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1.
BMJ Case Rep ; 12(8)2019 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-31466957

RESUMO

A 45-year-old man presented with a 3-month history of involuntary weight loss, anorexia, postural dizziness and intermittent fever. On investigation, he was found to have parathyroid hormone (PTH)-independent hypercalcaemia, with negative workup for 25-hydroxyvitamin D or 1,25-dihydroxyvitamin D excess, thyrotoxicosis, multiple myeloma and bony metastases. On further evaluation, he was detected to have primary hypoadrenalism with bilateral adrenal enlargement, secondary to adrenal histoplasmosis. Hypercalcaemia improved with hydration and physiological steroid replacement even before initiation of antifungal therapy, confirming adrenal insufficiency as the cause for hypercalcaemia. Hypercalcaemia resulting from hypoadrenalism secondary to adrenal histoplasmosis is rare and should be suspected whenever evaluating a patient with PTH-independent hypercalcaemia.


Assuntos
Insuficiência Adrenal/etiologia , Histoplasmose/diagnóstico por imagem , Hipercalcemia/etiologia , Insuficiência Adrenal/tratamento farmacológico , Biópsia , Diagnóstico Diferencial , Fludrocortisona/administração & dosagem , Fludrocortisona/uso terapêutico , Hidratação , Histoplasmose/complicações , Histoplasmose/tratamento farmacológico , Histoplasmose/terapia , Humanos , Hipercalcemia/terapia , Masculino , Pessoa de Meia-Idade , Prednisolona/administração & dosagem , Prednisolona/uso terapêutico , Tomografia Computadorizada por Raios X , Resultado do Tratamento
2.
Blood Purif ; 48(3): 272-275, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31291617

RESUMO

Peritoneal dialysis (PD)-related peritonitis is one of the most important factors affecting the long-term success of PD. Adrenal insufficiency is a clinical manifestation of inadequate production of glucocorticoids with accompanying deficiency of mineralocorticoids and adrenal androgens. We present a 58-year-old PD patient who admitted to hospital with fever, abdominal pain, vomiting, and confusion. The patient was treated with cephazolin and ceftazidime after the confirmation of peritonitis. Despite the resolution of peritonitis after 2 weeks with appropriate antibiotic treatment, the patient continued to suffer from vomiting, hypotension, and confusion. After the evaluation of basal serum cortisol and 250 µg ACTH stimulation test, the patient had been diagnosed as adrenal insufficiency and treated with fludrocortisone 0.1 mg/day. Patients remaining vomiting, hypotension, and confusion symptoms were corrected after the fludrocortisone therapy. Following 2 months of successful treatment of adrenal insufficiency, the patient had adherence problem with fludrocortisone for 3-4 weeks. On an outpatient visit, serum ACTH and cortisol levels were normal despite the discontinuation of fludrocortisone and so the patient had been evaluated as partial adrenal insufficiency secondary to PD-related peritonitis. In conclusion, adrenal insufficiency should be kept in mind in PD patients suffering from hypotension and peritonitis.


Assuntos
Insuficiência Adrenal/etiologia , Peritonite/complicações , Insuficiência Adrenal/tratamento farmacológico , Antibacterianos/uso terapêutico , Fludrocortisona/uso terapêutico , Humanos , Pessoa de Meia-Idade , Diálise Peritoneal/efeitos adversos , Peritonite/tratamento farmacológico , Peritonite/etiologia , Resultado do Tratamento
3.
BMJ Case Rep ; 12(5)2019 May 28.
Artigo em Inglês | MEDLINE | ID: mdl-31142485

RESUMO

Primary adrenal insufficiency (PAI) is a potentially fatal disease. Adrenal tuberculosis(TB) causing PAI is rare in the developed world. We present a seemingly well, 78-year-old Caucasianwoman in the UK who developed adrenal crisis following elective hip surgery. Biochemical tests confirmed PAI and steroid replacement was initiated. Imaging of the abdomen demonstrated bilateral adrenal masses and a fluorodeoxyglucose positron emission tomography (FDG-PET) scan showed increased uptake in both adrenals suggestive of malignancy. Following a retroperitoneoscopic left adrenalectomy, histology showed caseating necrosis with xanthogranulomatous inflammation favouring a diagnosis of TB. She was commenced on anti-TB treatment. Diagnosing adrenal TB in the west can be challenging especially in the absence of extra-adrenal TB. FDG-PET scans can be falsely positive in presence of chronic active inflammatory conditions, such as TB, and a tissue diagnosis is required. It is important that clinicians remain vigilant of this important disease, which can masquerade as malignancy.


