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Purpose <p>The diagnosis of hypocortisolism is challenging in hemodialysis (HD) patients due to shared clinical features between renal failure and cortisol deficiency. We tested the hypothesis that cortisol deficiency due to pituitary-adrenal axis insufficiency is missed a significant percentage of HD patients.</p> Methods <p>A prospective cohort of 56 end stage kidney disease patients on maintenance HD treatment (mean age 65.3 ± 13.1, females 80%) was studied. Low dose (1 mcg) adrenocorticotropic hormone (ACTH) test was performed on all patients and blood tests for cortisol, ACTH, insulin like growth factor 1 (IGF-1), triiodothyronine (TSH), free thyroxine (FT4), renin and aldosterone, were obtained before hemodialysis session. Adrenal insufficiency was defined as a peak serum cortisol level of &lt; 500 nmol/l at 30–60&#xa0;min after stimulation.</p> Results <p>14 patients (25%) out of the study population had an abnormal ACTH test. Mean systolic blood pressure in the group with abnormal ACTH test was 135.2 ± 22.0&#xa0;mm Hg with no difference in blood pressure in multivariable models between the groups with abnormal and normal ACTH test. Neither differences were observed in electrolyte levels, nor in renin/ aldosterone levels between these groups. Baseline ACTH level predicted an abnormal ACTH test in the study population in both, univariate and multivariate analyses. For each 1 pg/ml increase in baseline ACTH concentration the odds for abnormal ACTH test was 1.15 (95% CI: 1.03 to 1.29). In addition, IGF-SDS (standard deviation score) higher than − 0.04 significantly decreased odds for hypocortisolism (OR 0.14, 95% CI: 0.02 to 0.81) in multivaiable logistic regression models.</p> Conclusions <p>Routine evaluation of the hypothalamic-pituitary-adrenal axis (HPA) in symptomatic HD patients can reveal adrenal insufficiency, even without classic clinical signs. The 1&#xa0;µg ACTH test, alongside IGF-1 SDS and baseline ACTH levels, may assist in identifying patients at risk and support timely and life-saving intervention during acute clinical deterioration.</p>

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“Impaired adrenal responsiveness in hemodialysis patients: a low-dose ACTH stimulation test study”

  • 期刊论文

  • 发表日期：

    2025年10月23日

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  • Anat Bel-Ange,
  • Daniel Fux,
  • Dana Zelnik Yovel,
  • Ilia Beberashvili,
  • Ronit Koren,
  • Simona Grozinsky-Glasberg,
  • Shlomit Koren

摘要

Purpose

The diagnosis of hypocortisolism is challenging in hemodialysis (HD) patients due to shared clinical features between renal failure and cortisol deficiency. We tested the hypothesis that cortisol deficiency due to pituitary-adrenal axis insufficiency is missed a significant percentage of HD patients.

Methods

A prospective cohort of 56 end stage kidney disease patients on maintenance HD treatment (mean age 65.3 ± 13.1, females 80%) was studied. Low dose (1 mcg) adrenocorticotropic hormone (ACTH) test was performed on all patients and blood tests for cortisol, ACTH, insulin like growth factor 1 (IGF-1), triiodothyronine (TSH), free thyroxine (FT4), renin and aldosterone, were obtained before hemodialysis session. Adrenal insufficiency was defined as a peak serum cortisol level of < 500 nmol/l at 30–60 min after stimulation.

Results

14 patients (25%) out of the study population had an abnormal ACTH test. Mean systolic blood pressure in the group with abnormal ACTH test was 135.2 ± 22.0 mm Hg with no difference in blood pressure in multivariable models between the groups with abnormal and normal ACTH test. Neither differences were observed in electrolyte levels, nor in renin/ aldosterone levels between these groups. Baseline ACTH level predicted an abnormal ACTH test in the study population in both, univariate and multivariate analyses. For each 1 pg/ml increase in baseline ACTH concentration the odds for abnormal ACTH test was 1.15 (95% CI: 1.03 to 1.29). In addition, IGF-SDS (standard deviation score) higher than − 0.04 significantly decreased odds for hypocortisolism (OR 0.14, 95% CI: 0.02 to 0.81) in multivaiable logistic regression models.

Conclusions

Routine evaluation of the hypothalamic-pituitary-adrenal axis (HPA) in symptomatic HD patients can reveal adrenal insufficiency, even without classic clinical signs. The 1 µg ACTH test, alongside IGF-1 SDS and baseline ACTH levels, may assist in identifying patients at risk and support timely and life-saving intervention during acute clinical deterioration.