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Langouche L, Téblick A, Gunst J, Van den Berghe G. The Hypothalamus-pituitary-adrenocortical Response to Critical Illness: A Concept in Need of Revision. Endocr Rev 2023; 44:1096-1106. [PMID: 37409973 PMCID: PMC10638597 DOI: 10.1210/endrev/bnad021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 06/06/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
Based on insights obtained during the past decade, the classical concept of an activated hypothalamus-pituitary-adrenocortical axis in response to critical illness is in need of revision. After a brief central hypothalamus-pituitary-adrenocortical axis activation, the vital maintenance of increased systemic cortisol availability and action in response to critical illness is predominantly driven by peripheral adaptations rather than by an ongoing centrally activated several-fold increased production and secretion of cortisol. Besides the known reduction of cortisol-binding proteins that increases free cortisol, these peripheral responses comprise suppressed cortisol metabolism in liver and kidney, prolonging cortisol half-life, and local alterations in expression of 11βHSD1, glucocorticoid receptor-α (GRα), and FK506 binding protein 5 (FKBP51) that appear to titrate increased GRα action in vital organs and tissues while reducing GRα action in neutrophils, possibly preventing immune-suppressive off-target effects of increased systemic cortisol availability. Peripherally increased cortisol exerts negative feed-back inhibition at the pituitary level impairing processing of pro-opiomelanocortin into ACTH, thereby reducing ACTH-driven cortisol secretion, whereas ongoing central activation results in increased circulating pro-opiomelanocortin. These alterations seem adaptive and beneficial for the host in the short term. However, as a consequence, patients with prolonged critical illness who require intensive care for weeks or longer may develop a form of central adrenal insufficiency. The new findings supersede earlier concepts such as "relative," as opposed to "absolute," adrenal insufficiency and generalized systemic glucocorticoid resistance in the critically ill. The findings also question the scientific basis for broad implementation of stress dose hydrocortisone treatment of patients suffering from acute septic shock solely based on assumption of cortisol insufficiency.
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Affiliation(s)
- Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| | - Arno Téblick
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
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2
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Abstract
In sepsis, dysregulation of the hypothalamic-pituitary-adrenal axis, alterations in cortisol metabolism, and tissue resistance to glucocorticoids can all result in relative adrenal insufficiency or critical illness-related corticosteroid insufficiency (CIRCI). The symptoms and signs of CIRCI during sepsis are nonspecific, generally including decreased mental status, unexplained fever, or hypotension refractory to fluids, and the requirement of vasopressor therapy to maintain adequate blood pressure. While we have been aware of this syndrome for over a decade, it remains a poorly understood condition, challenging to diagnose, and associated with significantly diverging practices among clinicians, particularly regarding the optimal dosing and duration of corticosteroid therapy. The existing literature on corticosteroid use in patients with sepsis and septic shock is vast with dozens of randomized controlled trials conducted across the past 4 decades. These studies have universally demonstrated reduced duration of shock, though the effects of corticosteroids on mortality have been inconsistent, and their use has been associated with adverse effects including hyperglycemia, neuromuscular weakness, and an increased risk of infection. In this article, we aim to provide a thorough, evidence-based, and practical review of the current recommendations for the diagnosis and management of patients with sepsis who develop CIRCI, explore the controversies surrounding this topic, and highlight what lies on the horizon as new evidence continues to shape our practice.
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Affiliation(s)
- Cosmo Fowler
- Critical Care Center, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nina Raoof
- Critical Care Center, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stephen M Pastores
- Critical Care Center, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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3
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Mateska I, Witt A, Hagag E, Sinha A, Yilmaz C, Thanou E, Sun N, Kolliniati O, Patschin M, Abdelmegeed H, Henneicke H, Kanczkowski W, Wielockx B, Tsatsanis C, Dahl A, Walch AK, Li KW, Peitzsch M, Chavakis T, Alexaki VI. Succinate mediates inflammation-induced adrenocortical dysfunction. eLife 2023; 12:e83064. [PMID: 37449973 PMCID: PMC10374281 DOI: 10.7554/elife.83064] [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: 08/30/2022] [Accepted: 07/13/2023] [Indexed: 07/18/2023] Open
Abstract
The hypothalamus-pituitary-adrenal (HPA) axis is activated in response to inflammation leading to increased production of anti-inflammatory glucocorticoids by the adrenal cortex, thereby representing an endogenous feedback loop. However, severe inflammation reduces the responsiveness of the adrenal gland to adrenocorticotropic hormone (ACTH), although the underlying mechanisms are poorly understood. Here, we show by transcriptomic, proteomic, and metabolomic analyses that LPS-induced systemic inflammation triggers profound metabolic changes in steroidogenic adrenocortical cells, including downregulation of the TCA cycle and oxidative phosphorylation, in mice. Inflammation disrupts the TCA cycle at the level of succinate dehydrogenase (SDH), leading to succinate accumulation and disturbed steroidogenesis. Mechanistically, IL-1β reduces SDHB expression through upregulation of DNA methyltransferase 1 (DNMT1) and methylation of the SDHB promoter. Consequently, increased succinate levels impair oxidative phosphorylation and ATP synthesis and enhance ROS production, leading to reduced steroidogenesis. Together, we demonstrate that the IL-1β-DNMT1-SDHB-succinate axis disrupts steroidogenesis. Our findings not only provide a mechanistic explanation for adrenal dysfunction in severe inflammation, but also offer a potential target for therapeutic intervention.
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Affiliation(s)
- Ivona Mateska
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital, Technische Universität DresdenDresdenGermany
| | - Anke Witt
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital, Technische Universität DresdenDresdenGermany
| | - Eman Hagag
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital, Technische Universität DresdenDresdenGermany
| | - Anupam Sinha
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital, Technische Universität DresdenDresdenGermany
| | - Canelif Yilmaz
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital, Technische Universität DresdenDresdenGermany
| | - Evangelia Thanou
- Center of Neurogenomics and Cognitive Research (CNCR), Department of Molecular and 10 Cellular Neurobiology, Vrije UniversiteitAmsterdamNetherlands
| | - Na Sun
- Research Unit Analytical Pathology, German Research Center for Environmental Health, Helmholtz Zentrum MünchenMunichGermany
| | - Ourania Kolliniati
- Department of Clinical Chemistry, Medical School, University of CreteHeraklionGreece
| | - Maria Patschin
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital, Technische Universität DresdenDresdenGermany
| | - Heba Abdelmegeed
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital, Technische Universität DresdenDresdenGermany
| | - Holger Henneicke
- Department of Medicine III & Center for Healthy Ageing, Technische Universität DresdenDresdenGermany
- Center for Regenerative Therapies, TU Dresden, Technische Universität DresdenDresdenGermany
| | - Waldemar Kanczkowski
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital, Technische Universität DresdenDresdenGermany
| | - Ben Wielockx
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital, Technische Universität DresdenDresdenGermany
| | - Christos Tsatsanis
- Department of Clinical Chemistry, Medical School, University of CreteHeraklionGreece
| | - Andreas Dahl
- DRESDEN-concept Genome Center, Center for Molecular and Cellular Bioengineering, Technische Universität DresdenDresdenGermany
| | - Axel Karl Walch
- Research Unit Analytical Pathology, German Research Center for Environmental Health, Helmholtz Zentrum MünchenMunichGermany
| | - Ka Wan Li
- Center of Neurogenomics and Cognitive Research (CNCR), Department of Molecular and 10 Cellular Neurobiology, Vrije UniversiteitAmsterdamNetherlands
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital, Technische Universität DresdenDresdenGermany
| | - Triantafyllos Chavakis
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital, Technische Universität DresdenDresdenGermany
| | - Vasileia Ismini Alexaki
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital, Technische Universität DresdenDresdenGermany
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4
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Vandermosten L, Prenen F, Fogang B, Dagneau de Richecour P, Knoops S, Donkeu CJ, Nguefack CDP, Taguebue JV, Ndombo PK, Ghesquière B, Ayong L, Van den Steen PE. Glucocorticoid dysfunction in children with severe malaria. Front Immunol 2023; 14:1187196. [PMID: 37492570 PMCID: PMC10364055 DOI: 10.3389/fimmu.2023.1187196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/23/2023] [Indexed: 07/27/2023] Open
Abstract
Introduction Malaria remains a widespread health problem with a huge burden. Severe or complicated malaria is highly lethal and encompasses a variety of pathological processes, including immune activation, inflammation, and dysmetabolism. Previously, we showed that adrenal hormones, in particular glucocorticoids (GCs), play critical roles to maintain disease tolerance during Plasmodium infection in mice. Here, GC responses were studied in Cameroon in children with uncomplicated malaria (UM), severe malaria (SM) and asymptomatic controls (AC). Methods To determine the sensitivity of leukocytes to GC signaling on a transcriptional level, we measured the ex vivo induction of glucocorticoid induced leucine zipper (GILZ) and FK506-binding protein 5 (FKBP5) by GCs in human and murine leukocytes. Targeted tracer metabolomics on peripheral blood mononuclear cells (PBMCs) was performed to detect metabolic changes induced by GCs. Results Total cortisol levels increased in patients with clinical malaria compared to AC and were higher in the SM versus UM group, while cortisol binding globulin levels were unchanged and adrenocorticotropic hormone (ACTH) levels were heterogeneous. Induction of both GILZ and FKBP5 by GCs was significantly reduced in patients with clinical malaria compared to AC and in malaria-infected mice compared to uninfected controls. Increased activity in the pentose phosphate pathway was found in the patients, but this was not affected by ex vivo stimulation with physiological levels of hydrocortisone. Interestingly, hydrocortisone induced increased levels of cAMP in AC, but not in clinical malaria patients. Discussion Altogether, this study shows that patients with SM have increased cortisol levels, but also a decreased sensitivity to GCs, which may clearly contribute to the severity of disease.
