CRF（慢性肾功能衰竭）患者甲减如何处理
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主题：CRF患者甲减如何处理？
作者：zhbc
发布时间：2002-02-27 12:02
帖子内容：
慢性肾功能衰竭（CRF)患者表现为尿少，浮肿。贫血，高血压等，同时检测到甲状腺功能明显低下，请问该类病人除了针对肾衰治疗外，是否需要甲状腺素替代治疗？
答复：
zhbc, 你好！为了回答你的问题，我们查了一些资料，尤其是国外的资料，现汇总编译成一短文，希望对你能有所帮助。
急性阑尾炎7对甲状腺功能的影响可以表现为多种方式，包括甲状腺激素水平降低，激素代谢发生改变，载体蛋白受到影响和甲状腺中碘含量增高等等。血浆中T3和T4都有可能减少。血透和腹透时甲状腺素的流失是少量的，常不需要替代治疗。肾衰病人血清中无机碘和甲状腺中碘含量增加，常伴有甲状腺肿大。实验表明通过给予小剂量的LT3来替代治疗时，肾衰病人往往表现为氮平衡失调，白氨酸流失和蛋白质退化降解。因此，尿毒症患者出现甲低是体内为了避免蛋白质流失的代偿反应，试图纠正甲状腺素的做法可能加剧蛋白质的营养失衡。（1）
肾功能正常的甲低病人常伴有可逆转的血清肌氨酸酐的升高。目前对较严重的甲低治疗时导致血清肌氨酸酐显著减低的情况还很少见于报道。Nakahama H等报道了2例急性阑尾炎7病人在治疗甲低时导致明显而持续的血清肌氨酸酐水平的降低。（2）
网编译
注：以上答复仅供参考，不做为临床治疗的依据。
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参考文献：
1. Am J Kidney Dis 2001 Oct;38(4 Suppl 1):S80-4
Thyroid function in patients with chronic renal failure.
Lim VS.
Nephrology Division, Department of Internal Medicine, University of Iowa Hospitals, Iowa City, IA, USA. victoria-lim@uiowa.edu
[Abstracts]
Chronic renal failure affects thyroid function in multiple ways, including low circulating thyroid hormone concentration, altered peripheral hormone metabolism, disturbed binding to carrier proteins, possible reduction in tissue thyroid hormone content, and increased iodine store in thyroid glands. Both plasma triiodothyronine (T(3)) and thyroxine (T(4)) are reduced. The low serum T(3) is not due to increased T(3) degradation or to decreased thyroidal T(3) secretion but is a result of impaired extrathyroidal T(4) to T(3) conversion. The reduction in T(4) is attributed to the presence of circulating inhibitors, which impair binding of T(4) to thyroxine-binding globulin. Despite decreased circulating T(4) and T(3), thyroid-stimulating hormone (TSH) is not elevated. This absence of TSH elevation is not due to dysfunction of the hypothalamo-pituitary axis, because truly hypothyroid renal failure patients can mount a high TSH response. Thyroid hormone losses during hemodialysis and peritoneal dialysis are trivial and do not require replacement. Serum inorganic iodide and thyroidal iodine content are increased in renal failure patients, and thyroid gland enlargement is frequently encountered. Experiments performed to correct the low serum T(3) level by administration of small doses of LT(3) to renal failure patients resulted in lesser nitrogen balance, greater leucine flux, and protein degradation. We speculate that the low thyroid state in uremia serves to defend against protein wasting and that misguided attempts to replete thyroid hormone stores may worsen protein malnutrition.
Publication Types:
Review
Review, Tutorial
PMID: 11576928 [PubMed - indexed for MEDLINE]
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2.Nephron 2001 Jul;88(3):264-7
Treatment of severe hypothyroidism reduced serum creatinine levels in two chronic renal failure patients.
Nakahama H, Sakaguchi K, Horita Y, Sasaki O, Nakamura S, Inenaga T, Takishita S.
Division of Hypertension and Nephrology, National Cardiovascular Center, Suita, Japan. hnakaham@hsp.ncvc.go.jp
Short-term hypothyroidism has been associated with a reversible rise in serum creatinine levels in patients with normal renal function. A remarkable decline in serum creatinine levels associated with a treatment of severe and prolonged hypothyroidism has rarely been reported so far. We present here 2 patients with chronic renal failure in whom treatment for hypothyroidism resulted in a significant and sustained reduction of their serum creatinine levels. These cases indicate that because hypothyroidism may aggravate the serum creatinine levels, TSH should be considered in screening procedures of patients with chronic renal failure presenting with recent accelerated aggravation of renal function. Hypothyroidism per se, one of its complications or one of its associated autoimmune diseases might play a role in modifying the underlying renal problem. Copyright 2001 S. Karger AG, Basel
PMID: 11423759 [PubMed - indexed for MEDLINE]
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3. Nephron 2000 Mar;84(3):267-9
Exacerbation of renal failure due to hypothyroidism in a patient with ischemic nephropathy.
