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Ali MM, Parveen S, Williams V, Dons R, Uwaifo GI. Cardiometabolic comorbidities and complications of obesity and chronic kidney disease (CKD). J Clin Transl Endocrinol 2024; 36:100341. [PMID: 38616864 PMCID: PMC11015524 DOI: 10.1016/j.jcte.2024.100341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 04/16/2024] Open
Abstract
Obesity and chronic kidney disease are two ongoing progressive clinical pandemics of major public health and clinical care significance. Because of their growing prevalence, chronic indolent course and consequent complications both these conditions place significant burden on the health care delivery system especially in developed countries like the United States. Beyond the chance coexistence of both of these conditions in the same patient based on high prevalence it is now apparent that obesity is associated with and likely has a direct causal role in the onset, progression and severity of chronic kidney disease. The causes and underlying pathophysiology of this are myriad, complicated and multi-faceted. In this review, continuing the theme of this special edition of the journal on " The Cross roads between Endocrinology and Nephrology" we review the epidemiology of obesity related chronic kidney disease (ORCKD), and its various underlying causes and pathophysiology. In addition, we delve into the consequent comorbidities and complications associated with ORCKD with particular emphasis on the cardio metabolic consequences and then review the current body of evidence for available strategies for chronic kidney disease modulation in ORCKD as well as the potential unique role of weight reduction and management strategies in its improvement and risk reduction.
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Affiliation(s)
- Mariam M. Ali
- Southern Illinois School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, 751 North Rutledge Street, Moy Building, Suite 1700, Springfield, Il 62702, United States
| | - Sanober Parveen
- Southern Illinois School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, 751 North Rutledge Street, Moy Building, Suite 1700, Springfield, Il 62702, United States
| | - Vanessa Williams
- Southern Illinois School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, 751 North Rutledge Street, Moy Building, Suite 1700, Springfield, Il 62702, United States
| | - Robert Dons
- Southern Illinois School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, 751 North Rutledge Street, Moy Building, Suite 1700, Springfield, Il 62702, United States
| | - Gabriel I. Uwaifo
- Section of Endocrinology, Dept of Medicine, SIU School of Medicine, 751 N Rutledge St, Moy Building, Suite 1700, Room #1813, Springfield, Il 62702, United States
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Nickler M, Stampf S, Bernasconi L, Segerer S, Blum CA, Kim MJ. Performance of synacthen test in chronic hemodialysis patients. BMC Nephrol 2023; 24:330. [PMID: 37936106 PMCID: PMC10631216 DOI: 10.1186/s12882-023-03347-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/23/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Adrenal function tests (Synacthen test) in chronic hemodialysis (HD) patients are currently performed off dialysis. The study aimed to demonstrate equivalence of serum cortisol concentrations pre- and during HD, each for standard-dose (250 µg) and low-dose (1 µg) Synacthen test. METHODS In a single-center cross-over diagnostic equivalence study, Synacthen tests were performed in four settings, in standard- and low-dose as well as pre- and during HD. Serum cortisol concentration was measured at 30 and 60 min after Synacthen administration, and additionally at 20 min in low dose test. Based on a multivariable linear mixed model the means of cortisol concentration on log-scale were estimated in each dose and test time combination. Differences in means were calculated and the TOST approach was applied to test for equivalence. Equivalence was proven if the 90% confidence interval of the difference of two cortisol means was entirely between - 0.22 and 0.22. RESULTS In 28 chronic HD patients, serum cortisol concentrations at 30 and 60 min after Synacthen administration in both standard- and low-dose were shown to be equivalent pre- and during HD. In 10 of 56 low-dose tests, the cortisol peak was already reached after 20 min. However, cortisol concentrations at 20 and 30 min after low-dose Synacthen test pre- and during HD showed no significant difference. CONCLUSION These results suggest that the adrenal function test may be carried out during an ongoing HD session, leading to a more patient-friendly performance of the test, less organizational effort and potentially earlier diagnosis of adrenal insufficiency.
