Decrease in renal function associated with hypothyroidism
Deterioro de Función Renal Asociado a Hipotiroidismo
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Martín Navarro, Evangelina Mérida Herrero, Mª José Gutiérrez Sánchez" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Vladimir" "apellidos" => "Petkov Stoyanov" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:4 [ "nombre" => "Juan A." "apellidos" => "Martín Navarro" "email" => array:1 [ 0 => "juanmartinnav@hotmail. com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "nombre" => "Evangelina" "apellidos" => "Mérida Herrero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "nombre" => "Mª José" "apellidos" => "Gutiérrez Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "SECCIÓN DE NEFROLOGÍA, Hospital del Tajo, Aranjuez, Madrid, España, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Deterioro de Función Renal Asociado a Hipotiroidismo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10350_18030_5960_en_figure1.jpg" "Alto" => 350 "Ancho" => 519 "Tamanyo" => 105145 ] ] "descripcion" => array:1 [ "en" => "Progression after stant of levothyroxine treatment." ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Dear Editor, </span> </p><p class="elsevierStylePara"> The functional relationship between thyroid and kidneys has been described since the mid-twentieth century<span class="elsevierStyleSup">1 </span>and has been the subject of many publications with differing pathophysiologic approaches.<span class="elsevierStyleSup">2-5 </span> </p><p class="elsevierStylePara"> Here we present the case of a patient with a striking recovery of glomerular filtration rate (GFR) after correction of a diagnosed hypothyroidism. This was an 89-year-old woman with hypertension, hypertensive cardiomyopathy, atrial fibrillation (AF), mitral insufficiency, and moderate aortic insufficiency, cerebral small vessel disease, and obesity-hypoventilation syndrome. She had undergone a cholecystectomy in April 2008, with plasma creatinine in the normal range at that time. </p><p class="elsevierStylePara"> From April 2008 and March 2009, she required several hospitalisations for episodes of rapid AF, lacunar infarct, heart failure, and digoxin toxicity. Progressive deterioration of renal function (RF) was seen until May 2009, at which point evaluation by the nephrology service was requested (Table 1). Ultrasound showed left renal atrophy (76mm diameter with corticomedullary disruption) and 118mm right kidney with moderate cortical atrophy. At that time, the patient was diagnosed with stage 4 chronic kidney disease (CKD) secondary to reduction of functional renal mass and severe cardiovascular comorbidity, with therapeutic changes consistent with the degree of CKD. </p><p class="elsevierStylePara"> After laboratory detection of primary hypothyroidism and the subsequent diagnosis of multinodular goitre due to autoimmune thyroiditis, hormonal treatment was started with levothyroxine. In the subsequent 6 months, adequate control of hypothyroidism was seen with progressive recovery of GFR and increased haemoglobin levels, exceeding expectations of reversibility of renal impairment (Table 1 and Figure 1). </p><p class="elsevierStylePara"> Thyroid disorders cause abnormalities in many locations with the heart and kidneys being the main targets of action of thyroid hormones.<span class="elsevierStyleSup">2-5 </span>Primary hypothyroidism, which develops after intrauterine growth, is associated with impaired glomerular filtration which is reversible with hormonal treatment in approximately 55% of cases.<span class="elsevierStyleSup">2 </span>Hyponatraemia is common (45% of cases with coexisting CKD versus 21% with previously normal renal function), as is fluid overload.