Makino Y, Fujii T, Kuroda S, Inenaga T, Kawano Y, Takishita S.
Division of Hypertension and Nephrology, Department of Medicine, National Cardiovascular Center, Suita, Osaka, Japan.
A case of acute-on-chronic renal failure in a 70-year-old woman with ischemic nephropathy and primary hypothyroidism is presented. Her renal function became progressively worse as the level of serum creatinine increased from 283 to 628 micromol/l (3.2-7.1 mg/dl) within 8 months. Her thyroid function had been normal before the exacerbation of renal failure, but it was markedly reduced with a marked elevation of serum thyroid-stimulating hormone. Thyroid hormone replacement therapy resulted in rapid improvement of the renal function to 159 micromol/l (1.8 mg/dl) of serum creatinine. The development of primary hypothyroidism seemed to worsen the already impaired renal function in this case. We suggest the assessment of thyroid function in patients with unexplained deterioration of renal failure. Copyright 2000 S. Karger AG, Basel
PMID: 10720898 [PubMed - indexed for MEDLINE]
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4. Acta Paediatr 1999 Jul;88(7):715-7
Moderate renal failure in association with prolonged acquired hypothyroidism in children.
Al-Fifi S, Girardin C, Sharma A, Rodd C.
Department of Pediatrics, Montreal Children´s Hospital, Canada.
We evaluated five children with prolonged primary hypothyroidism and noted a significant reduction in renal function (40%), which was reversible with hormonal replacement. This decline was higher than reported in adults and was of sufficient magnitude to warrant altering drug-dosing schedules. Furthermore, patients with moderately reduced renal function should be carefully evaluated for signs and symptoms of hypothyroidism.
PMID: 10447128 [PubMed - indexed for MEDLINE]
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5. Perit Dial Int 1998 Sep-Oct;18(5):516-21
Thyroid dysfunction and nodular goiter in hemodialysis and peritoneal dialysis patients.
Lin CC, Chen TW, Ng YY, Chou YH, Yang WC.
Department of Medicine, Veterans General Hospital-Taipei, Taiwan, Republic of China.
OBJECTIVE: To investigate the prevalence of nodular goiter and thyroid dysfunction in uremic patients undergoing hemodialysis (HD) and peritoneal dialysis. DESIGN: Cross-sectional study. SETTING: Single dialysis unit and outpatient clinic. PATIENTS: The study included 221 patients [143 HD and 78 continuous ambulatory peritoneal dialysis (CAPD) patients] along with 135 consecutively selected outpatients as controls. MAIN OUTCOME MEASURES: Ultrasonography was used to detect patients´ thyroid function and nodular goiter. RESULTS: Nodular goiter was detected in 54.8% of the uremic patients and in 21.5% of the controls. Uremic patients had higher prevalence of thyroid dysfunction, which included reduced serum concentration of total T3, total T4, and free T4, and increased serum level of TSH. Hypothyroidism was also observed more frequently in uremic patients than in the control group (5.4% vs 0.7%, p < 0.05). Nodular goiter was more frequently found in females than in males (63.5% vs 48%, p < 0.05). Moreover, the prevalence of nodular goiter increased with age (p < 0.02) in uremic patients. Hemodialysis patients had a higher frequency of reduced total T3 level (46.9% vs 29.5%, p < 0.02). However, CAPD patients had lower T4 levels (6.23+/-1.82 microg/dL vs 7.15+/-1.99 microg/dL, p < 0.05). CONCLUSION: Because of the high incidence of hypothyroidism and nodular goiter in uremic patients, screening of thyroid function and goiter detection with ultrasound should be considered in evaluation of end-stage renal disease patients.
PMID: 9848631 [PubMed - indexed for MEDLINE]
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6. Medicine (Baltimore) 1988 May;67(3):187-97
The thyroid in end-stage renal disease.
Kaptein EM, Quion-Verde H, Chooljian CJ, Tang WW, Friedman PE, Rodriquez HJ, Massry SG.
Department of Medicine, University of Southern California, Los Angeles.
