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Qutob RA, Alaryni A, Alghamdi A, Alsolamy EN, Al Harbi K, Alammari Y, Alanazi AM, Ababtain AA, Hakami OA, Aleid ZA, Alhaqbani AS, Alshehri RA, Almoshiqeh BA, Alhejazi AQ. A Cross-Sectional Survey Study on the Diagnosis and Management of Critical Illness-Induced Corticosteroid Insufficiency in Saudi Arabia. Cureus 2023; 15:e49982. [PMID: 38179369 PMCID: PMC10766206 DOI: 10.7759/cureus.49982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 01/06/2024] Open
Abstract
Background The presence of critical illness-induced corticosteroid insufficiency (CIRCI) is correlated with elevated concentrations of circulating biomarkers associated with inflammation and coagulation in multiple domains. The management of adrenal insufficiency remains a topic of ongoing debate and disagreement among endocrinologists and intensivists. This study aimed to assess the extent of understanding regarding CIRCI among endocrinologists and intensivists who are actively practicing in Saudi Arabia. Methods This is an online cross-sectional survey study that was conducted between June and August 2023 to assess knowledge of CIRCI among endocrinologists and intensivists working in Saudi Arabia. The questionnaire tool for this study was constructed based on a previous literature review. Binary logistic regression analysis was used to define factors that affect participants' knowledge of CIRCI. Results A total of 76 physicians were involved in this study. Around 32.9% (n= 25) of the participants described CIRCI correctly as an impairment of the hypothalamic-pituitary axis during critical illness. Around 35.5% (n=27) of the participants identified that widespread use of corticosteroids in critically ill patients prompted the need to revisit the concept, diagnosis, and management of CIRCI, and a similar proportion of the participants (35.5%) (n=27) identified that the role of corticosteroids in the management of CIRCI in critically ill patients may be beneficial in selected cases. Around 42.1% (n=32) of the participants identified that CIRCI is specific to critically ill patients while AI can occur in any individual. Around 17.1% (n=13) of the participants confirmed that there is no task force agreement on whether corticosteroids should be used in adult patients with sepsis but without shock. The mean knowledge score of the study participants was 3.6 (sd: 2.2) out of 10, which demonstrates a weak level of knowledge of CIRCI (36.0%). Binary logistic regression analysis identified that physicians from the southern and western regions were less likely to be knowledgeable of CIRCI compared to physicians from the central region (p< 0.05). Conclusion The study revealed that the level of familiarity with CIRCI among endocrinologists and intensivists in Saudi Arabia fell short of the desired benchmark. Clinicians may opt to utilize delta cortisol levels following cosyntropin administration and random plasma cortisol levels as diagnostic measures for CIRCI, instead of relying on plasma-free cortisol or salivary cortisol levels in conjunction with plasma total cortisol. Adherence to customized treatment protocols is crucial to attain the most favorable results for patients.
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Affiliation(s)
- Rayan Abubakker Qutob
- Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Abdullah Alaryni
- Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Abdullah Alghamdi
- Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Eysa N Alsolamy
- Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Khalid Al Harbi
- Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Yousef Alammari
- Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | | | - Abdalmohsen A Ababtain
- Department of Critical Care Medicine, King Abdullah bin Abdulaziz University Hospital at Princess Nourah bint Abdulrahman University, Riyadh, SAU
| | - Osamah Ahmad Hakami
- Department of Internal Medicine, King Abdullah Medical City in Holy Capital (KAMC-HC), Makkah, SAU
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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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Melis MJ, Miller M, Peters VBM, Singer M. The role of hormones in sepsis: an integrated overview with a focus on mitochondrial and immune cell dysfunction. Clin Sci (Lond) 2023; 137:707-725. [PMID: 37144447 PMCID: PMC10167421 DOI: 10.1042/cs20220709] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/09/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023]
Abstract
Sepsis is a dysregulated host response to infection that results in life-threatening organ dysfunction. Virtually every body system can be affected by this syndrome to greater or lesser extents. Gene transcription and downstream pathways are either up- or downregulated, albeit with considerable fluctuation over the course of the patient's illness. This multi-system complexity contributes to a pathophysiology that remains to be fully elucidated. Consequentially, little progress has been made to date in developing new outcome-improving therapeutics. Endocrine alterations are well characterised in sepsis with variations in circulating blood levels and/or receptor resistance. However, little attention has been paid to an integrated view of how these hormonal changes impact upon the development of organ dysfunction and recovery. Here, we present a narrative review describing the impact of the altered endocrine system on mitochondrial dysfunction and immune suppression, two interlinked and key aspects of sepsis pathophysiology.
