Thyroid functions on hemodialyzed patients

Abnormalities in thyroid function tests are frequently encountered in uremic patients. Disturbance in endothelial dysfunction and inflammatory processes are common in individuals with chronic renal failure. This may predispose to accelerated atherosclerosis with all its complications. The study was performed to investigate relationship between thyroid function and markers of endothelium damage and inflammation in patients with regular hemodialysis [HID]. The study was performed on 50 patients with end stage renal diseases [ESRD] on regular ND for at least 10 months. All patients and control were subjected to complete history and clinical examination and measurements of thyroid function tests, marker of inflammation [CRP], marker of endothelial damage, [intracellular adhesion molecules [ICAM]], in addition to renal function, CBC, lipid profile, total protein and serum albumin. Out of 50 patients under hemodialysis, had cardiovascular events. The following parameters were significantly higher in patients under HD than control; blood urea [p < 0.001], serum creatinine [P <0.001], CRP [p <0.001], ICAM [p <0.001] and triglycerides [P <0.01]. The following parameters were significantly lower in patients under HD than controls; serum albumin [p < 0.001], FT3 [p <0.01, but still within the normal range] and hemoglobin [p < 0.01]. Using multiple regression analysis serum FT3 negatively correlated with, duration of RD [r=-0.830, p < 0.001], albumin [r=-0.770, p <0.001], CRP [r=-0.840, p < 0.001], ICAM [r=-0.500, p < 0.01], triglycerides [r=-0.540, p <0.01], and total protein [r=-0.520, P <0.01]. Logistic regression analysis and after adjusted for age, sex, BMI, hypertension, FT3 levels were independently related to CRP [OR 206, 95% CI 1.6-5.4, P < 0.001], followed by duration of dialysis [OR 2.58, 95% CI 1.7-5.2, P <0.001], lastly serum albumin [OR 2.32, 95% CI 1.6-3.9, p <0.001]. Interestingly, and serum albumin were significantly lower, while CRP and duration of dialysis were significantly higher in patients with vascular complications than the rest of patients [P < 0.01]. We can conclude that thyroid dysfunction in HID patients related to inflammation, duration of dialysis, malnutrition and to a lesser extent endothelial dysfunction. All these factors lead to accelerated atherosclerosis and cardiovascular complications and a clinical significance of these findings merits further studies

Relationship between thyroid function and endothelium dysfunction in hemodialyzed patients

Chronic renal failure affects thyroid function in many ways. Disturbances in hemostasis and inflammation are common complications of kidney diseases. Endothelial dysfunction may link these two processes. The study was performed to assess thyroid hormones in relation to markers of endothelial damage and inflammation in hemodialyzed [HD] patients. Sixty patients on regular HD [40 patients treated with erythropoietin and 20 patients without erythropoietin therapy] and 30 healthy controls were studied. Thyroid hormones, markers of endotherlial damage [Von Willebrand factor [vWF], intracellular adhesion molecule [ICAM], marker of inflammation [high-sensitivity C-reactive protein [hsCRP] and tumor necrosis factor alpha [TNF alpha], hemostatic parameter [tissue plasminogen activator [tPA], kidney function tests, complete blood count, lipid profile, serum iron, serum albumin and total protein, serum calcium and phosphate were measured. The weekly erythropoietin dose and the patient demographics were recorded. Free T[3] were lower in HD patients compared with controls, markers of hemostasis, inflammation and endotherlial dysfunction were significantly higher in HD patients compared with controls. In all hemodialysis patients, free T[3] was independently related to time on dialysis, albumin, serum iron, total protein, triglycerides, total calcium, vWF, tPA and hsCRP. In the HD patients with CRP less than 6 mg/L, free T[3] was related to time on dialysis, total protein and triglycerides. While in HD patients with CRP greater than or equal to 6 mg/L, free T[3] was related to total calcium and hsCRP. Also in multiple regression analysis the predictors of free T[3] were hsCRP and dose of erythropoietin. We describe a novel relation between thyroid hormones and markers of endothelial dysfunction and inflammation in HD patients. Thyroid dysfunction is related to time on dialysis, endothelial damage, and inflammatory state, frequently encountered in uremia could be responsible for accelerated atherosclerosis and development of cardiovascular complications. Therefore, the relations between thyroid axis and endothelium in HD subjects merit additional studies

