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Hao D, Guo L, Wang Q, Ito M, Huang B, Mineo C, Shaul PW, Li XA. Relative Adrenal Insufficiency Is a Risk Factor for Pediatric Sepsis: A Proof-of-Concept Study. J Infect Dis 2024; 229:1166-1177. [PMID: 37633660 PMCID: PMC11011189 DOI: 10.1093/infdis/jiad369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/16/2023] [Accepted: 08/24/2023] [Indexed: 08/28/2023] Open
Abstract
Glucocorticoid (GC) therapy had been strongly recommended for pediatric sepsis (grade 1A). However, the recommendation was changed to grade 2C in 2020 due to weak evidence. About 32.8% of patients with pediatric septic develop relative adrenal insufficiency (RAI). But whether GC therapy should be determined by RAI status is controversial. This study utilized 21-day-old SF1CreSRBIfl/fl mice as the first pediatric RAI mouse model to assess the pathogenesis of RAI and evaluate GC therapy. RAI mice exhibited a substantially higher mortality rate in cecal ligation and puncture and cecal slurry-induced sepsis. These mice featured persistent inflammatory responses and were effectively rescued by GC therapy. RNA sequencing analysis revealed persistent inflammatory responses in RAI mice, caused by transcriptional dysregulation of AP-1 and NF-κB, and cytokine-induced secondary inflammatory response. Our findings support a precision medicine approach to guide GC therapy for pediatric patients based on the status of RAI.
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Affiliation(s)
- Dan Hao
- Department of Pharmacology and Nutritional Sciences
| | - Ling Guo
- Saha Cardiovascular Research Center
| | | | - Misa Ito
- Department of Pharmacology and Nutritional Sciences
| | - Bin Huang
- Division of Cancer Biostatistics, College of Medicine, University of Kentucky, Lexington
| | - Chieko Mineo
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Philip W Shaul
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Xiang-An Li
- Department of Pharmacology and Nutritional Sciences
- Saha Cardiovascular Research Center
- Lexington VA Healthcare System
- Department of Physiology, College of Medicine, University of Kentucky, Lexington
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Watanabe H, Washio Y, Tamai K, Morimoto D, Okamura T, Yoshimoto J, Nakanishi H, Kageyama M, Uchiyama A, Tsukahara H, Kusuda S. Postnatal longitudinal analysis of serum Nitric oxide and eosinophil counts in extremely preterm infants. Pediatr Neonatol 2023:S1875-9572(23)00173-0. [PMID: 37989707 DOI: 10.1016/j.pedneo.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Nitric oxide (NO) may be related to the pathogenesis of several morbidities in extremely preterm infants, including late-onset adrenal insufficiency. However, eosinophilia is observed under pathological conditions with adrenal insufficiency. Therefore, this study explored postnatal changes in NO levels and eosinophil counts in extremely preterm infants with and without morbidities. METHODS Nineteen extremely preterm infants with a median gestational age of 27.0 weeks and median birth weight of 888 g were enrolled in this study. Serum levels of nitrogen oxides (NOx) and peripheral blood eosinophil counts were measured at birth and every 2 weeks thereafter. Morbidities of the study group were diagnosed using a single criterion. RESULTS Serum NOx levels (mean ± standard deviation) were 22.5 ± 14.9 μmol/L, 51.2 ± 23.7 μmol/L, 42.4 ± 15.2 μmol/L, and 33.8 ± 9.4 μmol/L at birth and 2, 4, and 6 weeks of age, respectively. The serum NOx level at 2 weeks of age was significantly higher than that at birth and 6 weeks of age. Eosinophil counts, which increase with adrenal insufficiency, were measured simultaneously and were 145 ± 199/μL, 613 ± 625/μL, 466 ± 375/μL, and 292 ± 228/μL at birth and 2, 4, and 6 weeks of age, respectively. These values showed that the eosinophil count was significantly higher at 2 weeks of age than at birth and 6 weeks of age. The serum NOx level of infants without chorioamnionitis was significantly increased at 4 weeks of age, and the eosinophil count of infants with necrotizing enterocolitis was significantly increased at 2 weeks of age. No correlation with the NOx level or eosinophil count was observed in infants with late-onset circulatory collapse. CONCLUSION The postnatal serum NOx level and eosinophil count were significantly correlated with each other and peaked at 2 weeks of age.
