Understanding the Drivers of Hypothyroidism in Patients Undergoing Chronic Hemodialysis

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Background/Objectives: Hypothyroidism is highly prevalent among HD patients, due to cumulative disturbances in thyroid hormone synthesis, metabolism, and clearance. Subclinical hypothyroidism—defined by elevated TSH with normal fT4—is common in HD, along with a distinct entity, the low-T3 syndrome. This study aims to examine the predictors of hypothyroidism in HD and its impact on cardiovascular morbidity and mortality. Methods: We conducted a retrospective cohort study including 282 hemodialysis (HD) patients, with evaluated thyroid function and monitored from January 2022 to June 2025. A total of 66 (23.4%) patients with hypothyroidism were identified, 15 (5.31%) of whom had autoimmune thyroiditis. Subclinical hypothyroidism was documented in 31.81% of the hypothyroid patients. Results: Hypothyroidism occurred predominantly in females (63.63% vs. 41.2%, p ≤ 0.001) and was associated with higher BMI (27.856 ± 6.216 vs. 25.759 ± 6.080, p = 0.017), hypoalbuminemia (3.534 ± 0.547 vs. 3.725 ± 0.471, p = 0.006), elevated LDL-cholesterol and triglyceride levels, as well as with amiodarone use. Hypothyroidism was further associated with atrial fibrillation (33.33 vs. 19.9%, p = 0.022), coronary artery revascularization procedures (18.18% vs. 9.72%, p = 0.047), neoplastic disease (25.75% vs. 12.03%, p = 0.008), and cancer-related mortality (10.6% vs. 1.85%, p = 0.001). Multivariable regression analysis revealed the following predictors of hypothyroidism: female sex (OR 3.848, 95%CI 1.704–8.693, p = 0.001), BMI (OR 1.072, 95%CI 1.007–1.146, p = 0.031), hypoalbuminemia (OR 0.412, 95%CI 0.177–0.962, p = 0.040), hypertriglyceridemia (OR 1.088, 95% CI 1.001–1.016, p = 0.022) and amiodarone use (OR 6.698, 95%CI 1.744–25.722, p = 0.006). Patients with autoimmune thyroiditis did not exhibit clinical or biochemical differences compared with other hypothyroid patients. Subclinical hypothyroidism was associated with longer HD duration (10.476 ± 7.910 vs. 6.567 ± 5.541, p = 0.003), dyslipidemia, hypertension, atrial fibrillation and amiodarone use. Cardiovascular conditions—particularly atrial fibrillation and ischemic coronary disease requiring revascularization—are more common in HD patients with clinical or subclinical hypothyroidism. However, in our cohort, the Kaplan–Meier survival curves at 12, 24, and 36 months for patients with both subclinical and clinical hypothyroidism do not show significant differences in cardiac or overall mortality. Conclusions: The increased incidence of hypothyroidism in HD patients, together with its impact on cardiovascular pathology, underscores the need for multidisciplinary management and supports annual routine assessment of thyroid hormones—particularly in overweight or dyslipidemic patients and in those receiving amiodarone.

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