|Year : 2018 | Volume
| Issue : 4 | Page : 126-129
To study the prevalence of thyroid disorders in chronic renal disease patients
Upendra Nath Gupta, Apoorva Jain, Prashant Prakash, Prabhat Agrawal, Ravi Kumar, Maaz Farooqui
Department of Medicine, S.N. Medical College, Agra, Uttar Pradesh, India
|Date of Web Publication||27-May-2019|
Dr. Prashant Prakash
Department of Medicine, S.N. Medical College, Agra, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background and Objectives: The high prevalence of thyroid dysfunction in chronic kidney disease (CKD) patients reveals significant association between CKD progression and thyroid dysfunction. The aim was to study the thyroid dysfunction in patients of CKD for the prevalence of subclinical hypothyroidism (SCH) and clinical hypothyroidism and study the correlation between thyroid dysfunction and severity of renal diseases. In view of the variability of thyroid profile in CKD patients in previous studies, a prospective study of various thyroid function has been undertaken to establish a correlation if any between thyroid dysfunction and severity of renal diseases. Materials and Methods: A total of 100 patients with CKD on conservative management fulfilling the criteria for CKD who were admitted at the Department of Medicine, SNMC, Agra, Uttar Pradesh, India, during the period of July 2016–June 2017, were selected in this study. Descriptive analysis of the collected data was done and association of various parameters with the presence or absence of SCH or overt hypothyroidism was studied using Chi-square test and correlated. Results: Results showed that out of the 100 patients with CKD, 53 patients had thyroid dysfunction which accounted for 53%. The prevalence of SCH and clinical hypothyroidism was 33% and 20%, respectively. The number of patients with hypothyroidism progressively increased with increased severity of renal failure. Conclusions: We observed a high prevalence of thyroid dysfunction in our CKD patients and revealed significant association between CKD progression and thyroid dysfunction.
Keywords: Chronic kidney disease, clinical hypothyroidism, subclinical hypothyroidism, thyroid dysfunction, thyroid-stimulating hormone
|How to cite this article:|
Gupta UN, Jain A, Prakash P, Agrawal P, Kumar R, Farooqui M. To study the prevalence of thyroid disorders in chronic renal disease patients. J Integr Nephrol Androl 2018;5:126-9
|How to cite this URL:|
Gupta UN, Jain A, Prakash P, Agrawal P, Kumar R, Farooqui M. To study the prevalence of thyroid disorders in chronic renal disease patients. J Integr Nephrol Androl [serial online] 2018 [cited 2019 Jun 26];5:126-9. Available from: http://www.journal-ina.com/text.asp?2018/5/4/126/259160
| Introduction|| |
The 2010 Global Burden of Disease study mentions chronic kidney disease (CKD) as the 27th cause of mortality in 1990, rising to 18th in 2010, second only to that for HIV, AIDS. Kidneys regulate the metabolism, degradation, and excretion of thyroid hormones; impaired kidney functions alter hormone production, distribution, and excretion. Data suggest that predialysis patients with CKD have an increased risk of hypothyroidism, with many cases being subclinical.,
Primary hyperthyroidism is rare, while the prevalence of subclinical hypothyroidism (SCH) and overt hypothyroidism is increased in patients with CKD.,,, Hypothyroidism shares common symptoms with CKD such as pallor, hypothermia, and asthenia, with diagnosis resting largely on biochemical tests. A dearth of Indian data with respect to SCH and overt hypothyroidism in patients with predialysis CKD mandated this study.
The aim and objective of our study were to see the prevalence of thyroid dysfunction in patients with CKD, the correlation between thyroid dysfunction, the severity of renal diseases, and the prevalence of SCH in CKD patients.
| Materials and Methods|| |
This was a prospective cross-sectional study conducted at the Post Graduate Department of Medicine, S. N. Medical College, Agra, Uttar Pradesh, India, between July 2016 and June 2017. This study was approved by the Institutional Ethical Review Board. A total of 100 patients were included in this study after fulfilling the inclusion criteria. We included CKD patients aged >18 years. All the 100 cases included in the study were classified into stages of CKD according to the glomerular filtration rate (GFR) calculated by Cockcroft–Gault formula. Staging of CKD was done according to the KDIGO guidelines.
We excluded patients undergoing peritoneal dialysis or hemodialysis, nephrotic range of proteinuria, acute illness of any nature, recent surgery, trauma or burns; those with diabetes mellitus and liver diseases; those on drugs altering thyroid profile such as amiodarone, steroids, dopamine, phenytoin, beta-blocker, estrogen pills, iodine-containing drugs; and patients with any previous long-term history of thyroid disorders. An informed written consent was taken from all the cases before enrolling into the study and a detailed history taking and general examination were done. Blood samples were collected from the participants and analyzed for free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone (TSH) by electrochemiluminescence technique using the kits by Advia Centaur XP analyzer system of Siemens (siiemens healthineers limited, siemens heakthcare GmbH, Henkestr, 127, 91052 Erlangen, Germany).