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Affiliation(s)
- Miranda J Melis
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Muska Miller
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Vera B M Peters
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
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Dembek K, Timko K, Moore C, Johnson L, Frazer M, Barr B, Toribio R. Longitudinal assessment of adrenocortical steroid and steroid precursor response to illness in hospitalized foals. Domest Anim Endocrinol 2023; 82:106764. [PMID: 36162341 DOI: 10.1016/j.domaniend.2022.106764] [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: 03/02/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
Sepsis is a major cause of morbidity and mortality in neonatal foals. Relative adrenal insufficiency (RAI), defined as an inadequate cortisol response to stress, has been associated with sepsis, prematurity, and poor outcome in newborn foals. In addition to cortisol, the adrenal gland synthesizes several biologically important steroids and steroid precursors, including aldosterone, androgens, and progestogens. However, concentration of these hormones during hospitalization and their association with the severity of disease and mortality in critically ill foals have not been completely evaluated. We hypothesized, that in addition to cortisol and aldosterone, concentration of steroid precursors (progestogens and androgens) will be altered in critically ill foals. We also proposed that septic foals will have higher concentrations of steroid precursors than healthy foals, and steroid concentrations will be persistently increased during hospitalization in non-surviving septic and premature foals. Foals <4 days of age were categorized as healthy, septic, sick non-septic, and premature based on physical exam, medical history, and laboratory data. Blood samples were collected on admission (0 h), 24 h, and 72 h after admission. Concentrations of steroids and ACTH were measured by immunoassays. The area under the curve over 72 h (AUC0-72h) of hospitalization was calculated for each hormone. Serum cortisol, aldosterone, progesterone, pregnenolone, dehydroepiandrosterone sulfate (DHEAS), and 17 α-hydroxyprogesterone concentrations were higher in septic and premature foals compared to healthy foals at 0 h and throughout 72 h of hospitalization (P < 0.05). Plasma ACTH concentrations were higher in septic and premature foals on admission compared to healthy controls (P < 0.05). The progesterone (AUC0-72h) cut-off value above which non-survival could be reliably predicted in hospitalized foals was 1,085 ng/mL/h, with 82% sensitivity and 77% specificity. Critically ill neonatal foals had an appropriate response to stress characterized by increased concentrations of cortisol and steroid precursors on admission. A rapid decline in steroid concentration was observed in healthy foals. However, persistently elevated progestogen and androgen concentrations were associated with a lack of improvement in the course of disease and poor outcome.
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Affiliation(s)
- K Dembek
- College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA.
