Triiodothyronine hormone supplementation therapy in septic shock patients with euthyroid sick syndrome: two pilot, placebo-controlled, randomized trials

BACKGROUND

To assess 28-day survival in two pilot groups of septic shock patients with euthyroid sick syndrome (ESS) supplemented with triiodothyronine (T3).

METHODS

A total of 95 septic shock patients with ESS were divided according to values of the thyroid hormones into low T3 and low T3T4 groups. Among 48 patients with low T3, 24 (50%) were randomized to T3 for 4 days and 24 (50%) to placebo. Among 47 patients with low T3T4, 24 (51%) were randomized to T3 for 4 days and 23 (49%) to placebo. The analysis included 28-day survival as the primary outcome and laboratory with hemodynamics as the secondary outcomes. Laboratory data were analyzed on the day of admission (T0), on the first (T1), third (T2) and seventh day (T3) with hemodynamics analyzed for the first four days.

RESULTS

In the low T3 population, 18 (75%) patients receiving T3 died at day 28 compared with 8 (33.3%) patients receiving placebo (p = 0.004). In the low T3T4 population, 6 (25%) patients receiving T3 died in ICU compared with 12 (52.1%) patients receiving placebo (p = 0.039). Oral T3 treatment increased mean arterial pressure values at day 1, day 3 and day 7 in the low T3T4 population, (p = 0.015, =0.005 and =0.042 respectively), and had no significant effect on these values in the low T3 population.

CONCLUSION

T3 supplementation was associated with a low 28-day mortality rate in patients with low T3T4 but with increased mortality in patients with low T3 ESS. These results suggest caution before initiating thyroid supplementation in septic patients.

REGISTRATION

ClinTrials.gov (NCT05270798).

Contrast-enhanced ultrasonography of the thyroid gland in healthy dogs, hypothyroid dogs and dogs with non-thyroidal illness

Diagnosis of canine hypothyroidism remains challenging, as non-thyroidal illness (NTI)-syndrome and medical treatment can influence thyroid hormone concentrations. Conventional ultrasound may give additional hints, however high interobserver variability has been described. Contrast-enhanced ultrasound (CEUS) allows detection of changes in tissue perfusion. The purpose of the present study was to assess the possible diagnostic value of CEUS regarding diagnosis of hypothyroidism. CEUS of the thyroid gland was performed in 52 healthy dogs, 16 hypothyroid dogs, and 20 NTI patients. The following perfusion parameters were calculated: Thyroid/carotid artery (TG/CA) ratios for peak enhancement (PE) and area under the curve (AUC), time to peak (TTP) and wash-in and wash-out rates (WiR, WoR) of the thyroid gland. Impact of sedation on perfusion parameters was investigated in 8 calm healthy dogs which were examined before and after sedation using midazolam and butorphanol. Significantly higher median TG/CA ratios for PE were detected for the left and right thyroid lobe in dogs with hypothyroidism (0.97/0.96) compared to healthy dogs (0.85/0.85) and dogs with NTI (0.84/0.84). AUCs were also significantly increased in hypothyroid dogs when compared to other groups. Dogs with NTI showed significantly lower WiR and WoR compared to other groups. Values for TTP were not significantly different between groups. Sedation had only impact on results of TTP which was significantly prolonged in sedated dogs. In conclusion, CEUS of the thyroid gland can provide an additional tool for diagnosis of hypothyroidism in dogs and support its differentiation from NTI. Sedation has limited impact on CEUS results.

Critically ill patients: Histopathological evidence of thyroid dysfunction

PURPOSE

Critical illness is characterized by severe biphasic physical and metabolic stress as result of systemic inflammatory response syndrome and/or multiple organ dysfunction syndrome, and is frequently associated with non-thyroidal illness. Purpose of this study is to better understand the cytomorphological basis of NTI by performing histopathological examinations of thyroid gland on autopsies of patients who died from critical illness.

METHODS

Histopathological examination of thyroid gland of 58 critically ill patients was performed in our hospital. The cases included 24 cases of burn injury, 24 cases of traumatic brain injury, and 10 cases of cerebral stroke. Thyroid samples obtained during autopsy were preserved in formol saline and stained with hematoxylin and eosin. The sections were visualized under light microscopy.

RESULTS

Out of 58 cases examined, 21 patients showed normal thyroid findings, and rest of the cases had unusual thyroid findings in the histopathological study. The principal finding was distortion of thyroid follicular architecture. Other findings include mononuclear cell infiltration, clumping of thyroglobulin, and exhaustion of thyroid follicles.

