Low triiodothyronine predicts mortality in critically ill patients

Association between serum TSH levels and all-cause mortality in critically ill patients

Thyroid dysfunction is common in critical illness and may influence prognosis. However, the value of TSH in patients with severe diseases remains unclear. The aim of this study was to investigate the association between TSH and the clinical prognosis of critically ill patients. Methods: This retrospective study identified patients who were admitted to the ICU in the Medical Information Mart for Intensive Care (MIMIC-IV) database (version 2.2). A total of 6432 patients were divided into four groups based on TSH quartiles (Q1, <0.92 mIU/L; Q2, 0.92-1.07 mIU/L; Q3, 1.07-3.10 mIU/L; Q4, >3.10 mIU/L). The clinical outcomes were defined as all-cause 7-, 30-, and 90-year mortality after ICU admission. Restricted cubic splines (RCSs) for nonlinear associations were generated to visualize the relationship between TSH levels and clinical outcomes. The survival differences among the four groups were also analyzed using Kaplan‒Meier curves and log rank tests. Univariable and multivariable Cox proportional hazards regression were further used to assess the association between TSH levels and clinical outcomes. Results: After multivariate adjustment, a U-shaped relationship was observed between TSH levels and all-cause 7-, 30-, and 90- mortality among patients with severe disease (all P < 0.05 for nonlinearity). The plot showed a risk reduction in the low range of TSH, which reached the lowest risk at approximately 2.9 μIU/mL and then increased thereafter. Compared with patients with Q3 TSH levels, those with Q1, Q2, and Q4 TSH levels had a significantly higher risk of all-cause 30-day mortality (Q1: hazard ratio, 1.28; 95% CI, 1.06-1.54; Q2: hazard ratio, 1.22; 95% CI, 1.01-1.48; Q4: hazard ratio, 1.25; 95% CI, 1.04-1.50). For all-cause 90-day mortality, only the Q4 group had a significantly higher mortality risk than the Q3 group (hazard ratio, 1.24; 95% CI, 1.07-1.44). In subgroup analyses, we found that Q1 TSH levels were associated with higher mortality risk in men and older (≥65 years) patients, while Q4 TSH had a greater risk in men and younger (<65 years) patients. Conclusions: TSH was significantly associated with all-cause 7-, 30-, and 90-day mortality in critically ill patients after admission to the ICU. TSH may serve as a valuable biomarker for risk stratification in critically ill patients.

Relationship among Low T3 Levels, Type 3 Deiodinase, Oxidative Stress, and Mortality in Sepsis and Septic Shock: Defining Patient Outcomes

Low T3 syndrome occurs frequently in patients with sepsis. Type 3 deiodinase (DIO3) is present in immune cells, but there is no description of its presence in patients with sepsis. Here, we aimed to determine the prognostic impact of thyroid hormones levels (TH), measured on ICU admission, on mortality and evolution to chronic critical illness (CCI) and the presence of DIO3 in white cells. We used a prospective cohort study with a follow-up for 28 days or deceased. Low T3 levels at admission were present in 86.5% of the patients. DIO3 was induced by 55% of blood immune cells. The cutoff value of 60 pg/mL for T3 displayed a sensitivity of 81% and specificity of 64% for predicting death, with an odds ratio of 4.89. Lower T3 yielded an area under the receiver operating characteristic curve of 0.76 for mortality and 0.75 for evolution to CCI, thus displaying better performance than commonly used prognostic scores. The high expression of DIO3 in white cells provides a novel mechanism to explain the reduction in T3 levels in sepsis patients. Further, low T3 levels independently predict progression to CCI and mortality within 28 days for sepsis and septic shock patients.

Study of Non-Thyroidal Illness Syndrome and Its Recovery in Critically Ill Patients at a Tertiary Care Centre in South India

Background and Objectives

Transient thyroid hormone alterations are common during critical illness and are termed non-thyroidal illness syndrome (NTIS). We studied the prevalence of NTIS in the ICU setting and its impact on predicting mortality and other outcomes and compared it to the Acute Physiology and Chronic Health Evaluation II (APACHE II) score.

