Transient adrenocortical insufficiency of prematurity and systemic hypotension in very low birthweight infants
Transient adrenocortical insufficiency of prematurity and systemic hypotension in very low birthweight infants
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DOI：
10.1136/adc.2002.021972
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发表时间：
2004-03-01
影响因子：
4.4
通讯作者：
Wong, E
中科院分区：
文献类型：
--
作者：
Ng, PC;Lee, CH;Wong, E
目的：一定比例的早产儿，极低出生体重（VLBW, < 1500 g）婴儿可能在出生后立即表现出对应激的肾上腺反应不足。人促肾上腺皮质激素释放激素（hCRH）刺激试验：(a)确定垂体-肾上腺反应与。这些婴儿的全身血压；(b)描述短暂性早产儿肾上腺皮质功能不全（TAP）的内分泌学特征。研究设计：在三级新生儿中心对137名VLBW婴儿在出生后第7天和第14天进行了226次hCRH测试。结果：第7天血清皮质醇（δ Cort(0-30)）的基础、峰值和增量升高与生命前两周记录的最低收缩压、平均血压和舒张压显著相关（r > 0.25, p < 0.005）。这些皮质醇浓度也与多巴胺（r > -0.22, p < 0.02）、多巴酚丁胺（r > -0.18, p < 0.04）、肾上腺素（r > -0.26, p < 0.004）、晶体总体积（r > -0.22, p < 0.02）和肌力治疗持续时间（r > -0.25, p < 0.006）的最大累积剂量和总累积剂量呈显著负相关。多因素回归分析显示，第7天的最低收缩压、平均血压和舒张压与血清皮质醇（基础、峰值和δ Cort(0-30)）保持独立相关。需要肌力药物的低血压婴儿（2组）比血压正常的婴儿（1组）明显更不成熟，更容易生病。在第7天（p = 0.004）和第14天（p = 0.004），第2组ACTH反应曲线下面积均显著大于第1组。相比之下，第7天第1组皮质醇反应曲线下面积明显大于第2组（p = 0.001），但第14天两组间无显著差异。此外，低血压婴儿第50百分位的血清皮质醇对预测早期新生儿低血压具有高特异性和阳性预测值（分别为0.80-0.93和0.81-0.89）。结论：本研究揭示了TAP的基本内分泌特征：正常或过度的垂体反应；肾上腺皮质机能不全;产后14天肾上腺功能恢复良好。结果还提供了低血压患者和血压正常的婴儿血清皮质醇的百分位数，并显示了VLBW婴儿血清皮质醇与血压之间的显著关系。
Objectives: A proportion of preterm, very low birthweight (VLBW, < 1500 g) infants may show inadequate adrenal response to stress in the immediate postnatal period. The human corticotrophin releasing hormone (hCRH) stimulation test was used to: (a) determine the relation between pituitary-adrenal response and. systemic blood pressure in these infants; (b) characterise the endocrinological features of transient adrenocortical insufficiency of prematurity (TAP).Study design: A total of 226 hCRH tests were performed on 137 VLBW infants on day 7 and 14 of life in a tertiary neonatal centre.Results: Basal, peak, and incremental rise in serum cortisol (Delta Cort(0-30)) on day 7 were associated significantly with the lowest systolic, mean, and diastolic blood pressures recorded during the first two weeks of life (r > 0.25, p < 0.005). These cortisol concentrations also correlated significantly but negatively with the maximum and total cumulative dose of dopamine (r > -0.22, p < 0.02), dobutamine (r > -0.18, p < 0.04), and adrenaline (r > -0.26, p < 0.004), total volume of crystalloid (r > -0.22, p < 0.02), and duration of inotrope treatment (r > -0.25, p < 0.006). Multivariate regression analysis of significant factors showed that the lowest systolic, mean, and diastolic blood pressures remained independently associated with serum cortisol (basal, peak, and Delta Cort(0-30)) on day 7. Hypotensive infants requiring inotropes (group 2) were significantly less mature and more sick than infants with normal blood pressure (group 1). The areas under the ACTH response curves were significantly greater in group 2 than in group 1, on both day 7 (p = 0.004) and day 14 (p = 0.004). In contrast, the area under the cortisol response curve was significantly greater in group 1 than in group 2 on day 7 (p = 0.001), but there was no significant difference between the two groups on day 14. In addition, serum cortisol at the 50th centile in hypotensive infants had high specificity and positive predictive value (0.80-0.93 and 0.81-0.89 respectively) for predicting early neonatal hypotension.Conclusion: This study characterises the fundamental endocrinological features of TAP: normal or exaggerated pituitary response; adrenocortical insufficiency; good recovery of adrenal function by day 14 of postnatal life. The results also provide the centiles of serum cortisol for hypotensive patients and infants with normal blood pressure, and show a significant relation between serum cortisol and blood pressure in VLBW infants.