Adrenocortical suppression in children with nephrotic syndrome treated with corticosteroids

Abstract

Background: While single morning cortisol values are used for screening, an ACTH stimulation test is more definitive to identify adrenocortical suppression in children with nephrotic syndrome. Methods: This cross-sectional study enrolled children (2-18 years) with both SSNS (n=27) and SRNS (n=25); those on daily prednsiolone or having serious bacterial infections or hospitalized were excluded. The primary objective was to determine prevalence of adrenocortical suppression in those on low dose alternate day steroids for more than 8 weeks or having received >2mg/kg/d for more than 2 weeks in past 1 year and currently in remission. A baseline morning fasting sample of serum cortisol was taken and 25 IU of ACTH (Acton Prolongatum*) injected intramuscularly and repeat serum cortisol sample was taken after 1 hour. All patients with 1 hr post ACTH cortisol <18.0 µgm/dl were diagnosed with adrenal insufficiency. Receiver operating characteristic curve was drawn to predict the prednisolone dose for adrenal insufficiency. Results: 52 (33 males) children were enrolled (meanage 9.4years);proportion of adrenal insufficiency was 50% and 64% using baseline and poststimulationcutoffs. The total cumulative annual dose of prednisolone 0.22 mg/kg/day predicted adrenocortical suppression with AUC 0.76 (95% CI as 0.63-0.89), with a sensitivity of 63.9% and specificity of 81.3%. Conclusions: A significant proportion of children with nephrotic syndrome were detected with adrenal insufficiency on ACTH stimulation test. A cumulative steroid intake of > 0.22 mg/kg/day emerged as a risk factor for predicting adrenocortical suppression.