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Affiliation(s)
- Hirokazu Watanabe
- Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama University, Okayama, Japan
| | - Yosuke Washio
- Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama University, Okayama, Japan.
| | - Kei Tamai
- Department of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
| | - Daisaku Morimoto
- Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama University, Okayama, Japan
| | - Tomoka Okamura
- Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama University, Okayama, Japan
| | - Junko Yoshimoto
- Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama University, Okayama, Japan
| | - Hidehiko Nakanishi
- Department of Neonatology, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Misao Kageyama
- Department of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
| | - Atsushi Uchiyama
- Department of Neonatology, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Hirokazu Tsukahara
- Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama University, Okayama, Japan
| | - Satoshi Kusuda
- Department of Neonatology, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
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Wu CH, Guo L, Hao D, Wang Q, Ye X, Ito M, Huang B, Mineo C, Shaul PW, Li XA. Relative adrenal insufficiency is a risk factor and endotype of sepsis - A proof-of-concept study to support a precision medicine approach to guide glucocorticoid therapy for sepsis. Front Immunol 2023; 13:1110516. [PMID: 36713379 PMCID: PMC9878847 DOI: 10.3389/fimmu.2022.1110516] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/28/2022] [Indexed: 01/13/2023] Open
Abstract
Introduction 25-60% of septic patients experience relative adrenal insufficiency (RAI) and glucocorticoid (GC) is frequently used in septic patients. However, the efficacy of GC therapy and whether GC therapy should be based on the status of RAI are highly controversial. Our poor understanding about the pathogenesis of RAI and a lack of RAI animal model present significant barriers to address these critical issues. Methods Scavenger receptor BI (SR-BI) regulates stress-induced GC (iGC) production in response to stress. We generated SF1CreSR-BIfl/fl mice and utilized the mice as a RAI model to elucidate the pathogenesis of RAI and GC therapy in sepsis. SF1CreSR-BIfl/fl mice did not express SR-BI in adrenal gland and lacked iGC production upon ACTH stimulation, thus, they are RAI. Results and Discussion RAI mice were susceptible to cecal ligation and puncture (CLP)-induced sepsis (6.7% survival in SF1CreSR-BIfl/fl mice versus 86.4% in SR-BIfl/fl mice; p = 0.0001). Compared to a well-controlled systemic inflammatory response in SR-BIfl/fl mice, SF1CreSR-BIfl/fl mice featured a persistent hyperinflammatory response. Supplementation of a low stress dose of GC to SF1CreSR-BIfl/fl mice kept the inflammatory response under control and rescued the mice. However, SR-BIfl/fl mice receiving GC treatment exhibited significantly less survival compared to SR-BIfl/fl mice without GC treatment. In conclusions, we demonstrated that RAI is a risk factor for death in this mouse model of sepsis. We further demonstrated that RAI is an endotype of sepsis, which features persistent hyperinflammatory response. We found that GC treatment benefits mice with RAI but harms mice without RAI. Our study provides a proof of concept to support a precision medicine approach for sepsis therapy - selectively applying GC therapy for a subgroup of patients with RAI.