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Affiliation(s)
- Manuela Nickler
- Medical University Department, Division of Nephrology, Kantonsspital Aarau, Aarau, Switzerland
| | - Susanne Stampf
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Luca Bernasconi
- Center for Laboratory Medicine, Institut of Immunology & Clinical Chemistry, Kantonsspital Aarau, Aarau, Switzerland
| | - Stephan Segerer
- Medical University Department, Division of Nephrology, Kantonsspital Aarau, Aarau, Switzerland
| | - Claudine A Blum
- Hormonpraxis Aarau, Aarau, Switzerland
- University of Basel, Basel, Switzerland
| | - Min Jeong Kim
- Medical University Department, Division of Nephrology, Kantonsspital Aarau, Aarau, Switzerland.
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Findling JW, Raff H. Recognition of Nonneoplastic Hypercortisolism in the Evaluation of Patients With Cushing Syndrome. J Endocr Soc 2023; 7:bvad087. [PMID: 37440963 PMCID: PMC10334485 DOI: 10.1210/jendso/bvad087] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Indexed: 07/15/2023] Open
Abstract
The evaluation of suspected hypercortisolism is one of the most challenging problems in medicine. The signs and symptoms described by Dr Harvey Cushing are common and often create diagnostic confusion to even experienced endocrinologists. Cushing syndrome is classically defined as neoplastic hypercortisolism resulting from an ACTH-secreting tumor or from autonomous secretion of excess cortisol associated with benign or malignant adrenal neoplasia. The increasing recognition of the negative cardiometabolic effects of mild cortisol excess without overt physical signs of Cushing syndrome has led to more screening for endogenous hypercortisolism in patients with adrenal nodular disease, osteoporosis, and the metabolic syndrome. However, sustained or intermittent activation of the dynamic hypothalamic-pituitary-adrenal axis caused by chemical (alcohol), inflammatory (chronic kidney disease), psychologic (major depression), and physical (starvation/chronic intense exercise) stimuli can result in clinical and/or biochemical features indistinguishable from neoplastic hypercortisolism. Nonneoplastic hypercortisolism (formerly known as pseudo-Cushing syndrome) has been recognized for more than 50 years and often causes diagnostic uncertainty. This expert consultation describes two patients with features of Cushing syndrome who were referred for inferior petrosal sinus sampling for the differential diagnosis of ACTH-dependent hypercortisolism. Both patients were discovered to have nonneoplastic hypercortisolism: one from a covert alcohol use disorder and the other to chronic kidney disease. This consultation emphasizes the value of a good history and physical examination, appropriate laboratory testing, and the desmopressin acetate stimulation test to aid in distinguishing neoplastic from nonneoplastic hypercortisolism.
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Affiliation(s)
- James W Findling
- Department of Medicine (Endocrinology and Molecular Medicine), Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Hershel Raff
- Correspondence: Hershel Raff, PhD, Endocrinology Research HRC4150, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA.
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Association between adrenal function and dialysis vintage in hemodialysis patients. Clin Exp Nephrol 2022; 26:933-941. [PMID: 35596828 DOI: 10.1007/s10157-022-02230-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 04/17/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Adrenal insufficiency in hemodialysis patients is commonly encountered in clinical practice. However, its association with end-stage renal disease is unclear. We investigated the relationship between adrenal function and relevant clinical parameters, focusing on dialysis vintage. METHODS Altogether, 100 maintenance hemodialysis patients were enrolled (age: 69.8 ± 11.8 years, dialysis vintage: 9.4 ± 9.2 years). Basal serum cortisol levels were measured and their associations with relevant clinical parameters were investigated. Subsequently, hormone stimulation tests were performed to assess adrenal function. RESULTS Basal serum cortisol significantly decreased with an increase in dialysis vintage (< 10 years, 11.9 ± 3.7 μg/dL; 10-19 years, 10.9 ± 2.9 μg/dL; ≥ 20 years, 9.7 ± 3.8 μg/dL). Basal cortisol was negatively correlated with dry weight, β2-microglobulin, creatinine, and lymphocyte count and positively correlated with brachial-ankle pulse wave velocity. Significant negative correlations were observed between basal cortisol and dialysis vintage after adjusting for confounding variables in the multivariate analysis. Standard adrenocorticotropic hormone (ACTH) and corticotropin-releasing hormone (CRH) stimulation tests were performed in 17 patients. Seven patients were diagnosed with adrenal insufficiency and all of them had a long dialysis vintage (≥ 10 years). According to the rapid ACTH test, cortisol responses were significantly decreased in patients with long dialysis vintage compared to those with short dialysis vintage (< 10 years). Similar findings were observed in ten patients without adrenal insufficiency. The CRH loading test showed similar tendencies, although the differences were not statistically significant. CONCLUSIONS Adrenal function decreased with an increase in dialysis vintage. Long-term dialysis patients might be susceptible to adrenal insufficiency.
