Rare acute kidney injury secondary to hypothyroidism-induced rhabdomyolysis

RISK FACTORS FOR ACUTE KIDNEY INJURY ASSOCIATED WITH SEVERE HYPOTHYROIDISM

Objective

This study aims to investigate the factors affecting development of acute kidney injury (AKI) in patients with severe hypothyroidism.

Methods

This retrospective observational study involved patients with primary hypothyroidism and thyroid stimulating hormone (TSH) levels of more than 50 mIU/L at their review in the endocrinology outpatient clinic, between January 2015 and April 2021. Factors affecting the development of AKI were examined by logistic regression analysis.

Results

A total of 100 patients, 20 (11 male (M), 9 female (F)) in the AKI (case) group and 80 (23 M, 57 F) patients in control group, were included in our study. The median age of the case group (56 years, interquartile range (IQR) 44.3-68.5) was significantly higher than the control group (49 years, IQR 32.3-60; p = 0.027), and the ratio of males to females was significantly higher in the case group (p = 0.001). Multivariate logistic regression analyses showed that hypothyroidism diagnosed after the age of 60 years (odds ratio (OR) 59.674, 95% confidence intervals (CI) 5.955-598.031; p = 0.001), free triiodothyronine (FT3) < 1.3 pg/mL (OR 17.151, 95% CI 2.491-118.089; p = 0.004) and creatine kinase (CK) > 1000 U/L (OR 1.522, 95% CI 1.602-82.848; p = 0.015) were predictors for the development of AKI in patients with severe hypothyroidism.

Conclusion

We recommend close follow-up and monitoring of patients with AKI caused by severe hypothyroidism if patients who are diagnosed at age > 60 years, CK > 1000 U/L or FT3 < 1.3 pg/mL.

Endocrinological disorders in acute kidney injury: an often overlooked field of clinical research

Acute kidney injury (AKI) is a common comorbidity, affecting approximately one in five hospitalized adults. The kidney is the site for the production, metabolism or excretion of most hormones, including the production of erythropoietin (EPO), the active form of vitamin D, renin, thrombopoietin, and the excretion of insulin, catecholamines, gastrin and many other hormones. Therefore, it is reasonable to say that AKI can have a considerable impact on the endocrine system. Although the effects of AKI on various parameters, including cardiovascular parameters, serum electrolytes and acid-base disorders, neuro-humoral mechanisms and neurological outcomes have been extensively studied, the endocrinological consequences of AKI are understudied. Thyroid dysfunction, mainly euthyroid sick syndrome, hypo/hyperglycemia, bone mineral disorders, changes in EPO and atrial natriuretic peptide (ANP) levels are commonly found in AKI. EPO, thyroxine and ANP administration have been evaluated as potential tools to prevent or treat AKI with varying success, while the effects of AKI on some key hormones, including cortisol and insulin, have never been studied. Aim of this narrative review is to illustrate what is known and what is not known about the endocrinological outcomes of AKI. Few clinical trials are ongoing: however, there is a clear need for large-scale randomized controlled trials investigating the endocrinological consequences of AKI.

Rhabdomyolysis Secondary to Hypothyroidism: Report of a Case

Rhabdomyolysis has many causes; however, hypothyroidism is a rare cause of such a condition. Usually, management is similar in many cases, but some exceptions do exist, especially in the case of hypothyroidism. Thus, we reviewed the literature to investigate further precipitant factors, clinical presentations, complications, management, and prognoses. We report a 19-year-old male with a history of hypothyroidism who was brought in for questionable suicidal ideation. Although asymptomatic, he was found to have an acute kidney injury (AKI). Further investigations revealed significantly elevated levels of creatine kinase (CK) and thyroid-stimulating hormone (TSH) in the setting of medication non-compliance. Management with intravenous (IV) fluids and thyroid hormone replacement resulted in an improvement in AKI and CK levels.

