A prospective study on the incidence and predictive factors of relative adrenal insufficiency in Korean critically-ill patients

PROGNOSTIC VALUE OF LOW-DOSE ADRENOCORTICOTROPIC HORMONE TEST IN CRITICALLY ILL PATIENTS

ABSTRACT

Background: Previous trials evaluated the incidence of critical illness-related corticosteroid insufficiency (CIRCI) using 250 μg adrenocorticotropic hormone (ACTH). However, this supraphysiological dose could result in false-positive levels. We aimed to determine the incidence of CIRCI in septic patients using a 1 μg ACTH stress test. Methods: We conducted a prospective cohort study on 39 patients with septic shock. Critical illness-related corticosteroid insufficiency was defined as a Δ max cortisol <9 μg/dL after 1 μg ACTH stress test. The primary outcome of the study was death. Secondary outcomes included days of vasopressors, days of mechanical ventilation (MV), amount of fluid per day, the incidence of acute kidney injury (AKI), and days of intensive care unit (ICU) stay. Results: The incidence of CIRCI in our cohort was 43.6% using 1 μg ACTH. There were no significant differences between groups in terms of ICU scores, laboratory investigations, vasopressors, MV days, amount of fluid per day, and the ICU stay ( P = > 0.05). The CIRCI group had lower median survival and survival probability rates (5 days and 48.4%, respectively) compared with the non-CIRCI group (7 days and 49.5%, respectively). In addition, the CIRCI group had a shorter time to develop AKI and a higher probability of developing AKI (4 days and 44.6%, respectively) in comparison with the non-CIRCI group (6 days and 45.57%, respectively). Conclusion: We concluded that the CIRCI group had a lower mean survival rate and a higher incidence of AKI. We recommend the use of 1 μg ACTH test in septic shock patients to identify this subgroup of patients.

Prognostic Implication of Adrenocortical Response during the Course of Critical Illness

Background

Critical illness-related corticosteroid insufficiency (CIRCI) and adrenocorticotropic hormone (ACTH)-cortisol dissociation are hormonal conditions frequently observed in patients in the intensive care unit (ICU). The aim of this study was to evaluate the association between ACTH-cortisol dissociation and clinical outcomes of critically ill patients.

Methods

We retrospectively reviewed the medical records of 94 ICU patients who underwent two rapid cosyntropin tests during hospital admission and compared the clinical aspects of patients with and without ACTH-cortisol dissociation. ACTH-cortisol dissociation was defined as plasma ACTH and serum cortisol concentrations of <22 pmol/L and >600 nmol/L, respectively.

Results

Dissociation was present in 30 of the 94 patients (31.9%). Patients with ACTH-cortisol dissociation in the initial test had significantly higher hospital mortality rate than those in the control group (55% vs. 25.7%, P=0.013) There was no difference in hospital mortality between patients classified as having CIRCI and those who were not. In multivariate adjusted Cox regression analysis, the mortality risk was higher in the group with ACTH-cortisol dissociation (hazard ratio, 2.98; 95% confidence interval, 1.34 to 6.63; P=0.007). Patients with dissociation in two consecutive stimulation tests showed the highest hospital mortality rate among groups classified according to stimulation test results (100% vs. 31.3%).

Conclusions

The hospital mortality was higher in ICU patients diagnosed with ACTH-cortisol dissociation. It is clinically feasible to evaluate the presence of ACTH-cortisol dissociation by analyzing rapid ACTH stimulation test results in critically ill patients.

EVALUATION OF THE HYPOTHALAMIC-PITUITARY-ADRENAL AXIS IN A PAEDIATRIC INTENSIVE CARE UNIT

Background

Relative adrenal insufficiency (RAI) is the inadequate production of cortisol due to dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis during a severe illness. We evaluated the HPA axis and RAI in a tertiary pediatric intensive care unit (PICU).