| | - K Timko
- College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - C Moore
- Jacksonville Equine Associates, Jacksonville, FL, USA
| | - L Johnson
- Fairfield Equine Associates, Newtown, CT, USA
| | - M Frazer
- Hagyard Equine Medical Institute, Lexington, KY, USA
| | - B Barr
- Rood and Riddle Equine Hospital, Lexington, KY, USA
| | - R Toribio
- College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
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Braukyliene R, Hedayat K, Zajanckauskiene L, Jurenas M, Unikas R, Aldujeli A, Petrokas O, Zabiela V, Steponaviciute R, Vitkauskiene A, Hedayat B, Simonyte S, Lesauskaite V, Lapraz JC, Zaliaduonyte D. Prognostic Value of Cortisol Index of Endobiogeny in Acute Myocardial Infarction Patients. ACTA ACUST UNITED AC 2021; 57:medicina57060602. [PMID: 34208003 PMCID: PMC8230642 DOI: 10.3390/medicina57060602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 01/10/2023]
Abstract
Background and Objectives: Serum cortisol has been extensively studied for its role during acute myocardial infarction (AMI). Reports have been inconsistent, with high and low serum cortisol associated with various clinical outcomes. Several publications claim to have developed methods to evaluate cortisol activity by using elements of complete blood count with its differential. This study aims to compare the prognostic value of the cortisol index of Endobiogeny with serum cortisol in AMI patients, and to identify if the risk of mortality in AMI patients can be more precisely assessed by using both troponin I and cortisol index than troponin I alone. Materials and methods: This prospective study included 123 consecutive patients diagnosed with AMI. Diagnostic coronary angiography and revascularization was performed for all patients. Cortisol index was measured on admission, on discharge, and after 6 months. Two year follow-up for all patients was obtained. Results: Our study shows cortisol index peaks at 7–12 h after the onset of AMI, while serum cortisol peaked within 3 h from the onset of AMI. The cortisol index is elevated at admission, then significantly decreases at discharge; furthermore, the decline to its bottom most at 6 months is observed with mean values being constantly elevated. The cortisol index on admission correlated with 24-month mortality. We established combined cut-off values of cortisol index on admission > 100 and troponin I > 1.56 μg/las a prognosticator of poor outcomes for the 24-month period. Conclusions: The cortisol index derived from the global living systems theory of Endobiogeny is more predictive of mortality than serum cortisol. Moreover, a combined assessment of cortisol index and Troponin I during AMI offers more accurate risk stratification of mortality risk than troponin alone.
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Affiliation(s)
- Rima Braukyliene
- Cardiology Department, Lithuanian University of Health Sciences, LT 50161 Kaunas, Lithuania; (L.Z.); (M.J.); (R.U.); (A.A.); (O.P.); (V.Z.); (R.S.); (A.V.); (S.S.); (V.L.); (D.Z.)
- Correspondence:
| | - Kamyar Hedayat
- Systems Biology Research Group, Chicago, IL 60603, USA; (K.H.); (B.H.); (J.C.L.)
| | - Laura Zajanckauskiene
- Cardiology Department, Lithuanian University of Health Sciences, LT 50161 Kaunas, Lithuania; (L.Z.); (M.J.); (R.U.); (A.A.); (O.P.); (V.Z.); (R.S.); (A.V.); (S.S.); (V.L.); (D.Z.)
| | - Martynas Jurenas
- Cardiology Department, Lithuanian University of Health Sciences, LT 50161 Kaunas, Lithuania; (L.Z.); (M.J.); (R.U.); (A.A.); (O.P.); (V.Z.); (R.S.); (A.V.); (S.S.); (V.L.); (D.Z.)
| | - Ramunas Unikas
- Cardiology Department, Lithuanian University of Health Sciences, LT 50161 Kaunas, Lithuania; (L.Z.); (M.J.); (R.U.); (A.A.); (O.P.); (V.Z.); (R.S.); (A.V.); (S.S.); (V.L.); (D.Z.)
| | - Ali Aldujeli
- Cardiology Department, Lithuanian University of Health Sciences, LT 50161 Kaunas, Lithuania; (L.Z.); (M.J.); (R.U.); (A.A.); (O.P.); (V.Z.); (R.S.); (A.V.); (S.S.); (V.L.); (D.Z.)
| | - Osvaldas Petrokas
- Cardiology Department, Lithuanian University of Health Sciences, LT 50161 Kaunas, Lithuania; (L.Z.); (M.J.); (R.U.); (A.A.); (O.P.); (V.Z.); (R.S.); (A.V.); (S.S.); (V.L.); (D.Z.)