CONCLUSION

Critical illness produces metabolically damaging effects on thyroid gland, which functionally corresponds to a state of low T3 syndrome. These changes are more pronounced in BI and cerebral stroke than in TBI.

The prevalence, hospitalization outcomes and risk factors of euthyroid sick syndrome in patients with diabetic ketosis/ketoacidosis

BACKGROUND

To investigate the prevalence of euthyroid sick syndrome (ESS) and to evaluate the outcomes and risk factors associated with ESS among hospitalized patients with diabetic ketosis (DK) or diabetic ketoacidosis (DKA).

METHODS

Laboratory and clinical data of 396 adult hospitalized DK/DKA patients with or without ESS were collected and analyzed. Spearman linear analysis and multivariable logistic regression analyses were used to evaluate correlated factors of thyroid hormones and risk factors of ESS.

RESULTS

Most of the individuals were diagnosed with type 2 diabetes (359/396, 90.7%). The prevalence of ESS was 57.8% (229/396). Patients in ESS group were older and had a longer course of diabetes. Levels of thyroid hormones, serum lipids, and parameters reflecting acidosis were significantly decreased in ESS group. The proportion of patients with infection, acute renal injury and DKA was significantly higher in ESS group than in control group, accompanied by longer hospitalization stay and higher hospitalization costs. Free triiodothyronine positively correlates with albumin, eGFR, parameters reflecting acidosis and lipid profiles (All P < 0.001), and negatively correlates with age, onset age, 24-h urine albumin, hsCRP and WBC count (All P < 0.001). Hypoalbuminemia, low level of carbon dioxide combining power, high level of HbA1c and WBC, and co-infection are shown to be risk factors for ESS (OR = 0.866, 0.933, 1.112, 1.146, 1.929, respectively; All P < 0.05).

CONCLUSIONS

The prevalence of ESS was high in adult DK/DKA patients. Patients with ESS had inferior clinical and socioeconomic outcomes. Early recognition and management of patients with ESS may be necessary to improve outcome.

Thyroid hormones and platelet activation in COVID-19 patients

PURPOSE

To retrospectively describe the association between thyroid hormones (TH) and platelet activation, as represented by mean platelet volume (MPV), in a cohort of patients hospitalized for COVID-19 with no known thyroid disease, and to correlate these data with the severity of COVID-19 and the occurrence of death/ARDS (Acute Respiratory Distress Syndrome).

METHODS

103 patients with real-time polymerase chain reaction (RT-PCR) testing-confirmed COVID-19 and hospitalized were enrolled. Serum samples were collected from patients upon admission before starting any treatment. Chi-squared test was used to determine the association between euthyroid sick syndrome (ESS) and COVID-19 severity. Multivariate logistic regression was performed to evaluate the best independent predictors of COVID-19 deaths/ARDS.

RESULTS

39/103 (37.9%) of patients were found to have ESS, and this condition was an independent predictor for the severity of COVID-19 (p = 0.003). Lower TSH and lower FT3/FT4 ratio correlated with higher MPV (p = 0,001 and p = 0.010), with an opposite trend with respect to what has been documented in non-COVID patients. Increasing MPV and lower FT3 significantly increased the risk, in COVID-19 patients, of an adverse outcome of death/ARDS.

CONCLUSION

Increased platelet activation, as represented by increased MPV, has already been reported to correlate with COVID-19 severity, possibly as a consequence of cytokine release. We demonstrated, in a cohort of 103 patients with COVID-19, that MPV is inversely correlated to TH levels, in particular in the case of ESS, where downregulation of TH axis may occur in case of systemic cytokine inflammation and more severe outcomes (death/ARDS). That ESS itself may directly cause platelet activation, as demonstrated by higher MPV in these patients, is an interesting hypothesis which deserves further investigation.

Low T3 syndrome upon admission and response to nutritional support in malnourished medical inpatients

INTRODUCTION

During illness, deiodination of thyroxine (T4) to triiodothyronine (T3) is down regulated. This is called "low T3 syndrome", an adaptive metabolic mechanism to reduce energy expenditure and prevent catabolism. We investigated the prognostic role of low T3 syndrome in patients at nutritional risk regarding mortality, clinical outcomes and response to nutritional support.

METHODS

This is a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized-controlled Swiss multicenter trial comparing effects of individualized nutritional support with usual care in adult medical inpatients at nutritional risk. The primary endpoint was all-cause mortality over 30-,180-days and 5-years.