Materials and Methods

The study included 119 consecutive patients admitted with a critical illness. APACHE II score was calculated. Total T3, total T4, TSH, free T3, and free T4 were measured at admission and after six weeks of discharge. NTIS and euthyroid groups were studied for ICU, hospital stays, mortality, readmission, and recovery. Predictors of mortality were compared between survivors and non-survivors.

Results

The mean age was 60.15 ± 14.50 years with M:F = 84 (71%):35 (29%). NTIS was observed in 84 (71%), low T3 being the most common abnormality in 53 (63%). The occurrence of NTIS was significantly higher among non-survivors (28/30, 93%) versus survivors (56/89, 63%) (P = 0.002). Non-survivors showed significantly lower T3, TSH, and FT3/FT4 ratios and higher readmissions. NTIS group showed significantly greater ICU stay (P = 0.02) and had higher readmission rates (P = 0.032). Baseline T3 had the greatest power to predict mortality. APACHE II score also correlated significantly with mortality (19.60 ± 10.58 vs 11.99 ± 6.80, P < 0.001). The area under the curve (0.677) for the T3 level was lower than the APACHE II score (0.760). After six weeks, 61% had recovered from NTIS.

Conclusions

NTIS was common amongst critically ill patients (71.5%), which reversed in 61% at six weeks. Low T3 was the most common abnormality and independently predicted mortality. Free T3/free T4 also significantly predicted mortality. The correlation between thyroid dysfunction and the severity of primary illness makes it an additional attractive low-cost marker of mortality.

Association of thyroid hormones and thyroid-stimulating hormone with mortality in adults admitted to the intensive care unit: A systematic review and meta-analysis

BACKGROUND

Thyroid hormones (THs) and thyroid-stimulating hormone (TSH) seem to show high potential in predicting the clinical death outcome of patients admitted to the intensive care unit (ICU). However, diverse studies on this topic are conflicting.

METHODS

A search was conducted by two investigators involved in this research in the PubMed, Embase, and Cochrane databases (all last launched on July 12, 2021). The quality of the included studies was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). Subgroup analyses were performed to determine the sources of heterogeneity. Sensitivity and publication bias analyses were also assessed.

RESULTS

A total of 27 studies (4970 participants) were included based on the eligibility criteria. Compared with survivors, nonsurvivors were found to have lower levels of THs (T3, T4, fT3, and fT4), whereas no significant difference was found in TSH levels (13 studies for T3: standardized mean differences [SMD], -0.78; 95% CI, -1.36 to -0.20; I2 = 96%; p = 0.008; 11 studies for T4: SMD = -0.79; 95% CI, -1.31 to -0.28; I2 =95%; p = 0.0002; 14 studies for fT3: SMD = -0.76; 95% CI, -1.21 to -0.32; I2 = 95%; p = 0.0008; 17 studies for fT4: SMD = -0.60; 95% CI, -0.99 to -0.22; I2 = 95%; p = 0.002; 20 studies for TSH: SMD = 0.00; 93% CI, -0.29 to 0.29; I2 = 93%; p = 0.98).

CONCLUSION

Nonsurvivors were associated with lower levels of THs (T3, T4, fT3, and fT4) than survivors. THs show great application potential in predicting ICU patients' death outcomes and improving already widely used prognostic scores in the ICU (ie, Acute Physiological and Chronic Health Evaluation [APACHE] II and Therapeutic Intervention Scoring System).

Serum total triiodothyronine (T3) as a predictor of mortality and morbidity in critically ill patients and its correlation of predictability with acute physiology and chronic health evaluation II score: A prospective observational study

Background:

The aim is to assess the prognostic value of total T3, total T4, and thyroid-stimulating hormone among critically ill patients admitted to the medical intensive care unit (ICU) in association with mortality and its correlation with the acute physiology and chronic health evaluation II (APACHE II) score.

METHODS

: Our prospective observational study consists of 257 patients without known thyroid diseases admitted to the medical ICU. The baseline characteristics of the patients were recorded, including the APACHE II score and thyroid hormone levels at ICU admission. Based on the primary outcome of mortality, we analyzed the data by appropriate statistical methods. A P < 0.05 was considered significant.