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Affiliation(s)
- Leen Vandermosten
- Laboratory of Immunoparasitology, Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - Fran Prenen
- Laboratory of Immunoparasitology, Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - Balotin Fogang
- Malaria Research Unit, Centre Pasteur du Cameroun, Yaoundé, Cameroon
| | - Pauline Dagneau de Richecour
- Laboratory of Immunoparasitology, Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - Sofie Knoops
- Laboratory of Immunoparasitology, Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | | | | | | | - Paul Koki Ndombo
- Mother and Child Center, Chantal Biya Foundation, Yaoundé, Cameroon
| | - Bart Ghesquière
- Metabolomics Expertise Center, Center for Cancer Biology, VIB Center for Cancer Biology, Leuven, Belgium
- Metabolomics Expertise Center, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Lawrence Ayong
- Malaria Research Unit, Centre Pasteur du Cameroun, Yaoundé, Cameroon
| | - Philippe E. Van den Steen
- Laboratory of Immunoparasitology, Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
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5
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Dorin RI, Urban FK, Perogamvros I, Qualls CR. Four-Compartment Diffusion Model of Cortisol Disposition: Comparison With 3 Alternative Models in Current Clinical Use. J Endocr Soc 2022; 7:bvac173. [PMID: 36628386 PMCID: PMC9815201 DOI: 10.1210/jendso/bvac173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
Context Estimated rates of cortisol elimination and appearance vary according to the model used to obtain them. Generalizability of current models of cortisol disposition in healthy humans is limited. Objective Development and validation of a realistic, mechanistic model of cortisol disposition that accounts for the major factors influencing plasma cortisol concentrations in vivo (Model 4), and comparison to previously described models of cortisol disposition in current clinical use (Models 1-3). Methods The 4 models were independently applied to cortisol concentration data obtained for the hydrocortisone bolus experiment (20 mg) in 2 clinical groups: healthy volunteers (HVs, n = 6) and corticosteroid binding globulin (CBG)-deficient (n = 2). Model 4 used Fick's first law of diffusion to model free cortisol flux between vascular and extravascular compartments. Pharmacokinetic parameter solutions for Models 1-4 were optimized by numerical methods, and model-specific parameter solutions were compared by repeated measures analysis of variance. Models and respective parameter solutions were compared by mathematical and simulation analyses, and an assessment tool was used to compare performance characteristics of the four models evaluated herein. Results Cortisol half-lives differed significantly between models (all P < .001) with significant model-group interaction (P = .02). In comparative analysis, Model 4 solutions yielded significantly reduced free cortisol half-life, improved fit to experimental data (both P < .01), and superior model performance. Conclusion The proposed 4-compartment diffusion model (Model 4) is consistent with relevant experimental observations and met the greatest number of empiric validation criteria. Cortisol half-life solutions obtained using Model 4 were generalizable between HV and CBG-deficient groups and bolus and continuous modes of hydrocortisone infusion.
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Affiliation(s)
- Richard I Dorin
- Correspondence: Richard Dorin, MD, New Mexico VA Healthcare System, 1501 San
Pedro Drive, SE, Albuquerque, NM 87108.
| | - Frank K Urban
- Department of Electrical and Computer Engineering, Florida International
University, Miami, FL 33199, USA
| | - Ilias Perogamvros
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical
Sciences, University of Manchester, Manchester M13
9PL, UK
| | - Clifford R Qualls
- Department of Mathematics and Statistics, University of New
Mexico, Albuquerque, NM 87131, USA,Department of Research, New Mexico Veterans Affairs Healthcare
System, Albuquerque, NM 87108, USA
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6
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Briegel J, Möhnle P, Keh D, Lindner JM, Vetter AC, Bogatsch H, Lange D, Frank S, Hinske LC, Annane D, Vogeser M, Bauer M, Brenner T, Meybohm P, Weigand M, Gründling M, Löffler M, Kiehntopf M, Bloos F, Elke G, Meersch-Dini M, Putensen C, Kaasch A, Kluge S. Corticotropin-stimulated steroid profiles to predict shock development and mortality in sepsis: From the HYPRESS study. Crit Care 2022; 26:343. [DOI: 10.1186/s13054-022-04224-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/28/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Rationale
Steroid profiles in combination with a corticotropin stimulation test provide information about steroidogenesis and its functional reserves in critically ill patients.
Objectives
We investigated whether steroid profiles before and after corticotropin stimulation can predict the risk of in-hospital death in sepsis.
Methods
An exploratory data analysis of a double blind, randomized trial in sepsis (HYPRESS [HYdrocortisone for PRevention of Septic Shock]) was performed. The trial included adult patients with sepsis who were not in shock and were randomly assigned to placebo or hydrocortisone treatment. Corticotropin tests were performed in patients prior to randomization and in healthy subjects. Cortisol and precursors of glucocorticoids (17-OH-progesterone, 11-desoxycortisol) and mineralocorticoids (11-desoxycorticosterone, corticosterone) were analyzed using the multi-analyte stable isotope dilution method (LC–MS/MS). Measurement results from healthy subjects were used to determine reference ranges, and those from placebo patients to predict in-hospital mortality.
Measurements and main results
Corticotropin tests from 180 patients and 20 volunteers were included. Compared to healthy subjects, patients with sepsis had elevated levels of 11-desoxycorticosterone and 11-desoxycortisol, consistent with activation of both glucocorticoid and mineralocorticoid pathways. After stimulation with corticotropin, the cortisol response was subnormal in 12% and the corticosterone response in 50% of sepsis patients. In placebo patients (n = 90), a corticotropin-stimulated cortisol-to-corticosterone ratio > 32.2 predicted in-hospital mortality (AUC 0.8 CI 0.70–0.88; sensitivity 83%; and specificity 78%). This ratio also predicted risk of shock development and 90-day mortality.
Conclusions
In this exploratory analysis, we found that in sepsis mineralocorticoid steroidogenesis was more frequently impaired than glucocorticoid steroidogenesis. The corticotropin-stimulated cortisol-to-corticosterone ratio predicts the risk of in-hospital death.
Trial registration Clinical trial registered with www.clinicaltrials.gov Identifier: NCT00670254. Registered 1 May 2008, https://clinicaltrials.gov/ct2/show/NCT00670254.
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7
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The hypothalamus-pituitary-adrenal axis in sepsis- and hyperinflammation-induced critical illness: Gaps in current knowledge and future translational research directions. EBioMedicine 2022; 84:104284. [PMID: 36162206 PMCID: PMC9519475 DOI: 10.1016/j.ebiom.2022.104284] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/30/2022] [Accepted: 09/09/2022] [Indexed: 12/15/2022] Open
Abstract
The classical model of the vital increase in systemic glucocorticoid availability in response to sepsis- and hyperinflammation-induced critical illness is one of an activated hypothalamus-pituitary-adrenocortical axis. However, research performed in the last decade has challenged this rather simple model and has unveiled a more complex, time-dependent set of responses. ACTH-driven cortisol production is only briefly increased, rapidly followed by orchestrated peripheral adaptations that maintain increased cortisol availability for target tissues without continued need for increased cortisol production and by changes at the target tissues that guide and titrate cortisol action matched to tissue-specific needs. One can speculate that these acute changes are adaptive and that treatment with stress-doses of hydrocortisone may negatively interfere with these adaptive changes. These insights also suggest that prolonged critically ill patients, treated in the ICU for several weeks, may develop central adrenal insufficiency, although it remains unclear how to best diagnose and treat this condition.
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Abstract
Hypothalamus-pituitary-adrenal axis assessment in patients with cirrhosis is challenging. The phenotype of fatigue, hypotension, electrolyte disarray, and abdominal pain characterizing primary adrenal insufficiency (AI) overlaps significantly with decompensated liver disease. Reliance on total cortisol assays in hypoproteinemic states is problematic, yet abnormal stimulated levels in cirrhosis are associated with poor clinical outcomes. Alternative measures including free plasma or salivary cortisol levels have theoretical merit but are limited by unclear prognostic significance and undefined cirrhosis-specific reference ranges. Further complicating matters is that AI in cirrhosis represents a spectrum of impairment. Although absolute cortisol deficiency can occur, this represents a minority of cases. Instead, there is an emerging concept that cirrhosis, with or without critical illness, may induce a “relative” cortisol deficiency during times of stress. In addition, the limitations posed by decreased synthesis of binding globulins in cirrhosis necessitate re-evaluation of traditional AI diagnostic thresholds.
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Affiliation(s)
- Brian J Wentworth
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia , Charlottesville, VA
| | - Helmy M Siragy
- Division of Endocrinology & Metabolism, School of Medicine, University of Virginia , Charlottesville, VA
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9
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Novel insights in endocrine and metabolic pathways in sepsis and gaps for future research. Clin Sci (Lond) 2022; 136:861-878. [PMID: 35642779 DOI: 10.1042/cs20211003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 11/17/2022]
Abstract
Sepsis is defined as any life-threatening organ dysfunction caused by a dysregulated host response to infection. It remains an important cause of critical illness and has considerable short- and long-term morbidity and mortality. In the last decades, preclinical and clinical research has revealed a biphasic pattern in the (neuro-)endocrine responses to sepsis as to other forms of critical illness, contributing to development of severe metabolic alterations. Immediately after the critical illness-inducing insult, fasting- and stress-induced neuroendocrine and cellular responses evoke a catabolic state in order to provide energy substrates for vital tissues, and to concomitantly activate cellular repair pathways while energy-consuming anabolism is postponed. Large randomized controlled trials have shown that providing early full feeding in this acute phase induced harm and reversed some of the neuro-endocrine alterations, which suggested that the acute fasting- and stress-induced responses to critical illness are likely interlinked and benefical. However, it remains unclear whether, in the context of accepting virtual fasting in the acute phase of illness, metabolic alterations such as hyperglycemia are harmful or beneficial. When patients enter a prolonged phase of critical illness, a central suppression of most neuroendocrine axes follows. Prolonged fasting and central neuroendocrine suppression may no longer be beneficial. Although pilot studies have suggested benefit of fasting-mimicking diets and interventions that reactivate the central neuroendocrine suppression selectively in the prolonged phase of illness, further study is needed to investigate patient-oriented outcomes in larger randomized trials.
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10
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Nieman LK. Septic Shock: A Disruptor of the Hypothalamic-Adrenal Axis as We Know It. Endocrinology 2022; 163:6520548. [PMID: 35134141 PMCID: PMC8978643 DOI: 10.1210/endocr/bqac010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Lynnette K Nieman
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892-1109, USA
- Correspondence: Lynnette K Nieman MD, Building 10, CRC, 1 East, Rm 1-3140, 10 Center Dr, MSC 1109, Bethesda, MD 20892-1109, USA.
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11
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Vanhorebeek I, Derese I, Gunst J, Wouters PJ, Hermans G, Van den Berghe G. Persisting neuroendocrine abnormalities and their association with physical impairment 5 years after critical illness. Crit Care 2021; 25:430. [PMID: 34915907 PMCID: PMC8675467 DOI: 10.1186/s13054-021-03858-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
Background Critical illness is hallmarked by neuroendocrine alterations throughout ICU stay. We investigated whether the neuroendocrine axes recover after ICU discharge and whether any residual abnormalities associate with physical functional impairments assessed 5 years after critical illness.
Methods In this preplanned secondary analysis of the EPaNIC randomized controlled trial, we compared serum concentrations of hormones and binding proteins of the thyroid axis, the somatotropic axis and the adrenal axis in 436 adult patients who participated in the prospective 5-year clinical follow-up and who provided a blood sample with those in 50 demographically matched controls. We investigated independent associations between any long-term hormonal abnormalities and physical functional impairments (handgrip strength, 6-min walk distance, and physical health-related quality-of-life) with use of multivariable linear regression analyses. Results At 5-year follow-up, patients and controls had comparable serum concentrations of thyroid-stimulating hormone, thyroxine (T4), triiodothyronine (T3) and thyroxine-binding globulin, whereas patients had higher reverse T3 (rT3, p = 0.0002) and lower T3/rT3 (p = 0.0012) than controls. Patients had comparable concentrations of growth hormone, insulin-like growth factor-I (IGF-I) and IGF-binding protein 1 (IGFBP1), but higher IGFBP3 (p = 0.030) than controls. Total and free cortisol, cortisol-binding globulin and albumin concentrations were comparable for patients and controls. A lower T3/rT3 was independently associated with lower handgrip strength and shorter 6-min walk distance (p ≤ 0.036), and a higher IGFBP3 was independently associated with higher handgrip strength (p = 0.031). Conclusions Five years after ICU admission, most hormones and binding proteins of the thyroid, somatotropic and adrenal axes had recovered. The residual long-term abnormality within the thyroid axis was identified as risk factor for long-term physical impairment, whereas that within the somatotropic axis may be a compensatory protective response. Whether targeting of the residual abnormality in the thyroid axis may improve long-term physical outcome of the patients remains to be investigated. Trial registration ClinicalTrials.gov: NCT00512122, registered on July 31, 2007 (https://www.clinicaltrials.gov/ct2/show/NCT00512122). Graphical Abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03858-1.
