scholarly journals Adrenal function testing in dialysis patients – a review of the literature

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Lara Brotzer ◽  
Manuela Nickler ◽  
Min Jeong Kim ◽  
Beat Mueller ◽  
Claudine A. Blum
Keyword(s):  
Renal Replacement Therapy ◽  
Adrenal Insufficiency ◽  
Replacement Therapy ◽  
Case Reports ◽  
Serum Cortisol ◽  
Current Evidence ◽  
Case Group ◽  
Acth Test ◽  
Review Of The Literature ◽  
Pubmed Database

Abstract Background Secondary adrenal insufficiency is a frequent issue in patients with renal replacement therapy. There are concerns about metabolism and clearance for adrenocorticotropic hormone (ACTH) and cortisol in addition to hemoconcentration as confounding factors during hemodialysis (HD). Therefore, ACTH testing is currently performed before or in between HD sessions. This review of the literature aims to evaluate the current evidence for validity of testing for adrenal insufficiency in patients on chronic renal replacement therapy. Methods A literature search of PubMed database for interventional and observational clinical trials was performed. Case reports and reviews were excluded. The search included all articles published until July 2020. Results Of 218 potentially eligible articles, 16 studies involving 381 participants were included. Seven studies performed an ACTH test before HD or in between HD sessions. There was no data available regarding ACTH testing during HD. But there was evidence of decreased cortisol levels during HD as compared to afterwards. All included 16 studies measured basal cortisol, and seven studies performed an ACTH test. Seven trials had comparable data of baseline cortisol for a quantitative analysis. Standardized mean difference of overall cortisol was 0.18 nmol/l (95%CI − 0.08 to 0.44) in the case group. Conclusions In patients undergoing renal replacement therapy, basal serum cortisol values are comparable to healthy volunteers. There is limited data on the validity of stimulated cortisol in these patients, especially during HD. Trial registration Registration no. CRD42020199245.

Ceftolozane/tazobactam exposure in critically ill patients undergoing continuous renal replacement therapy: a PK/PD approach to tailor dosing

2020 ◽  
Vol 76 (1) ◽  
pp. 199-205 ◽  
Author(s):  
Milo Gatti ◽  
Maddalena Giannella ◽  
Emanuel Raschi ◽  
Pierluigi Viale ◽  
Fabrizio De Ponti
Keyword(s):  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Flow Rate ◽  
Case Reports ◽  
Blood Flow Rate ◽  
Pubmed Database ◽  
Effluent Flow Rate ◽  
Dosing Regimens ◽  
Trough Concentrations

Abstract Objectives To investigate the influence of continuous renal replacement therapy (CRRT) intensity on the clearance of ceftolozane/tazobactam in critical care patients, and to evaluate if the reported doses would achieve an optimal pharmacokinetic/pharmacodynamic (PK/PD) target against Pseudomonas aeruginosa exhibiting different MICs. Methods The MEDLINE–PubMed database was searched from inception to January 2020 to retrieve observational studies or case reports investigating the PK behaviour of ceftolozane/tazobactam during CRRT. Relevant CRRT settings and PK variables were extracted, and the influence of CRRT intensity on ceftolozane/tazobactam total clearance (CLtot) was determined by simple linear regression. The optimal PK/PD target for the reported doses was deemed to be achieved when ceftolozane trough concentrations (Cmin) were above the MIC (less intensive target) or four times the MIC (intensive target) for P. aeruginosa. Results Data from six studies including 11 patients (mean age 56.6 years) were analysed. Mean blood flow rate and effluent flow rate were 161.8 mL/min and 2383.4 mL/h, respectively. Ceftolozane Cmin ranged from 25.8 to 79.4 mg/L. A significant correlation was found for ceftolozane CLtot and effluent flow rate (P = 0.027). The intensive PK/PD target was achieved by 100% and 50% of the reported doses for MIC, respectively, up to 4 and 8 mg/L. Conclusions A significant correlation between effluent flow rate and ceftolozane clearance during CRRT could be identified. Higher dosing regimens coupled with continuous/extended infusion may be required in the case of higher CRRT intensity, deep-seated infections or poorly susceptible isolates. Larger studies assessing ceftolozane PK in different CRRT settings are warranted.