RESULTS

We had complete data including fT3 concentration of 801/2028 (39.5%) patients from the initial trial. Of these 492 (61.4%) had low T3 syndrome (fT3 < 3.2 pmol/l). Low T3 syndrome was associated with higher mortality over 30 days (adjusted hazard ratio 1.97 [95%CI 1.17 to 3.31], p 0.011) and other adverse clinical outcomes. Nutritional support only lowered mortality in the group of patients with but not in those without low T3 syndrome (adjusted odds ratio of nutritional support of 0.82 [95%CI 0.47 to 1.41] vs. 1.47 [95%CI 0.55 to 3.94]). This finding, however, was not significant in interaction analysis (p for interaction = 0.401).

CONCLUSIONS

Our secondary analysis of a randomized trial suggests that medical inpatients at nutritional risk with low T3 syndrome have a substantial increase in mortality and may show a more pronounced beneficial response to nutritional support interventions.

Hypothyroxinemia in sick term neonates and its risk factors in an extramural neonatal intensive care unit: a prospective cohort study

Objective

Thyroid functions in the sick newborns may be altered in the first week of life. Transient hypothyroxinemia has been reported in these babies, which could be due to the immaturity of the hypothalamic-pituitary-thyroid axis or to acute illness. We conducted this study to estimate the incidence of hypothyroxinemia and determine its risk factors in sick term newborns.

Materials and methods

We analyzed free T4 (FT4) and thyroid-stimulating hormone (TSH) levels in sick term neonates (≤7 days of life) admitted to the neonatal intensive care unit. FT4 and TSH levels were estimated in the first week of life in all the enrolled neonates (N = 98) and then repeated at 14-21 days of life in 46 babies. Risk analysis was conducted using univariate and multivariate logistic regression, and numerical data was compared using the Mann-Whitney U test and t-test.

Results

Hypothyroxinemia was seen in 10 (10.2%) of the admitted term babies. Male gender, vaginal delivery, presence of hypoxic ischemic encephalopathy, and need for mechanical ventilation (>24 hours) were identified as risk factors. There was a significant negative linear correlation between FT4 level in the first week of life and duration of hospital stay.

Conclusion

Hypothyroxinemia is common in sick term neonates.

Euthyroid sick syndrome as an early surrogate marker of poor outcome in mild SARS-CoV-2 disease

BACKGROUND

The new coronavirus 19 disease (COVID-19) represents the current worldwide emergency. According to past evidence, a simple biomarker, such as low free triiodothyronine (fT3) levels, within the framework of euthyroid sick syndrome (ESS), might help to identify patients with unfavourable outcomes.

OBJECTIVE

Evaluation of ESS significance in hospitalized mild COVID-19 patients.

DESIGN

Prospective study, from 1 April 2020 to 31 May 2021.

PARTICIPANTS

COVID-19 patients with mild disease at hospital admission.

MAIN MEASURES

At hospital admission, eligible patients underwent a complete thyroid function evaluation. Subjects with previous thyroid disease or with thyroid-interfering medications were excluded. Levels of fT3 were correlated to biochemical markers and to patient outcome, the latter considered as favourable in the event of infection recovery and unfavourable in the event of death or transfer to an intensive care unit (ICU).

KEY RESULTS

Of 600 screened patients, 506 were eligible for this study. Of those, 94 (19%) died during hospitalization and 80 (18%) required a transfer to ICU. The most frequent thyroid disorder was ESS (57%). Admission levels of fT3 were significantly lower within the unfavourable outcome subgroup (p < 0.001) and were negatively associated with several poor prognostic markers, including IL-6 (p < 0.001). In Kaplan-Meier and Cox regression analyses, fT3 was independently associated with poor outcome and death (p = 0.005 and p = 0.037, respectively). A critical fT3 threshold for levels < 2.7 pmol/l (sensitivity 69%, specificity 61%) was associated with a 3.5-fold increased risk of negative outcome (95%CI 2.34-5.34).

CONCLUSION

Low fT3 levels, in the framework of ESS, resulted as being a valid predictor of unfavourable outcomes in a very early stage population of COVID-19.

Thyroid dysfunction in COVID-19 patients

PURPOSE

"Non thyroidal illness syndrome" (NTIS) or "euthyroid sick syndrome" (ESS) is a possible biochemical finding in euthyroid patients with severe diseases. It is characterized by a reduction of serum T₃ (fT3), sometimes followed by reduction of serum T₄ (fT4). The relationship between thyroid hormones levels and mortality is well known and different studies showed a direct association between NTIS and mortality. The sudden spread of the 2019 novel coronavirus (SARS-CoV 2) infection (COVID-19) and its high mortality become a world healthcare problem. Our aim in this paper was to investigate if patients affected by COVID-19 presented NTIS and the relationship between thyroid function and severity of this infection.

