyroid function and cardiovascular events in chronic kidney disease patients. J Nephrol 2016; 30:235-242. [PMID: 27039198 DOI: 10.1007/s40620-016-0300-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 03/22/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIMS Abnormalities of thyroid function are commonly seen in chronic kidney disease (CKD) patients. They are associated with adverse clinical conditions such as atherosclerosis, endothelial dysfunction, inflammation and abnormal blood pressure variability. We investigated the association between thyroid disorders and endothelial function, assessed by flow-mediated dilatation (FMD) and carotid intima-media thickness (CIMT), and cardiovascular events (CVE) in CKD patients. MATERIALS AND METHODS This observational cohort study included 305 CKD (stages 1-5) patients. Routine biochemistry, including free T3, free T4 and thyroid stimulating hormone, fibroblast growth factor-23 (FGF-23) and FMD, CIMT were measured. We divided patients into four groups according to thyroid hormone status: euthyroidism, subclinical hyperthyroidism, subclinical hypothyroidism, and euthyroid sick syndrome. Fatal and composite CVE were recorded for a median 29 months. RESULTS Patients with subclinical hypothyroidism had a higher prevalence of hypertension and diabetes and also were more likely to have higher values of systolic CIMT, phosphorus, intact parathormone (iPTH), FGF-23, homeostasis model assessment-insulin resistance and lower levels of FMD than euthyroid patients. In the unadjusted survival analysis, subclinical hypothyroidism and euthyroid sick syndrome were associated with an increased risk for the outcome as compared with euthyroidism [hazard ratio 30.63 (95 % confidence interval 12.27-76.48) and 12.17 (3.70-39.98), respectively]. The effects of subclinical hypothyroidism and euthyroid sick syndrome were maintained even in fully adjusted models. CONCLUSION We demonstrated that subclinical hypothyroidism and euthyroid sick syndrome are associated with increased CVE in CKD patients. Further studies are needed to explore these issues.
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Affiliation(s)
- Baris Afsar
- Department of Nephrology, Konya Numune State Hospital, Konya, Turkey
| | | | - Dimitrie Siriopol
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. PARHON' University Hospital, 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Hilmi Umut Unal
- Department of Nephrology, Gulhane School of Medicine, Ankara, Turkey
| | - Mutlu Saglam
- Department of Radiology, Gulhane School of Medicine, Ankara, Turkey
| | - Murat Karaman
- Department of Nephrology, Gulhane School of Medicine, Ankara, Turkey
| | - Mustafa Gezer
- Department of Nephrology, Gulhane School of Medicine, Ankara, Turkey
| | - Alper Sonmez
- Department of Endocrinology, Gulhane School of Medicine, Ankara, Turkey
| | - Tayfun Eyileten
- Department of Nephrology, Gulhane School of Medicine, Ankara, Turkey
| | - Ibrahim Aydin
- Department of Endocrinology, Gulhane School of Medicine, Ankara, Turkey
| | - Salih Hamcan
- Department of Biochemistry, Gulhane School of Medicine, Ankara, Turkey
| | - Yusuf Oguz
- Department of Nephrology, Gulhane School of Medicine, Ankara, Turkey
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. PARHON' University Hospital, 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Mehmet Kanbay
- Department of Nephrology, Gulhane School of Medicine, Ankara, Turkey. .,Department of Medicine, Division of Nephrology, Koc University School of Medicine, Topkapı, 03490, Istanbul, Turkey.
