Abstract #1405611: A Case Regarding Severe Hypothyroidism Which Complicated to De Novo Nephrotic Syndrome (Minimal Change Disease)

Abstract

Hypothyroidism is a condition of an under-reactive thyroid. More prevalent in women, 10% exhibit some degree of thyroid insufficiency. It has numerous metabolic effects and may have an impact on renal physiology and worsening kidney function. Hypothyroidism was cited in certain case studies as a contributing factor to minimal change disease, which we will be highlighting here. We report a case of an 82-year-old female with PMH of graves’ disease status post left thyroidectomy in 2009 and was started on Levothyroxine, reported non-compliance, presented to the emergency department with a complaint of generalized edema mostly lower extremities that is progressively worsening over 2 weeks along with foamy urine. Unremarkable physical exam except for 2+ lower extremity pitting edema. On lab, high thyroid stimulating hormone (TSH) was 65.2 ulU/ml, normal Free Thyroxin (FT4) and low Free Triiodothyronine (FT3) 0.4 pg/ml, Serum Creatinine is 4.35 mg/dl, Urinalysis shows >500 protein, urine protein/Cr was 3, hypoalbuminemia and hyperlipidemia were present. A Glomerulopathy workup was initiated. She was admitted for further testing. Autoimmune kidney diseases were ruled out and a renal biopsy was performed, the specimen revealed Minimal change disease. She was started on Prednisone 60 mg daily and Levothyroxine 125 mcg. Three weeks later, patient showed a good response to therapy with an improvement of symptoms and repeated creatinine was 3.8. Hypothyroidism can be caused by partial or total thyroidectomy. As a highly lipophilic substance, Thyroxine binds to receptors that are expressed in cells all over the body to exhibit its physiological action. In patients with thyroidectomy, exogenous levothyroxine is the thyroid hormone supply to the body. Not having enough supply, can alter kidney function by affecting vascular resistance, re-absorptive process, and renal blood flow. It can also affect the RAAS system, beta-adrenergic receptors, and dopaminergic activation of the renal tubular cells. Gradual worsening of kidney function leads to an increase in the loss of free and bound thyroid hormones and eventually increases thyroxine requirement. GFR is reversibly reduced (by about 40%) in more than 55% of adults with hypothyroidism. Thyroxine treatment is effective by reducing edema, capillary permeability of albumin, and plasma colloid osmotic pressure. Proteinuria can sometimes be reversible by prompt initiation of thyroxine treatment. Also, the severity of symptoms plays a role in recovery. More research is needed to determine the relationship between hypothyroidism and nephrotic syndrome as only a few isolated occurrences were reported in the literature.