| | - Vytautas Zabiela
- Cardiology Department, Lithuanian University of Health Sciences, LT 50161 Kaunas, Lithuania; (L.Z.); (M.J.); (R.U.); (A.A.); (O.P.); (V.Z.); (R.S.); (A.V.); (S.S.); (V.L.); (D.Z.)
| | - Rasa Steponaviciute
- Cardiology Department, Lithuanian University of Health Sciences, LT 50161 Kaunas, Lithuania; (L.Z.); (M.J.); (R.U.); (A.A.); (O.P.); (V.Z.); (R.S.); (A.V.); (S.S.); (V.L.); (D.Z.)
| | - Astra Vitkauskiene
- Cardiology Department, Lithuanian University of Health Sciences, LT 50161 Kaunas, Lithuania; (L.Z.); (M.J.); (R.U.); (A.A.); (O.P.); (V.Z.); (R.S.); (A.V.); (S.S.); (V.L.); (D.Z.)
| | - Brigita Hedayat
- Systems Biology Research Group, Chicago, IL 60603, USA; (K.H.); (B.H.); (J.C.L.)
| | - Sandrita Simonyte
- Cardiology Department, Lithuanian University of Health Sciences, LT 50161 Kaunas, Lithuania; (L.Z.); (M.J.); (R.U.); (A.A.); (O.P.); (V.Z.); (R.S.); (A.V.); (S.S.); (V.L.); (D.Z.)
| | - Vaiva Lesauskaite
- Cardiology Department, Lithuanian University of Health Sciences, LT 50161 Kaunas, Lithuania; (L.Z.); (M.J.); (R.U.); (A.A.); (O.P.); (V.Z.); (R.S.); (A.V.); (S.S.); (V.L.); (D.Z.)
| | - Jean Claude Lapraz
- Systems Biology Research Group, Chicago, IL 60603, USA; (K.H.); (B.H.); (J.C.L.)
| | - Diana Zaliaduonyte
- Cardiology Department, Lithuanian University of Health Sciences, LT 50161 Kaunas, Lithuania; (L.Z.); (M.J.); (R.U.); (A.A.); (O.P.); (V.Z.); (R.S.); (A.V.); (S.S.); (V.L.); (D.Z.)
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Blum CA, Schuetz P, Nigro N, Winzeler B, Arici B, Refardt J, Urwyler SA, Rodondi N, Blum MR, Briel M, Mueller B, Christ-Crain M. Cosyntropin testing does not predict response to glucocorticoids in community-acquired pneumonia in a randomized controlled trial. Clin Endocrinol (Oxf) 2019; 91:374-382. [PMID: 30485501 DOI: 10.1111/cen.13907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 11/23/2018] [Accepted: 11/24/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Glucocorticoids have been shown to improve outcome in community-acquired pneumonia (CAP). However, glucocorticoids have potential side-effects, and treatment response may vary. It is thus crucial to select patients with high likelihood to respond favourably. In critical illness, cosyntropin testing is recommended to identify patients in need for glucocorticoids. We investigated whether cosyntropin testing predicts treatment response to glucocorticoids in CAP. DESIGN Predefined secondary analysis of a randomized controlled trial. PATIENTS Hospitalized patients with CAP. MEASUREMENTS We performed 1 µg cosyntropin tests in a randomized trial comparing prednisone 50 mg for 7 days to placebo. We investigated whether subgroups based on baseline and stimulated cortisol levels responded differently to glucocorticoids with regard to time to clinical stability (TTCS) and other outcomes by inclusion of interaction terms into statistical models. RESULTS A total of 326 patients in the prednisone and 309 patients in the placebo group were evaluated. Neither basal cortisol nor a Δcortisol <250 nmol/L after stimulation nor the combination of basal cortisol and Δcortisol predicted treatment response as measured by TTCS (all P for interaction >0.05). Similarly, we found no effect modification with respect to mortality, rehospitalization, antibiotic treatment duration or CAP-related complications (all P for interaction >0.05). However, glucocorticoids had a stronger effect on shortening length of hospital stay in patients with a baseline cortisol of ≥938 nmol/L (P for interaction = 0.015). CONCLUSIONS Neither baseline nor stimulated cortisol after low-dose cosyntropin testing at a dose of 1 µg predicted glucocorticoid responsiveness in mild to moderate CAP. A treatment decision for or against adjunct glucocorticoids in CAP should not be made depending on cortisol values or cosyntropin testing results.
