The influence of end-stage liver disease and liver transplantation on thyroid hormones

Prevalence of hyperthyroidism and hypothyroidism in liver transplant recipients and associated risk factors

The prevalence of hyperthyroidism and hypothyroidism and associated risk factors are unknown in liver transplant recipients. We aimed to determine the prevalence of hyperthyroidism and hypothyroidism and associated risk factors in liver transplant recipients and to compare it with controls from the general population. As part of the Danish Comorbidity in Liver Transplant Recipients (DACOLT) Study, all Danish liver transplant recipients over the age of 20 were invited for measurements of concentrations of thyrotropin and thyroid hormones. The prevalence of hyperthyroidism and hypothyroidism was compared to age- and sex-matched controls from the Copenhagen General Population Study. Using logistic regression adjusted for age, sex, smoking, and body-mass index, we investigated potential risk factors. We recruited 489 liver transplant recipients and 1808 controls. Among liver transplant recipients, 14 (2.9%) had hyperthyroidism compared with 21 (1.2%) of controls (adjusted odds ratio [aOR] 2.24, 95% confidence interval [CI] 1.05-4.75, P = 0.04), while 42 (5.7%) had hypothyroidism compared with 139 (7.7%) of controls (aOR 0.68, 95% CI 0.43-1.08, P = 0.10). Female sex, and autoimmune hepatitis and primary sclerosing cholangitis as causes of transplantation were associated with hyperthyroidism after adjustments. Age, female sex, and autoimmune liver diseases as cause of transplantation were associated with hypothyroidism after adjustments. DACOLT is registered in ClinicalTrials.gov (NCT04777032).

CONSTRUCTION AND VALIDATION OF A BUNDLE FOR EVALUATION OF THYROID FUNCTION IN PATIENTS WITH CIRRHOSIS

Thyroid dysfunction has been reported in association with several chronic diseases, including advanced liver disease. •The bundle discussed here is aimed at proposing systematic assistance according to the best evidence-based practices available. •The process of constructing and validating the bundle was carried out in the following stages: a) bibliographic survey; b) bundle elaboration; and c) content validation. •The bundle was considered valid to facilitate medical decision making, aiding physicians to manage, in a practical and effective manner, the thyroid function of patients with liver cirrhosis. Background - Thyroid dysfunction has been reported in association with several chronic diseases, including advanced liver disease. This disease and its management are often neglected in clinical practice. The bundle discussed here is aimed at proposing systematic assistance according to the best evidence-based practices available. Objective - To construct and validate a bundle to evaluate thyroid function in patients with liver cirrhosis. Methods - The process of constructing and validating the bundle was carried out in the following stages: a) bibliographic survey; b) bundle elaboration; and c) content validation. The bibliographic survey was carried out in an integrative review about evidence related with the thyroid function of patients with liver cirrhosis. The findings from the integrative review were considered as supporting evidence for the elaboration of the bundle. The tool then created used accessible language and was evidence-based, ensuring that information was based on current literature. Results - The bundle was restructured to provide guidance on the management of patients with liver dysfunctions, including: cirrhosis due to general causes, cirrhosis due to hepatitis C, non-alcoholic fatty liver disease, primary biliary cholangitis, and hepatocellular carcinoma. The orientations in the bundle included: exams to be requested to screen for thyroid disorders, and guidance about the treatment of these dysfunctions and their associated complications. We analyzed specialist evaluation of the bundle using the Content Validity Index (CVI). We carried out a binomial test to evaluate consistency and specialist agreement regarding the items in the bundle, considering values >0.61 as a good level. The items in the bundle were considered to be valid (CVI >0.80). The general CVI of the instrument was 0.95 (CI95%: 0.91-0.98). Conclusion - The bundle was considered valid to facilitate medical decision making, aiding physicians to manage, in a practical and effective approach, the thyroid function of patients with liver cirrhosis. This tool should not be used as a replacement for individual, evaluation of the physician providing assistance. We recommend the structured bundle to be added to medical practice, considering its simple application, low cost, and potential to contribute for the management of these patients.

Resolved Severe Primary Hypothyroidism in Sensenbrenner Syndrome Post Hepatorenal Transplantation: A Case Report

INTRODUCTION

Sensenbrenner syndrome, or cranioectodermal dysplasia (OMIM #218330), is a rare genetic condition inherited as an autosomal recessive with less than 70 reported cases worldwide. It results in multiorgan abnormalities along with ectodermal structural defects. No previous reported cases demonstrated primary hypothyroidism in a matter of Sensenbrenner syndrome.