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Affiliation(s)
- Chia-Hua Wu
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY, United States
- Saha Cardiovascular Research Center, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Ling Guo
- Saha Cardiovascular Research Center, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Dan Hao
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Qian Wang
- Saha Cardiovascular Research Center, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Xiang Ye
- Saha Cardiovascular Research Center, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Misa Ito
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Bin Huang
- Division of Cancer Biostatistics, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Chieko Mineo
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Philip W. Shaul
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Xiang-An Li
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY, United States
- Saha Cardiovascular Research Center, University of Kentucky College of Medicine, Lexington, KY, United States
- Lexington Veterans Affairs (VA), Healthcare System, Lexington, KY, United States
- Department of Physiology, University of Kentucky College of Medicine, Lexington, KY, United States
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Li J, Zhang X, He Q, Feng W, Ding L, Wang Z, Yu H, Chen Q, Lu N, Xu D, Cui J. Pancreatic neuroendocrine tumor producing vasopressin: A case report. Medicine (Baltimore) 2021; 100:e27453. [PMID: 34622867 PMCID: PMC8500607 DOI: 10.1097/md.0000000000027453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/20/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Functional pancreatic neuroendocrine tumors (pNETs) rarely produce vasopressin. Here, we reported a case of pNET producing vasopressin in a 78-year-old man with hyponatremia. PATIENT CONCERNS The patient presented with anorexia approximately 4 years ago, and the laboratory test results indicated hyponatremia. He was hospitalized 3 times subsequently due to anorexia in the past 4 years, during which laboratory tests consistently indicated severe hyponatremia. DIAGNOSIS Upon admission, his serum osmolarity, urine osmolarity, urine sodium level, and 24-hour urine sodium level was 277 mOsm/kg H2O, 465 mOsm/kg H2O, 82.5 mmol/L, and 140.25 mmol, respectively. Gallium-68-labeled tetraazacyclododecanetetraacetic acid-Dphel-Tyr3-octreotate positron emission tomography-computed tomography showed a high uptake lesion measuring approximately 1 cm in diameter in the pancreatic body, and the possibility of pNET was considered. Besides, laboratory tests showed that adrenocorticotropic hormone, follicle-stimulating hormone, and luteinizing hormone released by the pituitary was insufficient in the case of low levels of cortisol, estradiol, progesterone, and testosterone. Thus, the diagnosis of the syndrome of inappropriate antidiuresis (SIAD) was considered along with hypopituitarism. INTERVENTIONS The patient underwent surgery, and pNET was confirmed by pathology examination. The immunohistochemical study showed that the tumor cells were positive for somatostatin receptors 2 and vasopressin. OUTCOMES In the last follow-up 17 months after surgery, the patient was in good condition, taking methylprednisolone 4 mg every other day, and had been free of anorexia or hyponatremia episodes. LESSONS This case illustrated the potential ectopic production of vasopressin resulting in SIAD in pNETs, highlighting the adoption of gallium-68-labeled tetraazacyclododecanetetraacetic acid-Dphel-Tyr3-octreotate positron emission tomography-computed tomography and vasopressin immunohistochemical staining in the evaluation of the etiology of SIAD.
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Affiliation(s)
- Jingyan Li
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Xinxin Zhang
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Qing He
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Wenli Feng
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Li Ding
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhuoqun Wang
- Department of Cardiovascular Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Haonan Yu
- Department of PET-CT, Tianjin Medical University General Hospital, Tianjin, China
| | - Qiusong Chen
- Department of PET-CT, Tianjin Medical University General Hospital, Tianjin, China
| | - Ning Lu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Dongbo Xu
- Department of Pathology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jingqiu Cui
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
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Wentworth BJ, Haug RM, Northup PG, Caldwell SH, Henry ZH. Abnormal cholesterol metabolism underlies relative adrenal insufficiency in decompensated cirrhosis. Liver Int 2021; 41:1913-1921. [PMID: 34028160 DOI: 10.1111/liv.14970] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/02/2021] [Accepted: 05/18/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Relative adrenal insufficiency (RAI) in patients with cirrhosis is associated with increased mortality. Although the pathogenesis of RAI remains unclear, disordered cholesterol metabolism may contribute. METHODS We performed a prospective cohort study of 96 non-critically ill subjects with decompensated cirrhosis at a tertiary care centre. Subjects were administered 250 µcg cosyntropin, with RAI defined as an increase in total cortisol <9 µg/dL. High-density lipoprotein (HDL) levels and serum cholesterol esterification percentage (%CE), a validated surrogate marker of lecithin-cholesterol acyltransferase (LCAT) activity, were measured to assess the relationship between disordered cholesterol metabolism and the presence of RAI. Subjects were followed until death, liver transplantation or a maximum of 6 months. RESULTS Subjects with RAI had decreased levels of HDL (18 vs 29 mg/dL, P < .01) and %CE (64% vs 66%, P = .03). Correlation was seen between HDL and %CE (r = 0.7, R2 = 0.49; P < .01) and each integer decrease in %CE predicted an approximately 2% increase in the probability of RAI. Transplant-free survival was reduced in subjects with RAI at both 6 months (43% vs 71%, P = .01) and 90 days (54% vs 81%, P < .01). CONCLUSIONS Disruption in cholesterol metabolism contributes to the development of RAI in cirrhosis, as decreased LCAT activity leads to reduced HDL trafficking to the adrenal gland.
