Elevated basal and abnormal thyrotropin-releasing hormone-induced thyroid-stimulating hormone secretion in chronic alcoholic men with liver disease

Thyroid hormone levels in children with liver cirrhosis awaiting a liver transplant

OBJECTIVES

Evidence exists that decreased in triiodothyronine (T3) and thyroxine (T4) levels are associated with the severity of liver disease, and these hormones could be used as disease prognostic factors, but there are paradoxes in this regard in the literature. This study aimed at evaluating the correlation between thyroid hormone levels and severity of liver disease.

MATERIALS AND METHODS

We measured thyroid hormone levels in 83 children with liver cirrhosis using radioimmunoassay techniques.

RESULTS

Four patients (4.8%) showed a decrease in the amount of T3 and 9 patients (10.8%) revealed increased levels of T3. Also, decreases were seen in the T4 levels of 7 patients (8.4%), and 4 patients (4.8%) showed increases in levels of T4. The serum albumin levels were lower and international normalized ratio was higher in patients with low T3 and low T4. This study reveals that the Model for End-Stage Liver Disease and Pediatric End-Stage Liver Disease scores are statistically related to the decreased amounts of T4 (P = .036). The Model for End-Stage Liver Disease and Pediatric End-Stage Liver Disease scores and the Child scores were higher in low T3 patients, but this was not significant (P > .05).

CONCLUSIONS

Decreased levels of thyroid hormones are correlated with the severity of disease and can be seen in more advanced cirrhosis. Patients with decreased T4 levels need a liver transplant more immediately than those patients that do not have decreased T4 levels.

Increase of serum triiodothyronine concentration in soldiers with combat-related chronic post-traumatic stress disorder with or without alcohol dependence

BACKGROUND

Post-traumatic stress disorder (PTSD) is a relatively new psychiatric disorder with three clusters of symptoms: trauma re-experiencing, avoidance, and increased arousal. The condition develops after a person sees, is involved in, or hears of an extreme traumatic stressor such as war, torture, natural catastrophe, assault, rape, or serious accident. PTSD is also often comorbid with other psychiatric disorders, especially with alcohol dependence. Several hormonal alterations have been reported in veterans with combat-related PTSD, including elevations in certain thyroid hormones, e.g., total T3; however, previous studies have not controlled for alcohol dependence, a common comorbid psychiatric disorder in this population.

OBJECTIVE

The first aim of our study was to assess possible differences in basal serum levels of free triiodothyronine (FT3), total triiodothyronine (TT3), free thyroxine (FT4), total thyroxine (TT4), and thyroid stimulating hormone (TSH) in Croatian soldiers with combat-related chronic PTSD alone or comorbid with alcohol dependence and in healthy controls. The second purpose of the study was to determine any correlation between duration of combat activities, number of combat traumas, intensity and duration of PTSD symptoms, and serum levels of TT3, FT3, TT4, FT4, and TSH in this sample.

METHOD

We analyzed basal serum FT3, TT3, FT4, TT4, and TSH concentrations in soldiers with combat-related chronic PTSD (N=43), combat-related chronic PTSD comorbid with alcohol dependence (N = 41), and in healthy controls (N = 39) using a luminoimmunochemical assay.

RESULTS

Soldiers with chronic combat-related PTSD with or without comorbid alcohol addiction had significantly higher values of TT3 than the control group (F = 19.556, p<0.01). There was a significant correlation between TT3 levels and number of traumatic events in both the PTSD group (r=0.663, p<0.01) and those with PTSD comorbid with alcohol dependence (r=0.836, p<0.01). There was also a significant correlation between TT3 levels and symptoms of increased arousal in both PTSD (r=0.419, p<0.01) and PTSD comorbid with alcohol dependence (r=0.516, p<0.01).

CONCLUSION

Elevated concentrations of serum TT3 are associated with combat-related PTSD, regardless of its comorbidity with alcohol dependence, and also with the number of traumatic events and symptoms of increased arousal. Given that current pharmacotherapy for PTSD is inadequate, reduction of TT3 may be a new strategy for pharmacologic intervention that could contribute to more effective treatment of this disorder.