<span class="elsevierStyleSup">2 </span>Renal function deterioration secondary to hypothyroidism involves heterogenous mechanisms dominated by haemodynamic abnormalities: a negative inotropic effect on the heart, reduced circulating intravascular volume, and increased peripheral resistance with renal vasoconstriction.<span class="elsevierStyleSup">2-4 </span> </p><p class="elsevierStylePara"> Among the effects of thyroid hormones are the following: </p><p class="elsevierStylePara"> 1. Gene regulation of structural and regulatory proteins such as Na+/K+ ATPase, Ca<span class="elsevierStyleSup">2</span>+ ATPase, Na+/Ca<span class="elsevierStyleSup">2</span>+ exchanger, betaadrenergic receptors, adenylate cyclase, phospholamban, myosin, voltage-gated potassium channels and G proteins, among others<span class="elsevierStyleSup">3-7 </span> </p><p class="elsevierStylePara"> 2. Extragenic regulation of Na+, K+, and Ca2+ channels in the cell membrane.<span class="elsevierStyleSup">3,7 </span> </p><p class="elsevierStylePara"> 3. Correlation with the reninangiotensinaldosterone system.<span class="elsevierStyleSup">4,6</span> </p><p class="elsevierStylePara"> 4. Correlation with levels of argininevasopressin (ADH),<span class="elsevierStyleSup">4,5 </span>brain natriuretic peptide (BNP),<span class="elsevierStyleSup">4,6 </span>and plasma creatinine not dependent on renal function<span class="elsevierStyleSup">8 </span>and erythropoietin.<span class="elsevierStyleSup">4 </span> </p><p class="elsevierStylePara"> 5. Activity on alpha-adrenergic receptor mediated vascular smooth muscle tone, activity of nitric oxide synthase (NOS), and endothelial hyperpolarising factor (EDHF).<span class="elsevierStyleSup">3,7 </span> </p><p class="elsevierStylePara"> 6. Thyroid hormone deficits, after foetal renal development, may manifest both as functional abnormalities and anatomic abnormalities related to the presence of immune complexes in autoimmune thyroiditis.<span class="elsevierStyleSup">9 </span> </p><p class="elsevierStylePara"> 7. Functional abnormalities: increased plasma creatinine, hyponatraemia, fluid retention, loss of ability to concentrate urine, and hyporegenerative anaemia. </p><p class="elsevierStylePara"> 8. Anatomic abnormalities<span class="elsevierStyleSup">10</span>: </p><p class="elsevierStylePara"> a) Glomerular: thickening of the glomerular basement membrane (GBM), amorphous mucopolysaccharide deposition in the mesangial matrix, and mesangial cell vacuolisation. </p><p class="elsevierStylePara"> b) Tubular: thickening of the GBM, cytoplasmic inclusions in the tubular epithelium, and tubular necrosis in cases of rhabdomyolisis. </p><p class="elsevierStylePara"> The deterioration of renal function in hypothyroidism may present with hyponatraemia, volume overload, metabolic acidosis, hypoaldosteronism relative low renin levels, rhabdomyolysis with variable proteinuria, and/or anaemia, but there is no common pattern of laboratory abnormalities. Meanwhile, CKD may cause abnormalities in the TSH circadian cycle, reduce peripheral conversion of T4 and decrease renal secretion of iodine, with prolongation of the Wolf- Chaikoff effect.<span class="elsevierStyleSup">2 </span>The presence of subclinical hypothyroidism in patients with GFR less than 60ml/min is 17.9% versus 7% in patients with GFR greater than 90ml/min.<span class="elsevierStyleSup">2 </span> </p><p class="elsevierStylePara"> There are numerous clinical case reports confirming the frequent association between hypothyroidism and decreased GFR, both with advanced CKD<span class="elsevierStyleSup">8 </span>and in patients with preserved renal function.