Dosing of radioactive iodine in end-stage renal disease patient with thyroid cancer

in Endocrinology, Diabetes & Metabolism Case Reports

Summary

We describe detailed administration of thyroidal and extrathyroidal doses of radioiodine to a patient with end-stage renal disease on hemodialysis. A thorough description of area under curve measurements in a patient with compromised renal function has rarely been described in the literature. Few publications have described thyroid cancer management of patients on hemodialysis, and we believe our management will aid in patient treatment in the future.

Learning points:

  • Scheduling of hemodialysis is important when administering radioactive iodine.

  • Treatment of thyroid cancer with radioiodine in patients with end-stage renal disease requires multidisciplinary approach coordinating dialysis, nuclear medicine and endocrinologists care.

  • Balancing ideal dosage of I131 and the timing of dialysis to insure maximal thyroidal uptake and minimal extra thyroidal I131 concentration is necessary.

Summary

We describe detailed administration of thyroidal and extrathyroidal doses of radioiodine to a patient with end-stage renal disease on hemodialysis. A thorough description of area under curve measurements in a patient with compromised renal function has rarely been described in the literature. Few publications have described thyroid cancer management of patients on hemodialysis, and we believe our management will aid in patient treatment in the future.

Learning points:

  • Scheduling of hemodialysis is important when administering radioactive iodine.

  • Treatment of thyroid cancer with radioiodine in patients with end-stage renal disease requires multidisciplinary approach coordinating dialysis, nuclear medicine and endocrinologists care.

  • Balancing ideal dosage of I131 and the timing of dialysis to insure maximal thyroidal uptake and minimal extra thyroidal I131 concentration is necessary.

Background

Radioiodine ablation is the most effective adjuvant treatment after thyroidectomy for certain well-differentiated thyroid cancers (1). Iodine, as the iodide ion (I) is almost entirely absorbed by the thyroid gland, while remaining circulating I is primarily cleared by the kidney. Therefore, in a patient with end-stage renal disease (ESRD) on dialysis, the administered activity of radioiodine (I131) and the timing of dialysis are crucial. There are neither current guidelines nor recommendations for management of thyroid cancer in patients with ESRD (2). We present a case of the use of I131 in the management of thyroid cancer in a patient on hemodialysis.

Case presentation

A 49-year-old woman with a history of hypertension, ESRD on hemodialysis (HD), goiter and post remote left thyroidectomy presented with compressive symptoms of shortness of breath and difficulty swallowing. Our patient complained of an enlarging right thyroid gland, which had been growing slowly over the past 8 years. Ultrasound revealed a large nodule measuring almost 8 cm in sagittal plane. Ultrasound-guided fine-needle aspiration was performed, and cytology revealed normal follicular cells.

On physical examination, the patient had a markedly enlarged right thyroid gland, and due to large size of nodule, completion thyroidectomy was recommended. Histopathology revealed a 5.5 cm classical papillary thyroid cancer with clear surgical margins and without lymphovascular or extrathyroidal invasion. Thyroglobulin measurement prior to surgery was detectable at 3.9 ng/mL. The American Joint Committee on Cancer (AJCC) staging consistent with Stage III T3N0 and placing her in the American Thyroid Association (ATA) low-to-intermediate risk category (2). The patient’s case was reviewed regarding necessity and dose of radioiodine therapy interdepartmentally with consideration of her need for renal transplant and 50 mCi of I131 was subsequently administered. Radioidine was given after levothyroxine withdrawal for 6 weeks. The decision to raise TSH via withdrawal as opposed to thyrogen (recombinant TSH) was discussed interdepartmentally given that recombinant TSH is eliminated significantly slower in dialysis-dependent ESRD patients, resulting in prolonged elevation of TSH levels. A diagnostic pre-scan with I123 was performed and showed residual thyroid tissue, an iodine uptake of 5% and no evidence of distant metastasis. Our treatment goal was to ablate remaining remnant thyroid tissue and to facilitate follow-up in the future. One week following the diagnostic pre-scan, the patient was administered 50 mCi (1.85e + 3 mBq) (Fig. 1). The patient subsequently received inpatient HD sessions at 15, 27 and 43 h. The time points were chosen to coincide with the availability of the hemodialysis center and patient transportation. Our patient was discharged once below release criterion of 5 mrem/h (0.05 mSv/h) at 1 m. The patient returned 7 days post ablation and received a post-ablation whole body scan (Fig. 2).