Impaired glucose tolerance after acute stroke

The objective of this work is to determine the prevalence of disturbances in glucose metabolism in patients with acute stroke. Research design and methods-Consecutively admitted acute stroke patient [n=100] were screened for glucose tolerance according to the standardized World Health Organization protocol in the 1[st] and 2[nd] week after the stroke event. In addition, we repeatedly measured fasting capillary blood glucose during the first 10 days. Of the 100 subjects analyzed, 30 [30%] were classified as having newly diagnosed diabetes, 28 [28%] as having IGF or IGT, 29 [29%] as having transient hyperglycemia and only 16 [16%] were normoglycemia. Patients with newly diagnosed diabetes had more severe stroke National Institutes of Health Stroke Scale [NIHSS] on admission], hypertension and HbAIc than other studied groups [p<0.001], a higher rate of pneumonia and urinary tract infection during the admission [P0.001] and a worse outcome at discharge [mRS 0-1 at discharge]; [P<0.001] than nondiabetic patients. Patients with normal glucose regulation were more often men [more women among diabetic patients] and significantly younger than patients classified as having abnormal glucose regulation. In multivariate logistic regression model, National Institutes of Health Stroke Scale [NIHSS] on admission, female sex and urinary tract infection were independently associated with the classification of newly diagnosed diabetes. Age < 70 years and normotension were factors associated with normal glucose values in OGTT. It could be concluded that - The majority of acute stroke patients have disorders of glucose metabolism and in most cases this fact has been unrecognized. Diabetes worsens the outcome of acute stroke. Therefore, in the post-acute phase, an oral glucose tolerance test should be recommended in all stoke patients with no prior history of diabetes

Peripheral arterial disease and risk of cardiac death in type 2-diabetes

The purpose of this study was to determine the natural history of peripheral arterial disease [PAD] complicating type2-diabetics, in particular the influence of PAD on the risk of cardiac death and the adequacy of PAD risk factor management. The study was a prospective study of diabetic patients. The study was performed at Al-Azhar University Hospitals on 15o patients with type 2-diabetes between March 2004 and May 2005, with follow-up period at least 2-years. All patients had a valid data at baseline and three or more subsequent consecutive annual reviews. Assessment consisted of a range of clinical and biochemical variables including the ankle/brachial index [ABI]. PAD was defined as an ABI

Left ventricular size and function in obese versus lean type 2 diabetes

The impact of type 2 diabetes and obesity on left ventricular size and function is not well established and still a matter of debate. The study was performed to assess LV size and function in type 2 diabetic patients obese or not. The study included 40 normotensive patients with type 2 diabetes, 20 of them were obese [group I], and the other 20 patients were lean [group II]. The control of the study included 40 healthy subjects with age and sex matched, 20 of them were obese [group III], and the other 20 subjects were lean [group IV]. The study was performed at Al-Azhar University hospitals from October 2005 to July 2006. Patients and controls were subjected to clinical evaluation, with special emphasis to measurements of body mass index [BMI], waist hip circumference ratio [WHR], ECG and standard 2-D echocardiograms. Laboratory investigations include; lipid profile, HbA1c, fasting blood sugar [FBS], fasting serum insulin and measurements of insulin resistance [IR]. LV functions [EF, FS% and E/A ratio] were significantly impaired in-group I and II when compared to controls [p<0.05] and more significantly impaired in-group I when compared to group II [p<0.05]. Left ventricular mass was significantly higher in obese groups [group I and III] when compared to lean groups [group II and IV], [p<0.01], and no significant changes were found between obese diabetic and non-diabetics. All values of LV mass, EF and FS% are still within the normal reference range and all patients had no ECG abnormalities. Hyperinsulinemia and insulin resistance were significantly higher in diabetic groups when compared to controls [p<0.01] and in-group I when compared to group II [p<0.01]. Total cholesterol, LDL-cholesterol, triglycerides, HbA1c, fasting insulin and IR were significantly higher, while HDL-cholesterol was significantly lower in-group I when compared to group II, in-group I when compared to group III, and in-group II when compared to group IV. In obese diabetic patients LV mass was correlated with BMI, waist circumference, serum insulin, and IR. EF and FS% correlated with BMI, waist circumference, triglycerides, HDL-cholesterol, disease duration, HbA1c, serum insulin, and IR. E/A ratio correlated with BMI, waist circumference, HDL-cholesterol, triglycerides, disease duration, HbA1c, serum insulin, and IR. In obese non-diabetic subjects LV mass was correlated with BMI, waist circumference, serum insulin and IR. EF and FS% correlated with BMI, waist circumference, serum insulin, and IR. E/A ratio correlated with BMI, waist circumference, serum insulin, and IR. We can claim that simple obesity has its main impaction on LV size rather than functions, while diabetes has its main impaction on the LV functions. These denoting the other mechanisms of cardiovascular affection in diabetes including endothelial dysfunction and microvascular angiopathy