National German Audit of Diagnosis, Treatment, and Teaching in Secondary Adrenal Insufficiency

2017 ◽  
Vol 49 (08) ◽  
pp. 580-588 ◽  
Author(s):  
Stephan Petersenn ◽  
Jürgen Honegger ◽  
Marcus Quinkler
Keyword(s):  
Clinical Practice ◽  
Adrenal Insufficiency ◽  
Replacement Therapy ◽  
Diagnostic Testing ◽  
Treatment Strategies ◽  
Serum Cortisol ◽  
National Audit ◽  
Secondary Adrenal Insufficiency ◽  
Endocrine Society ◽  
Great Heterogeneity

AbstractGreat heterogeneity seems to exist regarding diagnosis, therapy, and teaching of patients with secondary adrenal insufficiency (SAI) across Germany resulting in different diagnosis and treatment strategies. The aim of the work was to present the first national audit on diagnosis, treatment, and patient teaching of SAI reflecting common clinical practice in Germany. A self-designed questionnaire was sent via e-mail to all members of the German Endocrine Society (approx. 120 centers). Returned questionnaires (response rate 38.3%) were checked for duplicity of institutions and analyzed. Diagnostic testing focuses on those patients with relevant risk for adrenal insufficiency. Basal serum cortisol is mostly used as screening test. Short synacthen and CRH tests are the preferred confirmatory tests, however, cut-off values vary due to different assays used. Patients with radiation, second surgery, progressive disease or new symptoms are followed by serial re-testing. Perioperative management and frequency of postoperative re-evaluations differ among centers. Hydrocortisone is the preferred glucocorticoid for replacement therapy, but daily doses vary considerably (10–30 mg/day). Some centers perform hormone measurements for dose adjustment of glucocorticoid replacement therapy whereas others rely on clinical judgement. Patients’ teaching is done in 84% of centers, but only half of the centers include patients’ relatives. Homogeneity exists in patients’ teaching regarding intercurrent illnesses (fever, diarrhoea). Recommendations regarding dose adaptations in situations such as sport-activities, dental-procedures, or coughing are highly variable. This first national audit reveals great heterogeneity among German centers and could improve patients’ care in SAI, for example, by initiating new trials and developing clinical practice guidelines.

scholarly journals Primary adrenal insufficiency due to bilateral adrenal infarction in COVID-19: a case report

2021 ◽  
Author(s):  
Iza F R Machado ◽  
Isabel Q Menezes ◽  
Sabrina R Figueiredo ◽  
Fernando Morbeck Almeida Coelho ◽  
Debora R B Terrabuio ◽  
...  
Keyword(s):  
Case Report ◽  
Adrenal Insufficiency ◽  
Antiphospholipid Syndrome ◽  
Antiphospholipid Antibodies ◽  
Case Reports ◽  
Serum Cortisol ◽  
Primary Adrenal Insufficiency ◽  
Acute Adrenal Insufficiency ◽  
Adrenal Infarction ◽  
New Onset