Etiopathogenesis of depression in patients with alcoholism: role of changes in thyroid function

Alcoholism poses a significant risk for the development of depression. Alcohol abuse and dependence significantly affect thyroid function. Considerable evidence suggests that minor changes in thyroid function may affect mood and behavior. The author suggests that alcohol-induced changes in thyroid function may contribute the development of depression in patients with alcoholism. Probably, alcohol-induced alterations in thyroid function are not a sufficient cause of depression. Most likely, they work in concert with inherited, acquired, and environmental risk factors. Alcohol may be particularly damaging to the impaired thyroid gland. Studies of the interrelationships between alcoholism and depression may help elucidate the causes of both.

[Thyroid function tests in viral chronic hepatitis]

BACKGROUND

One hundred and twenty five patients with virus B or C chronic active hepatitis and postnecrotic cirrhosis and different degrees of liver dysfunction were studied.

AIM

1) To determine a thyroid hormonal profile; 2) to evaluate the prognostic value of these tests in relation to the progression of the disease and mortality; 3) compare these findings with Child-Pugh classification.

PATIENTS AND METHODS

The patients were divided in four groups: a) 31 with chronic active hepatitis; b) 41 with postnecrotic cirrhosis Child A; c) 35 with postnecrotic cirrhosis Child B and d) 18 with postnecrotic cirrhosis Child C. The protocol comprised serum measurements of albumin and bilirrubin, estimates of prothrombin time and clinical evaluation of ascites and encephalopathy, measurement of total serum triiodothyronine, thyroxine, thyroid-stimulating hormone, free thyroxine, reverse triiosothyronine, calculated rT3/T3 index (IrT3) and thyrotropin-releasing hormone test.

RESULTS

Total serum triiodothyromnine showed the most significant difference among the groups, gradually lower as the disease became more advanced (CAH: 149.2 +/- 42.3 ng/dL; PNC-A: 137.4 +/- 37.2 ng/dL; PNC-B: 88.0 +/- 28.4 ng/dL and PNC-C: 41.8 +/- 21.9 ng/dL). Low levels of T4 (4.5 +/- 2.0 micrograms/dL) and FT4 (0.7 +/- 0.4 ng/dL) and elevated levels of thyroid-stimulating hormone (7.2 +/- 11.5 microIU/mL), reverse triiosothyronine (60.8 +/- 52.1 ng/dL) and calculated rT3/T3 index (2.2 +/- 2.6) were more frequent in patients with postnecrotic cirrhosis Child C. Thyrotropin-releasing hormone test was normal in the majority of the patients.

CONCLUSION

The present study shows a positive relationship between the low serum levels of T3 and elevated serum levels of rT3 and IrT3/T3 with the degree of hepatic dysfunction according to the Child-Pugh classification.

Effects of thyrotropin-releasing hormone and metoclopramide on PRL secretion in normally cycling and amenorrheic alcoholic women

To assess the possible influence of alcoholism on the dopaminergic inhibitory control of prolactin (PRL) secretion, 10 mg of the dopaminergic antagonist metoclopramide (MTC), was injected i.v. in a group of eight healthy abstemious women (aged 28 +/- 6 (mean +/- S.E.) years) and in 16 aged-matched nondepressed female alcoholic subjects after 3-4 weeks of abstinence from alcohol. All normal controls and eight alcoholics had normal menstrual cycles and were tested in the early follicular phase (4-8 days), the remaining eight alcoholics were affected by amenorrhea (duration: 15 +/- 3 months). During the same period, all patients were also tested with TRH (200 micrograms in an i.v. bolus) to determine whether the pituitary PRL cell secretory capacity was preserved in alcoholics. The amenorrheic alcoholic group showed strikingly lower circulating estrogen levels than normally cycling groups. Similar basal PRL levels and PRL responses to TRH were observed in normal controls and normally cycling alcoholics, whereas basal and TRH-stimulated PRL levels were significantly higher in amenorrheic alcoholics. In contrast, the PRL response to MTC was significantly higher in cycling alcoholic patients than in normal controls and amenorrheic alcoholic subjects. However, when the statistical analysis of MTC test took into account the difference in estrogen levels among groups, the statistical differences in the PRL responses to MTC observed between normally cycling and amenorrheic alcoholics disappeared. These data suggest the presence of an enhanced dopaminergic inhibitory control of PRL secretion in 2-3 week abstinent alcoholics with normal menstrual cycles and normal circulating estrogen levels. In contrast, amenorrhea in abstinent alcoholics appears to be associated with an enhancement of PRL cell secretory activity.

