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Chatzitomaris A, Hoermann R, Midgley JE, Hering S, Urban A, Dietrich B, Abood A, Klein HH, Dietrich JW. Thyroid Allostasis-Adaptive Responses of Thyrotropic Feedback Control to Conditions of Strain, Stress, and Developmental Programming. Front Endocrinol (Lausanne) 2017; 8:163. [PMID: 28775711 PMCID: PMC5517413 DOI: 10.3389/fendo.2017.00163] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 06/27/2017] [Indexed: 12/21/2022] Open
Abstract
The hypothalamus-pituitary-thyroid feedback control is a dynamic, adaptive system. In situations of illness and deprivation of energy representing type 1 allostasis, the stress response operates to alter both its set point and peripheral transfer parameters. In contrast, type 2 allostatic load, typically effective in psychosocial stress, pregnancy, metabolic syndrome, and adaptation to cold, produces a nearly opposite phenotype of predictive plasticity. The non-thyroidal illness syndrome (NTIS) or thyroid allostasis in critical illness, tumors, uremia, and starvation (TACITUS), commonly observed in hospitalized patients, displays a historically well-studied pattern of allostatic thyroid response. This is characterized by decreased total and free thyroid hormone concentrations and varying levels of thyroid-stimulating hormone (TSH) ranging from decreased (in severe cases) to normal or even elevated (mainly in the recovery phase) TSH concentrations. An acute versus chronic stage (wasting syndrome) of TACITUS can be discerned. The two types differ in molecular mechanisms and prognosis. The acute adaptation of thyroid hormone metabolism to critical illness may prove beneficial to the organism, whereas the far more complex molecular alterations associated with chronic illness frequently lead to allostatic overload. The latter is associated with poor outcome, independently of the underlying disease. Adaptive responses of thyroid homeostasis extend to alterations in thyroid hormone concentrations during fetal life, periods of weight gain or loss, thermoregulation, physical exercise, and psychiatric diseases. The various forms of thyroid allostasis pose serious problems in differential diagnosis of thyroid disease. This review article provides an overview of physiological mechanisms as well as major diagnostic and therapeutic implications of thyroid allostasis under a variety of developmental and straining conditions.
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Affiliation(s)
- Apostolos Chatzitomaris
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
- *Correspondence: Apostolos Chatzitomaris,
| | - Rudolf Hoermann
- Private Consultancy, Research and Development, Yandina, QLD, Australia
| | | | - Steffen Hering
- Department for Internal Medicine, Cardiology, Endocrinology, Diabetes and Medical Intensive Care Medicine, Krankenhaus Bietigheim-Vaihingen, Bietigheim-Bissingen, Germany
| | - Aline Urban
- Department for Anesthesiology, Intensive Care and Palliative Medicine, Eastern Allgäu-Kaufbeuren Hospitals, Kaufbeuren, Germany
| | | | - Assjana Abood
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
| | - Harald H. Klein
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
- Ruhr Center for Rare Diseases (CeSER), Ruhr University of Bochum and Witten/Herdecke University, Bochum, Germany
| | - Johannes W. Dietrich
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
- Ruhr Center for Rare Diseases (CeSER), Ruhr University of Bochum and Witten/Herdecke University, Bochum, Germany
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Dietrich JW, Müller P, Schiedat F, Schlömicher M, Strauch J, Chatzitomaris A, Klein HH, Mügge A, Köhrle J, Rijntjes E, Lehmphul I. Nonthyroidal Illness Syndrome in Cardiac Illness Involves Elevated Concentrations of 3,5-Diiodothyronine and Correlates with Atrial Remodeling. Eur Thyroid J 2015; 4:129-37. [PMID: 26279999 PMCID: PMC4521060 DOI: 10.1159/000381543] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 03/10/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although hyperthyroidism predisposes to atrial fibrillation, previous trials have suggested decreased triiodothyronine (T3) concentrations to be associated with postoperative atrial fibrillation (POAF). Therapy with thyroid hormones (TH), however, did not reduce the risk of POAF. This study reevaluates the relation between thyroid hormone status, atrial electromechanical function and POAF. METHODS Thirty-nine patients with sinus rhythm and no history of atrial fibrillation or thyroid disease undergoing cardiac surgery were prospectively enrolled. Serum concentrations of thyrotropin, free (F) and total (T) thyroxine (T4) and T3, reverse (r)T3, 3-iodothyronamine (3-T1AM) and 3,5-diiodothyronine (3,5-T2) were measured preoperatively, complemented by evaluation of echocardiographic and electrophysiological parameters of cardiac function. Holter-ECG and telemetry were used to screen for POAF for 10 days following cardiac surgery. RESULTS Seven of 17 patients who developed POAF demonstrated nonthyroidal illness syndrome (NTIS; defined as low T3 and/or low T4 syndrome), compared to 2 of 22 (p < 0.05) patients who maintained sinus rhythm. In patients with POAF, serum FT3 concentrations were significantly decreased, but still within their reference ranges. 3,5-T2 concentrations directly correlated with rT3 concentrations and inversely correlated with FT3 concentrations. Furthermore, 3,5-T2 concentrations were significantly elevated in patients with NTIS and in subjects who eventually developed POAF. In multivariable logistic regression FT3, 3,5-T2, total atrial conduction time, left atrial volume index and Fas ligand were independent predictors of POAF. CONCLUSION This study confirms reduced FT3 concentrations in patients with POAF and is the first to report on elevated 3,5-T2 concentrations in cardiac NTIS. The pathogenesis of NTIS therefore seems to involve more differentiated allostatic mechanisms.