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Rhee CM. Low-T3 Syndrome in Peritoneal Dialysis: Metabolic Adaptation, Marker of Illness, or Mortality Mediator? Clin J Am Soc Nephrol 2015; 10:917-9. [PMID: 25979973 DOI: 10.2215/cjn.04310415] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Connie M Rhee
- Division of Nephrology and Hypertension, University of California Irvine, Orange, California
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Rhee CM, Brent GA, Kovesdy CP, Soldin OP, Nguyen D, Budoff MJ, Brunelli SM, Kalantar-Zadeh K. Thyroid functional disease: an under-recognized cardiovascular risk factor in kidney disease patients. Nephrol Dial Transplant 2015; 30:724-37. [PMID: 24574542 PMCID: PMC4425477 DOI: 10.1093/ndt/gfu024] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 01/17/2014] [Indexed: 01/07/2023] Open
Abstract
Thyroid functional disease, and in particular hypothyroidism, is highly prevalent among chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients. In the general population, hypothyroidism is associated with impaired cardiac contractility, endothelial dysfunction, atherosclerosis and possibly higher cardiovascular mortality. It has been hypothesized that hypothyroidism is an under-recognized, modifiable risk factor for the enormous burden of cardiovascular disease and death in CKD and ESRD, but this has been difficult to test due to the challenge of accurate thyroid functional assessment in uremia. Low thyroid hormone levels (i.e. triiodothyronine) have been associated with adverse cardiovascular sequelae in CKD and ESRD patients, but these metrics are confounded by malnutrition, inflammation and comorbid states, and hence may signify nonthyroidal illness (i.e. thyroid functional test derangements associated with underlying ill health in the absence of thyroid pathology). Thyrotropin is considered a sensitive and specific thyroid function measure that may more accurately classify hypothyroidism, but few studies have examined the clinical significance of thyrotropin-defined hypothyroidism in CKD and ESRD. Of even greater uncertainty are the risks and benefits of thyroid hormone replacement, which bear a narrow therapeutic-to-toxic window and are frequently prescribed to CKD and ESRD patients. In this review, we discuss mechanisms by which hypothyroidism adversely affects cardiovascular health; examine the prognostic implications of hypothyroidism, thyroid hormone alterations and exogenous thyroid hormone replacement in CKD and ESRD; and identify areas of uncertainty related to the interplay between hypothyroidism, cardiovascular disease and kidney disease requiring further investigation.
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Affiliation(s)
- Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Gregory A. Brent
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Departments of Medicine and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Offie P. Soldin
- Department of Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - Danh Nguyen
- Department of Medicine, University of California Irvine, Orange, CA, USA
| | - Matthew J. Budoff
- Division of Cardiology, LA Biomedical Research Institute, Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Steven M. Brunelli
- Division of Nephrology, Brigham and Women's Hospital, Boston, MA, USA
- DaVita Clinical Research, Minneapolis, MN, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
- Department of Medicine, University of California Irvine, Orange, CA, USA
- Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA, USA
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Rhee CM, Kim S, Gillen DL, Oztan T, Wang J, Mehrotra R, Kuttykrishnan S, Nguyen DV, Brunelli SM, Kovesdy CP, Brent GA, Kalantar-Zadeh K. Association of thyroid functional disease with mortality in a national cohort of incident hemodialysis patients. J Clin Endocrinol Metab 2015; 100:1386-95. [PMID: 25632971 PMCID: PMC4399303 DOI: 10.1210/jc.2014-4311] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
CONTEXT Hypothyroidism is a common condition that disproportionately affects hemodialysis patients. In the general population, hypothyroidism is associated with higher mortality, particularly in populations with underlying cardiovascular risk. Despite their heightened cardiovascular mortality, the impact of hypothyroidism on the survival of hemodialysis patients remains uncertain. OBJECTIVE To examine whether hypothyroidism is independently associated with higher mortality in hemodialysis patients. DESIGN, SETTING, AND PATIENTS Among 8840 incident hemodialysis patients receiving care from a large national dialysis provider from January 2007 to December 2011, we examined the association of hypothyroidism (TSH >5.0 mIU/L) with mortality. MAIN OUTCOME MEASURES Associations between baseline and time-dependent hypothyroidism with all-cause mortality were determined using case-mix adjusted Cox models. In secondary analyses, we examined the impact of low-normal, upper-normal, subclinical range, and overt range TSH levels (TSH ≥ 0.5-3.0, >3.0-5.0, >5.0-10.0, and >10.0 mIU/L, respectively) on mortality risk. RESULTS The study population consisted of 1928 (22%) hypothyroid and 6912 (78%) euthyroid patients. Baseline and time-dependent hypothyroidism were associated with higher mortality: adjusted hazard ratios (95% confidence intervals) were 1.47 (1.34-1.61) and 1.62 (1.45-1.80), respectively. Compared to low-normal TSH, upper-normal, subclinical hypothyroid, and overt hypothyroid TSH levels were associated with incrementally higher adjusted death risk in baseline and time-dependent analyses. In time-dependent analyses, the hypothyroidism-mortality association was increasingly stronger across higher body mass index strata. CONCLUSIONS Hypothyroidism as well as upper-normal TSH levels are associated with higher mortality in hemodialysis patients. Further studies are needed to determine whether restoration of TSH to low-normal levels with thyroid hormone replacement therapy ameliorates adverse outcomes in hemodialysis patients.