Results:

Of the 257 patients included in the study, 47 (18.28%) succumbed to their illnesses. A significant difference in T3 levels (P < 0.001), T4 levels (P < 0.001), and APACHE II score (P < 0.001) was found between the survivors and the nonsurvivors. There was negative correlation observed between T3 and APACHE II score (r = −0.448, P < 0.001) and T4 and APACHE II score (r = −0.221, P ≤ 0.001). Multivariate logistic regression analysis determined T3 to be the only independent predictor of ICU mortality among thyroid hormones. The area under the curve (AUC) for T3 (0.811 ± 0.04) was almost equal to that of the APACHE II score (0.858 ± 0.029). The duration of ICU stay and hospital stay in patients with low T3 was significantly higher compared to patients with normal T3.

Conclusion:

Serum T3 is a good indicator for predicting mortality and morbidity among critically ill patients.

Preoperative thyroid hormone levels predict ICU mortality after cardiopulmonary bypass in congenital heart disease patients younger than 3 months old

BACKGROUND

We aimed to study the effectiveness of preoperative thyroid hormone levels in predicting intensive care unit (ICU) mortality after cardiopulmonary bypass (CPB) in infants with congenital heart disease (CHD).

METHODS

We retrospectively reviewed and analyzed data from 133 patients younger than 3 months old who underwent cardiac surgery with CPB from June 2017 to November 2019. ICU mortality prediction was assessed by multivariate binary logistic regression analysis and area under the curve (AUC) analysis.

RESULTS

Non-survivors were younger (17.46 ± 17.10 days vs. 38.63 ± 26.87 days, P = 0.006), with a higher proportion of neonates (9/13 vs. 41/120, P = 0.017) and a higher proportion of individuals with a Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) score ≥ 4 (8/13 vs. 31/120, P = 0.020). No significant difference was found in CPB and aortic cross-clamping (ACC) time. The levels of free triiodothyronine (FT3) (3.91 ± 0.99 pmol/L vs. 5.11 ± 1.55 pmol/L, P = 0.007) and total triiodothyronine (TT3) (1.55 ± 0.35 nmol/L vs. 1.90 ± 0.57 nmol/L, P = 0.032) were higher in survivors than in non-survivors. In the ICU mortality prediction assessment, FT3 was an independent mortality predictor and showed a high AUC (0.856 ± 0.040).

CONCLUSIONS

The preoperative FT3 level was a powerful and independent predictor of ICU mortality after CPB in infants with CHD younger than 3 months old.

Prognostic Value of Thyroid Hormone FT3 in General Patients Admitted to the Intensive Care Unit

Low plasma triiodothyronine (T3) concentration indicates nonthyroidal illness syndrome (NTIS), which might be associated with a poor outcome in patients in the intensive care unit (ICU). This study evaluated the relationship between NTIS and prognostic indicators in patients admitted to the ICU and examined the fT3 cut-off points that could be associated with 28-day mortality. This prospective observational study included patients admitted to the ICU of The Third Hospital of Hebei Medical University from February to November 2018. The baseline variables and the occurrence of low free T3 (FT3) were collected. The patients were divided into the NTIS (FT3 < 3.28) and non-NTIS groups. Among 305 patients, 118 (38.7%) were in the NTIS group. FT3 (P < 0.001) and FT4 (P = 0.001) were lower, while the 28-day mortality rate (P < 0.001) and hospitalization expenses in ICU (P = 0.001) were higher in the NTIS group. The univariable analyses identified NTIS, FT3, free thyroxine/FT3, APACHEII, sequential organ failure score, duration of mechanical ventilation, creatinine, oxygenation index, white blood cells, albumin, age, and brain natriuretic peptide as being associated with 28-day mortality (all P < 0.05). The cut-off value of FT3 for 28-day mortality was 2.88 pmol/L. The 28-day mortality rate and hospitalization expenses in the ICU were higher in patients with NTIS. NTIS was independently associated with 28-day mortality.

