Successful Management of Thyroid Storm with Continuous Renal Replacement Therapy without Plasma Exchange

Calvin Kurnia Mulyadi; Elizabeth Yasmine Wardoyo; Anggraini Permata Sari; Aryan Yohanes; Johanes Sarwono; Fidkya Allisha; Marina Epriliawati; Muhammad Ikhsan Mokoagow

doi:10.32867/inakidney.v2i2.195

Calvin Kurnia Mulyadi Division of Nephrology and Hypertension, Department of Internal Medicine, Fatmawati Central General Hospital, Indonesia https://orcid.org/0000-0002-6069-0328
Elizabeth Yasmine Wardoyo Division of Nephrology and Hypertension, Department of Internal Medicine, Fatmawati Central General Hospital, Indonesia https://orcid.org/0000-0002-3381-5172
Anggraini Permata Sari Division of Nephrology and Hypertension, Department of Internal Medicine, Fatmawati Central General Hospital, Indonesia https://orcid.org/0000-0001-6005-0104
Aryan Yohanes Division of Nephrology and Hypertension, Department of Internal Medicine, Fatmawati Central General Hospital, Indonesia https://orcid.org/0000-0001-7282-4920
Johanes Sarwono Division of Nephrology and Hypertension, Department of Internal Medicine, Fatmawati Central General Hospital, Indonesia
Fidkya Allisha Division of Nephrology and Hypertension, RSUP Fatmawati https://orcid.org/0000-0001-6233-0417
Marina Epriliawati Division of Endocrine Diabetes and Metabolic, Department of Internal Medicine, Fatmawati Central General Hospital, Indonesia https://orcid.org/0000-0001-9410-1651
Muhammad Ikhsan Mokoagow Division of Endocrine Diabetes and Metabolic, Department of Internal Medicine, Fatmawati Central General Hospital, Indonesia https://orcid.org/0000-0001-8141-0324

DOI: https://doi.org/10.32867/inakidney.v2i2.195

Keywords: Medical-treatment refractory thyroid storm, continuous renal replacement therapy, hemodynamic instability

Abstract

Background: Thyroid storm is a life-threatening endocrine emergency that needs urgent management. Conventional therapies, however, may not always yield satisfactory outcome. Hereby, we report a case of refractory thyroid storm with hemodynamic and cardiac instability that showed significant improvement following continuous renal replacement therapy (CRRT) instead of therapeutic apheresis.

Case Illustration: A 46-year-old woman presented to the emergency department with severe thyrotoxicosis and pneumonia. On arrival, she was alert and hemodynamically stable. Physical examination revealed rapid irregular heart rate, fever, exophthalmos, diffuse goitre, and bilateral pulmonary rales. Laboratory findings indicated primary thyrotoxicosis, remarkable leukocytosis, and high procalcitonin that was consistent with sepsis. The Burch-Wartofsky score was 65, indicating thyroid storm. Clinical deterioration including loss of consciousness occurred on the next few days with electrocardiography changing into unstable supraventricular tachycardia despite optimal medical treatment administered to manage thyrotoxicosis and infection. Due to a suboptimal response, continuous veno-venous hemofiltration (CVVH) was initiated for 33 hours. This resulted in marked clinical improvement, including a reduction in free thyroxine (fT4), hemodynamic stabilization and recovery of consciousness.

Discussion: While therapeutic plasma exchange (TPE) is the recommended adjunctive therapy for refractory thyroid storm according to the ASFA 2016 guidelines, it is often unavailable in many centers, particularly in low-resource settings. CRRT may serve as an alternative, offering hemodynamic stabilization through mechanisms not yet fully understood.

Conclusion: CRRT may be considered a safe and effective alternative treatment for thyroid storm in patients who are refractory to standard medical therapy and particularly for those presenting with hemodynamic instability.

Downloads

Download data is not yet available.

References

1. Groot LJ De, Bartalena L, Feingold KR. Thyroid Storm. Endotext [Internet]. 2022 Jun 1 [cited 2024 Sep 17]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK278927/
2. Kahaly GJ, Bartalena L, Hegedüs L, Leenhardt L, Poppe K, Pearce SH. 2018 European thyroid association guideline for the management of graves’ hyperthyroidism. Vol. 7, European Thyroid Journal. S. Karger AG; 2018. p. 167–86.
3. Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016;26(10):1343–421.
4. Tan AWK, Lim BSP, Hoe JKM, Hoi WH, Leow MKS. Therapeutic plasma exchange for control of thyroid storm. J Clin Apher [Internet]. 2021;36(1):189–95. Available from: https://pubmed.ncbi.nlm.nih.gov/32823374/
5. Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher. 2019;34(3):171–354.
6. Lim SL, Wang K, Lui PL, Ramanathan K, Yang SP. Crash Landing of Thyroid Storm: A Case Report and Review of the Role of Extra-Corporeal Systems. Vol. 12, Frontiers in Endocrinology. Frontiers Media S.A.; 2021.
7. Ba JH, Wu BQ, Wang YH, Shi YF. Therapeutic plasma exchange and continuous renal replacement therapy for severe hyperthyroidism and multi-organ failure: A case report. World J Clin Cases. 2019;7(4):500–7.
8. Park HS, Kwon SK, Kim YN. Successful treatment of thyroid storm presenting as recurrent cardiac arrest and subsequent multiorgan failure by continuous renal replacement therapy. Endocrinol Diabetes Metab Case Rep. 2017;2017.
9. Muller C, Perrin P, Faller B, Richter S, Chantrel F. Role of plasma exchange in the thyroid storm. Ther Apher Dial [Internet]. 2011 Dec [cited 2024 Sep 17];15(6):522–31. Available from: https://pubmed.ncbi.nlm.nih.gov/22107688/