Non-traumatic and non-drug-induced rhabdomyolysis

Rhabdomyolysis (RM), a fortunately rare disease of the striated muscle cells, is a complication of non-traumatic (congenital (glycogen storage disease, discrete mitochondrial myopathies and various muscular dystrophies) or acquired (alcoholic myopathy, systemic diseases, arterial occlusion, viral illness or bacterial sepsis)) and traumatic conditions. Additionally, RM can occur in some individuals under specific circumstances such as toxic substance use and illicit drug abuse. Lipid-lowering drugs in particular are capable of causing RM. This comprehensive review will focus on non-traumatic and non-drug-induced RM. Moreover, the pathology of RM, its clinical manifestation and biochemical effects, and finally its management will be discussed.

Severe hypothyroidism presenting as reversible proteinuria: two case reports

Background

Hypothyroidism is a common medical disorder which results in many metabolic effects, such as dyslipidemia, hypertension, accelerated atherosclerosis, and coronary artery disease. Hypothyroidism affects the renal physiology by affecting the renal blood flow, vascular resistance, and sodium handling. Recent studies have shown hypothyroidism is associated with decreased estimated renal function and proteinuria. Rhabdomyolysis and acute renal insufficiency have also been described in association with hypothyroidism. The severity of the proteinuria was directly proportional to thyroid-stimulating hormone levels. Currently, there is a lack of evidence on the reversibility of proteinuria in hypothyroidism. This is the first report in the literature, to the best of our knowledge, demonstrating the reversibility of proteinuria associated with hypothyroidism, with treatment.

Case presentation

Here we describe two cases, a 72-year-old Sinhalese man and a 47-year-old Tamil woman, from Sri Lanka, presenting with overt hypothyroidism; they were found to have elevated creatinine, proteinuria, and elevated creatinine kinase levels. Due to lack of active sediment in urine analysis, these patients were observed after the initiation of thyroxine therapy. They were investigated in the adult-onset proteinuria pathway, excluding common reasons for proteinuria. Both patients responded to treatment: their serum creatinine, creatinine kinase, and urine protein levels reverted to physiological levels within 6 months of treatment with thyroxine, and with normalization of thyroid-stimulating hormone.

Conclusion

Hypothyroidism can present as renal insufficiency, proteinuria, and can mimic rhabdomyolysis. Prompt initiation of thyroxine treatment and control of thyroid-stimulating hormone levels could reverse these changes.

Untreated primary hypothyroidism with simultaneous rhabdomyolysis, pericardial effusion, and sudden sensorineural hearing loss: a case report

BACKGROUND

Hypothyroidism, one of the prevalent endocrine disorders worldwide, has a broad spectrum of clinical manifestations, from an asymptomatic condition to myxedema coma. Although the majority of patients with hypothyroidism have minor clinical symptoms, which are recovered with levothyroxine treatment, some patients occasionally do experience fatal complications. Here we report, for the first time, the case of a patient who had hypothyroidism with simultaneous occurrence of rhabdomyolysis with acute kidney injury, moderate pericardial effusion, and sudden sensorineural hearing loss.

CASE PRESENTATION

A 57-year-old man with a previous history of dyslipidemia and untreated hypothyroidism was admitted to the hospital due to shortness of breath, lethargy, lower extremity discomfort, and unilateral hearing loss. Laboratory results revealed rhabdomyolysis with acute kidney injury and severe hypothyroidism. We detected cardiomegaly without lung parenchymal infiltration on chest radiography and moderate pericardial effusion on transthoracic echocardiography. We performed pure tone audiometry and identified profound unilateral sensorineural hearing loss. Aggressive fluid resuscitation, levothyroxine treatment, and systemic and intratympanic steroid therapy alleviated the patient's severe hypothyroidism, rhabdomyolysis, and pericardial effusion; however, sensorineural hearing loss was not fully recovered.

CONCLUSIONS

Early recognition of life-threatening complications is important in patients with severe hypothyroidism to prevent adverse outcomes. This case suggests that hypothyroidism should be considered in patients who have rhabdomyolysis with acute kidney disease and pericardial effusion. Moreover, sudden sensorineural hearing loss should be kept in mind as a rare complication of hypothyroidism.