Assuntos
Doenças das Glândulas Suprarrenais/diagnóstico por imagem , Tuberculose Endócrina/diagnóstico por imagem , Doença de Addison/diagnóstico por imagem , Doença de Addison/tratamento farmacológico , Idoso , Antituberculosos/uso terapêutico , Diagnóstico Diferencial , Quimioterapia Combinada , Feminino , Fludrocortisona/uso terapêutico , Fluordesoxiglucose F18 , Humanos , Hidrocortisona/uso terapêutico , Imagem Multimodal , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons , Compostos Radiofarmacêuticos , Doenças Raras , Tomografia Computadorizada por Raios X
4.
Probl Endokrinol (Mosk) ; 65(1): 39-45, 2019 05 14.
Artigo em Russo | MEDLINE | ID: mdl-31091049

RESUMO

We report a case of cerebral salt-wasting syndrome in a 12-year-old boy with severe traumatic brain injury. The child developed refractory intracranial hypertension at the time of injury, which required decompressive craniectomy on the 7th day after injury. Infusion of hypertonic sodium chloride solutions performed at the intensive care unit resulted in hypernatremia on the 5th day and polyuria and hypovolemia on the 11th day, which was regarded as manifestations of central diabetes insipidus. Persistent hyponatremia developed on the 17th day after injury; on the next day, the therapy was supplemented with Fludrocortisone at a dose of 100 µg/day, followed by an increase in the dose to 150 µg/day, which had no significant effect. Fludrocortisone was discontinued on the 30th day of therapy, but it was re-used at a dose of 400 µg/day from the 54th day. During this treatment, polyuria gradually decreased to 4 to 5 l/day, and the plasma sodium concentration remained within the reference values. The dose of Fludrocortisone was increased to 600 µg/day since the 66th day. The child was transferred to a specialized department on the 67th day after injury. At the Department of Neurosurgery, the dose of Cortineff was gradually reduced starting with the 94th day and completely discontinued on the 122nd day after injury. On day 132th of the post-traumatic period, the patient was transferred to another hospital for rehabilitation therapy.


Assuntos
Lesões Encefálicas Traumáticas/patologia , Hiponatremia/etiologia , Poliúria/etiologia , Sódio/sangue , Anti-Inflamatórios/administração & dosagem , Anti-Inflamatórios/uso terapêutico , Lesões Encefálicas Traumáticas/sangue , Lesões Encefálicas Traumáticas/complicações , Criança , Fludrocortisona/administração & dosagem , Fludrocortisona/análogos & derivados , Fludrocortisona/uso terapêutico , Humanos , Hiponatremia/tratamento farmacológico , Masculino , Poliúria/tratamento farmacológico
5.
BMJ Case Rep ; 12(2)2019 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-30814097

RESUMO

A 24-year-old man with no significant medical history presented to the medical clinic with vomiting and giddiness for 2 days, loss of appetite for 1 month and progressive fatigability for the preceding 4 months. On examination, he was found to be hypotensive and was admitted to the hospital for work-up. Considering his abnormal labs and physical findings, he was worked up and was diagnosed with primary adrenal insufficiency. On further work-up for the aetiology of his Addison's disease, he was found to have concurrent autoimmune thyroiditis and vitiligo. A final diagnosis of autoimmune polyglandular syndrome type 2 was made. The patient was started on hormone replacement therapy and reported improvement of symptoms on 3-month follow-up visit.


