Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 106556

AbstractMaterial and MethodsResultsDiscussionConclusionAcknowledgementReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : SC10 - SC13 Full Version

Thyroid Function Status in Nephrotic Syndrome in Paediatric Age Group: A Hospital-based Cross-sectional Study


Published: December 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/59062.17369
Atish Kumar Basu, Arijit Chakraborty, Syamaprasad Sit, Jadab Kumar Jana, Swarupananda Maiti, Anusree Krishna Mandal

1. Postgraduate Trainee, Department of Paediatrics, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India. 2. Postgraduate Trainee, Department of Paediatrics, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India. 3. Associate Professor, Department of Paediatrics, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India. 4. Assistant Professor, Department of Paediatrics, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India. 5. Assistant Professor, Department of Paediatrics, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India. 6. Postgraduate Trainee, Department of Paediatrics, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India.

Correspondence Address :
Dr. Jadab Kumar Jana,
Hironmoy Pati Campus, Mirbazar, Medinipore-721101, West Bengal, India.
E-mail: jadabjana69@gmail.com

Abstract

Introduction: Nephrotic syndrome, being one of the common glomerular diseases in the paediatric population, is characterised by massive proteinuria and has a negative impact on thyroid function, necessitating investigation.

Aim: To assess the status of thyroid function in nephrotic syndrome in the paediatric age group.

Materials and Methods: This descriptive cross-sectional study was carried out at Bankura Sammilani Medical College and Hospital (BSMCH) in Bankura, West Bengal, India. The study included 100 children of both sexes, aged one to eight-year-old who had nephrotic syndrome, either newly diagnosed or relapsed, and who were either hospitalised to the Paediatric Department or visited an Outpatient Department (OPD), between April 2020 and September 2021. Thyroid hormone profiles, as well as, other relevant investigations, were estimated in all children. Data was analysed using the Epi-Info (version 3.5.1) software.

Results: Out of 100 children, 64% were males and the rest, 36%, were females. The mean age of presentation was 4.31±1.90 years. A total of 62% of them had a higher serum level of Thyroid Stimulating Hormone (TSH). Low levels of thyroxine (T4) and triiodothyronine (T3) were observed in 56% and 54% of cases, respectively. The serum albumin and serum TSH levels showed a significant negative correlation (r=-0.249, p=0.013). While T3 had a significant positive correlation (r=0.221, p=0.027), serum levels of T4 had a positive correlation (r=0.187), but turned out to be statistically insignificant (p=0.063).

Conclusion: It was found that, 62% of the children having nephrotic syndrome, also had increased levels of TSH. Serum T4 and T3 levels were low in 54% and 56% of the study population, respectively, necessitating further investigation.

Keywords

Hormone, Proteinuria, Thyroxine, Triiodothyronine

Nephrotic syndrome is a common renal disorder in the paediatric population. It is a glomerular disease, characterised by nephrotic-range proteinuria, which is proteinuria greater than 3.5 g/24 hour or a urine protein: creatinine ratio greater than 2, along with the triad of clinical findings associated with it resulting from large urinary protein losses are hypoalbuminaemia (≤2.5 g/dL), oedema, and hyperlipidaemia (cholesterol greater than 200 mg/dL) (1). Urinary albumin losses are not entirely compensated by increased hepatic synthesis in children with nephrotic syndrome, thus, leading to hypoalbuminaemia. Many other proteins, in addition to albumin, are also excreted in the urine of patients with proteinuria, some of them being hormones and hormone-binding proteins. The substantial urinary losses of thyroid hormones and Thyroxin-Binding Globulin (TBG) have widely been found in patients with proteinuria and validated by several publications (2),(3),(4),(5). In patients with nephrotic syndrome, thyroid hormone loss can result in lower free thyroid hormone levels unless there is also a simultaneous increase in production under the influence of TSH. Also, the loss of albumin and TBG may decrease thyroid hormone binding fractions, resulting in lower total T4 and T3 levels (6). Thyroid hormones regulates the function of various organ systems, including the urinary system. Thyroid hormones are considered indispensable for the renal growth and development along with regulation of fluid and electrolyte homeostasis (7),(8). According to the researchers, hypothyroidism is associated with decreased glomerular infiltration, hyponatremia, and changes in urine osmolality (9),(10). The primary paediatrician rarely considers hormonal disorders, particularly thyroid disorders caused by excessive protein loss through urine, when treating children with nephrotic syndrome. As a result, subclinical or overt hypothyroidism remains undiagnosed, even though, researchers have known about it for a long-time (11). It is known that, a chronic hypothyroid condition can cause physical growth and developmental issues. As a result, in terms of the paediatric age group, early detection and treatment of such disorders are critical. Considering this issue, present study was planned to investigate the thyroid function status, in children with nephrotic syndrome.

