NDT Advance Access originally published online on March 10, 2008
Nephrology Dialysis Transplantation 2008 23(6):2107-2108; doi:10.1093/ndt/gfn088
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Reply
Correspondence and offprint requests to: E-mail: sofia_lionaki{at}med.unc.eduWe kindly thank you for the opportunity to comment on the letter by Rothe et al. presenting a case with ANCA small vessel vasculitis (ANCA-SVV) in the setting of autoimmune hypothyroidism [1]. Autoimmune thyroid disease is relatively common in the general population and in females particularly [2] while ANCA-SVV, a rare disease, is almost equally distributed among genders [3]. As we recently reported, a prior history of thyroid disease was 3.7 times more likely among patients with ANCA-SVV compared to controls and 5.6 times more frequent in women [4]. Accordingly, in the case described by Rothe and colleagues, the absence of any exposure to thioamides eliminates any chance of consideration of the established drug-induced scenario for the development of ANCA-SVV [5]. The patient received a diagnosis of autoimmune hypothyroidism with Anti-TPO and TSH receptor blocking 2 months before the diagnosis of ANCA-associated glomerulonephritis. However, the natural course of autoimmune thyroid disease varies substantially among patients with an asymptomatic or sub-clinical phase, often preceding the overt thyroid hormone depletion [6]. The patient described was also MPO-ANCA positive, as has been reported in the majority of patients with thyroid disease and ANCA-SVV [5]. ANCA-SVV was proven by kidney biopsy with no other expression of SVV in this particular episode, although the findings of pulmonary fibrosis might also represent chronic damage arising from manifestations of the ANCA-SVV in the lungs, which preceded the diagnosis of autoimmune thyroid disease, although the true onset of either disease may be difficult to determine.
This association between thyroid disease and ANCA-SVV, even in the absence of the use of anti-thyroid agents, suggests that all patients with disorders of the thyroid gland should be worked up intensively in the presence of potential signs and/or symptoms of SVV. Conversely, all patients with ANCA-SVV should be evaluated for disorders of thyroid function as the awareness of physicians treating patients with ANCA-SVV with a concurrent need for management of thyroid disease is also crucial. This is particularly important since the pharmacokinetics of steroids can be profoundly altered by both hyper- and hypothyroidism, thereby requiring closer monitoring and adjustment of the dose over time [7].
Conflict of interest statement. None declared.
1 UNC Kidney Center and Division of Nephrology and Hypertension University of North Carolina at Chapel Hill, Chapel Hill, NC, USA 2 Department of Nephrology and Transplantation, Laikon Hospital Athens, Greece 3 Department of Pathology and Laboratory Animal Medicine University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
References
- Rothe H, Siegmund J, Muller H. Letter to the editor. Nephrol Dial Transplant (2007).
- Rosenthal MJ, Hunt WC, Garry PJ, et al. Thyroid failure in the elderly. Microsomal antibodies as discriminant for therapy. JAMA (1987) 258:209–213.
[Abstract/Free Full Text] - Hogan SL, Falk RJ, Chin H, et al. Predictors of relapse and treatment resistance in antineutrophil cytoplasmic antibody-associated small-vessel vasculitis. Ann Intern Med (2005) 143:621–631.
[Abstract/Free Full Text] - Lionaki S, Hogan SL, Falk RJ, et al. Association between thyroid disease and its treatment with ANCA small-vessel vasculitis: a case control study. Nephrol Dial Transplant (2007) 22:3508–3515.
[Abstract/Free Full Text] - ten Holder SM, Joy MS, Falk RJ. Cutaneous and systemic manifestations of drug-induced vasculitis. Ann Pharmacother (2002) 36:130–147.[Abstract]
- Pearce EN, Farwell AP, Braverman LE. Thyroiditis. N Engl J Med (2003) 348:2646–2655.
[Free Full Text] - Bergamaschi S, Rusconi R, Gervasoni M, et al. Pharmacokinetics of prednisone and prednisolone in a case of hypothyroidism: effect of replacement therapy. Steroids (2005) 70:787–789.[CrossRef][Web of Science][Medline]
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