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Affiliation(s)
- Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology (C.M.R., K.K.-Z.), Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California 92868; Los Angeles Biomedical Research Institute (C.M.R., K.K.-Z.), Harbor-UCLA Medical Center Torrance, California 90502; Department of Statistics (S.K., D.L.G., T.O., J.W.), University of California Irvine School of Medicine, Irvine, California 92697; Division of Nephrology (R.M., S.K.), Harborview Medical Center, University of Washington, Seattle, Washington 98104; Division of General Internal Medicine (D.V.N.), University of California Irvine Medical Center, Orange, California 92868; DaVita Clinical Research (S.M.B.), Minneapolis, Minnesota 55404; Nephrology Section (C.P.K.), Memphis Veterans Affairs Medical Center, Memphis, Tennessee 38104; Division of Nephrology (C.P.K.), University of Tennessee Health Science Center, Memphis, Tennessee 38163; and Division of Endocrinology (G.A.B.), University of California Los Angeles, Los Angeles, California 90095
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Abstract
IMPORTANCE Subclinical hypothyroidism (SCH) is a common clinical entity with a putative role in a wide range of disorders. The impact of SCH on mortality and markers of morbidity has been demonstrated, but studies have shown inconsistent results. Evidence regarding the effect of levothyroxine treatment on reversing morbidity markers is emerging, but the value of treatment is still unclear. OBJECTIVE The objectives of this review were to assess recent, high-quality studies evaluating the role of SCH in cardiovascular health, cognition, mood, pregnancy, anemia, and renal disease; to examine the effects of levothyroxine on reducing mortality or reversing markers of morbidity in these conditions; and to consider how new research insights may help guide clinical practice. EVIDENCE REVIEW A PubMed search was conducted (using 'subclinical hypothyroidism' [Title/Abstract] AND morbidity [MeSH Subheading] as search criteria) and was restricted to human studies published in the English language between 1990 and 2013. Subsequent searches of retrieved articles yielded further studies, which were included based on quality. Emphasis was given to large observational studies, well-conducted meta-analyses, and randomized controlled trials. FINDINGS The difficulty of diagnosing SCH, particularly in the elderly, may underlie many of the conflicting results seen in the literature. Increased understanding of the at-risk patient population will result in better selection of study subjects and, likely, unequivocal results. Regardless of the current confusion, emerging evidence suggests that certain markers of morbidity are reversed by levothyroxine therapy across the disorders examined here. CONCLUSION AND RELEVANCE Future large, well-controlled studies will not only clarify the role of SCH but also help identify patients for whom levothyroxine treatment will provide the most benefit.