METHODS

We evaluated the thyroid function in two different groups of consecutive patients affected by COVID-19 with respect to a control group of euthyroid patients. Group A included patients hospitalized for COVID-19 pneumonia while patients requiring intensive care unit (ICU) for acute respiratory syndrome formed the group B. Group C identified the control group of euthyroid patients.

RESULTS

Patients from group A and group B showed a statistically significant reduction in fT3 and TSH compared to group C. In group B, compared to group A, a further statistically significant reduction of fT3 and TSH was found.

CONCLUSIONS

COVID-19 in-patients can present NTIS. FT3 and TSH serum levels are lower in patients with more severe symptoms.

Clinical Significance of Low-Triiodothyronine Syndrome in Patients Requiring Non-Surgical Intensive Care - Triiodothyronine Is a Comprehensive Prognostic Marker for Critical Patients With Cardiovascular Disease

Background: Low-triiodothyronine (T₃) syndrome is a known complication in intensive care unit (ICU) patients, but the underlying mechanisms and prognostic impact are unclear.

Methods and Results: This study retrospectively enrolled 2,976 patients who required care in the ICU. Of these patients, 2,425 were euthyroid and were divided into normal (n=1,666; free T₃ [FT₃] ≥1.88 µIU/L) and low-FT₃ (n=759; FT₃ <1.88 µIU/L) groups. Multivariate logistic regression analysis revealed that prognostic nutritional index >46.03 (odds ratio [OR] 2.392; 95% confidence interval [CI] 1.904–3.005), age (per 1-year increase; OR 1.022; 95% CI 1.013–1.031), creatinine (per 0.1-mg/dL increase; OR 1.019; 95% CI 1.014–1.024), and C-reactive protein (per 1-mg/dL increase; OR 1.123; 95% CI 1.095–1.151) were independently associated with low FT₃. Survival rates (within 365 days) were significantly lower in the low-FT₃ group. A multivariate Cox regression model showed that low FT₃ was an independent predictor of 365-day mortality (hazard ratio 1.785; 95% CI 1.387–2.297). Low-T₃ syndrome was significantly more frequent in patients with non-cardiovascular than cardiovascular diseases (73.5% vs. 25.8%). Prognosis was significantly poorer in the low-FT₃ than normal group for patients with cardiovascular disease, particularly those with acute coronary syndrome and acute heart failure.

Conclusions: Low-T₃ syndrome was associated with aging, inflammatory reaction, malnutrition, and renal insufficiency and could lead to adverse outcomes in patients admitted to a non-surgical ICU.

Euthyroid sick syndrome in hip fractures: Valuation of vitamin D and parathyroid hormone axis

INTRODUCTION

Femur fracture is an acute event with a high incidence and mortality worldwide. Euthyroid sick syndrome (ESS) is a disease characterized by an alteration of fT3 in the absence of a primary thyroid pathology. The aim of the study is evaluating the association between femur fracture and ESS and post-operative fluctuations of the parathyroid hormone (PTH) and vitamin D and their physio-pathological implications.

MATERIALS AND METHODS

All patients older than 65 years, admitted in our emergency care unit with a diagnosis of proximal femur fracture were recruited. Exclusion criteria were acute cardio-pulmonary events, neoplastic diseases, any thyroid or endocrine pathology and use of drugs with thyroidal interactions. All patients underwent surgery within 48 h from the injury. The outcome of the study is the presence of ESS, moreover, post-operative fluctuations of the PTH and vitamin D are also evaluated.

RESULT

45 patients (13 men and 32 females) were enrolled. 20 patients had a normal thyroidal function, while 23 had a diagnosis of ESS. Mean age was 81.9. BMI was lower in the ESS group than the controls (25,3 vs 22,7; p < 0.02). In the ESS group a significantly higher decrease in Vitamin D levels was observed, compared to controls (3.96 ng/ml, p<0.001). Values of PTH were significantly different between the two groups, with a level 44.29 pg/ml lower among the ESS group compared to controls (p = 0.002). In the ESS group a significant decrease of serum calcium on the first post-surgery day was observed, compared to controls (8,7 vs 8,3; p < 0,01). There were no differences in the CCI, serum electrolytes and other variables collected between the two groups.

CONCLUSION

Part of the geriatric population suffering from fractures of the proximal femur are affected by ESS. This population displays anomalies of the Vitamin d-PTH axis and a lower BMI.