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Affiliation(s)
- Brian J Wentworth
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Rebecca M Haug
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Patrick G Northup
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Zachary H Henry
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
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Kumar M, Gupta GK, Wanjari SJ, Tak V, Ameta M, Nijhawan S. Relative Adrenal Insufficiency in Patients with Alcoholic Hepatitis. J Clin Exp Hepatol 2019; 9:215-220. [PMID: 31024204 PMCID: PMC6477128 DOI: 10.1016/j.jceh.2018.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 09/04/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND/AIMS Alcoholic hepatitis (AH) is an acute hepatic inflammation associated with high morbidity and mortality. Treatment with steroids is known to decrease short-term mortality in severe AH patients. Hence, we hypothesize that adrenal insufficiency can be associated with severe AH and affects prognosis. The aim of this study was (1) to evaluate relative adrenal insufficiency (RAI) in patients with AH and (2) to Compare RAI with the severity of AH. METHODS Newly diagnosed cases of AH hospitalized in SMS Medical College and Hospital, Department of Gastroenterology were, enrolled. All patients of AH were classified as mild and severe AH on the basis of Maddrey discriminant function (DF). After baseline serum cortisol, 25 IU ACTH (Adreno Corticotrophic Hormone) was injected intramuscularly and blood sample was collected after 1 h and assessed for serum cortisol. RAI was defined as <7 μg increase in the cortisol level from baseline. RAI was compared with severity of AH. RESULTS Of 120 patients of AH, 58 patients fulfilled the inclusion criteria, in which 48 patients were diagnosed as severe AH and 10 patients were diagnosed as mild AH. In patients with severe AH, the baseline mean serum cortisol level was significantly high as compared with mild AH; 26 patients (54.16 %) of 48 patients with severe AH showed RAI (P ≤ 0.001).Whereas in patients with mild AH, none of patients showed RAI. RAI also showed negative correlation with DF. There was no difference in RAI with respect to acute kidney injury (AKI). CONCLUSION RAI is a common entity in patients with severe AH, and it is related with the severity of disease.
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Key Words
- ACTH, Adreno Corticotrophic Hormone
- AH, Alcoholic Hepatitis
- AI, Adrenal Insuffiency
- AKI, Acute Kidney Injury
- ALD, Alcoholic Liver Disease
- ALT, Alanine Aminotranferase
- AST, Aspartate Aminotransferase
- CIRCI (Critical Illness Related Corticosteroid Insufficiency)
- CIRCI, Critical Illness Related Corticosteroid Insufficiency
- DF, Discriminant Function
- HPA, Hypothalamic Pituitary Adrenal
- INR, International Normalised Ratio
- MELD, Model for End-stage Liver Disease
- PT, Prothrombin Time
- RAI, Relative Adrenal Insuffiency
- TLC, Total Leucocyte Count
- alcoholic hepatitis
- relative adrenal insufficiency
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Affiliation(s)
| | - Gaurav K. Gupta
- Address for correspondence: Gaurav Kumar Gupta, MD, DM. Department of Gastroenterology, SMS Medical College & Hospital, Jaipur, India. Tel.: +91 9214027938.