Material and Methods

This descriptive cross-sectional study was conducted in the Department of Paediatrics, BSMCH, Bankura, West Bengal, India, from April 2020 to September 2021. Before the commencement of the present study, ethical clearance from the concerned Institutional Ethical Committee (IEC) had been obtained (No. BSMC/Aca: 381, dated February 4, 2020).

Inclusion criteria: A total of 100 children of either sex, aged one to eight-year-old with nephrotic syndrome, either newly diagnosed or relapsed, and those who were admitted to the Paediatric Department, as well as, those who attended the OPD, during the study period, were included in the present study after taking consent from either parents or guardians. Children with onset of uncomplicated nephrotic syndrome between one and eight years of age are likely to have steroid-responsive minimal change nephrotic syndrome, and steroid therapy may be initiated without a diagnostic renal biopsy. Renal biopsy was not feasible in the study Institution, which is why this particular age group was selected.

Exclusion criteria: Children with derangement of hypothalmo-pituitary axis, thyroid disorders; chronic infections like tuberculosis, diabetes mellitus, cystic fibrosis; malabsorption syndromes, moderate to severe protein energy malnutrition; chronic renal or hepatic diseases; steroid-resistant nephrotic syndrome; and those parents/guardians, who did not give consent were excluded from the present study.

Sample size calculation: A minimum sample size of 100 participants were estimated using modified Cochran’s formula; with a 95% confidence interval, a margin of error of 10%, a 68% prevalence of thyroid disorder in children with nephrotic syndrome, as reported by Hajizadeh N et al., and a further 10% increment to decrease type II error (12).

Along with relevant investigations like urine analysis, Complete Blood Count (CBC), Renal Function Test (RFT), serum electrolytes, Liver Function Test (LFT), and lipid profile, the thyroid hormones (T4 and T3) and TSH levels, were estimated to fulfill the inclusion criteria. TSH=0.5-5.5 mIU/L, T4=5.5-13.5 μg/dL, and T3=90-260 ng/dL were considered normal thyroid profile levels. Upon diagnosis of nephrotic syndrome, all children were put on treatment with prednisolone, as per existing standard protocol. All information regarding the demographical profile, detailed clinical examination, and review of medical records of all study populations, were put into the predesigned proforma.

Statistical Analysis

Collected data was entered into a Microsoft Excel Spreadsheet and analysed with Epi-Info (version 3.5.1) software. Continuous variables were expressed as mean±Standard Deviation (SD), whereas categorical variables as percentages and ratios. A Pearson’s correlation coefficient (linear regression) test was performed to find out the correlation between serum albumin and thyroid hormone levels. A p-value <0.05 was set as statistically significant.

Results

There were 100 children, with a male to female ratio of 1.78:1. The mean age of presentation was 4.31±1.90 years. Children aged four to six-year-old were affected the most (Table/Fig 1). All the children came from the countryside.

Out of 100 participants, 17% of the cases were found to have urinary tract infection and no one had haematuria. Specific gravity and pH in all the participants were within normal limits, whereas granular cast was present in 100% of the cases (Table/Fig 2).

