Impact of thyroid dysfunction on erythropoietin dosage in hemodialysis patients

Association between roxadustat use and suppression of thyroid function: a systematic review and meta-analysis

BACKGROUND

Based on several case reports and observational studies, there is a growing concern regarding the potential association between roxadustat, a hypoxia-inducible factor prolyl-hydroxylase inhibitor, and suppression of thyroid function. In this systematic review and meta-analysis (PROSPERO: CRD42023471516), we aimed to evaluate the relationship between roxadustat use and suppression of thyroid function.

METHODS

We conducted a comprehensive search of MEDLINE via PubMed, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials databases using the search term "roxadustat" to identify all relevant studies. The study population comprised adults with renal anemia who participated in a randomized controlled trial or observational study, with roxadustat as the intervention and a placebo or erythropoiesis-stimulating agent (ESA) as the comparator. The primary outcome was suppression of thyroid function and the secondary outcome was hypothyroidism. A meta-analysis was conducted using the DerSimonian-Laird random effects model based on the size of the intention-to-treat population, and the odds ratio (OR) and 95% confidence interval (CI) were calculated. Two reviewers independently screened the articles, extracted data, and assessed studies using the ROBINS-I tool.

RESULTS

Of the six studies eligible for inclusion, a meta-analysis was performed using data from two observational studies comparing roxadustat and ESA. The meta-analysis showed that the incidence of suppression of thyroid function was significantly higher with roxadustat use than with ESA use (OR: 6.45; 95% CI: 3.39-12.27; I2 = 12%). Compared with ESA, roxadustat seemed to potentially increase the risk for suppression of thyroid function in patients with renal anemia.

CONCLUSIONS

Our findings highlighted the importance of monitoring thyroid function in patients treated with roxadustat. The results of this review may enhance the safety of using roxadustat to treat renal anemia through advance recognition of the risk for suppression of thyroid function.

A prognostic role for non-thyroidal illness syndrome in chronic renal failure:a systematic review and meta-analysis

BACKGROUND

Chronic renal failure (CRF) is a serious disease that has become a burden on global and local economics and public health. In addition, non-thyroidal illness syndrome (NTIS) has become increasingly more prevalent in CRF patients.

MATERIALS AND METHODS

A data search was conducted on the PubMed/Medline, Cochrane Library, Web of Science, Embase, and CBM databases to identify studies up to November 1st, 2018, that compared low T3 and normal T3 levels in patients with CRF. Data analysis was done by calculating the relative risks (RR) and 95% confidence intervals (95% CI) and continuous variables were described by weighted mean difference (WMD) and 95% CI. The efficacy outcomes included renal function and mortality. The Newcastle-Ottawa Scale and Agency for Healthcare Research and Quality scale were used to assess the quality of the cohort and cross-sectional studies, respectively. A funnel plot was used to identify publication bias.

RESULTS

Seventeen studies with a total of 4593 patients were finally included in the analysis. Among the 17 studies, 11 reported the mortality of CRF patients with low T3 and normal T3 levels. Subgroups were assigned according to different follow-up times and different methods of treatment. The mortality rate in the low T3 group was much higher than in the normal T3 group. 11 studies reported creatinine (Cr) results in patients with low T3 and normal T3 levels and our analysis found no significant differences between the two groups (95%CI: 0.46-0.25; P-heterogeneity = 0.000; P = 0.559). Five studies reported uric acid results and we found no significant differences between the two groups (95%CI: 0.08-0.22; P-heterogeneity = 0.438; P = 0.377). Five studies reported the urea levels in the two groups and our analysis found no significant differences (95%CI: 1.60-1.23; I² = 0.0%; P-heterogeneity = 0.498;P = 0.798).

CONCLUSION

Low T3 had a greater impact on the short-term prognosis of patients with CRF than on the long-term prognosis. NTIS did not cause substantial kidney damage.

High prevalence of subclinical hypothyroidism and nodular thyroid disease in patients on hemodialysis

Chronic kidney disease has been known to affect thyroid hormone metabolism. Low serum levels of T3 and T4 are the most remarkable laboratorial findings. A high incidence of goiter and nodules on thyroid ultrasonography has been reported in patients with end-stage renal disease (ESRD). Our objective is to evaluate the prevalence of laboratorial and morphologic alterations in the thyroid gland in a cohort of patients with ESRD on hemodialysis (HD). Sixty-one patients with ESRD on HD were selected and compared with 43 healthy subjects matched by age, gender, and weight. Patients were submitted to thyroid ultrasonography. T3, free T4 (FT4), thyroid-stimulating hormone, antithyroglobulin, and antithyroperoxidase antibodies were measured. The mean age of patients with ESRD was 47.4 ± 12.3 and 61% were women. ESRD was mainly caused by hypertensive nephrosclerosis and diabetic nephropathy. Mean thyroid volume, as determined by ultrasonography, was similar in both groups. Patients with ESRD had more hypoechoic nodules when compared with the control group (24.1% vs. 7.9%, P = 0.056). Mean serum FT4 and T3 levels were significantly lower in patients with ESRD, and subclinical hypothyroidism was more prevalent in patients with ESRD (21.82% vs. 7.14% control group, P = 0.04). Titers of antithyroid antibodies were similar in both groups. ESRD was associated with a higher prevalence of subclinical hypothyroidism and lower levels of T3 and FT4. Almost a quarter of patients showed thyroid nodules >10 mm. Periodic ultrasound evaluation and assessment of thyroid function are recommended in patients with ESRD on HD.

Thyroid functional disease: an under-recognized cardiovascular risk factor in kidney disease patients

Thyroid functional disease, and in particular hypothyroidism, is highly prevalent among chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients. In the general population, hypothyroidism is associated with impaired cardiac contractility, endothelial dysfunction, atherosclerosis and possibly higher cardiovascular mortality. It has been hypothesized that hypothyroidism is an under-recognized, modifiable risk factor for the enormous burden of cardiovascular disease and death in CKD and ESRD, but this has been difficult to test due to the challenge of accurate thyroid functional assessment in uremia. Low thyroid hormone levels (i.e. triiodothyronine) have been associated with adverse cardiovascular sequelae in CKD and ESRD patients, but these metrics are confounded by malnutrition, inflammation and comorbid states, and hence may signify nonthyroidal illness (i.e. thyroid functional test derangements associated with underlying ill health in the absence of thyroid pathology). Thyrotropin is considered a sensitive and specific thyroid function measure that may more accurately classify hypothyroidism, but few studies have examined the clinical significance of thyrotropin-defined hypothyroidism in CKD and ESRD. Of even greater uncertainty are the risks and benefits of thyroid hormone replacement, which bear a narrow therapeutic-to-toxic window and are frequently prescribed to CKD and ESRD patients. In this review, we discuss mechanisms by which hypothyroidism adversely affects cardiovascular health; examine the prognostic implications of hypothyroidism, thyroid hormone alterations and exogenous thyroid hormone replacement in CKD and ESRD; and identify areas of uncertainty related to the interplay between hypothyroidism, cardiovascular disease and kidney disease requiring further investigation.