AKUT KARACİĞER YETMEZLİĞİ OLAN ÇOCUKLARDA TİROİD HORMONLARININ VE HASTALIĞIN SEYRİ İLE İLİŞKİSİNİN DEĞERLENDİRİLMESİ

Yıl 2019, Cilt: 13 Sayı: 2, 87 - 94, 26.03.2019

Zeren Barış Oya Balcı Sezen Figen Özçay

https://doi.org/10.12956/tchd.507591

Öz

Giriş: Çalışmamızda akut
karaciğer yetmezliği ile başvuran çocuk hastalarda TSH, serbest T4 ve serbest
T3 düzeylerinin hastalık seyrini belirlemedeki etkilerini inceledik.

Gereç ve Yöntemler: Çalışmaya
hastanemize 2000-2017 yılları arasında akut karaciğer yetmezliği ile başvuran
108 hasta içerisinden, başvuru sırasında tiroid hormonları bakılmış olan 39
hasta alındı. Bu hastaların geriye dönük olarak klinik ve laboratuvar bulguları
değerlendirilerek, başvuru sırasındaki tiroid hormonları ile hastalığın seyri
arasındaki ilişki incelendi.

Bulgular: TSH
düzeyleri hastaların 29/39’unda (%74,4) normalden düşük, serbest T3 düzeyleri 27/29
hastada (%93,1) normalden düşük saptanmıştır. Serbest T4 düzeyleri ise
hastaların %69,4’sında (25/36 hasta) normal düzeylerde bulunmuştur. Hastalar,
hastalığın seyrine göre, kendiliğinden düzelen hastalar (Grup 1) ile
kaybedilen/nakil olan hastalar (Grup 2) olarak iki gruba ayrılmıştır. Grup
2’deki hastaların başvuru sırasında bakılan INR, total ve direk bilirubin
düzeyleri ve PELD skorları grup 1’deki hastalara göre istatistiksel olarak
anlamlı şekilde yüksek bulunmuştur (sırasıyla p=0,022,
p<0,0001, p=0,003, p=0,004).
TSH düzeylerinin ensefalopati evresi ve hemoglobin düzeyi arttıkça azaldığı
(sırasıyla p=0,003, r=-0,464 ve p=0,046, r=-0,367),
sT4 düzeylerinin ise serum albümin düzeyi arttıkça arttığı (p=0,005, r=0,459) saptanmıştır.

Tartışma: Akut
karaciğer yetmezliğinde, serum TSH ve sT3 düzeyleri baskılanmaktadır. Serum TSH
düzeyleri ensefalopati evresi ve hemoglobin düzeyi arttıkça azalmakta, sT4
düzeyleri ise serum albümin düzeyi arttıkça artmaktadır. 

Anahtar Kelimeler

akut karaciğer hastalığı, tiroid hormonları

EVALUATION of THE RELATIONSHIP BETWEEN THYROID FUNCTIONS and DISEASE OUTCOME in CHILDREN WITH ACUTE LIVER FAILURE

Öz

Objective: We
investigated if serum TSH, free T4 and free T3 could be prognostic factors in
patients with acute liver failure.

Materials and Methods: There
were 39 out of 108 children with acute liver failure who applied to our
hospital between 2000-2017 and whose thyroid function tests were measured at
the time of arrival. We retrospectively collected the clinical and laboratory
parameters of these 39 patients, and evaluated the relationship between thyroid
hormones and prognosis of the patients.

Results: TSH levels were low in
29/39 (74.4%) patients, while 27/29 (93.1%) patients had low fT3 levels. Free
T4 levels were normal in 25/36 (69.4%) patients. Patients were divided into two
groups according to disease course: group 1 (n=17) included patients with
spontaneous resolution and group 2 (n=22) included patients who either died or
underwent liver transplantation. Total and direct bilirubin levels, INR and
PELD values were significantly higher in group 2 compared to the levels of
group 1 (p=0.022, p<0.0001, p=0.003, p=0.004, respectively). Serum TSH
levels were found to decrease with increasing levels of hemoglobin levels and
with increasing stages of encephalopathy, and these correlations were
statistically significant (p=0.003, r=-0.464 and p=0.046, r=-0.367, respectively).
Serum free T4 levels were found to decrease significantly with decreasing
levels of serum albumin levels (p=0.005, r=0.459).

Conclusion: Serum
TSH and free T3 levels are suppressed in pediatric patients with ALF. Serum TSH
levels negatively correlates with increasing stages of encephalopathy, while
fT4 levels decrease with decreasing levels of serum albümin.

