The ACTH test fails to diagnose adrenal insufficiency and augments cytokine production in sepsis
Dan Hao, … , Philip W. Shaul, Xiang-An Li
Dan Hao, … , Philip W. Shaul, Xiang-An Li
Published March 6, 2025
Citation Information: JCI Insight. 2025;10(8):e187487. https://doi.org/10.1172/jci.insight.187487.
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Research Article Infectious disease Inflammation

The ACTH test fails to diagnose adrenal insufficiency and augments cytokine production in sepsis

Abstract

The adrenocorticotropic hormone (ACTH) test diagnoses relative adrenal insufficiency (RAI) or critical illness–related corticosteroid insufficiency (CIRCI). Initially, guidelines recommended corticosteroid/glucocorticoid (GC) therapy for septic patients with RAI, but later trials did not show a survival benefit, leading to updated guidelines that abandon targeting RAI or CIRCI. Recent studies with an RAI mouse model showed a clear survival benefit from GC therapy in mice with RAI, suggesting that inconclusive GC clinical trials might be due to issues with the ACTH test rather than targeting RAI. To investigate, we performed the ACTH test in septic mice. Interestingly, the ACTH test identified most mice as having adrenal insufficiency in early and middle stages of sepsis, even those with a normal adrenal stress response. Surprisingly, the ACTH test increased inflammatory cytokines to lethal levels, moderately increasing mortality in septic mice. This study revealed significant flaws in the ACTH test for diagnosing RAI/CIRCI. It not only fails to correctly identify these conditions, leading to misguided use of GCs, but also induces a lethal inflammatory response in sepsis. These findings suggest that inconclusive GC therapy trials may be due to the problematic nature of the ACTH test rather than ineffectiveness of targeting RAI/CIRCI.

Authors

Dan Hao, Qian Wang, Misa Ito, Jianyao Xue, Ling Guo, Bin Huang, Chieko Mineo, Philip W. Shaul, Xiang-An Li

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Figure 1

ACTH test fails to correctly identify adrenal stress response in early and middle stages of sepsis.

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ACTH test fails to correctly identify adrenal stress response in early a...
(A and B) C57BL/6J mice were treated with 0.1 IU ACTH via subcutaneous injection. Serum corticosterone (A) and Δcorticosterone (B) levels were measured before and 1 hour after the ACTH test (n = 6). Data are presented as mean ± SEM. Statistical testing using 2-tailed unpaired Student’s t test. (C) C57BL/6J mice were challenged with CLP (25G, full ligation) for different times (0, 3, 24, 48 hours). Serum corticosterone and IL-6 levels were measured (n = 6–9). (D and E) C57BL/6J mice were challenged with CLP (25G, full ligation) for different times (0, 3, 24, 48 hours). Then, the mice were treated with 0.1 IU ACTH. Serum corticosterone (D) and Δcorticosterone (E) levels were measured before and 1 hour after the ACTH test (n = 6). (F and G) C57BL/6J mice were challenged with CLP for different times (0, 3, 24, 48 hours). Then, mice were treated with 4 IU ACTH. Serum corticosterone (F) and Δcorticosterone (G) levels were measured before and 1 hour after the ACTH test (n = 7–9). Data are presented as mean ± SEM. Statistical testing using 1-way ANOVA with Tukey’s multiple-comparison correction. (H and I) C57BL/6J mice were challenged with or without CLP for 3 hours (H) and stimulated with ACTH (4 IU) or PBS for 45 minutes (I). GC synthesis–related gene expression in the adrenal gland was analyzed by RNA-seq analysis. Data are presented as mean ± SEM. Statistics using 2-way ANOVA with Tukey’s multiple-comparison correction. NS, no significance; *P < 0.05; **P < 0.01; ****P < 0.0001. For RNA-seq analysis, pairwise comparisons between the various conditions were run using a negative binomial generalized log-linear model through the glmLRT fit function in edgeR (https://bioconductor.org/packages/release/bioc/html/edgeR.html).