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Sagmeister MS, Harper L, Hardy RS. Cortisol excess in chronic kidney disease - A review of changes and impact on mortality. Front Endocrinol (Lausanne) 2022; 13:1075809. [PMID: 36733794 PMCID: PMC9886668 DOI: 10.3389/fendo.2022.1075809] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/27/2022] [Indexed: 01/18/2023] Open
Abstract
Chronic kidney disease (CKD) describes the long-term condition of impaired kidney function from any cause. CKD is common and associated with a wide array of complications including higher mortality, cardiovascular disease, hypertension, insulin resistance, dyslipidemia, sarcopenia, osteoporosis, aberrant immune function, cognitive impairment, mood disturbances and poor sleep quality. Glucocorticoids are endogenous pleiotropic steroid hormones and their excess produces a pattern of morbidity that possesses considerable overlap with CKD. Circulating levels of cortisol, the major active glucocorticoid in humans, are determined by a complex interplay between several processes. The hypothalamic-pituitary-adrenal axis (HPA) regulates cortisol synthesis and release, 11β-hydroxysteroid dehydrogenase enzymes mediate metabolic interconversion between active and inactive forms, and clearance from the circulation depends on irreversible metabolic inactivation in the liver followed by urinary excretion. Chronic stress, inflammatory states and other aspects of CKD can disturb these processes, enhancing cortisol secretion via the HPA axis and inducing tissue-resident amplification of glucocorticoid signals. Progressive renal impairment can further impact on cortisol metabolism and urinary clearance of cortisol metabolites. Consequently, significant interest exists to precisely understand the dysregulation of cortisol in CKD and its significance for adverse clinical outcomes. In this review, we summarize the latest literature on alterations in endogenous glucocorticoid regulation in adults with CKD and evaluate the available evidence on cortisol as a mechanistic driver of excess mortality and morbidity. The emerging picture is one of subclinical hypercortisolism with blunted diurnal decline of cortisol levels, impaired negative feedback regulation and reduced cortisol clearance. An association between cortisol and adjusted all-cause mortality has been reported in observational studies for patients with end-stage renal failure, but further research is required to assess links between cortisol and clinical outcomes in CKD. We propose recommendations for future research, including therapeutic strategies that aim to reduce complications of CKD by correcting or reversing dysregulation of cortisol.