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Affiliation(s)
- Claudine A Blum
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- Department of General Internal & Emergency Medicine and Department of Endocrinology, Diabetology and Clinical Nutrition, Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Schuetz
- Department of General Internal & Emergency Medicine and Department of Endocrinology, Diabetology and Clinical Nutrition, Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - Nicole Nigro
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Bettina Winzeler
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Birsen Arici
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Julie Refardt
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Sandrine A Urwyler
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Manuel R Blum
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Briel
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Beat Mueller
- Department of General Internal & Emergency Medicine and Department of Endocrinology, Diabetology and Clinical Nutrition, Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - Mirjam Christ-Crain
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, Basel, Switzerland
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Téblick A, Langouche L, Van den Berghe G. Anterior pituitary function in critical illness. Endocr Connect 2019; 8:R131-R143. [PMID: 31340197 PMCID: PMC6709544 DOI: 10.1530/ec-19-0318] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/24/2019] [Indexed: 12/13/2022]
Abstract
Critical illness is hallmarked by major changes in all hypothalamic-pituitary-peripheral hormonal axes. Extensive animal and human studies have identified a biphasic pattern in circulating pituitary and peripheral hormone levels throughout critical illness by analogy with the fasting state. In the acute phase of critical illness, following a deleterious event, rapid neuroendocrine changes try to direct the human body toward a catabolic state to ensure provision of elementary energy sources, whereas costly anabolic processes are postponed. Thanks to new technologies and improvements in critical care, the majority of patients survive the acute insult and recover within a week. However, an important part of patients admitted to the ICU fail to recover sufficiently, and a prolonged phase of critical illness sets in. This prolonged phase of critical illness is characterized by a uniform suppression of the hypothalamic-pituitary-peripheral hormonal axes. Whereas the alterations in hormonal levels during the first hours and days after the onset of critical illness are evolutionary selected and are likely beneficial for survival, endocrine changes in prolonged critically ill patients could be harmful and may hamper recovery. Most studies investigating the substitution of peripheral hormones or strategies to overcome resistance to anabolic stimuli failed to show benefit for morbidity and mortality. Research on treatment with selected and combined hypothalamic hormones has shown promising results. Well-controlled RCTs to corroborate these findings are needed.
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Affiliation(s)
- Arno Téblick
- 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
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Correspondence should be addressed to G Van den Berghe:
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8
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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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Iyer P, Harrington B, Fadrowski JJ, Sibinga E, Amankwah EK. Correlation between Cosyntropin Stimulation Study and Disease Severity in Children with Fluid- and Catecholamine-Refractory Shock in the Pediatric and Cardiovascular Intensive Care Unit. Horm Res Paediatr 2018; 89:31-37. [PMID: 29151100 DOI: 10.1159/000484561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 10/24/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The cosyntropin stimulation study (CSS) measures the patient's ability to adequately mount a cortisol response. Clinically, CSS results may not be used to guide hydrocortisone use. The objective of this study was to examine how the CSS results are associated with clinical parameters, mortality/disease severity, and use of glucocorticoids in pediatric patients with catecholamine- and fluid-resistant shock. METHODS This was a retrospective cohort study of patients who had a CSS during 2009-2014 in the intensive care unit at a children's hospital. Data collected included clinical variables, mortality, biochemical studies, and glucocorticoid use. PRISM III scores were used to determine the association between CSS results and disease severity. Adequate response to cosyntropin was defined as peak cortisol of 18 µg/dL or higher. RESULTS Of the 76 patients that underwent CSS, 68 (89%) had an adequate response to cosyntropin. There was a positive correlation between peak cortisol and PRISM III score (r = 0.45, r2 = 0.2). Glucocorticoid was administered in 52/76 (68%) despite several patients with normal CSS results. CONCLUSIONS Sicker patients were more likely to have an adequate response to CSS. Clinically, glucocorticoid supplementation was not based on CSS results. Further prospective studies are needed to elucidate if CSS is a valuable clinical tool.