Figure 1
Figure 1

I123 thyroid scan and uptake imaged 24 h post administration of 8.18 megabecquerel (mBq) of I-123 (218 microcuries). Iodine uptake to the thyroid remnant is 5%.

Citation: Endocrinology, Diabetes & Metabolism Case Reports 2017, 1; 10.1530/EDM-17-0111

Figure 2
Figure 2

Whole body post-ablation scan. (A) Seven days following the administration of 1850 mBq ofI131. The image shows uptake in the thyroid bed and suggestive of uptake in one or more nearby lymph nodes. Additional mild increased activity is seen in the liver. Diffuse liver uptake may be seen on post-therapy scans and is indicative of thyroxine production. Thyroid hormone (T3, T4) is metabolized in the liver and activity can be seen there after 3–7 days. In post-ablation patients, liver activity suggests that I-131 has been incorporated into thyroid hormone by functioning metastases or residual thyroid activity in the neck. (B) Anterior planar view showing I-131 uptake in the thyroid bed, as well as physiologic activity in the salivary glands and nasopharyngeal area. The area outlined in red is a substernal notch marker.

Citation: Endocrinology, Diabetes & Metabolism Case Reports 2017, 1; 10.1530/EDM-17-0111

Investigation

The effect of any radioactive substance on biological tissues depends on three important properties: the administered activity of the radioisotope, the radiologic half-life of the isotope and the biological half-life in the particular organ for the specific element. Radiologic half-life is the time required for one half of the number of atoms of the particular isotope to undergo physical decay. Biological half-life is the time taken to eliminate one half of the amount of a compound or chemical on a biological basis. The radiological half-life of I-131 is 8.02 days (3, 4). The thyroidal biologic half-life of iodide is approximately 80 days, whereas the extrathyroidal biologic half-life of I131 is 0.33 days (4, 5). The effective half-life is the result of the combined actions of physical decay and biological elimination (Fig. 3). It is related to the radiologic half-life and the biologic half-life, and it is always the shorter of the shorter of the two half-lives. The formula used t1/2e = t1/2p × t1/2b/t1/2p + t1/2b where t1/2e is the effective half-life, t1/2p is the physical half-life and t1/2b is the biological half-life.

Figure 3
Figure 3

Graph representing the I131 excretion curve, with the X axis depicting the time in hours and the Y axis depicting the radioactivity. The green curve indicates the physical decay and the blue indicates the extrathyroidal biological half-life.

Citation: Endocrinology, Diabetes & Metabolism Case Reports 2017, 1; 10.1530/EDM-17-0111

Treatment

The management challenges of treating the patient were to determine the dosage of I131 and the schedule of the HD. We used the concept of ‘Necessary Balancing Act’ to formulate the management plan (Fig. 4). The balancing act aims at deciding the ideal dosage of I131 and the timing of dialysis to insure maximal thyroidal uptake and minimal extrathyroidal I131 concentration, thereby maximizing the therapeutic effect and minimizing short-term and long-term radioactive side effects (1).

Figure 4
Figure 4

Necessary balancing act in dosing I131.

Citation: Endocrinology, Diabetes & Metabolism Case Reports 2017, 1; 10.1530/EDM-17-0111

The area under the curve (AUC) approach was chosen as it aims for a safe extrathyroidal dose. AUC is the area under the curve in a plot of concentration of drug in blood plasma against time. Typically, the area is computed starting at the time the drug is administered and ending when the concentration in plasma is negligible (5) (Fig. 3). Utilizing our approach, the AUC for a patient with compromised renal function is compared and adjusted to that of a patient with normal renal function.