Assuntos
Poliendocrinopatias Autoimunes/diagnóstico , Adulto , Anti-Inflamatórios , Diagnóstico Diferencial , Fludrocortisona/uso terapêutico , Humanos , Hidrocortisona/uso terapêutico , Masculino , Poliendocrinopatias Autoimunes/sangue , Poliendocrinopatias Autoimunes/tratamento farmacológico , Glândula Tireoide/diagnóstico por imagem , Tireotropina/sangue , Tiroxina/uso terapêutico , Resultado do Tratamento , Ultrassonografia , Adulto Jovem
6.
BMJ Case Rep ; 12(3)2019 Mar 07.
Artigo em Inglês | MEDLINE | ID: mdl-30850564

RESUMO

Hyponatraemia is a common electrolyte disturbance with multiple causes. We present a case of a 49-year-old Caucasian female with cholangiocarcinoma, who had a hyponatraemia which was initially assumed to be based on a syndrome of inappropriate antidiuretic hormone secretion as paraneoplastic phenomenon. At physical examination, hyperpigmentation was seen and multiple episodes with syncope were reported. Subsequent endocrine assessment with a synthetic adrenocorticotropin hormone (ACTH) stimulation test and measurement of ACTH levels revealed primary adrenal insufficiency also known as Morbus Addison. We started hydrocortisone and fludrocortisone replacement therapy, resulting in resolving of symptoms, hyponatraemia and hyperpigmentation.


Assuntos
Doença de Addison/diagnóstico , Hiperpigmentação/diagnóstico , Hiponatremia/diagnóstico , Doença de Addison/tratamento farmacológico , Doença de Addison/etiologia , Hormônio Adrenocorticotrópico/análise , Anti-Inflamatórios/uso terapêutico , Colangiocarcinoma/complicações , Diagnóstico Diferencial , Evolução Fatal , Feminino , Fludrocortisona/administração & dosagem , Fludrocortisona/uso terapêutico , Humanos , Hidrocortisona/administração & dosagem , Hidrocortisona/uso terapêutico , Hiperpigmentação/etiologia , Hiponatremia/etiologia , Síndrome de Secreção Inadequada de HAD/complicações , Pessoa de Meia-Idade , Síndromes Paraneoplásicas/complicações
7.
BMJ Case Rep ; 12(1)2019 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-30700462

RESUMO

We report a case of a 10-day-old male infant who presented to the emergency department with severe electrolyte imbalance and life-threatening arrhythmia. The parents reported a 3-day history of poor feeding and lethargy. On examination, he was bradycardic (heart rate of 65 beats/min) with signs of dehydration. His ECG showed broad complex bradycardia. Blood gas showed metabolic acidosis with hyponatraemia and hyperkalaemia. A probable diagnosis of congenital adrenal hyperplasia (CAH) with salt-wasting crisis was made and treatment was commenced. He was given saline bolus, nebulised salbutamol, calcium gluconate and hydrocortisone. Following the above interventions, his heart rate rose to 150 beats/min with a regular sinus rhythm within a period of 40 min. The diagnosis of CAH secondary to 21-hydroxylase deficiency with mutation in CYP21A2 was confirmed by genetic studies. He was discharged home with hydrocortisone, fludrocortisone and sodium chloride.


Assuntos
Hiperplasia Suprarrenal Congênita/complicações , Arritmias Cardíacas/complicações , Desequilíbrio Hidroeletrolítico/complicações , Hiperplasia Suprarrenal Congênita/diagnóstico , Hiperplasia Suprarrenal Congênita/terapia , Anti-Inflamatórios/uso terapêutico , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/terapia , Diagnóstico Diferencial , Fludrocortisona/uso terapêutico , Humanos , Hidrocortisona/uso terapêutico , Recém-Nascido , Masculino , Cloreto de Sódio/uso terapêutico , Desequilíbrio Hidroeletrolítico/diagnóstico , Desequilíbrio Hidroeletrolítico/terapia
8.
A A Pract ; 12(3): 63-65, 2019 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-30020102

RESUMO

Acute adrenal insufficiency is a rare but potentially life-threatening event during the perioperative period. The usual manifestations of an acute adrenal crisis can mimic common postoperative complications and a high index of suspicion is required for the diagnosis. Early diagnosis and prompt treatment can be lifesaving. We present the case of a 65-year-old man who, after a partial nephrectomy, developed acute adrenal insufficiency, which remained undiagnosed in the postoperative period, eventually leading to cardiac arrest. This case highlights the need for perioperative physicians to have a watchful eye for diagnosing and treating this uncommon yet lethal condition.