Long-term observation of the hypothalamic-pituitary-thyroid (HPT) axis in alcohol-dependent patients

Thyroid hormone levels and thyrotrophin (TSH) were measured in 45 alcohol-dependent patients before detoxification and 8 days, 3 months and 6 months after detoxification, and compared to levels in healthy controls. Before detoxification, levels of thyroxine (T4) and thyroxine-binding globulin (TBG) were significantly reduced in patients compared with healthy controls, while triiodothyronine (T3), reverse T3, and TSH levels did not differ from those in healthy controls. During the entire observation period, free T4 (fT4) and free T3 (fT3) levels were slightly elevated compared with those in healthy controls. T4 and TBG levels increased significantly during the first week of abstinence. Severity of withdrawal symptoms was negatively correlated with the total T4 levels after 8 days of abstinence. Three months after detoxification, relapsers displayed significantly lower T4 and TBG levels compared with abstinent patients. The increase in T3 levels was most pronounced between 8 days and 3 months of abstinence in both relapsing and abstinent patients. Six months after detoxification, only abstinent patients could be assessed, and they displayed increased TBG and T3 levels compared to healthy controls. Our findings suggest a different time-course for T3 and T4 levels after detoxification in alcohol-dependent patients, and indicate that T4 levels after detoxification interact with withdrawal symptoms.

Hypothalamic-pituitary-thyroid (HPT) axis in chronic alcoholism. I. HPT axis in chronic alcoholics during withdrawal and after 3 weeks of abstinence

Thyroxine (T4), free T4 (fT4), triiodothyronine (T3), free T3 (fT3), reverse T3 (rT3), thyrotropin (TSH), thyroxine binding globulin (TBG), and T3 uptake were measured in 14 chronic alcoholics during withdrawal and after 21 days of abstinence. Results were compared with those of 16 healthy volunteers. During withdrawal, the fT4 and fT3 concentrations were subnormal, whereas the respective protein-bound fractions were normal. T4, T3, and TBG increased during the abstinence period, T3 and TBG being significantly higher than in normals at the second measuring time. T3 uptake values fell, but remained well within the normal range at both measuring times. During abstinence, the fT3 levels remained significantly lower than in healthy subjects. rT3 concentrations decreased, but not significantly. The TSH values were normal throughout. These results showed numerous abnormalities in the hypothalamic-pituitary-thyroid axis in alcoholics, the reasons for which are as yet unclear. The following possible interpretations are suggested: 1. The abnormally low serum fT3 and fT4 levels during withdrawal might reflect an increase in tissue uptake. 2. The increases in T4--and partly those in T3--during abstinence seem to reflect increased binding by TBG, the level of which rose markedly for reasons as yet unknown. 3. If increases in TBG during abstinence are taken into account, the decreases in rT3 concentrations may reach the level of statistical significance. These falls in rT3 concentrations may reflect an increase in rT3 metabolization (deiodination) in various tissues, including the CNS, leading to a reduction in serum rT3 bioavailability. 4. Factors such as liver disease, protein caloric malnutrition, and "psychological stress" do not fully explain all these abnormalities. A direct effect of ethanol on intracellular thyroid hormone metabolism and/or function seems conceivable.

