Dept of Pulmonology, Medical Clinic 1, University Hospital Carl Gustav Carus, Fetscherstr 74, 01307 Dresden, Germany.
Eur Respir J. 2010 Sep;36(3):615-21. doi: 10.1183/09031936.00191709. Epub 2010 Jan 28.
The aim of our study was to prospectively examine adrenal function, including cosyntropin stimulation, and its prognostic value in patients with moderate community-acquired pneumonia (CAP). 59 consecutive adult patients hospitalised on normal wards because of CAP were enrolled. A cosyntropin stimulation test was performed and serum concentrations of C-reactive protein, procalcitonin, interleukin-6, tumour necrosis factor-α, ACTH, cortisol, dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulfate (DHEAS) were measured. Predefined outcome parameters were clinical instability after 72 h, mortality and combined intensive care unit (ICU) admission or mortality. Critical illness-related corticosteroid insufficiency (CIRCI) occurred in six patients (10.3%). Cortisol, age-corrected DHEA, ACTH and the DHEA/DHEAS ratio were elevated in patients remaining unstable after 72 h. In multivariate analysis, cortisol (p = 0.03), ACTH (p = 0.04) and the pneumonia severity index (PSI) score (p = 0.005) independently predicted clinical instability after 72 h, and only cortisol predicted mortality (p = 0.04) and combined ICU-admission or mortality (p = 0.006). The predictive value of serum cortisol after receiver operating characteristic curve analysis equalled that of the PSI score. Patients with serum cortisol >734 nmol·L(-1) had a high probability for mortality (OR 38.3; p = 0.002). CIRCI is rare in patients with moderate CAP. Adrenal function is related to the prognosis of CAP. The diagnostic accuracy of serum cortisol equals that of the PSI score. Serum cortisol should be evaluated within clinical prediction scores on larger studies.
我们的研究目的是前瞻性地检查肾上腺功能，包括促肾上腺皮质激素刺激试验，并评估其在社区获得性肺炎（CAP）患者中的预后价值。共纳入 59 例因 CAP 入住普通病房的成年患者。进行促肾上腺皮质激素刺激试验，并检测血清 C 反应蛋白、降钙素原、白细胞介素 6、肿瘤坏死因子-α、促肾上腺皮质激素、皮质醇、脱氢表雄酮（DHEA）和硫酸脱氢表雄酮（DHEAS）的浓度。预设的结局参数为 72 小时后临床不稳定、死亡率以及综合重症监护病房（ICU）入住或死亡。6 例患者（10.3%）发生危重病相关皮质激素不足（CIRCI）。72 小时后仍不稳定的患者中，皮质醇、校正年龄后的 DHEA、ACTH 和 DHEA/DHEAS 比值升高。多变量分析显示，皮质醇（p = 0.03）、ACTH（p = 0.04）和肺炎严重指数（PSI）评分（p = 0.005）独立预测 72 小时后的临床不稳定，只有皮质醇预测死亡率（p = 0.04）和综合 ICU 入住或死亡率（p = 0.006）。接受者操作特征曲线分析后，血清皮质醇的预测价值与 PSI 评分相当。血清皮质醇>734 nmol·L(-1)的患者死亡率高（OR 38.3；p = 0.002）。中度 CAP 患者中 CIRCI 罕见。肾上腺功能与 CAP 的预后相关。血清皮质醇的诊断准确性与 PSI 评分相当。在更大的研究中，应在临床预测评分中评估血清皮质醇。