CASE PRESENTATION

Herein, we report a 6-year-old girl who suffered from progressive liver failure and end-stage renal disease secondary to Sensenbrenner syndrome, which was associated with severe primary hypothyroidism that completely recovered after a combined renal and liver transplant.

CONCLUSION

For the first time in the literature, we report an association of Sensenbrenner syndrome with hypothyroidism that resolved after a combined renal and liver transplant. Such findings expand the clinical spectrum of this syndrome. However, a larger cohort is needed to confirm or exclude such an association. Our case highlights the importance of thyroid function monitoring in any patient with renal and liver failure prior to and after a hepatorenal transplant.

The impact of serum thyroid-stimulation hormone levels on the outcome of hepatitis B virus related acute-on-chronic liver failure: an observational study

Background

Thyroid dysfunction has been reported in severe liver diseases. The aim of this study was to analyze the impact of serum thyroid-stimulation hormone (TSH) levels on the prognosis of patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF).

Methods

This retrospective cohort study included 1,862 patients with HBV-related ACLF. Risk factors associated with 30-day and 90-day survival, hazard ratios (HRs), and 95% confidence intervals (CIs) for TSH were estimated using Cox proportional hazards regression. The Area Under the ROC curve (AUROC) analysis was carried out, and the cut-off values were calculated. After grouping by the cut-off value, survival was compared between the groups using the log-rank test. This study data is from the “Survival Cohort Study (SCS)”, which has been registered at ClinicalTrials.gov (NCT03992898).

Results

Multivariate analysis indicated that an elevated TSH level was a highly significant predictor for 30-day survival (HR = 0.743, 95% CI: 0.629–0.878, P < 0.001) and 90-day survival (HR = 0.807, 95% CI: 0.717–0.909, P < 0.001). The AUROC of TSH level for 30-day and 90-day mortality were 0.655 and 0.620, respectively, with the same best cut-off values of 0.261 µIU/mL. Log-rank test showed that the group with higher TSH level had higher 30-day (78.5%, 95% CI: 76.1%-80.9% vs. 56.9%, 95% CI: 53.4%-60.4%; P < 0.001) and 90-day survival rate (61.5%, 95% CI: 58.6%-64.4% vs. 42.8%, 95% CI: 39.3%-46.3%; P < 0.001). Similar findings were observed in subgroups analysis. After adjusting for age and other risk factors, the higher level of TSH remained associated with 30-day survival (HR = 0.602, 95% CI: 0.502–0.721, P < 0.001) and 90-day survival (HR = 0.704, 95% CI, 0.609–0.814, P < 0.001).

Conclusions

Serum TSH level significantly correlate with HBV-related ACLF patients’ survival and may be of value for predicting 30-day and 90-day survival of patients with HBV-related ACLF.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02406-7.

Low T3 syndrome as a prognostic factor in patients in the intensive care unit: an observational cohort study

OBJECTIVE

To assess euthyroid sick syndrome as a prognostic factor in patients in the intensive care unit; to detect factors that may affect mortality; and to develop an equation to calculate death probability.

METHODS

This was a longitudinal, observational, nonconcurrent cohort study developed in the intensive care unit of Fundação Santa Casa de Misericórdia do Pará. One hundred adults with no prior documented endocrinopathy were submitted to a 20mL blood sample collection for the measurement of thyroid stimulating hormone, free tetraiodothyronine, free triiodothyronine and reverse triiodothyronine.

RESULTS

Most patients were female, aged 20 to 29 years. Most patients who died were older (median age of 48 years), and euthyroid sick syndrome was present in 97.5% of them. Euthyroid sick syndrome was related to death, comorbidities, age and length of stay in the intensive care unit (median of 7.5 days).There was an association between lower thyroid stimulating hormone and death. Patients with free triiodothyronine levels below 2.9pg/mL were more likely to die; reverse triiodothyronine rates were above 0.2ng/mL in those who died. Free triiodothyronine had greater sensitivity and accuracy, and reverse triiodothyronine had greater specificity to predict mortality. Based on the results and cutoff points, a multiple logistic regression formula was developed to calculate the probability of death.

CONCLUSION

The main limitation of this study is the fact that it was conducted in a reference hospital for maternal and child care; therefore, there was a greater number of female patients and, consequently, a sampling bias existed. However, opportune measurement of free and reverse triiodothyronine levels in critical patients and application of the proposed equation are suggested.

