Plasmapheresis Induces High Reverse T<sup>3</sup>Levels in Euthyroid and Hyperthyroid Patients

Schlienger, J.-L.; Sapin, R; Faradji, A.

doi:10.1055/s-2007-1003251

Cited by 4 publications

(3 citation statements)

References 3 publications

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“…From a pathophysiological point of view, each TPE session consists of removing plasma, which contains components such as protein-bound hormones. The replacement with albumin solution brings new binding sites for free thyroid hormones leading, to a decrease in fT3 and fT4 levels [13]. In the case of GD, a reduction in TSH receptor-stimulating antibodies can also play a role.…”

Section: Discussionmentioning

confidence: 99%

Therapeutic Plasma Exchange in Refractory Hyperthyroidism

Saie¹,

Ghander²,

Saheb³

et al. 2020

Eur Thyroid J

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Introduction: Hyperthyroid patients who are unresponsive to medical treatment remain a challenging clinical problem. Objective: The goal of our study was to evaluate the use of therapeutic plasma exchange (TPE) in hyperthyroid patients and their outcome after TPE. Method: We retrospectively reviewed 22 patients who underwent TPE for refractory thyrotoxicosis in our institution: 13 with Graves’ disease, 7 with amiodarone-induced thyrotoxicosis (AIT), 1 with toxic goiter, and 1 pregnant patient with familial nonautoimmune thyrotoxicosis. Results: Before TPE, all patients had severe hyperthyroidism, and antithyroid drugs were either contraindicated or not sufficiently effective to restore euthyroidism promptly. After all the TPEs, free T₄ (fT4) decreased significantly by 48% (p = 0.001) and fT3 by 52% (p = 0.0001). The median number of TPE sessions per patient was 4 (range: 1–10). There were no complications during the 91 TPE sessions. Total thyroidectomy with no severe side effects was performed on 16/22 patients and 1 other patient was treated with radioactive iodine. One patient died from severe thyrotoxicosis during medical care. The remaining 4 patients were followed up without any radical treatment. For all 7 patients with AIT, iterative TPE led to a significant clinical improvement, and amiodarone was continued for 1 patient. Available treatments were continued between TPE sessions (cholestyramine for 13 patients [60%] and glucocorticoids for 16 patients [73%]). Conclusion: TPE allowed a safe decrease of 50% in thyroid hormone levels, and it should be considered for refractory hyperthyroid patients when medical treatments are contraindicated or have failed to restore euthyroidism, irrespective of the etiology of the thyrotoxicosis.

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Section: Discussionmentioning

confidence: 99%

Therapeutic Plasma Exchange in Refractory Hyperthyroidism

Saie¹,

Ghander²,

Saheb³

et al. 2020

Eur Thyroid J

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“…5 The amount of thyroid hormone extracted appears to be proportional to the plasma volume exchanged, serum thyroid hormone concentration, as well as the amount of thyroxine-binding globulin (TBG) removed. [6][7][8] It is therefore believed that TPE works by removing the intravascular thyroid hormones bound to serum proteins (TBG and, to a lesser extent, albumin). Other mechanisms by which TPE exerts its beneficial effects in thyroid storm include the introduction of additional unsaturated binding sites for free thyroid hormones (when FFP or colloid solutions such as albumin are used as replacement fluids), and the removal of other factors potentially involved in the pathogenesis of thyroid storm such as thyroid autoantibodies, cytokines, and catecholamines.…”

Section: Discussionmentioning

confidence: 99%

“…Most reports demonstrated reductions in serum free and total thyroid hormone levels of 10% to 80% 5 . The amount of thyroid hormone extracted appears to be proportional to the plasma volume exchanged, serum thyroid hormone concentration, as well as the amount of thyroxine‐binding globulin (TBG) removed 6‐8 . It is therefore believed that TPE works by removing the intravascular thyroid hormones bound to serum proteins (TBG and, to a lesser extent, albumin).…”

Section: Discussionmentioning

confidence: 99%

Therapeutic plasma exchange for control of thyroid storm

Tan

Lim

Hoe

et al. 2020

J of Clinical Apheresis

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Therapeutic plasma exchange (TPE) for thyroid storm has recently been upgraded to a category II indication after decades though its recommendation level still remains at Grade 2C according to the American Society for Apheresis (ASFA). In the absence of prospective randomized controlled trials due to the rarity of thyroid storm, retrospective data from case series continue to elevate the clinical evidence supporting TPE as a life-saving modality for complicated thyroid storm patients. We report three cases of life-threatening thyroid storm from Graves' disease rescued by TPE via rapid reduction in circulating thyroid hormones. Each patient underwent TPE when it was judged that other thyroid storm treatment options were futile or unsafe. The first patient received 4 cycles of TPE while the second patient received 9 cycles of TPE, and the third patient received 2 cycles of TPE with satisfactory clinical improvement. Plasma FT4 and TSH receptor antibody levels of the first case declined by 41.3% and >50% respectively right after the first round of TPE; plasma FT4 of the second patient dropped by up to 31.6% during the course of TPE; plasma FT4 and TSH receptor antibody of the third patient declined by 66% and 56.2% respectively after the first cycle of TPE. This demonstrates the safety, efficacy, and feasibility of TPE in thyroid storm especially when other therapeutic interventions are contraindicated. TPE operates via the elimination of serum proteins-bound thyroid hormones, thyroid autoantibodies, cytokines, and catecholamines in addition to increasing unsaturated binding sites for thyroid hormones.

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Preanalytical considerations in testing thyroid function

Keffer

1996

Clinical Chemistry

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Remarkable technical advances have permitted analytical measurement of thyrotropin (TSH) and estimates of free thyroxine (FT4) with precision, accuracy, and favorable economics. Combined with an increased appreciation of the key insights into the pituitary-thyroid relation, preanalytical considerations infrequently introduce confounding variables. In reviewing thyroid data, preanalytical considerations include physiological and specimen-based issues. Central to the improvement in thyroid assessment is the recognition that physiological individuals maintain their FT4 within narrow limits. When this deviates, there is a logarithmic response of the TSH concentration to the arithmetic shift in FT4. In effect, the TSH deviation magnifies the subtle shift in FT4. Artifact and other nonthyroid-related preanalytical considerations are infrequently the cause of nonconcordance when discrepancy occurs between the reported values for FT4 and TSH. When abnormalities of TSH and FT4 are encountered, the probability strongly favors a disease state rather than a preanalytical variable. Infrequent but real extrathyroidal pathophysiological states are increasingly recognized as a result of the reliable assessment of the pituitary-thyroid relation.

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Plasmapheresis Induces High Reverse T³Levels in Euthyroid and Hyperthyroid Patients

Cited by 4 publications

References 3 publications

Therapeutic Plasma Exchange in Refractory Hyperthyroidism

Therapeutic Plasma Exchange in Refractory Hyperthyroidism

Therapeutic plasma exchange for control of thyroid storm

Preanalytical considerations in testing thyroid function

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Plasmapheresis Induces High Reverse T3Levels in Euthyroid and Hyperthyroid Patients

Cited by 4 publications

References 3 publications

Therapeutic Plasma Exchange in Refractory Hyperthyroidism

Therapeutic Plasma Exchange in Refractory Hyperthyroidism

Therapeutic plasma exchange for control of thyroid storm

Preanalytical considerations in testing thyroid function

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Plasmapheresis Induces High Reverse T³Levels in Euthyroid and Hyperthyroid Patients