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Fudulu DP, Gibbison B, Upton T, Stoica SC, Caputo M, Lightman S, Angelini GD. Corticosteroids in Pediatric Heart Surgery: Myth or Reality. Front Pediatr 2018; 6:112. [PMID: 29732365 PMCID: PMC5920028 DOI: 10.3389/fped.2018.00112] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/04/2018] [Indexed: 11/17/2022] Open
Abstract
Background: Corticosteroids have been administered prophylactically for more than 60 years in pediatric heart surgery, however, their use remains a matter of debate. There are three main indications for corticosteroid use in pediatric heart surgery with the use of cardiopulmonary bypass (CPB): (1) to blunt the systemic inflammatory response (SIRS) induced by the extracorporeal circuit; (2) to provide perioperative supplementation for presumed relative adrenal insufficiency; (3) for the presumed neuroprotective effect during deep hypothermic circulatory arrest operations. This review discusses the current evidence behind the use of corticosteroids in these three overlapping areas. Materials and Methods: We conducted a structured research of the literature using PubMed and MEDLINE databases to November 2017 and additional articles were identified by cross-referencing. Results: The evidence suggests that there is no correlation between the effect of corticosteroids on inflammation and their effect on clinical outcome. Due to the limitations of the available evidence, it remains unclear if corticosteroids have an impact on early post-operative outcomes or if there are any long-term effects. There is a limited understanding of the hypothalamic-pituitary-adrenal axis function during cardiac surgery in children. The neuroprotective effect of corticosteroids during deep hypothermic circulatory arrest surgery is controversial. Conclusions: The utility of steroid administration for pediatric heart surgery with the use of CPB remains a matter of debate. The effect on early and late outcomes requires clarification with a large multicenter randomized trial. More research into the understanding of the adrenal response to surgery in children and the effect of corticosteroids on brain injury is warranted.
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Affiliation(s)
- Daniel P. Fudulu
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
- Henry Welcome Laboratories for Integrative Neuroscience and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Ben Gibbison
- Cardiac Anesthesia and Intensive Care, Bristol Heart Institute - University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Thomas Upton
- Henry Welcome Laboratories for Integrative Neuroscience and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Serban C. Stoica
- Department of Congenital Cardiac Surgery, Bristol Royal Hospital for Children - University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Massimo Caputo
- Department of Congenital Cardiac Surgery, Bristol Royal Hospital for Children - University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Stafford Lightman
- Henry Welcome Laboratories for Integrative Neuroscience and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Gianni D. Angelini
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
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8
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Iwanaga K, Yamamoto A, Matsukura T, Niwa F, Kawai M. Corticotrophin-releasing hormone stimulation tests for the infants with relative adrenal insufficiency. Clin Endocrinol (Oxf) 2017; 87:660-664. [PMID: 28802067 DOI: 10.1111/cen.13446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/30/2017] [Accepted: 08/10/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Very low birthweight (VLBW) infants are considered to be vulnerable to relative adrenal insufficiency (RAI); however, diagnosis is difficult in some clinical settings. Considering this background, it is necessary to establish a diagnosis of RAI in preterm infants. OBJECTIVE In this study, we attempted to clarify the difference in response to CRH stimulation tests for preterm infants with or without RAI. METHODS Between June 2009 and December 2015, we performed CRH stimulation tests for preterm infants born at a gestational age of <30 weeks at around 2 weeks of age. Retrospectively, subjects were classified into two groups: infants with RAI (n = 9) or without RAI (n = 17) based on the clinical symptoms and responsiveness to hydrocortisone. RESULTS We found no difference in base or peak serum cortisol levels related to CRH stimulation tests between the two groups; however, delta cortisol levels and responsive ratio (peak-to-base ratio) were significantly reduced in infants with RAI. 140 nmol/L for delta cortisol or 1.5 times for peak-to-base ratio may be cut-off levels in preterm infants. CONCLUSION This study provides evidence that base cortisol levels of preterm infants with RAI were not different from those without RAI; however, CRH stimulation tests may be a useful tool for the diagnosis of RAI in preterm infants.
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Affiliation(s)
- Kougoro Iwanaga
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akane Yamamoto
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Matsukura
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Fusako Niwa
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masahiko Kawai
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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9
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Pisano SRR, Howard J, Posthaus H, Kovacevic A, Yozova ID. Hydrocortisone therapy in a cat with vasopressor-refractory septic shock and suspected critical illness-related corticosteroid insufficiency. Clin Case Rep 2017; 5:1123-1129. [PMID: 28680609 PMCID: PMC5494402 DOI: 10.1002/ccr3.1018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/05/2017] [Accepted: 05/01/2017] [Indexed: 01/22/2023] Open
Abstract
A 27‐month‐old female cat was presented with septic peritonitis secondary to a ruptured pyometra and subsequent pyothorax. Vasopressor‐refractory septic shock led to a suspicion of critical illness‐related corticosteroid insufficiency, successfully treated with intravenous hydrocortisone. Previous megestrol acetate administration may have played a role in the development of adrenocortical dysfunction.