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Affiliation(s)
- Michael S. Sagmeister
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- *Correspondence: Michael S. Sagmeister,
| | - Lorraine Harper
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Rowan S. Hardy
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Research into Inflammatory Arthritis Centre Versus Arthritis, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Institute of Clinical Science, University of Birmingham, Birmingham, United Kingdom
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Brotzer L, Nickler M, Kim MJ, Mueller B, Blum CA. Adrenal function testing in dialysis patients - a review of the literature. BMC Nephrol 2021; 22:360. [PMID: 34724905 PMCID: PMC8561863 DOI: 10.1186/s12882-021-02541-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/22/2021] [Indexed: 11/18/2022] Open
Abstract
Background Secondary adrenal insufficiency is a frequent issue in patients with renal replacement therapy. There are concerns about metabolism and clearance for adrenocorticotropic hormone (ACTH) and cortisol in addition to hemoconcentration as confounding factors during hemodialysis (HD). Therefore, ACTH testing is currently performed before or in between HD sessions. This review of the literature aims to evaluate the current evidence for validity of testing for adrenal insufficiency in patients on chronic renal replacement therapy. Methods A literature search of PubMed database for interventional and observational clinical trials was performed. Case reports and reviews were excluded. The search included all articles published until July 2020. Results Of 218 potentially eligible articles, 16 studies involving 381 participants were included. Seven studies performed an ACTH test before HD or in between HD sessions. There was no data available regarding ACTH testing during HD. But there was evidence of decreased cortisol levels during HD as compared to afterwards. All included 16 studies measured basal cortisol, and seven studies performed an ACTH test. Seven trials had comparable data of baseline cortisol for a quantitative analysis. Standardized mean difference of overall cortisol was 0.18 nmol/l (95%CI − 0.08 to 0.44) in the case group. Conclusions In patients undergoing renal replacement therapy, basal serum cortisol values are comparable to healthy volunteers. There is limited data on the validity of stimulated cortisol in these patients, especially during HD. Trial registration Registration no. CRD42020199245. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02541-5.
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Affiliation(s)
- Lara Brotzer
- Department of Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland.,Departments of General Internal and Emergency Medicine, Medical University Clinic, Kantonsspital Aarau, Tellstrasse H7, CH-5001, Aarau, Switzerland
| | - Manuela Nickler
- Department of Nephrology, Kantonsspital Aarau, Aarau, Switzerland
| | - Min Jeong Kim
- Department of Nephrology, Kantonsspital Aarau, Aarau, Switzerland
| | - Beat Mueller
- Department of Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland.,Departments of General Internal and Emergency Medicine, Medical University Clinic, Kantonsspital Aarau, Tellstrasse H7, CH-5001, Aarau, Switzerland
| | - Claudine A Blum
- Department of Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland. .,Departments of General Internal and Emergency Medicine, Medical University Clinic, Kantonsspital Aarau, Tellstrasse H7, CH-5001, Aarau, Switzerland.
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Gusev E, Solomatina L, Zhuravleva Y, Sarapultsev A. The Pathogenesis of End-Stage Renal Disease from the Standpoint of the Theory of General Pathological Processes of Inflammation. Int J Mol Sci 2021; 22:ijms222111453. [PMID: 34768884 PMCID: PMC8584056 DOI: 10.3390/ijms222111453] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/18/2021] [Accepted: 10/21/2021] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease can progress to end-stage chronic renal disease (ESRD), which requires the use of replacement therapy (dialysis or kidney transplant) in life-threatening conditions. In ESRD, irreversible changes in the kidneys are associated with systemic changes of proinflammatory nature and dysfunctions of internal organs, skeletal muscles, and integumentary tissues. The common components of ESRD pathogenesis, regardless of the initial nosology, are (1) local (in the kidneys) and systemic chronic low-grade inflammation (ChLGI) as a risk factor for diabetic kidney disease and its progression to ESRD, (2) inflammation of the classical type characteristic of primary and secondary autoimmune glomerulonephritis and infectious recurrent pyelonephritis, as well as immune reactions in kidney allograft rejection, and (3) chronic systemic inflammation (ChSI), pathogenetically characterized by latent microcirculatory disorders and manifestations of paracoagulation. The development of ChSI is closely associated with programmed hemodialysis in ESRD, as well as with the systemic autoimmune process. Consideration of ESRD pathogenesis from the standpoint of the theory of general pathological processes opens up the scope not only for particular but also for universal approaches to conducting pathogenetic therapies and diagnosing and predicting systemic complications in severe nephropathies.