Persistent anemia and hypoalbuminemia in rheumatoid arthritis patients with low serum triiodothyronine level

Objectives: To determine the clinical characteristics of rheumatoid arthritis (RA) patients with low serum triiodothyronine (T3) levels.Methods: We evaluated serum free T3 (fT3), free T4, and thyroid-stimulating hormone (TSH) levels in 338 RA patients. After excluding patients taking anti-thyroid drugs or having anti-thyroid antibodies, we compared the clinical characteristics of the RA patients with low fT3 to those with normal/high fT3, before and after RA treatment.Results: Six percent of RA patients had low fT3 levels. Patients with low fT3 were older and had higher disease activity scores (DAS28), higher Steinbrocker stage, higher health assessment questionnaire scores, lower body mass index, and lower hemoglobin and albumin levels compared with normal/high-fT3 patients. After RA treatment, fT3 levels normalized in half of the low-fT3 patients and remained low in the other half. Although DAS28 scores were similarly improved in both subgroups of the low-fT3 patients, anemia and hypoalbuminemia did not normalize in the persistently low-fT3 subgroup.Conclusion: Low serum fT3 levels represent the profound wasting seen in RA patients that is characterized by anemia and hypoalbuminemia and that cannot be evaluated by DAS28 scores alone.

Oral Triiodothyronine Supplementation Decreases Low Cardiac Output Syndrome After Pediatric Cardiac Surgery

The oral triiodothyronine for infants and children undergoing cardiopulmonary bypass (OTICC) trial showed that Triiodothyronine (T3) supplementation improved hemodynamic and clinical outcome parameters. We tested the validity of low cardiac output syndrome (LCOS), derived using clinical parameters and laboratory data, by comparing the LCOS diagnosis with objective parameters commonly measured in a cardiac intensive care unit (CCU) setting. OTICC, a randomized, placebo-controlled trial included children younger than 3 years with an Aristotle score between 6 and 9. We used the existing trial data set to compare the LCOS diagnosis with echocardiographic hemodynamic parameters. Additionally, we determined if LCOS, prospectively assigned during a clinical trial, served as an early predictor of clinical outcomes. All LCOS subjects at 6 and 12 h after cross-clamp release later showed significantly lower pulse pressure, stroke volume and cardiac output, and higher systemic vascular resistance. These LCOS patients also had significantly longer time to extubation (TTE) and higher mortality rate. LCOS incidence was significantly lower in the T3 treatment group [n = 86 vs. 66, respectively, p < 0.001; OR (95% CI) 0.43 (0.36-0.52)] particularly at 6 h. Also, LCOS patients in the placebo group had significantly lower FT3 serum levels over time. These analyses confirm that early clinically defined LCOS successfully predicts cardiac dysfunction determined later by objective hemodynamic echocardiographic parameters. Furthermore, early LCOS significantly impacts TTE and mortality. Finally, the data support prior clinical trial data, showing that oral T3 supplementation decreases early LCOS in concordance with reducing TTE.

Thyroid Hormone (Triiodothyronine) Therapy in Children After Congenital Heart Surgery: A Meta-Analysis

Thyroid hormone modifies metabolic, immune and cardiovascular functions and has been administered perioperatively to treat a relative reduction of thyroid function in children following cardiopulmonary bypass (CPB) for correction of congenital heart disease. However, it remains unclear whether its use is associated with improved outcomes. We performed a meta-analysis of studies that evaluated the impact of thyroid hormone supplementation on clinical outcomes in children undergoing repair of congenital heart disease using CPB. A systematic review of published trials was conducted to identify studies of children randomized to thyroid hormone supplementation or placebo undergoing congenital heart surgery. A meta-analysis was then conducted to determine the clinical impact of thyroid hormone replacement on cardiac function and postoperative characteristics. The following outcomes were included for the study: duration of mechanical ventilation, duration of intensive care unit (ICU) stay, duration of postoperative hospital stay, inotrope score, cardiac index at 24 hours postoperatively, and inpatient mortality. A total of 9 studies with 711 patients were included in the analyses. All included studies were prospective and patients were randomized to either thyroid hormone or placebo. There was wide variation in thyroid hormone dosing, ranging from 0.4 μg/kg up to 5 μg/kg over a 24-hour period, and duration of therapy, ranging from a single dose after cessation of CPB to continued thyroid hormone for the duration of the ICU stay. There was a significant difference in the mean inotrope score between the 2 groups of -1.249 (95% confidence interval -1.570 to -0.929, P < 0.001), with the inotrope score being significantly lower in the thyroid group. There was no difference in duration of mechanical ventilation, duration of ICU stay, duration of hospital stay, cardiac index, and mortality between groups. In this meta-analysis, routine thyroid hormone replacement with approximately 1-5 μg/kg administered over 24 hours does not significantly alter the postoperative course in children following CPB. However, given a clinically small but significant difference in respect to lower inotrope score and shorter duration of ICU and hospital stays with higher thyroid replacement additional studies are warranted.