Anahtar Kelimeler

acute liver failure, thyroid hormones

Kaynakça

• 1. Özdemir S. Thyroid and liver. Cerrahpaşa J Med 2005;36:206-12.
• 2. Sheridan P. Thyroid hormones and the liver. Clin Gastroenterol 1983;12:797-818.
• 3. Wu Y, You S, Zang H, Liu H, Mao Y, Mao P et al. Usefulness of serum thyroid-stimulation hormone (TSH) as a prognostic indicator for acute-on-chronic liver failure. Ann Hepatol 2015;14:218-24.
• 4. Iervasi G, Pingitore A, Landi P, Raciti M, Ripoli A, Scarlattini M et al. Low-T3 syndrome: a strong prognostic predictor of death in patients with heart disease. Circulation 2003;107:708-13.
• 5. Friberg L, Werner S, Eggertsen G, Ahnve S. Rapid down-regulation of thyroid hormones in acute myocardial infarction: is it cardioprotective in patients with angina? Arch Intern Med 2002;162:1388-94.
• 6. Den Brinker M, Joosten KFM, Visser TJ, Hop WCJ, De Rijke YB, Hazelzet JA et al. Euthyroid sick syndrome in meningococcal sepsis: the impact of peripheral thyroid hormone metabolism and binding proteins. J Clin Endocrinol Metab 2005;90:5613-20.
• 7. Kostopanagiotou G, Kalimeris K, Mourouzis I, Kostopanagiotou K, Arkadopoulos N, Panagopoulos D et al. Thyroid hormones alterations during acute liver failure: possible underlying mechanisms and consequences. Endocrine 2009;36:198-204.8. Warner MH, Beckett GJ. Mechanisms behind the non-thyroidal illness syndrome: an update. J Endocrinol 2010;205:1-13.
• 9. Antonelli A, Ferri C, Pampana A, Fallahi P, Nesti C, Pasquini M et al. Thyroid disorders in chronic hepatitis C. Am J Med 2004;117:10-3.
• 10. Borzio M, Caldara R, Borzio F, Piepoli V, Rampini P, Ferrari C. Thyroid function tests in chronic liver disease: evidence for multiple abnormalities despite clinical euthyroidism. Gut 1983;24:631-6.
• 11. Oren R, Sikuler E, Wong F, Blendis LM, Halpern Z. The effects of hypothyroidism on liver status of cirrhotic patients. J Clin Gastroenterol 2000;31:162-3.
• 12. Oren R, Brill S, Dotan I, Halpern Z. Liver function in cirrhotic patients in the euthyroid versus the hypothyroid state. J Clin Gastroenterol 1998;27:339-41.
• 13. Squires RH Jr, Shneider BL, Bucuvalas J, Alonso E, Sokol RJ, Narkewicz MR et al. Acute liver failure in children: the first 348 patients in the pediatric acute liver failure study group. J Pediatr 2006;148:652-8.
• 14. O'Grady JG, Schalm SW, Williams R. Acute liver failure: redefining the syndromes. Lancet 1993;342:273-5.
• 15. Kapelari K, Kirchlechner C, Högler W, Schweitzer K, Virgolini I, Moncayo R. Pediatric reference intervals for thyroid hormone levels from birth to adulthood: a retrospective study. BMC Endocr Disord 2008;8:15.
• 16. Ray DC, Macduff A, Drummond GB, Wilkinson E, Adams B, BeckettGJ. Endocrine measurements in survivors and non-survivors from critical illness. Intensive Care Medicine 2002;28:1301-8.
• 17. Spencer C, Eigen A, Shen D, Duda M, Qualls S, Weiss S, Nicoloff J. Specificity of sensitive assays of thyrotropin (TSH) used to screen for thyroid disease in hospitalized patients. Clinical Chemistry 1987;33:1391-6.
• 18. Anastasiou O, Sydor S, Sowa JP, Manka P, Katsounas A, Syn WK et al. Higher Thyroid-Stimulating Hormone, Triiodothyronine and Thyroxine Values Are Associated with Better Outcome in Acute Liver Failure. PLoS One 2015;10:e0132189.
• 19. Attwood EC, Atkin GE. The T4:TBG ratio: a re-evaluation with particular reference to low and high serum TBG levels. Ann Clin Biochem 1982;19:101-3.
• 20. Pilo A, Iervasi G, Vitek F, Ferdeghini M, Cazzuola F, Bianchi R. Thyroidal and peripheral production of 3,5,30-triiodothyronine in humans by multicompartmental analysis. American Journal of Physiology 1990;258:715-26.
• 21. Ataoğlu HE, Ahbab S, Serez MK, Yamak M, Kayaş D, Canbaz ET et al. Prognostic significance of high free T4 and low free T3 levels in non-thyroidal illness syndrome. Eur J Intern Med 2018;6205:30290-5.
• 22. Taş A, Köklü S, Beyazit Y, Kurt M, Sayilir A, Yeşil Y, et al. Thyroid hormone levels predict mortality in intensive care patients with cirrhosis. Am J Med Sci 2012;344:175 9.
• 23. Wang L, Yu W, Cao W, Lu W. The abnormality of thyroid hormones in patients with type A hepatic encephalopathy. Oncotarget 2017;8:67821-8.
• 24. Fliers E, Guldenaar SE, Wiersinga WM, Swaab DF. Decreased hypothalamic thyrotropin-releasing hormone gene expression in patients with nonthyroidal illness. J Clin Endocrinol Metab1997;82:4032-6.
• 25. Fliers E, Alkemade A, Wiersinga WM, Swaab DF. Hypothalamic thyroid hormone feedback in health and disease. Prog Brain Res 2006;153:189-207.
• 26. Nomura R, Miyai K, Kuge R, Okura T, Goto M, Hasegawa Y. Free T3 to free T4 ratio less than 2.0 suggests low T3 syndrome rather than central hypothyroidism from the age of two to eighteen years. Endocr J 2017;64:213-9.
• 27. Malik R, Mellor N, Selden C, Hodgson H. Triiodothyronine enhances the regenerative capacity of the liver following partial hepatectomy. Hepatology 2003;37:79-86.
• 28. Malik R, Saich R, Rahman T, Hodgson H. During thioacetamide-induced acute liver failure, the proliferative response of hepatocytes to thyroid hormone is maintained, indicating a potential therapeutic approach to toxin-induced liver disease. Dig Dis Sci 2006;51:2235-41.
• 29. Fernández V, Castillo I, Tapia G, Romanque P, Uribe-Echevarría S, Uribe M, et al. Thyroid hormone preconditioning: protection against ischemia-reperfusion liver injury in the rat. Hepatology 2007;45:170-7.