572 Article
Could Red Cell Distribution Width be a Marker in Hashimoto’s Thyroiditis?
Affiliations
Key words ▶ Hashimoto’s thyroiditis ● ▶ red cell distribution width ● ▶ inflammation ●
received 05.02.2014 first decision 28.04.2014 accepted 06.06.2014 Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1383564 Exp Clin Endocrinol Diabetes 2014; 122: 572–574 © J. A. Barth Verlag in Georg Thieme Verlag KG Stuttgart · New York ISSN 0947-7349 Correspondence G. Aktas, MD Department of Internal Medicine Abant Izzet Baysal University Hospital 14280 Bolu Turkey Tel.: + 90/374/2534 656 Fax: + 90/374/2534 615 [email protected]
G. Aktas1, M. Sit2, O. Dikbas3, B. K. Tekce4, H. Savli1, H. Tekce1, A. Alcelik1 1
Department of Internal Medicine, Abant Izzet Baysal University Hospital, Bolu, Turkey Department of General Surgery, Abant Izzet Baysal University Hospital, Bolu, Turkey 3 Department of Endocrinology, Abant Izzet Baysal University Hospital, Bolu, Turkey 4 Department of Medical Biochemistry, Abant Izzet Baysal University Hospital, Bolu, Turkey 2
Abstract
▼
Aims: Hashimoto’s Thyroiditis (HT) is the most common autoimmune thyroiditis worldwide and characterized with lymphomonocytic inflammation of the thyroid gland. Red cell distribution width (RDW) reflects erythrocyte anisocytosis and besides it increases in iron deficiency anemia, recent studies reported that RDW was also associated with conditions characterized with overt or subclinical inflammation. We aimed to answer whether RDW increased in Hashimoto’s thyroiditis. Methods: Patients with HT admitted to outpatient clinic of our hospital were included to the study. Patients with anemia (especially iron deficiency), diabetes mellitus, chronic inflammatory disease and on medication that may affect hemogram results (e. g., aspirin) excluded from the
Introduction
▼
Hashimoto’s Thyroiditis (HT) is the most common autoimmune thyroiditis worldwide. The prevalence of the disease reaches as high as 6 % in iodine sufficient regions [1]. It usually effects female population [2]. The disease is characterized with lymphomonocytic inflammation of the thyroid gland and with an increase in serum levels of anti-thyroid peroxidase (anti-TPO) and/or anti-thyroglobulin (Anti-Tg) auto-antibodies [3]. Red cell distribution width (RDW) reflects erythrocyte anisocytosis. Despite it increases in iron deficiency anemia recent studies reported that RDW was associated with conditions characterized with overt or subclinical inflammation; such as hypertension [4], heart failure [5, 6], myocardial infarction [7], inflammatory bowel diseases [8], rheumatoid arthritis [9], hepatosteatosis [10] and pneumonia [11]. Furthermore, RDW has been found to be a predictor of mortality in several diseases [12–14]. Elevation in RDW in such
study. Patient characteristics, thyroid stimulating hormone (TSH), Free T3 (FT3), Free T4 (FT4), Anti-thyroid peroxidase (Anti-TPO), Anti-Thyroglobulin (Anti-TG), leukocyte count (WBC), Hemoglobin (Hb), Hematocrit (Htc), mean corpuscular volume (MCV), RDW and platelet count (PLT) values of the study cohort were obtained from computerized database of our institution. Results: There was no significant difference between study and control groups in terms of WBC, Hb, Htc, MCV, PLT, PDW and FT3 levels. However, FT4 level was significantly lower and TSH was significantly higher in study group compared to controls. RDW was significantly increased in study group compared to control group. Conclusion: We suggest that elevated RDW values in patients without iron deficiency anemia may require further evaluation for HT, especially in female population.
inflammatory conditions reflects the increase in serum levels of inflammatory molecules (IL-6, TNF-a and hepcidin) [15]. Studies on RDW have proven that it might have diagnostic or prognostic role in certain conditions [16]. Various studies reported an association between elevated levels of RDW and cardiovascular morbidity-mortality [17, 18]. Moreover it is suggested to predict even the risk of future cardiovascular diseases [19]. Because RDW increases in inflammatory conditions and because HT is also characterized with lymphomonocytic inflammation, in present retrospective study, we aimed to answer the question whether RDW increased in Hashimoto’s thyroiditis.