Study of some endogenous factors and hormones contributing in the pathogenesis of ketosis in obese versus lean type 2 diabetes mellitus

Diabetic Ketoacidosis [DKA], resulting from severe insulin deficiency, accounts for most hospitalization in type 1 DM. However, the frequency, distinguishing features and pathogenesis of this syndrome in type 2 DM remain to be defined. The study was performed to evaluate the role of some endogenous factors and hormones contributing in the vulnerability of some type 2 DM that developed DKA easily than other. The study was conducted on 80 known type 2 diabetic patients [45 males and 35 females], 48 of them were obese body mass index [BMI] > 30 kg/m[2], admitted to Al-Azhar University Hospitals [emergency department] with manifestations of DKA [group I] from July 2003 to January 2005, and 20 type 2 diabetic patients of the same duration of DM, without history of DKA, [group II] with age and sex matched [12 males and 8 females], 10 of them were obese, as controls. After complete clinical examination and routine laboratory investigations, which confirm the diagnosis of DKA, the following investigations were studied; serum glucagon, C-peptide, glutamic acid decarboxylase antibody [GAD-ab], and C-peptide / glucagon ratio, random blood sugar [RBS], renal and liver function tests, arterial blood gases [bicarbonate and pH], serum electrolyte [sodium, potassium and chloride], lipid profile, CBC, complete urine analysis with special attention to level of ketone bodies Serum levels of glucagon, RBS and urine ketone were significantly higher in-group I than group II, while serum levels of C-peptide, C-peptide / glucagon ratio, sodium, potassium, and bicarbonate were significantly lower in-group I than group II. On the other hand no significant differences in the age, sex, disease duration, GAD abs, lipid profile, blood pH and serum chloride between group I and II. In patients with DKA, the age, disease duration, C-peptide, glucagon and C-peptide / glucagon ratio were significantly lower in lean than obese parents [p<0.05] for all. While serum levels of GAD-abs were significantly higher in lean than obese patients [p<0.05]. Interestingly in patients without DKA, serum levels of C-peptide were significantly lower [p<0.05], while serum levels of GAD-abs were significantly higher in lean than obese patients [p<0.05] and no significant changes in other parameters between them. On the other hand C-peptide correlated negatively with glucagon [r=-650] and GAD abs [r=-684], while serum glucagon correlated positively with GAD-abs [r=644]. It could be concluded that the pathogenesis of ketosis in type 2 diabetes is triggered mainly by deficient endogenous insulin in lean patients [had a criteria of type 1 diabetes such as; younger age of onset of DKA short duration of disease, elevated GAD-abs and low C-peptide / glucagon ratio but still classified as type 2diabetes] and relative increase glucagon level activity in obese patietrts. However, the C-peptide / glucagon ratio is the main denominator or determinant factor for ketosis in type 2 diabetes mellitus

