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Evolution of Hashimoto
thyroiditis in children with type 1
diabetes mellitus (TIDM)
Feneli Karachaliou*, Nikitas Skarakis, Evangelia Bountouvi, Theodora Spyropoulou, Eleni Tsintzou,
Aristofania Simatou and Vassiliki Papaevangelou

Criticized by
Muhammad Mustaqiblat
ABSTRACT
Objectives: Treatment of children with Hashimoto thyroiditis (HT) and
particularly of those with coexistent diabetes mellitus type 1 (TIDM)
and normal/mildly elevated serum TSH is controversial. The aim of the
study was to evaluate the natural course of HT in children with TIDM
compared with children with no other coexistent autoimmunity and
investigate for possible predictive factors of thyroid function
deterioration.

Methods: Data from 96 children with HT, 32 with T1DM (23 girls, nine
boys) mean (sd) age: 10.6 (2.3) years, and 64 age and sex-matched
without T1DΜ (46 girls, 18 boys), mean (sd) age: 10.2 (2.9) years were
evaluated retrospectively. They all had fT4 and TSH values within
normal ranges and available data for at least three years’ follow-up
Results: During the follow-up period, 11 children (34.4%) with TIDM
exhibited subclinical hypothyroidism and two children (6.2%)
progressed to overt hypothyroidism compared to 12 (18.8%) and two
(3.1%) among children without TIDM, respectively. Among children with
HT, a higher percentage (40.6%) of children with T1DM progressed to
subclinical or overt hypothyroidism, compared with children (21.9%)
with similar characteristics but without TIDM or other coexistent
autoimmunity.

Conclusions: The annual conversion rate from euthyroidism to

hypothyroidism in children with T1DM was significantly higher
compared to sex and age-matched children without TIDM. Prospective
randomized trials are needed to support the view of an earlier
intervention therapy even in milder degrees of thyroid failure in these
children.
INTRODUCTION
 Hashimoto thyroiditis (HT)
the most common cause
of acquired thyroid
disease in children and
adolescents
Patients with T1DM have
a fivefold increased risk of
developing HT compared
with the general
population
Thyroid hormone replacement
is recommended in all
patients with overt
hypothyroidism and/or TSH
values >10 IU/mL
The aim of the study was to
evaluate the natural course of
euthyroid thyroiditis in children
and adolescents with and without
TIDM and assess the risk of
progression to hypothyroidism in
these two groups of patients
METHODS
 Data from cohorts of
children with and without
T1DM matched for age
and sex were evaluated
retrospectively

INCLUSION study (visit A) study (visit B)

 serum levels of TSH,  the visit when TSH

fT4 every six months was found >5 U/L
 Group of TIDM  L-thyroxine
children, thyroid treatment was
function tests initiated at that
 Serum levels of time in children
TPOAb, and TGAb with TIDM
and thyroid
ultrasound

The statistical analysis of the data was performed using the SPSS
statistical software
RESULTS
 no
differences

not
significant
difference
significantly

No
significantly
 not
signifi
cant

significant
DISCUSSION
 • In this retrospective study on the evolution of HT,

This
73.4% of initially euthyroid children remained
euthyroid, whereas 21.9 and 4.7% progressed to
subclinical and overt hypothyroidism,

study respectively. The progression to hypothyroidism

was at 8.9% on an annual basis.

• In the five-year follow-up study by Radetti in 2006,

Other
64.5% of patients with HT remained or became
euthyroid without treatment. Finally in a more recent
study on a larger population [15], only 57.1% of

study initially euthyroid children remained euthyroid after

five years of follow-up.
 • 11 children with T1DM during an observation period of three
years progressed to subclinical or overt hypothyroidism. The

This annual conversion rate of 11.5% was significantly higher

compared to sex and age-matched children without TIDM.

study

• in the three-year follow-up study by Radetti et al , elevated baseline

TSH and TPOAb increased the risk of developing hypothyroidism

Other after three years by 4.0 and 3.4 folds, respectively

• Yoshida et al. also suggested an important role of the immune
system, as shown by the coexistence of other autoimmune diseases

study and/or severe thyroid lymphocytic infiltration (elevated TPOAb), in

addition to signs of thyroid dysfunction (increased TSH) in the
progression of thyroid failure
 CONCLUSIONS

findings from our study confirm that close observation with no

intervention remains a safe approach for euthyroid children with
HT. However, in children with HT and coexistence of T1DM, there
is a higher risk of progression to thyroid dysfunction The steeper
increase of TPOAb levels in these children may be associated with
future deterioration of thyroid function, possibly justifying earlier
intervention
“CRITICAL APPRAISAL OF JOURNAL”