Assuntos
Insuficiência Adrenal/etiologia , Parada Cardíaca/etiologia , Nefrectomia/efeitos adversos , Insuficiência Adrenal/complicações , Idoso , Diagnóstico Precoce , Fludrocortisona/uso terapêutico , Parada Cardíaca/tratamento farmacológico , Humanos , Hidrocortisona/uso terapêutico , Masculino , Resultado do Tratamento
11.
Indian J Pediatr ; 86(2): 154-158, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30097840

RESUMO

OBJECTIVES: To retrospectively assess growth of children with congenital adrenal hyperplasia (CAH) with special reference to puberty and to assess longitudinal growth and final height of subset of children with CAH. METHODS: A retrospective analysis of 30 children (14 boys) with classic CAH (11 salt wasters, 19 simple virilisers) followed up for a mean duration of 9.9 ± 2.4 y (Study period December 2002 through December 2016) was performed. Height Z scores, target height Z scores, height velocities and laboratory parameters were analysed. RESULTS: Children were treated with hydrocortisone in a mean dose of 15.7 ± 3.3 mg/m2/d. Mean 17-hydroxy progesterone in boys and girls were 10.8 ± 6.7 ng/ml and 11.3 ± 9.3 ng/ml respectively. Fifteen children (7 boys) developed central precocious puberty at mean age of 7.6 ± 1.8 y and 13 were treated with GnRH analogues for 3.5 y. Of all patients, 18 (10 girls, 8 boys) reached final height at a mean age of 14.2 ± 1.6 y. Mean final height achieved was 158.0 ± 8.5 cm in boys [target height (TH) -165.5 ± 3.8 cm] and in girls it was 149.9 ± 6.7 cm [target height (TH) 154.7 ± 6.4 cm]. Final height standard deviation scores (SDS) for boys and girls were - 2.06 ± 1.1 (TH-SDS -1.06 ± 0.5) and - 1.47 ± 1.1 (TH-SDS -0.56 ± 1.2) respectively and were not significantly different from target height Z scores (p > 0.05). Growth velocity was attenuated during pubertal years. CONCLUSIONS: Monitoring growth and puberty in children with CAH is critical for optimizing final height.


Assuntos
Hiperplasia Suprarrenal Congênita/complicações , Fludrocortisona/uso terapêutico , Crescimento/efeitos dos fármacos , Crescimento/fisiologia , Hidrocortisona/uso terapêutico , 17-alfa-Hidroxiprogesterona/sangue , Administração Oral , Adolescente , Hormônio Adrenocorticotrópico/sangue , Estatura/efeitos dos fármacos , Estatura/fisiologia , Índice de Massa Corporal , Criança , Eletrólitos/sangue , Feminino , Humanos , Índia , Masculino , Progesterona/sangue , Estudos Retrospectivos , Fatores Sexuais , Maturidade Sexual/efeitos dos fármacos , Testosterona/sangue , Resultado do Tratamento
13.
J Pediatr Endocrinol Metab ; 31(9): 1019-1022, 2018 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-30173205

