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    "textoCompleto" => "<p class="elsevierStylePara">To the editor&#58;</p><p class="elsevierStylePara">Afew cases of glomerular diseases associated to thyroid diseases have been described&#46;<span class="elsevierStyleSup">1-6</span></p><p class="elsevierStylePara">A 41-year old female went to the General Practitioner because of malaise and palpitations&#46; On blood analysis&#44; we only detected abnormal free T4 &#40;fT4&#41; &#40;100 pmol&#47;L&#41; and TSH &#40;0&#46;01 mIU&#47;mL&#41; values &#40;normal fT4 levels&#58; 12-22 pmol&#47;L and normal TSH levels 0&#46;3-4&#46;2 mIU&#47;mL&#41;&#44; compatible with hyperthyroidism&#46; A Doppler ultrasound of the thyroid showed a homogeneous increase in size and diffuse increased uptake with signs of hypervascularization&#46; A diagnosis of Graves-asedow&#191;s disease was made and symptomatic treatment with beta-blockers and synthetic antithyroid drugs &#40;methimazole&#41; was initiated&#46;</p><p class="elsevierStylePara">One month later she went to the hospital because of asthenia&#44; generalized edemas and anasarca&#44; and intolerance to cold&#46; Blood analysis disclosed hypoalbuminemia &#40;14&#46;9 mg&#47;dL&#41; and hypercholesterolemia &#40;350 mg&#47;dL&#41; with normal renal function&#46; Urinary sediment did not show activity signs&#46; A proteinuria of 6&#46;5 g&#47;day was detected&#46; The diagnosis was oriented to pure nephrotic syndrome&#44; as well as iatrogenic hypothyroidism due to excessive doses of anti-thyroid drugs&#46; Treatment was initiated with levothyroxine&#44; ACE inhibitors&#44; diuretics and statins&#46; The immunological investigations &#40;including immunoglobulin levels&#44; complement fractions&#44; cryoglobulins&#44; ANA&#44; ANCA and anti-basement membrane antibodies&#41;&#44; viral serology &#40;HBV&#44; HIV&#44; HCV&#41;&#44; and tumoral markers &#40;AFP&#44; CEA&#44; Ca 12&#46;5&#44; Ca&#46; 15&#46;3&#44; Ca 19&#46;9&#41; were unremarkable&#46; A percutaneous renal biopsy was performed&#44; which showed glomeruli with no hypercellularity&#44; no alterations in the capillary wall&#44; no tubular atrophy&#44; no significant inflammatory infiltrate and negative immunofluorescence&#44; compatible with minimal changes disease&#46; With the treatment&#44; the evolution was rapidly favorable&#44; the thyroid hormones recovered&#44; the edemas disappeared&#44; and the proteinuria completely regressed &#40;0&#46;16 g&#47;day&#41;&#46;</p><p class="elsevierStylePara">The most frequent thyroid condition associated to renal alterations is Graves&#191; disease&#46; The most frequently reported associated renal condition in these cases is membranous glomerulonephritis with nephrotic syndrome&#46;<span class="elsevierStyleSup">3&#44;4</span> However&#44; there are sporadic cases of membranoproliferative glomerulonephritis or minimal changes disease associated to thyroid disease&#46;<span class="elsevierStyleSup">1&#44;5&#44;6</span> Some authors suggest that the incidence of the association of glomerular alterations and thyroid conditions could be higher than suspected&#44; since the presence of constant proteinuria is not infrequent when a diagnosis of autoimmune thyroiditis is made&#46;<span class="elsevierStyleSup">2</span> The coexistence of the two pathologies could be explained by a common autoimmune pathogenesis&#46; On the other hand&#44; nephrotic syndrome secondary to structural changes of the glomerular basement membrane and tubular membrane has been reported in cases of sustained hypothyroidism&#46;<span class="elsevierStyleSup">2&#44;7-9</span> Given the temporal coincidence of the diagnosis and the nephrotic flare after the iatrogenic hypothyroidism&#44; we think that in the reported patient the underlying thyroid disease provoked a glomerular alteration&#44; which was maintained by the situation of hypothyroidism&#46; Most patients are controlled with steroids or other immunosuppressive drugs&#44; although therapy with iodine or radical thyroidectomy has been efficacious in those patients with repetitive flares&#46;<span class="elsevierStyleSup">10&#44;11</span> Immunosuppressive therapy was not initiated in this patient because of the rapid improvement&#46;</p><p class="elsevierStylePara">In summary&#44; we report a patient who presented minimal changes disease associated to Graves&#191; disease in the setting of pharmacological hypothyroidism&#46; The infrequent association of both entities and the complete remission without immunosuppressive therapy are remarkable&#46; </p>"
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Graves disease, drug-related hypothyroidism, and nephrotic syndrome due to minimal changes disease
Enfermedad de Graves, hipotiroidismo farmacológico y síndrome nefrótico por enfermedad de cambios mínimos