Materials and Methods
▼
Patients with Hashimoto’s thyroiditis admitted to outpatient clinic of our hospital were included to the study. The data obtained from study group
Aktas G et al. Red Cell Distribution width in Hashimato’s Thyroiditis … Exp Clin Endocrinol Diabetes 2014; 122: 572–574
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Authors
Article 573
Results
▼
We included a total of 165 subjects into the study (102 patients with Hashimoto’s thyroiditis and 63 as control subjects). ▶ Table 1 shows general characteristics and laboratory data of ● the study and the control groups. Mean age of the subjects in study (36.8 ± 12.1 years) and control (38.6 ± 8.8 years) groups was not statistically different (p = 0.32). 85 of 102 patients (83.3 %) in study group and 55 of 63 subjects (87.7 %) in control group were women. Gender was not statistically different between groups (p = 0.49). There was no significant difference between study and control groups in terms of WBC, Hb, Htc, MCV, PLT, PDW and FT3 levels (all p > 0.05). However, median FT4 level of the study (1.13 [0.5– 3.9]) and control (1.22 [0.7–1.65]) groups were in normal range but significantly lower in study group compared to controls (p = 0.013). In addition, median TSH level of the study group (2.25 [0.01–47.5]) was higher compared to control subjects (1.43 [0.3–4.9]). The difference was statistically significant (p < 0.001). RDW in study group (16.2 [14.9–17.8]) was significantly increased compared to control (16 [12–17]) group (p = 0.015). Table 1 General characteristics and laboratory data of the study and the control groups. Study group Gender
age (years) WBC (u/mm3) Hb (gr/dL) Htc ( %) MCV (fL) RDW ( %) PLT (u/mm3) TSH (uIU/mL) FT3 (pg/mL) FT4 (ng/dL)
Control Group
Women (n)
85
55
Men (n)
17
8
Mean ± SD 38.6 ± 8.8 7.1 ± 1.5 13.6 ± 1.4 40.8 ± 3.9 85.8 ± 5.1 Median (Min–Max) 16.2 (14.9–17.8) 16 (12–17) 272 (175–507) 276 (149–477) 2.2 (0.01–47.5) 1.4 (0.3–4.9) 3.23 (1–8.3) 3.24 (2.3–4.5) 1.13 (0.5–3.94) 1.22 (0.7–1.65) 36.8 ± 12.1 6.9 ± 1.8 13.3 ± 1.2 39.9 ± 3.2 85.4 ± 6.3
p 0.49 0.32 0.29 0.10 0.12 0.66 0.015 0.69 < 0.01 0.39 0.013
Discussion
▼
The main finding of present study is that RDW increased in patients with HT compared to healthy controls. Several studies in literature reported that TSH was associated with RDW. Montagnana et al. have been reported that RDW was positively correlated with serum TSH levels [20]. Increased TSH was associated with increased RDW in their study. Furthermore, it is reported that RDW was significantly higher in patients with hypothyroidism compared to euthyroid subjects [21]. Although there was no information about the TSH levels of the subjects in that study, hypothyroidism is known to be characterized with increased levels of TSH. At this point, the results of the report mentioned above were similar to those of Montagnana et al. study. TSH was also higher in study group compared to control group in our study. Therefore, our results are consisted with literature. Why RDW increases in HT? Patients with HT may develop hypothyroidism. Bremmer et al. reported that serum T4 was negatively correlated with RDW [22]. Similar to the data in literature, T4 was significantly lower and RDW was significantly increased in study group compared to controls in our report. Therefore, results of present study are consisted with literature. HT is characterized with lymphomonocytic inflammation of the thyroid gland [23]. On the other hand, RDW was considered to be associated with inflammatory diseases [24, 25], in fact, authors suggest RDW should be assessed with other inflammatory molecules in clinical practice [26]. Therefore, it is not surprising RDW increased in HT, an inflammatory disease of thyroid gland. Authors paid an attention on increased rate of subclinical hypothyroidism in patients with deep venous thrombosis [27]. The relationship between hypothyroidism and thrombosis was described by Müller et al., whom reported increased levels of Factor 7:C in patients with subclinical