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Saudi J Kidney Dis Transpl 2016;27(4):828-829
© 2016 Saudi Center for Organ Transplantation
Letter to the Editor
Nephrotic Syndrome Related to Immunoglobulin M Nephropathy and
Hypothyroidism: An Uncommon Association
To the Editor,
Thyroid hormones influence glomerular fil-
tration rate and the function of many transport
systems along the nephron. Hypo- and hyper-
thyroidism may coexist with multiple forms of
glomerular disease. IgM nephropathy has rarely
been reported in association with hypothy-
roidism.
Thyroid function should be considered in
patients with edema since both nephrotic state
and hypothyroidism can cause edema. Syste-
matic thyroid hormonal testing is necessary if
nephrotic syndrome is severe and prolonged.
We report here an unusual association of
hypothyroidism with nephrotic syndrome due
to IgM nephropathy.
A previously healthy 40-year-old woman was
referred to our Internal Medicine Department
for fatigue, dyspnea, and generalized swelling.
At presentation, the patient weighed 60 kg and
measured 165 cm in height and her blood
pressure was 120/80 mm Hg. Physical exami-
nation showed peripheral edema without any
other abnormalities.
Blood analysis showed hypoproteinemia (53
mg/dL), hypoalbuminemia (25 mg/dL), hyper-
cholesterolemia (424 mg/dL), and normal re-
nal function. A 24 h urine collection contained
7.6 g protein. A diagnosis of pure nephrotic
syndrome was made and the treatment was
initiated with diuretics, angiotensin-converting
enzyme (ACE) inhibitor, and statins.
Immunological tests including complement
Saudi Journal
of Kidney Diseases
and Transplantation
fractions, cryoglobulins, anti-nuclear antibody,
antineutrophil cytoplasmic antibodies, viral
serology (hepatitis B virus, hepatitis C virus,
and human immunodeficiency virus), and
tumor markers (ACE, AFP, CA 15-3, CA 19-
9, and CA 125) were negative.
Thyroid function tests revealed thyroid sti-
mulating hormone (TSH) more than 100
µU/mL (reference range: 0.4–4.5 µU/mL) and
abnormal free tetraiodothyronine (T4), 0.28
ng/dL (reference range: 0.5–1.04 ng/dL); addi-
tional laboratory evaluation showed the ab-
sence of anti-thyroglobulin antibodies and
anti-thyroperoxydase antibodies.
A percutaneous renal biopsy was performed
which revealed minimal cellular proliferation
without alteration in capillary wall and no tubu-
lar atrophy. Immunofluorescence study showed
mesangial IgM staining. A final diagnosis of
nephrotic syndrome secondary to IgM nephro-
pathy associated with hypothyroidism was
made.
The patient was treated with series of medical
treatments including high-dose prednisolone
(60 mg/day), diuretics, ACE inhibitor, statins,
and levothyroxine.
Three months later, the patient was in better
clinical condition with no edema. Laboratory
tests showed a partial remission of nephrotic
syndrome with normal thyroid function.
The kidney and thyroid function and dys-
function are interrelated through several me-
chanisms, and the association of thyroid di-
sease and glomerulonephritis is established.1
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Letter to the Editor
The coexistence of nephrotic syndrome and
hypothyroidism could be explained by several
mechanisms. A common autoimmune patho-
genesis involving formation of immune com-
plexes has been reported; also immune com-
plex deposits in the basement membrane of
thyroid follicular epithelium and the glomeruli
have been reported in patients with Hashi-
moto’s thyroiditis and glomerulonephritis.2
Simultaneous occurrence of thyroid and glo-
merular disease can be explained by proteinu-
ria. Indeed, urinary losses of binding proteins
such as thyroxine binding globulin, transthy-
retin, and albumin could reduce T4 levels and
sometimes, total T3 levels. These hormonal
changes are related to the degree of proteinuria
and the serum albumin levels.1
Clinical presentation of both hypothyroidism
and nephrotic syndrome include fatigue and
edema and coexistence of these diseases may
aggravate edema.
In case reports describing association of glo-
merulonephritis and hypothyroidism, when
renal biopsy is performed, membranous glo-
merular disease has been the most common
histological finding.2,3 However, few reports of
association with IgA nephropathy,4 minimal
change disease,5 and membranoproliferative
glomerulonephritis 6 have also been reported.
The association of IgM nephropathy and hypo-
thyroidism, as found in our patient, is very
rare.
IgM nephropathy is a relatively recently
described entity.7 Immunofluorescence is ne-
cessary for its diagnosis. The presence of
immunoglobulin M in the mesangium of the
glomeruli makes the diagnosis.8
The parallelism between remission of neph-
rotic syndrome and TSH normalization as seen
in our patient emphasize the role of simul-
taneous use of levothyroxine, corticosteroids,
and symptomatic treatment of the nephrotic
syndrome.
In conclusion, this case suggests that thyroid
function should be considered in cases of
apparent idiopathic nephrotic syndrome.
Simultaneous use of both corticosteroids and
hormonal treatment could provide a prompt
improvement in the patient.
829
Conflict of interest: None declared.
Dr. Badreddine Ben Kaab,
Dr. Syrine Bellakhal,
Dr. Asmahane Souissi,
Dr. Akil Mestiri,
Dr. Hnia Smida,
Dr. Mohamed-Hedi Douggui
Department of Internal Medicine,
Internal Security Forces Hospital,
Marsa, Tunis, Tunisia
E-mail: bbk_22061983@hotmail.com
References
1. Iglesias P, Díez JJ. Thyroid dysfunction and
kidney disease. Eur J Endocrinol 2009;160:
503-15.
2. Weetman AP, Pinching AJ, Pussel BA, Evans
DJ, Sweny P, Rees AJ. Membranous glome-
rulonephritis and autoimmune thyroid disease.
Clin Nephrol 1981;15:50-1.
3. Illies F, Wingen AM, Bald M, Hoyer PF.
Autoimmune thyroiditis in association with
membranous nephropathy. J Pediatr Endocrinol
Metab 2004;17:99-104.
4. Sasaki H, Joh K, Ohtsuka I, et al. Interstitial
nephritis associated with glomerulonephritis in
a patient with Hashimoto's disease and idio-
pathic portal hypertension. Intern Med 1992;
31:641-8.
5. Iwazu Y, Nemoto J, Okuda K, et al. A case of
minimal change nephrotic syndrome with
acute renal failure complicating Hashimotoâs
disease. Clin Nephrol 2008;69:47-52.
6. Uddin J, Alam KM, Rabbi MF, Alam B.
Hypothyroidism and nephrotic syndrome: A
rare association. J Med 2009;10:34-5.
7. Al-Eisa A, Carter JE, Lirenman DS, Magil AB.
Childhood IgM nephropathy: Comparison with
minimal change disease. Nephron 1996;72:37-
43.
8. Bhasin HK, Abuelo JG, Nayak R, Esparza AR.
Mesangial proliferative glomerulonephritis.
Lab Invest 1978;39:21-9.