THE ASSOCIATION OF LOW TRIIODOTHYRONINE SYNDROME, PROTEIN-ENERGY WASTING AND CHRONIC INFLAMMATION WITH MORTALITY IN PREVALENT DIALYSIS PATIENTS

SUMMARY – This prospective study in prevalent dialysis patients investigated prognostic properties of low triiodothyronine syndrome, protein-energy wasting and chronic inflammation. Ninety-four prevalent dialysis patients were followed-up for a median of 39 months. Demographic, anthropometric and biochemical parameters were collected at baseline. Univariate and multivariate analysis was done using Cox regression analysis. ROC curve analysis using survival status as a classification variable was performed with the goal of determining optimal cut-off values for numerical variables. In our population, low total triiodothyronine (hazard ratio (HR) 2.19, p=0.038), catheter as vascular access (HR 2.76, p=0.023), higher vintage (HR 1.01, p=0.014) and higher Charlson comorbidity index (HR 1.28, p=0.017) were statistically significantly associated with inferior survival. In our group of steady-state dialysis patients, total triiodothyronine seemed to be the strongest predictor of inferior survival among thyroid hormones. Taking this parameter into account, it was possible to identify patients at an increased risk of death even after adjustment for other prognostically relevant variables. However, after further adjustment for significant risk factors, the impact of C-reactive protein and albumin on survival disappeared due to the overlapping prognostic properties. We concluded that triiodothyronine was an independent prognostic factor in our study group.

Prevalence and Related Factors of Euthyroid Sick Syndrome in Children with Untreated Cancer According to Two Different Criteria

OBJECTIVE

In this study, we evaluated the frequency of euthyroid sick syndrome (ESS) among patients with childhood cancer and its association with the stage of disease, nutritional parameters and cytokines levels.

METHODS

Eighty newly diagnosed children were included in the study. ESS was assessed in two different ways. According to criteria 1 ESS was present if free triiodothyronine (fT3) was below the lower limit and free thyroxine was within the normal or low limits, thyroid-stimulating hormone (TSH) was in the normal range. According to criteria 2, in addition to the above, it was required that reverse triiodothyronine (rT3) be performed and was higher than normal limits.

RESULTS

Three of our pediatric patients had subclinical hypothyroidism and two had subclinical hyperthyroidism. Out of 75 patients, ESS was identified in 14 (17.3%) according to criteria 1 and in eight (10.6%) according to criteria 2. Only fT3 levels were significantly different in the ESS (+) and ESS (-) groups (p<0.05) according to criteria 1. A significantly negative correlation between interleukin (IL)-6 and fT3 was found, according to both sets of criteria. tumor necrosis factor alpha was negatively correlated with fT3 levels only in the criteria 1 group. There were no correlations between IL-1β and fT3, free thyroxine, rT3 and TSH levels.

CONCLUSION

ESS may occur in childhood cancer and thyroid function testing should be performed routinely when cancer is diagnosed.

Investigation of the Oxidative Stress and DIO1 Expression in CRF Patients Accompanied With and Without Euthyroid Sick Syndrome

BACKGROUND/AIMS

Chronic renal failure (CRF) is often accompanied by increased oxidative stress and euthyroid sick syndrome (ESS). The cause of ESS is unknown, and it is unknown whether there exists a link between oxidant stress and ESS in CRF patients. Therefore, we aim to investigate oxidative stress and type 1 deiodinase (DIO1) expression, which plays the key role in the ESS in CRF patients.

METHODS

In-patients with CRF were divided into the two group: Group 1 is ESS patients consisting of 60 patients with low free triiodothyronine (FT3) and Group 2 consisting of 60 patients with normal FT3. Group 3 consisted of 60 healthy volunteers recruited as controls. The baseline clinical parameters of patients were evaluated with standard routine methods in a clinical laboratory. Serum levels of 8-isoprostane and DIO1 were measured by enzyme-linked immunosorbent assay (ELISA). Multiple regression analysis was used to analyze the relationship between oxidative stress, DIO1 and FT3.

RESULTS

The concentrations of serum 8-Isoprostane in Group 1 and Group 2 were substantially higher than that of Group 3 (p< 0.05), however there was no significant difference between Group 1 and Group 2 (p=0.516). The serum DIO1 level was higher in Group 2 than in Group 1 and Group 3 (p< 0.001). Multivariate linear regression analysis revealed that the DIO1 concentration and FT3 level were not associated with the concentration of serum 8-Isoprostane.