Regulation of apo B mRNA expression in liver and intestine during liver regeneration induced by CCl4

Acute liver damage in CCl4-treated rats is accompanied by a decrease of the lipoprotein particles HDL and VLDL. However, once the regenerative process has occurred both lipoproteins increase to values higher than control. In this study we have further analyzed the molecular mechanism involved in the induction of the hyperlipidemia during liver regeneration in rats treated with CCl4. The expression of apolipoprotein (apo) B gene at the apo B mRNA editing level has been analyzed during the regenerative process of the liver. The percent of apo B-48 and apo B-100 mRNA was determined and compared to the plasma levels of LDL and VLDL. These results confirm the existence of two different hyperlipidemic stages during liver regeneration. Total apo B mRNA is increased in liver and intestine during both hyperlipidemic stages. The ratio of apo B-100/apo B-48 mRNA remains constant during the first hyperlipidemic stage but the serum levels of VLDL are decreased. Then once the regenerative process has occurred, the steady-state levels of total apo B mRNA remaining, increased with higher amounts of apo B-100 than apo B-48. At this experimental time point the high levels of total apo B mRNA correlate with serum levels of VLDL that are significantly higher than control. These results indicate that apo B gene expression is induced at the mRNA level in liver and intestine during liver regeneration affecting the apo B mRNA editing mechanism in a complex manner and suggest further regulation at the translational or post-translational level.

Behavioral and endocrine interactions between thyrotropin-releasing hormone and ethanol in normal human subjects

Thyrotropin-releasing hormone (TRH) has been shown to antagonize the depressant effects of ethanol in animals, but conflicting findings have been reported in humans. To test whether TRH counteracts any of a variety of ethanol-sensitive behavioral measures in normal human subjects and for an effect of ethanol on TRH-induced thyrotropin (TSH) and prolactin (PRL) response, we administered TRH (500 micrograms) or placebo over 1 min intravenously, 30 min after subjects had ingested 0.8 g/kg of ethanol or a placebo drink. Blood samples for TSH and PRL were drawn prior to and 15 and 30 min after injection. Eight male subjects were studied in a balanced, crossover design with each subject receiving placebo-placebo, TRH-placebo, placebo-ethanol, and TRH-ethanol. Whereas ethanol had significant and expected effects on subjective measures, memory, disinhibition, reaction time and time perception, TRH failed to counteract any ethanol effect, except for a small effect in one memory task. Similarly, no effect of ethanol on TRH-induced TSH or PRL response was found. Though the behavioral findings could be interpreted to indicate that TRH does not alter ethanol sensitive behaviors in humans it will be necessary to utilize higher dosages of TRH and/or TRH analogues before firmly drawing this conclusion.

TRH: behavioral and endocrine effects in man

1. The tripeptide TRH exerts a spectrum of biological activities in both animals and man. Some of these activities have been extensively studied, particularly in psychiatric patients. 2. Behaviorally, TRH appears to increase the sense of well-being, motivation, relaxation, and coping capacity in both normal subjects and patients with psychiatric and neurologic disease. These effects are not disease-specific; attempts to use TRH as a treatment tool have thus been disappointing. 3. Endocrinologically, administration of TRH stimulates the response of TSH; this response has been reported to be blunted in approximately 30% of patients with major depression. However, TSH blunting is not specific for depression, it has also been observed in a variety of other psychiatric conditions. 4. The relevance of these effects for psychiatry in general, and for psychoneuroendocrinology especially, is discussed in this review.

Thyroid and pituitary hormone responses to TRH in advanced nonalcoholic liver disease

Basal T4, T3, TSH, prolactin and growth hormone levels were determined in several groups: patients with postnecrotic cirrhosis with hepatocellular carcinoma (n = 14); patients with postnecrotic cirrhosis but without hepatocellular carcinoma (n = 26); cholangiolar carcinoma (n = 9); and normal controls age-matched to within 5 yr of the liver disease subjects studied. In addition, TRH stimulation (400 micrograms TRH) was performed; TSH, prolactin and growth hormone responses over a 180-min time interval were evaluated for each subject. The responses observed varied between liver disease groups. The presence or absence of hepatocellular carcinoma was found to determine, at least in part, the type of response observed. Similarly, the presence or absence of hepatic encephalopathy determined, and/or reflected, at least in part, the type of response observed. Finally, for purposes of continuity, basal and TRH-stimulated levels of TSH, prolactin, growth hormone, T4 and T3 are compared in 3 settings of cirrhosis: alcoholic, nonalcoholic postnecrotic cirrhosis, and postnecrotic cirrhosis with hepatocellular carcinoma.