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Affiliation(s)
- Pallavi Iyer
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brittany Harrington
- Garden City Hospital, Michigan State University COM, Garden City, Michigan, USA
| | | | | | - Ernest K Amankwah
- Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
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Xu R, Wang Q, Huang Y, Wu L, Liu Q, Hu W, Zhou C, Du Q. Do low-dose corticosteroids improve survival or shock reversal from septic shock in adults? Meta-analysis with trial sequential analysis. J Int Med Res 2018; 46:2513-2524. [PMID: 29911468 PMCID: PMC6124298 DOI: 10.1177/0300060518774985] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective This meta-analysis with trial sequential analysis (TSA) was performed to determine whether low-dose corticosteroids (LDCs) can improve survival or shock reversal from septic shock in adults. Methods A literature search was performed using several databases (Medline, Cochrane Library, Embase, and Chinese Biological Medical Database) until 23 October 2017. The systematic review was registered in PROSPERO. Results Nine randomized controlled trials (RCTs) (n = 1182) were included. LDC intervention improved 7-day shock reversal compared with the control group (relative risk, 1.36; TSA-adjusted 95% confidence interval, 1.20–1.54). LDCs had no statistically significant effects on gastrointestinal bleeding or superinfection. LDCs did not reduce 28-day mortality from septic shock (relative risk, 0.96; TSA-adjusted 95% confidence interval, 0.74–1.24). The TSA indicated that RCTs of about 3000 patients would be needed to draw definitive conclusions; similar results were obtained in a subgroup analysis of nonresponders. Conclusions LDCs improve 7-day shock reversal. However, whether LDCs improve 28-day survival from septic shock in adults remains unclear. The results of well-designed larger RCTs are needed.
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Affiliation(s)
- Rui Xu
- 1 Department of Anesthesiology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China.,2 Department of Anesthesiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qian Wang
- 2 Department of Anesthesiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yan Huang
- 2 Department of Anesthesiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ling Wu
- 2 Department of Anesthesiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qi Liu
- 2 Department of Anesthesiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Hu
- 2 Department of Anesthesiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chengfu Zhou
- 2 Department of Anesthesiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Quan Du
- 2 Department of Anesthesiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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11
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Galvão ACDM, de Almeida RN, Silva EADS, Freire FAM, Palhano-Fontes F, Onias H, Arcoverde E, Maia-de-Oliveira JP, de Araújo DB, Lobão-Soares B, Galvão-Coelho NL. Cortisol Modulation by Ayahuasca in Patients With Treatment Resistant Depression and Healthy Controls. Front Psychiatry 2018; 9:185. [PMID: 29867608 PMCID: PMC5952178 DOI: 10.3389/fpsyt.2018.00185] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 04/20/2018] [Indexed: 12/20/2022] Open
Abstract
Major depression is a highly prevalent mood disorder, affecting about 350 million people, and around 30% of the patients are resistant to currently available antidepressant medications. Recent evidence from a randomized controlled trial (RCT) supports the rapid antidepressant effects of the psychedelic ayahuasca in treatment-resistant depression. The aim of this study was to explore the effect of ayahuasca on plasma cortisol and awakening salivary cortisol response, in the same group of treatment-resistant patients (MD) and in healthy volunteers (C). Subjects received a single dose of ayahuasca or placebo (dosing session), and both plasma and awakening salivary cortisol response were measured at baseline (before dosing session) and 48 h after the dosing session. Baseline assessment (D0) showed blunted awakening salivary cortisol response and hypocortisolemia in patients, with respect to healthy controls. Salivary cortisol was also measured during dosing session, and we observed higher increases for both C and MD that ingested ayahuasca than placebo. After 48 h from the dosing session with ayahuasca, patients' awakening salivary cortisol response is similar to the ones detected in controls. No significant changes in plasma cortisol levels were observed 48 h after the sessions. Therefore, these findings point to new evidence on the modulation of salivary cortisol levels as a result of an ayahuasca session, both in healthy and depressive volunteers. Considering that cortisol acts in regulation of distinct physiological pathways, emotional and cognitive processes, it is assumed to be critically involved to the etiology of depression and its regulation seems to be important for the treatment and remission of major depression, ayahuasca use as antidepressant should be further investigated. Moreover, this study highlights the importance of psychedelics in the treatment of human mental disorders.