hypothyroidism [28]. Similarly, authors stated decreased clearance of factors II, VII, IX and X from plasma in patients with myxoedema [29]. Moreover, both fibrinogen [30] and d-dimer [31] found to be elevated in hypothyroidism. It has been reported that hypothyroidism should be associated with prothrombotic situations [32]. These findings suggest hypercoagulable state in patients with overt and subclinical hypothyroidism. An association described between RDW and cerebral sinus thrombosis [33] and pulmonary embolism [34]. These findings suggest that increase in RDW may be associated with thrombotic states. Because thrombotic states associated with both increased RDW and hypothyroidism, which characterized with elevated TSH levels, it can be speculated that elevation in TSH correlates with RDW increase. Present study has 2 major limitations; retrospective design of the work, and relatively small study population. Therefore, prospective larger studies are needed to confirm our results. In conclusion, we suggest that elevated RDW values in patients without iron deficiency anemia may require further evaluation for Hashimoto’s Thyroiditis, especially in female population.
Funding: This work has not been funded by any organizations. Conflict of interest: None to declare.
Aktas G et al. Red Cell Distribution width in Hashimato’s Thyroiditis … Exp Clin Endocrinol Diabetes 2014; 122: 572–574
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
at the time of HT diagnosis. We included only the patients with ultrasound scan findings compatible with thyroiditis. Healthy volunteers visited our outpatient clinics for a routine check-up were included as control group. Patients with anemia (especially iron deficiency), diabetes mellitus, chronic inflammatory disease and on medication that may affect hemogram results (e. g., aspirin) excluded from the study. Patient characteristics and thyroid stimulating hormone (TSH), Free T3 (FT3), Free T4 (FT4), Anti-thyroid peroxidase (Anti-TPO), Anti-Thyroglobulin (AntiTG), leukocyte count (WBC), Hemoglobin (Hb), Hematocrit (Htc), mean corpuscular volume (MCV), RDW and platelet count (PLT) levels of the study cohort were obtained from computerized database of our institution. Statistical analyses were performed with SPSS software (SPSS 15.0 for Windows, Chicago, IL, USA). Normally distributed variables expressed as mean ± SD and conducted with independent samples t test whereas, non-normally distributed variables expressed as median (min-max) and conducted with Mann-Whitney U test. A p value < 0.05 was considered as statistically significant. The study was approved by local ethics committee of Abant Izzet Baysal University.
References 1 Bjoro T, Holmen J, Kruger O et al. Prevalence of thyroid disease, thyroid dysfunction and thyroid peroxidase antibodies in a large, unselected population. The Health Study of Nord-Trondelag (HUNT). Eur J Endocrinol 2000; 143: 639–647 2 Lorini R, Gastaldi R, Traggiai C et al. Hashimoto’s Thyroiditis. Pediatric endocrinology reviews: PER 2003; 1: 205–211 discussion 211 3 Tunbridge WMG, Brewis M, French JM et al. Natural-History of Autoimmune-Thyroiditis. Brit Med J 1981; 282: 258–262 4 Gunebakmaz O, Kaya MG, Duran M et al. Red blood cell distribution width in ‘non-dippers’ versus ‘dippers’. Cardiology 2012; 123: 154–159 5 Nishizaki Y, Yamagami S, Suzuki H et al. Red Blood Cell Distribution Width as an Effective Tool for Detecting Fatal Heart Failure in Superelderly Patients. Internal Med 2012; 51: 2271–2276 6 Makhoul BF, Khourieh A, Kaplan M et al. Relation between changes in red cell distribution width and clinical outcomes in acute decompensated heart failure. Int J Cardiol 2013; 167: 1412–1416 7 Karabulut A, Uzunlar B. Correlation Between Red Cell Distribution Width and Coronary Ectasia in the Acute Myocardial Infarction. Clin Appl Thromb-Hem 2012; 18: 551–552 8 Yesil A, Senates E, Bayoglu IV et al. Red Cell Distribution Width: A Novel Marker of Activity in Inflammatory Bowel Disease. Gut Liver 2011; 5: 460–467 9 Lee