Thyroid hormones for acute kidney injury

Abstract

Acute kidney injury (AKI), which is common in hospitalised patients, is associated with significant morbidity and mortality. Despite recent advances in treatment, AKI outcomes have not changed substantially during the past four decades, and incidence is increasing. There is an urgent need to explore novel therapeutic agents and revisit some older drugs to review their roles in the management of AKI. Although thyroid hormone therapy has shown promise in experimental animal studies, clinical efficacy and safety have not been systematically assessed for the management of people with AKI. To evaluate the benefits and harms of thyroid hormones for the treatment of hospitalised adults with AKI of any aetiology. We searched the Cochrane Renal Group's Specialised Register, CENTRAL, MEDLINE, and EMBASE. We also checked the reference lists of retrieved studies and articles.Date of search: November 2012 Randomised controlled trials (RCTs) and quasi-RCTs (in which allocation to treatment was obtained by alternation, use of alternate medical records, date of birth or other predictable methods) that compared any dose or form of thyroid hormone therapy alone or in combination with other agents compared with placebo or supplemental treatment (such as furosemide, dopamine, or atrial natriuretic peptide) in adult AKI patients. Two authors independently assessed study quality and extracted data. The quality of included studies was assessed using the Cochrane Collaboration's risk of bias assessment tool. For dichotomous outcomes (death, need for renal replacement therapy (RRT), progression to end-stage kidney disease (ESKD)), we planned to express results as risk ratios (RR) with 95% confidence intervals (CI). Where continuous scales of measurement were used to assess the effects of treatment (length of hospital stay, durations of AKI and RRT), we planned to use the mean difference (MD). Two studies, enrolling 97 participants, met our inclusion criteria. The studies differed significantly in terms of study populations, natural history of AKI (multifactorial AKI in patients with native kidneys versus delayed graft function associated with acute tubular necrosis in transplant recipients), and study interventions; hence, data were not meta-analysed. One study reported a significant increase in the risk of all-cause mortality associated with thyroid hormone interventions compared with placebo (59 participants, RR 3.32, 95% CI 1.21 to 9.12); no deaths were reported in the other study. Both studies reported no significant difference in the need for RRT associated with thyroid hormone therapy when compared to placebo. Neither study reported incidence of progression to ESKD. There was a significantly longer duration of AKI (MD 2.00 days, 95% CI 0.18 to 3.82) and RRT (5.00 days, 95% CI 2.05 to 7.95) associated with thyroid hormone therapy compared with placebo in one study; no differences in durations of AKI (MD 2.00 days, 95% CI -3.53 to 7.53) and RRT (MD 2.00 days, 95% CI -2.36 to 6.36) were noted in the other study. One study reported similar lengths of stay in the intensive care unit and hospital in both intervention and control arms (MD -0.20 days, 95% CI -8.17 to 7.77); the other did not report this outcome. No adverse events were noted to be associated with thyroid hormone therapy in either study. Adequate data were not available to assess changes in kidney function or numbers of RRT sessions. Both included studies were small and methodological quality was suboptimal. We found a paucity of large, high quality studies to inform analysis of thyroid hormone interventions for the treatment of people with AKI. Current evidence suggested that thyroid hormone therapy may be associated with worse outcomes for patients with established AKI; therefore, its use for these patients should be avoided. The role of thyroid hormone therapy in preventing AKI has not been adequately investigated and may be considered in future clinical studies.