Comparison between acute kidney injury (AKI) and non-AKI patients secondary to severe hypothyroidism

Hypothyroidism was a rare cause of rhabdomyolysis, which finally progressed to acute kidney injury (AKI). We compared nine patients with AKI secondary to hypothyroidism and six patients with severe hypothyroidism. Besides creatine kinase, globulin could be an alternative biomarker of rhabdomyolysis related to hypothyroidism.

Thyroid Hormones Play Role in Sarcopenia and Myopathies

Skeletal muscle maintains posture and enables movement by converting chemical energy into mechanical energy, further contributing to basal energy metabolism. Thyroid hormones (thyroxine, or T4, and triiodothyronine, or T3) participate in contractile function, metabolic processes, myogenesis and regeneration of skeletal muscle. T3 classically modulates gene expression after binding to thyroid hormone nuclear receptors. Thyroid hormone effects depend on nuclear receptor occupancy, which is directly related to intracellular T3 levels. Sarcolemmal thyroid hormone levels are regulated by their transport across the plasma membrane by specific transporters, as well as by the action of deiodinases types 2 and 3, which can activate or inactivate T4 and T3. Thyroid hormone level oscillations have been associated with the worsening of many myopathies such as myasthenia gravis, Duchenne muscular dystrophy (DMD) and rhabdomyolysis. During aging skeletal muscle show a decrease in mass and quality, known as sarcopenia. There is increasing evidence that thyroid hormones could have a role in the sarcopenic process. Therefore, in this review, we aim to discuss the main effects of thyroid hormones in skeletal muscular aging processes and myopathy-related pathologies.

Hypothyroid myopathy: A peculiar clinical presentation of thyroid failure. Review of the literature

Abnormalities in thyroid function are common endocrine disorders that affect 5-10 % of the general population, with hypothyroidism occurring more frequently than hyperthyroidism. Clinical symptoms and signs are often nonspecific, particularly in hypothyroidism. Muscular symptoms (stiffness, myalgias, cramps, easy fatigability) are mentioned by the majority of patients with frank hypothyroidism. Often underestimated is the fact that muscle symptoms may represent the predominant or the only clinical manifestation of hypothyroidism, raising the issue of a differential diagnosis with other causes of myopathy, which sometimes can be difficult. Elevated serum creatine kinase, which not necessarily correlates with the severity of the myopathic symptoms, is certainly suggestive of muscle impairment, though it does not explain the cause. Rare muscular manifestations, associated with hypothyroidism, are rhabdomyolysis, acute compartment syndrome, Hoffman's syndrome and Kocher-Debré-Sémélaigne syndrome. Though the pathogenesis of hypothyroid myopathy is not entirely known, proposed mechanisms include altered glycogenolytic and oxidative metabolism, altered expression of contractile proteins, and neuro-mediated damage. Correlation studies of haplotype, muscle gene expression and protein characterization, could help understanding the pathophysiological mechanisms of this myopathic presentation of hypothyroidism.

Rhabdomyolysis case based on hypothyroidism

Hypothyroidism is a wide clinical spectrum disorder and only a few cases in literature show this. Rhabdomyolysis and acute renal impairment can be seen concurrently in a hypothyroid state. We report a case of severe hypothyroidism with poor drug compliance leading to rhabdomyolysis and acute kidney injury.

Rhabdomyolysis and acute renal impairment in a patient with hypothyroidism: a case report

We report the case of a 33-year-old male with hypothyroidism who developed acute renal impairment with rhabdomyolysis after strenuous physical activity (snow shoveling). His thyroid function test confirmed marked hypothyroidism. Severe elevation of serum CK consistent with rhabdomyolysis was noted and an elevated creatinine indicated acute renal impairment. Patient's condition improved significantly after starting him on thyroid hormone replacement therapy and aggressive hydration. Acute renal impairment with rhabdomyolysis in patients with hypothyroidism is quite rare and we expect that this case report adds to the existing literature on this subject. We also emphasize that thyroid status should be evaluated in patients with unexplained acute renal impairment and presenting with the symptoms of muscle involvement.