WS, Kim TY. Relation Between Red Blood Cell Distribution Width and Inflammatory Biomarkers in Rheumatoid Arthritis. Arch Pathol Lab Med 2010; 134: 505–506 10 Aktas G, Alcelik A, Tekce BK et al. Mean Platelet Volume and Red Cell distribution width in Hepatosteatosis. National Journal of Medical Research 2013; 3: 264–266 11 Braun E, Domany E, Kenig Y et al. Elevated red cell distribution width predicts poor outcome in young patients with community acquired pneumonia. Crit Care 2011; 15 12 Hong N, Oh J, Kang SM et al. Red blood cell distribution width predicts early mortality in patients with acute dyspnea. Clin Chim Acta 2012; 413: 992–997 13 Hunziker S, Celi LA, Lee J et al. Red cell distribution width improves the simplified acute physiology score for risk prediction in unselected critically ill patients. Crit Care 2012; 16 14 Ku NS, Kim HW, Oh HJ et al. Red Blood Cell Distribution Width Is an Independent Predictor of Mortality in Patients with Gram-Negative Bacteremia. Shock 2012; 38: 123–127 15 de Gonzalo-Calvo D, de Luxan-Delgado B, Rodriguez-Gonzalez S et al. Interleukin 6, soluble tumor necrosis factor receptor I and red blood cell distribution width as biological markers of functional dependence in an elderly population: A translational approach. Cytokine 2012; 58: 193–198 16 Marsh W Jr, Bishop J, Darcy T. Evaluation of red cell volume distribution width (RDW). Hematologic pathology 1987; 1: 117 17 Felker GM, Allen LA, Pocock SJ et al. Red cell distribution width as a novel prognostic marker in heart failure – Data from the CHARM program and the Duke Databank. J Am Coll Cardiol 2007; 50: 40–47 18 Tonelli M, Sacks F, Arnold M et al. Relation between red blood cell distribution width and cardiovascular event rate in people with coronary disease. Circulation 2008; 117: 163–168
19 Vaya A, Hernandez JL, Zorio E et al. Association between red blood cell distribution width and the risk of future cardiovascular events. Clin Hemorheol Micro 2012; 50: 221–225 20 Montagnana M, Lippi G, Targher G et al. The red blood cell distribution width is associated with serum levels of thyroid stimulating hormone in the general population. Int J Lab Hematol 2009; 31: 581–582 21 Bashir H, Bhat MH, Farooq R et al. Comparison of hematological parameters in untreated and treated subclinical hypothyroidism and primary hypothyroidism patients. Medical journal of the Islamic Republic of Iran 2012; 26: 172 22 Bremner AP, Feddema P, Joske DJ et al. Significant association between thyroid hormones and erythrocyte indices in euthyroid subjects. Clin Endocrinol 2012; 76: 304–311 23 Hammerstad SS, Jahnsen FL, Tauriainen S et al. Inflammation and Increased Myxovirus Resistance Protein A Expression in Thyroid Tissue in the Early Stages of Hashimoto’s Thyroiditis. Thyroid 2013; 23: 334–341 24 Hu Z-D, Chen Y, Zhang L et al. Red blood cell distribution width is a potential index to assess the disease activity of systemic lupus erythematosus. Clin Chim Acta 2013; 425: 202–205 25 Ramirez-Moreno JM, Gonzalez-Gomez M, Ollero-Ortiz A et al. Relation between red blood cell distribution width and ischemic stroke: a casecontrol study. Int J Stroke 2013; 8: E36 26 Ephrem G. Red Blood Cell Distribution Width Should Indeed Be Assessed with Other Inflammatory Markers in Daily Clinical Practice. Cardiology 2013; 124: 61 27 Squizzato A, Romualdi E, Piantanida E et al. Subclinical hypothyroidism and deep venous thrombosis. A pilot cross-sectional study. Thrombosis and haemostasis 2007; 97: 803–806 28 Müller B, Tsakiris D, Roth C et al. Haemostatic profile in hypothyroidism as potential risk factor for vascular or thrombotic disease. European journal of clinical investigation 2001; 31: 131–137 29 Loeliger E, Van Der Esch B, Mattern MJ et al. The biological disappearance rate of prothrombin, factors VII, IX and X from plasma in hypothyroidism, hyperthyroidism, and during fever. Thromb Diath Haemorrh 1964; 10: 267–277 30 Chadarevian R, Bruckert E, Ankri A et al. Relationship between thyroid hormones and plasma D-dimer levels. Thrombosis