Prognostic Value of Thyroid Profile in Critical Care Condition

BACKGROUND

Patients suffering from critical illness admitted to the Intensive Care Unit (ICU) exhibit alterations in their thyroid hormone levels, collectively termed as euthyroid sick syndrome or nonthyroidal illness syndrome. Our study was conducted to determine the correlation between these changes in thyroid hormone levels and the prognosis of ICU-admitted patients.

METHODS

A total of 270 ICU-admitted patients without previous history of thyroid disorder were included in the study. We recorded their baseline characteristics, acute physiology and chronic health evaluation (APACHE-II) score, thyroid hormone levels, lactate, and other parameters on admission. ICU mortality was the primary outcome. We analyzed the ability of each parameter to predict mortality in the participants. Further, we also evaluated whether the combination of thyroid hormone levels with APACHE-II score could improve the mortality prediction.

RESULTS

The mean age of the study population was 38.99 ± 18.32 years. A total of 81 patients (30%) expired during their ICU treatment. Both fT3 and fT4 levels were lower in nonsurvivors compared to survivors. Among the thyroid hormones, fT3 had the highest predictive value for ICU mortality, as seen by the largest area under the curve (AUC) value (0.990 ± 0.007) which was even greater than AUC of APACHE-II score (0.824 ± 0.051) and fT4 (0.917 ± 0.049). Univariate logistic regression analysis showed that fT3 (β = 140.560) had the highest predictive potential for ICU mortality compared with APACHE-II score (β = 0.776), fT4 (β = 17.62) and other parameters. Multivariate logistic regression analysis revealed that the combination of fT3 and APACHE-II (R² = 0.652) was superior in predicting mortality than APACHE-II alone (R² = 0.286).

CONCLUSION

We observed that fT3 was the strongest predictor of ICU mortality compared to all other parameters included in our study. Further, the combination of fT3 levels and APACHE-II scores provided for a higher probability for predicting mortality in ICU patients.

Impairment of Thyroid Function in Critically Ill Patients in the Intensive Care Units

Unexplained hypotension in the intensive care unit is commonly attributed to volume depletion, cardiorespiratory failure, sepsis, or relative adrenal insufficiency. In these acute conditions, thyroid hormone levels measured in blood, serum or plasma are often altered and solely attributed to critical illness. We report a series of 3 critically ill patients with prolonged respiratory failure, suppressed mental status and unexplained hypotension. Thyroid stimulating hormone levels ranged from normal to mildly elevated (2.36-7.65IU/mL; normal: 0.27-4.20), but free thyroxin was markedly suppressed (0.239-0.66ng/dL; normal: 0.93-1.70). After initiation of intravenous levothyroxine (75-100μg/day), the patients could be weaned off vasopressors and were successfully extubated shortly thereafter. These cases demonstrate that hypothyroid intensive care unit patients may exhibit even seemingly normal or mildly abnormal thyroid stimulating hormone values. Early recognition and treatment of a hypothyroid state superimposed on critical illness may contribute to recovery from hypotension or the need for mechanical ventilation.

Assessment of serum zinc, selenium, and prolactin concentrations in critically ill children

Background

In critically ill patients, there are reduced stores of antioxidants, which are associated with increased organ failure and even higher mortality. Trace elements, especially zinc and selenium, are the cornerstone of the antioxidant defense in acute systemic inflammatory response syndrome. Prolactin (PRL) is the counterregulatory stress hormone that prevents cortisol/stress-induced lymphocyte apoptosis. The aim of our study is to detect the serum levels of zinc, selenium, and PRL hormone as important immunomodulators in critically ill children and to investigate the relationship between these immunomodulators and the severity of illness.

Subjects and methods

This was a prospective study that included two groups; group 1: 50 critically ill children within 72 hours of intensive care unit admission, and group 2: 30 healthy children as controls. Blood samples were collected from the two groups for zinc, selenium, and PRL level measurement.

Results

Zinc and PRL levels were found to be decreased in critically ill children compared to control group, and these levels were inversely correlated with organ failure index and pediatric logistic organ dysfunction scores. Selenium levels were decreased in patients with sepsis and in patients with multiple organ failure.

