Reference range for serum cortisol in well preterm infants

Heckmann, Matthias; Wudy, Stefan A.; Haack, D.; Pohlandt, Frank

doi:10.1136/fn.81.3.f171

Cited by 62 publications

(37 citation statements)

References 27 publications

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“…Serum cortisol levels in preterm infants change in accordance with the general clinical condition, as is the case in adults (Heckmann et al 1999;Cooper and Stewart 2003). However, in preterm infants both GA and the time since birth play additional roles (Huysman et al 2000;Watterberg et al 2001).…”

Section: Discussionmentioning

confidence: 90%

Late-Onset Glucocorticoid-Responsive Circulatory Collapse in Preterm Infants: Clinical Characteristics of 14 Patients

Shimokaze

Akaba

Saito

2015

Tohoku J. Exp. Med.

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Preterm infants may develop acute systemic hypotension that responds to glucocorticoid therapy, but not to volume loading or vasopressors, during the postnatal period. This condition is termed late-onset circulatory collapse (LCC) that develops a few weeks after birth in relatively stable infants. LCC may cause periventricular leukomalacia, periventricular necrosis in the white matter. The aim of this study was to identify the clinical characteristics of LCC. We retrospectively reviewed the clinical data of infants with LCC. Among 41 infants born at < 29 weeks of gestation between 2010 and 2014, we identified 14 infants (median gestational age 25.6 weeks) with LCC. All infants were stable before the acute onset of circulatory collapse at a median age of 21 days, which is characterized by the decreased physical activity, systolic blood pressure (12 mmHg decrease), urine output (76% decrease), and serum sodium level (4 mEq/L decrease), and the increased resistance index in the cerebral and renal arteries on Doppler ultrasonography. Both left ventricular dimension and contraction were well preserved. Three infants developed hyperkalemia. The median time from the initial hydrocortisone dose to improvements was 4 h (interquartile range 3-5 h). Hydrocortisone therapy was effective, but had to be withdrawn slowly to prevent relapse. The median duration of hydrocortisone therapy was 23 days. There was no evidence of periventricular leukomalacia in any of the infants. None of the infants developed adrenal insufficiency during the follow-up period. During the acute stage of LCC, the main priority is the early initiation of glucocorticoid therapy.

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Section: Discussionmentioning

confidence: 90%

Late-Onset Glucocorticoid-Responsive Circulatory Collapse in Preterm Infants: Clinical Characteristics of 14 Patients

Shimokaze

Akaba

Saito

2015

Tohoku J. Exp. Med.

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“…homologous down-regulation) has been demonstrated to be a mechanism to limit hormone responsiveness (31,32). Although not completely elucidated, the cellular mechanisms of homologous down-regulation include inhibition of GR transcription (15,16) and decreased GR protein stability (21,33,34). These pathways also appear to be cell-type specific (32).…”

mentioning

confidence: 99%

Expression and Regulation of Glucocorticoid Receptor in Human Placental Villous Fibroblasts

Lee¹,

Wang²,

Yee³

et al. 2005

Endocrinology

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The human placenta is a glucocorticoid (GC)-responsive organ consisting of multiple cell types including smooth muscle cells, fibroblasts, and trophoblast that demonstrate changes in gene expression after hormone treatment. However, little is known about the relative expression or activity of the GC receptor (GR) among the various placental cell types. Normal term human placentas were examined by immunohistochemistry using either GR phosphorylation site-specific antibodies that are markers for various activation states of the GR or a GR antibody that recognizes the receptor independent of its phosphorylation state (total GR). We found strong total GR and phospho-GR immunoreactivity in stromal fibroblasts of terminal villi, as well as perivascular fibroblasts and vascular smooth muscle cells of the stem villi. Lower levels of both total GR and phospho-GR were found within cytotrophoblast cells relative to fibroblasts, whereas syncytiotrophoblast showed very little total GR or phospho-GR immunoreactivity. This pattern holds true for immunoblot analysis of extracts from cell fractions cultured ex vivo. In cultured placental fibroblasts, phosphorylation of GR increased upon short-term GC treatment, consistent with a role for GR phosphorylation in receptor transactivation. Total GR levels were reduced by nearly 90% after long-term hormone treatment; however, this down-regulation was independent of changes in GR mRNA levels. These findings demonstrate that GR levels in fibroblasts can be modulated by changes in hormone exposure. Such cell type-specific differences in GR protein expression and phosphorylation may provide the means of differentially regulating the GC response among the cells of the human placenta. (Endocrinology 146: 4619 -4626, 2005)

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“…15,16,24 For example, Heckmann et al 16 measured cortisol in medically stable preterm infants with a GA of <30 weeks during the first two weeks of life. Cortisol levels ranged from 66 to 744 nmol l À1 in this cohort.…”

Section: Hypoadrenalism-related Hypotension O Hochwald Et Almentioning

confidence: 99%

“…13 As a result, random cortisol levels used as a marker for adrenal insufficiency are not adequate, particularly as 'normal' cortisol levels in premature babies vary greatly. [14][15][16] Because of the lack of an obvious cutoff level of cortisol upon which clinicians can diagnose adrenal insufficiency early in preterm infants, a stimulation test, that is, adrenocorticotropin hormone (ACTH) test, may be a more accurate measure of adequacy of adrenal function. ACTH tests have been shown to have higher sensitivity for identifying adrenal insufficiency during critical illnesses.…”

Section: Introductionmentioning

confidence: 99%

The use of an early ACTH test to identify hypoadrenalism-related hypotension in low birth weight infants

2012

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Objective: To investigate if in preterm newborns, an early adrenocorticotropin hormone (ACTH) test can identify possible transient adrenal insufficiency (TAI), using significant hypotension as a clinical marker.Study Design: We studied 40 premature newborns born 24 to 29 weeks gestational age (GA) before 8 h of life. Serum cortisol levels were obtained before and 40 min after administration of 1.0 mcg kg À1 cosyntropin.Inotropes were used to treat hypotension based on clinical assessment following no response to fluid boluses. Functional echocardiogram was used to support the clinical diagnosis of hypotension. The accuracy of the ACTH test was evaluated using receiver operating characteristic (ROC) curve.Result: Study patients had mean GA of 26.6 weeks and birth weight of 876 g. In all, 30% required inotropes. The area under the ROC curve for the ACTH test was 87%. Using a cutoff of an increase in cortisol below 12% from baseline had 75% sensitivity and 93% specificity for detecting hypotension. This cutoff was associated with bronchopulmonary dysplasia (8/12 vs 7/28, 95% CI: 0.1 to 0.72), but not with other morbidities or death.Conclusion: An early ACTH test using the above cutoff has high specificity for detecting hypotension, and thus, can serve as a marker for potential TAI in preterm newborns. Future studies should focus on identifying those newborns for which steroid supplementation would be most beneficial.

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Reference range for serum cortisol in well preterm infants

Cited by 62 publications

References 27 publications

Late-Onset Glucocorticoid-Responsive Circulatory Collapse in Preterm Infants: Clinical Characteristics of 14 Patients

Late-Onset Glucocorticoid-Responsive Circulatory Collapse in Preterm Infants: Clinical Characteristics of 14 Patients

Expression and Regulation of Glucocorticoid Receptor in Human Placental Villous Fibroblasts

The use of an early ACTH test to identify hypoadrenalism-related hypotension in low birth weight infants

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