and haemostasis 1998; 79: 99–103 31 Chadarevian R, Bruckert E, Giral P et al. Relationship between thyroid hormones and fibrinogen levels. Blood Coagul Fibrin 1999; 10: 481–486 32 Marongiu F, Biondi G, Conti M et al. Is a hypercoagulable state present in hypothyroidism? Thrombosis and haemostasis 1992; 67: 729 33 Demir R, Saritemur M, Ozel L et al. Red Cell Distribution Width Identifies Cerebral Venous Sinus Thrombosis in Patients With Headache. Clinical and applied thrombosis/hemostasis: official journal of the International Academy of Clinical and Applied Thrombosis/Hemostasis 2013 34 Ozsu S, Abul Y, Gunaydin S et al. Prognostic Value of Red Cell Distribution Width in Patients With Pulmonary Embolism. Clinical and applied thrombosis/hemostasis: official journal of the International Academy of Clinical and Applied Thrombosis/Hemostasis 2012
Aktas G et al. Red Cell Distribution width in Hashimato’s Thyroiditis … Exp Clin Endocrinol Diabetes 2014; 122: 572–574
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
574 Article
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Could Red Cell Distribution Width be a Marker in Hashimoto’s Thyroiditis?
Affiliations
Key words ▶ Hashimoto’s thyroiditis ● ▶ red cell distribution width ● ▶ inflammation ●
received 05.02.2014 first decision 28.04.2014 accepted 06.06.2014 Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1383564 Exp Clin Endocrinol Diabetes 2014; 122: 572–574 © J. A. Barth Verlag in Georg Thieme Verlag KG Stuttgart · New York ISSN 0947-7349 Correspondence G. Aktas, MD Department of Internal Medicine Abant Izzet Baysal University Hospital 14280 Bolu Turkey Tel.: + 90/374/2534 656 Fax: + 90/374/2534 615 [email protected]
G. Aktas1, M. Sit2, O. Dikbas3, B. K. Tekce4, H. Savli1, H. Tekce1, A. Alcelik1 1
Department of Internal Medicine, Abant Izzet Baysal University Hospital, Bolu, Turkey Department of General Surgery, Abant Izzet Baysal University Hospital, Bolu, Turkey 3 Department of Endocrinology, Abant Izzet Baysal University Hospital, Bolu, Turkey 4 Department of Medical Biochemistry, Abant Izzet Baysal University Hospital, Bolu, Turkey 2
Abstract
▼
Aims: Hashimoto’s Thyroiditis (HT) is the most common autoimmune thyroiditis worldwide and characterized with lymphomonocytic inflammation of the thyroid gland. Red cell distribution width (RDW) reflects erythrocyte anisocytosis and besides it increases in iron deficiency anemia, recent studies reported that RDW was also associated with conditions characterized with overt or subclinical inflammation. We aimed to answer whether RDW increased in Hashimoto’s thyroiditis. Methods: Patients with HT admitted to outpatient clinic of our hospital were included to the study. Patients with anemia (especially iron deficiency), diabetes mellitus, chronic inflammatory disease and on medication that may affect hemogram results (e. g., aspirin) excluded from the
Introduction
▼
Hashimoto’s Thyroiditis (HT) is the most common autoimmune thyroiditis worldwide. The prevalence of the disease reaches as high as 6 % in iodine sufficient regions [1]. It usually effects female population [2]. The disease is characterized with lymphomonocytic inflammation of the thyroid gland and with an increase in serum levels of anti-thyroid peroxidase (anti-TPO) and/or anti-thyroglobulin (Anti-Tg) auto-antibodies [3]. Red cell distribution width (RDW) reflects erythrocyte anisocytosis. Despite it increases in iron deficiency anemia recent studies reported that RDW was associated with conditions characterized with overt or subclinical inflammation; such as hypertension [4], heart failure [5, 6], myocardial infarction [7], inflammatory bowel diseases [8], rheumatoid arthritis [9], hepatosteatosis [10] and pneumonia [11]. Furthermore, RDW has been found to be a predictor of mortality in several diseases [12–14]. Elevation in RDW in such