Vicente Esteve Simóa, N.. Fontseréa, A.. Saurinaa, M.. Ramírez de Arellanoa
a Servei de Nefrologia, Consorci Sanitari de Terrassa, Terrassa, Barcelona, España,
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    "textoCompleto" => "<p class="elsevierStylePara">To the editor&#58;</p><p class="elsevierStylePara">Afew cases of glomerular diseases associated to thyroid diseases have been described&#46;<span class="elsevierStyleSup">1-6</span></p><p class="elsevierStylePara">A 41-year old female went to the General Practitioner because of malaise and palpitations&#46; On blood analysis&#44; we only detected abnormal free T4 &#40;fT4&#41; &#40;100 pmol&#47;L&#41; and TSH &#40;0&#46;01 mIU&#47;mL&#41; values &#40;normal fT4 levels&#58; 12-22 pmol&#47;L and normal TSH levels 0&#46;3-4&#46;2 mIU&#47;mL&#41;&#44; compatible with hyperthyroidism&#46; A Doppler ultrasound of the thyroid showed a homogeneous increase in size and diffuse increased uptake with signs of hypervascularization&#46; A diagnosis of Graves-asedow&#191;s disease was made and symptomatic treatment with beta-blockers and synthetic antithyroid drugs &#40;methimazole&#41; was initiated&#46;</p><p class="elsevierStylePara">One month later she went to the hospital because of asthenia&#44; generalized edemas and anasarca&#44; and intolerance to cold&#46; Blood analysis disclosed hypoalbuminemia &#40;14&#46;9 mg&#47;dL&#41; and hypercholesterolemia &#40;350 mg&#47;dL&#41; with normal renal function&#46; Urinary sediment did not show activity signs&#46; A proteinuria of 6&#46;5 g&#47;day was detected&#46; The diagnosis was oriented to pure nephrotic syndrome&#44; as well as iatrogenic hypothyroidism due to excessive doses of anti-thyroid drugs&#46; Treatment was initiated with levothyroxine&#44; ACE inhibitors&#44; diuretics and statins&#46; The immunological investigations &#40;including immunoglobulin levels&#44; complement fractions&#44; cryoglobulins&#44; ANA&#44; ANCA and anti-basement membrane antibodies&#41;&#44; viral serology &#40;HBV&#44; HIV&#44; HCV&#41;&#44; and tumoral markers &#40;AFP&#44; CEA&#44; Ca 12&#46;5&#44; Ca&#46; 15&#46;3&#44; Ca 19&#46;9&#41; were unremarkable&#46; A percutaneous renal biopsy was performed&#44; which showed glomeruli with no hypercellularity&#44; no alterations in the capillary wall&#44; no tubular atrophy&#44; no significant inflammatory infiltrate and negative immunofluorescence&#44; compatible with minimal changes disease&#46; With the treatment&#44; the evolution was rapidly favorable&#44; the thyroid hormones recovered&#44; the edemas disappeared&#44; and the proteinuria completely regressed &#40;0&#46;16 g&#47;day&#41;&#46;</p><p class="elsevierStylePara">The most frequent thyroid condition associated to renal alterations is Graves&#191; disease&#46; The most frequently reported associated renal condition in these cases is membranous glomerulonephritis with nephrotic syndrome&#46;<span class="elsevierStyleSup">3&#44;4</span> However&#44; there are sporadic cases of membranoproliferative glomerulonephritis or minimal changes disease associated to thyroid disease&#46;<span class="elsevierStyleSup">1&#44;5&#44;6</span> Some authors suggest that the incidence of the association of glomerular alterations and thyroid conditions could be higher than suspected&#44; since the presence of constant proteinuria is not infrequent when a diagnosis of autoimmune thyroiditis is made&#46;<span class="elsevierStyleSup">2</span> The coexistence of the two pathologies could be explained by a common autoimmune pathogenesis&#46; On the other hand&#44; nephrotic syndrome secondary to structural changes of the glomerular basement membrane and tubular membrane has been reported in cases of sustained hypothyroidism&#46;<span class="elsevierStyleSup">2&#44;7-9</span> Given the temporal coincidence of the diagnosis and the nephrotic flare after the iatrogenic hypothyroidism&#44; we think that in the reported patient the underlying thyroid disease provoked a glomerular alteration&#44; which was maintained by the situation of hypothyroidism&#46; Most patients are controlled with steroids or other immunosuppressive drugs&#44; although therapy with iodine or radical thyroidectomy has been efficacious in those patients with repetitive flares&#46;<span class="elsevierStyleSup">10&#44;11</span> Immunosuppressive therapy was not initiated in this patient because of the rapid improvement&#46;</p><p class="elsevierStylePara">In summary&#44; we report a patient who presented minimal changes disease associated to Graves&#191; disease in the setting of pharmacological hypothyroidism&#46; The infrequent association of both entities and the complete remission without immunosuppressive therapy are remarkable&#46; </p>"
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Article information
ISSN: 20132514
Original language: English
DOI:
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