RESUMO

Background The dose of hydrocortisone therapy required to maintain normal growth in infants with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is lower than in later childhood. This reflects the presence of excess non-aromatisable rather than aromatisable androgen but there has been relatively little focus on the role of mineralocorticoid therapy. Methods Growth data of infants with CAH due to 21-hydroxylase deficiency (2008-2016) were reviewed and information regarding hydrocortisone and fludrocortisone regimen was collected. Change in height standard deviation (SD) and height velocity standard deviation score (SDS) were analysed during the first year of life. Results Growth data from 13 children (8 M) were analysed. Height (length) declined from a median of -0.69 SD at 3 months to -1.23 SD at 12 months with a reduction in height velocity SDS from 0.02 between 3 and 6 months to -2.22 between 9 and 12 months (p=0.017) despite a hydrocortisone dose at the lower end of the range as recommended in consensus guidelines. The glucocorticoid activity of hydrocortisone and fludrocortisone was negatively associated with growth velocity (r=-0.55; p=0.049) although renin activity was not suppressed. Conclusions Infants with 21-hydroxylase deficiency can be managed with replacement hydrocortisone. The reasons for this paradigm are now understood although our data confirm that the glucocorticoid activity of fludrocortisone needs to be taken into consideration as well.


Assuntos
Hiperplasia Suprarrenal Congênita/tratamento farmacológico , Estatura/fisiologia , Desenvolvimento Infantil/fisiologia , Fludrocortisona/uso terapêutico , Glucocorticoides/uso terapêutico , Hidrocortisona/uso terapêutico , Hiperplasia Suprarrenal Congênita/fisiopatologia , Feminino , Terapia de Reposição Hormonal , Humanos , Lactente , Masculino , Resultado do Tratamento
14.
J Med Case Rep ; 12(1): 212, 2018 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-30012213

RESUMO

BACKGROUND: Combined central diabetes insipidus and cerebral salt wasting syndrome is a rare clinical finding. However, when this happens, mortality is high due to delayed diagnosis and/or inadequate treatment. CASE PRESENTATION: A 42-year-old white man was referred to neurosurgery due to a non-functional pituitary macroadenoma. He underwent a partial resection of the tumor on July 2, 2015. On the day following surgery he presented polyuria with sodium 149 mEq/L, plasma osmolality 301 mOsm/kg, and urine osmolality 293 mOsm/kg. He started nasal desmopressin 0.05 mg/day with good response. He was already on dexamethasone 4 mg and levothyroxine 75 mcg due to hypopituitarism after surgery. On July 9 he became confused. Cerebral computed tomography was performed with no significant changes. His natremia dropped to 128 mEq/L with development of polyuria despite maintenance of desmopressin dose. His hemoglobin and hematocrit rose from 9.1 g/L to 11.6 g/L and 27.5 to 32.5, respectively. His thyroid function was normal and he was on hydrocortisone 30 mg/day. At 12 p.m. 150 mg/hydrocortisone infusion was initiated, but sodium did not increase. Plasma and urine osmolality were 264 mOsm/kg and 679 mOsm/kg, respectively. At 4 p.m. hydrocortisone was increased and hypertonic saline replacement started. Two hours later he was dehydrated with polyuria and vomiting, and natremia of 124 mEq/L. Hyponatremia was very resistant to treatment despite hypertonic saline replacement, hence desmopressin was suspended. The following day, urine spot analysis showed that natriuresis was 63 mEq/L with serum sodium 132 mEq/L. This was interpreted as a cerebral salt wasting syndrome and control was achieved with aggressive hypertonic saline replacements and fludrocortisone 0.1 mg/three times a day. CONCLUSIONS: We present a rare case of a patient with diabetes insipidus and cerebral salt wasting syndrome, who was successfully treated. Hyponatremia in a patient with diabetes insipidus may erroneously be interpreted as inadequate diabetes insipidus control or as syndrome of inappropriate antidiuretic hormone secretion, leading to therapeutic errors. Thus, all clinical and analytical data should be evaluated together for early and correct diagnosis.