study. Patient characteristics, thyroid stimulating hormone (TSH), Free T3 (FT3), Free T4 (FT4), Anti-thyroid peroxidase (Anti-TPO), Anti-Thyroglobulin (Anti-TG), leukocyte count (WBC), Hemoglobin (Hb), Hematocrit (Htc), mean corpuscular volume (MCV), RDW and platelet count (PLT) values of the study cohort were obtained from computerized database of our institution. Results: There was no significant difference between study and control groups in terms of WBC, Hb, Htc, MCV, PLT, PDW and FT3 levels. However, FT4 level was significantly lower and TSH was significantly higher in study group compared to controls. RDW was significantly increased in study group compared to control group. Conclusion: We suggest that elevated RDW values in patients without iron deficiency anemia may require further evaluation for HT, especially in female population.
inflammatory conditions reflects the increase in serum levels of inflammatory molecules (IL-6, TNF-a and hepcidin) [15]. Studies on RDW have proven that it might have diagnostic or prognostic role in certain conditions [16]. Various studies reported an association between elevated levels of RDW and cardiovascular morbidity-mortality [17, 18]. Moreover it is suggested to predict even the risk of future cardiovascular diseases [19]. Because RDW increases in inflammatory conditions and because HT is also characterized with lymphomonocytic inflammation, in present retrospective study, we aimed to answer the question whether RDW increased in Hashimoto’s thyroiditis.
Materials and Methods
▼
Patients with Hashimoto’s thyroiditis admitted to outpatient clinic of our hospital were included to the study. The data obtained from study group
Aktas G et al. Red Cell Distribution width in Hashimato’s Thyroiditis … Exp Clin Endocrinol Diabetes 2014; 122: 572–574
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Authors
Article 573
Results
▼
We included a total of 165 subjects into the study (102 patients with Hashimoto’s thyroiditis and 63 as control subjects). ▶ Table 1 shows general characteristics and laboratory data of ● the study and the control groups. Mean age of the subjects in study (36.8 ± 12.1 years) and control (38.6 ± 8.8 years) groups was not statistically different (p = 0.32). 85 of 102 patients (83.3 %) in study group and 55 of 63 subjects (87.7 %) in control group were women. Gender was not statistically different between groups (p = 0.49). There was no significant difference between study and control groups in terms of WBC, Hb, Htc, MCV, PLT, PDW and FT3 levels (all p > 0.05). However, median FT4 level of the study (1.13 [0.5– 3.9]) and control (1.22 [0.7–1.65]) groups were in normal range but significantly lower in study group compared to controls (p = 0.013). In addition, median TSH level of the study group (2.25 [0.01–47.5]) was higher compared to control subjects (1.43 [0.3–4.9]). The difference was statistically significant (p < 0.001). RDW in study group (16.2 [14.9–17.8]) was significantly increased compared to control (16 [12–17]) group (p = 0.015). Table 1 General characteristics and laboratory data of the study and the control groups. Study group Gender
age (years) WBC (u/mm3) Hb (gr/dL) Htc ( %) MCV (fL) RDW ( %) PLT (u/mm3) TSH (uIU/mL) FT3 (pg/mL) FT4 (ng/dL)
Control Group
Women (n)
85
55
Men (n)
17
8
Mean ± SD 38.6 ± 8.8 7.1 ± 1.5 13.6 ± 1.4 40.8 ± 3.9 85.8 ± 5.1 Median (Min–Max) 16.2 (14.9–17.8) 16 (12–17) 272 (175–507) 276 (149–477) 2.2 (0.01–47.5) 1.4 (0.3–4.9) 3.23 (1–8.3) 3.24 (2.3–4.5) 1.13 (0.5–3.94) 1.22 (0.7–1.65) 36.8 ± 12.1 6.9 ± 1.8 13.3 ± 1.2 39.9 ± 3.2 85.4 ± 6.3
p 0.49 0.32 0.29 0.10 0.12 0.66 0.015 0.69 < 0.01 0.39 0.013
Discussion
▼
