Investigating the clinical appropriateness of Short Synacthen Testing (SST) and utility of a pre-test cortisol to predict SST outcome: A tertiary centre experience in Southeast Asia.

BACKGROUND: No studies have investigated the predictors of an adequate cortisol response to short synacthen test (SST) and appropriateness of patient selection for SST in Southeast Asian population. AIM: To investigate the predictors and indications of SSTs and concordance with SST outcomes. DESIGN: A retrospective study investigating all SSTs performed over a year in a tertiary center. METHODS: We extracted clinical data of patients who had SST between February 2022 and February 2023. We determined the appropriateness of SST testing. Binary logistic regression was used to assess the parameters that predict adequate cortisol response on SST. Proportion of individuals with biochemical "pass" or "fail" on SST were compared with chi-square test. Baseline cortisol level that predicted SST pass were determined using AuROC curves. RESULTS: Of the 781 SSTs, 83.9% of SSTs showed an adequate cortisol response. Postural hypotension (26.9%) and exogenous GC administration (14.2%) were common indications for SST. In our cohort, 50.2% of the SSTs were inappropriately indicated. Pre-test serum cortisol and albumin predict biochemical pass on SST. A pre-test cortisol level of 300nmol/L predicted SST response with 93% sensitivity, and a cortisol level of < 100nmol/L confirmed adrenal insufficiency (AI) with 97.3% specificity. Using these cortisol thresholds could avoid 302 (38.5%) of SSTs. CONCLUSION: Our analysis showed that clinical features of AI do not reliably predict SST outcomes. We advocate careful assessment of the pre-test probability of AI in patients referred for SST. A pre-test cortisol level can reduce the number of SSTs, with cost savings implications.

Aminoglycoside-associated acute kidney injury in elderly patients with and without shock.

OBJECTIVES: Multiresistant Gram-negative pathogens pose major healthcare concerns with a limited therapeutic armamentarium. Aminoglycosides (AG) are under-utilized due to nephrotoxicity. We aimed to evaluate AG-associated acute kidney injury (AG-AKI) in elderly inpatients, with and without shock. METHODS: We examined the incidence and predictors of AG-AKI by KDIGO criteria and extended renal dysfunction (ERD) in patients aged >60 years. ERD represented a composite of hospital mortality or absence of renal recovery over 6 months following AG-AKI. RESULTS: Two hundred and seventy-eight patients (aged 74 ±â€Š8 years) were studied; 43% and 19% received >7 and >10 days of AG therapy, respectively, and 70% gentamicin (versus amikacin). Thirteen per cent had shock and 17% developed AG-AKI. Comparing all patients with shock versus no shock, AG-AKI developed in 33% versus 14%, respectively (P = 0.005); correspondingly among 47 patients with AG-AKI, more with shock had stage 2/3 AKI (92% versus 43%) and dialysis (50% versus 9%) (P < 0.01), but more had other strong AKI confounders than AG therapy alone (83% versus 40%, P = 0.02). Multivariate analyses identified mechanical ventilation, frusemide administration and AG therapy >10 days as predictors of AG-AKI (P < 0.05), whereas shock, pneumonia and frusemide administration predicted more severe stage 2/3 AG-AKI (P < 0.05). Hospital mortality was 30% versus 7% with AG-AKI versus none (P < 0.001). Twenty-three of 211 (11%) patients with extended analysis had ERD, with 47% experiencing renal recovery following AG-AKI. Mechanical ventilation and contrast administration during index hospitalization predicted ERD (P < 0.05). CONCLUSIONS: AG-AKI is common in the elderly, with a significant risk of ERD, but the cause and severity are greatly influenced by critical illness and shock, more so than AG therapy alone.

Predicting first-year mortality in incident dialysis patients with end-stage renal disease - the UREA5 study.

We aimed to develop a risk prediction model for first-year mortality (FYM) in incident dialysis patients with end-stage renal disease. We retrospectively examined patient comorbidities and biochemistry, prior to dialysis initiation, using a single-center, prospectively maintained database from 2005-2010, and analyzed these variables in relation to FYM. A total of 983 patients were studied. 22% had left ventricular ejection fraction (LVEF) <45%. FYM was 17%, and independent predictors included URate <500 or >600 µmol/l, LVEF <45% (higher odds ratio if <30%), Age >70 years, Arteriopathies (cerebrovascular and/or peripheral-vascular diseases), serum Albumin <30 g/l, and Alkaline phosphatase >80 U/l (p < 0.05, C-statistic 0.74), and these constitute the acronym UREA5. Using linear modeling, risk weightage/integer of 3 was assigned to LVEF <30%, 2 to age >70 years, and 1 to each remaining variable. Cumulative UREA5 scores of ≤ 1, 2, 3, 4, and ≥ 5 were associated with FYM of 6, 8, 22, 31, and 46%, respectively (p < 0.0001). Increasing UREA5 scores were strongly associated with stepwise worsening of FYM after dialysis initiation.