Assuntos
Adenoma/cirurgia , Diabetes Insípido Neurogênico/terapia , Hiponatremia/terapia , Hipopituitarismo/terapia , Neoplasias Hipofisárias/cirurgia , Solução Salina Hipertônica/uso terapêutico , Adenoma/complicações , Adulto , Diabetes Insípido Neurogênico/complicações , Fludrocortisona/uso terapêutico , Humanos , Hiponatremia/sangue , Hiponatremia/etiologia , Hipofisectomia/efeitos adversos , Hipopituitarismo/etiologia , Masculino , Mineralocorticoides/uso terapêutico , Neoplasias Hipofisárias/complicações , Sódio/sangue , Síndrome
16.
Blood Press ; 27(5): 304-312, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29742971

RESUMO

BACKGROUND: Primary aldosteronism (PA) is the most common cause of secondary hypertension and bilateral adrenal hyperplasia (BAH) and aldosterone-producing adenoma (APA) seem to be the most common causes of PA. Unilateral adrenalectomy (UA) is the preferred treatment for APA, although the benefits are still difficult to assess. CASE REPORT: We present a case report of a 69-year old man with a 30 year history of hypertension and probably long-standing PA due to APA, with typical organ complications. Since repeated abdominal CT scans were equivocal, not showing radiological changes characteristic for PA, the diagnosis of APA was delayed and was only finally confirmed by adrenal venous sampling which demonstrated unilateral aldosteronism. The patient underwent UA, complicated by mineralocorticoid deficiency syndrome and increased creatinine and potassium levels. At 12 months follow-up the patient still had hyperkalemia and was fludrocortisone dependent. CONCLUSIONS: Older patients and patients with long-lasting PA who are treated with UA may demonstrate deterioration of renal function and develop transient or persistent insufficiency of the zona glomerulosa of the remaining adrenal gland necessitating fludrocortisone supplementation. Transient hyperkalemia may be observed following UA as a result of the prolonged effects of aldosterone antagonists and/or transient mineralocorticoid/glucocorticoid insufficiency. Additionally, the level of progression of chronic kidney disease after UA is difficult to predict. There likely exists a group of patients who might paradoxically have higher cardiovascular risk due to significant deterioration in kidney function not only resulting from the removal of the aldosterone induced glomerular hyperfiltration phenomenon. Identification of such a group requires further detailed investigation.


Assuntos
Córtex Suprarrenal/fisiopatologia , Adrenalectomia/efeitos adversos , Insuficiência Renal/etiologia , Zona Glomerulosa/fisiopatologia , Idoso , Anti-Inflamatórios , Fludrocortisona/uso terapêutico , Humanos , Hiperaldosteronismo/complicações , Hiperpotassemia/etiologia , Hipertensão/complicações , Masculino
17.
J Clin Endocrinol Metab ; 103(6): 2336-2345, 2018 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-29584889

RESUMO

Context: Patients with congenital adrenal hyperplasia (CAH) are at risk for life-threatening adrenal crises. Management of illness episodes aims to prevent adrenal crises. Objective: We evaluated rates of illnesses and associated factors in patients with CAH followed prospectively and receiving repeated glucocorticoid stress dosing education. Methods: Longitudinal analysis of 156 patients with CAH followed at the National Institutes of Health Clinical Center over 23 years was performed. The rates of illnesses and stress-dose days, emergency room (ER) visits, hospitalizations, and adrenal crises were analyzed in relation to phenotype, age, sex, treatment, and hormonal evaluations. Results: A total of 2298 visits were evaluated. Patients were followed for 9.3 ± 6.0 years. During childhood, there were more illness episodes and stress dosing than adulthood (P < 0.001); however, more ER visits and hospitalizations occurred during adulthood (P ≤ 0.03). The most robust predictors of stress dosing were young age, low hydrocortisone and high fludrocortisone dose during childhood, and female sex during adulthood. Gastrointestinal and upper respiratory tract infections (URIs) were the two most common precipitating events for adrenal crises and hospitalizations across all ages. Adrenal crisis with probable hypoglycemia occurred in 11 pediatric patients (ages 1.1 to 11.3 years). Undetectable epinephrine was associated with ER visits during childhood (P = 0.03) and illness episodes during adulthood (P = 0.03). Conclusions: Repeated stress-related glucocorticoid dosing teaching is essential, but revised age-appropriate guidelines for the management of infectious illnesses are needed for patients with adrenal insufficiency that aim to reduce adrenal crises and prevent hypoglycemia, particularly in children.


