International Journal of Contemporary Pediatrics

Choudhury J. Int J Contemp Pediatr. 2016 Aug;3(3):752-754

http://www.ijpediatrics.com pISSN 2349-3283 | eISSN 2349-3291

DOI: http://dx.doi.org/10.18203/2349-3291.ijcp20161865
Research Article

A study on thyroid function test in children with nephrotic syndrome

Jasashree Choudhury*

Department of Pediatrics, IMS and SUM Hospital, Kalinga Nagar, Bhubaneswar, Odisha, India

Received: 03 June 2016

Accepted: 07 June 2016

*Correspondence:
Dr. Jasashree Choudhury,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: This is a comparative study which was conducted to find out any impact of nephrotic syndrome on
status of thyroid hormone level in children with nephrotic syndrome.
Methods: Study was done from December 2014 to December 2015 at a tertiary care hospital in BBSR, Odisha. The
study was carried out in total of 60 children of age between 1-8 years out of which 30 children(N group) were
admitted for reason other than nephrotic syndrome(excluding known cases of thyroid disorder) and 30 children were
suffering from nephrotic syndrome (NS group). Thyroid hormone level (T3, T4 and TSH) was tested in all children.
Results: The T4 and T3 levels in nephrotic syndrome (NS group) patients were low. TSH level were high in NS
group. T4 level was low in NS group in comparison to N group which was statistically significant. Hypothyroidism
was found more in younger children <6 years of age in comparison to children >6 years which was statistically
significant.
Conclusions: This study concluded that incidence of hypothyroidism was more in children with nephrotic syndrome.

Keywords: Hypothyroidism, Nephrotic syndrome, T3, T4, TSH

INTRODUCTION thyroid hormone level and increase TSH level. So early

diagnosis of hypothyroidism must be made to prevent
Epstenin in 1917 first reported possibility of physical and mental retardation in children. Our study
hypothyroidism in nephrotic syndrome Thyroid was done to find out the thyroid status of children with
hormones are necessary for growth and development of nephrotic syndrome in comparison to children without
the kidney and for the maintenance of water and nephrotic children.
electrolyte homeostasis.1,2 Thyroid hormone in the
circulation is bound to proteins, mainly thyroid binding METHODS
globulin, prealbumin and albumin.3,4 Renal albumin
excretion is not compensated by increased liver albumin This comparative study was carried out on 60 children of
production in patients with nephrotic syndrome that lead age between 1-8 years of either sex at a tertiary care
to decreased albumin level.5 Several studies have shown hospital in BBSR, Odisha. Out of 60, 30 children (N
renal excretion of thyroid hormones and thyroid binding group) were admitted for reason other than nephrotic
globulin in subjects with nephrotic syndrome, but TSH, syndrome (excluding known cases of thyroid disorder)
free tri iodothyronine and free thyroxine level remain and 30 children were suffering from nephrotic syndrome
more or less normal.6 In some patients with sustained (NS group). Study was done from December 2014 to
nephrotic syndrome and prolonged proteinuria December 2015.
continuous excretion of TBG can reduce level of free

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 Choudhury J. Int J Contemp Pediatr. 2016 Aug;3(3):752-754