Methods

A total of 100 PICU patients were included in this prospective cohort study. Basal serum levels of adrenocorticotropic hormone (ACTH), cortisol values were compared with those in the control group. A low-dose ACTH stimulation test was performed in patients with basal cortisol levels below 18 µg/dL.

Results

The basal cortisol levels of the PICU patients were significantly higher than those of the control group (P < 0.05). All tested patients (n= 24) had delta cortisol levels > 9 µg/dL and a peak cortisol response > 18 µg/dL. Basal cortisol levels were positively correlated with Pediatric Risk of Mortality (PRISM) III scores (P < 0.05; r = 0.363). The basal or stimulated cortisol levels of the patients who received glucocorticoid treatment were higher than the cut-off levels.

Conclusions

High basal or stimulated cortisol levels are indicative of disease severity in the acute phase of stress. Patients with very high cortisol levels should be particularly carefully monitored because of the high mortality risk.

Prognostic Impact of Combined Dysglycemia and Hypoxic Liver Injury on Admission in Patients With ST-Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention (from the INTERSTELLAR Cohort)

Dysglycemia on admission is known to predict the prognosis of ST-segment elevation myocardial infarction (STEMI). Recently, hypoxic liver injury (HLI) has been proposed as a novel prognosticator for STEMI. We evaluated the prognostic impact of combined dysglycemia and HLI at the time of presentation in patients with STEMI who underwent primary percutaneous coronary intervention. From 2007 to 2014, 1,525 consecutive patients (79% men, mean age 61 years) who underwent primary percutaneous coronary intervention for STEMI in the INTERSTELLAR (Incheon-Bucheon Cohort of Patients Undergoing Primary PCI for Acute ST-Elevation Myocardial Infarction) cohort were analyzed retrospectively. Dysglycemia was defined as either hypoglycemia (serum glucose <90 mg/dl) or hyperglycemia (serum glucose >250 mg/dl). HLI was defined as more than twofold increase of any serum aminotransferases above the upper normal limit. Patients were divided into 4 groups according to their dysglycemia and HLI status on admission: group 1, normoglycemia without HLI; group 2, dysglycemia without HLI; group 3, normoglycemia with HLI; and group 4, dysglycemia with HLI. Primary end point was inhospital death and secondary end point was all-cause mortality at 12 months after the index procedure. Of the 1,525 patients, there were 87 inhospital deaths (5.7%) and 113 all-cause deaths (7.4%) at 12 months after the index procedure. Both dysglycemia and HLI on admission were independent predictors of inhospital death. Inhospital mortality rate was the highest in group 4 (32.1%), followed by groups 2 and 3. Kaplan-Meier survival analysis at 12 months showed similar trends among the 4 groups. In conclusion, combined dysglycemia and HLI on admission predicts early prognosis for STEMI.

The utility of the corticotropin test to diagnose adrenal insufficiency in critical illness: an update

OBJECTIVE

One of the most common dynamic testing procedures for assessment of adrenocortical function is the standard corticotropin or the cosyntropin test. The aim of this review was to examine the evidence base underlying the corticotropin test in the management of the critically ill patient.

DATA SYNTHESIS

The principle behind the corticotropin test is the demonstration of an inappropriately low cortisol production in response to exogenous ACTH, a situation analogous to physiological stress. The corticotropin test was originally described in nonstressed subjects, and its applicability and interpretation in the setting of critical illness continues to generate controversy. Attempting to determine the prevalence of an abnormal corticotropin test in critical illness is complicated by the use of different end-points and different populations. Moreover, the test result is also influenced by the assay used for measurement of plasma cortisol. Trials assessing the relationship between corticotropin response and severity of stress and organ dysfunction have produced divergent results, which may reflect differences in the methodology and the association being measured. Moreover, controversy exists with respect to the methodology and the interpretation with respect to the following variables: dose of corticotropin, end-points for assessment of total or free cortisol, effect of plasma cortisol variability, adrenal blood flow and its equivalence with other tests of adrenocortical function.