Proteinuria as a risk factor for stroke in type 2 diabetes mellitus

The study was designed to assess the relation between proteinuria and stroke in patients with type 2 diabetes mellitus. The study was conducted on two groups; Group I included 60 patients with type 2 DM with ischemic stroke, group II included 60 patients with type 2 DM without stroke. Both groups were matched by age, sex, body mass index and duration of diabetes. The study was performed at Al-Azhar University Hospitals from May 2005 to January 2006. The patients were evaluated clinically using Glasgow Coma Scale [GCS] for comatose patients and Canadian Neurological Scale [CNS] for conscious patients. Routine laboratory investigations as well as 24 hours urine protein were measured for both groups. CT scans were performed to all patients of group I within two days and after one week from the onset of stroke to determined site, depth and size of infarction. Systolic and diastolic blood pressures, prevalence of smoking and 24 hours proteinuria were significantly higher in group I than group II. On the other hand no significant changes were found on duration of DM, fasting and postprandial blood sugar, total cholesterol, LDL cholesterol, triglycerides, HbAlc, age and gender between two groups. In group I 38 patients were found to have proteinuria 38/60 [63%] versus 16 patients 16/60 [26.7%] had proteinuria in-group II, which was statistically significant. HDL-cholesterol only was significantly lower in-patients with proteinuria than those without proteinuria in-group I [p<0.01]. On the other hand no significant correlations were found between proteinuria and severity of strokes and CT findings. In multivariate logistic regression analysis, the ORs and 95% CLs for the variables identified as risk factors for stroke were as follow; SBP [OR 14.5, 95% CL 2.5-13.9], DBP [OR 13.1, 95% CL 2.4-15.9], proteinuria [OR 7.6, 95% CL 2.5-22.9], HDL cholesterol [OR 5.5,95% CL 2.1-23.5] and smoking [OR 4.89, 95% CL 1. 7-22.3]. Our results give evidence that proteinuria is an independent risk factor for ischemic stroke in patients with type 2 DM. Further support from additional prospective studies is recommended to confirm these findings

Pulmonary function tests in Parkinson's disease

The study was a cross-sectional and patient-control study. The study was performed at Al-Azhar university Hospitals from May 2005 to January 2006. The study was performed to document changes in respiratory pump and ventilatory function in idiopathic Parkinson's disease [PD] patients and its relationship with the main clinical presentation and the specific daily living activities [DLA] inthose patients. The study was conducted on 30 patients with PD and 10 healthy control volunteers. Patients were subjected to clinical evaluation by Unified Parkinson Disease Rating Scale [UPDRS] and respiratory pump function evaluation was done for patients and controls. Among patients group, 3 patients had normal pulmonary function [PF], 15 had obstructive PF pattern, 2 had restrictive PF pattern and 17 had upper airway obstruction. A significant disturbance in respiratory neuromuscular drive represent by the tracheal occlusion pressure after 100 m / sec from the start of quit inspiration [PO.l], decrease in respiratory muscle strength evaluated by maximum inspiratory pressure [PImax], marked respiratory muscle fatigue evaluated by [PO.l / PO.lmax]. A significant decrease in partial arterial oxygen pressure [PaO[2]] and increase in PaCO2 was found in patients group when compared to control group. Rigid / hypokinetic group patients 16/30 [53.3%] had significant [p<0.05] respiratory dysfunction rather than tremulous 14/30 [46.7%] group of patients. A significant negative correlation between the duration of disease, severity of illness, total daily living activity [DLA] and the severity of pulmonary dysfunction was found. Among the specific DLA, salivation and severe axial involvement was negatively correlated with maximum voluntary ventilation [MVV], PImax and PaO[2] Patients with Parkinsonis disease have impaired pulmonary function showing both obstructive and restrictive pattern, also abnormalities in mouth occlusion pressure and maximum inspiratory pressure were evident

