A 58-year-old woman with chronic kidney disease of unknown etiology since 1995 and on three-week HD since 1999.
In April 2011 a frank TSH of 0.04 μIU/ml was investigated in routine tests, so it was referred in 2012 to endocrinological evaluation, where hyperthyroidism was confirmed by clinical manifestations.
Graves Basedow disease was diagnosed with thyroid scintigraphy showing goiter.
Anti-TSH receptor antibodies were not evaluated due to lack of access to this test.
He was treated with propylthiouracil, the only antithyroid drug available in our institution at the time of diagnosis, this treatment was maintained for 30 months, achieving euthyroidism and was gradually withdrawn.
Five months after drug withdrawal, suppressed TSH was again observed, but with normal T3 and T4, so it was decided to administer 131-I therapy.
The patient received17 mCi of 131-I in capsule form (as the next sodium starch), immediately after a complete HD session and hospitalized in radioactive isolation for 7 days.
There were no complications secondary to treatment.
It is worth noting that this patient presented residual diuresis, at 400 cc/day.
The first HD after 131-I administration was performed at 90 h with a Fresenius 4008 ml equipment and ultraethra tapered (QB) 300 ml (PES) 210 with a blood flow rate of 1.900 ml.
The second HD was at 46 h of the first (6th day), with the same equipment, with a PES 170 filter, using the same parameters of QB, QD and QT, obtaining a net UF of 2,000 ml.
Radiation exposure measurements were performed with Geiger Muller Fluke Biomedical model 489-110D meter in direct contact with the thyroid, at 1 and 1.5 meters from the patient on the days shown in Table 1, where rates are shown.
During HD sessions we measured the exposure rate to which the nurse in charge was exposed and the dialysis team; in addition, we took aliquots of 1 ml Alfa Bec blood and dialysis fluid 131MB in order to measure the activity.
1.
The radiation exposure rates after the first and second HD were 0 μSv/h and 0.3 μSv/h for the equipment, and 3 μSv/h and 0.36 μSv/h for the dialysis filter, respectively.
The exposure measurement of the nurse in charge of the HD sessions was performed with a direct reading dosimeter RAD-51/60/62, which resulted in 1.0 mR (10μSv) during the first HD session (4 h exposed).
It is worth noting that the nurse used the wet apron and sat down after a shielded biombo when she was not in direct contact with the patient.
Table 2 summarizes the activity of 131I measured in blood and dialysate fluid before, during and after HD sessions.
1.
One month after therapy thyroid function parameters still showed hyperthyroidism with TSH of 0.004 μIU/ml (VN: 0.27-4.2) and free T4 of 2.07 ng/dl (VN: 0.9-1.7).
After 4 months, normalization of TSH (2.31 μIU/ml) and decrease of free T4 (0.730 ng/ml) were observed, which confirmed the effectiveness of the treatment, after which the patient continued treatment with oxygen.
