1. Introduction

A complex interrelated function is present between kidneys and the thyroid gland which has significant clinical implications. A major role in metabolizing, degrading, and excreting thyroid hormones is played by the kidney, while the thyroid hormones are of importance for renal embryogenesis, growth, and normal renal physiological functioning [1].

Chronic kidney disease (CKD) is global public health issue of increasing concern in the past decade, that approximately affects 10–15 % of the population worldwide. The National Kidney Foundation’s Kidney Disease Outcome Quality Initiative (K/DOQI) defines CKD as the renal abnormalities that persists for more than three months with or without decreased glomerular filtration rate (GFR), progressing through stages resulting in end-stage kidney disease (ESKD) [1]. Hemodialysis is the modulator of ESKD management worldwide, which sustains millions of patients [11].

Several studies concluded that patients with advanced CKD mainly those on maintenance hemodialysis, are more likely to have thyroid abnormalities in comparison to age-matched population with normal renal function [12].

Biochemical abnormalities are not the only complication of thyroid dysfunction in CKD patients; it was stated that these patients have an increased cardiovascular morbidity, renal failure progression, as well as increased risk of mortality [13–15]. Confounding factors including altered protein-binding, hemodialysis effects, and metabolites accumulation limit thyroid functions in CKD [9,16].

2. Methodology

2.1 Search strategy

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature review was conducted. PubMed/MEDLINE, Scopus, Web of science, and Google Scholar were the electronic database used to search for studies published between January 1, 2020, and March 15, 2026.

2.2 Inclusion and Exclusion criteria

Inclusion Criteria:

1. Study published between January 2020 and March 2026
2. Study examines thyroid function in adult patients (≥ 18 years) with CKD (any stage) or undergoing hemodialysis
3. Studies reporting prevalence, determinants, clinical outcomes, or management of thyroid dysfunction
4. Published in English
5. Full-text availability

Exclusion Criteria:

1. Published before 2020
2. Case reports, case series (<10 patients), editorials, commentaries, and conference abstracts
3. Studies focused exclusively on pediatric populations
4. Duplicate publications or overlapping cohorts

3. Results

3.1 Study Selection and Characteristics

The primary result of the database search was 847 potentially relevant record. 613 articles underwent title and abstract screening after removing the duplicates (n=234). Full-text review of 97 articles yielded and resulted in 34 studies meeting the mentioned inclusion criteria. Their characteristics are summarized in Table 1

Fig. 1. PRISMA Flow Diagram

Table 1

Characteristics of Included studies

3.2 Prevalence of Thyroid Dysfunction in CKD

3.2.1 Overall Estimate of Prevalence

Between 25.9–33.3 % of the cases of hypothyroidism in patients undergoing hemodialysis were subclinical hypothyroidism, making it the majority (57.8–77.4 %). According to Adani et al. [1] hypothyroidism was found in 28 % of Somali hemodialysis patients, of which 57.8 % of them were exhibiting subclinical and 42.2 % over hypothyroidism. German et al. [17] showed 31.4 % hypothyroidism among Pakistani ESKD patients (24.3 % subclinical, 7.0 % overt), while in Shakya et al. [9] 33.3 % in Indian ESKD patients (23.1 %, 10.2 % overt)

Non-CKD populations had a prevalence of hypothyroidism ranging between 10.5–32.0 %, which shows a clear association with the disease severity [13, 18]. Ansari et al. [19] documented 32.0 % overall hypothyroidism across CKD stages 1–5 in India. Low T3 syndrome (euthyroid sick syndrome) was found out to be highly prevalent, affecting 15.5–41.7 % of CKD patients [5, 20, 21].

3.2.2 Prevalence by CKD Stage

A consistent pattern was found across the studies: thyroid dysfunction prevalence shows an abrupt increase and progression with the renal function decline [19,22]. Adani et al. [1] cited the Third National Health and Nutrition Examination Survey (NHANES), stating hypothyroidism prevalence of 5.4 %, 10.9 %, 20.4 %, 23.0 %, and 23.1 % among individuals with eGFRs of ≥90, 60–89, 45–59, 30–44, and <30 mL/min/1.73m², respectively.

According to Yuasa et al. [7] Japanese patients had a prevalence of hypothyroidism in CKD stage 3–12.3 %, CKD stage 4–18.7 %, and 24.5 % in stage 5. In a Korean study carried by Kim et al. [12] found an increase of prevalence with declining eGFR. Matsuoka-Uchiyama [23] and Scandelai et al. [16] have also confirmed the reduced kidney function and higher rates of hypothyroidism.

4. Discussion

This comprehensive review synthesizes evidence from 34 studies published between 2020–2026, providing updated insights into the complex relationship between thyroid dysfunction and chronic kidney disease [8,24]. The findings confirm that thyroid abnormalities, particularly hypothyroidism, are highly prevalent across the CKD spectrum and correlate with disease severity.

4.1 Prevalence in Context

Estimates of prevalence synthesized in the CKD population with thyroid dysfunction (25.9–33.3 % in hemodialysis, 10.5–32.0 % in CKD) surpasses those in the general population (4–10 % hypothyroidism), which is a confirmation that CKD is of high-risk significance for thyroid dysfunction [12,25]. Subclinical hypothyroidism predominance [26] does suggest that thyroid failure traditional mechanisms may be supplemented as well by uremia-related functional disturbances.

4.2 Clinical Significance of Determinants

Modifiable risks factors, such as, hypoalbuminemia, inflammation, and proteinuria, when identified can be potential intervention targets [16,27]. Theoretically nutritional support aimed to improve these factors can improve thyroid function, though prospective validation is required. Thyroid dysfunction was found to be associated with anemia, cardiovascular events and mortality [13,18].

Lower creatinine and overt hypothyroidism association [1,28] challenges the conventional understanding and highlights the unique physiology of hemodialysis patients. This can be possibly explained by the reduce in muscle mass (sarcopenia), which associated with hypothyroidism and is common in dialysis, or by the differential clearance of creatinine in hypothyroid versus euthyroid states. Another novel proposed mechanism contributing to hypothyroidism in proteinuric CKD patients is the loss of thyroid hormones in urine [10].

Roxadustat-induced central hypothyroidism emergence [6,7] shows the great importance in considering iatrogenic, as this medication is gaining wider use. Thyroid function monitoring must be done vigilantly by clinicians in patients receiving Roxadustat, along with differentiating the effect of drug from primary thyroid disease. The role of thyroid autoantibodies and biomarkers such as FT3/FT4 ratio has been explored by some studies to predict outcomes [15, 29].

5. Conclusion

This comprehensive review demonstrates the high prevalence of thyroid dysfunction, particularly hypothyroidism, in the CKD patients, affecting 10–15 % approximately in early CKD patients, and 25–33 % in those with end-stage disease [2, 3]. Subclinical hypothyroidism being predominant, by accounting for 60–75 % of the cases [1, 4, 30].

The clinical implications are substantial, with thyroid dysfunction linked to cardiovascular disease, endothelial dysfunction, anemia, nutritional abnormalities, and increased mortality [14,19,31]. Regular screening is warranted, with careful attention to the confounding effects of uremia, medications, and dialysis procedures on thyroid function test interpretation [9, 16].

Future research should focus on prospective interventional trials to determine the benefits of treating subclinical hypothyroidism, development of CKD-specific diagnostic criteria, and elucidation of optimal management strategies for special situations such as roxadustat-associated dysfunction [5, 10, 32].

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