Citation : Evolution of Hashimoto thyroiditis in

children with type 1 diabetes mellitus (TIDM)
Feneli Karachaliou*, Nikitas Skarakis, Evangelia Bountouvi, Theodora Spyropoulou, Eleni Tsintzou,
Aristofania Simatou and Vassiliki Papaevangelou

criticized by
Muhammad Mustaqiblat
 WORKSHEET FOR DIAGNOSTIC PREDICTION TEST
I. Validity
 Is this Evidence about diagnostic prediction Valid ??
1. Was there an independent, blind comparison with a reference standard?
Is reference standard used acceptable?
Were both reference standard and test applied to all patients?
[ v] Yes [ ] No [ ] Can't Tell
2. Did the patient sample include an appropriate spectrum of
patients to whom the diagnostic test will be applied in clinical
practice?
[ v] Yes [ ] No [ ] Can't Tell

18
WORKSHEET FOR DIAGNOSTIC PREDICTION TEST
 Is this Evidence about diagnostic prediction Valid ??
3. Did the results of the test being evaluated influence the decision
to perform the reference standard? "Verification" or "work-up"
bias?
[ ] Yes [ ] No [ v] Can't Tell
4. Were the methods for performing the test
described in sufficient detail to permit replication?
Preparation of patient?
Performance of test?
Analysis and interpretation of results?
[v ] Yes [ ] No [ ] Can't Tell
5. Overall, are the results of the study valid?
[ v] Yes [ ] No [ ] Can't Tell
19
WORKSHEET FOR DIAGNOSTIC PREDICTION TESTS

II. Important
 Are the valid results clinically important /relevant ???

1. How likely are the diagnostic prediction percentage “true ” at a

particular point in time ?
[v ] Yes [ ] No [ ] Can't Tell

2. How precise are the diagnostic prediction estimates?

95% CI
[v ] Yes [ ] No [ ] Can't Tell

20
WORKSHEET FOR DIAGNOSTIC PREDICTION TESTS
III. APPLICABILITY
 Can we apply this Valid, Important Evidence about diagnostic
prediction to our patient ???
1. Are the study patients similar to our own?
[v ] Yes [ ] No [ ] Can't Tell
2. Are the results applicable to our patient?
Compelling reasons why the results should not be applied?
[ v ] Yes [ ] No [ ] Can't Tell
3. Will the results change my management?
[ ] Yes [v ] No [ ] Can't Tell
 Level of evidence dan
Recommendation Grades:
Level of evidence Recommendation Grades
• Level 1: Systematic review/meta-analysis. • Grade A : Strongly recommended
• Level 2: At least 1 randomized controlled because the scientific basis is strong.
trial (RCT). • Grade B : Recommended because
• Level 3: A non-RCT prospective cohort there is some scientific basis.
study with controls. • Grade C1 : Recommended despite
• Level 4: An analytical epidemiologic _cohort having only a weak scientific basis.
study or case-control_ study or single-arm • Grade C2 : Not recommended because
intervention study (no controls). there is only a weak scientific basis.
• Level 5: A descriptive study_case report or • Grade D: Not recommended because
case series). scientific evidence shows treatment to
• Level 6: Opinion of an expert committee or be ineffective or harmful.
an individual expert, which is not based on
patient data.
 Conclusion
Citation : Evolution of Hashimoto thyroiditis in children with
type 1 diabetes mellitus (TIDM)
Feneli Karachaliou*, Nikitas Skarakis, Evangelia Bountouvi, Theodora Spyropoulou, Eleni Tsintzou,
Aristofania Simatou and Vassiliki Papaevangelou

“Hashimoto's thyroiditis patients required close

observation to reduce the incidence of thyroid
dysfunction”.
“ This scientific evidence is suitable for for Referral hospital such Wahidin
Sudirohusodo hospital
(Level 3, Grade B )
THANK YOU

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