Assuntos
Hiperplasia Suprarrenal Congênita/tratamento farmacológico , Insuficiência Adrenal/tratamento farmacológico , Fludrocortisona/uso terapêutico , Hidrocortisona/uso terapêutico , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Progressão da Doença , Feminino , Glucocorticoides/uso terapêutico , Humanos , Lactente , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Fenótipo , Fatores Sexuais , Adulto Jovem
18.
N Engl J Med ; 378(9): 809-818, 2018 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-29490185

RESUMO

BACKGROUND: Septic shock is characterized by dysregulation of the host response to infection, with circulatory, cellular, and metabolic abnormalities. We hypothesized that therapy with hydrocortisone plus fludrocortisone or with drotrecogin alfa (activated), which can modulate the host response, would improve the clinical outcomes of patients with septic shock. METHODS: In this multicenter, double-blind, randomized trial with a 2-by-2 factorial design, we evaluated the effect of hydrocortisone-plus-fludrocortisone therapy, drotrecogin alfa (activated), the combination of the three drugs, or their respective placebos. The primary outcome was 90-day all-cause mortality. Secondary outcomes included mortality at intensive care unit (ICU) discharge and hospital discharge and at day 28 and day 180 and the number of days alive and free of vasopressors, mechanical ventilation, or organ failure. After drotrecogin alfa (activated) was withdrawn from the market, the trial continued with a two-group parallel design. The analysis compared patients who received hydrocortisone plus fludrocortisone with those who did not (placebo group). RESULTS: Among the 1241 patients included in the trial, the 90-day mortality was 43.0% (264 of 614 patients) in the hydrocortisone-plus-fludrocortisone group and 49.1% (308 of 627 patients) in the placebo group (P=0.03). The relative risk of death in the hydrocortisone-plus-fludrocortisone group was 0.88 (95% confidence interval, 0.78 to 0.99). Mortality was significantly lower in the hydrocortisone-plus-fludrocortisone group than in the placebo group at ICU discharge (35.4% vs. 41.0%, P=0.04), hospital discharge (39.0% vs. 45.3%, P=0.02), and day 180 (46.6% vs. 52.5%, P=0.04) but not at day 28 (33.7% and 38.9%, respectively; P=0.06). The number of vasopressor-free days to day 28 was significantly higher in the hydrocortisone-plus-fludrocortisone group than in the placebo group (17 vs. 15 days, P<0.001), as was the number of organ-failure-free days (14 vs. 12 days, P=0.003). The number of ventilator-free days was similar in the two groups (11 days in the hydrocortisone-plus-fludrocortisone group and 10 in the placebo group, P=0.07). The rate of serious adverse events did not differ significantly between the two groups, but hyperglycemia was more common in hydrocortisone-plus-fludrocortisone group. CONCLUSIONS: In this trial involving patients with septic shock, 90-day all-cause mortality was lower among those who received hydrocortisone plus fludrocortisone than among those who received placebo. (Funded by Programme Hospitalier de Recherche Clinique 2007 of the French Ministry of Social Affairs and Health; APROCCHSS ClinicalTrials.gov number, NCT00625209 .).


Assuntos
Anti-Inflamatórios/uso terapêutico , Fludrocortisona/uso terapêutico , Hidrocortisona/uso terapêutico , Choque Séptico/tratamento farmacológico , Idoso , Anti-Inflamatórios/efeitos adversos , Causas de Morte , Terapia Combinada , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Fludrocortisona/efeitos adversos , Humanos , Hidrocortisona/efeitos adversos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Recidiva , Terapia de Substituição Renal , Respiração Artificial , Choque Séptico/complicações , Choque Séptico/mortalidade , Choque Séptico/terapia , Escala Psicológica Aguda Simplificada , Análise de Sobrevida , Resultado do Tratamento
19.
Pediatr Transplant ; 22(2)2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29345400

