title: Toxic multinodular goiter in a patient with end-stage renal disease and hemodialysis.
abstract: The management of symptomatic hyperthyroidism in patients with end stage renal disease (ESRD) is challenging because of altered clearance of medications and iodine with dialysis; moreover, many patients meeting these criteria are medically fragile. A 77-year-old man with type 2 diabetes and ESRD requiring hemodialysis, with dilated cardiomyopathy and paroxysmal atrial fibrillation, was found to have subclinical hyperthyroidism. Over a 2-year period he became clinically hyperthyroid with serum TSH level of <0.05 mIU/L and free T4 level of 4.3 ng/dL, attributed to toxic multinodular goiter. Despite antithyroid medication, he developed rapid ventricular rate from his atrial fibrillation that resulted in decompensated heart failure and multiple hospitalizations. His hyperthyroidism was successfully controlled with high dose methimazole and potassium iodide treatment, which were eventually discontinued after prolonged use. Nearly 6 months off medications, his hyperthyroidism recurred but was readily resolved when methimazole was restarted. Hyperthyroidism in the medically fragile ESRD patient may precipitate emergent conditions. Antithyroid medications are effective and should be considered as primary therapy for the treatment of hyperthyroidism in patients with hemodialysis. Moreover, clinical guidelines for the characterization and management of individuals with ESRD and subclinical hyperthyroidism should be developed.
authors.affiliation: University of Hawai'i, John A. Burns School of Medicine, Department of Medicine, Honolulu, HI.
authors.forename: Edison
authors.initials: E
authors.lastname: So
authors.affiliation: University of Hawai'i, John A. Burns School of Medicine, Department of Medicine, Honolulu, HI.
authors.forename: Richard
authors.initials: R
authors.lastname: Arakaki
mesh_terms: D000368:Aged; D006044:Goiter, Nodular / Q000188:drug therapy*; D006801:Humans; D007676:Kidney Failure, Chronic; D008297:Male; D006435:Renal Dialysis; D013971:Thyrotoxicosis / Q000188:drug therapy*
references.citation: Clin Pharmacokinet. 1985 Sep-Oct;10(5):443-50
references.pmid: 4042519
references.citation: Eur J Endocrinol. 2009 Apr;160(4):503-15
references.pmid: 19095779
references.citation: Am J Kidney Dis. 1998 Apr;31(4):698-700
references.pmid: 9531189
references.citation: Endocr Rev. 1996 Feb;17(1):45-63
references.pmid: 8641223
references.citation: Clin J Am Soc Nephrol. 2008 Sep;3(5):1296-300
references.pmid: 18550654
references.citation: Perit Dial Int. 1998 Sep-Oct;18(5):516-21
references.pmid: 9848631
references.citation: Semin Dial. 2004 Jan-Feb;17(1):53-6
references.pmid: 14717812
references.citation: Am J Nephrol. 1985;5(4):292-5
references.pmid: 4050889
references.citation: Artif Organs. 2005 Apr;29(4):329-32
references.pmid: 15787628
references.citation: J Fam Pract. 2013 Apr;62(4):E1-2
references.pmid: 23570035
references.citation: N Engl J Med. 2005 Mar 3;352(9):905-17
references.pmid: 15745981
references.citation: Eur J Clin Pharmacol. 1980 Apr;17(4):295-9
references.pmid: 6156842
references.citation: Clin Exp Nephrol. 2004 Mar;8(1):71-4
references.pmid: 15067521
references.citation: Nephrol Ther. 2010 Jul;6(4):251-4
references.pmid: 20488772
references.citation: J Clin Endocrinol Metab. 2012 Aug;97(8):2653-60
references.pmid: 22577172
references.citation: Arch Intern Med. 1987 Apr;147(4):785-6
references.pmid: 3827468
references.citation: Arch Intern Med. 1980 May;140(5):708-9
references.pmid: 7396599