Abstract Context Coronavirus disease 2019 (COVID-19) is a proinflammatory and prothrombotic condition, but its impact on adrenal function has not been adequately evaluated. Case report A 46-year-old woman presented with abdominal pain, hypotension, skin hyperpigmentation after COVID-19 infection. The patient had hyponatremia, serum cortisol <1.0 ug/dL, ACTH of 807 pg/mL and aldosterone <3 ng/dL. Computed tomography (CT) findings of adrenal enlargement with no parenchymal and minimal peripheral capsular enhancement after contrast were consistent with bilateral adrenal infarction. The patient had autoimmune hepatitis and positive antiphospholipid antibodies, but no previous thrombotic events. The patient was treated with intravenous hydrocortisone, followed by oral hydrocortisone and fludrocortisone. Discussion Among 115 articles, we identified nine articles, including case reports, of new-onset adrenal insufficiency and/or adrenal hemorrhage/infarction on CT in COVID-19. Adrenal insufficiency was hormonally diagnosed in five cases, but ACTH levels were measured in only three cases (high in one case and normal/low in other two cases). Bilateral adrenal non- or hemorrhagic infarction was identified in five reports (two had adrenal insufficiency, two had normal cortisol levels and one case had no data). Interestingly, the only case with well-characterized new-onset acute primary adrenal insufficiency after COVID-19 had a previous diagnosis of antiphospholipid syndrome. In our case, antiphospholipid syndrome diagnosis was established only after the adrenal infarction triggered by COVID-19. Conclusions Our findings support the association between bilateral adrenal infarction and antiphospholipid syndrome triggered by COVID-19. Therefore, patients with positive antiphospholipid antibodies should be closely monitored for symptoms or signs of acute adrenal insufficiency during COVID-19.

scholarly journals Renal Replacement Therapy in the Critical Care Setting

2019 ◽  
Vol 2019 ◽  
pp. 1-11 ◽  
Author(s):  
Adeel Rafi Ahmed ◽  
Ayanfeoluwa Obilana ◽  
David Lappin
Keyword(s):  
Critical Care ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Kidney Injury ◽  
Bleeding Risk ◽  
Current Evidence ◽  
Regional Citrate Anticoagulation ◽  
Optimal Timing ◽  
Function Preservation ◽  
Randomized Control

Renal replacement therapy (RRT) is frequently required to manage critically ill patients with acute kidney injury (AKI). There is limited evidence to support the current practice of RRT in intensive care units (ICUs). Recently published randomized control trials (RCTs) have further questioned our understanding of RRT in critical care. The optimal timing and dosing continues to be debatable; however, current evidence suggests delayed strategy with less intensive dosing when utilising RRT. Various modes of RRT are complementary to each other with no definite benefits to mortality or renal function preservation. Choice of anticoagulation remains regional citrate anticoagulation in continuous renal replacement therapy (CRRT) with lower bleeding risk when compared with heparin. RRT can be used to support resistant cardiac failure, but evolving therapies such as haemoperfusion are currently not recommended in sepsis.

scholarly journals Salivary Cortisol Determination in ACTH Stimulation Test to Diagnose Adrenal Insufficiency in Patients with Liver Cirrhosis

2019 ◽  
Vol 2019 ◽  
pp. 1-8
Author(s):  
Lara Albert ◽  
Joaquím Profitós ◽  
Jordi Sánchez-Delgado ◽  
Ismael Capel ◽  
José Miguel González-Clemente ◽  
...  
Keyword(s):  
Liver Cirrhosis ◽  
Adrenal Insufficiency ◽  
Salivary Cortisol ◽  
Serum Cortisol ◽  
Stimulation Test ◽  
Decompensated Cirrhosis ◽  
Acth Test ◽  
Acth Stimulation Test ◽  
Acth Stimulation ◽  
Cirrhotic Patients

Purpose. The prevalence of adrenal insufficiency (AI) in patients with decompensated liver cirrhosis is unknown. Because these patients have lower levels of cortisol-binding carrier proteins, their total serum cortisol (TSC) correlates poorly with free serum cortisol (FC). Salivary cortisol (SaC) correlates better with FC. We aimed to establish SaC thresholds for AI for the 250 μg intravenous ACTH test and to estimate the prevalence of AI in noncritically ill cirrhotic patients. Methods. We included 39 patients with decompensated cirrhosis, 39 patients with known AI, and 45 healthy volunteers. After subjects fasted ≥8 hours, serum and saliva samples were collected for determinations of TSC and SaC at baseline 0’(T0) and at 30-minute intervals after intravenous administration of 250 μg ACTH [30’(T30), 60’(T60), and 90’(T90)]. Results. Based on the findings in healthy subjects and patients with known AI, we defined AI in cirrhotic patients as SaC-T0< 0.08 μg/dL (2.2 nmol/L), SaC-T60 < 1.43 μg/dl (39.5 nmol/L), or ΔSaC<1 μg/dl (27.6 nmol/L). We compared AI determination in cirrhotic patients with the ACTH test using these SaC thresholds versus established TSC thresholds (TSC-T0< 9 μg/dl [248 nmol/L], TSC-T60 < 18 μg/dl [497 nmol/L], or ΔTSC<9 μg/dl [248 nmol/L]). SaC correlated well with TSC. The prevalence of AI in cirrhotic patients was higher when determined by TSC (48.7%) than by SaC (30.8%); however, this difference did not reach statistical significance. AI was associated with sex, cirrhosis etiology, and Child-Pugh classification. Conclusions. Measuring SaC was more accurate than TSC in the ACTH stimulation test. Measuring TSC overestimated the prevalence of AI in noncritically ill cirrhotic patients.