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Kim YJ, Kim JH, Hong AR, Park KS, Kim SW, Shin CS, Kim SY. Stimulated Salivary Cortisol as a Noninvasive Diagnostic Tool for Adrenal Insufficiency. Endocrinol Metab (Seoul) 2020; 35:628-635. [PMID: 32981305 PMCID: PMC7520577 DOI: 10.3803/enm.2020.707] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/20/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Salivary cortisol is routinely used as a diagnostic test for Cushing syndrome. The diagnostic use of salivary cortisol for adrenal insufficiency (AI), however, is less established. We aimed to investigate the utility of morning basal and adrenocorticotropic hormone-stimulated salivary cortisol in diagnosing AI in Korean adults. METHODS We prospectively included 120 subjects (female, n=70) from Seoul National University Hospital. AI was defined as a stimulated serum cortisol level of <496.8 nmol/L during the short Synacthen test (SST). Serum and saliva samples were drawn between 8:00 AM and 10:00 AM. Salivary cortisol levels were measured using an enzyme immunoassay kit. RESULTS Thirty-four patients were diagnosed with AI according to the SST results. Age, sex, body mass index, serum albumin levels, and serum creatinine levels did not significantly differ between the normal and AI groups. Basal and stimulated salivary cortisol levels were positively correlated with basal (r=0.538) and stimulated serum cortisol levels (r=0.750), respectively (all P<0.001). Receiver operating characteristic curve analysis yielded a cutoff level of morning basal salivary cortisol of 3.2 nmol/L (sensitivity, 84.9%; specificity, 73.5%; area under the curve [AUC]=0.822). The optimal cutoff value of stimulated salivary cortisol was 13.2 nmol/L (sensitivity, 90.7%; specificity, 94.1%; AUC=0.959). Subjects with a stimulated salivary cortisol level above 13.2 nmol/L but a stimulated serum cortisol level below 496.8 nmol/L (n=2) had lower serum albumin levels than those showing a concordant response. CONCLUSION The diagnostic performance of stimulated salivary cortisol measurements after the SST was comparable to serum cortisol measurements for diagnosing AI.
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Affiliation(s)
- Yoon Ji Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mediplex Sejong Hospital, Incheon, Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - A Ram Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyeong Seon Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Chan Soo Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seong Yeon Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Li R, Li Y, Li C, Zheng D, Chen P. Gut Microbiota and Endocrine Disorder. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1238:143-164. [DOI: 10.1007/978-981-15-2385-4_9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Valentin A, Borresen SW, Rix M, Elung-Jensen T, Sørensen SS, Feldt-Rasmussen U. Adrenal insufficiency in kidney transplant patients during low-dose prednisolone therapy: a cross-sectional case–control study. Nephrol Dial Transplant 2019; 35:2191-2197. [DOI: 10.1093/ndt/gfz180] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Indexed: 12/31/2022] Open
Abstract
Abstract
Background
Maintenance immunosuppressive regimens after renal transplantation (RTx) most often include prednisolone, which may induce secondary adrenal insufficiency, a potentially life-threatening side effect to glucocorticoid (GC) treatment due to the risk of acute adrenal crisis. We investigated the prevalence of prednisolone-induced adrenal insufficiency in RTx patients receiving long-term low-dose prednisolone treatment.
Methods
We performed a case–control study of patients on renal replacement therapy differing in terms of GC exposure. The study included 30 RTx patients transplanted >11 months before enrolment in the study and treated with prednisolone (5 or 7.5 mg prednisolone/day for ≥6 months) and 30 dialysis patients not treated with prednisolone. Patients underwent testing for adrenal insufficiency by a 250-µg Synacthen test performed fasting in the morning after a 48-h prednisolone pause. Normal adrenal function was defined as P-cortisol ≥420 nmol/L 30 min after Synacthen injection. This cut-off is used routinely for the new Roche Elecsys Cortisol II assay and is validated locally based on the Synacthen test responses in 100 healthy individuals.
Results
Thirteen RTx patients {43% [95% confidence interval (CI) 27–61]} had an insufficient response to the Synacthen test compared with one patient in the control group [3% (95% CI 0.6–17)] (P = 0.0004). Insufficient responses were seen in 9/25 and 4/5 RTx patients treated with 5 and 7.5 mg prednisolone/day, respectively.
Conclusions
We found a high prevalence of adrenal insufficiency among RTx patients receiving low-dose prednisolone treatment. We therefore advocate for increased clinical alertness towards prednisolone-induced adrenal insufficiency in RTx patients and thus their potential need of rescue GC supplementation during stress.