The Pattern of Dyslipidemia in Chronic Liver Disease Patients

Introduction Patients with chronic liver disease are expected to report derangements in serum lipid profiles. Lipid profile monitoring is not a part of the routine management of these patients in our hospital. Few recent studies show how lipid profile varies with the severity of disease and should be considered in the management planning of such patients. The objective of this study was to determine the pattern of dyslipidemia in chronic liver disease patients. Materials and methods A cross-sectional study was conducted involving 171 patients of all genders aged between 18 years and 60 years presenting with chronic liver disease with disease severity graded on Child-Pugh class as A, B, and C. Lipid profile was acquired in all these patients and was compared across various subgroups. Individual serum lipid parameters were graded as normal, high, or very high. Each patient was required to provide written informed consent. Statistical Package for Social Sciences (SPSS) version 21.0 (IBM Corp. Armonk, NY) was used to analyze data statistically, taking a p-value of ≤0.05 as significant. Results The mean age of patients was 51.2±7.3 years. The male to female ratio came out to be 1.5:1, with 103 (60.2%) male and 68 (39.8%) female patients included in the study. The disease was classified as Child-Pugh A in 20 (11.7%) patients, Child-Pugh B in 67 (39.2%) patients, and Child-Pugh C in 84 (49.1%) patients. Forty-four (25.7%) patients were hypertensive while 62 (36.3%) were diabetic. The mean body mass index (BMI) of these patients was 25.9±2.4 kg/m2. Mean serum values among Child-Pugh A, Child-Pugh B, and Child-Pugh C of low-density lipoproteins (LDL) (113.15±14.08 vs. 95.58±14.25 vs. 53.46±5.90 mg/dl; p-value 0.001), high-density lipoproteins (HDL) (50.60±3.19 vs. 40.70±2.95 vs. 35.40±3.88 mg/dl; p-value 0.001), total cholesterol (174.20±17.33 vs. 164.00±17.82 vs. 128.64±24.73 mg/dl; p-value 0.001), and triglycerides (127.15±8.98 vs. 100.84±27.12 vs. 93.36±25.56 mg/dl; p-value 0.001) decreased significantly with increasing severity of disease. Nineteen (11.1%) patients had hyperlipidemia (serum values of two or more parameters above normal) while 152 (88.9%) patients had normal lipid profile. When stratified, no statistically significant difference was found in the frequency of hyperlipidemia across various subgroups based on the patient's gender, age, duration, and severity of the disease, BMI, or diabetic and hypertensive status. Conclusions A substantial proportion of patients with chronic liver disease had hyperlipidemia which varied with the severity of disease on Child-Pugh classification. Routine monitoring of the lipid profile of such patients is necessary for timely identification and management of dyslipidemia to improve the outcome of such patients. It also suggests an important role of lipid profile in the risk stratification and treatment of chronic liver disease patients and warrants further studies in this regard.

Can hypothyroidism be a protective factor for hepatocellular carcinoma in cirrhosis?

Despite many studies, the molecular mechanisms of hepatocellular carcinoma (HCC) development remain unclear. Thyroid hormone (TH) levels may vary in many chronic diseases including cirrhosis. The aim of this study was to evaluate TH status in patients with cirrhosis and HCC and to investigate the relationship between THs and HCC development.Five hundred seventy-seven patients with cirrhosis who applied to Demiroğlu Bilim University, Faculty of Medicine, Gastroenterology Department between 2004 and 2019 were included the study. Three hundred sixty-seven patients who applied to Internal Medicine Unit for general health check-up were included in the study as healthy control group. Demographic, laboratory, and imaging findings of study groups were retrospectively reviewed and recorded from hospital information system.In the cirrhosis group, 252 patients had HCC (43.67%), and 325 patients had non-HCC cirrhosis (56.33%). Free thyroxine (FT4) levels were higher in the control group than in the cirrhotic group but there was no significant difference (P = .501). Thyroid-stimulating hormone (TSH) and FT4 levels were similar between groups, while free triiodothyronine (FT3) levels were significantly different between HCC group, non-HCC cirrhosis group, and control group (P = .299 for TSH, P = .263 for FT4, P < .001 for FT3). FT3 levels were significantly higher in HCC group than non-HCC cirrhosis group, but significantly lower than control group (P < .05).Our study confirmed the presence of hypothyroidism in cirrhosis patients and clearly demonstrated a strong relationship between FT3 levels and HCC development.