Previous studies of patients with end-stage renal disease (ESRD) indicate that the prevalence of goiter varies from 0 to 58% while that of hypothyroidism ranges from 0 to 9.5%. In addition, altered serum thyroid hormone levels are present in euthyroid patients with ESRD and may be related to nonthyroidal disorders including malnutrition. To examine these issues further, 306 patients with ESRD were compared to 139 hospitalized patients without renal disease (control population). Goiter was present in 43% with ESRD compared to 6.7% of controls (P less than 0.001). Goiter frequency was greater (49.6%, P = 0.047) and serum parathyroid hormone levels higher (mean: 238.6 microlitersEq/ml, P less than 0.001; normal: less than 15 microlitersEq/ml) in 115 patients dialyzed for longer than 1 year than in 191 dialyzed for less than 1 year or not at all (38.7%, and 61.5 microlitersEq/ml, respectively). In addition, goiter was more common in females (50.0%) than in males (35.1%, P = 0.008) with ESRD. No significant relationships were observed between goiter frequency and age, race, diabetes mellitus, or elevated antimicrosomal antibody titers. The prevalence of primary hypothyroidism was higher in ESRD (2.6%) than in 2122 in- and out-patients (1.1%) (P = 0.024). Compared to the total group of ESRD patients, the hypothyroid patients were predominantly female (88% vs. 50%) and had a higher frequency of positive antimicrosomal antibody titers (50% vs. 6.7%, P = 0.029). The frequency of hyperthyroidism was not significantly different, being 1.0% in ESRD compared to 0.3% in the general population (P = 0.057). There was a higher frequency of reduced free T4 index values in the 287 euthyroid patients with ESRD (12.9%) than in controls (3.6%) (P = 0.002). Similarly, free T3 index values were reduced below 100 in 65.5% with ESRD compared to 33.8% of controls (P less than 0.001). In addition, serum albumin levels were lower in euthyroid patients with ESRD (3.5 g/dl, P less than 0.001) than in controls (3.8 g/dl). Serum T3 levels correlated directly with both serum albumin (r = 0.57, P less than 0.001) and transferrin (r = 0.54, P less than 0.001) levels in ESRD as well as in controls (r = 0.74, P less than 0.001, and r = 0.69, P less than 0.001, respectively).(ABSTRACT TRUNCATED AT 400 WORDS)
PMID: 3259281 [PubMed - indexed for MEDLINE]
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7. Clin Nephrol 1986 Jan;25(1):11-4
Primary hypothyroidism in chronic renal failure.
Rao MB, Bay WH, George JM, Hebert LA.
Serum thyroid hormone concentrations have been measured in 8 patients with chronic renal failure (CRF) who are currently enrolled on a chronic hemodialysis program. Three of these patients were diagnosed to be suffering from coexistent primary hypothyroidism whereas the other 5 were considered euthyroid. There was a variable decline in serum thyroid hormone levels in both groups. However, the serum TSH response to TRH was normal or blunted in the euthyroid group but was characteristically brisk in subjects with CRF and coexistent primary hypothyroidism. The TRH test may be useful in the diagnosis of primary hypothyroidism coexistent with CRF.
PMID: 3082548 [PubMed - indexed for MEDLINE]
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8. Clin Nephrol 1983 Apr;19(4):172-8 Related Articles, Books, LinkOut
Thyroid status in patients with chronic renal failure.
Beckett GJ, Henderson CJ, Elwes R, Seth J, Lambie AT.
Serum thyroid hormone concentrations have been measured in 21 patients with chronic renal failure, treated conservatively and compared with values from 19 control subjects. Many patients had serum total T3 and T4 concentrations below the reference ranges. The concentrations of free T4 and free T3 and the free thyroxine index were significantly lower in patients with abnormal total concentrations of the thyroid hormones than in the controls. Both the free and the total concentrations of T4 correlated inversely with the degree of renal failure. The concentration of thyroxine binding globulin (TBG), fell within the reference range in each of the patients, but was significantly lower in the patient group when compared with the controls. These TBG concentrations, however, were not sufficiently decreased to explain the low total thyroid hormone concentrations found in the patients. The affinity of TBG for T4 and T3 in the patient and control groups was not significantly different. The TSH response to TRH was diminished in many of the patients, but the measurement of other pituitary hormones indicated that pituitary function was normal in these patients. The possible mechanisms responsible for the changes observed in thyroid and pituitary hormones are discussed.
PMID: 6851253 [PubMed - indexed for MEDLINE]
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