Diagnosis, treatment, and management of gestational hypothyroidism. The TIROGEST study.

INTRODUCTION: There is no agreement on the procedures to be used for diagnosis and treatment of gestational thyroid dysfunction. Controversy still exists on the normal range of thyroid-stimulating hormone (TSH) levels and use of gestational hypothyroidism (GH) screening. The aim of this study was to assess diagnosis and treatment of thyroid dysfunction during pregnancy in a group of Spanish hospitals. STUDY DESIGN: This was a retrospective, multicenter study in pregnant females with GH attending Spanish healthcare centers from March 2013 to July 2014. Variables analyzed included diagnosis criteria for GH (availability of universal screening for gestational thyroid disorders and TSH reference values (RVs) by trimester of pregnancy): risk factors for GH, iodine intake from food or supplementation, gestational age (at diagnosis/treatment) and l-thyroxine treatment. RESULTS: Fourteen centers participated in the study. Universal screening was performed in only half of the centers, and only 14% had their own TSH RVs. Overall, 257 pregnant women were enrolled, 53.7% with hypothyroidism (HT) diagnosed before pregnancy (pre-GH) and 46.3% with HT diagnosed during pregnancy (intra-GH). A comparison of intra-GH and pre-GH women showed that intra-GH women made their first visit later (59.7% vs. 75.4% respectively before week 12, p=0.007) and had more frequently high TSH levels (>2.5µIU/ml) during the first trimester (94.4% vs. 67.0% respectively, p<0.001). CONCLUSIONS: Our results suggest that GH may be underdiagnosed or inadequately diagnosed in most healthcare centers. These findings suggest the need of improving the current practice in Spain.

Pancreas and kidney transplantation: long-term endocrine function.

OBJECTIVE: To describe the characteristics of metabolic control and beta-cell function in the long-term follow-up of patients with type-1 diabetes (T1D) who have undergone pancreas and kidney transplantation (PKTx). PATIENTS AND METHODS: Twelve patients (eight males/four females) with normal pancreas and kidney graft function for more than 15 yr were included. Patient age at the time of transplantation was 35.8 ± 6.9, with a duration of diabetes of 19.0 ± 4.6 yr and time on dialysis of 18.7 ± 12.4 months. In all the cases, bladder derivation was performed to drain exocrine secretion, with subsequent conversion to the intestinal tract in 42% of the patients. The functional evaluation was made at one, five, 10, and 15 yr after PKTx determining: glycosylated hemoglobin (HbA1c), oral glucose tolerance test (OGTT), measuring insulinemia, and anti-GAD antibody. RESULTS: Comparing the results between one and 15 yr after transplantation: (i) no differences were observed in either HbA1c (4.68% vs. 4.76%) or basal glycemia (71 vs. 79 mg/dL), but an increase was seen in the area under the curve (AUC) of glucose (11,983 vs. 15,875 mg/dL/120', p = 0.02); (ii) a trend to a reduction in basal insulinemia (24 vs. 15 mU/L, p = 0.11) and a trend to a reduction in the AUC of insulinemia (8446 vs. 7057 mU/L/120', p = 0.22) were observed. The OGTT was normal in six patients, intolerant in two and diabetic in four patients. No variations were seen in insulin resistance (FIRI, QUICKI). Anti-GAD antibody became positive in one case. CONCLUSIONS: The results of this study demonstrate that pancreas transplantation has long-term functional viability, being an essential strategy for the treatment of patients with T1D with end-stage renal failure. Nevertheless, lesser response to OGTT can be expected suggesting certain deterioration in the functional capability of the pancreas graft during follow-up.