Nephrol Dial Transplant (2008) 23: 2107
1
Division of Nephrology, Miulli Carlo Basile1
General Hospital, Acquaviva delle Luigi Vernaglione2
Fonti Carlo Lomonte1
2
Division of Nephrology, Hospital
of Manduria, Manduria, Italy
E-mail: basile.miulli@libero.it
1. Basile C, Lomonte C, Vernaglione L et al. The relationship between
the flow of arteriovenous fistula and cardiac output in haemodialysis
patients. Nephrol Dial Transplant 2008; 23: 282–287
2. Pfitzner J. Poiseuille and his law. Anaesthesia 1976; 31: 273–275
doi: 10.1093/ndt/gfn057
Advance Access publication 6 March 2008
Association of ANCA-positive vasculitis with thyroid
disease
Sir,
In the December 2007 issue of this journal, Lionaki et al.
[1] reported a case control study in which they found that
thyroid disease was associated with ANCA small vessel
disease, especially among women, and was most frequently
associated with MPO-ANCA. They did not find an as-
sociation with anti-thyroid drugs as suspected in several
previous papers. The authors state as a limitation of the
study that they cannot provide the specific diagnosis and
detailed clinical history of thyroid disease in these patients.
We are currently treating a 58-year-old female patient with
pauci-immune rapidly progressive glomerulonephritis due
to MPO-ANCA vasculitis. She presented with acute re-
nal failure (oedematous state, creatinine 3.5 mg/dl) and
severe anaemia (haemoglobin 6 g/dl), having been diag-
nosed with autoimmune hypothyroidism with Anti-TPO
and TSH receptor blocking antibodies 2 months before. She
had received thyroid hormones and also allopurinol, which
has been reported in association with p-ANCA vasculitis
[2]. After the diagnosis of RPGN had been established by
a percutaneous kidney biopsy, treatment with intravenous
cyclophosphamide and hydrocortisone was initiated. The
patient required three sessions of haemodialysis with ultra-
filtration due to pulmonary oedema; the first session was
complicated by a tonic–clonic seizure warranting admission
to the intensive care unit for one night. Currently the clin-
ical situation is stable with a maintenance dose of 100 mg
cyclophosphamide/day, creatinine levels ranging ∼2.5 mg/
dl and urine output sufficient with 125 mg torasemide and
100 mg spironolactone/day. Apart from the recently diag-
nosed autoimmune hypothyroidism, her past medical his-
tory included a mild restrictive lung disorder that had been
diagnosed as a patchy lung fibrosis in a CT scan in 2003,
but it did not cause severe problems in the following years
and the patient had ‘almost forgotten about it’. Our case
seems to support the findings of Lionaki et al. in that the
patient was female, had MPO-ANCA vasculitis and pre-
2107
vious thyroid disease but was not receiving anti-thyroid
medication.
Conflict of interest statement. None declared.
Department of Nephrology and Rothe H. M.
Hypertension, Klinikum Neumarkt Siegmund J.
Nürnberger strasse 12, D-92318 Müller H.
Neumarkt, Neumarkt, Bavaria Wopperer J.
92318, Germany
E-mail: hansjoerg.rothe@kfh-dialyse.de
1. Lionaki S, Hogan SL, Falk RJ et al. Association between thyroid disease
and its treatment with ANCA small-vessel vasculitis: a case control
study. Nephrol Dial Transplant 2007; 12: 3508–3515 (Epub 8 August
2007)
2. Choi HK, Merkel PA, Niles JL. ANCA-positive vasculitis associated
with allopurinol therapy. Clin Exp Rheumatol 1998; 6: 743–744
Downloaded from ndt.oxfordjournals.org by guest on March 20, 2011
doi: 10.1093/ndt/gfn030
Advance Access publication 10 March 2008
Reply
Sir,
We kindly thank you for the opportunity to comment on the
letter by Rothe et al. presenting a case with ANCA small
vessel vasculitis (ANCA-SVV) in the setting of autoim-
mune hypothyroidism [1]. Autoimmune thyroid disease is
relatively common in the general population and in females
particularly [2] while ANCA-SVV, a rare disease, is almost
equally distributed among genders [3]. As we recently re-
ported, a prior history of thyroid disease was 3.7 times
more likely among patients with ANCA-SVV compared to
controls and 5.6 times more frequent in women [4]. Ac-
cordingly, in the case described by Rothe and colleagues,
the absence of any exposure to thioamides eliminates any
chance of consideration of the established drug-induced
scenario for the development of ANCA-SVV [5]. The pa-
tient received a diagnosis of autoimmune hypothyroidism
with Anti-TPO and TSH receptor blocking 2 months be-
fore the diagnosis of ANCA-associated glomerulonephri-
tis. However, the natural course of autoimmune thyroid
disease varies substantially among patients with an asymp-
tomatic or sub-clinical phase, often preceding the overt
thyroid hormone depletion [6]. The patient described was
also MPO-ANCA positive, as has been reported in the ma-
jority of patients with thyroid disease and ANCA-SVV [5].
ANCA-SVV was proven by kidney biopsy with no other
expression of SVV in this particular episode, although the
findings of pulmonary fibrosis might also represent chronic
damage arising from manifestations of the ANCA-SVV in
the lungs, which preceded the diagnosis of autoimmune
thyroid disease, although the true onset of either disease
may be difficult to determine.
This association between thyroid disease and ANCA-
SVV, even in the absence of the use of anti-thyroid agents,