Conclusion

Serum concentrations of zinc and PRL are generally low in critically ill children, with a greater decrease in patients with sepsis and in the presence of multiple organ failure. The levels of zinc and PRL are inversely correlated with severity of illness. Selenium levels were decreased in patients with sepsis and in patients with multiple organ failure.

Significance of changes in thyroid and gonadal function in patients with chronic liver diseases

AIM: To investigate the changes in thyroid and gonadal function in patients with chronic liver diseases and to explore the relationship between serum thyroid and gonadal hormone levels and severity of chronic liver diseases.

METHODS: Serum thyroid and gonadal hormone levels were measured by chemiluminescence method in 162 male cases with chronic liver diseases. Patients with chronic liver diseases were divided into a cirrhosis group and a non-cirrhosis group, and cirrhosis was graded by Child-Pugh score (A, B, C).

RESULTS: Thyroid dysfunction was present in ~13% of patients with chronic liver diseases. Serum total T3 and free T3 levels in patients with chronic liver diseases were significantly lower than those of the control group (1.73 nmol/L ± 0.38 nmol/L vs 2.59 nmol/L ± 0.46 nmol/L, 4.09 pmol/L ± 1.35 pmol/L vs 5.23 pmol/L ± 1.56 pmol/L, P < 0.01). Cirrhotic patients had significantly lower serum total T3 and free T3 levels than non-cirrhotic patients (0.96 nmol/L ± 0.33 nmol/L vs 1.84 nmol/L ± 0.32 nmol/L, 3.02 pmol/L ± 1.10 pmol/L vs 4.33 pmol/L ± 1.42 pmol/L, P < 0.01). Serum total T3, T4 and free T3 and T4 levels in cirrhotic cases with Child-Pugh B or C grade were significantly lower than those of Child-Pugh A grade cases. Chronic liver diseases were more serious in patients with low T3 syndrome than in those without. Approximately 42% of patients with chronic liver diseases had secondary gonadal dysfunction. Serum testosterone levels were significantly lower and estrogen levels were significantly higher in patients with chronic liver disease than in the control group (4.36 ng/mL ± 2.12 ng/mL vs 7.85 ng/mL ± 3.31 ng/mL, 45.53 pg/mL ± 18.79 pg/mL vs 32.26 pg/mL ± 12.19 pg/mL, P < 0.01). Serum testosterone levels were significantly lower and estrogen levels were significantly higher in cirrhotic cases with Child-Pugh B and C grades than in Child-Pugh A grade cases. Chronic liver diseases were more serious in patients with secondary gonadal dysfunction than in those without.

CONCLUSION: Thyroid and gonadal dysfunction is present in patients with chronic liver diseases, so the determination of thyroid and sex hormones has important value for the evaluation of severity and prognosis of the disease.

Thyroid Hormone Profile in Patients With Acute Coronary Syndrome

Background:

Thyroid hormone has the a major role in the cardiovascular system function and cardiac a As well as to maintain the cardiovascular homeostasis A slightly change ind thyroid status actually affects cardiovascular mortality hemodynamic. The background of this study was to define the prevalence of thyroid dysfunction in acute coronary syndrome (ACS).

Objectives:

The primary objective was to define the prevalence of thyroid dysfunction in acute coronary syndrome, including Non-ST Segment Elevation Myocardial Infarction (NSTEMI), ST-segment Elevation Myocardial Infarction (STEMI), and unstable angina groups. The secondary objective was to determine any associations of thyroids function tests with cardiac catheterization and mortality.

Patients and Methods:

In a prospective, observational, and cross section study, we enrolled 400 patients admitted at the coronary care unit of King Abdulaziz University Hospital in Jeddah, Saudi Arabia. Venous blood samples were collected from patients for the evaluation of thyroid function (thyroids stimulating hormones, free triiodothyronine, and free thyroxin).