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Affiliation(s)
- Ilse Vanhorebeek
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Inge Derese
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Jan Gunst
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter J Wouters
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Greet Hermans
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Greet Van den Berghe
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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12
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Van den Berghe G. Adrenal function/dysfunction in critically ill patients: a concise narrative review of recent novel insights. J Anesth 2021; 35:903-910. [PMID: 34302540 DOI: 10.1007/s00540-021-02977-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 12/23/2022]
Abstract
The "fight or flight" response to critical illness relies on increased cortisol availability, traditionally attributed to several-fold-increased cortisol production via hypothalamus-pituitary-adrenal-axis activation. Recent studies provided evidence against this concept with clinical implications. First, high cortisol availability during critical illness is driven by suppressed cortisol binding and reduced cortisol breakdown rather than increased cortisol production. This implies reduction of hydrocortisone doses when prescribed in ICU. Second, plasma ACTH is low, explained by feedback inhibition by peripherally driven high free cortisol and/or other central glucocorticoid-receptor ligands. Third, ICU patients have elevated plasma concentrations of the ACTH-precursor hormone, pro-opiomelanocortin, because of impaired pituitary processing into ACTH, and pro-opiomelanocortin could drive some adrenocortical cortisol production in face of low ACTH. Fourth, in prolonged critically ill patients, endogenously suppressed ACTH, aggravated by exogenous corticosteroids, associates with poor outcome. In long-stay ICU patients, central adrenal insufficiency may occur due to lack of trophic ACTH signaling. Finally, the Cosyntropin test is not suitable to assess adrenocortical reserve in ICU patients as the test is confounded by increased cortisol distribution volume. These insights necessitate further research focusing on the need, if any, of treating ICU patients with corticosteroids, and timing thereof, outside indications for pharmacological anti-inflammatory drugs.
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Affiliation(s)
- Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, 3000, Leuven, Belgium.
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Whyte MB, Vas PRJ, Umpleby AM. Could Exogenous Insulin Ameliorate the Metabolic Dysfunction Induced by Glucocorticoids and COVID-19? Front Endocrinol (Lausanne) 2021; 12:649405. [PMID: 34220705 PMCID: PMC8249851 DOI: 10.3389/fendo.2021.649405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/02/2021] [Indexed: 01/08/2023] Open
Abstract
The finding that high-dose dexamethasone improves survival in those requiring critical care due to COVID-19 will mean much greater usage of glucocorticoids in the subsequent waves of coronavirus infection. Furthermore, the consistent finding of adverse outcomes from COVID-19 in individuals with obesity, hypertension and diabetes has focussed attention on the metabolic dysfunction that may arise with critical illness. The SARS coronavirus itself may promote relative insulin deficiency, ketogenesis and hyperglycaemia in susceptible individuals. In conjunction with prolonged critical care, these components will promote a catabolic state. Insulin infusion is the mainstay of therapy for treatment of hyperglycaemia in acute illness but what is the effect of insulin on the admixture of glucocorticoids and COVID-19? This article reviews the evidence for the effect of insulin on clinical outcomes and intermediary metabolism in critical illness.
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Affiliation(s)
- Martin Brunel Whyte
- Faculty of Health Sciences, University of Surrey, Guildford, United Kingdom
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Anne M. Umpleby
- Faculty of Health Sciences, University of Surrey, Guildford, United Kingdom
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Wasyluk W, Wasyluk M, Zwolak A. Sepsis as a Pan-Endocrine Illness-Endocrine Disorders in Septic Patients. J Clin Med 2021; 10:jcm10102075. [PMID: 34066289 PMCID: PMC8152097 DOI: 10.3390/jcm10102075] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 12/18/2022] Open
Abstract
Sepsis is defined as "life-threatening organ dysfunction caused by a dysregulated host response to infection". One of the elements of dysregulated host response is an endocrine system disorder. Changes in its functioning in the course of sepsis affect almost all hormonal axes. In sepsis, a function disturbance of the hypothalamic-pituitary-adrenal axis has been described, in the range of which the most important seems to be hypercortisolemia in the acute phase. Imbalance in the hypothalamic-pituitary-thyroid axis is also described. The most typical manifestation is a triiodothyronine concentration decrease and reverse triiodothyronine concentration increase. In the somatotropic axis, a change in the secretion pattern of growth hormone and peripheral resistance to this hormone has been described. In the hypothalamic-pituitary-gonadal axis, the reduction in testosterone concentration in men and the stress-induced "hypothalamic amenorrhea" in women have been described. Catecholamine and β-adrenergic stimulation disorders have also been reported. Disorders in the endocrine system are part of the "dysregulated host response to infection". They may also affect other components of this dysregulated response, such as metabolism. Hormonal changes occurring in the course of sepsis require further research, not only in order to explore their potential significance in therapy, but also due to their promising prognostic value.
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Affiliation(s)
- Weronika Wasyluk
- Chair of Internal Medicine and Department of Internal Medicine in Nursing, Faculty of Health Sciences, Medical University of Lublin, 20-093 Lublin, Poland;
- Doctoral School, Medical University of Lublin, 20-093 Lublin, Poland
- Correspondence:
| | - Martyna Wasyluk
- Student’s Scientific Association at Chair of Internal Medicine and Department of Internal Medicine in Nursing, Faculty of Health Sciences, Medical University of Lublin, 20-093 Lublin, Poland;
| | - Agnieszka Zwolak
- Chair of Internal Medicine and Department of Internal Medicine in Nursing, Faculty of Health Sciences, Medical University of Lublin, 20-093 Lublin, Poland;
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Lovato CM, Thévenot T, Borot S, Di Martino V, Qualls CR, Urban FK, Dorin RI. Decreased maximal cortisol secretion rate in patients with cirrhosis: Relation to disease severity. JHEP Rep 2021; 3:100277. [PMID: 34027338 PMCID: PMC8121968 DOI: 10.1016/j.jhepr.2021.100277] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/13/2021] [Accepted: 03/07/2021] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Hepatic enzymes play a major role in the metabolic elimination of cortisol, and reduced rates of cortisol clearance have been consistently observed in patients with chronic liver disease. It is less clear whether there are concomitant abnormalities of adrenocortical function in patients with cirrhosis. In the present study, we sought to assess adrenocortical function in patients with cirrhosis using measures of free cortisol appearance and elimination rates that are independent of serum concentrations of cortisol binding proteins. Methods Post hoc analysis used computer-assisted numerical and modelling methods with serial total and free cortisol concentration data to obtain rates of free cortisol appearance and elimination. Rate parameters were obtained in 114 patients with chronic liver disease, including Child-Pugh (CP) ≤8 (n = 53) and CP >8 (n = 61). Results Maximal cortisol secretion rate (CSRmax) was significantly decreased (p = 0.01) in patients with cirrhosis with CP >8 (0.28 nM/s; 95% CI 0.24–0.34) compared with those with CP ≤8 (0.39 nM/s; 95% CI 0.33–0.46), and CSRmax was negatively correlated with CP score (r = −0.19, p = 0.01). Free cortisol elimination rate was significantly (p = 0.04) decreased in the CP >8 group (0.16 ± 0.20 min−1) compared with that in the CP ≤8 group (0.21 ± 0.21 min−1), and free cortisol elimination rates were negatively correlated with CP score (r = −0.23, p = 0.01). A significant correlation between CSRmax and free cortisol elimination rate (r = 0.88, p <0.001) was observed. Conclusions CSRmax and free cortisol elimination rates were significantly reduced according to severity of cirrhosis. In contrast to stimulated total cortisol concentrations, CSRmax estimates were independent of cortisol-binding protein concentrations. Results provide additional evidence of subnormal adrenocortical function in patients with cirrhosis. Lay summary We applied numerical analytic methods to characterise adrenocortical function in patients with varying stages of chronic liver disease. We found that patients with more severe cirrhosis have decreased rate of free cortisol elimination and decreased maximal cortisol secretion rate, which is a measure of adrenocortical function. In contrast to conventional measures of adrenocortical function, those obtained using numerical methods were not affected by variation in corticosteroid binding globulin and albumin concentrations. We conclude that patients with cirrhosis demonstrate measurable abnormalities of adrenocortical function, evidence of which supports aspects of the hepatoadrenal syndrome hypothesis. Free cortisol appearance and elimination rates were obtained by computer-assisted numerical analysis. Maximal cortisol secretion rates, a measure of adrenocortical function, were inversely related to severity of cirrhosis. Variation in concentrations of cortisol binding proteins bias measures of adrenocortical function that rely on total cortisol. Chronically reduced rate of free cortisol elimination in patients with cirrhosis may contribute to the pathophysiology of subnormal adrenocortical function. Evidence of subnormal adrenocortical function supports the hepatoadrenal syndrome hypothesis.