[Thyroid hormones in women with liver cirrhosis]

Basal thyroid hormone levels were measured in 68 women with liver cirrhosis (LC) of different etiology (alcoholic n = 34, posthepatitic B n = 9, PBC n = 5, cryptogenetic n = 18, M. Wilson n = 2). In addition the rise of TSH after 400 micrograms TRH was measured in 23 women with LC and compared with the data obtained from 17 women of a control group. There was no difference of the median T4-concentrations (LC 8.0 micrograms/dl versus 7.2 micrograms/dl) but a significant correlation of T4 to the grade of decompensation of LC. In contrast of T4 there was a marked decrease of T3 in LC-patients (109 ng/dl versus 143 ng/dl) and a rise of reverse T3 (0.21 ng/ml versus 0.13 ng/ml). The decrease of T3 and rise of reverse T3 equally correlated to the severeness of LC. TBG concentrations fell according to the grade of decompensation of LC and T4/TBG-quotient exhibited no difference to the control data (0.51 both). Though basal thyroid hormones and TSH show euthyroidism the significant augmented TSH release after TRH (delta-TSH 7.0 versus 3.2 microU/ml) indicate a status of latent hypothyroidism. In alcoholic cirrhosis the degree of TSH release was much higher than in non alcoholic cirrhosis. Estradiol and estrone levels correlated significantly negatively to T4, T3, estrone negatively to TBG and positively to reverse T3 but not to TSH and TSH release. Otherwise TSH release correlated positively to estradiol. The thyroid status in women with liver cirrhosis does not differ from the thyroid hormone profile found in men with cirrhosis.

Ethanol feeding and thyroid hormone monodeiodination

Adult male rats were placed on a 3 week regimen of ethanol (as 20% of total calories) in a nutritionally adequate diet, and controls were matched equicalorically without ethanol. Serum measurements of T4, T3, FT4, rT3, and TSH were performed in both the fed and the fasted state (18 hours). In the fed state, serum hormone measurements did not differ between control and ethanol-treated rats. Overnight fasting had a significant effect in decreasing serum T3 level in both experimental and control rats and in decreasing serum T4 level in ethanol-treated animals; FT4 and rT3 levels were not affected. Fasting also decreased in vitro hepatic T4 to T3 production to an equivalent degree in control and ethanol-treated rats, but did not alter hepatic T4 to rT3 production rates in control animals. In the fed state, hepatic rT3 neogenesis in animals given ethanol declined relative to the levels observed in control fed rats; fasting restored the depressed rT3 neogenesis to the levels noted in the fed state. Because decreased rT3 production in ethanol-treated rats in the fed state could not be explained on the basis of a change in 5'-deiodinase activity, it is suggested that ethanol administered with a nutritionally adequate diet may inhibit hepatic rT3 generation by inhibiting T4(5)-deiodinase.

Ethanol inhibition of pituitary-thyroid axis: an effect secondary to nutritional deficiency

Ethanol as either 20% or 36% of total calories in a Lieber diet was administered to male rats. At these concentrations, ethanol consumption relative to body weight did not differ. Pair-fed controls were restricted to the amount of calories consumed by rats given ethanol. Under these conditions, a direct effect of ethanol on the hypothalamic-hypophyseal-thyroid axis could not be demonstrated. There were no differences between pair-fed control and ethanol treated rats in serum or pituitary TSH, TSH response to TRH, or T4 and T3 levels. On the other hand, in rats given ethanol as 36% of total calories ("36%" ethanol-treated), and in their pair-fed controls, a marked decrease in serum T4 levels occurred (25% and 30%), relative to the corresponding "20%" groups. The decreased T4 in the "36%" groups was associated with a pronounced fall in caloric intake, decreased serum TSH, and declines in adenohypophyseal and body weights -- all of which were of similar magnitude in experimental and control rats. Thus, inanition was probably the primary cause of reduced thyroid function in the "36%" groups. An interesting aspect of this change was the finding of no difference in serum T3 levels between pair-fed control and ethanol treated rats in the 36% and 20% groups despite the reduced T4 and caloric intake in 36% animals; the lack of decrease in T3 concentration in 36% animals may reflect augmented peripheral conversion of T4 to T3 or reduced T3 clearance.