CONCLUSIONS

CRF patients showed elevated oxidative stress. The CRF patients without ESS showed higher expression of DIO1 than patients with ESS and the control group. The concentration of serum 8-Isoprostane was not correlated with FT3 and DIO1 levels.

Higher free triiodothyronine concentration is associated with lower prevalence of microangiopathic complications and better metabolic control in adult euthyroid people with type 1 diabetes

PURPOSE

Type 1 diabetes mellitus (T1DM) is a disorder of insulin deficiency but with a wide range of hormones simultaneously disturbed. The study was performed to explore relation of free triiodothyronine (FT3) with metabolic control and occurrence of microangiopathic complications.

METHODS

A total of 266 adult T1DM participants [56% men; 32 (interquartile range, IQR: 25-39) years and disease duration 13 (IQR: 8-19) years] in euthyroid state with negative history for hypothyroidism were included to the study. Participants were screened for thyroid-stimulating hormone (TSH), free thyroxine (FT4) and FT3. Moreover, microangiopathic complications (retinopathy, diabetic kidney disease, peripheral and autonomic neuropathy), markers of metabolic control such as glycated hemoglobin (HbA_1c) were evaluated.

RESULTS

A total of 114 (42.9%) people had diagnosed at least one microangiopathic complication. In multivariable linear regression higher HbA_1c was statistically significant independent predictor of lower FT3 (β = -0.25; p < 0.0001) after adjustment for sex, T1DM duration, HbA_1c, waist-to-hip ratio (WHR) (R² = 0.15, p < 0.0001). Higher FT3 was simultaneously a predictor of lower prevalence of microangiopathy in multivariate logistic regression analysis (odds ratio, 0.51; 95% confidence interval, 0.27-0.98; p = 0.04) after an adjustment for: age, hypertension, HbA_1c, WHR and total cholesterol (TC).

CONCLUSIONS

FT3 as tissue active hormone plays a clinically important role in T1DM people. The higher FT3 concentration is related to the lower prevalence of microangiopathy and better metabolic control of the disease in adult euthyroid people with T1DM.

[Prevalence and prognostic value of non-thyroidal illness syndrome among critically ill children]

INTRODUCTION

Alterations in thyroid hormones during critical illness, known as non-thyroidal illness syndrome (NTIS), were suggested to have a prognostic value. However, pediatric data is limited. The aim of this study was to assess prevalence and prognostic value of NTIS among critically ill children.

MATERIALS AND METHODS

A prospective observational study conducted on 70 critically ill children admitted into pediatric intensive care unit (PICU). Free triiodothyronine (FT3), free thyroxine (FT4), and thyroid stimulating hormone (TSH) were measured within 24hours of PICU admission. Primary outcome was 30-day mortality.

RESULTS

NTIS occurred in 62.9% of patients but it took several forms. The most common pattern was low FT3 with normal FT4 and TSH (25.7% of patients). Combined decrease in FT3, FT4, and TSH levels occurred in 7.1% of patients. An unusual finding of elevated TSH was noted in three patients, which might be related to disease severity. Low FT4 was significantly more prevalent among non-survivors compared with survivors (50% versus 19.2%, P=.028). NTIS independently predicted mortality (OR=3.91; 95% CI=1.006-15.19; P=.0491). Concomitant decrease in FT3, FT4, and TSH was the best independent predictor of mortality (OR=16.9; 95% CI=1.40-203.04; P=.026). TSH was negatively correlated with length of PICU stay (r_s=-0.35, P=.011). FT3 level was significantly lower among patients who received dopamine infusion compared with those who did not receive it (2.1±0.66 versus 2.76±0.91pg/mL, P=.011).

CONCLUSION

NTIS is common among critically ill children and appears to be associated with mortality and illness severity.

Abnormal thyroid hormones and non-thyroidal illness syndrome in obstructive sleep apnea, and effects of CPAP treatment

OBJECTIVE

In obstructive sleep apnea (OSA), while both hypothyroidism and hyperthyroidism have been studied, the occurrence of non-thyroidal illness syndrome (NTIS) (normal thyroid stimulating hormone [TSH] with low triiodotironine) has not been investigated. We explored the occurrence of NTIS in patients with moderate to severe OSA and its relationship to the severity of nocturnal respiratory disorders. We also studied the occurrence of subclinical hypothyroidism (SH, ie, high TSH with normal thyroxine) in OSA and changes in circulating TSH, free triiodotironine (fT3) and free thyroxine (fT4) after CPAP treatment.

