Uticaj promene reaktivnosti hipotalamo-hipofizno-adrenalne osovine na ishod kod bolesnika sa sistemskim inflamatornim odgovorom
Influence of the change of the hypothalamo-pituitary-adrenal axis reactivity on the outcome in patients with systemic inflammatory response
Author
Bjekić Macut, Jelica D.Mentor
Žarković, MilošCommittee members
Lalić, NebojšaVujović, Svetlana
Ignjatović, Svetlana

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Uvod: Sindrom sistemskog inflamatornog odgovora (SIRS) predstavlja inflamatorno stanje
uzrokovano infekcijom ili sepsom i koje se širi na ceo organizam. SIRS se smatra delom
„citokinske oluje“ i manifestuje se disregulacijom različiutih citokina. Ozbiljnost bolesti se
najbolje prediktuje korišćenjem APACHE II skora (Acute Physiology and Chronic Health
Evaluation II) dok se ishod kod pacijenta, odnosno organska disfunkcija ili insuficijencija
prediktuje pomoću SOFA skora (Sequential Organ Failure Assessment). SIRS dovodi do
značajnih promena u dinamici kortizola ukazujući na disocijaciju između adrenalnog
korteksa i hipotalamo-hipofizne jedinice. Navedena promena se manifestuje visokim
koncentracijama kortizola i ACTH odmah nakon početka SIRS-a. Međutim, nekoliko dana
kasnije, ACTH se spušta do veoma niskih koncentracija dok koncentracije kortizola ostaju
visoke. Navedeno se objašnjava direktnim efektom citokina, kao što je interleukin 6 (IL-6),
na koru nadbubrega koji stimulišu oslobađ...anje glukokortikoida. Odgovor kortizola na
stimulaciju sa ACTH predstavlja važan prediktor ishoda kod kritično bolesnih. Bolesnici sa
neadekvatnim odgovorom kortizola na stimulaciju sa ACTH imaju visoku stopu
mortaliteta. Stimulacija sa 250 μg ACTH se smatra zlatnim standardom u proceni adrenalne
funkcije. Međutim, niskodozni test sa 1 μg ACTH (NDT) predstavlja senzitivniji test u
detekciji specifičnih formi adrenalne insuficijencije kao što je hipotalamo-hipofizna
disfunkcija. Upotreba NDT u kritično obolelih nije jasno definisana jer postoji mali broj
podataka za formiranje jasne preporuke...
Introduction: Systemic inflammatory response syndrome (SIRS) represens inflamatory
condition caused bz infection or sepsis that spreads all over the body. SIRS is considered a
part of the „cytokine storm“ and is manifested by dysregulation of different cytokines. The
severity of the disease is best predicted using Acute Physiology and Chronic Health
Evaluation II (APACHE II) score while the patient’s outcome, namely organ
dysfunction/failure during Intensive Care Unit (ICU) monitoring is predicted using
Sequential Organ Failure Assessment (SOFA) score. SIRS leads to significant changes in
cortisol dynamics indicating on the disociation between adrenal cortex and the
hypothalamo-pituitary unit. This is manifested by the very high concentrations of cortisol
and ACTH immediatly after commencement of SIRS. However, a few days later ACTH
falls to the very low concentration while the concentrations of cortisol remains high. This is
explained by direct effect of cytokines, as it is interleuki...n 6 (IL-6), on the adrenal cortex
that is simulating glucocorticoid realease. Cortisol response on the stimulation with ACTH
was shown to be important predictor of the outcome in critically ill patients. Patients with
inadequate cortisol response on stimulation with ACTH had high mortality rate.
Stimulation with 250 μg of ACTH is considered to be gold standard test for the assessment
of adrenal function. However, the low-dose (1 μg) test (LDT) represents a more sensitive
test for detecting specific forms of adrenal insufficiency as it is hypothalamo-pituitary
disfunction. The use of LDT in critically ill patients is not clearly defined as the data on
LDT are limited and not sufficient for the clear recommendation...