The total serum protein (g/dL) and albumin (g/dL) were 4.54±0.50 and 2.04±0.31, respectively and were lower than normal value. The total cholesterol (mg/dL) level was 282.5±14.20 which was higher than the normal value (<200). The serum urea (mg/dL), creatinine (mg/dL), sodium (mEq/L), and potassium levels (mEq/L) were 18.66±6.27, 0.48±0.12, 136.47±0.89, and 3.67±0.10 respectively, and were considered as normal values (Table/Fig 3) The normal values of various parameters are shown in tables (13).

The mean haemoglobin (gram/dL) level was 10.15±0.85, which was in the anaemic range. About 11% and 18% of the participants were found to be erythropenic and microcytic, respectively. There was no significant leucocytosis or thrombocytopenia (Table/Fig 4).

The mean serum TSH (mIU/L) level was 9.01±5.25, which was well above the upper cut-off value (0.5-5.5 mIU/L) for the cohort and total serum T4 (μg/dL) and T3 (ng/dL) levels were 5.21±1.57 and 89.08±20.63, respectively, and which are just below the lower limit of normal reference values (Table/Fig 5).

The Pearson’s correlation coefficient (linear regression) test was performed, to find out the relationship between serum albumin with serum thyroid hormones (T4 and T3), and TSH levels (Table/Fig 6). There was a significant negative correlation (r=-0.249) between serum albumin level and TSH. Whereas, serum albumin with T4 (r=0.187) and T3 (r=0.221) showed a positive correlation. From this observation, it was concluded that, in nephrotic syndrome, urinary loss of albumin along with other macromolecules such as TBG, transthyretin, T3 and T4 is associated with decreased serum thyroid hormones level, which in turn stimulates TSH secretion from anterior pituitary gland via hypothalamic thyroid releasing hormone by positive feedback mechanism.

Discussion

Thyroid dysfunction is fairly common in children with nephrotic syndrome and may also be affected by the specific type of renal pathology. The interactions between thyroid and renal function and the intricacies involved may pose treatment challenges and hence, require proper cooperation between endocrinologists and nephrologists. The present study showed variably affected thyroid dysfunction with respect to TSH, T4 and T3 levels. T4 and T3 serum levels of 5.5-13.5 g/dL and 90–260 ng/dL, respectively, are being used as normal reference values in the study population (14). The findings of the present study, were comparable to those of Ebadi A et al., and Gattoo I et al., who reported thyroid dysfunction in children with nephrotic syndrome to have low T4 and T3 levels but high TSH levels during the active phase (15),(16). Sharma M et al., found that T3 and T4 readings were normal during active disease, while TSH values were elevated (17). In the present study, population with nephrotic syndrome, the mean serum levels for TSH were high, and that of T4 and T3 were both low. In a study of 85 nephrotic children aged 2-12 years, Pelletier J et al., also reported that the mean value of TSH during nephrosis was higher than the usual level (18). In their studies, Gilles R et al., and Junglee NA et al., observed that nephrotic syndrome is associated to abnormalities in serum thyroid hormone levels (6),(19). In addition, Afroz S et al., determined that urinary losses of different binding proteins in nephrotic syndrome leads to transient subclinical hypothyroidism, with serum T3 and T4 levels in the normal range during and after attack, while the levels of TSH increases (2). Thyroid hormonal alterations may be caused by urinary loss of several macromolecules and binding proteins, including TBG, transthyretin, or prealbumin, and albumin, resulting in a decrease in serum total thyroxin and, in certain cases, total T3 levels which was observed in present study. These shifts in various hormone levels may also be related to the duration of proteinuria.