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Affiliation(s)
- James V Hennessey
- Department of Medicine, Division of Endocrinology, Beth Israel Deaconess Medical Center , Boston, MA , USA
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Jung HY, Cho JH, Jang HM, Kim YS, Kang SW, Yang CW, Kim NH, Choi JY, Park SH, Kim CD, Kim YL. Free thyroxine level as an independent predictor of infection-related mortality in patients on peritoneal dialysis: a prospective multicenter cohort study. PLoS One 2014; 9:e112760. [PMID: 25436457 PMCID: PMC4249823 DOI: 10.1371/journal.pone.0112760] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/14/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Previous studies have reported the relationship between thyroid hormone levels and mortality in dialysis patients. However, little is known about the association of free thyroxine (fT4) and mortality in patients on peritoneal dialysis (PD). This study investigated the association between basal and annual variation in fT4 level and mortality in PD patients. METHODS Patients on maintenance PD were enrolled from a prospective multicenter cohort study in Korea; their serum triiodothyronine, fT4, and thyroid-stimulating hormone levels were measured 12 months apart. Patients with overt thyroid disease and those receiving thyroid hormone replacement therapy were excluded from the analysis. Patients were divided into two groups based on the median levels of fT4. The differences of all-cause, infection-related, and cardiovascular mortalities were analyzed between the two groups. The association of basal levels and annual variation with mortality was investigated with Kaplan-Meier curves and Cox proportional hazard models. RESULTS Among 235 PD patients, 31 (13.2%) deaths occurred during the mean follow-up period of 24 months. Infection (38.7%) was the most common cause of death. Lower basal fT4 levels were an independent predictor of all-cause and infection-related death (hazard ratio [HR] = 2.74, 95% confidence interval [CI] 1.27-5.90, P = 0.01, and HR = 6.33, 95% CI 1.16-34.64, P = 0.03, respectively). Longitudinally, patients with persistently lower fT4 levels during the 12-month period had significantly higher all-cause mortality than those with persistently higher levels (HR = 3.30, 95% CI 1.15-9.41, P = 0.03). The area under the receiver operating characteristic curve of fT4 for predicting all-cause and infection-related mortality was 0.60 and 0.68, respectively. CONCLUSIONS fT4 level is an independent predictor of mortality and is especially attributable to infection in PD patients. This predictor was consistent when considering both baseline measurements and annual variation patterns. Close attention to infection in PD patients with relatively lower fT4 levels should be considered.
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Affiliation(s)
- Hee-Yeon Jung
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - Jang-Hee Cho
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - Hye Min Jang
- Department of Statistics, Kyungpook National University, Daegu, Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - Chul Woo Yang
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - Nam-Ho Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - Ji-Young Choi
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - Sun-Hee Park
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, Korea
- Bk21 Plus KNU Biomedical Convergence Program, Department of Biomedical Science, Kyungpook National University, Daegu, Korea
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Kim TH, Choi HS, Bae JC, Moon JH, Kim HK, Choi SH, Lim S, Park DJ, Park KS, Jang HC, Lee MK, Cho NH, Park YJ. Subclinical hypothyroidism in addition to common risk scores for prediction of cardiovascular disease: a 10-year community-based cohort study. Eur J Endocrinol 2014; 171:649-57. [PMID: 25184283 DOI: 10.1530/eje-14-0464] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE This study was carried out to determine whether serum TSH levels improve the prediction of cardiovascular risk in addition to common clinical risk scores, given the association between subclinical hypothyroidism (SCH) and cardiovascular disease (CVD). DESIGN We carried out an observational study in a prospective cohort. METHODS The study included a total of 344 SCH and 2624 euthyroid participants aged over 40 years and who were without previously recorded CVDs were included in this study analysis. We measured thyroid function and traditional risk factors at baseline and estimated the 10-year cumulative incidence of CVD in a gender-stratified analysis. RESULTS During 10 years of follow-up, 251 incident cardiovascular events were recorded. The elevation of serum TSH levels significantly increased the CV risk independent of conventional risk factors in men. In the atherosclerotic CVD (ASCVD) risk score or the Reynolds risk score (RRS) model, the addition of serum TSH levels had no effect on model discrimination as measured by the area under the curve in either women or men. Adding serum TSH did not improve the net reclassification improvement in either women (3.48% (P=0.29) in the ASCVD, -0.89% (P=0.75) in the RRS, respectively) or men (-1.12% (P=0.69), 3.45% (P=0.20), respectively) and only mildly affected the integrated discrimination Improvement in the ASCVD-adjusted model (0.30% in women and 0.42% in men, both P=0.05). CONCLUSIONS In the context of common risk scoring models, the additional assessment of serum TSH levels provided little incremental benefit for the prediction of CV risk.