The aim of our dialysis schedule was to achieve an AUC close to that of a patient with normal renal function. After reviewing previous studies, we devised a schedule of HD at 15, 27 and 43 h using a dose of I131 50 mCi. The schedule deviated from 12, 24 and 48 h time points to accommodate dialysis coordination (Fig. 5). Plotting of the AUC after the treatment revealed an AUC similar to normal renal function (Fig. 6). Since the iodide ion is extremely small compared to the dialysis filtering size, there is no method to either increase or decrease the rate of extra-thyroidal iodine removal by changing the parameters of the dialysis unit. The elimination depends on modality of dialysis and duration of dialysis therapy. Hemodialysis is superior to peritoneal dialysis, and no studies have shown that high efficiency dialysis is superior to low efficiency dialysis (6).

Figure 5
Figure 5

Depicts our attempt to obtain an AUC similar to that in a patient with normal renal function as can be seen below.

Citation: Endocrinology, Diabetes & Metabolism Case Reports 2017, 1; 10.1530/EDM-17-0111

Figure 6
Figure 6

Area under the curve similar to that in a patient with normal renal function.

Citation: Endocrinology, Diabetes & Metabolism Case Reports 2017, 1; 10.1530/EDM-17-0111

An ion chamber dose rate instrument was used to estimate the amount I131 in the body at any time point. Immediately following the administration of the I131, a dose rate measurement was obtained 1 m away and directly across from the patient’s umbilicus. This dose rate measurement exactly correlates with the administered activity of 50 mCi. Subsequent measurements were made at the same position and distance from the patient. The dose rates obtained are directly proportional to the activity remaining in the body at the time the measurement is made.

The thyroidal and the extra-thyroidal doses were esti­mated to be 360 Gy (target thyroidal dose of 150–500 Gy) and 0.2 Gy, respectively (1). A total-body scan 7 days after treatment confirmed 131I uptake at thyroid bed, with no evidence of distant metastases. Biochemical data consisting of thyroglobulin and antithyroglobulin antibody were undetectable at follow-up visits. Ultrasound and an rTSH stimulated I-131 whole body scan performed 5 years later did not reveal residual thyroid tissue in the thyroid bed or any abnormal tissue or uptake throughout the body.

Discussion

There are conflicting recommendations in the literature regarding changing dose of radioiodine and the timing of dialysis in patients with ESRD and thyroid cancer requiring therapeutic doses of 131I. When compared to a patient with normal renal function, authors Holst, Howard and Daumerie recommend decreasing the dose (7, 8, 9). In contrast, Jimenez and coworkers and Murcutt recommended using equivalent dosing; while Magne and Morrish increased dosing of I131 in ESRD patients as compared to their normal renal function counterparts (10, 11, 12, 13). In recommending a dose for patients, the timing of hemodialysis is of utmost importance (Table 1). Most of the radioiodine is delivered to the thyroid bed, but in anuric patients, there is an increased risk of exposure to bone marrow, which theoretically would lead to administration of a decreased dose of I131. The greatest reduction in radioiodine was after the first session of hemodialysis as was described in previous case reports, but subsequent hemodialysis reduced patients radioactivity to appropriate levels for discharge.

Table 1

Radioiodine dose and timing of dialysis.

StudyDose used (mCi)Dialysis timing (days after I131)Recommendations on dose (in comparison to dose used in patients with normal renal function)
Holst et al. (7)982, 3, 4Use 21–28% of dose and perform dialysis day 2, 3 and 4

Use 13–16% of the dose and perform dialysis day 2 and 4
Bohan et al. (12)1522, then thrice weeklyDecrease the dose for ESRD patients; no comment on the extent of decrease
Howard et al. (6)202Reduce the dose by a factor of 4 and perform dialysis at 48 h
Daumerie et al. (8)25 in 2 sessions 6 months apart1, 2, 5, 7Use 25% of the dose and start dialysis at 24 h
Jimenez et al. (9)75, 87 and 120 in 3 patientsDaily for 5 daysUse same dose
Morrish et al. (11)50–250 in 4 sessions over 4.8 yearsNo comment on timing of dialysis for first 2 treatments; 2 days for the 3rd treatmentIncrease the dose
Magne et al. (10)501, 3, 6Increase dose up to 25%

The ATA guidelines for use of Radioiodine Ablation in Differentiated Thyroid Cancers usually recommends radioiodine remnant ablation all patients with primary size of tumor >4 cm due to an increased risk of recurrence. The guidelines also recommend the usage of minimum activity as appropriate if any residual microscopic disease is suspected or documented (2). In addition, although initial fine-needle aspiration of the patient’s nodule did not reveal carcinoma, given the large size of her nodule, we believe there may have been sampling error.

