Thyroid status in children with steroid sensitive Nephrotic syndrome

Introduction: Nephrotic syndrome (NS) is one of a major illness in childhood which needs prolonged immunosuppressive therapy due to its relapsing nature. Thyroid hormones and thyroxin-binding globulin (TBG) are known to lose in patients with NS. The main objectives of this research was to study the thyroid profile among the children with nephrotic syndrome during nephrosis and remission. Methods: An observational analytical study was carried out among total of 65 children with NS who were attending to University Nephrology Clinic, Teaching Hospital Karapitiya. Demographic details of patients and their relevant clinical details were obtained by an interviewer administered questionnaire. Blood for free T4, TSH, serum Albumin and Cholesterol were taken together and kept in -80 C after separating serum. Results; There were 35 and 30 patients in remission and in relapses respectively. Out of all 55.4% (n= 36) were males. The mean age in remission and relapse groups were 86.9 months ± 42.0 and 85.73 months ± 38.45. The proportions of patients who were on prednisolone, cyclophosphamide and cyclosporine were 92.3% (n=60), 21.5% (n=14) and 3.1% (n=2). The mean TSH levels in remission group and relapse group were 1.99 ±1.02 mIU/L and 4.69 ± 2.99 mIU/L respectively (P= Conclusion; In conclusion, though subclinical hypothyroidism is evident in children with steroid sensitive nephrotic syndrome at the time of proteinuria, clinical or subclinical hypothyroidism do not exist among those who were in remission.


Introduction
Nephrotic syndrome (NS) is characterized by proteinuria, hypoalbuminemia, edema, and hypercholestorelemia.1It is one of a major illness in childhood which needs prolonged immunosuppressive therapy due to its relapsing nature.
In patients with NS many other proteins are excreted in the urine in addition to albumin. Thyroid hormones and thyroxin-binding globulin (TBG) are known to lose in patients with NS during relapses whichmay decrease the binding capacity of Thyroxine (T4) and triiodothyronine (T3).2Therefore, as a compensatory mechanism Thyroid Introduction: Nephrotic syndrome (NS) is one of a major illness in childhood which needs prolonged immunosuppressive therapy due to its relapsing nature. Thyroid hormones and thyroxin-binding globulin (TBG) are known to lose in patients with NS. The main objectives of this research was to study the thyroid profile among the children with nephrotic syndrome during nephrosis and remission.

Methods:
An observational analytical study was carried out among total of 65 children with NS who were attending to University Nephrology Clinic, Teaching Hospital Karapitiya. Demographic details of patients and their relevant clinical details were obtained by an interviewer administered questionnaire. Blood for free T4, TSH, serum albumin and cholesterol were taken together and kept in -80 C after separating serum.

Results:
There were 35 and 30 patients in remission and in relapses respectively. Out of all 55.4% (n= 36) were males. The mean age in remission and relapse groups were 86.9 months ± 42.0 and 85.73 months ± 38.45. The proportions of patients who were on prednisolone, cyclophosphamide and cyclosporine were 92.3% (n=60), 21.5% (n=14) and 3.1% (n=2). The mean TSH levels in remission group and relapse group were 1.99 ±1.02 mIU/L and 4.69 ± 2.99 mIU/L respectively (P= < 0.001). There was no statistical difference (P= 0.36) in the mean free T4 level of the remission group (1.084± 0.50) ng/dL compared to that of the relapse group (1.23±0.74) ng/dL. In contrast, total protein and serum albumin levels were significantly lower in the relapse group whereas, serum cholesterol was significantly higher (P=0.001) in the remission group.

Conclusion:
In conclusion, though subclinical hypothyroidism is evident in children with steroid sensitive nephrotic syndrome at the time of proteinuria, clinical or subclinical hypothyroidism do not exist among those who were in remission.
Stimulating Hormone (TSH) would gone up in order to normalize thyroid status in the body.3 Hypothyroidism is a known complication of steroid resistant nephrotic syndrome and it is a routine practice to screen for it.4The main objectives of this research were to study the thyroid profile among children with nephrotic syndrome during nephrosis and remission and to assess the relationship (if any) between serum albumin and thyroid profile in children with nephrotic syndrome.

Methods
An observational analytical study was carried out among total of 65 children with NS who were attending to University Nephrology Clinic, Teaching Hospital Karapitiya.Patients who fulfilled the standard definition of nephrotic syndrome presenting in first attack or relapse were included in one group whereas, those who were in remission included in another group. Consecutive sampling was carried out during the period of 2 years from July 2015 to June 2017. Measures were adopted to not to enrolled the same patient in two stages of the illness. Children with Steroid Resistance Nephrotic Syndrome were excluded. Socio-economic status of patients and their relevant clinical details were obtained by an interviewer administered questionnaire. Blood for free T4, TSH, serum Albumin and Cholesterol were taken together and kept in -80 C after separating serum. All samples were analysed using ELISA method in a single assay. Normal level was taken as Serum T4 = 0.80 -2.00 ng/dL and TSH = 0.70 -5.97 mIU/l. An ethical approval for the study was obtained from Ethical Review committee, Faculty of Medicine, University of Ruhuna.

Results
There were 35 and 30 patients in remission and in relapses respectively. Out of all 55.4% (n= 36) were males. The mean age in remission and relapse groups were 86.9 months ± 42.0 and 85.73 months ± 38.45 with no statistical significance (P=0.9). The proportions of patients who were on prednisolone, cyclophosphamide and cyclosporine were 92.3% (n=60), 21.5% (n=14) and 3.1% (n=2). All of them were clinically euthyroid.  In contrast, total protein and serum albumin levels were significantly lower in the relapse group whereas, serum cholesterol was significantly higher (P=0.001) in the remission group. (Table 2) There was no difference in the level of globulin in between two groups (p=0.133).

Discussion
The  6,7,8,9 Findings of the present study is compatible with that of the aforementioned studies though the methodology was different because in this study two groups of patients who were in relapse and in remission were enrolled.

Conclusion
In conclusion, though subclinical hypothyroidism is evident in children with steroid sensitive nephrotic syndrome at the time of proteinuria, clinical or subclinical hypothyroidism do not exist among those were in remission. However, further studies are needed to assess thyroid function tests of children who have prolonged and recurrent episodes of proteinuria since it would affect their growth potential. Conflict of interestThe authors declare no conflict of interest.