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Affiliation(s)
- Tae Hyuk Kim
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of MedicineSamsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam, KoreaDepartment of Preventive MedicineAjou University School of Medicine, #5 Wonchon-Dong, Youngtong-Gu, Suwon 442-749, Korea
| | - Hoon Sung Choi
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of MedicineSamsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam, KoreaDepartment of Preventive MedicineAjou University School of Medicine, #5 Wonchon-Dong, Youngtong-Gu, Suwon 442-749, Korea
| | - Ji Cheol Bae
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of MedicineSamsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam, KoreaDepartment of Preventive MedicineAjou University School of Medicine, #5 Wonchon-Dong, Youngtong-Gu, Suwon 442-749, Korea
| | - Jae Hoon Moon
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of MedicineSamsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam, KoreaDepartment of Preventive MedicineAjou University School of Medicine, #5 Wonchon-Dong, Youngtong-Gu, Suwon 442-749, Korea
| | - Hyung-Kwan Kim
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of MedicineSamsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam, KoreaDepartment of Preventive MedicineAjou University School of Medicine, #5 Wonchon-Dong, Youngtong-Gu, Suwon 442-749, Korea
| | - Sung Hee Choi
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of MedicineSamsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam, KoreaDepartment of Preventive MedicineAjou University School of Medicine, #5 Wonchon-Dong, Youngtong-Gu, Suwon 442-749, Korea
| | - Soo Lim
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of MedicineSamsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam, KoreaDepartment of Preventive MedicineAjou University School of Medicine, #5 Wonchon-Dong, Youngtong-Gu, Suwon 442-749, Korea
| | - Do Joon Park
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of MedicineSamsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam, KoreaDepartment of Preventive MedicineAjou University School of Medicine, #5 Wonchon-Dong, Youngtong-Gu, Suwon 442-749, Korea
| | - Kyong Soo Park
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of MedicineSamsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam, KoreaDepartment of Preventive MedicineAjou University School of Medicine, #5 Wonchon-Dong, Youngtong-Gu, Suwon 442-749, Korea
| | - Hak Chul Jang
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of MedicineSamsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam, KoreaDepartment of Preventive MedicineAjou University School of Medicine, #5 Wonchon-Dong, Youngtong-Gu, Suwon 442-749, Korea
| | - Moon-Kyu Lee
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of MedicineSamsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam, KoreaDepartment of Preventive MedicineAjou University School of Medicine, #5 Wonchon-Dong, Youngtong-Gu, Suwon 442-749, Korea
| | - Nam H Cho
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of MedicineSamsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam, KoreaDepartment of Preventive MedicineAjou University School of Medicine, #5 Wonchon-Dong, Youngtong-Gu, Suwon 442-749, Korea
| | - Young Joo Park
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of MedicineSamsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam, KoreaDepartment of Preventive MedicineAjou University School of Medicine, #5 Wonchon-Dong, Youngtong-Gu, Suwon 442-749, Korea
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Rhee CM, Kalantar-Zadeh K. Resistance exercise: an effective strategy to reverse muscle wasting in hemodialysis patients? J Cachexia Sarcopenia Muscle 2014; 5:177-80. [PMID: 25163460 PMCID: PMC4159495 DOI: 10.1007/s13539-014-0160-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 08/08/2014] [Indexed: 12/27/2022] Open
Abstract
Muscle wasting is a common complication afflicting maintenance hemodialysis (HD) patients, and it is associated with decreased muscle function, exercise performance, physical function, and quality of life. Meanwhile, numerous epidemiologic studies have consistently shown that greater muscle mass (ascertained by body anthropometry surrogates, body composition tests such as dual x-ray absorptiometry, and/or serum creatinine in patients with little to no residual kidney function) is associated with increased survival in this population. The pathophysiology of muscle wasting in HD patients is complex and may be caused by poor dietary intake, catabolic effects of dialysis therapy, hormonal alterations (e.g., decreased levels or resistance to anabolic hormones, increased levels of catabolic hormones), inflammation, metabolic acidosis, and concurrent comorbidities. Muscle disuse resulting from low physical activity is an important yet under-appreciated risk factor for muscle wasting. Intra-dialytic resistance exercise training has been suggested as a potential strategy to correct and/or prevent this complication in HD patients, but prior studies examining this exercise modality as an anabolic intervention have shown mixed results. In a recently published 12-week randomized controlled trial of a novel intra-dialytic progressive resistance exercise training (PRET) program vs. control therapy conducted in HD and non-HD patients, PRET resulted in increased muscle volume and strength in both groups. At this time, further study is needed to determine if anabolic improvements imparted by resistance exercise translates into improved physical function and quality of life, decreased hospitalization and mortality risk, and greater cost-effectiveness in HD patients.
