19100006004 - THESIS

 TITLE : 

“THYROID DYSFUNCTION IN PATIENTS WITH CHRONIC KIDNEY DISEASE” 

INTRODUCTION

Chronic kidney disease (CKD) has been recognized as a leading public health problem worldwide. The global estimated prevalence of CKD is 13.4% (11.7-15.1%), and patients with end-stage renal disease (ESRD) needing renal replacement therapy is estimated between 4.902 and 7.083 million1. Through its effect on cardiovascular risk and ESRD, CKD directly affects the global burden of morbidity and mortality worldwide. The global increase in this disease is mainly driven by the increase in the prevalence of diabetes mellitus, hypertension, obesity, and aging. But in some regions, other causes such as infection, herbal and environmental toxins are still common. The large number of deaths for poor access to renal replacement therapy in developing countries, and also large increase of patients with ESRD in future, will produce substantial financial burden for even the wealthiest countries2.

Chronic kidney disease (CKD) is a clinical syndrome secondary to the definitive change in function and/or structure of the kidney and is characterized by its irreversibility and slow and progressive evolution. The main causes of CKD include diabetes, hypertension, chronic glomerulonephritis, chronic pyelonephritis, chronic use of anti-inflammatory medication, autoimmune diseases, polycystic kidney disease, Alport disease, congenital malformations, and prolonged acute renal disease2. The functions of thyroid and kidney are interrelated3-6. The thyroid hormones are essential for growth and development of the kidney and for maintaining electrolyte and water homeostasis. On the other hand, kidney has its vital role in metabolism and elimination of thyroid hormones3.

In CKD patients reduction of renal function leads to change in the synthesis, secretion, metabolism and elimination of thyroid hormone. And also treatment strategies of one organ affect the other organ. The kidney helps in the clearance of iodine mainly by glomerular filtration. So excretion of iodine is reduced in advanced renal failure. Impaired renal clearance of iodine leads to elevated serum levels of inorganic iodide that potentially blocks thyroid hormone production resulting in “Wolff Chaikoff” effect4.

Chronic kidney disease is associated with thyroid function abnormalities leading to low levels of serum total and free T3 concentration and normal reverse T3 and free T4 levels. The TSH levels are almost normal in most patients and found to be in euthyroid state.

CKD patients may have various symptoms and signs suggestive of hypothyroidism like cold intolerance, dry coarse skin, sallow complexion, lethargy, fatigue, edema, reduced basal metabolic rate, alopecia, hyporeflexia and asthenia. So it is difficult to exclude thyroid function abnormality in patients with chronic kidney disease merely on clinical background.

Various studies have been conducted to study thyroid function abnormalities in chronic kidney disease patients. All abnormalities like hypothyroidism, hyperthyroidism and euthyroid state have been reported in the studies done previously5.

The relation between severity of renal failure and thyroid dysfunction is not clear. The estimated problem of hypothyroidism is between 0-9 percent in end stage renal disease. In ESRD increased prevalence of thyroid swelling (goitre) has also been noted. In view of variability of thyroid profile in chronic kidney disease patients in previous studies, a cross-sectional biochemical and clinical study on thyroid function has been undertaken.

AIM

To study the thyroid function status (T3, T4, TSH) in patients with chronic kidney disease

OBJECTIVES

To study thyroid dysfunction in patients with chronic Kidney disease.

To study the relationship between thyroid dysfunction and severity of renal disease. (Severity assessed by serum creatinine, serum urea, creatinine clearance). 

PATIENTS AND METHODS

The present study was a single-center, Cross-sectional Study conducted on all the patients with Chronic Kidney Disease above age of 18 years of age, admitted in the department of General Medicine of Kamineni Institute of Medical Sciences, Sreepuram, Narketpally, Nalgonda District, Telangana from October 2019 to September 2021.

Prior initiation of the study, obtained Ethical and Research Committee clearance from Kamineni Institute of Medical Sciences, Sreepuram, Narketpally, Nalgonda District, Telangana. During present study total 163 Patients were reviewed in department of general Medicine, among 100 patients were enrolled into the study according to present study inclusion criteria and 63 patients were excluded according exclusion criteria.     

Patients were included in the study based on the inclusion and the exclusion criteria as mentioned below.   

Inclusion Criteria 

Patients who fulfill the criteria for CKD and who are on conservative management. 

Patients age above 18 years.

Both sexes are included.

Criteria for Chronic Kidney Disease :

 1. Presence of uremic symptoms for 3 months or more.

 2. Raised blood urea, serum creatinine and reduced creatinine clearance (estimated by cockroft-gault formula).

 3. Ultra sonogram evidence of chronic kidney disease like Bilateral contracted kidneys — size less than 9 cm.; Poor cortico-medullary differentiation.

 4. Supportive laboratory evidence of CKD like anaemia, changes in serum electrolytes, etc.

Exclusion criteria

Patients on peritoneal dialysis or hemodialysis. 

Nephrogenic range of proteinuria (>3.5gm/24hrs). 

Low serum protein especially albumin. 

Other conditions like: 

Acute illness 

Recent surgery, trauma or bums 

Diabetes mellitus 

Liver diseases

Drugs altering thyroid profile like amiodarone, steroids, phenytoin, beta-blocker, estrogen pills, hormonal therapy iodine-containing drugs 

Methodology

After getting approval from the institutional ethics committee and prior informed consent obtained from patients the study was conducted.    

A detailed history was elicited. Emphasis regarding history of onset, duration, progression of chief complaints and associated complaints such as pain, nausea and vomiting, headache, bowel habits, fever, abdominal distension and any family history were taken.

A thorough general physical examination of patient was done.

A thorough systemic examination was done. 

INVESTIGATIONS :

 Complete Hemogram

Renal function test 

Complete Urine examination 

RBS

Special Investigations;

Thyroid Function test :

Components of thyroid profile in this study: 

Serum triiodothyronine(T3) 

Serum thyroxine(T4) 

Serum thyroid stimulating hormone (TSH) 

Quantitative determination of T3, T4, TSH is done by Enzyme Linked Immunosorbent Assay. 

Serum albumin

USG Abdomen 

USG neck in patients with thyroid swelling.

Method of Collection of Data:

Cases were selected from the patients diagnosed with Chronic Kidney Disease, after taking consent, will be analyzed clinically and radiologically. All the patients selected for the study will be examined according to protocol, clinical and laboratory investigations will be carried. 

Informed Consent

All the patients fulfilling inclusion criteria were explained about the disease course, options of treatment, possible complications, prognosis and outcomes and a written informed consent was obtained before enrollment. They were informed of their right to withdraw from the study at any stage.

Link to complete thesis and master chart 

https://drive.google.com/file/d/1iAU8rAVl8jA3_82qXhWdiH7oQTye9qHz/view?usp=drivesdk