Endocrine Diseases and the Liver: An Update

The endocrine system is a complex interconnected system of organs that control corporeal processes and function. Primary endocrine organs are involved in hormonal production and secretion but rely on a bevy of signals from the hypothalamic-pituitary axis and secondary endocrine organs, such as the liver. In turn, proper hepatic function is maintained through hormonal signaling. Thus, the endocrine system and liver are codependent, and diseases affecting either organs can lead to alterations in function within their counterparts. This article explores the hepato-endocrine relationship, including the effects on endocrine diseases on the liver.

Frequency of Thyroid Dysfunction in Patients With Diabetes Mellitus Before and After Liver Transplantation

BACKGROUND

There is mutual influence between the liver and thyroid hormone metabolism. Patients with diabetes mellitus (DM) also have an increased prevalence of thyroid disorders (TDs). The objectives of this study were to evaluate the frequency of TD before and after liver transplantation (LT) in a population of patients with DM as a whole and when categorized by sex.

MATERIALS AND METHODS

This was a retrospective study involving interview and medical record analysis of 46 consecutive patients followed at the diabetes mellitus and liver transplantation unit of a tertiary university hospital.

RESULTS

Of all patients, 76.1% were men with a median age of 60 years old (interquartile range: 56 to 65 years) and time since LT of 5 years (range, 0.6 to 9 years). Hypertension, hypercholesterolemia, hypertriglyceridemia, alcoholism, and smoking were present in 47.8%, 34.8%, 23.9%, 34.8%, and 30.4% of the patients, respectively. The most frequent immunosuppressant in use was tacrolimus (71.1%). TD was present in 4.3% and 13% before and after LT, respectively (P = .058). In women and men, these frequencies were 9.1% and 18.2% (P = .563), and 2.9% and 11.8% (P = .045), respectively.

CONCLUSIONS

Frequency of TD was high both before and after LT. After transplantation, prevalence of TD increased in men and differences between males and females almost disappeared. Further studies are needed to assess if screening for TD before and after LT in patients with DM might be beneficial, especially in men.

Significance of changes in thyroid and gonadal function in patients with chronic liver diseases

AIM: To investigate the changes in thyroid and gonadal function in patients with chronic liver diseases and to explore the relationship between serum thyroid and gonadal hormone levels and severity of chronic liver diseases.

METHODS: Serum thyroid and gonadal hormone levels were measured by chemiluminescence method in 162 male cases with chronic liver diseases. Patients with chronic liver diseases were divided into a cirrhosis group and a non-cirrhosis group, and cirrhosis was graded by Child-Pugh score (A, B, C).

RESULTS: Thyroid dysfunction was present in ~13% of patients with chronic liver diseases. Serum total T3 and free T3 levels in patients with chronic liver diseases were significantly lower than those of the control group (1.73 nmol/L ± 0.38 nmol/L vs 2.59 nmol/L ± 0.46 nmol/L, 4.09 pmol/L ± 1.35 pmol/L vs 5.23 pmol/L ± 1.56 pmol/L, P < 0.01). Cirrhotic patients had significantly lower serum total T3 and free T3 levels than non-cirrhotic patients (0.96 nmol/L ± 0.33 nmol/L vs 1.84 nmol/L ± 0.32 nmol/L, 3.02 pmol/L ± 1.10 pmol/L vs 4.33 pmol/L ± 1.42 pmol/L, P < 0.01). Serum total T3, T4 and free T3 and T4 levels in cirrhotic cases with Child-Pugh B or C grade were significantly lower than those of Child-Pugh A grade cases. Chronic liver diseases were more serious in patients with low T3 syndrome than in those without. Approximately 42% of patients with chronic liver diseases had secondary gonadal dysfunction. Serum testosterone levels were significantly lower and estrogen levels were significantly higher in patients with chronic liver disease than in the control group (4.36 ng/mL ± 2.12 ng/mL vs 7.85 ng/mL ± 3.31 ng/mL, 45.53 pg/mL ± 18.79 pg/mL vs 32.26 pg/mL ± 12.19 pg/mL, P < 0.01). Serum testosterone levels were significantly lower and estrogen levels were significantly higher in cirrhotic cases with Child-Pugh B and C grades than in Child-Pugh A grade cases. Chronic liver diseases were more serious in patients with secondary gonadal dysfunction than in those without.

CONCLUSION: Thyroid and gonadal dysfunction is present in patients with chronic liver diseases, so the determination of thyroid and sex hormones has important value for the evaluation of severity and prognosis of the disease.