A definite correlation between serum albumin levels and serum TSH, T4, and T3 levels was further observed. It was found that, the serum level of TSH had a negative correlation (r=-0.249) with serum albumin levels, whereas T4 and T3 have a positive correlation. There are several studies conducted by different authors, which showed a negative correlation between serum albumin and serum TSH in nephrotic syndrome (20),(21). Because tests for the urinary levels of TSH, T4, T3, and free T4 were not done, it was not possible to ascertain the mechanism by which the risk of hypothyroidism increased with the onset of nephrotic syndrome. However, in the presence of massive proteinuria, substantial loss of free and protein-bound hormones in urine may be a major risk factor for hypothyroidism. According to observations of the present study, there was a statistically significant correlation between serum albumin and serum TSH, as well as, serum T3 levels at the onset of nephrotic syndrome, but not with serum T4, implying that other factors such as T4 to T3 conversion ability and thyroid compensatory mechanisms due to nephrotic syndrome may be involved besides urinary loss. Renal tubule injury, which reduces Low Molecular Weight (LMW) protein reabsorption and can disrupt thyroid functions, is well established. Furthermore, when Glomerular Filtration Rate (GFR) diminishes, the incidence of hypothyroidism increases (22),(23). The mean serum total protein (g/dL) and albumin (g/dL) levels observed in the present study were 4.54±0.50 and 2.04±0.31, respectively.

Limitation(s)

The first one was that the thyroid hormone status was investigated, only during the active phase of nephrotic syndrome and not during remission. So, the status of the thyroid function in remission could not be evaluated, to see, whether it remits with resolution of proteinuria or not. Second, due to a lack of facilities in our esteemed Institution, authors could only measured total serum T4 and T3, but not free T4 and free T3, as well. Third, the urinary levels of TBG, T4, and T3 were not measured. Hence, urinary protein losses could not be correlated with urinary thyroid hormone excretion.

Conclusion

It was found that, 62% of the study population had high serum levels of TSH. It was also observed that serum T4 and T3 levels were low in 54% and 56% of the study population, respectively. Hence, this abnormal thyroid function must be addressed right from the beginning because if it persists even after remission, it will cause several physiological and developmental changes in the child population. To address such preventable physiological changes, in-depth evaluation of the thyroid functions, both during the active phase and in remission is recommended.

Acknowledgement

The IEC approval is duly acknowledged. The authors, would like to express their profound gratefulness to the Department of Biochemistry, for their generous help and contribution to the study.