The main finding of present study is that RDW increased in patients with HT compared to healthy controls. Several studies in literature reported that TSH was associated with RDW. Montagnana et al. have been reported that RDW was positively correlated with serum TSH levels [20]. Increased TSH was associated with increased RDW in their study. Furthermore, it is reported that RDW was significantly higher in patients with hypothyroidism compared to euthyroid subjects [21]. Although there was no information about the TSH levels of the subjects in that study, hypothyroidism is known to be characterized with increased levels of TSH. At this point, the results of the report mentioned above were similar to those of Montagnana et al. study. TSH was also higher in study group compared to control group in our study. Therefore, our results are consisted with literature. Why RDW increases in HT? Patients with HT may develop hypothyroidism. Bremmer et al. reported that serum T4 was negatively correlated with RDW [22]. Similar to the data in literature, T4 was significantly lower and RDW was significantly increased in study group compared to controls in our report. Therefore, results of present study are consisted with literature. HT is characterized with lymphomonocytic inflammation of the thyroid gland [23]. On the other hand, RDW was considered to be associated with inflammatory diseases [24, 25], in fact, authors suggest RDW should be assessed with other inflammatory molecules in clinical practice [26]. Therefore, it is not surprising RDW increased in HT, an inflammatory disease of thyroid gland. Authors paid an attention on increased rate of subclinical hypothyroidism in patients with deep venous thrombosis [27]. The relationship between hypothyroidism and thrombosis was described by Müller et al., whom reported increased levels of Factor 7:C in patients with subclinical hypothyroidism [28]. Similarly, authors stated decreased clearance of factors II, VII, IX and X from plasma in patients with myxoedema [29]. Moreover, both fibrinogen [30] and d-dimer [31] found to be elevated in hypothyroidism. It has been reported that hypothyroidism should be associated with prothrombotic situations [32]. These findings suggest hypercoagulable state in patients with overt and subclinical hypothyroidism. An association described between RDW and cerebral sinus thrombosis [33] and pulmonary embolism [34]. These findings suggest that increase in RDW may be associated with thrombotic states. Because thrombotic states associated with both increased RDW and hypothyroidism, which characterized with elevated TSH levels, it can be speculated that elevation in TSH correlates with RDW increase. Present study has 2 major limitations; retrospective design of the work, and relatively small study population. Therefore, prospective larger studies are needed to confirm our results. In conclusion, we suggest that elevated RDW values in patients without iron deficiency anemia may require further evaluation for Hashimoto’s Thyroiditis, especially in female population.
Funding: This work has not been funded by any organizations. Conflict of interest: None to declare.
Aktas G et al. Red Cell Distribution width in Hashimato’s Thyroiditis … Exp Clin Endocrinol Diabetes 2014; 122: 572–574
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
at the time of HT diagnosis. We included only the patients with ultrasound scan findings compatible with thyroiditis. Healthy volunteers visited our outpatient clinics for a routine check-up were included as control group. Patients with anemia (especially iron deficiency), diabetes mellitus, chronic inflammatory disease and on medication that may affect hemogram results (e. g., aspirin) excluded from the study. Patient characteristics and thyroid stimulating hormone (TSH), Free T3 (FT3), Free T4 (FT4), Anti-thyroid peroxidase (Anti-TPO), Anti-Thyroglobulin (AntiTG), leukocyte count (WBC), Hemoglobin (Hb), Hematocrit (Htc), mean corpuscular volume (MCV), RDW and platelet count (PLT) levels of the study cohort were obtained from computerized database of our institution. Statistical analyses were performed with SPSS software (SPSS 15.0 for Windows, Chicago, IL, USA). Normally distributed variables expressed as mean ± SD and conducted with independent samples t test whereas, non-normally distributed variables expressed as median (min-max) and conducted with Mann-Whitney U test. A p value < 0.05 was considered as statistically significant. The study was approved by local ethics committee of Abant Izzet Baysal University.