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Affiliation(s)
- Simone R R Pisano
- Department of Clinical Veterinary Medicine Vetsuisse Faculty University of Bern Bern Switzerland
| | - Judith Howard
- Department of Clinical Veterinary Medicine Vetsuisse Faculty University of Bern Bern Switzerland
| | - Horst Posthaus
- Department of Infectious Diseases and Pathobiology Vetsuisse Faculty University of Bern Bern Switzerland
| | - Alan Kovacevic
- Department of Clinical Veterinary Medicine Vetsuisse Faculty University of Bern Bern Switzerland
| | - Ivayla D Yozova
- Institute of Veterinary, Animal and Biomedical Sciences Massey University Palmerston North New Zealand
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Orozco F, Anders M, Mella J, Antinucci F, Pagano P, Esteban P, Cartier M, Romero G, Francini B, Mastai R. [Adrenal insufficiency in cirrhotic patients]. Medicina (B Aires) 2016; 76:208-212. [PMID: 27576278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
Relative adrenal insufficiency (RAI) is a common finding in cirrhotic patients with severe sepsis, and increased mortality. Its significance is unknown in stable conditions. The aim of this study was to evaluate the prevalence of RAI in stable cirrhotic patients at different stages of the disease. Also, the impact of RAI on the survival was evaluated and basal cortisol levels between plasma and saliva was correlated in control subjects and cirrhotic patients. Forty seven ambulatory patients and 16 control subjects were studied. RAI was defined as a serum cortisol increase of less than 9 υg/dl from baseline after the stimulation with 250 mg of synthetic ACTH. Twenty two had Child-Pugh = 8 and 25 = 9. The prevalence of RAI in patients with stable cirrhosis was 22%. A higher incidence of RAI was observed in patients with a Child-Pugh = 9 (8/32) than in those with = 8 (3/13, p < 0.05). A correlation between salivary cortisol and basal plasma cortisol (r = 0.6, p < 0.0004) was observed. Finally, survival at 1 year (97%) and 3 years (91%) was significantly higher without RAI than those who developed this complication (79% and 51%, p < 0.05, respectively). In summary, the prevalence of RAI is frequent in patients with stable cirrhosis and that it is related to the severity of liver diseaseand increased mortality.
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Affiliation(s)
- Federico Orozco
- Servicio de Hepatología y Unidad de Trasplante, Hospital Alemán, Argentina.E-mail:
| | - María Anders
- Servicio de Hepatología y Unidad de Trasplante, Hospital Alemán, Argentina
| | - José Mella
- Servicio de Hepatología y Unidad de Trasplante, Hospital Alemán, Argentina
| | | | | | | | - Mariano Cartier
- Unidad de Hepatología, Hospital Bonorino Udaondo, Buenos Aires, Argentina
| | - Gustavo Romero
- Unidad de Hepatología, Hospital Bonorino Udaondo, Buenos Aires, Argentina
| | - Bettina Francini
- Servicio de Hepatología y Unidad de Trasplante, Hospital Alemán, Argentina
| | - Ricardo Mastai
- Servicio de Hepatología y Unidad de Trasplante, Hospital Alemán, Argentina
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Creedon JMB. Controversies surrounding critical illness-related corticosteroid insufficiency in animals. J Vet Emerg Crit Care (San Antonio) 2014; 25:107-12. [PMID: 25516097 DOI: 10.1111/vec.12270] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 05/28/2014] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To describe the controversies surrounding critical illness-related corticosteroid insufficiency (CIRCI) and the use of hydrocortisone in critically ill patients, and to present published diagnostic and therapeutic strategies in companion veterinary species. ETIOLOGY Critical illness-related corticosteroid insufficiency may be due to hypothalamic-pituitary-adrenal (HPA) axis dysfunction, alterations in cortisol-plasma protein binding, target cell enzymatic changes, changes in glucocorticoid receptor (GR) function, or a combination of these or other factors present during critical illness. DIAGNOSIS Appropriate tests to diagnose CIRCI are unknown. The diagnosis in people is currently based on response to treatment with hydrocortisone. There is currently no consensus on appropriate diagnostic feature(s) in veterinary species. THERAPY Low-dose hydrocortisone is the treatment of choice for patients with CIRCI. PROGNOSIS If the patient survives the critical illness, prognosis for resolution of CIRCI and hydrocortisone dependence is very good.
