Pro-opiomelanocortin and ACTH-cortisol dissociation during pediatric cardiac surgery

Abstract

In critically ill adults, high plasma cortisol in face of low ACTH coincides with high pro-opiomelanocortin (POMC) levels. Glucocorticoids further lower ACTH without affecting POMC. We hypothesized that in pediatric cardiac surgery-induced critical illness, plasma POMC is elevated, plasma ACTH transiently rises intraoperatively but becomes suppressed post-operatively, and glucocorticoid administration amplifies this phenotype. From 53 patients (0-36 months), plasma was obtained pre-operatively, intraoperatively and on post-operative day 1 and 2. Plasma was also collected from 24 healthy children. In patients, POMC was supra-normal pre-operatively (p<0.0001) but no longer thereafter (p<0.05). ACTH was never high in patients. While in glucocorticoid-naive patients ACTH became suppressed by post-operative day 1 (p<0.0001), glucocorticoid-treated patients had suppressed ACTH already intraoperatively (p≤0.0001). Pre-operatively high POMC, not accompanied by increased plasma ACTH, suggests a centrally-activated HPA-axis with reduced pituitary processing of POMC into ACTH. Increasing systemic glucocorticoid availability with glucocorticoid treatment accelerated the suppression of plasma ACTH.

Figure 1

Study design and sample availability.

Figure 2

Plasma hormone concentrations pre-, intra-, and post-operatively (PICU days 1 and 2). Box-and-whiskers represent median, interquartile range (IQR), and the furthest points within 1.5 times the IQR of the patients. Gray bars represent IQR of the matched-healthy controls. P values above each box-and-whiskers plot indicate significance between the respective patient group and the matched-healthy controls.