Diminished adrenal sensitivity to endogenous and exogenous adrenocorticotropic hormone in critical illness: a prospective cohort study.
Diminished adrenal sensitivity to endogenous and exogenous adrenocorticotropic hormone in critical illness: a prospective cohort study.
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DOI：
10.1186/s13054-014-0721-8
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发表时间：
2015-01-06
期刊：
影响因子：
--
通讯作者：
Groeneveld AB
中科院分区：
文献类型：
--
作者：
de Jong MF;Molenaar N;Beishuizen A;Groeneveld AB
肾上腺功能障碍可能代表严重疾病相关的皮质类固醇功能不全（CIRCI），正如皮质醇对外源性促肾上腺皮质激素（ACTH）的反应减弱所证明的那样，但这一概念及其临床意义仍然存在高度争议。我们研究了在重症和急性期恢复期间，肾上腺对外源性ACTH的反应作为内源性皮质醇与ACTH比值的函数，这是肾上腺敏感性和临床变量的衡量标准。我们前瞻性地纳入了重症监护病房59例患有治疗不敏感性低血压且怀疑有CIRCI的脓毒性和非脓毒性患者；接受依托咪酯和长期皮质类固醇治疗的患者被排除在外。急性期患者行ACTH检测（250 μg），≥7天后进行第二次检测。评估血清总皮质醇和游离皮质醇、ACTH和临床变量。根据第一次和第二次测试时皮质醇对ACTH的反应（delta， Δ）对患者进行分组。随着时间的推移，Δ皮质醇水平低（<250 nM）的患者（n = 14 ~ 17）比Δ皮质醇水平正常（≥250 nM）的患者有更高的基线皮质醇和ACTH，但皮质醇/ACTH比值较低。低Δ皮质醇及时与更严重的疾病、培养阳性败血症和延长激活凝血酶原时间相关。游离皮质醇的结果相似。尽管在危重疾病期间应激后垂体-肾上腺轴被激活，但肾上腺对内源性ACTH的敏感性降低预示着皮质醇对外源性ACTH的低升高，提示肾上腺功能障碍，与疾病的阶段无关。数据进一步表明疾病严重程度和培养阳性败血症的作用。
Adrenal dysfunction may represent critical illness-related corticosteroid insufficiency (CIRCI), as evidenced by a diminished cortisol response to exogenous adrenocorticotropic hormone (ACTH), but this concept and its clinical significance remain highly controversial. We studied the adrenal response to exogenous ACTH as a function of the endogenous cortisol-to-ACTH ratio, a measure of adrenal sensitivity, and of clinical variables, during critical illness and recovery from the acute phase. We prospectively included 59 consecutive septic and nonseptic patients in the intensive care unit with treatment-insensitive hypotension in whom CIRCI was suspected; patients having received etomidate and prolonged corticosteroids were excluded. An ACTH test (250 μg) was performed, followed by a second test after ≥7 days in acute-phase survivors. Serum total and free cortisol, ACTH, and clinical variables were assessed. Patients were divided according to responses (delta, Δ) of cortisol to ACTH at the first and second tests. Patients with low (<250 nM) Δ cortisol (n = 14 to 17) had higher baseline cortisol and ACTH but lower cortisol/ACTH ratios than patients with a normal Δ cortisol (≥250 nM) in the course of time. A low Δ cortisol in time was associated with more-severe disease, culture-positive sepsis, and prolonged activated prothrombin time. Results for free cortisol were similar. Even though the pituitary-adrenal axis is activated after stress during critical illness, diminished adrenal sensitivity to endogenous ACTH predicts a low increase of cortisol to exogenous ACTH, suggesting adrenal dysfunction, irrespective of the stage of disease. The data further suggest a role of disease severity and culture-positive sepsis.
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DOI：
10.1056/nejmoa1214969
发表时间：
2013-04-18
期刊：
The New England journal of medicine
影响因子：
--
作者：
Boonen E;Vervenne H;Meersseman P;Andrew R;Mortier L;Declercq PE;Vanwijngaerden YM;Spriet I;Wouters PJ;Vander Perre S;Langouche L;Vanhorebeek I;Walker BR;Van den Berghe G
通讯作者：
Van den Berghe G
影响因子：
15.1
作者：
Guerrero, Julia;Gatica, Hector A.;Annelise Goecke, Irmgadt
通讯作者：
Annelise Goecke, Irmgadt
影响因子：
158.5
作者：
Sprung, Charles L.;Annane, Djillali;Briegel, Josef
通讯作者：
Briegel, Josef
影响因子：
38.9
作者：
Goodman, S;Sprung, CL;Weiss, YG
通讯作者：
Weiss, YG
影响因子：
3.7
作者：
Guzman, Jorge A.;Guzman, Cristina B.
通讯作者：
Guzman, Cristina B.