Patients with possible secondary causes of nephrotic between proteinuria and serum TSH and urinary T 4
syndrome, age <1 year, patients with levels. Mattoo TK et al has shown the existence of a
hypothalamopituitary axis derangement, pituitary tumors, hypothyroid state in some infants with nephrotic
grave’s disease, thyroid gland tumors, hashimottos syndrome. They recommended routine thyroid screening
disease, hypothyroidism or hyperthyroidism before the and early replacement therapy.8 Ito et al have studied
onset of nephrotic syndrome were excluded from the thyroid profile in children with untreated nephrotic
study. Written informed consent was taken from the legal syndrome and found massive urinary losses of T 4, T3
guardian or parent of all participants. A thorough history TBG, free T4 and free T3 in the untreated nephrotic
and elaborate clinical examination were done. children. These findings provide evidence of mild
Biochemical and other necessary investigations were hypothyroidism in children with untreated nephrotic
done to fulfill the criteria for diagnosis of nephrotic syndrome because of losses of T 4, T3 free T4 free T3 and
syndrome. Serum T3, T4 and TSH were measured in all TBG into the urine.9
60 children. Statistical analysis for each sub group was
done by ANOVA and represented as mean±standard B.U. Sawant et al in his study suggested that nephrotic
deviation. Data were analyzed using SPSS statistical syndrome patient have an increased risk of subclinical
softwere. hypothyroidism. Thyroid profile becomes normal when
the non-thyroid illness is resolved.10
RESULTS
Gilles et al reported that abnormalities in thyroid function
In our study we have compared thyroid profile of 30 are seen in patients with proteinuria. Specifically, TSH
normal children with 30 children with nephrotic levels were higher in patients with proteinuric renal
syndrome. Thyroid profiles in normal children were in diseases when compared with controls.11 Iglesias et al in
normal range. The T4 and T3 levels in in nephrotic his study concluded that proteinuria results in loss of
syndrome (NS group) patients were low. TSH level were thyroid hormone, stimulating TSH production. Thyroid
high in NS group. T4 level was low in NS group in function returns to the normal when the non-thyroid
comparison to N group which was statistically significant illness is resolved.12
(Table 1). Hypothyroidism was found more in <6 year
children in comparison to >6 year children which was Afroz S et al in 2011 found that mean value of
statistically significant (Table 2). stimulating hormone (TSH) was higher than normal level
during nephrosis. This study concluded that nephrotic
Table 1: Comparison of thyroid profile in both group. syndrome have a state of mild or subclinical
hypothyroidism during proteinuria although they are
Variable Group Mean ±SD p clinically euthyroid.13 Our findings suggest that nephrotic
N 1.83±0.34 syndrome patients have an increased risk of subclinical
T3 0.14 hypothyroidism particularly in younger children.
NS 1.48±0.14
N 8.24±1.25 Proteinuria results in loss of thyroid hormones, most
T4 0.01 probably caused by loss of thyroxine-blinding globulin.
NS 4.75±2.10
N 3.55±3.15
TSH 0.46 Kaptein et al in his study showed that nephrotic
NS 3.85±2.82
syndrome is associated with changes in serum TSH
levels.14 Urinary losses of binding proteins, such as TBG,
Table 2: Distribution of incidence of hypothyroidism
transthyretin or prealbumin, albumin, result in reduction
in patients in NS group.
in serum total thyroxine and sometimes, in total T3 levels.
These hormonal changes are related both to the degree of
Age in n=30 Hypothyroid state proteinuria and to serum albumin levels.
years n % n %
<6 years 12 40 7 58.33 Kapoor et al has studied children with nephrotic
>6 years 18 60 8 44.44 syndrome by checking serum levels of FT 3, FT4 and TSH
Total 30 100 15 50 in 20 children aged 1-16 years with steroid resistant
nephrotic syndrome (SRNS) and similar number of
DISCUSSION controls. They found an overt hypothyroidism with low
FT4 (normal values: 0.7-2.0 ng/mL) and elevated serum
Nephrotic syndrome causes changes in the concentrations TSH above reference values (0.45-mIU/L).15
of thyroid hormones primarily due to loss of protein in Hypothyroidism should be actively sought for in patients
the urine. Acute kidney injury and chronic kidney disease with nephrotic syndrome as it is a treatable complication
have notable effects on the hypothalamus-pituitary- which increases morbidity in children. Given the urinary
thyroid axis.7 Previous studies have reported that in losses of multiple proteins in addition to albumin, it is
nephrotic syndrome, thyroid hormone levels decrease important to monitor all children with nephrosis for
while serum thyroid stimulating hormone (TSH) levels secondary metabolic complications and to treat these
increase. Also several studies have found a correlation complications at the earliest.

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 Choudhury J. Int J Contemp Pediatr. 2016 Aug;3(3):752-754

CONCLUSION 7. Iglesias P, Diez JJ. Thyroid dysfunction and kidney

disease. Eur J Endocrinol. 2009;160:503-15.
We concluded from this study that nephrotic syndrome 8. Matto TK. Hypothyroidism in infants with nephrotic
commonly have a state of mild or subclinical syndrome. Pediatric Nephrology. 1994;8(6):657-9.
hypothyroidsm during proteinuria although they are 9. Ito S, Kano K, Ando T, Ichimura T. Thyroid
clinically euthyroid. This temporary hypothyroid state function in children with nephrotic syndrome.
improves with remission and needs no treatment in older Pediatr Nephrol. 1994;8(4):412-5.
children but early treatment may be considered in 10. Sawant BU, Nadkarni GD, Thakare UR, Joseph LJ,
younger children to prevent physical and mental sub Rajan MGR. Changes in lipid peroxidation and free
normality. radical scavengers in kidney of hypothyroid and
hyperthyroid. 2003:1334-7.
Funding: No funding sources 11. Gilles R, den Heijer M, Ross AH, Sweep FC,
Conflict of interest: None declared Hermus AR, Wetzels JF. Thyroid function in
Ethical approval: The study was approved by the patients with proteinuria. Netherlands J Med.
Institutional Ethics Committee 2008;66(11):483-5.
12. Iglesias P, Diez JJ. Thyroid dysfunction and kidney
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