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Key Words
- ACLF, acute-on-chronic liver failure
- ACTH, adrenocorticotrophin
- AI, adrenal insufficiency
- Adrenal insufficiency
- CBG, corticosteroid-binding globulin
- CIRCI, critical illness-related corticosteroid insufficiency
- CP, Child-Pugh
- CPR, cortisol production rate
- CRP, C-reactive protein
- CRT, corticosteroid replacement therapy
- CSR, cortisol secretion rate
- CSRbase, basal CSR (before ACTH stimulation)
- CSRmax, maximal CSR
- Computer-assisted numerical analysis
- HPA, hypothalamic–pituitary–adrenal
- HSD, hydroxysteroid dehydrogenase
- Hydrocortisone
- INR, international normalised ratio
- Liver disease
- MCR, metabolic clearance rate
- MELD, model for end-stage liver disease
- Metabolic clearance rate
- PAI, primary adrenal insufficiency
- RAI, relative adrenal insufficiency
- RCT, randomised clinical trial
- SAI, secondary adrenal insufficiency
- SCOTCH, Supplemental Corticosteroids in Cirrhotic Hypotensive Patients With Suspicion of Sepsis
- STB, standardised beta
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Affiliation(s)
- Christina M Lovato
- Department of Internal Medicine/Endocrinology, Diabetes and Metabolism, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Thierry Thévenot
- Service d'Hépatologie et de Soins Intensifs Digestifs, Hôpital Universitaire Jean Minjoz, Besançon, France
| | - Sophie Borot
- Service d'Endocrinologie-Métabolisme et Diabétologie-Nutrition, Hôpital Jean Minjoz, Besançon, France
| | - Vincent Di Martino
- Service d'Hépatologie et de Soins Intensifs Digestifs, Hôpital Universitaire Jean Minjoz, Besançon, France
| | - Clifford R Qualls
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque, NM, USA.,New Mexico Veterans Affairs Healthcare System, Albuquerque, NM, USA
| | - Frank K Urban
- Department of Electrical and Computer Engineering, Florida International University, Miami, FL, USA
| | - Richard I Dorin
- Department of Internal Medicine/Endocrinology, Diabetes and Metabolism, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.,New Mexico Veterans Affairs Healthcare System, Albuquerque, NM, USA
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16
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Petrowski K, Herhaus B, Conrad R, Bornstein SR. Hormonal responsiveness in the Trier Social Stress Test and the dexamethasone-corticotropin releasing hormone test in healthy individuals. Psych J 2021; 10:305-317. [PMID: 33511783 DOI: 10.1002/pchj.424] [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: 08/01/2019] [Revised: 11/30/2020] [Accepted: 12/04/2020] [Indexed: 11/07/2022]
Abstract
A number of different laboratory procedures investigate the hormonal response in a standardized pharmacological challenge test (dexamethasone-corticotropin releasing hormone; DEX-CRH) or in a psychosocial stress induction on the hypothalamic-pituitary-adrenocortical axis by the Trier Social Stress Test (TSST). However, the magnitude of the response related to the different stressors and the interaction of the responsiveness between the two tests is still unclear. Fifty-two participants underwent both the DEX-CRH test and the TSST on two separate days. The cortisol and the plasma adrenocorticotropic hormone (ACTH) release were assessed before and after the stress tests. For a specification of the cortisol response to both conditions, subgroups of high- and low-cortisol responders to the TSST and the DEX-CRH test were formed. The healthy participants showed a substantial increase in the ACTH and the cortisol concentration after the two tests. This increase was 3 times greater in the TSST than the DEX-CRH test. High responders in both tests demonstrated a higher factor of the cortisol reactivity ratio (TSST/DEX-CRH test). Psychosocial stress as induced by the TSST was associated with a significantly greater increase in cortisol compared to the DEX-CRH test, even though the ACTH response displayed no differences. Our findings indicate an interaction of the hormonal responsiveness between the two tests with regard to the cortisol patterns.
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Affiliation(s)
- Katja Petrowski
- Medical Psychology and Medical Sociology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Department of Internal Medicine III, University Hospital Carl Gustav Carus Dresden, Technische Universitaet Dresden, Dresden, Germany
| | - Benedict Herhaus
- Medical Psychology and Medical Sociology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Rupert Conrad
- Department of Psychosomatic Medicine and Psychotherapy, University Bonn, Bonn, Germany
| | - Stefan R Bornstein
- Department of Internal Medicine III, University Hospital Carl Gustav Carus Dresden, Technische Universitaet Dresden, Dresden, Germany
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17
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Swales H, Batchelor DJ, O'Connell EM. Evaluation of serum cortisol concentration as a prognostic indicator for nonsurvival to hospital discharge in critically ill dogs. J Am Vet Med Assoc 2020; 256:1034-1040. [PMID: 32301661 DOI: 10.2460/javma.256.9.1034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate whether serum cortisol (SC) concentration is a useful prognostic indicator for survival versus nonsurvival to hospital discharge in critically ill dogs. ANIMALS 229 client-owned dogs. PROCEDURES Medical records were retrospectively reviewed to identify critically ill dogs that were hospitalized between January 2010 and May 2018 and that had SC concentrations measured ≤ 3 days after admission. Results for SC concentrations were compared for dogs grouped by survival versus nonsurvival to hospital discharge, with versus without sepsis, and other variables of interest. The predictive value of SC concentration for nonsurvival to hospital discharge was assessed (OR, sensitivity, and specificity) for cutoffs determined from a ROC curve or reference limit. RESULTS Median SC concentration was higher in dogs that did not survive to hospital discharge (8.5 μg/dL; interquartile [25th to 75th percentile] range, 4.8 to 11.8 μg/dL), compared with concentration in those that were discharged alive (4.5 μg/dL; interquartile range, 2.5 to 6.9 μg/dL). The area under the ROC curve was 0.72 (95% confidence interval [CI], 0.64 to 0.81) for SC concentration predicting nonsurvival. The calculated optimum cutoff of SC concentration was 7.6 μg/dL, at which the OR, sensitivity, and specificity for nonsurvival were 5.4 (95% CI, 2.7 to 10.9), 58%, and 80%, respectively. Alternatively, when the upper reference limit for SC concentration (5.8 μg/dL) was used as the cutoff, the OR, sensitivity, and specificity for nonsurvival were 3.6 (95% CI, 1.8 to 7.1), 67%, and 64%, respectively. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that SC concentration could be used as part of an overall assessment of prognosis in critically ill dogs.
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18
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Dorin RI, Urban FK, Qualls CR. Letter to the Editor: "Dynamic Pituitary-Adrenal Interactions in the Critically ill After Cardiac Surgery". J Clin Endocrinol Metab 2020; 105:5864812. [PMID: 32598466 DOI: 10.1210/clinem/dgaa418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/27/2020] [Indexed: 02/13/2023]
Affiliation(s)
- Richard I Dorin
- Medical Service, New Mexico VA Healthcare System, Albuquerque, New Mexico
- Departments of Medicine and Biochemistry, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Frank K Urban
- Department of Electrical and Computer Engineering, Florida International University, Miami, Florida
| | - Clifford R Qualls
- Professor of Statistics and Mathematics Emeritus, University of New Mexico, Albuquerque, New Mexico
- Biostatistician, New Mexico VA Healthcare System, Albuquerque, New Mexico
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19
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Gibbison B, Keenan DM, Roelfsema F, Evans J, Phillips K, Rogers CA, Angelini GD, Lightman SL. Dynamic Pituitary-Adrenal Interactions in the Critically Ill after Cardiac Surgery. J Clin Endocrinol Metab 2020; 105:dgz206. [PMID: 31738827 PMCID: PMC7089849 DOI: 10.1210/clinem/dgz206] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/15/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with critical illness are thought to be at risk of adrenal insufficiency. There are no models of dynamic hypothalamic-pituitary-adrenal (HPA) axis function in this group of patients and thus current methods of diagnosis are based on aggregated, static models. OBJECTIVE To characterize the secretory dynamics of the HPA axis in the critically ill (CI) after cardiac surgery. DESIGN Mathematical modeling of cohorts. SETTING Cardiac critical care unit. PATIENTS 20 male patients CI at least 48 hours after cardiac surgery and 19 healthy (H) male volunteers. INTERVENTIONS None. MAIN OUTCOME MEASURES Measures of hormone secretory dynamics were generated from serum adrenocorticotrophic hormone (ACTH) sampled every hour and total cortisol every 10 min for 24 h. RESULTS All CI patients had pulsatile ACTH and cortisol profiles. CI patients had similar ACTH secretion (1036.4 [737.6] pg/mL/24 h) compared to the H volunteers (1502.3 [1152.2] pg/mL/24 h; P = .20), but increased cortisol secretion (CI: 14 447.0 [5709.3] vs H: 5915.5 [1686.7)] nmol/L/24 h; P < .0001). This increase in cortisol was due to nonpulsatile (CI: 9253.4 [3348.8] vs H: 960 [589.0] nmol/L/24 h, P < .0001), rather than pulsatile cortisol secretion (CI: 5193.1 [3018.5] vs H: 4955.1 [1753.6] nmol/L/24 h; P = .43). Seven (35%) of the 20 CI patients had cortisol pulse nadirs below the current international guideline threshold for critical illness-related corticosteroid insufficiency, but an overall secretion that would not be considered deficient. CONCLUSIONS This study supports the premise that current tests of HPA axis function are unhelpful in the diagnosis of adrenal insufficiency in the CI. The reduced ACTH and increase in nonpulsatile cortisol secretion imply that the secretion of cortisol is driven by factors outside the HPA axis in critical illness.
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Affiliation(s)
- Ben Gibbison
- Department of Anaesthesia, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daniel M Keenan
- Department of Statistics, University of Virginia, Charlottesville, VA, US
| | - Ferdinand Roelfsema
- Department of Internal Medicine, Section Endocrinology, University of Leiden, Leiden, The Netherlands
| | - Jon Evans
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Kirsty Phillips
- Department of Pathology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Department of Cardiac Surgery, Bristol Medical School, University of Bristol, Bristol, UK
| | - Stafford L Lightman
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, University of Bristol, Bristol, UK
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20
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Keenan DM, Pichler Hefti J, Veldhuis JD, Von Wolff M. Regulation and adaptation of endocrine axes at high altitude. Am J Physiol Endocrinol Metab 2020; 318:E297-E309. [PMID: 31770013 DOI: 10.1152/ajpendo.00243.2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
As a model of extreme conditions, eight healthy women, part of a 40-member Nepal mountain-climbing expedition, were monitored for dynamic endocrine adaptations. Endocrine measurements were made at frequent intervals over a 6-10-h period at four altitudes: 450 m, 4,800 m (base camp), 6,050 m, and again at 4,800 m (on descent) after an acclimatization (A) period (4,800 mA). Quantified hormones were growth hormone (GH), prolactin (PROL), cortisol (Cort), thyroid-stimulating hormone (TSH), and free thyroxine. These hormones are important to the anabolic/catabolic balance of the body, and are vital to growth, homeostasis, hypothalamic inhibition, regulation of stress, and metabolism. A key secondary question was the degree to which acclimatization can stabilize hormonal disruption. On the basis of statistical false discovery rates, the present analyses unveil marked adaptive changes in the thyroid axis at the level of pulsatile secretion of the pituitary hormone TSH and its downstream product, free thyroxine; strong effects on the mass of GH, TSH, Cort, and PROL secretion per burst; and prominent pulsatile frequency disruption and recovery for PROL and Cort. Because pulsatility changes reflect de facto perturbations in hypothalamo-pituitary control mechanisms, the present data introduce the concept of both frequency- and amplitude-dependent adaptive control of brain-pituitary neuroendocrine signals under conditions of extreme altitude exertion and exposure.