I131 is mostly excreted renally and requires consideration of dose delivered to thyroid remnant while minimizing delivery to bone marrow. The dose delivered ultimately also depends on the timing of hemodialysis and the availability of health care providers to coordinate administration of I131 and hemodialysis sessions. Our facility was able to administer I131 after delivery from the pharmacy by the afternoon, explaining why our time points deviate somewhat from 12-, 24- and 48-h time points for hemodialysis. This patient was discussed at interdisciplinary rounds and RAI ablation was agreed upon to decrease risk of recurrence and facilitate follow-up. The majority of RAI therapies are performed in the outpatient setting, but patients on hemodialysis patients are unique due to the increased risk of exposure to dialysis staff, decreased clearance of I131 from the patient and potential contamination of the dialysis machine. In our patient case, proper radiation precautions were facilitated by admitting patient to hospital and performing hemodialysis within a designated patient room followed by appropriate handling of the dialysis machine and tubing. In considering therapies with higher doses of RAI therapy that would be required in setting of metastatic disease, one would again have to maximize administration of therapy to remnant tissue; however, our data do not apply to higher dose RAI therapy. In the future, an outpatient dialysis center with appropriate training and ability to comply with precautions may be feasible for patients requiring I131 therapy.

Patient outcome

The patient has followed up with endocrinology for 4 years since her radioiodine treatment with no evidence of recurrence of thyroid cancer on both imaging and biochemical examinations. The patient has received a renal transplant one year after her thyroid cancer treatment and remains in excellent health.

Definitions

Measurement of radioactivity (administered activity)

Measures the number of events of transformation/decay/disintegration per unit time.

1 curie (Ci) = 3.7 × 1010 decays per second (1 bequerel (Bq) = 1 days/s).

Measurement of dose

Gamma constant for I-131: 0.22 mR/h per mCi at 1.0 m (7.647E-5 mSv/h per MBq at 1.0 m.

Different materials absorb different amounts of energy.

Radiation absorbed dose (rad) is a unit of absorbed radiation dose. The SI equivalent unit is the Gray (Gy). 100 rad = 1 Gray.

Biological effect of radiation depends on the type of ionizing radiation.

Roentgen equivalent in man, or mammal (rem) is a unit of radiation dose equivalent.

Rem = rad * weighting factor WF.

(WF is between 1 and 20; 1 for X-rays/gamma rays).

The SI equivalent for the REM is the Seivert (Sv).

100 Rem = 1 Sv.

The equivalent dose is the dose to the whole body calculated by summing the dose to specific tissues times their tissue weighting factors. The tissue weighting factor for thyroid is 0.05 and for bone marrow is 0.12. These are the two most significant tissues in this case.

Declaration of interest

There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.

Funding

This research did not receive any specific grant from any funding agency in the public, commercial or not-for profit sector.

Patient consent

Patient consent has been obtained from the patient for publication of the submitted article and accompanying images.

Author contribution statement

All authors contributed equally to the care of the patient and the writing of this report.

References

  • 1

    SilbersteinEBAlaviABalonHRClarkeSEDivgiCGelfandMJGoldsmithSJJadvarHMarcusCSMartinWH 2012 The SNMMI practice guideline for therapy of thyroid disease with 131I 3.0. Journal of Nuclear Medicine 53 16331651. (doi:10.2967/jnumed.112.105148)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    HaugenBRAlexanderEKBibleKCDohertyGMMandelSJNikiforovYEPaciniFRandolphGWSawkaAMSchlumbergerM 2016 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid 26 1133. (doi:10.1089/thy.2015.0020)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    SnyderWSFordMRWarnerGGWatsonSB 1975 Absorbed dose per unit cumulated activity for selected radionuclides and organs (part 1). Society of Nuclear Medicine MIRD Pamphlet #11.

