Cortisol levels and adrenal response in severe community-acquired pneumonia: a systematic review of the literature.

Intensive Care Unit and Postgraduate Program, Instituto Nacional de Câncer, Rio de Janeiro, Brazil.
Journal of critical care (Impact Factor: 2.13). 09/2010; 25(3):541.e1-8. DOI: 10.1016/j.jcrc.2010.03.004
Source: PubMed

ABSTRACT Our aim was to review the literature on the prevalence and impact of critical-illness related corticosteroid insufficiency (CIRCI) on the outcomes of patients with severe community-acquired pneumonia (CAP).
We reviewed Cochrane, Medline, and CINAHL databases (through July 2008) to identify studies evaluating the adrenal function in severe CAP. Main data collected were prevalence of CIRCI and its mortality.
We screened 152 articles and identified 7 valid studies. Evaluation of adrenal function varied, and most studies used baseline total cortisol levels. The prevalence of CIRCI in severe CAP ranged from 0% to 48%. Among 533 patients, 56 (10.7%) had cortisol levels of 10 μg/dL or less and 121 patients (21.2%) had cortisol levels of 15 μg/dL or less. In a raw analysis, there was no significant difference in mortality when patients with cortisol levels less than 10 μg/dL (8.6 vs 15.5%; P = .55) or less than 15 μg/dL (12.4 vs 16%; P = .38) were compared with those with cortisol above these levels. In the meta-analysis, relative risk for mortality were 0.81 (confidence interval, 0.39-1.7; P = .59; χ(2) = 1.04) for cortisol levels less than 10 μg/dL and relative risk was 0.67 (confidence interval, 0.4-1.14; P = .84; χ(2) = 1.4) for cortisol levels less than 15 μg/dL.
A significant proportion of patients with severe CAP fulfilled criteria for CIRCI. However, CIRCI does not seem to affect the outcomes. Noteworthy, the presence of elevated cortisol levels is associated with increased mortality and may be useful as a prognostic marker in patients with severe CAP.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Acute stroke has a high morbidity and mortality. We evaluated the predictive value of adrenal function testing in acute ischemic stroke. In a cohort of 231 acute ischemic stroke patients, we measured dehydroepiandrosterone (DHEA), DHEA-Sulfate (DHEAS), cortisol at baseline and 30 minutes after stimulation with 1 ug ACTH. Delta cortisol, the amount of rise in the 1 ug ACTH-test, was calculated. Primary endpoint was poor functional outcome defined as modified Rankin scale 3-6 after 1 year. Secondary endpoint was nonsurvival after 1 year. Logistic regression analysis showed that DHEAS (OR 1.21, 95% CI 1.01-1.49), but not DHEA (OR 1.01, 95% CI 0.99-1.04), was predictive for adverse functional outcome. Neither DHEA (OR 0.99, 95% CI 0.96-1.03) nor DHEAS (OR 1.10, 95% CI 0.82-1.44) were associated with mortality. Baseline and stimulated cortisol were predictive for mortality (OR 1.41, 95% CI 1.20-1.71; 1.35, 95% CI 1.15-1.60), but only basal cortisol for functional outcome (OR 1.20, 95% CI 1.04-1.38). Delta cortisol was not predictive for functional outcome (OR 0.86, 95% CI 0.71-1.05) or mortality (OR 0.92, 95% CI 0.72-1.17). The ratios cortisol/DHEA and cortisol/DHEAS discriminated between favorable outcome and nonsurvival (both p<0.0001) and between unfavorable outcome and nonsurvival (p = 0.0071 and 0.0029), but are not independent predictors for functional outcome or mortality in multivariate analysis (adjusted OR for functional outcome for both 1.0 (95% CI 0.99-1.0), adjusted OR for mortality for both 1.0 (95% CI 0.99-1.0 and 1.0-1.01, respectively)). DHEAS and the cortisol/DHEAS ratio predicts functional outcome 1 year after stroke whereas cortisol levels predict functional outcome and mortality. NCT00390962 (Retrospective analysis of this cohort).
    PLoS ONE 05/2013; 8(5):e63224. · 3.53 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The benefit of corticosteroids in community-acquired pneumonia (CAP) remains controversial. We did a meta-analysis to include all the randomized controlled trials (RCTs) which used corticosteroids as adjunctive therapy, to examine the benefits and risks of corticosteroids in the treatment of CAP in adults. Databases including Pubmed, EMBASE, the Cochrane controlled trials register, and Google Scholar were searched to find relevant trials. Randomized and quasi-randomized trials of corticosteroids treatment in adult patients with CAP were included. Effects on primary outcome (mortality) and secondary outcomes (adverse events) were accessed in this meta-analysis. Nine trials involving 1001 patients were included. Use of corticosteroids did not significantly reduce mortality (Peto odds ratio [OR] 0.62, 95% confidence interval [CI] 0.37-1.04; P = 0.07). In the subgroup analysis by the severity, a survival benefit was found among severe CAP patients (Peto OR 0.26, 95% CI 0.11-0.64; P = 0.003). In subgroup analysis by duration of corticosteroids treatment, significant reduced mortality was found among patients with prolonged corticosteroids treatment (Peto OR 0.51, 95% CI 0.26-0.97; P = 0.04; I(2) = 37%). Corticosteroids increased the risk of hyperglycemia (Peto OR 2.64, 95% CI 1.68-4.15; P<0.0001), but without increasing the risk of gastroduodenal bleeding (Peto OR 1.67, 95% CI 0.41-6.80; P = 0.47) and superinfection (Peto OR 1.36, 95% CI 0.65-2.84; P = 0.41). Results from this meta-analysis did not suggest a benefit for corticosteroids treatment in patients with CAP. However, the use of corticosteroids was associated with improved mortality in severe CAP. In addition, prolonged corticosteroids therapy suggested a beneficial effect on mortality. These results should be confirmed by future adequately powered randomized trials.
    PLoS ONE 10/2012; 7(10):e47926. · 3.53 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The immunoneuroendocrine axis plays a major role in the regulation of the host's response to infection, but its role in severe H7N9 pneumonia is still unknown. Therefore, this study is carried out to explore the relationship between the immunoneuroendocrine axis and severe H7N9 pneumonia.Case presentantion: The study included two H7N9 pneumonia patients. Endocrine response and cellular immune function in prolonged phase of these two severe H7N9 pneumonia cases were reported and analyzed. A 57-year-old male patient (case 1) and a 68-year-old male patient (case 2) were admitted because of cough, fever and dyspnea. Moist rales were present in both lungs. The rest of the examination was reportedly normal. The laboratory test showed that (1) The patients had loss of cortisol rhythm and elevated cortisol level at 4 pm. (2) The patients showed decline of cellular immune function. (3) The patients showed vitamin D insufficiency. (4) Case 2 had higher cortisol level but lower DHEAS, serum phosphorus and vitamin D level as well as cellular immune function than case 1. (5) The thyroid axis, gonadal and lactotropic axis were normal, so were the level of FT3, FT4, STSH and LH, FSH, T, E2 as well as PRL in these two cases. Chest CT revealed inflammation of both lungs especially in right lung. Real time RT-PCR by Centers for Disease Control and Prevention (CDC) confirmed H7N9 infection. Immunoneuroendocrine axis dysfunction may play an important role in severe H7N9 pneumonia. We need pay more attention to hypophosphatemia and vitamin D insufficiency in H7N9 pneumonia.
    BMC Infectious Diseases 01/2014; 14(1):44. · 2.56 Impact Factor

Full-text (2 Sources)

Available from
May 16, 2014