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Affiliation(s)
- Amalie Valentin
- Department of Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Stina Willemoes Borresen
- Department of Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Rix
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Elung-Jensen
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Schwartz Sørensen
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Saygili S, Canpolat N, Sever L, Caliskan S, Atayar E, Ozaltin F. Persistent hypoglycemic attacks during hemodialysis sessions in an infant with congenital nephrotic syndrome: Answers. Pediatr Nephrol 2019; 34:77-79. [PMID: 29959533 DOI: 10.1007/s00467-018-3982-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 04/30/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Seha Saygili
- Department of Pediatric Nephrology, Istanbul University Cerrahpasa Faculty of Medicine, Fatih, 34098, Istanbul, Turkey.
| | - Nur Canpolat
- Department of Pediatric Nephrology, Istanbul University Cerrahpasa Faculty of Medicine, Fatih, 34098, Istanbul, Turkey
| | - Lale Sever
- Department of Pediatric Nephrology, Istanbul University Cerrahpasa Faculty of Medicine, Fatih, 34098, Istanbul, Turkey
| | - Salim Caliskan
- Department of Pediatric Nephrology, Istanbul University Cerrahpasa Faculty of Medicine, Fatih, 34098, Istanbul, Turkey
| | - Emine Atayar
- Nephrogenetics Laboratory, Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Sihhiye, Ankara, Turkey
| | - Fatih Ozaltin
- Nephrogenetics Laboratory, Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Sihhiye, Ankara, Turkey.,Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Sihhiye, Ankara, Turkey.,Hacettepe University Center for Biobanking and Genomics, Ankara, Turkey
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Cardoso EMDL, Arregger AL, Budd D, Zucchini AE, Contreras LN. Dynamics of salivary cortisol in chronic kidney disease patients at stages 1 through 4. Clin Endocrinol (Oxf) 2016; 85:313-9. [PMID: 26800302 DOI: 10.1111/cen.13023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/10/2016] [Accepted: 01/13/2016] [Indexed: 12/30/2022]
Abstract
CONTEXT End-stage renal disease has been associated with derangement of the HPA function. The dynamics of this axis in early stages of renal disease (CKD) has not been assessed. OBJECTIVES To evaluate in patients with CKD at stages 1-4 (KDOQI): the diurnal variation of salivary cortisol; the suppressibility of cortisol in saliva and serum after an overnight oral 1 mg dexamethasone suppression test (1 mg DST) with simultaneous measurement of circulating dexamethasone. DESIGN AND METHODS 80 CKD outpatients and 40 healthy subjects were included. All CKD collected whole saliva at 08·00 and 23·00 h (SAF23 ) on two nonconsecutive days. Thereafter at 08·00 h, following 1 mg DST, saliva and blood were obtained. Salivary and serum cortisol as well as CBG were assessed by RIA, dexamethasone by ELISA and serum free cortisol was calculated. RESULTS SAF23 correlated negatively with glomerular filtration rate (GFR). The fraction of free cortisol in serum and saliva after 1 mg DST, correlated positively and significantly in both patients with CKD and healthy subjects (r: 0·86 and r: 0·85, respectively; P < 0·0001 for both). Ten percent of CKD with GFR < 90 ml/min/1·73 m(2) had false positive results unrelated to dexamethasone and CBG concentrations. CONCLUSIONS False positive responses to 1 mg DST were associated with GFR < 90 ml/min/1·73 m(2) . This could not be ascribed to either defects in dexamethasone absorption or CBG concentrations. Higher dexamethasone doses were necessary to achieve adequate HPA suppression. Salivary cortisol was useful to assess circadian cortisol levels and feed-back regulation in CKD.