<span class="elsevierStyleSup">11 </span>In published series of adult patients with primary hypothyroidism (Montenegro, with 41 patients<span class="elsevierStyleSup">12</span>) or post-thyroidectomy (Karanikas, with 27 patients,<span class="elsevierStyleSup">5 </span>Den Hollander, with 37 patients,<span class="elsevierStyleSup">13 </span>Baajafer, with 124 patients,<span class="elsevierStyleSup">14 </span>Kreisman, with 24 patients<span class="elsevierStyleSup">15</span>) there is a reversible decline in GFR that tends to recover 6-24 weeks after correction of thyroid function. Muscular symptoms with CPK elevations were found in more than 90% of cases.<span class="elsevierStyleSup">8 </span> </p><p class="elsevierStylePara"> In the case presented, the spectacular recovery of the RF after correction of hypothyroidism forced us to review our initial diagnostic impression. The advanced age of the patient with many cardiovascular risk factors, respiratory disease, and probable loss of function of the left kidney, in addition to frequent hospital admissions, made a diagnosis of multifactorial CKD very likely, with little hope of improvement. During follow-up, there were no significant ionic changes in blood or urine. No proteinuria, metabolic acidosis, or increased muscle enzymes were found. There had been no changes to the standard treatment or other causes of renal failure to which we could attribute the progression, nor was specific treatment implemented for the anaemia. Both the improvement in GFR, with the corresponding decline in serum creatinine, as well as the spontaneous increase of haemoglobin levels are primarily attributable to the hormonal correction of hypothyroidism. In our opinion, thyroid function testing is recommended as part of the diagnostic process for renal failure of undetermined cause, considering subclinical or manifest hypothyroidism among the possible causes of impaired renal function. </p><p class="elsevierStylePara"><a href="grande/10350_18030_5959_en_table1.jpg" class="elsevierStyleCrossRefs"><img src="10350_18030_5959_en_table1.gif" alt="Laboratory progression of plasma creatinine, TSH, T4, sodium, pH, and haemoglobin"></img></a></p><p class="elsevierStylePara">Table 1. Laboratory progression of plasma creatinine, TSH, T4, sodium, pH, and haemoglobin</p><p class="elsevierStylePara"><a href="grande/10350_18030_5960_en_figure1.jpg" class="elsevierStyleCrossRefs"><img src="10350_18030_5960_en_figure1.jpg" alt="Progression after stant of levothyroxine treatment."></img></a></p><p class="elsevierStylePara">Figure 1. Progression after stant of levothyroxine treatment.</p>" "pdfFichero" => "P1-E46-S1860-A10350-EN.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "10350_18030_5959_en_table1.jpg" "imagenAlto" => 318 "imagenAncho" => 521 "imagenTamanyo" => 158935 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Laboratory progression of plasma creatinine, TSH, T4, sodium, pH, and haemoglobin" ] ] 1 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10350_18030_5960_en_figure1.jpg" "Alto" => 350 "Ancho" => 519 "Tamanyo" => 105145 ] ] "descripcion" => array:1 [ "en" => "Progression after stant of levothyroxine treatment." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Yount E, Little JM. 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Arch Intern Med 1999; 159:79-82. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9892334" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003000000003/v0_201502091603/X2013251410035866/v0_201502091604/en/main.assets" "Apartado" => array:4 [ "identificador" => "35436" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003000000003/v0_201502091603/X2013251410035866/v0_201502091604/en/P1-E46-S1860-A10350-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251410035866?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 5 | 20 |