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Affiliation(s)
- Daniel M Keenan
- Department of Statistics, University of Virginia, Charlottesville, Virginia
| | - Jacqueline Pichler Hefti
- Department of Pulmonary Medicine, University Hospital and University of Berne, Inselspital, Berne, Switzerland
| | - Johannes D Veldhuis
- Department of Medicine, Endocrine Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Michael Von Wolff
- Women's University Hospital, Department of Gynecological endocrinology and Reproductive Medicine, Berne, Switzerland
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21
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Jacobs A, Derese I, Vander Perre S, Wouters PJ, Verbruggen S, Billen J, Vermeersch P, Garcia Guerra G, Joosten K, Vanhorebeek I, Van den Berghe G. Dynamics and prognostic value of the hypothalamus-pituitary-adrenal axis responses to pediatric critical illness and association with corticosteroid treatment: a prospective observational study. Intensive Care Med 2019; 46:70-81. [PMID: 31713058 PMCID: PMC6954148 DOI: 10.1007/s00134-019-05854-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE Increased systemic cortisol availability during adult critical illness is determined by reduced binding-proteins and suppressed breakdown rather than elevated ACTH. Dynamics, drivers and prognostic value of hypercortisolism during pediatric critical illness remain scarcely investigated. METHODS This preplanned secondary analysis of the PEPaNIC-RCT (N = 1440), after excluding 420 children treated with corticosteroids before PICU-admission, documented (a) plasma ACTH, (free)cortisol and cortisol-metabolism at PICU-admission, day-3 and last PICU-day, their prognostic value, and impact of withholding early parenteral nutrition (PN), (b) the association between corticosteroid-treatment and these hormones, and (c) the association between corticosteroid-treatment and outcome. RESULTS ACTH was normal upon PICU-admission and low thereafter (p ≤ 0.0004). Total and free cortisol were only elevated upon PICU-admission (p ≤ 0.0003) and thereafter became normal despite low binding-proteins (p < 0.0001) and persistently suppressed cortisol-metabolism (p ≤ 0.03). Withholding early-PN did not affect this phenotype. On PICU-day-3, high free cortisol and low ACTH independently predicted worse outcome (p ≤ 0.003). Also, corticosteroid-treatment initiated in PICU, which further suppressed ACTH (p < 0.0001), was independently associated with poor outcomes (earlier live PICU-discharge: p < 0.0001, 90-day mortality: p = 0.02). CONCLUSION In critically ill children, systemic cortisol availability is elevated only transiently, much lower than in adults, and not driven by elevated ACTH. Further ACTH lowering by corticosteroid-treatment indicates active feedback inhibition at pituitary level. Beyond PICU-admission-day, low ACTH and high cortisol, and corticosteroid-treatment, predicted poor outcome. This suggests that exogenously increasing cortisol availability during acute critical illness in children may be inappropriate. Future studies on corticosteroid-treatment in critically ill children should plan safety analyses, as harm may be possible.
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Affiliation(s)
- An Jacobs
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Inge Derese
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Sarah Vander Perre
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter J Wouters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Sascha Verbruggen
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Jaak Billen
- Department of Laboratory Medicine, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter Vermeersch
- Department of Laboratory Medicine, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Gonzalo Garcia Guerra
- Department of Pediatrics, Intensive Care Unit, Stollery Children's Hospital, University of Alberta, 8440, 112 St NW, Edmonton, AB, T6G 2B7, Canada
| | - Koen Joosten
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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22
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Téblick A, Peeters B, Langouche L, Van den Berghe G. Adrenal function and dysfunction in critically ill patients. Nat Rev Endocrinol 2019; 15:417-427. [PMID: 30850749 DOI: 10.1038/s41574-019-0185-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Critical illnesses are characterized by increased systemic cortisol availability, which is a vital part of the stress response. Relative adrenal failure (later termed critical-illness-related corticosteroid insufficiency (CIRCI)) is a condition in which the systemic availability of cortisol is assumed to be insufficiently high to face the stress of the illness and is most typically thought to occur in the acute phase of septic shock. Researchers suggested that CIRCI could be diagnosed by a suppressed incremental cortisol response to an injection of adrenocorticotropic hormone, irrespective of the baseline plasma cortisol. This concept triggered several randomized clinical trials on the impact of large stress doses of hydrocortisone to treat CIRCI, which gave conflicting results. Recent novel insights into the response of the hypothalamic-pituitary-adrenal axis to acute and prolonged critical illnesses challenge the concept of CIRCI, as currently defined, as well as the current practice guidelines for diagnosis and treatment. In this Review, these novel insights are integrated within a novel conceptual framework that can be used to re-appreciate adrenocortical function and dysfunction in the context of critical illness. This framework opens new avenues for further research and for preventive and/or therapeutic innovations.
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Affiliation(s)
- Arno Téblick
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Bram Peeters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium.
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23
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Peeters B, Meersseman P, Vander Perre S, Wouters PJ, Debaveye Y, Langouche L, Van den Berghe G. ACTH and cortisol responses to CRH in acute, subacute, and prolonged critical illness: a randomized, double-blind, placebo-controlled, crossover cohort study. Intensive Care Med 2018; 44:2048-2058. [PMID: 30374692 PMCID: PMC6280831 DOI: 10.1007/s00134-018-5427-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 10/17/2018] [Indexed: 01/05/2023]
Abstract
Purpose Low plasma ACTH in critically ill patients may be explained by shock/inflammation-induced hypothalamus-pituitary damage or by feedback inhibition exerted by elevated plasma free cortisol. One can expect augmented/prolonged ACTH-responses to CRH injection with hypothalamic damage, immediately suppressed responses with pituitary damage, and delayed decreased responses in prolonged critical illness with feedback inhibition. Methods This randomized, double-blind, placebo-controlled crossover cohort study, compared ACTH responses to 100 µg IV CRH and placebo in 3 cohorts of 40 matched patients in the acute (ICU-day 3–6), subacute (ICU-day 7–16) or prolonged phase (ICU-day 17–28) of critical illness, with 20 demographically matched healthy subjects. CRH or placebo was injected in random order on two consecutive days. Blood was sampled repeatedly over 135 min and AUC responses to placebo were subtracted from those to CRH. Results Patients had normal mean ± SEM plasma ACTH concentrations (25.5 ± 1.6 versus 24.8 ± 3.6 pg/ml in healthy subjects, P = 0.54) but elevated free cortisol concentrations (3.11 ± 0.27 versus 0.58 ± 0.05 µg/dl in healthy subjects, P < 0.0001). The order of the CRH/placebo injections did not affect the ACTH responses, hence results were pooled. Patients in the acute phase of illness had normal mean ± SEM ACTH responses (5149 ± 848 pg/mL min versus 4120 ± 688 pg/mL min in healthy subjects; P = 0.77), whereas those in the subacute (2333 ± 387 pg/mL min, P = 0.01) and prolonged phases (2441 ± 685 pg/mL min, P = 0.001) were low, irrespective of sepsis/septic shock or risk of death. Conclusions Suppressed ACTH responses to CRH in the more prolonged phases, but not acute phase, of critical illness are compatible with feedback inhibition exerted by elevated free cortisol, rather than by cellular damage to hypothalamus and/or pituitary. Electronic supplementary material The online version of this article (10.1007/s00134-018-5427-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bram Peeters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Philippe Meersseman
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Medical Intensive Care Unit, Department of General Internal Medicine, UZ Leuven, Leuven, Belgium
| | - Sarah Vander Perre
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter J Wouters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Yves Debaveye
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Peeters B, Meersseman P, Vander Perre S, Wouters PJ, Vanmarcke D, Debaveye Y, Billen J, Vermeersch P, Langouche L, Van den Berghe G. Adrenocortical function during prolonged critical illness and beyond: a prospective observational study. Intensive Care Med 2018; 44:1720-1729. [PMID: 30215187 PMCID: PMC6182356 DOI: 10.1007/s00134-018-5366-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/05/2018] [Indexed: 11/25/2022]
Abstract
Purpose For patients suffering from prolonged critical illness, it is unknown whether and when the hypothalamus–pituitary–adrenal axis alterations recover, and to what extent adrenocortical function parameters relate to sepsis/septic shock, to clinical need for glucocorticoid treatment, and to survival. Methods Patients still in ICU on day 7 (N = 392) and 20 matched healthy subjects were included. Morning blood and 24-h urine were collected daily and cosyntropin tests (250 µg) performed weekly, repeated 1 week after ICU discharge on the regular ward. Results In all patients free of glucocorticoid treatment up until ICU day 28 (N = 347), plasma ACTH always remained low/normal, whereas free cortisol remained high (P ≤ 0.002) explained by reduced binding proteins (P ≤ 0.02) and suppressed cortisol breakdown (P ≤ 0.001). Beyond ICU day 28 (N = 64 long-stayers), plasma (free)cortisol was no longer elevated. One week after ICU discharge, plasma ACTH and (free)cortisol always rose to supra-normal levels (P ≤ 0.006), most pronounced in long-stayers. Long-stayers always showed low incremental total (P ≤ 0.001), but normal incremental free cortisol responses to weekly cosyntropin tests, explained by low cortisol plasma binding proteins. Sepsis/septic shock patients were not different from others, patients subsequently receiving glucocorticoids (N = 45) were not different from those who did not, and non-survivors were distinguishable from survivors only by higher (free)cortisol. Conclusions Irrespective of sepsis/septic shock, need for glucocorticoids and survival, low cortisol plasma binding proteins and suppressed cortisol breakdown determine systemic (free)cortisol availability in prolonged critical illness, the latter no longer elevated beyond ICU day 28. The uniform rise in ACTH and cortisol to supra-normal levels 1 week after ICU discharge indicates recovery of a central adrenocortical suppression while in ICU. Low cortisol plasma binding invalidates the cosyntropin test. Electronic supplementary material The online version of this article (10.1007/s00134-018-5366-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bram Peeters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Philippe Meersseman
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Medical Intensive Care Unit, Department of General Internal Medicine, UZ Leuven, Leuven, Belgium
| | - Sarah Vander Perre
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter J Wouters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Dimitri Vanmarcke
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Yves Debaveye
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Jaak Billen
- Department of Laboratory Medicine, UZ Leuven, Leuven, Belgium
| | | | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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25
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Jenniskens M, Weckx R, Dufour T, Vander Perre S, Pauwels L, Derde S, Téblick A, Güiza F, Van den Berghe G, Langouche L. The Hepatic Glucocorticoid Receptor Is Crucial for Cortisol Homeostasis and Sepsis Survival in Humans and Male Mice. Endocrinology 2018; 159:2790-2802. [PMID: 29788135 DOI: 10.1210/en.2018-00344] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/09/2018] [Indexed: 01/15/2023]
Abstract
Sepsis is hallmarked by hypercortisolemia, a stress response essential for survival. This elevation in plasma cortisol is partially brought about by suppressed hepatic cortisol breakdown. We demonstrate that a controlled downregulation of the hepatic glucocorticoid receptor (hepatic GR) is crucial. In a mouse model of fluid-resuscitated, antibiotic-treated abdominal sepsis and in human intensive care unit patients, sepsis reduced hepatic GR expression and signaling but increased (free) plasma cortisol/corticosterone, explained by suppressed cortisol/corticosterone-binding proteins and A-ring reductases. However, further experimental inhibition of hepatic GR with short hairpin RNA (shRNA) in septic mice increased mortality fivefold. Acutely, this further hepatic GR suppression prevented the rise in total corticosterone but further reduced binding proteins, resulting in elevated free corticosterone. After 3 days of shRNA-GR inhibition in sepsis, both total and free corticosterone levels were elevated, now explained by an additional reduction in A-ring reductase expression. Hepatic GR inhibition blunted the hyperglycemic stress response without causing hypoglycemia but also markedly increased circulating and hepatic inflammation markers and caused liver destruction, the severity of which explained increased mortality. In human sepsis, glucocorticoid treatment further suppressed hepatic GR expression, which could directly predispose to worse outcomes. In conclusion, sepsis partially suppressed hepatic GR expression, which appeared crucial to upregulate free cortisol/corticosterone availability. However, further sustained hepatic GR suppression evoked lethal excessive liver and systemic inflammation, independent of systemic cortisol/corticosterone availability.
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Affiliation(s)
- Marc Jenniskens
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Ruben Weckx
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Thomas Dufour
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Sarah Vander Perre
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lies Pauwels
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Sarah Derde
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Arno Téblick
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Fabian Güiza
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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26
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Gibbison B. Diagnosing adrenal insufficiency in critical illness: Time to go back to the start. Resuscitation 2018; 129:A11-A12. [PMID: 29906499 DOI: 10.1016/j.resuscitation.2018.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 06/06/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Ben Gibbison
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, United Kingdom.