Descriptive analysis of the collected data was done, and the association of various parameters with the presence or absence of SCH or overt hypothyroidism was studied using Chi-square test and correlated.
| Results|| |
The study group comprised of 100 cases of CKD. Various demographic data, clinical characteristics, and thyroid profile were collected and subjected to statistical analysis.
In our study, 100 patients of CKD who were on conservative management fulfilling the criteria for CKD were studied, among these 60 were males and 40 were females [Figure 1].
|Figure 1: Out of 100 patients taken for study 60 were males and 40 were females|
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Of the males, 20 had SCH, 9 had overt hypothyroidism, while in females, the corresponding numbers were 13 and 11, respectively [Figure 2].
|Figure 2: Among the males, 20 had subclinical hypothyroidism, 9 had overt hypothyroidism, while in females, the corresponding numbers were 13 and 11, respectively|
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Age of the participants varied from 22 to 72 years, the number of patients aged 30 or below were 27, between 31 and 60 years were 59, and that of 60 years and above were 14 [Figure 3].
Among all the 100 cases, patients of Stage II were 10%, 16% patients were Stage III, 22% patients were Stage IV, and 52% of patients were Stage V. Among the patients studied, most belonged to Stage V [Table 1].
|Table 1: Distribution of cases based on creatinine Clearance (Cockcroft and Gault equation)|
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Correlation of thyroid dysfunction with the glomerular filtration rate and stage of chronic kidney disease
Most participants (n = 33, 66%) had abnormal serum thyroid function test results. Thirty-three (33%) participants had SCH (i.e., TSH values >5 mIU/L with normal FT4 levels), whereas 20% (n = 20) had clinical hypothyroidism (i.e., TSH >5 mIU/L with low FT4 [<0.8 ng/mL] levels). The mean values of creatinine clearance, serum TSH, and FT4 concentrations of SCH were 22.77 ± 17.81 mL/min/1.73 m2, 8.44 ± 0.79 mIU/L, and 11.89 ± 1.21 ng/dL, and in clinical hypothyroidism, the corresponding values were 24.25 ± 15.42 mL/min/1.73 m2, 8.44 ± 0.79 mIU/L, and 13.29 ± 1.25 ng/dL, respectively.
Cases of clinical and subclinical hypothyroidism categorized according to glomerular filtration rate and stage of chronic kidney disease
There were 33 CKD patients with SCH, 3 patients (9.09%) were Stage II CKD, 1 patient (3.03%) had Stage IIIA, 5 patients (15.15%) had Stage IIIB, 9 patients (27.27%) had Stage IV, and 15 patients (45.45%) had Stage V CKD.
There were 20 CKD patients with overt hypothyroidism, of which 3 patients (5%) had Stage II CKD, 1 patient (5%) had Stage IIIA, 2 patients (10%) had Stage IIIB, 8 patients (40%) had Stage IV, and 8 patients (40%) had CKD Stage V [Table 2].
|Table 2: Correlation of thyroid dysfunction with the GFR and stage of CKD|
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| Discussion|| |
A large number of hormonal systems are affected by CKD, yet it remains unclear to what extent these changes are responsible for manifestations of uremic syndrome.
Patients with CKD often have signs and symptoms suggestive of thyroid dysfunction and hence the diagnosis of thyroid disease in these patients has obvious prognostic implications. Thyroid autoimmunity and subclinical primary hypothyroidism are highly prevalent in CKD patients not requiring long-term dialysis treatment.
The present study was aimed at to assess the prevalence of thyroid dysfunction in CKD and to determine the correlation between thyroid dysfunction and severity of renal disease.
The association of thyroid dysfunction in CKD has been variable according to previous studies. In our study, CKD patients only on conservative management were studied because thyroid profile is altered due to dialysis. In a study by Chandra., SCH and clinically apparent hypothyroidism have been reported to occur in ~40% and 16% of patients, respectively, with CKD not requiring renal replacement therapy.
This study differs from these previous observations by demonstrating a prevalence of SCH and clinical hypothyroidism (53%). An increased prevalence of subclinical and clinical primary hypothyroidism in persons with reduced estimated GFR (eGFR) independent of age and gender was seen in this study. This is in line with the observation made by Chonchol et al. Our study included 100 cases of CKD, out of which 53 cases were having thyroid dysfunction in which 20 patients had clinical hypothyroidism and 33 patients had SCH. In this study, the absolute prevalence of hypothyroidism in the lower GFRs was higher than that reported in other studies, which may be due to the smaller sample size in the present study. Majority of the patients in this study fell in the CKD Stage IV/V category, which could be due to the fact that most of the CKD patients referred to this tertiary care center had a low GFR.
Higher TSH levels are seen with increasing age. The mean age in this study was 39.00 ± 12.16 and 47.5 ± 14.37 years in SCH and clinical hypothyroidism groups, respectively.
