Letter to the Editor
Usefulness of preoperative plasmapheresis in patients with thyrotoxicosis
Utilidad de la plasmaféresis en el tratamiento preoperatorio de la tirotoxicosis
a Servicio de Endocrinología y Nutrición, Hospital Universitario Vall d’Hebron, Barcelona, Spain
b Unidad de Cirugía Endocrina, Bariátrica y Metabólica, Servicio de Cirugía General, Hospital Universitario Vall d’Hebron, Barcelona, Spain
c Servicio de Endocrinología y Nutrición, Hospital Universitario Arnau de Vilanova, Lleida, Spain
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"https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020615001576?idApp=UINPBA00004N" "url" => "/23870206/0000014400000006/v1_201512090148/S2387020615001576/v1_201512090148/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Usefulness of preoperative plasmapheresis in patients with thyrotoxicosis" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "282" "paginaFinal" => "283" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Silvia Valladares, Andreea Ciudin, Óscar González, Albert Lecube" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Silvia" "apellidos" => "Valladares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Andreea" "apellidos" => "Ciudin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Óscar" "apellidos" => "González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:4 [ "nombre" => "Albert" "apellidos" => "Lecube" "email" => array:1 [ 0 => "alecube@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitario Vall d’Hebron, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cirugía Endocrina, Bariátrica y Metabólica, Servicio de Cirugía General, Hospital Universitario Vall d’Hebron, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitario Arnau de Vilanova, Lleida, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad de la plasmaféresis en el tratamiento preoperatorio de la tirotoxicosis" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">It has been suggested that plasmapheresis may be useful in the preoperative period of total thyroidectomy in cases of thyrotoxicosis that are refractory to conventional medical treatment.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1–3</span></a> However, there is little written evidence in the medical literature, where the largest reported series consists of 11 cases in a Turkish population,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> and most of the communications are limited to specific cases.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5–7</span></a> The following is a description of our experience with 8 patients who had frank hyperthyroidism. Between January 2010 and January 2013, these patients underwent plasmapheresis previous to a thyroidectomy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patients were 5 females and 3 males, with a mean age 48.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.6. Thyrotoxicosis was secondary to Graves-Basedow in 5 patients and was caused by amiodarone (type II) in the other 3 patients. The treatment of Graves-Basedow disease was based on high doses of neotomizol (daily 30-45<span class="elsevierStyleHsp" style=""></span>mg), prednisone (daily 50<span class="elsevierStyleHsp" style=""></span>mg) and beta blockers (daily bisoprolol 10<span class="elsevierStyleHsp" style=""></span>mg). Meanwhile, type II thyrotoxicosis caused by amiodarone was mainly treated with corticosteroids, even though patients were also given neotomizol y beta blockers. The surgical indication was lack of response to medical treatment (5 patients) or cardiovascular instability associated with atrial fibrillation with quick ventricular response and cardiac failure.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Plasmapheresis was conducted 24<span class="elsevierStyleHsp" style=""></span>hours before surgery. In each session, there was a replacement of 1–2<span class="elsevierStyleHsp" style=""></span>L of plasma, where 50% was replaced by fresh plasma and 50% by 5% albumin. Only one patient affected with Graves-Basedow disease had to undergo a second plasmapheresis because of the persistence of very high levels of free thyroxine (T4) after the first session. Thyroid hormones were determined by means of enzyme-linked immunosorbent assay (ELISA). The data was expressed as mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation, and the comparison between groups was conducted by means of the Student's <span class="elsevierStyleItalic">t</span> test. We complied with the protocols established by our hospital for access to patient clinical records.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Prior to the plasmapheresis treatment, all patients presented high rates of free T4, while only 5 showed high levels of total triiodothyronine (T3). The average concentration of thyroid hormones was 5.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.9<span class="elsevierStyleHsp" style=""></span>ng/dl for free T4 (NV: 0.7–.9<span class="elsevierStyleHsp" style=""></span>ng/dl) and 322.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>229.1<span class="elsevierStyleHsp" style=""></span>ng/dl for total T3 (NV: 60 a 160<span class="elsevierStyleHsp" style=""></span>ng/dl). After plasmapheresis, only 2 patients achieved normal levels of free T4 and only one achieved normal values of total T3. Nevertheless, globally, both free T4 and total T3 level reductions were statistically significant. Thus, the rate of free T4 had an overall drop of 32.7% after plasmapheresis and dropped to 4.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.3<span class="elsevierStyleHsp" style=""></span>ng/dl (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.034). Meanwhile, total T3 concentrations decreased to 232.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>197.8<span class="elsevierStyleHsp" style=""></span>ng/dl (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.026).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Significant clinical improvements were observed in 7 out of 8 cases, and previous thyrotoxicosis-related symptoms (perspiration, shaking, palpitations) decreased. An increase in heart rate was detected in one patient, which was attributed to the plasmapheresis effect on plasma concentrations of beta blockers. No further complications related to the plasmapheresis procedure were observed. In all cases, thyroidectomy was conducted without complications during or after the procedure.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Since uncontrolled thyrotoxicosis may lead to higher risk of post-operative complications, it is necessary to have a therapeutic alternative that can optimise the excess circulating thyroid hormones, thereby performing surgery with less risk. One of these alternatives, with which there is little clinical experience, is plasmapheresis.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2,8</span></a> This process significantly reduces plasma concentrations of thyroid hormones, not only by removing a circulating hormone percentage, but also by diluting or connecting non-removed hormones to the new infused albumin molecules.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the largest series published to date, Ezer et al. report their experience with 11 hyperthyroid patients from Turkey who underwent plasmapheresis.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> In that series, there is a similar detailed description about how the standardisation of peripheral hormones is not always attained, regardless of the improved symptoms in all cases. Furthermore, there were no complications related to the plasmapheresis procedure or during surgery.</p><p id="par0040" class="elsevierStylePara elsevierViewall">As a consequence of the results obtained and the results reported in the medical literature, we believe that plasmapheresis should be considered a useful method to reduce thyroid hormone excess during the immediate pre-operative period when total thyroidectomy is indicated for severe thyrotoxicosis that does not respond to conventional treatment. However, experience is still limited and, due to great inter-individual variability, we believe that it is necessary to continue increasing our experience with this procedure in the future.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Valladares S, Ciudin A, González Ó, Lecube A. Utilidad de la plasmaféresis en el tratamiento preoperatorio de la tirotoxicosis. Med Clin (Barc). 2015;144:282–283.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hyperthyroidism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2017 October | 3 | 1 | 4 |
| 2017 September | 5 | 1 | 6 |
| 2017 August | 4 | 4 | 8 |
| 2017 July | 4 | 0 | 4 |
| 2017 June | 14 | 2 | 16 |
| 2017 May | 8 | 6 | 14 |
| 2017 April | 6 | 0 | 6 |
| 2017 March | 7 | 2 | 9 |