The effects of alcohol on the endocrine system

Male hypogonadism is the best documented endocrine effect of chronic alcoholism. A reversible clinical syndrome resembling Cushing's syndrome has also recently been described in some chronic alcoholics. The pituitary-thyroid axis is relatively resistant to the effects of ethanol, although mild abnormalities in various thyroid tests are frequently noted in the presence of alcoholic liver disease.

Patterns of hypothalamic-pituitary-gonadal dysfunction in men with liver disease due to differing etiologies

The hypothalamic-pituitary-gonadal axis was evaluated in two groups of age-matched men with documented biochemical and histologic liver disease and compared to that of age-matched normal controls. Basal testosterone levels (p less than 0.05), spermatozoa concentrations (p less than 0.01), and seminal plasma volume (p less than 0.01) were reduced in the alcoholics studied with liver disease, but not the hemophiliacs with liver disease when compared to the normal controls. No difference in estradiol levels was noted between groups. Basal follicle-stimulating hormone and luteinizing hormone (LH) concentrations were increased (both p less than 0.01) in the alcoholics while only LH concentrations were increased (p less than 0.01) in the hemophiliacs compared to the normal controls. Gonadotropins (follicle-stimulating hormone and LH) and testosterone responses to clomiphene and to luteinizing hormone-releasing factor (LH only) in the alcoholic population studied, further distinguished the alcoholics from the hemophiliacs and the normal controls. The basal levels of the other anterior pituitary hormones (growth hormone and thyroid-stimulating hormone) as well as their provocative responses to thyrotropin-releasing hormone also distinguished the alcoholics from the hemophiliac population. Based upon these results, we propose that factors other than the liver disease per se are responsible for the disturbances of hypothalamic-pituitary-gonadal function observed in men with biochemically as well as histologically advanced stable liver disease.

Alcohol and sexual function

The pathophysiologic factors which either document or which have been shown to be responsible for not only the hypogonadism and feminization of chronic alcoholic men but also the loss of gonadal function with resultant defeminization of chronic alcoholic women are reviewed. Evidence is presented which suggests that alcohol abuse is associated with the production of a primary form of hypogonadism characterized by loss of endocrine and reproductive function of the gonads. Moreover, evidence is presented which suggests that alcohol abuse is associated with the production of an associated hypothalamic-pituitary defect in gonadotropin secretion which prevents appropriate enhancement of gonadotropin secretion in response to the primary gonadal injury. Finally, the factors which have been found to partially explain the feminization often seen in chronic alcoholic men with advanced liver disease are discussed individually and a composite mechanism incorporating each is presented.

Hormonal changes during alcohol intoxication and withdrawal

The endocrine effects of alcohol are briefly reviewed. Alcohol enhances glucose-induced insulin secretion and may thus cause reactive hypoglycemia. However, inappropriate insulin secretion is not the reason for alcohol-induced hypoglycemia in fasted subjects. The direct effects of alcohol in thyroid function in humans are small, although alcoholics often have low concentrations of thyroid hormones in their plasma because of liver damage. Alcohol increases cortisol secretion from adrenal cortex either by increasing ACTH secretion or, more probably, by directly stimulating the adrenals. Alcohol also increases aldosterone secretion. The production of epinephrine and norepinephrine by the adrenal medulla is increased during alcohol intoxication and withdrawal. Plasma testosterone concentration is decreased during hangover and during alcohol withdrawal. The decrease is due to direct effects of alcohol on the testes, because plasma LH concentration is increased simultaneously. Alcohol has no significant effect on the LRH-induced secretion of LH. Plasma growth hormone concentration is decreased during alcohol intoxication and increased during hangover. TRH-induced secretion of prolactin is increased during alcohol intoxication and inhibited during hangover and withdrawal. The last finding suggests that there is dopaminergic overactivity in hypothalamus during alcohol withdrawal.