Results:

Excluding those taking thyroid hormone preparations, 76.7% of patients admitted with acute coronary heart disease (ST-segment elevation myocardial infarction and Non-ST segment elevation myocardial infarction), and unstable angina had euthyroidism. Thyroid dysfunction was reported in 23.3% of patients with coronary heart disease. Overall hypothyroidism prevalence was 7.8%, while subclinical hyperthyroidism in our study was 2.7%. Overt hyperthyroidism and subclinical hyperthyroidism was reported 2.0% and 0.5%, respectively. Euthyroid sick syndrome was noticed in 41 (10.2%) of critically ill patients. The mortality rate was 9.8%; all death patients had low triiodothyronine (T3) syndrome and were associated with statistically significant low free triiodothyronine (FT3) (P > 0.001).

Conclusions:

No significant variance was observed among patients underwent for cardiac catheterization, STEMI, NSTEMI, unstable angina, and atrial fibrillation with respect to FT4, FT3, and TSH levels during coronary care unit hospitalization based on their profile data.

Assessment of thyroid and gonadal function in liver diseases

INTRODUCTION

Liver is involved with the synthesis of carrier proteins and metabolism of various hormones and liver diseases may, therefore, be associated with various endocrine disturbances. This study was conducted to assess thyroid and gonadal function in subjects with acute hepatitis (AH), chronic liver disease (CLD), and those who had undergone liver transplantation (LT).

MATERIALS AND METHODS

Patients with AH, CLD with Child-Pugh stage A (CLD-1) and Child-Pugh stage B or C (CLD-2), and LT seen at our tertiary level hospital were assessed clinically, biochemically, and for thyroid and gonadal functions besides 25 healthy controls.

RESULTS

Thyroid dysfunction and hypogonadism were present in 14 (16%) and 24 (28%) patients with liver diseases respectively. Among thyroid dysfunction, the commonest was sick euthyroid syndrome six (7%), followed by subclinical hypothyroidism in three patients (3.5%), subclinical hyperthyroidism and thyrotoxicosis in two patients each (2.3%) and overt hypothyroidism in one patient. Among patients with LT and AH groups, the only abnormality was significantly lower total T3 compared with healthy controls. The CLD2 group had significantly lower levels of all thyroid hormones compared with controls and CLD1 group. Hypogonadism was commonest in patients with CLD-2 (14; 50%) followed by LT (3; 33%), CLD-1 (4; 20%), and AH (3; 14%). Hypogonadism was predicted by older age, lower levels of serum albumin, total cholesterol, and triglycerides and higher levels of plasma glucose, serum bilirubin, aspartate transaminases, and international normalized ratio. Gonadal functions showed recovery following LT.

CONCLUSIONS

Thyroid dysfunction and hypogonadism form an important part of the spectrum of acute and CLD, and patients with LT. Deterioration of synthetic functions of liver disease predicts presence of hypogonadism.

Can non-thyroid illness syndrome predict mortality in lung cancer patients? A prospective cohort study

This study aims to evaluate the incidence of non-thyroid illness syndrome (NTIS) among patients diagnosed as lung cancer and its association with the stage of the disease, Eastern Cooperative Oncology Group (ECOG) performance score, nutritional parameters, and survival. We enrolled 120 patients that 71 of them with newly diagnosed and staged non-small cell lung cancer and 49 of them small-cell lung cancer. The cases were examined for thyroid function tests, ECOG performance score, and nutritional evaluation before treatment. Also, cases were evaluated for their overall survival rates. NTIS was identified in 30 (42 %) of the 71 non-small cell lung cancer patients and 22 (44 %) of the 49 small-cell lung cancer patients. NTIS was more frequent among advanced stage of cases. Serum albumin level, cholesterol level, lymphocyte level, and body mass index were detected to be significantly low and ECOG performance score was significantly high in cases with NTIS when compared to cases without NTIS. NTIS was found to be negatively correlated with body mass index, ECOG performance score, and serum albumin level, and it was positively correlated with disease stage. NTIS was detected significantly as a poor prognostic factor for lung cancer. NTIS was frequently seen in cases with non-small cell lung cancer and small-cell lung cancer. NTIS can be used as a predictor of poor prognosis for lung cancer patients.