Journal Information
Vol. 28. Issue. 4.August 2008
Pages 361-473
Vol. 28. Issue. 4.August 2008
Pages 361-473
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Iatrogenic thyroid dysfunction in peritoneal dialysis
Disfunción tiroidea yatrogénica en diálisis peritoneal
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Aránzazu Sastre Lópeza, María Victoria Mascarós Ferrera
a Servicio de Nefrolog??a, Hospital Son LL??tzer, Palma de Mallorca, Islas Baleares, Espa??a,
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La lista de drogas que pueden causar alteraciones en los niveles de las hormonas tiroideas sería interminable (amiodarona, metformina, dopamina, dobutamina, propanolol, carbamazepina, litio, glucocorticoides¿.).1,2 Pero también los contrastes radiológicos3 y soluciones que contienen yodo usadas como antiséptico general y desinfectante de amplio espectro como la povidona yodada pueden causar disfunción tiroidea4. Así se sabe que la povidona yodada contenida en los tapones de desconexión de diálisis peritoneal puede ser un factor que contribuya a cambios en la función tiroidea. Si bien, la población de pacientes con mayor riesgo de verse afectada se limita a lactantes y niños en diálisis peritoneal con pequeños volúmenes de llenado, donde la concentración de yodo en el líquido de diálisis es mayor, considerándose infrecuente en población adulta5.
To the editor: The list of drugs that may cause changes in thyroid hormone levels would be endless (amiodarone, metformin, dopamine, dobutamine, propranolol, carbamazepine, lithium, glucocorticoids¿.).1,2 However, radiographic contrast agents3 and iodine-containing solutions used as general antiseptics and broad-spectrum disinfectants, such as povidone iodine, may also cause thyroid dysfunction. 4 Thus, it is known that povidone iodine contained in the disconnect caps of peritoneal dialysis may be a factor contributing to changes in thyroid function.. The patient population with a higher risk is however limited to infants and children on peritoneal dialysis with small filling volumes, where iodine concentration in the dialysis fluid is higher, while thyroid function changes are considered uncommon in the adult population.5
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To the editor: The list of drugs that may cause changes in thyroid hormone levels would be endless (amiodarone,

metformin, dopamine, dobutamine, propranolol, carbamazepine, lithium, glucocorticoids¿.).1,2 However,

radiographic contrast agents3 and iodine-containing solutions used as general antiseptics and broad-spectrum

disinfectants, such as povidone iodine, may also cause thyroid dysfunction. 4 Thus, it is known that povidone iodine contained in the disconnect caps of peritoneal dialysis may be a factor contributing to changes in thyroid function.. The patient population with a higher risk is however limited to infants and children on peritoneal dialysis with small filling volumes, where iodine concentration in the dialysis fluid is higher, while thyroid function changes are considered uncommon in the adult population.5



The case of an elderly female patient who showed changes in TSH levels probably induced by the iodine contained

in the peritoneal dialysis cap is reported.



This 70-year-old patient had been diagnosed CKD secondary to renal amyloidosis in the setting of a familial

amyloidotic polyneuropathy. She also had cardiac amyloid infiltration, and had been implanted a pacemaker in 2005. In addition, the patient had chronic diarrhea due to intestinal infiltration.



Proteinuria was initially found in January 2004, and progressed to levels in the nephrotic range. The patient showed

a progressive renal function impairment since April 2005, and was implanted a peritoneal dialysis catheter in

February 2006.



Continuous ambulatory peritoneal dialysis was started on 12-04-06, but a catheter leak occurred and a switch to intermittent nocturnal peritoneal dialysis with cycler and low volume (1200 mL per cycle) was made on 28-04-06. The leak subsequently resolved.



The patient had not previously shown any change in thyroid function, and normal TSH levels were found before the start of dialysis. Low, sometimes undetectable TSH levels were seen after the low volume dialysis technique was started. T3 and T4 levels were within the normal range, and anti-thyroid antibodies were normal. The endocrinology department was consulted, and a thyroid ultrasound was performed, showing a diffuse thyroid enlargement that was related to the underlying disease. Fine needle puncture allowed for ruling out malignancy or an amyloid infiltrate. While uncommonly, infiltrative diseases such as amyloidosis may also cause thyroid dysfunction.6



The patient was asymptomatic at all times and did not require additional treatment. Once the catheter leak was

resolved, filling volume could be increased, but continues to be low (1500 mL), now because of the discomfort

experienced by the patient with higher volumes. Hormonal changes persist.



Similar to when treatment is started with drugs altering thyroid function, thyroid hormone monitoring is also recommended in patient on peritoneal dialysis with small filling volumes, because the iodine contained in the disconnect cap may reach high concentrations in peritoneal fluid and pass into the blood, inducing iatrogenic changes such as those occurring in the rare case reported.
Bibliography
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1.Vigersky, RA, Filmore-Nassar, A, Glass, AR. Thyrotropin suppression by metformin. J Clin Endocrinol Metab 91:225; 2006. [Pubmed]
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2.Figge, HL, Figge, J. The effects of amiodarone on thyroid hormone function: A review of the physiology and clinical manifestations. J Clin Pharmacol 30:588;1990. [Pubmed]
[3]
3.Martin, FI, Tress, BW, Colman, PG, Deam, DR. Iodine-induced hyperthyroidism due to nonionic contrast radiography in the elderly. Am J Med 95:78;1993. [Pubmed]
[4]
4.Lim VS, Thyroid function in patients with chronic renal failure. Am J Kidney Dis 38(4):80-4; 2001.
[5]
5.Brough R, Jones C. Iatrogenic iodine as a cause of hypothyroididm in infants with end-stage renal failure. Pediatr Nephrol. 21(3):400-2; 2006. [Pubmed]
[6]
6.Kimura, H, Yamashita, S, Ashizawa, K, et al. Thyroid dysfunction in patients with amyloid goiter. Clin Endocrinol 46:769; 1997.
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