CONCLUSIONS

The corticotropin test is used widely in the evaluation of adrenocortical function in the endocrine clinics. Its role in the critically ill patient is less well established. Several confounding variables exist and to have a 'one-size-fits-all' approach with a single end-point in the face of several methodological and pathophysiological confounders may be flawed and may result in the institution of inappropriate therapy. The current evidence does not support the use of the corticotrophin test in critical illness to assess adrenocortical function and guiding steroid therapy in critical illness.

Etomidate, adrenal function, and mortality in critically ill patients

BACKGROUND

In critically ill patients, induction with etomidate is hypothesized to be associated with an increased risk of mortality. Previous randomized studies suggest a modest trend toward an increased risk of death among etomidate recipients; however, this relationship has not been measured with great statistical precision. We aimed to test whether etomidate is associated with risk of hospital mortality and other clinical outcomes in critically ill patients.

METHODS

We conducted a retrospective cohort study from January 1, 2001, to December 31, 2005, of 824 subjects requiring mechanical ventilation, who underwent adrenal function testing in the ICUs of 2 academic medical centers. The primary outcome was in-hospital mortality, comparing subjects given etomidate (n = 452) to those given an alternative induction agent (n = 372). The secondary outcome was diagnosis of critical illness-related corticosteroid insufficiency following etomidate exposure.

RESULTS

Overall mortality was 34.3%. After adjustment for age, sex, and baseline illness severity, the relative risk of death among the etomidate recipients was higher than that of subjects given an alternative agent (relative risk 1.20, 95% CI 0.99-1.45). Among subjects whose adrenal function was assessed within the 48 hours following intubation, the adjusted risk of meeting the criteria for critical illness-related corticosteroid insufficiency was 1.37 (95% CI 1.12-1.66), comparing etomidate recipients to subjects given another induction agent.

CONCLUSIONS

In this study of critically ill patients requiring endotracheal intubation, etomidate administration was associated with a trend toward a relative increase in mortality, similar to the collective results of smaller randomized trials conducted to date. If a small relative increased risk is truly present, though previous trials have been underpowered to detect it, in absolute terms the number of deaths associated with etomidate in this high-risk population would be considerable. Large, prospective controlled trials are needed to finalize the role of etomidate in critically ill patients.

Serum cytokines and critical illness-related corticosteroid insufficiency

PURPOSE

Little information exists regarding the association of specific cytokine levels and different subgroups of patients with critical illness-related corticosteroid insufficiency (CIRCI).

METHODS

Data from a previous prospective study on adrenal function in the ICU were used in this study. CIRCI was diagnosed when either the basal cortisol was less than 10 μg/ml or the Δ cortisol was less than 9 μg/ml. The patients with CIRCI were further divided into a low basal cortisol (LBC) group (basal cortisol < 10 μg/ml), and low Δ cortisol (LDC) group (basal cortisol ≥ 10 μg/ml and Δ cortisol < 9 μg/ml). Serum cytokine levels were compared among the normal (NOM), LBC, and LDC groups.

RESULTS

The serum of 82 out of 123 (67%) patients included in the previous study was available for analysis; these patients were included in the present study. The overall incidence of CIRCI was 43.9% (36 out of 82 patients). Among patients with CIRCI, 16 (44.4%) were classified as the LBC group and 20 (55.6%) as the LDC group. The LDC group had significantly higher levels of IL-6 and IL-10 compared to both the NOM and LBC groups (p < 0.01). The LDC group also had significantly increased TNF-α (p = 0.002) compared to the LBC group. There were no significant differences in any of the cytokine levels between the NOM and LBC groups.

CONCLUSIONS

Elevated cytokines were associated with adrenal dysfunction in a subset of patients meeting the criteria for CIRCI (normal or high basal cortisol and low Δ cortisol).