scholarly journals MON-174 Circadian Misalignment of the 24-H Profiles of Melatonin and Cortisol in Adrenal Insufficiency

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Monika Darji ◽  
Silvana Pannain ◽  
Susan Sam ◽  
Eve Van Cauter ◽  
Erin C Hanlon
Keyword(s):  
Adrenal Insufficiency ◽  
Replacement Therapy ◽  
Dose Range ◽  
Serum Cortisol ◽  
Peripheral Oscillators ◽  
Metabolic Outcomes ◽  
Peripheral Clocks ◽  
Low Levels ◽  
Cycle Dependent ◽  
Cortisol Release

Abstract Patients with adrenal insufficiency (AI), in whom cortisol release is absent, need to be on lifelong replacement therapy. Depending on the modality of glucocorticoid replacement, the resulting 24-h profile of circulating cortisol levels maybe dampened, enhanced, abnormally timed or inconsistent. The 24-h cortisol profile is a major internal synchronizing signal between central and peripheral circadian clocks. Misalignment between central and peripheral clocks has a host of adverse effects, particularly on metabolism and cardiovascular function. Melatonin, normally secreted by the pineal gland exclusively at night and considered a robust marker of central circadian timing, also plays a role as an internal synchronizing signal. Conditions like AI, where the 24-h profile of glucocorticoid levels deviates from normality, could produce misalignment between central and peripheral oscillators. We examined whether AI patients are at higher risk of disturbances of the circadian system. Participants were 13 AI patients (11 females, 2 men; mean age 45.8 yrs old; mean BMI 25.5) and 13 controls (11 females, 2 males; mean age 48.5 yrs old, mean BMI 26.4) matched for age, sex, and BMI. 10 of the AI patients were on hydrocortisone treatment (total dose range: 20 to 40mg/day, number of doses: 1-5 doses/day) and 3 of the AI patients were on prednisone treatment. Cortisol and melatonin were measured over a 24-h period every 30-60 minutes in all patients and controls. The 24-h profile of cortisol was quite variable across patients, dependent on replacement therapy. Those on prednisone had very little detectable cortisol with small peaks that occurred around dosing. Those on hydrocortisone, had multiple peaks across the 24-h cycle dependent on medication regime and dosing. As expected, control subjects had a quiescent period of cortisol release from early evening to mid-sleep (18:00 to 02:00) and a mid-sleep rise in serum cortisol that peaks in the morning and subsequently dissipates across the day. In contrast, AI patients have low levels of cortisol across the entire sleep period, with a sharp morning rise, delayed compared to controls. Unexpectedly, we observed a marked difference in the melatonin profile in AI subjects compared to controls. Indeed, a significant daytime phase of elevated melatonin levels was detected in 7 of the 13 AI patients. The nocturnal elevation in the patients was similar to that observed in controls albeit advanced. In conclusion, the abnormalities of the circadian profile of glucocorticoid levels in AI are associated with an abnormal 24-hr profile of melatonin release, a marker of central circadian function, suggesting that the disruption of the glucocorticoid rhythm may affect central circadian function. It is possible that this circadian dysfunction contributes to the well-known adverse cardio-metabolic outcomes in AI.

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