Abstract
BackgroundCortisol levels in response to stress are highly variable. Baseline and stimulated cortisol levels are commonly used to determine adrenal function following unilateral adrenalectomy. We report the results of synacthen stimulation testing following unilateral adrenalectomy in a tertiary referral center.MethodsData were collected retrospectively for 36 patients who underwent synacthen stimulation testing one day post unilateral adrenalectomy. None of the patients had clinical signs of hypercortisolism preoperatively. No patient received pre- or intraoperative steroids. Patients with overt Cushing’s syndrome were excluded.ResultsThe median age was 58 (31-79) years. Preoperatively, 16 (44%) patients had a diagnosis of pheochromocytoma, 12 (33%) patients had primary aldosteronism and 8 (22%) patients had non-functioning adenomas with indeterminate/atypical imaging characteristics necessitating surgery. Preoperative overnight dexamethasone suppression test results revealed that 6 of 29 patients failed to suppress cortisol to <50 nmol/L. Twenty (56%) patients achieved a stimulated cortisol ≥450 nmol/L at 30 minutes and 28 (78%) at 60 minutes. None of the patients developed clinical adrenal insufficiency necessitating steroid replacement.ConclusionsSynacthen stimulation testing following unilateral adrenalectomy using standard stimulated cortisol cut-off values would wrongly label many patients adrenally insufficient and may lead to inappropriate prescriptions of steroids to patients who do not need them.
Highlights
Adrenal insufficiency (AI) is caused by failure of the adrenal cortex to produce adequate amounts of corticosteroids and is associated with increased morbidity and mortality [1]
The study was approved by the Imperial College Healthcare NHS Trust governance team who confirmed that as we are reporting on routinely collected non-identifiable clinical audit data, no approval from a research ethics committee was required under the UK policy framework for Health and Social Care
Sixteen (44%) patients had a diagnosis of phaeochromocytoma, 12 (33%) patients had primary aldosteronism and 8 (22%) patients had nonfunctioning lesions with indeterminate/atypical imaging characteristics necessitating surgery (Table 1)
Summary
Adrenal insufficiency (AI) is caused by failure of the adrenal cortex to produce adequate amounts of corticosteroids and is associated with increased morbidity and mortality [1]. Unilateral adrenalectomy can be a rare cause of adrenal insufficiency. Patients with unilateral adrenal cortisol-producing lesions (adrenal Cushing’s syndrome) may develop adrenal insufficiency after. Synacthen Stimulation Post Unilateral Adrenalectomy adrenalectomy due to contralateral adrenal suppression [2]. Patients with autonomous cortisol secretion (subclinical Cushing’s syndrome) are considered to be at risk of adrenal insufficiency following adrenalectomy [2]. A 30-minute stimulated cortisol level in response to intramuscular or intravenous injection of 250 micrograms of synacthen has been used as a criterion to define adrenal insufficiency [3]. SSTs alone may not be applicable in the immediate post unilateral adrenalectomy setting to reliably diagnose adrenal insufficiency [4, 5]. Baseline and stimulated cortisol levels are commonly used to determine adrenal function following unilateral adrenalectomy. We report the results of synacthen stimulation testing following unilateral adrenalectomy in a tertiary referral center
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