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27
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De Silva MSI, Dayton AW, Rhoten LR, Mallett JW, Reese JC, Squires MD, Dalley AP, Porter JP, Judd AM. Involvement of adenosine monophosphate activated kinase in interleukin-6 regulation of steroidogenic acute regulatory protein and cholesterol side chain cleavage enzyme in the bovine zona fasciculata and zona reticularis. Steroids 2018; 134:53-66. [PMID: 29501754 DOI: 10.1016/j.steroids.2018.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 02/01/2018] [Accepted: 02/22/2018] [Indexed: 10/17/2022]
Abstract
In bovine adrenal zona fasciculata (ZF) and NCI-H295R cells, interleukin-6 (IL-6) increases cortisol release, increases expression of steroidogenic acute regulatory protein (StAR), cholesterol side chain cleavage enzyme (P450scc), and steroidogenic factor 1 (SF-1) (increases steroidogenic proteins), and decreases the expression of adrenal hypoplasia congenita-like protein (DAX-1) (inhibits steroidogenic proteins). In contrast, IL-6 decreases bovine adrenal zona reticularis (ZR) androgen release, StAR, P450scc, and SF-1 expression, and increases DAX-1 expression. Adenosine monophosphate (AMP) activated kinase (AMPK) regulates steroidogenesis, but its role in IL-6 regulation of adrenal steroidogenesis is unknown. In the present study, an AMPK activator (AICAR) increased (P < 0.01) NCI-H295R StAR promoter activity, StAR and P450scc expression, and the phosphorylation of AMPK (PAMPK) and acetyl-CoA carboxylase (PACC) (indexes of AMPK activity). In ZR (decreased StAR, P450scc, SF-1, increased DAX-1) (P < 0.01) and ZF tissues (increased StAR, P450scc, SF-1, decreased DAX-1) (P < 0.01), AICAR modified StAR, P450scc, SF-1 and DAX-1 mRNAs/proteins similar to the effects of IL-6. The activity (increased PAMPK and PACC) (P < 0.01) of AMPK in the ZF and ZR was increased by AICAR and IL-6. In support of an AMPK role in IL-6 ZF and ZR effects, the AMPK inhibitor compound C blocked (P < 0.01) the effects of IL-6 on the expression of StAR, P450scc, SF-1, and DAX-1. Therefore, IL-6 modification of the expression of StAR and P450scc in the ZF and ZR may involve activation of AMPK and these changes may be related to changes in the expression of SF-1 and DAX-1.
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Affiliation(s)
- Matharage S I De Silva
- Department of Physiology and Developmental Biology and Neuroscience Center, Brigham Young University, 4005 LSB, Provo, Utah 84602, United States
| | - Adam W Dayton
- Department of Physiology and Developmental Biology and Neuroscience Center, Brigham Young University, 4005 LSB, Provo, Utah 84602, United States
| | - Lance R Rhoten
- Department of Physiology and Developmental Biology and Neuroscience Center, Brigham Young University, 4005 LSB, Provo, Utah 84602, United States
| | - John W Mallett
- Department of Physiology and Developmental Biology and Neuroscience Center, Brigham Young University, 4005 LSB, Provo, Utah 84602, United States
| | - Jared C Reese
- Department of Physiology and Developmental Biology and Neuroscience Center, Brigham Young University, 4005 LSB, Provo, Utah 84602, United States
| | - Mathieu D Squires
- Department of Physiology and Developmental Biology and Neuroscience Center, Brigham Young University, 4005 LSB, Provo, Utah 84602, United States
| | - Andrew P Dalley
- Department of Physiology and Developmental Biology and Neuroscience Center, Brigham Young University, 4005 LSB, Provo, Utah 84602, United States
| | - James P Porter
- Department of Physiology and Developmental Biology and Neuroscience Center, Brigham Young University, 4005 LSB, Provo, Utah 84602, United States
| | - Allan M Judd
- Department of Physiology and Developmental Biology and Neuroscience Center, Brigham Young University, 4005 LSB, Provo, Utah 84602, United States.
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Critical Illness-Related Corticosteroid Insufficiency (CIRCI): A Narrative Review from a Multispecialty Task Force of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). Crit Care Med 2017; 45:2089-2098. [PMID: 28938251 DOI: 10.1097/ccm.0000000000002724] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide a narrative review of the latest concepts and understanding of the pathophysiology of critical illness-related corticosteroid insufficiency (CIRCI). PARTICIPANTS A multi-specialty task force of international experts in critical care medicine and endocrinology and members of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. DATA SOURCES Medline, Database of Abstracts of Reviews of Effects (DARE), Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews. RESULTS Three major pathophysiologic events were considered to constitute CIRCI: dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, altered cortisol metabolism, and tissue resistance to glucocorticoids. The dysregulation of the HPA axis is complex, involving multidirectional crosstalk between the CRH/ACTH pathways, autonomic nervous system, vasopressinergic system, and immune system. Recent studies have demonstrated that plasma clearance of cortisol is markedly reduced during critical illness, explained by suppressed expression and activity of the primary cortisol-metabolizing enzymes in the liver and kidney. Despite the elevated cortisol levels during critical illness, tissue resistance to glucocorticoids is believed to occur due to insufficient glucocorticoid alpha-mediated anti-inflammatory activity. CONCLUSIONS Novel insights into the pathophysiology of CIRCI add to the limitations of the current diagnostic tools to identify at-risk patients and may also impact how corticosteroids are used in patients with CIRCI.
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29
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Peeters B, Langouche L, Van den Berghe G. Adrenocortical Stress Response during the Course of Critical Illness. Compr Physiol 2017; 8:283-298. [DOI: 10.1002/cphy.c170022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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30
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Mateos Moreno L, Palacios García N, Estrada García FJ. Adrenal insufficiency in critical patients: New ethiopathogenic concepts and therapeutic implications. ENDOCRINOL DIAB NUTR 2017; 64:557-563. [PMID: 29137961 DOI: 10.1016/j.endinu.2017.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 09/14/2017] [Accepted: 09/23/2017] [Indexed: 11/15/2022]
Abstract
Recently, there have been advances in understanding of the changes that occur in the hypothalamic-pituitary-adrenal axis during the different stages of critical disease. Such advances have led to a paradigm change, so that the aforementioned adaptations are no longer considered the result of adrenal axis activation, but a consequence of decreased cortisol metabolism illness. Knowledge of this new pathophysiological bases should lead to reconsider the diagnosis and treatment of adrenal insufficiency in critically ill patients, a condition poorly understood to date.
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Affiliation(s)
- Laura Mateos Moreno
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España.
| | - Nuria Palacios García
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
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31
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Critical illness-related corticosteroid insufficiency (CIRCI): a narrative review from a Multispecialty Task Force of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). Intensive Care Med 2017; 43:1781-1792. [DOI: 10.1007/s00134-017-4914-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/16/2017] [Indexed: 01/02/2023]
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32
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Dorin RI, Qiao ZG, Bouchonville M, Qualls CR, Schrader RM, Urban FK. Characterization of Cortisol Secretion Rate in Secondary Adrenal Insufficiency. J Endocr Soc 2017; 1:945-956. [PMID: 29264545 PMCID: PMC5686692 DOI: 10.1210/js.2017-00198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 05/26/2017] [Indexed: 01/28/2023] Open
Abstract
Context: In secondary adrenal insufficiency (SAI), chronic deficiency of adrenocorticotropin (ACTH) is believed to result in secondary changes in adrenocortical function, causing an altered dose-response relationship between ACTH concentration and cortisol secretion rate (CSR). Objective: We sought to characterize maximal cortisol secretion rate (CSRmax) and free cortisol half-life in patients with SAI, compare results with those of age-matched healthy controls, and examine the influence of predictor variables on ACTH-stimulated cortisol concentrations. Design: CSRmax was estimated from ACTH1-24 (250 μg)–stimulated cortisol time-concentration data. Estimates for CSRmax and free cortisol half-life were obtained for both dexamethasone (DEX) and placebo pretreatment conditions for all subjects. Setting: Single academic medical center. Patients: Patients with SAI (n = 10) compared with age-matched healthy controls (n = 21). Interventions: The order of DEX vs placebo pretreatment was randomized and double-blind. Cortisol concentrations were obtained at baseline and at intervals for 120 minutes after ACTH1-24. Main Outcome Measures: CSRmax and free cortisol half-life were obtained by numerical modeling analysis. Predictors of stimulated cortisol concentrations were evaluated using a multivariate model. Results: CSRmax was significantly (P < 0.001) reduced in patients with SAI compared with controls for both placebo (0.17 ± 0.09 vs 0.46 ± 0.14 nM/s) and DEX (0.18 ± 0.13 vs 0.43 ± 0.13 nM/s) conditions. Significant predictors of ACTH1-24–stimulated total cortisol concentrations included CSRmax, free cortisol half-life, and baseline total cortisol, corticosteroid-binding globulin, and albumin concentrations (all P < 0.05). Conclusions: Our finding of significantly decreased CSRmax confirms that SAI is associated with alterations in the CSR-ACTH dose-response curve. Decreased CSRmax contributes importantly to the laboratory diagnosis of SAI.
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Affiliation(s)
- Richard I Dorin
- Medical Service, New Mexico VA Healthcare System, University of New Mexico School of Medicine, Albuquerque, New Mexico 87108.,Departments of Medicine and Biochemistry, University of New Mexico School of Medicine, Albuquerque, New Mexico 87106
| | - Zhi George Qiao
- Departments of Medicine and Biochemistry, University of New Mexico School of Medicine, Albuquerque, New Mexico 87106
| | - Matthew Bouchonville
- Departments of Medicine and Biochemistry, University of New Mexico School of Medicine, Albuquerque, New Mexico 87106
| | - Clifford R Qualls
- Clinical and Translational Science Center, University of New Mexico, Albuquerque, New Mexico 87106
| | | | - Frank K Urban
- Department of Electrical and Computer Engineering, Florida International University, Miami, Florida 33174
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Gibbison B, López-López JA, Higgins JPT, Miller T, Angelini GD, Lightman SL, Annane D. Corticosteroids in septic shock: a systematic review and network meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:78. [PMID: 28351429 PMCID: PMC5371269 DOI: 10.1186/s13054-017-1659-4] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 02/28/2017] [Indexed: 02/08/2023]
Abstract
Background Multiple corticosteroids and treatment regimens have been used as adjuncts in the treatment of septic shock. Qualitative and quantitative differences exist at cellular and tissular levels between the different drugs and their patterns of delivery. The objective of this study was to elucidate any differences between the drugs and their treatment regimens regarding outcomes for corticosteroid use in adult patients with septic shock. Methods Network meta-analysis of the data used for the recently conducted Cochrane review was performed. Studies that included children and were designed to assess respiratory function in pneumonia and acute respiratory distress syndrome, as well as cross-over studies, were excluded. Network plots were created for each outcome, and all analyses were conducted using a frequentist approach assuming a random-effects model. Results Complete data from 22 studies and partial data from 1 study were included. Network meta-analysis provided no clear evidence that any intervention or treatment regimen is better than any other across the spectrum of outcomes. There was strong evidence of differential efficacy in only one area: shock reversal. Hydrocortisone boluses and infusions were more likely than methylprednisolone boluses and placebo to result in shock reversal. Conclusions There was no clear evidence that any one corticosteroid drug or treatment regimen is more likely to be effective in reducing mortality or reducing the incidence of gastrointestinal bleeding or superinfection in septic shock. Hydrocortisone delivered as a bolus or as an infusion was more likely than placebo and methylprednisolone to result in shock reversal. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1659-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ben Gibbison
- Cardiac Anaesthesia and Intensive Care, Bristol Heart Institute - University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, UK.