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Affiliation(s)
- Estela María Del Luján Cardoso
- Endocrine Research Department, Instituto de Investigaciones Médicas Alfredo Lanari, University of Buenos Aires, Buenos Aires, Argentina
- Unidad Ejecutora Instituto de Investigaciones Médicas, National Council of Technical and Scientific Research, Buenos Aires, Argentina
- Laboratory of Salivary Glands, School of Dentistry, University of Buenos Aires, Buenos Aires, Argentina
| | - Alejandro Luis Arregger
- Endocrine Research Department, Instituto de Investigaciones Médicas Alfredo Lanari, University of Buenos Aires, Buenos Aires, Argentina
| | - Dianne Budd
- Endocrine Research Department, Instituto de Investigaciones Médicas Alfredo Lanari, University of Buenos Aires, Buenos Aires, Argentina
| | - Alfredo Enrique Zucchini
- Chief Research Department, Instituto de Investigaciones Médicas Alfredo Lanari, University of Buenos Aires, Buenos Aires, Argentina
| | - Liliana Noemí Contreras
- Endocrine Research Department, Instituto de Investigaciones Médicas Alfredo Lanari, University of Buenos Aires, Buenos Aires, Argentina
- Unidad Ejecutora Instituto de Investigaciones Médicas, National Council of Technical and Scientific Research, Buenos Aires, Argentina
- Laboratory of Salivary Glands, School of Dentistry, University of Buenos Aires, Buenos Aires, Argentina
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Koh TJK, Chan CT. Adrenal insufficiency presenting as unexplained hypotension in nocturnal home hemodialysis. Hemodial Int 2016; 20:E10-3. [PMID: 27028788 DOI: 10.1111/hdi.12412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Adrenal insufficiency is a complication of chronic corticosteroid therapy. Unexplained hypotension may be a manifestation of an adrenal insufficient state in patients with a history of corticosteroid therapy on hemodialysis. We present a series of five cases of patients on nocturnal home hemodialysis with hypotension as the main manifestation of adrenal insufficiency. Unexplained hypotension in patients with a history of corticosteroid therapy should prompt the managing clinician to consider adrenal insufficiency as a possible cause.
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Affiliation(s)
- Timothy Jee Kam Koh
- Department of Internal Medicine, Division of Nephrology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Renal Medicine, Division of Medicine, Tan Tock Seng Hospital, Singapore
| | - Christopher T Chan
- Department of Internal Medicine, Division of Nephrology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
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14
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Verardo LL, Silva FF, Lopes MS, Madsen O, Bastiaansen JWM, Knol EF, Kelly M, Varona L, Lopes PS, Guimarães SEF. Revealing new candidate genes for reproductive traits in pigs: combining Bayesian GWAS and functional pathways. Genet Sel Evol 2016; 48:9. [PMID: 26830357 PMCID: PMC4736284 DOI: 10.1186/s12711-016-0189-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 01/20/2016] [Indexed: 12/18/2022] Open
Abstract
Background Reproductive traits such as number of stillborn piglets (SB) and number of teats (NT) have been evaluated in many genome-wide association studies (GWAS). Most of these GWAS were performed under the assumption that these traits were normally distributed. However, both SB and NT are discrete (e.g. count) variables. Therefore, it is necessary to test for better fit of other appropriate statistical models based on discrete distributions. In addition, although many GWAS have been performed, the biological meaning of the identified candidate genes, as well as their functional relationships still need to be better understood. Here, we performed and tested a Bayesian treatment of a GWAS model assuming a Poisson distribution for SB and NT in a commercial pig line. To explore the biological role of the genes that underlie SB and NT and identify the most likely candidate genes, we used the most significant single nucleotide polymorphisms (SNPs), to collect related genes and generated gene-transcription factor (TF) networks. Results Comparisons of the Poisson and Gaussian distributions showed that the Poisson model was appropriate for SB, while the Gaussian was appropriate for NT. The fitted GWAS models indicated 18 and 65 significant SNPs with one and nine quantitative trait locus (QTL) regions within which 18 and 57 related genes were identified for SB and NT, respectively. Based on the related TF, we selected the most representative TF for each trait and constructed a gene-TF network of gene-gene interactions and identified new candidate genes. Conclusions Our comparative analyses showed that the Poisson model presented the best fit for SB. Thus, to increase the accuracy of GWAS, counting models should be considered for this kind of trait. We identified multiple candidate genes (e.g. PTP4A2, NPHP1, and CYP24A1 for SB and YLPM1, SYNDIG1L, TGFB3, and VRTN for NT) and TF (e.g. NF-κB and KLF4 for SB and SOX9 and ELF5 for NT), which were consistent with known newborn survival traits (e.g. congenital heart disease in fetuses and kidney diseases and diabetes in the mother) and mammary gland biology (e.g. mammary gland development and body length). Electronic supplementary material The online version of this article (doi:10.1186/s12711-016-0189-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lucas L Verardo
- Department of Animal Science, Universidade Federal de Viçosa, Viçosa, 36570000, Brazil. .,Animal Breeding and Genomics Centre, Wageningen University, 6700 AH, Wageningen, The Netherlands.