RESUMO

Calcineurin inhibitors post-renal transplantation are recognized to cause tubulopathies in the form of hyponatremia, hyperkalemia, and acidosis. Sodium supplementation may be required, increasing medication burden and potentially resulting in poor compliance. Fludrocortisone has been beneficial in addressing tubulopathies in adult studies, with limited paediatric data available. A retrospective review of data from an electronic renal database from December 2014 to January 2016 was carried out. Forty-seven post-transplant patients were reviewed with 23 (49%) patients on sodium chloride or bicarbonate. Nine patients, aged 8.3 years (range 4.9-16.4), commenced fludrocortisone 22 months (range 1-80) after transplant and were followed up for 9 months (range 2-20). All patients stopped sodium bicarbonate; all had a reduction or no increase in total daily doses of sodium chloride. Potassium levels were significantly lower on fludrocortisone, 5.2 vs 4.5 mmol/L, P = .04. No difference was noted in renal function (eGFR 77.8 vs 81.7 mL/min/1.73 m2 , P = .45) and no significant increase in systolic blood pressure (z-scores 0.99 vs 0.85, P = .92). No side effects secondary to treatment with fludrocortisone were reported. A significant proportion of renal transplant patients were on sodium supplementation and fludrocortisone reduced sodium supplementation without significant effects on renal function or blood pressure. Fludrocortisone appears to be safe and effective for tubulopathies in children post-transplantation.


Assuntos
Anti-Inflamatórios/uso terapêutico , Fludrocortisona/uso terapêutico , Nefropatias/tratamento farmacológico , Transplante de Rim , Túbulos Renais/fisiopatologia , Complicações Pós-Operatórias/tratamento farmacológico , Adolescente , Criança , Pré-Escolar , Esquema de Medicação , Feminino , Seguimentos , Humanos , Nefropatias/etiologia , Nefropatias/fisiopatologia , Masculino , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos
20.
World Neurosurg ; 109: 222-229, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28987848

RESUMO

BACKGROUND: Current guidelines for the management of hyponatremia in patients with subarachnoid hemorrhage (SAH) are not based on a systematic assessment of the literature. We evaluated published studies on the efficacy and safety of current preventative and treatment strategies for hyponatremia in patients with SAH. METHODS: We searched the Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and PubMed for relevant studies. Primary outcomes of interest included neurologic functional outcomes, symptomatic vasospasm, and others. Secondary outcomes included measures of sodium and volume status. RESULTS: We included 5 out of 117 identified studies: 1 before-and-after observational trial (using fludrocortisone) and 4 randomized controlled trials (2 using fludrocortisone; 2 using hydrocortisone). All 5 trials had a high risk of bias in at least 1 domain. We could not perform a meta-analysis of functional outcomes; however, individual studies did not demonstrate statistically significant differences. Mineralocorticoid use did not statistically significantly reduce the incidence of symptomatic vasospasm (relative risk, 0.60; 95% confidence interval, 0.35-1.03; I2 = 0%). The studies did not report other primary outcomes. In the 4 RCTs, mineralocorticoid use reduced natriuresis and volume contraction. CONCLUSIONS: Current evidence does not demonstrate a benefit of preventative treatment with mineralocorticoids in clinically important outcomes, although a difference cannot be ruled out due to imprecision. Larger well-designed trials are needed to establish the impact of mineralocorticoids and fluid and sodium supplementation strategies on clinically relevant outcomes in the prevention and treatment of hyponatremia in patients with SAH.


Assuntos
Hiponatremia/tratamento farmacológico , Hiponatremia/prevenção & controle , Hemorragia Subaracnóidea/complicações , Fludrocortisona/uso terapêutico , Humanos , Hidrocortisona/uso terapêutico , Hiponatremia/etiologia , Resultado do Tratamento , Vasoespasmo Intracraniano/tratamento farmacológico , Vasoespasmo Intracraniano/etiologia , Vasoespasmo Intracraniano/prevenção & controle
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