METHODS

After a nocturnal respiratory polysomnography, 125 consecutive patients with moderate to severe OSA and 60 control subjects with normal nocturnal respiration were recruited. Morning circulating TSH, fT3, and fT4 were measured in all subjects. In a subsample of patients, nocturnal polysomnography and hormonal determinations were repeated after CPAP treatment for five months.

RESULTS

NTIS was found in 13 (10.4%), and SH in ten (8%) OSA subjects, but not in any control subjects. Patients with NTIS showed worse mean nocturnal oxygen saturation and time with saturation <90% (both p < 0.001). After treatment, NTIS subjects (n = 13) showed an increase in fT3 (p < 0.001) to the normal range, and SH subjects (n = 6) a slight decrease in TSH (p = 0.01). In the patients with normal hormones before treatment (n = 45), no change was observed.

CONCLUSIONS

NTIS may occur in OSA patients with severe nocturnal hypoxemia. OSA treatment is followed by an improvement in TSH in patients with abnormal baseline levels of this hormone, and by recovery of NTIS.

The role of hypothyroidism in the etiology and progression of dilated cardiomyopathy in Doberman Pinschers

BACKGROUND

Hypothyroidism and dilated cardiomyopathy (DCM) are both common diseases in Doberman Pinschers. A possible influence of hypothyroidism on the etiology and progression of DCM is controversial.

OBJECTIVES

Evaluation of the role of hypothyroidism in etiology and progression of DCM.

ANIMALS

A total of 175 Doberman Pinschers.

METHODS

In this longitudinal prospective study, echocardiography and 24-hour ambulatory ECG recordings were performed in all dogs as screening tests for DCM. Total thyroxine (TT4 ) and thyroid ultrasonography served as initial screening tests for hypothyroidism and low TT4 values were followed up by a thyroid stimulating hormone (TSH) test or free total thyroxine (fT4 )/cTSH measurements. Additionally, a follow-up study of dogs affected by both DCM and hypothyroidism under optimal treatment for hypothyroidism was conducted.

RESULTS

A total of 107 dogs were healthy, 45 dogs had DCM, 11 hypothyroidism, and 12 dogs had both DCM and hypothyroidism. TT4 values as well as the thyroid volumes were equivalent in the healthy dogs and in those with DCM. Neither ventricular premature complexes nor echocardiographic parameters differed between healthy and hypothyroid dogs. Dogs with DCM had a 2.26-fold (CI0.95 = 1.1-4.8) higher risk of also being affected by hypothyroidism. Despite optimal thyroid treatment of dogs with hypothyroidism and DCM, there was a progression of the heart disease.

CONCLUSIONS AND CLINICAL IMPORTANCE

This study did not confirm a role of hypothyroidism in the etiology or progression of DCM. Treatment of hypothyroidism did not improve the clinical outcome.

Risk factors for short term thyroid dysfunction after hematopoietic stem cell transplantation in children

Purpose

The purpose of this study was to evaluate short-term thyroid dysfunction and related risk factors in pediatric patients who underwent hematopoietic stem cell transplantation (HSCT) during childhood.

Methods

We studied 166 patients (100 boys and 66 girls) who underwent HSCT at the Catholic HSCT Center from January 2004 through December 2009. The mean age at HSCT was 10.0±4.8 years. Thyroid function of the patients was tested before and during 3 months of HSCT.

Results

Out of 166 patients, 165 (99.4%) underwent allotransplantation. Acute graft-versus-host disease (GVHD, grades II to IV) developed in 76 patients. Conditioning regimens before HSCT include total body irradiation (n=57), busulfan (n=80), and reduced intensity (n=29). Forty-five (27.1%) had thyroid dysfunction during 3 months after HSCT (29 euthyroid sick syndrome [ESS], 6 subclinical hyperthyroidism, 4 subclinical hypothyroidism, 3 hypothyroxinemia, 2 overt hyperthyroidism, and 1 high T₄ syndrome). In a univariate logistic regression analysis, age at HSCT (P=0.002) and acute GVHD (P=0.009) had statistically significant relationships with thyroid dysfunction during 3 months after HSCT. Also, in a univariate logistic regression analysis, ESS (P=0.014) showed a strong statistically significant association with mortality.

Conclusion

In our study 27.1% patients experienced thyroid dysfunction during 3 months after HSCT. Increase in age and acute GVHD may be risk factors for thyroid dysfunction during 3 months after HSCT. There was a significant association between ESS and mortality.