Assessment of thyroid function and autoantibody in type 2 diabetes mellitus

The associations between type 1 diabetes mellitus [DM] and autoimmune thyroid disease and other autoimmune diseases have long been recognized. However, these associations in type 2 DM are not certain. The study was performed to assess the thyroid function and autoimmune thyroiditis by detection of thyroglobulin antibodies [TG-ab] and thyroid peroxidase antibodies [TPO-ab] in type 2 diabetes mellitus. The study included 50 patients with type 2 diabetes over 10 years duration and 20 control subjects. The study was performed at Al-Azhar University Hospitals for control or management of diabetic complications. Patients with non-thyroidal illness or drug therapy, which known to affect thyroid functions were excluded from the study. The subjects of this study were submitted to the following: complete history and clinical examination, BMI, blood sugar, lipid profile, thyroid function test [FT3, FT4, and TSH], HbAlc and thyroid autoantibodies [Tg-ab and TPO-ab]. Twenty-six patients out of 50 having abnormal levels of TSH, 6 of them below the normal reference range, while the other 18 patients with elevated TSH levels. Patients with elevated TSH had significantly lowered serum FT3, FT4 and elevated levels of TPO-ab, TG-ab, HbAlc, disease duration and BMI when compared to those with normal TSH [p<0.01, for all]. Patients with decreased levels of TSH had significantly elevated levels of FT3, FT4, HbAlc and BMI when compared to those with normal TSH [p<0.01], but no significant changes were found in serum levels of autoantibodies. Interestingly the incidence of abnormal thyroid function and elevated thyroid auto-antibodies were significantly higher in patients treated by insulin [70%] versus those treated by oral hypoglycemic drugs [30%], [p<0.01]. Twenty two patients out of 50 [44%] had elevated TPO-ab levels, 13 of them have TSH abnormality, 12 of these 13 patients have subclinical hypothyroidism and one has subclinical hyperthyroidism. 25 patients of 50 [50%], have increased level of TG-ab, 18 of them have abnormal TSH values, 16 out of these 18 have subclinical hypothyroidism and two patients have subclinical hyperthyroidism. Serum level of TSH only was significantly higher in females than males [p<0.05]. Serum levels of autoantibodies were correlated positively with serum levels of TSH, BMI, HbAlc, disease duration and insulin therapy and correlated negatively with FT3 and FT4. Type 2 diabetes may be associated with alteration in thyroid function especially subclinical hypothyroidism that is not fully explained by the mere presence of antithyroid antibodies

Role of adhesion molecules in vascular complications of type 2 diabetes mellitus

The present study was undertaken to evaluate the plasma levels of soluble adhesion molecules [intercellular adhesion molecule-1 [ICAM-1] and vascular cell adhesion molecule-1 [VCAM-l] in type 2 DM to elucidate its potential involvement in pathogenesis of diabetic vascular complications and its association with other independent risk factors for diabetic atherosclerosis. The study was conducted on 60 patients with type 2 DM [27 with vascular complications Vs. 33 without vascular complications, assessed by fundus examinations] and 20 healthy controls, at Al-Azhar University Hospitals between March 2004 to August 2004. Serum levels of ICAM-l and VCAM-l in association with fasting blood sugar, fasting insulin and insulin resistance were measured, as wall as lipid profile, plasminogen activator inhibitor [PAl] and factor VII. Serum levels of ICAM-1 and VCAM-1 were significantly higher in type 2 diabetic patients with vascular complication than those without vascular complications, but no significant changes in their levels were found between patients without vascular complications and controls. Serum levels of ICAM- 1 and VCAM- I were significantly correlated with other studied parameters in patients with and without vascular complications except fasting serum insulin levels. Serum levels of insulin resistance [IR] and lipid profile were significantly higher in patients with type 2 DM than controls and in patients with vascular complications than those without vascular complications. Serum levels of fasting blood glucose, factor VII and PAl were significantly higher in diabetic patients with and without vascular complications than controls, on the other hand no significant changes was found between patients with and those without vascular complications. The present study suggested that the levels of soluble adhesion molecules in type 2 DM with dyslipidaemia, hyperinsulinemia and hypercoagulable state may be a marker of endothelial cell activation or dysfunction and may be related to the activity of multiple cell types in atherosclerotic lesion. Serum levels of ICAMs were closely related to vascular diabetic complications. Furthermore, they may serve as a tool for monitoring the impact of prevention and intervention on vascular damage