As shown in [Table 2], of 100 patients of CKD, 20 were found to be clinically hypothyroid having the maximum percentage in Stage V (40%), while in Stage II, they had the lowest prevalence of hypothyroidism (8%). Lo et al. found that the prevalence of hypothyroidism increased with fall in GFR occurring in 5.4% of patients with GFR ≥90, 10.9% with GFR 60–89, 20.4% with GFR 45–59, 23.0% with GFR 30–44, and 23.1% with GFR <30 (P < 0.001 for trend). Prevalence of SCH increases with fall in GFR, Stage V (45.45%) and Stage II (9.09%). Among 100 CKD patients who were studied, 53 patients were found to have thyroid dysfunction. The overall prevalence of SCH in CKD was 33%. This prevalence was higher than that of most of the studies done previously. In a study published in 2008, among 3089 adult participants, 293 (9.5%) had subclinical primary hypothyroidism and 277 (9%) had an eGFR <60 mL/min/1.73 m2.
Although numerous hypotheses exist for contributing factors, such as altered iodine metabolism, decreased peripheral sensitivity to hormones, and autoimmune thyroiditis, the exact underlying mechanisms linking advanced CKD and primary thyroid dysfunction remain unclear.
To summarize, our study showed a higher prevalence of SCH and clinical hypothyroidism in patients of CKD. The severity of thyroid dysfunction increases with progressive fall in GFR.
| Conclusions|| |
We found that reduced kidney function was associated with an increased prevalence of SCH and clinical hypothyroidism.
In our study, population of 100 CKD patients who were on conservative management were studied. Among them, 53% of patients had thyroid disorder. The most common thyroid hormone disorder was SCH (33%) followed by clinical hypothyroidism (20%), which was higher than that has been reported previously. The severity of thyroid dysfunction increases with progressive fall in GFR.
The role of clinical or SCH on physical function, cognitive function, quality of life, and depression in CKD is unknown. However, health professionals caring for patients with CKD should be cognizant that CKD and hypothyroidism may exhibit overlapping symptom complexes. Hyperthyroidism which was found in some previous studies was not found in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jha V, Garcia-Garcia G, Iseki K, Li Z, Naicker S, Plattner B, et al.
Chronic kidney disease: Global dimension and perspectives. Lancet 2013;382:260-72.
Ramírez G, Jubiz W, Gutch CF, Bloomer HA, Siegler R, Kolff WJ, et al.
Thyroid abnormalities in renal failure. A study of 53 patients on chronic hemodialysis. Ann Intern Med 1973;79:500-4.
Castellano M, Turconi A, Chaler E, Maceiras M, Rivarola MA, Belgorosky A. Thyroid function and serum thyroid binding proteins in prepubertal and pubertal children with chronic renal insufficiency receiving conservative treatment, undergoing hemodialysis, or receiving care after renal transplantation. J Pediatr 1996;128:784-90.
Gomez-Pan A, Alvarez-ude F, Yeo PB, Hall R, Evered DC, Kerr DN. Function of the hypothalamic-hypophyseal-thyroid axis in chronic renal failure. Clin Endocrinol 1996;2:567-74.
Kaptein EM, Quion-Verde H, Chooljian CJ, Tang WW, Friedman PE, Rodriquez HJ, et al.
The thyroid in end-stage renal disease. Medicine (Baltimore) 1988;67:187-97.
Takeda S, Michigishi T, Takazakura E. Iodine-induced hypothyroidism in patients on regular dialysis treatment. Nephron 1993;65:51-5.
Schaefer F, Anderzej W, Eberhard R. The patient with failing renal function, endocrine disorders. In: Alex DM, Stewart CJ, Eberhard R, David N, Krr S, Jean-Pierre G, editors. Oxford Textbook of Clinical Nephrology. New York, USA: Oxford University Press; 1997. p. 3187-94.
Mohamedali M, Reddy Maddika S, Vyas A, Iyer V, Cheriyath P. Thyroid disorders and chronic kidney disease. Int J Nephrol 2014;2014:520281.
Stevens PE, Levin A; Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members. Evaluation and management of chronic kidney disease: Synopsis of the kidney disease: Improving global outcomes 2012 clinical practice guideline. Ann Intern Med 2013;158:825-30.
Targher G, Chonchol M, Zoppini G, Salvagno G, Pichiri I, Franchini M, et al.
Prevalence of thyroid autoimmunity and subclinical hypothyroidism in persons with chronic kidney disease not requiring chronic dialysis. Clin Chem Lab Med 2009;47:1367-71.
Chandra A. Prevalence of hypothyroidism in patients with chronic kidney disease: A cross-sectional study from North India. Kidney Res Clin Pract 2016;35:165-8.
Chonchol M, Lippi G, Salvagno G, Zoppini G, Muggeo M, Targher G, et al
. Prevalence of subclinical hypothyroidism in patients with chronic kidney disease. Clin J Am Soc Nephrol 2008;3:1296-300.
Surks MI, Hollowell JG. Age-specific distribution of serum thyrotropin and antithyroid antibodies in the US population: Implications for the prevalence of subclinical hypothyroidism. J Clin Endocrinol Metab 2007;92:4575-82.
Lo JC, Chertow GM, Go AS, Hsu CY. Increased prevalence of subclinical and clinical hypothyroidism in persons with chronic kidney disease. Kidney Int 2005;67:1047-52.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]