| | - José A López-López
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Julian P T Higgins
- Centre for Research Synthesis and Decision Analysis, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Tom Miller
- Cardiac Anaesthesia and Intensive Care, Bristol Heart Institute - University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Cardiac Surgery, Bristol Heart Institute - University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Stafford L Lightman
- Henry Wellcome Laboratories for Integrative Neuroscience and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Djillali Annane
- Medicine: Critical Care Medicine, Hôpital Raymond Poincaré, Assistance Publique Hôpitaux de Paris (APHP), Garches, France.,School of Medicine, Université de Versailles Saint-Quentin-en-Yvelines, Versailles, France
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34
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Strickland J, McIlmoil S, Williams BJ, Seager DC, Porter JP, Judd AM. Interleukin-6 increases the expression of key proteins associated with steroidogenesis in human NCI-H295R adrenocortical cells. Steroids 2017; 119:1-17. [PMID: 28063793 DOI: 10.1016/j.steroids.2016.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 12/29/2016] [Accepted: 12/30/2016] [Indexed: 01/03/2023]
Abstract
Mechanisms of interleukin-6 (IL-6)-induced cortisol release (CR) were investigated by exposing H295R cells to IL-6 and determining mRNA/protein expression (PCR/western blots) for steroidogenic enzymes (SE), steroidogenic acute regulatory protein (StAR), steroidogenic factor-1 (SF-1) (enhances SE/StAR expression), activator protein 1 (AP-1) (regulates SE/StAR expression) and adrenal hypoplasia congenita-like protein (DAX-1) (inhibits SE/StAR expression). Promoter activity of StAR (SPA) was measured by a luciferase-coupled promoter. Cortisol release was increased by 10ng/mL IL-6 (24h P<0.01). Proteins/mRNAs (StAR, cholesterol side chain cleavage enzyme, SF-1, AP-1) and SPA were increased by IL-6 (60min 1-50ng/mL IL-6; 5ng/mL IL-6 30-120min P<0.05). Four other SE proteins/mRNAs were also increased by 10ng/mL IL-6 (60min P<0.01). Protein/mRNA for DAX-1 was decreased by IL-6 (60min 1-50ng/mL IL-6; 5ng/mL IL-6 30-120min P<0.01). Phosphorylation of Janus kinase (JAK) and signal transducer and activator of transcription (STAT) was increased by IL-6 (JAK2 60min 1-50ng/mL IL-6; 10ng/mL IL-6 5-60min P<0.05; STAT1 and STAT3 60min 10ng/mL IL-6 P<0.01). Inhibition of JAK/STAT with AG490 (10μM) or piceatannol (50μM) blocked (P<0.01 10ng/mL IL-6vs. IL-6 plus AG490 or piceatannol) IL-6-induced increases in SPA and StAR mRNA. In summary, IL-6-induced CR may be facilitated by increased StAR and SE mediated by increased SF-1 and AP-1, decreased DAX-1, and increased phosphorylation of JAK/STAT.
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Affiliation(s)
- Janae Strickland
- Department of Physiology and Developmental Biology and Neuroscience Center, 2025 LSB, Brigham Young University, Provo, UT 84602, United States
| | - Stephen McIlmoil
- Department of Physiology and Developmental Biology and Neuroscience Center, 2025 LSB, Brigham Young University, Provo, UT 84602, United States
| | - Brice J Williams
- Department of Physiology and Developmental Biology and Neuroscience Center, 2025 LSB, Brigham Young University, Provo, UT 84602, United States
| | - Dennis C Seager
- Department of Physiology and Developmental Biology and Neuroscience Center, 2025 LSB, Brigham Young University, Provo, UT 84602, United States
| | - James P Porter
- Department of Physiology and Developmental Biology and Neuroscience Center, 2025 LSB, Brigham Young University, Provo, UT 84602, United States
| | - Allan M Judd
- Department of Physiology and Developmental Biology and Neuroscience Center, 2025 LSB, Brigham Young University, Provo, UT 84602, United States.
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Peeters B, Güiza F, Boonen E, Meersseman P, Langouche L, Van den Berghe G. Drug-induced HPA axis alterations during acute critical illness: a multivariable association study. Clin Endocrinol (Oxf) 2017; 86:26-36. [PMID: 27422812 DOI: 10.1111/cen.13155] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/30/2016] [Accepted: 07/12/2016] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Critical illness is hallmarked by low plasma ACTH in the face of high plasma cortisol. We hypothesized that frequently used drugs could play a role by affecting the hypothalamic-pituitary-adrenal axis. DESIGN Observational association study. PATIENTS A total of 156 medical-surgical critically ill patients. MEASUREMENTS Plasma concentrations of ACTH and total/free cortisol were quantified upon ICU admission and throughout the first 3 ICU days. The independent associations between drugs administered 24 h prior to ICU admission and plasma ACTH and cortisol concentrations upon ICU admission were quantified with use of multivariable linear regression analyses. RESULTS Upon ICU admission, compared with healthy subjects, patients had low mean±SEM plasma ACTH concentrations (2·7 ± 0·6 pmol/l vs 9·0 ± 1·6 pmol/l, P < 0·0001) in the face of unaltered total plasma cortisol (336·7 ± 30·4 nmol/l vs 300·8 ± 16·6 nmol/l, P = 0·3) and elevated free plasma cortisol concentrations (41·4 ± 5·5 nmol/l vs 5·5 ± 0·8 nmol/l, P = 0·04). Plasma ACTH concentrations remained low (P < 0·001) until day 3, whereas plasma (free) cortisol concentrations steeply increased and remained high (P < 0·001). No independent correlations with plasma ACTH were found. In contrast, the total admission plasma cortisol concentration was independently and negatively associated with the cumulative opioid (P = 0·001) and propofol (P = 0·02) dose, the use of etomidate (P = 0·03), and positively with the cumulative dobutamine dose (P = 0·0007). CONCLUSIONS Besides the known suppressive effect of etomidate, opioids and propofol may also suppress and dobutamine increases plasma cortisol in a dose-dependent manner. The observed independent associations suggest drug effects not mediated centrally via ACTH, but rather peripherally by a direct or indirect action on the adrenal cortex.
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Affiliation(s)
- Bram Peeters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Fabian Güiza
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Eva Boonen
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Philippe Meersseman
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, Department of General Internal Medicine, UZ Leuven, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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Van den Berghe G. On the Neuroendocrinopathy of Critical Illness. Perspectives for Feeding and Novel Treatments. Am J Respir Crit Care Med 2016; 194:1337-1348. [DOI: 10.1164/rccm.201607-1516ci] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Van den Berghe G. The 2016 ESPEN Sir David Cuthbertson lecture: Interfering with neuroendocrine and metabolic responses to critical illness: From acute to long-term consequences. Clin Nutr 2016; 36:348-354. [PMID: 27780617 DOI: 10.1016/j.clnu.2016.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 10/12/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department Cellular and Molecular Medicine, KU Leuven University and Hospitals, B-3000 Leuven, Belgium.
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Boonen E, Van den Berghe G. MECHANISMS IN ENDOCRINOLOGY: New concepts to further unravel adrenal insufficiency during critical illness. Eur J Endocrinol 2016; 175:R1-9. [PMID: 26811405 DOI: 10.1530/eje-15-1098] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 01/25/2016] [Indexed: 02/02/2023]
Abstract
The concept of 'relative' adrenal insufficiency during critical illness remains a highly debated disease entity. Several studies have addressed how to diagnose or treat this condition but have often yielded conflicting results, which further fuelled the controversy. The main reason for the controversy is the fact that the pathophysiology is not completely understood. Recently, new insights in the pathophysiology of the hypothalamic-pituitary-adrenal axis response to critical illness were generated. It was revealed that high circulating levels of cortisol during critical illness are explained more by reduced cortisol breakdown than by elevated cortisol production. Cortisol production rate during critical illness is less than doubled during the day but lower than in healthy subjects during the night. High plasma cortisol concentrations due to reduced breakdown in turn reduce plasma ACTH concentrations via feedback inhibition, which with time may lead to an understimulation and hereby a dysfunction of the adrenal cortex. This could explain the high incidence of adrenal insufficiency in the prolonged phase of critical illness. These novel insights have created a new framework for the diagnosis and treatment of adrenal failure during critical illness that has redirected future research.
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Affiliation(s)
- Eva Boonen
- Clinical Division and Laboratory of Intensive Care MedicineDepartment of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care MedicineDepartment of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium
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McIlmoil S, Strickland J, Judd AM. Interleukin 6 increases the in vitro expression of key proteins associated with steroidogenesis in the bovine adrenal zona fasciculata. Domest Anim Endocrinol 2016; 55:11-24. [PMID: 26700094 DOI: 10.1016/j.domaniend.2015.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/20/2015] [Accepted: 10/11/2015] [Indexed: 10/22/2022]
Abstract
In this study, the in vitro effects of interleukin 6 (IL-6) on the messenger RNAs (mRNAs) and proteins for key steroidogenic factors in the bovine adrenal zona fasciculata (ZF) were determined. Bovine adrenal glands were obtained from an abattoir, and the ZF was isolated. Strips of ZF were then exposed to different concentration of murine IL-6 and/or adrenocorticotropic hormone (ACTH) for various intervals, the protein and mRNA extracted, and the mRNA and protein expression determined by real-time polymerase chain reaction and Western blots. Exposure (1 h) to IL-6 increased in a concentration-dependent manner (10-pg IL-6/mL, P < 0.05 vs control; 100-pg IL-6/mL, P < 0.01 vs control) the relative expression of the mRNAs and proteins for steroidogenic acute regulatory protein (StAR), cholesterol side-chain cleavage enzyme (P450scc), 3β hydroxysteroid dehydrogenase type 2 (3β HSD), 17α-hydroxylase/17,20-lyase/17,20-desmolase (P450 17OH), steroid 21-hydroxylase (P450 21OH), steroid 11-β-hydroxylase type 1 (P450 11βOH), and steroidogenic factor 1 (SF-1), a nuclear factor that increases StAR and steroidogenic enzymes (SEs) expression. Similarly, IL-6 (10 pg/mL) increased the relative expression of proteins and mRNAs for StAR, P450scc, 3β HSD, P450 17OH, P450 21 OH, P450 11βOH, and SF-1 in a time-dependent manner (30 min, P < 0.05 vs control; 60, 120, and 240 min, P < 0.01 vs control). In contrast, IL-6 decreased in a concentration-dependent (P < 0.01 vs control for 1, 10, and 100 pg IL-6/mL) and time-dependent (P < 0.05 vs control for 30, 60,120, and 240 min of 10 pg IL-6/mL) manner the relative expression of the mRNA and protein for adrenal hypoplasia congenita-like protein (DAX-1), a nuclear factor that decreases expression of StAR and SEs. Incubation (1 h) of ZF with 100-nM ACTH increased (P < 0.05 vs control) the relative expression of StAR, P450scc, 3β HSD, P450 17OH, P450 21OH, P450 11βOH, and SF-1 and decreased (P < 0.01 vs control) the relative expression of DAX-1. Murine IL-6 (10 pg/mL) augmented (P < 0.05 vs ACTH) both the stimulatory and inhibitory effects of ACTH. Bovine IL-6 (100 pg/mL, 1-h incubation) also increased (P < 0.01 vs control) the relative expression of the proteins for StAR, P450scc, and SF-1 and decreased (P < 0.01 vs control) the relative expression of DAX-1. In summary, IL-6 increased ZF expression of StAR and 5 SEs, which may be mediated in part by decreasing DAX-1 expression and increasing SF-1 expression.