    • Search Google Scholar
    • Export Citation
  • 4

    SnyderWFordMWarnerGWatsonS 1975 Absorbed dose per unit cumulated activity for selected radionuclides and organs (part 2). Society of Nuclear Medicine MIRD Pamphlet #11.

    • Search Google Scholar
    • Export Citation
  • 5

    SnyderWFordMWarnerGWatsonS 1975 Absorbed dose per unit cumulated activity for selected radionuclides and organs. Society of Nuclear Medicine MIRD Pamphlet #11:Part 1.

    • Search Google Scholar
    • Export Citation
  • 6

    KapteinELevensonMSiegelMGadallahMAkmalM 2000 Radioiodine dosimetry in patients with end stage renal disease receiving continuous ambulatory peritoneal dialysis therapy. Journal of Clinical Endocrinology and Metabolism 85 30583064.

    • Search Google Scholar
    • Export Citation
  • 7

    HowardNGlasserM 1981 Iodine 131 ablation therapy for a patient on maintenance haemodialysis. British Journal of Radiology 54 259. (doi:10.1259/0007-1285-54-639-259)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    HolstJPBurmanKDAtkinsFUmansJGJonklaasJ 2005 Radioiodine therapy for thyroid cancer and hyperthyroidism in patients with end-stage renal disease on hemodialysis. Thyroid 15 13211331. (doi:10.1089/thy.2005.15.1321)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    DaumerieCVynckierSCaussinJJadoulMSquiffletJPde PatoulNWambersieA 1996 Radioiodine treatment of thyroid carcinoma in patients on maintenance hemodialysis. Thyroid 6 301304. (doi:10.1089/thy.1996.6.301)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    JimenezRGMorenoASGonzalezENSimónFJLRodriguezJRJimenezJCCórdobaMHAlbertinoRVJimenezRA 2001 Iodine-131 treatment of thyroid papillary carcinoma in patients undergoing dialysis for chronic renal failure: a dosimetric method. Thyroid 11 10311034. (doi:10.1089/105072501753271716)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    MagneNMagneJBraccoJBussiereF 2002 Disposition of radioiodine (131)I therapy for thyroid carcinoma in a patient with severely impaired renal function on chronic dialysis: a case report. Japanese Journal of Clinical Oncology 32 202205. (doi:10.1093/jjco/hyf049)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    MorrishDWFilipowLJMcEwanAJSchmidtRMurlandKRvon WestarpCBetcherKB 1990 131I treatment of thyroid papillary carcinoma in a patient with renal failure. Cancer 66 25092513. (doi:10.1002/1097-0142(19901215)66:12<2509::AID-CNCR2820661211>3.0.CO;2-M)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    MurcuttGEdwardsJBoakyeJDavenportA 2008 Hemodialysis of chronic kidney failure patients requiring ablative radioiodine therapy. Kidney International 73 13161319. (doi:10.1038/ki.2008.95)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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Figures

  • View in gallery

    I123 thyroid scan and uptake imaged 24 h post administration of 8.18 megabecquerel (mBq) of I-123 (218 microcuries). Iodine uptake to the thyroid remnant is 5%.

  • View in gallery

    Whole body post-ablation scan. (A) Seven days following the administration of 1850 mBq ofI131. The image shows uptake in the thyroid bed and suggestive of uptake in one or more nearby lymph nodes. Additional mild increased activity is seen in the liver. Diffuse liver uptake may be seen on post-therapy scans and is indicative of thyroxine production. Thyroid hormone (T3, T4) is metabolized in the liver and activity can be seen there after 3–7 days. In post-ablation patients, liver activity suggests that I-131 has been incorporated into thyroid hormone by functioning metastases or residual thyroid activity in the neck. (B) Anterior planar view showing I-131 uptake in the thyroid bed, as well as physiologic activity in the salivary glands and nasopharyngeal area. The area outlined in red is a substernal notch marker.

