LETTER TO THE EDITOR
Year : 2016 | Volume
: 27 | Issue : 4 | Page : 828--829
Nephrotic syndrome related to immunoglobulin M nephropathy and hypothyroidism: An uncommon association
Badreddine Ben Kaab, Syrine Bellakhal, Asmahane Souissi, Akil Mestiri, Hnia Smida, Mohamed-Hedi Douggui
Department of Internal Medicine, Internal Security Forces Hospital, Marsa, Tunis, Tunisia
Dr. Badreddine Ben Kaab
Department of Internal Medicine, Internal Security Forces Hospital, Marsa, Tunis
|How to cite this article:|
Kaab BB, Bellakhal S, Souissi A, Mestiri A, Smida H, Douggui MH. Nephrotic syndrome related to immunoglobulin M nephropathy and hypothyroidism: An uncommon association.Saudi J Kidney Dis Transpl 2016;27:828-829
|How to cite this URL:|
Kaab BB, Bellakhal S, Souissi A, Mestiri A, Smida H, Douggui MH. Nephrotic syndrome related to immunoglobulin M nephropathy and hypothyroidism: An uncommon association. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2023 Jan 29 ];27:828-829
Available from: https://www.sjkdt.org/text.asp?2016/27/4/828/185284
To the Editor,
Thyroid hormones influence glomerular filtration rate and the function of many transport systems along the nephron. Hypoand hyperthyroidism may coexist with multiple forms of glomerular disease. IgM nephropathy has rarely been reported in association with hypothyroidism.
Thyroid function should be considered in patients with edema since both nephrotic state and hypothyroidism can cause edema. Systematic 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 examination showed peripheral edema without any other abnormalities.
Blood analysis showed hypoproteinemia (53 mg/dL), hypoalbuminemia (25 mg/dL), hypercholesterolemia (424 mg/dL), and normal renal 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 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 stimulating hormone (TSH) more than 100μU/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); additional laboratory evaluation showed the absence 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 tubular atrophy. Immunofluorescence study showed mesangial IgM staining. A final diagnosis of nephrotic syndrome secondary to IgM nephropathy 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 dysfunction are interrelated through several mechanisms, and the association of thyroid disease and glomerulonephritis is established. 
The coexistence of nephrotic syndrome and hypothyroidism could be explained by several mechanisms. A common autoimmune pathogenesis involving formation of immune complexes has been reported; also immune complex deposits in the basement membrane of thyroid follicular epithelium and the glomeruli have been reported in patients with Hashimoto's thyroiditis and glomerulonephritis.  Simultaneous occurrence of thyroid and glomerular disease can be explained by proteinuria. Indeed, urinary losses of binding proteins such as thyroxine binding globulin, transthyretin, 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. 
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 glomerulonephritis and hypothyroidism, when renal biopsy is performed, membranous glomerular disease has been the most common histological finding. , However, few reports of association with IgA nephropathy,  minimal change disease,  and membranoproliferative glomerulonephritis  have also been reported. The association of IgM nephropathy and hypothyroidism, as found in our patient, is very rare.
IgM nephropathy is a relatively recently described entity.  Immunofluorescence is necessary for its diagnosis. The presence of immunoglobulin M in the mesangium of the glomeruli makes the diagnosis. 
The parallelism between remission of nephrotic syndrome and TSH normalization as seen in our patient emphasize the role of simultaneous 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.
Conflict of interest: None declared.
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