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Affiliation(s)
- S McIlmoil
- Department of Physiology and Developmental Biology and Neuroscience Center, Brigham Young University, Provo, UT, 84602, USA
| | - J Strickland
- Department of Physiology and Developmental Biology and Neuroscience Center, Brigham Young University, Provo, UT, 84602, USA
| | - A M Judd
- Department of Physiology and Developmental Biology and Neuroscience Center, Brigham Young University, Provo, UT, 84602, USA.
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Bienertová-Vašků J, Zlámal F, Nečesánek I, Konečný D, Vasku A. Calculating Stress: From Entropy to a Thermodynamic Concept of Health and Disease. PLoS One 2016; 11:e0146667. [PMID: 26771542 PMCID: PMC4714750 DOI: 10.1371/journal.pone.0146667] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 12/21/2015] [Indexed: 11/18/2022] Open
Abstract
To date, contemporary science has lacked a satisfactory tool for the objective expression of stress. This text thus introduces a new-thermodynamically derived-approach to stress measurement, based on entropy production in time and independent of the quality or modality of a given stressor or a combination thereof. Hereto, we propose a novel model of stress response based on thermodynamic modelling of entropy production, both in the tissues/organs and in regulatory feedbacks. Stress response is expressed in our model on the basis of stress entropic load (SEL), a variable we introduced previously; the mathematical expression of SEL, provided here for the first time, now allows us to describe the various states of a living system, including differentiating between states of health and disease. The resulting calculation of stress response regardless of the type of stressor(s) in question is thus poised to become an entirely new tool for predicting the development of a living system.
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Affiliation(s)
- Julie Bienertová-Vašků
- Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Kamenice 5 A18, Brno, 625 00, Czech Republic
- * E-mail:
| | - Filip Zlámal
- Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Kamenice 5 A18, Brno, 625 00, Czech Republic
| | - Ivo Nečesánek
- Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Kamenice 5 A18, Brno, 625 00, Czech Republic
| | - David Konečný
- Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Kamenice 5 A18, Brno, 625 00, Czech Republic
| | - Anna Vasku
- Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Kamenice 5 A18, Brno, 625 00, Czech Republic
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Boonen E, Bornstein SR, Van den Berghe G. New insights into the controversy of adrenal function during critical illness. Lancet Diabetes Endocrinol 2015; 3:805-15. [PMID: 26071883 DOI: 10.1016/s2213-8587(15)00224-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/17/2014] [Accepted: 10/17/2014] [Indexed: 12/18/2022]
Abstract
Critical illness represents a life-threatening disorder necessitating recruitment of defence mechanisms for survival. Herein, the hypothalamic-pituitary-adrenal axis is essential. However, the relevance of a relative insufficiency of the hypothalamic-pituitary-adrenal axis in critical illness, which is diagnosed by a suppressed cortisol response to exogenous adrenocorticotropic hormone (ACTH) irrespective of the plasma cortisol concentration, is controversial. Findings from several studies have provided insights that clarify at least part of this controversy. Rather than an activated hypothalamic-pituitary-adrenal axis, ACTH-independent regulators have been reported to contribute to increased cortisol availability during critical illness. One of these regulators is reduced cortisol breakdown, mediated by suppressed expression and activity of cortisol metabolising enzymes in the liver and kidneys. This downstream mechanism increases concentrations of plasma cortisol, but the ensuing feedback-inhibited ACTH release, when sustained for more than 1 week, has been shown to negatively affect adrenocortical integrity and function. Reduced adrenocortical ACTH signalling could explain reduced cortisol responses to exogenous ACTH. Whether such reduced cortisol responses in the presence of raised plasma (free) cortisol identifies adrenal failure needing treatment is unlikely. Additionally, reduced cortisol breakdown affects the optimum dose of hydrocortisone treatment during critical illness. Identification of patients with an insufficient hypothalamic-pituitary-adrenal axis response and the optimum treatment for this disorder clearly need more well designed preclinical and clinical studies.
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Affiliation(s)
- Eva Boonen
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Stefan R Bornstein
- Department of Medicine III, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany; Diabetes and Nutritional Sciences, Rayne Institute, Denmark Hill Campus, King's College London, London, UK
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium.
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Peeters B, Boonen E, Langouche L, Van den Berghe G. The HPA axis response to critical illness: New study results with diagnostic and therapeutic implications. Mol Cell Endocrinol 2015; 408:235-40. [PMID: 25462585 DOI: 10.1016/j.mce.2014.11.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 11/18/2014] [Accepted: 11/19/2014] [Indexed: 10/24/2022]
Abstract
For decades, elevated plasma cortisol concentrations in critically ill patients were exclusively ascribed to a stimulated hypothalamus-pituitary-adrenal axis with increased circulating adrenocorticotropic hormone (ACTH) inferred to several-fold increase adrenal cortisol synthesis. However, 'ACTH-cortisol dissociation' has been reported during critical illness, referring to low circulating ACTH coinciding with elevated circulating cortisol. It was recently shown that metabolism of cortisol is significantly reduced in critically ill patients explained by a suppression of the activity and expression of cortisol metabolizing enzymes in kidney and liver. This reduced cortisol breakdown determines hypercortisolemia, much more than increased cortisol production, in the critically ill. Although the low plasma ACTH concentrations, evoked by the elevated plasma cortisol via feedback inhibition, are part of this adaptation, they may negatively affect adrenocortical structure and function in the prolonged phase of critical illness. These new insights have implications for diagnosis and treatment of adrenal insufficiency in critically ill patients.
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Affiliation(s)
- B Peeters
- Clinical Division and Laboratory of Intensive Care Medicine, Department Cellular and Molecular Medicine, KU Leuven University, Leuven B-3000, Belgium
| | - E Boonen
- Clinical Division and Laboratory of Intensive Care Medicine, Department Cellular and Molecular Medicine, KU Leuven University, Leuven B-3000, Belgium
| | - L Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department Cellular and Molecular Medicine, KU Leuven University, Leuven B-3000, Belgium
| | - G Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department Cellular and Molecular Medicine, KU Leuven University, Leuven B-3000, Belgium.
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Abstract
OBJECTIVE Cortisol clearance is reduced in sepsis and may contribute to the development of impaired adrenocortical function that is thought to contribute to the pathophysiology of critical illness-related corticosteroid insufficiency. We sought to assess adrenocortical function using computer-assisted numerical modeling methodology to characterize and compare maximal cortisol secretion rate and free cortisol half-life in septic shock, sepsis, and healthy control subjects. DESIGN Post hoc analysis of previously published total cortisol, free cortisol, corticosteroid-binding globulin, and albumin concentration data. SETTING Single academic medical center. PATIENTS Subjects included septic shock (n = 45), sepsis (n = 25), and healthy controls (n = 10). INTERVENTIONS I.v. cosyntropin (250 μg). MEASUREMENTS AND MAIN RESULTS Solutions for maximal cortisol secretion rate and free cortisol half-life were obtained by least squares solution of simultaneous, nonlinear differential equations that account for free cortisol appearance and elimination as well as reversible binding to corticosteroid-binding globulin and albumin. Maximal cortisol secretion rate was significantly greater in septic shock (0.83 nM/s [0.44, 1.58 nM/s] reported as median [lower quartile, upper quartile]) compared with sepsis (0.51 nM/s [0.36, 0.62 nM/s]; p = 0.007) and controls (0.49 nM/s [0.42, 0.62 nM/s]; p = 0.04). The variance of maximal cortisol secretion rate in septic shock was also greater than that of sepsis or control groups (F test, p < 0.001). Free cortisol half-life was significantly increased in septic shock (4.6 min [2.2, 6.3 min]) and sepsis (3.0 min [2.3, 4.8 min] when compared with controls (2.0 min [1.2, 2.6 min]) (both p < 0.004). CONCLUSIONS Results obtained by numerical modeling are consistent with comparable measures obtained by the gold standard stable isotope dilution method. Septic shock is associated with generally not only higher levels but also greater variance of maximal cortisol secretion rate when compared with control and sepsis groups. Additional studies would be needed to determine whether assessment of cortisol kinetic parameters such as maximal cortisol secretion rate and free cortisol half-life is useful in the diagnosis or management of critical illness-related corticosteroid insufficiency.
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Hofland J, Bakker J, Feelders RA. What's new on the HPA axis? Intensive Care Med 2015; 41:1477-9. [PMID: 25851386 PMCID: PMC4502291 DOI: 10.1007/s00134-015-3771-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 03/22/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Johannes Hofland
- Section of Endocrinology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands,
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Elevated Plasma-Free Cortisol Concentrations and Ratios Are Associated With Increased Mortality Even in the Presence of Statin Therapy in Patients With Severe Sepsis*. Crit Care Med 2015; 43:630-5. [DOI: 10.1097/ccm.0000000000000750] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Critical illness represents a major challenge for the human body, implicating that an adequate stress response is indispensable for survival. Therefore, for a long time, activation of the hypothalamic pituitary adrenal axis was assumed to be increased to respond to this stressful situation. Recent novel insights, however, provided evidence that the HPA-axis is regulated differently during critical illness. Cortisol metabolism was shown to be reduced which contributed to hypercortisolism in an energy efficient way without increasing cortisol production dramatically. Yet, the concomitant low ACTH levels, explained by negative feedback inhibition, could lead to an understimulation of the adrenal gland and affect adrenal structure and function, given the crucial role of ACTH for adrenal gland maintenance. This side-effect could negatively affect outcome predominantly in the prolonged phase of critical illness and could explain the increased incidence of adrenal failure in these patients. Altogether, novel findings represent a paradigm shift in our current understanding of HPA-axis regulation during critical illness and redirect future research perspectives with an urgent need to well-designed clinical trials to further explore HPA-axis functioning during critical illness.
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Boonen E, Van den Berghe G. Understanding the HPA response to critical illness: novel insights with clinical implications. Intensive Care Med 2014; 41:131-3. [PMID: 25406407 DOI: 10.1007/s00134-014-3545-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 11/01/2014] [Indexed: 01/31/2023]
Affiliation(s)
- Eva Boonen
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Herestraat 49, 3000, Leuven, Belgium
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