| | - Fabyano F Silva
- Department of Animal Science, Universidade Federal de Viçosa, Viçosa, 36570000, Brazil.
| | - Marcos S Lopes
- Animal Breeding and Genomics Centre, Wageningen University, 6700 AH, Wageningen, The Netherlands. .,Topigs Norsvin, Research Center, 6641 SZ, Beuningen, The Netherlands.
| | - Ole Madsen
- Animal Breeding and Genomics Centre, Wageningen University, 6700 AH, Wageningen, The Netherlands.
| | - John W M Bastiaansen
- Animal Breeding and Genomics Centre, Wageningen University, 6700 AH, Wageningen, The Netherlands.
| | - Egbert F Knol
- Topigs Norsvin, Research Center, 6641 SZ, Beuningen, The Netherlands.
| | - Mathew Kelly
- Queensland Alliance for Agriculture and Food Innovation, The University of Queensland, St Lucia, QLD, 4072, Australia.
| | - Luis Varona
- Departamento de Anatomía, Embriología y Genética, Universidad de Zaragoza, 50013, Saragossa, Spain.
| | - Paulo S Lopes
- Department of Animal Science, Universidade Federal de Viçosa, Viçosa, 36570000, Brazil.
| | - Simone E F Guimarães
- Department of Animal Science, Universidade Federal de Viçosa, Viçosa, 36570000, Brazil.
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15
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Gosmanov AR, Gosmanova EO, Kovesdy CP. Evaluation and management of diabetic and non-diabetic hypoglycemia in end-stage renal disease. Nephrol Dial Transplant 2015; 31:8-15. [PMID: 26152404 DOI: 10.1093/ndt/gfv258] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 05/22/2015] [Indexed: 02/06/2023] Open
Abstract
Patients with end-stage renal disease (ESRD) regardless of diabetes status are at increased risk of hypoglycemia with a resultant array of adverse clinical outcomes. Therefore, hypoglycemia should be thoroughly evaluated in ESRD patients. In diabetic dialysis patients, hypoglycemic agents and nutritional alterations can trigger hypoglycemia in the background of diminished gluconeogenesis, reduced insulin clearance by the kidney and improved insulin sensitivity following initiation of renal replacement therapy. Detailed evaluation of antidiabetic regimen and nutritional patterns, patient education on self-monitoring of blood glucose and/or referral to a diabetes specialist may reduce risk of subsequent hypoglycemia. In certain situations, it is important to recognize the possibility of non-diabetic causes of hypoglycemia in patients with diabetes and to avoid treating pseudo-hyperglycemia caused by glucose- non-specific glucometers in patients utilizing icodextrin-based solutions for peritoneal dialysis. Adrenal insufficiency, certain medications, malnutrition and/or infection are among the most common causes of hypoglycemia in non-diabetic ESRD patients, and they should be suspected after exclusion of inadvertent use of hypoglycemic agents. The goal of this review article is to summarize approaches and recommendations for the work up and treatment of hypoglycemia in ESRD.
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Affiliation(s)
- Aidar R Gosmanov
- Division of Endocrinology, Diabetes, and Metabolism, University of Tennessee Health Science Center, Memphis, TN 38103, USA
| | - Elvira O Gosmanova
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
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