References 1 Bjoro T, Holmen J, Kruger O et al. Prevalence of thyroid disease, thyroid dysfunction and thyroid peroxidase antibodies in a large, unselected population. The Health Study of Nord-Trondelag (HUNT). Eur J Endocrinol 2000; 143: 639–647 2 Lorini R, Gastaldi R, Traggiai C et al. Hashimoto’s Thyroiditis. Pediatric endocrinology reviews: PER 2003; 1: 205–211 discussion 211 3 Tunbridge WMG, Brewis M, French JM et al. Natural-History of Autoimmune-Thyroiditis. Brit Med J 1981; 282: 258–262 4 Gunebakmaz O, Kaya MG, Duran M et al. Red blood cell distribution width in ‘non-dippers’ versus ‘dippers’. Cardiology 2012; 123: 154–159 5 Nishizaki Y, Yamagami S, Suzuki H et al. Red Blood Cell Distribution Width as an Effective Tool for Detecting Fatal Heart Failure in Superelderly Patients. Internal Med 2012; 51: 2271–2276 6 Makhoul BF, Khourieh A, Kaplan M et al. Relation between changes in red cell distribution width and clinical outcomes in acute decompensated heart failure. Int J Cardiol 2013; 167: 1412–1416 7 Karabulut A, Uzunlar B. Correlation Between Red Cell Distribution Width and Coronary Ectasia in the Acute Myocardial Infarction. Clin Appl Thromb-Hem 2012; 18: 551–552 8 Yesil A, Senates E, Bayoglu IV et al. Red Cell Distribution Width: A Novel Marker of Activity in Inflammatory Bowel Disease. Gut Liver 2011; 5: 460–467 9 Lee WS, Kim TY. Relation Between Red Blood Cell Distribution Width and Inflammatory Biomarkers in Rheumatoid Arthritis. Arch Pathol Lab Med 2010; 134: 505–506 10 Aktas G, Alcelik A, Tekce BK et al. Mean Platelet Volume and Red Cell distribution width in Hepatosteatosis. National Journal of Medical Research 2013; 3: 264–266 11 Braun E, Domany E, Kenig Y et al. Elevated red cell distribution width predicts poor outcome in young patients with community acquired pneumonia. Crit Care 2011; 15 12 Hong N, Oh J, Kang SM et al. Red blood cell distribution width predicts early mortality in patients with acute dyspnea. Clin Chim Acta 2012; 413: 992–997 13 Hunziker S, Celi LA, Lee J et al. Red cell distribution width improves the simplified acute physiology score for risk prediction in unselected critically ill patients. Crit Care 2012; 16 14 Ku NS, Kim HW, Oh HJ et al. Red Blood Cell Distribution Width Is an Independent Predictor of Mortality in Patients with Gram-Negative Bacteremia. Shock 2012; 38: 123–127 15 de Gonzalo-Calvo D, de Luxan-Delgado B, Rodriguez-Gonzalez S et al. Interleukin 6, soluble tumor necrosis factor receptor I and red blood cell distribution width as biological markers of functional dependence in an elderly population: A translational approach. Cytokine 2012; 58: 193–198 16 Marsh W Jr, Bishop J, Darcy T. Evaluation of red cell volume distribution width (RDW). Hematologic pathology 1987; 1: 117 17 Felker GM, Allen LA, Pocock SJ et al. Red cell distribution width as a novel prognostic marker in heart failure – Data from the CHARM program and the Duke Databank. J Am Coll Cardiol 2007; 50: 40–47 18 Tonelli M, Sacks F, Arnold M et al. Relation between red blood cell distribution width and cardiovascular event rate in people with coronary disease. Circulation 2008; 117: 163–168
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