Hypothalamic pituitary thyroid axis in critically ill patients

Patient with critical illness has disturbed thyroid function tests sick euthyroid syndrome' in the form of low total and free T 3, T 4 [FT 3, PT 4] and low level of the serum TSH. We investigated the hypothalamic-pituitary-thyroid axis and its relation to the mortality and/or morbidity before and after TRH stimulation. Bas-line serum TSR, free T 3, T 4 and after 200 microgram TRH, stimulated serum TSR, free T 3,and free T 4, were measured in 17 patients presented with acute critical illness, in 24 patients with chronic illness and in 20 healthy control. The results showed significant reduction in baseline and impaired secretion of thyroid hormones [FT 4 and PT 3] as well as TSH level in patients groups compared to control group. In acutely ill patients this reduction is mainly in PT 3, while in chronic patients reduction of both FT 3 and FT 4 were evident. A bolus I.V. injection of TRH in critically ill patients leads to marked increases in the serum TSR without changes in serum FT 3 or FT 4 and outcome of patients. It was found that serum TSH, FT 4 and serum albumin were correlated significantly with the mortality and morbidity of critically ill patients than APACHE II score inspite of its long term used in the prediction of morbidity and mortality in such patients. However follow up measurements of FT 4 and TSH can take it as a marker of recovery of critical illness. The results demonstrated an impairment of the hypothalamic-pituitary-thyroid axis in patients with critical illness and serum levels of FT 4 and TSH can be used in the prediction of morbidity and mortality in such patients

Role of adhesion molecules in the pathogenes of chronic obstructive pulmonary disease

Interaction between cell adhesion molecules and their ligands are an important step of inflammatory processes and may have direct relevance to the pathology of airway inflammation in patients with COPD. To determine the possible role of adhesion molecules in increased airway inflammation in subjects with COPD. Serum levels of adhesion molecules [ICAM-1, VCAM-1 and P-Selectin] were measured in 30 patients with COPD and in 20 healthy controls, as well as in broncho-alveolar lavage [BAL] obtained from both groups [patients and controls]. In addition, pulmonary function tests [ventilatory function FEV [1], FVC, and FEV [1]/ FVC], E.C.G. and echocardiography for all studied subjects were studied. Serum adhesion molecules were significantly higher in patients than controls, p < 0.01 [in the serum as well as in BAL]. Smoking significantly increases expression of adhesion molecules in patients and controls in the serum as well as in BAL [p < 0.01]. The degree of airway obstruction was significantly higher in smoker versus non-smoker and correlated significantly with serum levels of adhesion molecules [r = 0.520, 0.560 and 0.500] for serum ICAM 1, VCAM 1 and P-selectin respectively. Increased airway inflammation and obstruction in patients with COPD is associated with an increased expression of adhesion molecules in the serum as well as in BAL, especially in smokers, where they may reflect the degree of ongoing airway inflammation in patients with COPD

Apoptosis and arterial thrombosis: expression of CD31 and CD146 in recent and old thrombotic disorders

Apoptosis [programmed cell death] of vascular lining endothelium is one of the causes of increased thrombogenicity. The Luminal release of apoptotic endothelium-derived microparticles can cause activation of tissue factor [TF], the most potent known inhibitor of the blood clotting system. The study was carried out at Al-Azhar University Hospitals on 70 cases of arterial thrombosis above the age of 25 years: Group 1: consisted of 15 apparently healthy subjects as a control group. Group 11: including 32 patients of recent thrombosis; 13 with cerebral infarction, 12 with acute myocardial in farction [MI] and 7 patients with peripheral arterial thrombosis. Group 111: including 38 patients with old thrombosis; 12 with cerebral infarction, 18 with MI and 8 patients with old peripheral arterial thrombosis. Endothelial-derived CD31 and CD146 were statistically higher in patients with recent and old arterial thrombosis than controls [p<0.005, p< 0.01] respectively and statistically higher in old than in recent arterial thrombosis [p<0.05]. Hypertension DM, smoking and lipid profile have no significant effect on CD31 and CD146. Finally, endothelial microparticle detection among cases of arterial thrombosis may indicate the persistence of the danger of re-thrombosis. Patients with acute and chronic ischemia have altered response of endothelial cells. It remains to be determined whether the reduction of the increased activity of CD31 and CD146 could provide an effective rationale for acute arterial thrombosis therapy