cosyntropin and Kidney-Diseases

Glucocorticoids (GCs) are frequently used to treat glomerular diseases but are associated with multiple adverse effects including hypothalamic-pituitary-adrenal axis inhibition that can lead to adrenal insufficiency (AI) on withdrawal. There is no agreed GC tapering strategy to minimise this risk.. This is a single centre retrospective study, between 2013 to 2016, of patients with glomerular disease on GC therapy for more than 3 months screened for GC induced AI with short synacthen stimulation tests (SSTs) done prior to complete GC withdrawal. We investigated the prevalence of AI, predictors, choice of screening tool and recovery.. Biochemical evidence of GC induced AI was found in 57 (46.3%) patients. Total duration of GC did not differ between those with and without AI (p = 0.711). Patients with GC induced AI had a significantly lower pre-synacthen baseline cortisol as compared to patients without AI. A cut off pre-synacthen baseline cortisol of ≥223.5 nmol/l had a specificity of 100% for identifying individuals without biochemical AI. Patients with GC induced AI took a mean of 8.7 ± 4.6 months (mean ± SD) to recover. Patients with persistent AI had a significantly lower index post-synacthen cortisol measurement.. We demonstrate that biochemically proven GC induced AI is common in patients with glomerular diseases, is not predicted by daily dose or duration and takes a considerable time to recover. The study supports the use of morning basal cortisol testing as an appropriate means to avoid the need for SSTs in all patients and should be performed in all patients prior to consideration of GC withdrawal after 3 months duration.

Topics: Adrenal Insufficiency; Biomarkers; Cosyntropin; Female; Glucocorticoids; Humans; Hydrocortisone; Hypothalamo-Hypophyseal System; Kidney Diseases; Kidney Glomerulus; Male; Methylprednisolone; Middle Aged; Pituitary-Adrenal System; Prednisolone; Retrospective Studies; ROC Curve; Time Factors

Acute liver failure and septic shock share many clinical features, including hyperdynamic cardiovascular collapse. Adrenal insufficiency may result in a similar cardiovascular syndrome. In septic shock, adrenal insufficiency, defined using the short synacthen test (SST), is associated with hemodynamic instability and poor outcome. We examined the SST, a dynamic test of adrenal function, in 45 patients with acute hepatic dysfunction (AHD) and determined the association of these results with hemodynamic profile, severity of illness, and outcomes. Abnormal SSTs were common, occurring in 62% of patients. Those who required noradrenaline (NA) for blood pressure support had a significantly lower increment (median, 161 vs. 540 nmol/L; P <.001) following synacthen compared with patients who did not. Increment and peak were lower in patients who required ventilation for the management of encephalopathy (increment, 254 vs. 616 nmol/L, P <.01; peak, 533 vs. 1,002 nmol/L, P <.01). Increment was significantly lower in those who fulfilled liver transplant criteria compared with those who did not (121 vs. 356 nmol/L; P <.01). Patients who died or underwent liver transplantation had a lower increment (148 vs. 419 nmol/L) and peak (438 vs. 764 nmol/L) than those who survived (P <.01). There was an inverse correlation between increment and severity of illness (Sequential Organ Failure Assessment, r = -0.63; P <.01). In conclusion, adrenal dysfunction assessed by the SST is common in AHD and may contribute to hemodynamic instability and mortality. It is more frequent in those with severe liver disease and correlates with severity of illness.

Topics: Adolescent; Adrenal Insufficiency; Adult; Aged; Bacterial Infections; Cosyntropin; Critical Care; Female; Hemodynamics; Humans; Hydrocortisone; Kidney Diseases; Liver Failure, Acute; Liver Transplantation; Male; Middle Aged; Pregnancy; Respiration, Artificial; Severity of Illness Index; Treatment Outcome

