it has been reported that hypothyroidism may occur in 23.1% of stage 4 chronic kidney disease ( ckd ) patients , and ranges from 0 to 9.5% in end - stage kidney disease ( eskd ) patients . in general , life - threatening thyrotoxicosis or thyroid storm is rare , especially in hemodialysis ( hd ) patients , and is characterized by multisystem involvement and a high mortality rate if not immediately recognized and treated [ 3 , 4 ] . a multimodality treatment approach to patients with thyroid storm should be used , including -adrenergic blockade , antithyroid drug therapy , inorganic iodine , corticosteroid therapy , volume resuscitation , and respiratory support and monitoring in an intensive care unit . we report a case of severe symptomatic thyroid storm in a patient receiving long - term hd and glucocorticoid therapy . a 56-year - old female japanese patient with diabetic nephropathy had been on maintenance hd three times a week since january 2006 . she was diagnosed with rheumatoid arthritis ( ra ) and was taking prednisolone at a dose of 4 mg per day . in august 2010 , she began complaining of dyspnea , nausea , and fever . one month earlier , she had had severe high blood pressure ( 180/78 mm hg ) , tachycardia ( 110/min ) , and cardiomegaly . the nephrologist made a presumptive diagnosis of congestive heart failure , and suggested she lose body weight gradually . on physical examination , her blood pressure was 200/58 mm hg , pulse 148 beats / min and regular , and temperature 38.2c . she had fine - finger tremor and a slightly enlarged thyroid gland without palpable nodules , which are integumentary changes suggestive of hyperthyroidism . the heart examination showed s3 on apex and a grade 2/6 systolic murmur , and coarse crackles were present in both lungs , with slight peripheral edema . a chest x - ray showed cardiomegaly ( cardiothoracic ratio 58% ) with pulmonary congestion . laboratory data on admission were compatible with chronic renal failure receiving hd ( serum creatinine 5.18 mg / dl ; urea nitrogen 66 mg / dl ) . a blood test showed hemoglobin of 11.0 g / dl , hematocrit 35.1% and white blood cell count 9,700/l . a thyroid function test revealed a tsh level of < 0.01 iu / ml ( normal 0.55 ) , ft4 level > 7.8 ng / dl ( normal 0.91.7 ) , ft3 level 11.4 pg / ml ( normal 2.34.3 ) , and tsh receptor antibody 10.9 iu / l ( normal < 1 ) . on the basis of the burch - wartofsky score , which is widely used as a global scale for the evaluation of thyrotoxicosis , the patient 's condition was diagnosed as thyroid storm due to graves disease [ thyrotoxicosis with hyperthermia ( 10 points ) , agitation ( 10 points ) , gastrointestinal symptoms , nausea , vomiting ( 10 points ) , tachycardia ( 25 points ) , and moderate heart failure ( 10 points ) ] . treatment was initiated with methimazole ( mmi ) at a dose of 15 mg per day , and hd was performed . her body weight was adjusted to improve the pulmonary congestion , hypertension , and level of atrial natriuretic peptide ( anp ) for hyperthyroidism - induced weight loss . target dry weight was decreased gradually , ranging from 0.2 to 1.0 kg ( median 0.4 ) at each dialysis . a few days later , agitation and gastrointestinal symptoms disappeared while her plasma level of anp decreased from 202 to 100 pg / ml ; we continued to reduce her target dry weight . the patient 's ft4 level decreased to 2.6 ng / dl when titration of the mmi dose was started . propranolol was maintained for control of hypertension and sinus tachycardia , and the same dosage of glucocorticoid as before admission was also continued . since the thyroid function parameters were normalized , she was discharged from the hospital and her dry weight was finally reduced from 47.2 to 39.2 kg . approximately 1 year after discharge , she is well and without any subjective symptoms . it has been reported that hypothyroidism may occur in 23.1% of stage 4 ckd patients , and ranges from 0 to 9.5% in eskd patients . in general , life - threatening thyrotoxicosis or thyroid storm is rare , especially in hd patients , and is characterized by multisystem involvement and a high mortality rate if not immediately recognized and treated . the diagnosis of thyroid storm was determined on the basis of the burch - wartofsky score , which is widely used for evaluation of the severity of thyrotoxicosis [ 4 , 5 ] . in this case , clinical findings showed a total score of 65 or more , which is highly suggestive of definite thyroid storm . ckd affects both the hypothalamus - pituitary - thyroid axis and peripheral metabolism of thyroid hormones [ 6 , 7 ] . serum thyrotropin concentrations are usually normal or elevated , and free and total t3 and t4 concentrations are normal or low in patients with ckd . it is possible that some of these patients had impaired renal handling of iodine , resulting in elevation of serum iodine levels with prolongation of the wolff - chaikoff effect [ 7 , 8 ] . since our patient was confirmed as euthyroid 5 months before admission , her thyroid function might have risen gradually over several months . the other feature was that she had been prescribed prednisolone for several years for the treatment of ra by a rheumatologist . glucocorticoid agents ( e.g. prednisone or dexamethasone ) inhibit t4-to - t3 conversion , and the effect of the agent enables rapid reduction of serum t3 in patients with thyroid storm or severe cardiac disease . thus , a variety of signs and symptoms characterized by thyrotoxicosis was probably masked by long - term hd and glucocorticoid therapy . ra and graves disease are two common autoimmune diseases with similar prevalence in the general population and both of them affect predominantly middle - aged women . recently , a possible common pathogenic mechanism in graves disease and ra involving an insulin - like growth factor receptor-1 ( igf1-r ) on fibroblasts , a pathway that mediates inflammatory responses , was reported . moreover , it was suggested that a functional variant of the fcrl3 gene , encoding fc receptor - like 3 , is associated with ra and several autoimmune diseases , including graves disease . a multimodality treatment approach should be used in patients with thyroid storm , including -adrenergic blockade , antithyroid drug therapy , inorganic iodine , corticosteroid therapy , volume resuscitation , and if necessary , respiratory support and monitoring in an intensive care unit . the present case was treated using oral prednisolone , a reduced dose of mmi and -adrenergic blockade , with careful consideration of her body weight , loss of kidney function , drug removal by dialysis , and accumulation of the drug in the body . antithyroid drugs , specifically thionamides ( either mmi or propylthiouracil ) , are commonly used and primarily interfere with thyroid hormone synthesis . the use of antithyroid drugs as initial treatment varies according to geographic location ; they are used in the majority of patients in europe and asia , but radioiodine is used more often than medication in the united states [ 13 , 14 ] . the superiority of either mmi or propylthiouracil is not clearly established ; however , mmi has a longer intrathyroidal half - life , often allowing for once - daily dosing , and some studies have shown that it has greater efficacy and fewer side effects [ 9 , 13 , 15 ] . this case illustrates successful management by initiation of mmi and -adrenergic blockade in a patient with thyroid storm on hd . in conclusion , the management of patients with severe symptomatic thyroid storm on hd represents a challenge for nephrologists . we should recognize and treat such patients immediately , together with endocrinologists and critical care physicians , using appropriate treatment modalities in order to avoid a catastrophic outcome .
thyroid function test values are generally at low levels in patients with end - stage kidney disease . life - threatening thyrotoxicosis or thyroid storm is rare , especially in hemodialysis ( hd ) patients , and is characterized by multisystem involvement and a high mortality rate if not immediately recognized and treated . here , we report a female patient with severe symptomatic thyroid storm , receiving long - term hd and glucocorticoid therapy . 
 methimazole at a dose of 15 mg per day , -adrenergic blockade and hd succeeded in controlling the patient 's condition by gradually adjusting the target dry weight for hyperthyroidism - induced weight loss . 
 when she was discharged from the hospital , her dry weight was reduced from 47.2 to 39.2 kg . 
 the management of patients with severe symptomatic thyroid storm on hd represents a rare scenario . 
 it is essential to initiate the available treatments as early as possible to reduce its mortality .