| 2024 October | 98 | 37 | 135 |
| 2024 September | 96 | 30 | 126 |
| 2024 August | 123 | 69 | 192 |
| 2024 July | 98 | 38 | 136 |
| 2024 June | 102 | 43 | 145 |
| 2024 May | 120 | 60 | 180 |
| 2024 April | 96 | 34 | 130 |
| 2024 March | 74 | 24 | 98 |
| 2024 February | 73 | 36 | 109 |
| 2024 January | 127 | 28 | 155 |
| 2023 December | 65 | 30 | 95 |
| 2023 November | 115 | 37 | 152 |
| 2023 October | 121 | 34 | 155 |
| 2023 September | 123 | 35 | 158 |
| 2023 August | 116 | 22 | 138 |
| 2023 July | 113 | 37 | 150 |
| 2023 June | 117 | 23 | 140 |
| 2023 May | 122 | 26 | 148 |
| 2023 April | 91 | 20 | 111 |
| 2023 March | 98 | 19 | 117 |
| 2023 February | 78 | 18 | 96 |
| 2023 January | 99 | 27 | 126 |
| 2022 December | 105 | 23 | 128 |
| 2022 November | 137 | 36 | 173 |
| 2022 October | 168 | 58 | 226 |
| 2022 September | 110 | 38 | 148 |
| 2022 August | 121 | 48 | 169 |
| 2022 July | 105 | 60 | 165 |
| 2022 June | 146 | 38 | 184 |
| 2022 May | 166 | 42 | 208 |
| 2022 April | 177 | 63 | 240 |
| 2022 March | 261 | 146 | 407 |
| 2022 February | 146 | 45 | 191 |
| 2022 January | 134 | 40 | 174 |
| 2021 December | 78 | 41 | 119 |
| 2021 November | 126 | 41 | 167 |
| 2021 October | 203 | 45 | 248 |
| 2021 September | 125 | 35 | 160 |
| 2021 August | 153 | 44 | 197 |
| 2021 July | 182 | 42 | 224 |
| 2021 June | 112 | 33 | 145 |
| 2021 May | 136 | 37 | 173 |
| 2021 April | 544 | 107 | 651 |
| 2021 March | 293 | 42 | 335 |
| 2021 February | 229 | 33 | 262 |
| 2021 January | 154 | 20 | 174 |
| 2020 December | 138 | 16 | 154 |
| 2020 November | 125 | 20 | 145 |
| 2020 October | 80 | 13 | 93 |
| 2020 September | 125 | 19 | 144 |
| 2020 August | 130 | 5 | 135 |
| 2020 July | 156 | 11 | 167 |
| 2020 June | 149 | 22 | 171 |
| 2020 May | 143 | 24 | 167 |
| 2020 April | 139 | 26 | 165 |
| 2020 March | 160 | 15 | 175 |
| 2020 February | 225 | 25 | 250 |
| 2020 January | 218 | 40 | 258 |
| 2019 December | 203 | 23 | 226 |
| 2019 November | 206 | 43 | 249 |
| 2019 October | 182 | 25 | 207 |
| 2019 September | 234 | 31 | 265 |
| 2019 August | 178 | 17 | 195 |
| 2019 July | 162 | 32 | 194 |
| 2019 June | 121 | 20 | 141 |
| 2019 May | 164 | 24 | 188 |
| 2019 April | 262 | 42 | 304 |
| 2019 March | 144 | 33 | 177 |
| 2019 February | 118 | 38 | 156 |
| 2019 January | 142 | 36 | 178 |
| 2018 December | 280 | 47 | 327 |
| 2018 November | 617 | 21 | 638 |
| 2018 October | 235 | 10 | 245 |
| 2018 September | 98 | 18 | 116 |
| 2018 August | 96 | 19 | 115 |
| 2018 July | 70 | 9 | 79 |
| 2018 June | 52 | 11 | 63 |
| 2018 May | 50 | 13 | 63 |
| 2018 April | 64 | 8 | 72 |
| 2018 March | 45 | 14 | 59 |
| 2018 February | 46 | 6 | 52 |
| 2018 January | 53 | 8 | 61 |
| 2017 December | 46 | 13 | 59 |
| 2017 November | 33 | 6 | 39 |
| 2017 October | 37 | 5 | 42 |
| 2017 September | 53 | 11 | 64 |
| 2017 August | 54 | 6 | 60 |
| 2017 July | 42 | 13 | 55 |
| 2017 June | 32 | 8 | 40 |
| 2017 May | 42 | 8 | 50 |
| 2017 April | 33 | 6 | 39 |
| 2017 March | 33 | 6 | 39 |
| 2017 February | 36 | 14 | 50 |
| 2017 January | 33 | 8 | 41 |
| 2016 December | 76 | 9 | 85 |
| 2016 November | 96 | 21 | 117 |
| 2016 October | 123 | 17 | 140 |
| 2016 September | 176 | 5 | 181 |
| 2016 August | 212 | 8 | 220 |
| 2016 July | 150 | 15 | 165 |
| 2016 June | 111 | 0 | 111 |
| 2016 May | 121 | 0 | 121 |
| 2016 April | 95 | 0 | 95 |
| 2016 March | 81 | 0 | 81 |
| 2016 February | 101 | 0 | 101 |
| 2016 January | 103 | 0 | 103 |
| 2015 December | 107 | 0 | 107 |
| 2015 November | 79 | 0 | 79 |
| 2015 October | 84 | 0 | 84 |
| 2015 September | 76 | 0 | 76 |
| 2015 August | 71 | 0 | 71 |
| 2015 July | 61 | 0 | 61 |
| 2015 June | 35 | 0 | 35 |
| 2015 May | 59 | 0 | 59 |
| 2015 April | 10 | 0 | 10 |
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