  • View in gallery

    Graph representing the I131 excretion curve, with the X axis depicting the time in hours and the Y axis depicting the radioactivity. The green curve indicates the physical decay and the blue indicates the extrathyroidal biological half-life.

  • View in gallery

    Necessary balancing act in dosing I131.

  • View in gallery

    Depicts our attempt to obtain an AUC similar to that in a patient with normal renal function as can be seen below.

  • View in gallery

    Area under the curve similar to that in a patient with normal renal function.

References

  • 1

    SilbersteinEBAlaviABalonHRClarkeSEDivgiCGelfandMJGoldsmithSJJadvarHMarcusCSMartinWH 2012 The SNMMI practice guideline for therapy of thyroid disease with 131I 3.0. Journal of Nuclear Medicine 53 16331651. (doi:10.2967/jnumed.112.105148)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    HaugenBRAlexanderEKBibleKCDohertyGMMandelSJNikiforovYEPaciniFRandolphGWSawkaAMSchlumbergerM 2016 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid 26 1133. (doi:10.1089/thy.2015.0020)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    SnyderWSFordMRWarnerGGWatsonSB 1975 Absorbed dose per unit cumulated activity for selected radionuclides and organs (part 1). Society of Nuclear Medicine MIRD Pamphlet #11.

    • Search Google Scholar
    • Export Citation
  • 4

    SnyderWFordMWarnerGWatsonS 1975 Absorbed dose per unit cumulated activity for selected radionuclides and organs (part 2). Society of Nuclear Medicine MIRD Pamphlet #11.

    • Search Google Scholar
    • Export Citation
  • 5

    SnyderWFordMWarnerGWatsonS 1975 Absorbed dose per unit cumulated activity for selected radionuclides and organs. Society of Nuclear Medicine MIRD Pamphlet #11:Part 1.

    • Search Google Scholar
    • Export Citation
  • 6

    KapteinELevensonMSiegelMGadallahMAkmalM 2000 Radioiodine dosimetry in patients with end stage renal disease receiving continuous ambulatory peritoneal dialysis therapy. Journal of Clinical Endocrinology and Metabolism 85 30583064.

    • Search Google Scholar
    • Export Citation
  • 7

    HowardNGlasserM 1981 Iodine 131 ablation therapy for a patient on maintenance haemodialysis. British Journal of Radiology 54 259. (doi:10.1259/0007-1285-54-639-259)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    HolstJPBurmanKDAtkinsFUmansJGJonklaasJ 2005 Radioiodine therapy for thyroid cancer and hyperthyroidism in patients with end-stage renal disease on hemodialysis. Thyroid 15 13211331. (doi:10.1089/thy.2005.15.1321)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    DaumerieCVynckierSCaussinJJadoulMSquiffletJPde PatoulNWambersieA 1996 Radioiodine treatment of thyroid carcinoma in patients on maintenance hemodialysis. Thyroid 6 301304. (doi:10.1089/thy.1996.6.301)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    JimenezRGMorenoASGonzalezENSimónFJLRodriguezJRJimenezJCCórdobaMHAlbertinoRVJimenezRA 2001 Iodine-131 treatment of thyroid papillary carcinoma in patients undergoing dialysis for chronic renal failure: a dosimetric method. Thyroid 11 10311034. (doi:10.1089/105072501753271716)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    MagneNMagneJBraccoJBussiereF 2002 Disposition of radioiodine (131)I therapy for thyroid carcinoma in a patient with severely impaired renal function on chronic dialysis: a case report. Japanese Journal of Clinical Oncology 32 202205. (doi:10.1093/jjco/hyf049)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    MorrishDWFilipowLJMcEwanAJSchmidtRMurlandKRvon WestarpCBetcherKB 1990 131I treatment of thyroid papillary carcinoma in a patient with renal failure. Cancer 66 25092513. (doi:10.1002/1097-0142(19901215)66:12<2509::AID-CNCR2820661211>3.0.CO;2-M)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    MurcuttGEdwardsJBoakyeJDavenportA 2008 Hemodialysis of chronic kidney failure patients requiring ablative radioiodine therapy. Kidney International 73 13161319. (doi:10.1038/ki.2008.95)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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