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Affiliation(s)
- Connie M. Rhee
- />Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medicine Center, 101 The City Drive South, City Tower, Orange, CA 92868-3217 USA
- />Los Angeles Biomedical Research Institute, Harbor-UCLA, Torrance, CA USA
| | - Kamyar Kalantar-Zadeh
- />Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medicine Center, 101 The City Drive South, City Tower, Orange, CA 92868-3217 USA
- />Los Angeles Biomedical Research Institute, Harbor-UCLA, Torrance, CA USA
- />Veterans Affairs Long Beach Health Care System, Long Beach, CA USA
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47
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Abstract
Thyroid hormone deficiency can have important repercussions. Treatment with thyroid hormone in replacement doses is essential in patients with hypothyroidism. In this review, we critically discuss the thyroid hormone formulations that are available and approaches to correct replacement therapy with thyroid hormone in primary and central hypothyroidism in different periods of life such as pregnancy, birth, infancy, childhood, and adolescence as well as in adult patients, the elderly, and in patients with comorbidities. Despite the frequent and long term use of l-T4, several studies have documented frequent under- and overtreatment during replacement therapy in hypothyroid patients. We assess the factors determining l-T4 requirements (sex, age, gender, menstrual status, body weight, and lean body mass), the major causes of failure to achieve optimal serum TSH levels in undertreated patients (poor patient compliance, timing of l-T4 administration, interferences with absorption, gastrointestinal diseases, and drugs), and the adverse consequences of unintentional TSH suppression in overtreated patients. Opinions differ regarding the treatment of mild thyroid hormone deficiency, and we examine the recent evidence favoring treatment of this condition. New data suggesting that combined therapy with T3 and T4 could be indicated in some patients with hypothyroidism are assessed, and the indications for TSH suppression with l-T4 in patients with euthyroid multinodular goiter and in those with differentiated thyroid cancer are reviewed. Lastly, we address the potential use of thyroid hormones or their analogs in obese patients and in severe cardiac diseases, dyslipidemia, and nonthyroidal illnesses.
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Affiliation(s)
- Bernadette Biondi
- Department of Clinical Medicine and Surgery (B.B.), University of Naples Federico II, 80131 Naples, Italy; and Washington Hospital Center (L.W.), Washington, D.C. 20010
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48
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Hypothyroidism induced severe rhabdomyolysis in a hemodialysis patient. Case Rep Med 2014; 2014:501890. [PMID: 24803938 PMCID: PMC3997939 DOI: 10.1155/2014/501890] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 03/12/2014] [Indexed: 12/02/2022] Open
Abstract
Hypothyroidism occurs relatively common and is a significant cause of morbidity and mortality during the course of chronic kidney disease. Rhabdomyolysis is a potentially life-threatening condition characterised by necrosis of muscular tissue and rarely associates with hypothyroidism. Here we describe a case of rhabdomyolysis due to severe hypothyroidism in a 56-year-old female hemodialysis patient.
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49
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Prognostic biomarkers in thyroid cancer. Virchows Arch 2014; 464:333-46. [PMID: 24487783 DOI: 10.1007/s00428-013-1521-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/25/2013] [Indexed: 12/23/2022]
Abstract
Thyroid carcinomas represent a challenging problem from the prognostic standpoint. Despite an overall good prognosis of the most frequent endocrine malignancy, 10-15 % of papillary thyroid carcinomas (PTCs) turn refractory to radioactive iodine therapy. The increased incidence of thyroid cancer has led to the search for solid prognostic biomarkers that predict the behaviour of these tumours. Clinical and histopathological prognostic factors remain the only safe elements to be used for diagnosis and prognosis of patients with thyroid tumours. Despite the huge amount of genetic information of thyroid tumours, very few new markers revealed diagnostic or prognostic value per se. BRAF mutation can have some value if associated to other clinico-pathological parameters, or in the particular setting of iodine refractory tumours. Others can prove interesting in the future as predictive biomarkers of therapeutic response, but more studies are needed to confirm these potential biomarkers.
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50
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The thyroid and the kidney: a complex interplay in health and disease. Int J Artif Organs 2014; 37:1-12. [PMID: 24634329 DOI: 10.5301/ijao.5000300] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2013] [Indexed: 11/20/2022]
Abstract
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.
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