Tordjman K, Jaffe A, Trostanetsky Y, Greenman Y, Limor R, Stern N
Institute of Endocrinology, Tel Aviv-Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel.
Clin Endocrinol (Oxf). 2000 May;52(5):633-40. doi: 10.1046/j.1365-2265.2000.00984.x.
We have shown previously that in contrast to the standard high-dose 250-microgram ACTH test, a low-dose 1-microgram ACTH stimulation test correctly identified all patients with pituitary disease who had impaired hypothalamo-pituitary-adrenal (HPA) function. In this study we further compared the performances of these two tests as screening procedures for possible HPA impairment.
A comparison of the 1-microgram and the 250-microgram ACTH stimulation tests in healthy controls and in patients with pituitary disease whose HPA axis status was characterized formally by a gold standard test.
A total of 89 subjects were investigated: 27 healthy normal controls, 43 patients with pituitary disease and normal HPA function, and 19 patients with various pituitary diseases and impaired HPA function.
All 89 subjects underwent stimulation with 1 microgram ACTH; 80 also underwent the high-dose 250-microgram ACTH test. A receiver operating characteristic analysis (ROC) was performed to compare the tests.
Using a stimulated cortisol > 500 nmol/l as the criterion for a normal response, the 1-microgram ACTH stimulation identified 18 of the 19 subjects with impaired HPA function (94.7% sensitivity with a likelihood ratio of 0.0588 for a negative test). In contrast, 15/16 passed the high-dose test (a 6.2% sensitivity with a likelihood ratio of 0.875 for a negative test). All normal controls, and 36/43 patients with preserved HPA function, passed the 1-microgram ACTH test (90% specificity). This degree of accuracy was unrivalled by the high dose test at all the cut-off levels considered.
More sensitive and accurate, the low-dose 1-microgram ACTH test is as simple and safe as the standard 250-microgram test. We suggest it should replace it in screening for adrenal insufficiency.
我们之前已经表明，与标准的高剂量250微克促肾上腺皮质激素（ACTH）试验不同，低剂量1微克ACTH刺激试验能正确识别所有下丘脑 - 垂体 - 肾上腺（HPA）功能受损的垂体疾病患者。在本研究中，我们进一步比较了这两种试验作为可能的HPA功能受损筛查程序的性能。
对1微克和250微克ACTH刺激试验在健康对照者以及HPA轴状态通过金标准试验正式确定的垂体疾病患者中进行比较。
共调查了89名受试者：27名健康正常对照者、43名垂体疾病且HPA功能正常的患者以及19名患有各种垂体疾病且HPA功能受损的患者。
所有89名受试者均接受1微克ACTH刺激；80名还接受了高剂量250微克ACTH试验。进行了受试者操作特征分析（ROC）以比较这两种试验。
以刺激后皮质醇>500 nmol/l作为正常反应的标准，1微克ACTH刺激试验识别出19名HPA功能受损受试者中的18名（敏感性为94.7%，阴性试验似然比为0.0588）。相比之下，16名中有15名通过了高剂量试验（敏感性为6.2%，阴性试验似然比为0.875）。所有正常对照者以及43名HPA功能保留的患者中有36名通过了1微克ACTH试验（特异性为90%）。在所考虑的所有截断水平上，高剂量试验都无法达到这种准确度。
低剂量1微克ACTH试验更敏感、准确，并且与标准的250微克试验一样简单安全。我们建议在肾上腺功能不全的筛查中应使用低剂量试验取代标准试验。