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Affiliation(s)
- Johannes W. Dietrich
- Department of Endocrinology and Diabetes, Medical Hospital I, Berlin, Germany
- *Dr. Johannes W. Dietrich, Department of Endocrinology and Diabetes, Medical Hospital I, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bürkle-de-la-Camp-Platz 1, DE-44789 Bochum (Germany), E-Mail
| | - Patrick Müller
- Department of Cardiology and Angiology, Medical Hospital II, Berlin, Germany
- Heart Center Bad Neustadt, Clinic for Interventional Electrophysiology, Bad Neustadt an der Saale, Berlin, Germany
| | - Fabian Schiedat
- Department of Cardiology and Angiology, Medical Hospital II, Berlin, Germany
| | - Markus Schlömicher
- Department of Cardiac Surgery, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Berlin, Germany
| | - Justus Strauch
- Department of Cardiac Surgery, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Berlin, Germany
| | | | - Harald H. Klein
- Department of Endocrinology and Diabetes, Medical Hospital I, Berlin, Germany
| | - Andreas Mügge
- Department of Cardiology and Angiology, Medical Hospital II, Berlin, Germany
| | - Josef Köhrle
- Institut für Experimentelle Endokrinologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Eddy Rijntjes
- Institut für Experimentelle Endokrinologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ina Lehmphul
- Institut für Experimentelle Endokrinologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Dietrich JW, Stachon A, Antic B, Klein HH, Hering S. The AQUA-FONTIS study: protocol of a multidisciplinary, cross-sectional and prospective longitudinal study for developing standardized diagnostics and classification of non-thyroidal illness syndrome. BMC Endocr Disord 2008; 8:13. [PMID: 18851740 PMCID: PMC2576461 DOI: 10.1186/1472-6823-8-13] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Accepted: 10/13/2008] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Non-thyroidal illness syndrome (NTIS) is a characteristic functional constellation of thyrotropic feedback control that frequently occurs in critically ill patients. Although this condition is associated with significantly increased morbidity and mortality, there is still controversy on whether NTIS is caused by artefacts, is a form of beneficial adaptation, or is a disorder requiring treatment. Trials investigating substitution therapy of NTIS revealed contradictory results. The comparison of heterogeneous patient cohorts may be the cause for those inconsistencies. OBJECTIVES Primary objective of this study is the identification and differentiation of different functional states of thyrotropic feedback control in order to define relevant evaluation criteria for the prognosis of affected patients. Furthermore, we intend to assess the significance of an innovative physiological index approach (SPINA) in differential diagnosis between NTIS and latent (so-called "sub-clinical") thyrotoxicosis.Secondary objective is observation of variables that quantify distinct components of NTIS in the context of independent predictors of evolution, survival or pathophysiological condition and influencing or disturbing factors like medication. DESIGN The approach to a quantitative follow-up of non-thyroidal illness syndrome (AQUA FONTIS study) is designed as both a cross-sectional and prospective longitudinal observation trial in critically ill patients. Patients are observed in at least two evaluation points with consecutive assessments of thyroid status, physiological and clinical data in additional weekly observations up to discharge. A second part of the study investigates the neuropsychological impact of NTIS and medium-term outcomes.The study design incorporates a two-module structure that covers a reduced protocol in form of an observation trial before patients give informed consent. Additional investigations are performed if and after patients agree in participation. TRIAL REGISTRATION ClinicalTrials.gov NCT00591032.
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Affiliation(s)
- Johannes W Dietrich
- Medical Hospital 1, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, NRW, Germany
| | - Axel Stachon
- Institute of Clinical Chemistry, Transfusion and Laboratory Medicine, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, NRW, Germany
| | - Biljana Antic
- Klinik für Innere Medizin, Evangelisches Krankenhaus Hattingen, Hattingen, NRW, Germany
| | - Harald H Klein
- Medical Hospital 1, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, NRW, Germany
| | - Steffen Hering
- Medical Hospital 1, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, NRW, Germany
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