腎不全時の尿中ならびに血中glucocorticoidの変動に関する臨床的研究 第2編: 慢性腎不全時ことに長期血液透析患者における血中glucocorticoidの変動について

Abstract

Adrenocortical function was evaluated before and after hemodialysis in 21 patients receiving maintenance hemodialysis either by Kolff type or Kiil type artificial Kidney. 1. Urinary total 17-OHCS was low in the patients whose urinary output was over 1000 ml per day, and it correlated well with creatinine clearance. The ACTH-stimulation test showed increase of urinary 17-OHCS but reaction was rather delayed and slight. In these patients low urinary 17-OHCS does not necessarily mean hypofunction of the adrenal cortex, because in primary nephron failure corticoids metabolites cannot be excreted normally. 2. Before hemodialysis was begun the blood cortisol level was low normal or slightly low and the ACTH-stimulation showed delayed reaction. After hemodialysis was initiated, the cortisol level returned to the normal level and normal response was proved in the ACTH-stimulation and dexamethasone suppression test. Also, there was no clinical hypoadrenocorticism, but metabolic clearance rate of cortisol was approximately half of the normal value in these patients. 3. The diurnal change of the blood cortisol level was investigated. Before hemodialysis was begun, it was low and there was little difference between the morning and the afternoon. Aiter hemodialysis was initiated, the blood level itself became higher but still kept the rhythmic pattern characterized by difference between the morning and the evening. The patients dialysed more than one year, showed high blood level of cortisol in the afternoon which continued until the following day and was transfered to the same rhythm mentioned above. Repeated hemodialysis might have acted as a kind of stress and caused disturbed diurnal change of the blood cortisol level. 4. A question arose if cortisol is lost through the dialysis membrane during hemodialysis. Great part of the blood cortisol is combined with protein and seems to be non-dialysable when the cortisol level is normal. In vitro dialysis experiment, towever, showed possibility of cortisol loss due to escape of free cortisol if the level is higher than normal. The extraction ratio of the blood cortisol during hemodialysis increased if the blood level was high. This fact is consistent with the result of in vitro experiment. 5. Change of the blood cortisol level during hemodialysis might be caused by many factors besides cortisol loss through the dialysis membrane. It also differed according to type of dialysis machine used. When Kolff type artificial kidney was used, the blood cortisol level was elevated in 2 to 3 hours of dialysis. When Kiil type was used, the blood level did not change greatly or slightly decreased in 1 to 2 hours. Those changes, however, differed from dialysis to dialysis even in the same patient. Many of the patients dialysed more than one year with Kiil type, transient elevation 01 the cortisol level was observed at two to three hours of dialysis.