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Zimmerman JJ, Donaldson A, Barker RM, Meert KL, Harrison R, Carcillo JA, Anand KJ, Newth CJ, Berger J, Willson DF, Jack R, Nicholson C, Dean JM; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Real-time free cortisol quantification among critically ill children. Pediatr Crit Care Med 2011; 12:525-31. [PMID: 21057361 DOI: 10.1097/PCC.0b013e3181fe4474] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Ascertainment of adrenal function assessing free rather that total cortisol may be beneficial for the diagnosis of critical illness-related cortisol insufficiency. We hypothesized that centrifugal ultrafiltration would provide timely free cortisol data that highly correlated with the gold standard, but logistically cumbersome, equilibrium dialysis technique when the free cortisol fractions were identically quantified by chemiluminescence immunoassay. We also hypothesized that free cortisol would correlate with illness severity in a large cohort of critically ill children. DESIGN Prospective, multi-institutional, observational cohort investigation. SETTING Seven pediatric intensive care units within the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. PATIENTS One hundred sixty-five critically ill children across the spectrum of illness severity. INTERVENTIONS Blood sampling. MEASUREMENTS AND MAIN RESULTS Time to derive plasma free cortisol concentrations after centrifugal ultrafiltration or equilibrium dialysis fractionation with chemiluminescence immunoassay was approximately 2 vs. approximately 24 hrs, respectively. Using centrifugal ultrafiltration, mean plasma free cortisol was 4.1 ± 6.7 μg/dL (median, 1.6 μg/dL; range, 0.2-43.6 μg/L), representing an average of 15.2 ± 9.4% of total cortisol. Nearly 60% of subjects exhibited free cortisol <2 and 30% <0.8 μg/dL, previously suggested threshold concentrations for defining critical illness-related cortisol insufficiency. Plasma-free cortisol concentrations comparing centrifugal ultrafiltration vs. equilibrium dialysis fractionation demonstrated a strong correlation (R2 = 0.97). For free cortisol <2 μg/dL, Bland-Altman analysis revealed minimal negative bias for the centrifugal ultrafiltration technique. Illness severity assessed by Pediatric Risk of Mortality III correlated moderately with free cortisol and percent total cortisol as free cortisol. CONCLUSIONS Determination of centrifugal ultrafiltration fractionated free cortisol was fast and results correlated highly with equilibrium dialysis fractionated free cortisol. Many children exhibited free cortisol <2 and <0.8 μg/dL but did not demonstrate clinical evidence of critical illness-related cortisol insufficiency. This study ascertains that real-time free cortisol quantification is feasible to potentially help guide clinical decision-making for cortisol replacement therapy in the pediatric intensive care unit.
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Abstract
The use of corticosteroids in septic shock remains controversial. It has been demonstrated that high doses of steroids (30 mg/kg methylprednisolone) for short periods of time are not beneficial. More recent studies using smaller doses (200-300 mg/day hydrocortisone) for longer periods of time have shown beneficial effects. These positive effects have included reversal of shock, trends toward decreased organ system dysfunction and decreased mortality. Based on the high proportion of patients who have relative adrenal insufficiency, the benefits of low doses of steroids and the minimal risks, steroids should be used to treat septic shock.
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Affiliation(s)
- Sergey Goodman
- Senior physician, Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, The Hebrew University of Jerusalem, Israel
| | - Charles L Sprung
- Director, General Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, The Hebrew University of Jerusalem, Israel
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