Amyloidosis is a multisystem disease which may cause organ loss. Renal involvement is the most common clinical problem in amyloidosis, however involvement of endocrin organs is possible. In this study to assess adrenocortical function and to evaluate the usefulness of low dose ACTH test in patients with renal amyloidosis, we determined cortisol, 17-hydroxyprogesteron (17-OHP) and 11-deoxycortisol (11-DOC) responses to both 1 microg and 250 microg Synacthen. We also determined the size of adrenal glands radiologically by using computerized tomography. Twenty one patients with renal amyloidosis and 16 healthy subjects for hormonal evaluation, and 20 patients with renal amyloidosis and 22 healthy subjects for radiologic evaluation were included in the study. In four patients (19%) peak serum cortisol levels following stimulation with the low dose of Synacthen were less than 20 microg/dL (550 nmol/L). Two of them had also subnormal cortisol response to the 250 microg Synacthen stimulation test. Basal and stimulated levels of 11-DOC were lower than those of control values (p=0.000 and p<0.01 respectively). The mean 11-DOC responses to stimulation with 1 microg Synacthen were also significantly lower than the values obtained after the simulation with 250 microg Synacthen (p<0.01 and p=0.000). Cortisol responses to the stimulation with 250 microg Synacthen were also lower than the control responses (p<0.05). 17-OHP responses were similar to the control values in both tests. In the radiological evaluation the mean maximum width of right adrenal glands and the mean anterior and maximum width of left adrenal glands were significantly greater in the patient group (p<0.01). In conclusion, adrenal involvement and adrenal insufficiency is common in amyloidosis. Low 11-DOC levels in amyloidosis is a new finding and further detailed studies is required to explain its cause.

Topics: 17-alpha-Hydroxyprogesterone; Adolescent; Adrenal Glands; Adult; Amyloidosis; Child; Cortodoxone; Cosyntropin; Delayed-Action Preparations; Female; Humans; Hydrocortisone; Kidney Diseases; Male; Middle Aged; Radiography

The mechanisms behind secondary hyperlipidemia in patients with various chronic inflammatory diseases are not known in detail. We have recently demonstrated that ACTH exerts strong hypolipidemic effects in healthy volunteers. To test the clinical relevance of this finding, we administrated ACTH during three weeks to nine hyperlipidemic steroid-treated patients with kidney disease. Before administration of ACTH 1-24, plasma ACTH concentrations were low. Treatment with ACTH led to 20 to 50% reductions in serum concentrations of triglycerides, cholesterol, LDL cholesterol and Apo B as well as of Lp(a). HDL cholesterol and Apo A1 concentrations increased by 10 to 25%. HL activity in postheparin plasma decreased by about 40% and LPL activity, which was initially low, increased by about 140%. The effects of ACTH were similar in kidney transplant recipients and in patients with inflammatory kidney disease. Our results indicate that hyperlipidemia in steroid treated patients with kidney disease may at least partly be due to iatrogenic ACTH deficiency.

Topics: Adrenocorticotropic Hormone; Adult; Cosyntropin; Humans; Hyperlipidemias; Hypolipidemic Agents; Kidney Diseases; Lipids; Lipoproteins; Male; Middle Aged; Steroids; Time Factors

Amyloidosis is a multi-system disease. Renal involvement often leads to end-stage renal failure, which carries a poor prognosis. This paper reports the adrenal status of 22 patients with renal amyloid who were considered for or who had been commenced on renal replacement therapy. Twelve patients were considered or found to have AA amyloid and the remaining 10 had AL amyloid. Of 16 patients tested, seven demonstrated an abnormal response to a synacthen test. Four patients died at Addisonian crisis and hypo-adrenalism probably contributed to the deaths of a further two patients. Amyloid deposition was found in the adrenal glands in seven patients who died of systemic amyloidosis and renal failure. It is recommended that all patients with renal amyloid should have an assessment of adrenal function performed and if abnormal replacement steroid therapy should be commenced.

Topics: Adrenal Gland Diseases; Adrenal Glands; Adult; Aged; Amyloidosis; Cosyntropin; Female; Humans; Kidney; Kidney Diseases; Kidney Failure, Chronic; Kidney Transplantation; Liver; Male; Middle Aged; Myocardium