References

1.
Erkan E. Nephrotic syndrome. In: Kliegman RM, Blum NJ, Shah S, St Geme III JW, Taskar RC, Wilson KM, Behrman RE. Nelson Text Book of Pediatrics, 21st eds, Elsevier, 2020;2752-60.
2.
Afroz S, Khan AH, Roy DK. Thyroid function in children with nephrotic syndrome. Mymensingh Med J. 2011;20(3):407-11.
3.
Abd El-Aal, Hegab A, Masoud E. Thyroid function in children with nephrotic syndrome: A prospective hospital-based study. Sohag Medical Journal. 2020;24(2):153-57. [crossref]
4.
Choudhury J. A study on thyroid function test in children with nephrotic syndrome. Int J Contemporary Pediatrics. 2016;3(3):752-54. [crossref]
5.
Jain D, Aggarwal HK, Pavan Kumar YM, Jain P. Evaluation of thyroid dysfunction in patients with nephrotic syndrome. Med Pharm Rep. 2019;92(2):139-44. [crossref] [PubMed]
6.
Gilles R, Heijer M, Ross AH, Sweep FC, Hermus AR, Wetzels JF. Thyroid function in patients with proteinuria. Neth J Med. 2008;66(11):483-85.
7.
Basu G, Mohapatra A. Interactions between thyroid disorders and kidney disease. Indian J Endocrinol Metab. 2012;16(2):204-13. [crossref] [PubMed]
8.
Campbell AG, McIntosh N. Endocrine gland disorders in Klenar CJ, Forfar and Areil’s text book of paediatrics. 4th ed. London New York and Tokyo: Campbell, AG, and McIntosh N; 1992.
9.
Kelly G. Peripheral metabolism of thyroid hormones: A review. Alternative Medicine Review. 2005;5(4):306-33.
10.
Sawant SU, Chandran S, Almeida AF, Rajan MG. Correlation between oxidative stress and thyroid function in patients with nephrotic syndrome. Int J Nephrol. 2011;2011:256420. [crossref] [PubMed]
11.
Trouillier S, Delèvaux I, Rancé N, André M, Voinchet H, Aumaître O. Nephrotic syndrome: Don’t forget to search for hypothyroidism. Rev Med Interne. 2008;29(2):139-44. [crossref] [PubMed]
12.
Hajizadeh N, Marashi S, Nabavizadeh B, Elhami E, Mohammadi T, Nobandegani M, et al. Examine of thyroid function in pediatric nephrotic syndrome. Tehran-Iran. International Journal of Pediatrics. 2015;3(2.1):59-65.
13.
Andropoulos DB. Pediatric Normal Laboratory Values. In: Gregory GA, Andropoulos DB. Gregory’s Pediatric Anaesthesia, 5th eds, Blackwell Publishing Ltd., 2012, 1300-1314.
14.
Wassner AJ, Smith JR. Hypothyroidism. In: Kliegman RM, Blum NJ, Shah SS, St Geme III JW, Taskar RC, Wilson KM, et al. Nelson Textbook of Pediatrics, 21st eds, Elsevier, 2020, 2914-2922. [crossref]
15.
Ebadi A, Yadollahpour A, Shirali S, Daneghian S, Saki S. Evaluating thyroid function in pediatric nephrotic syndrome: A study conducted in Ahvaz, Iran. Int J Pharm Res Allied Sci. 2016;5(2):82-85.
16.
Gattoo I, Aziz A, Latief M, Nazar BA. Thyroid function in pediatric nephrotic syndrome: A hospital based observational study. Int J Adv Res. 2015;3(5):500-05.
17.
Sharma M, Sharma R, McCarthy ET. The FSGS factor: Enrichment and in vivo effect of activity from focal segmental glomerulo-sclerosis plasma. J Am Soc Nephrol. 2011;10:552-53. [crossref] [PubMed]
18.
Pelletier J, Bruening W, Kashtan CE. Germline mutations in the Wilms’ tumor suppressor gene are associated with abnormal urogenital development in Denys–Drash syndrome. Cell. 1991;67(2):437-47. [crossref] [PubMed]
19.
Junglee NA, Scanlon MF, Rees DA. Increasing thyroxine requirements in primary hypothyroidism. Don’t forget the urinanalysis. Journal of Postgradraduate Medicine. 2006;52:201-03.
20.
Ito S, Kano K, Ando T, Ichimura T. Thyroid function in children with nephrotic syndrome. Pediatr Nephrol. 1994;8:412-15. [crossref] [PubMed]
21.
Guo QY, Zhu QJ, Liu YF, Zhang HJ, Ding Y, Zhai WS, et al. Steroids combined with levothyroxine to treat children with idiopathic nephrotic syndrome: A retrospective single-center study. Pediatr Nephrol. 2014;29:1033-38. [crossref] [PubMed]
22.
Lo JC, Chertow GM, Go AS, Hsu CY. Increased prevalence of subclinical and clinical hypothyroidism in persons with chronic kidney disease. Kidney Int. 2005;67:1047-52. [crossref] [PubMed]
23.
Rhee CM. The interaction between thyroid and kidney disease: An overview of the evidence. Curr Opin Endocrinol Diabetes Obes. 2016;23:407-15. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/59062.17369

Date of Submission: Jul 13, 2022
Date of Peer Review: Sep 08, 2022
Date of Acceptance: Oct 21, 2022
Date of Publishing: Dec 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 15, 2022
• Manual Googling: Oct 14, 2022
• iThenticate Software: Oct 20, 2022 (11%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com