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Affiliation(s)
- Ana C de Menezes Galvão
- Laboratory of Hormone Measurement, Department of Physiology, Federal University of Rio Grande do Norte, Natal, Brazil.,Postgraduate Program in Psychobiology, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Raíssa N de Almeida
- Laboratory of Hormone Measurement, Department of Physiology, Federal University of Rio Grande do Norte, Natal, Brazil.,Postgraduate Program in Psychobiology, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Erick A Dos Santos Silva
- Laboratory of Hormone Measurement, Department of Physiology, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Fúlvio A M Freire
- Postgraduate Program in Psychobiology, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Fernanda Palhano-Fontes
- Brain Institute, Federal University of Rio Grande do Norte, Natal, Brazil.,Onofre Lopes University Hospital, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Heloisa Onias
- Brain Institute, Federal University of Rio Grande do Norte, Natal, Brazil.,Onofre Lopes University Hospital, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Emerson Arcoverde
- Onofre Lopes University Hospital, Federal University of Rio Grande do Norte, Natal, Brazil.,Department of Clinical Medicine, Federal University of Rio Grande do Norte, Natal, Brazil
| | - João P Maia-de-Oliveira
- Onofre Lopes University Hospital, Federal University of Rio Grande do Norte, Natal, Brazil.,Department of Clinical Medicine, Federal University of Rio Grande do Norte, Natal, Brazil.,National Institute of Science and Technology in Translational Medicine, Natal, Brazil
| | - Dráulio B de Araújo
- Brain Institute, Federal University of Rio Grande do Norte, Natal, Brazil.,Onofre Lopes University Hospital, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Bruno Lobão-Soares
- National Institute of Science and Technology in Translational Medicine, Natal, Brazil.,Department of Biophysics and Pharmacology, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Nicole L Galvão-Coelho
- Laboratory of Hormone Measurement, Department of Physiology, Federal University of Rio Grande do Norte, Natal, Brazil.,Postgraduate Program in Psychobiology, Federal University of Rio Grande do Norte, Natal, Brazil.,National Institute of Science and Technology in Translational Medicine, Natal, Brazil
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12
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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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13
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Ingels C, Gunst J, Van den Berghe G. Endocrine and Metabolic Alterations in Sepsis and Implications for Treatment. Crit Care Clin 2017; 34:81-96. [PMID: 29149943 DOI: 10.1016/j.ccc.2017.08.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sepsis induces profound neuroendocrine and metabolic alterations. During the acute phase, the neuroendocrine changes are directed toward restoration of homeostasis, and also limit unnecessary energy consumption in the setting of restricted nutrient availability. Such changes are probably adaptive. In patients not recovering quickly, a prolonged critically ill phase may ensue, with different neuroendocrine changes, which may represent a maladaptive response. Whether stress hyperglycemia should be aggressively treated or tolerated remains a matter of debate. Until new evidence from randomized controlled trials becomes available, preventing severe hyperglycemia is recommended. Evidence supports withholding parenteral nutrition in the acute phase of sepsis.
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Affiliation(s)
- Catherine Ingels
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, Leuven 3000, Belgium.
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