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Updated: Jun 25, 2025
Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform
Published on: April 12, 2021
Adrenal insufficiency in pediatric kidney transplantation recipients
Hyunwoong Harry Chae1, Azim Ahmed1, Jeffrey N Bone2
1Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
Insights
Pediatric kidney transplant recipients on corticosteroids face a significant risk of adrenal insufficiency (AI), with higher steroid doses and rejection episodes increasing this risk. Early detection and monitoring are crucial for managing AI in these vulnerable patients.
Area of Science:
- Pediatric Nephrology
- Endocrinology
- Transplantation Medicine
Background:
- Pediatric kidney transplant (PKT) recipients commonly receive corticosteroids for immunosuppression.
- Prolonged corticosteroid use is linked to secondary adrenal insufficiency (AI), but its specific impact on PKT patients is understudied.
Purpose of the Study:
- To evaluate the prevalence of AI in PKT recipients.
- To identify risk factors associated with AI.
- To determine adverse clinical effects of AI in this population.
Main Methods:
- Retrospective cohort review of PKT recipients.
- AI risk assessed via morning cortisol (MC) levels.
- Diagnosis confirmed with ACTH stimulation testing.
- Analysis of risk factors and adverse effects linked to MC and AI diagnosis.
Main Results:
- AI confirmed in 25.5% of 51 PKT recipients.
- Risk factors for AI included higher prednisone dosage, longer exposure, daily administration, and rejection episodes.
- Lower MC levels correlated with increased medication burden, hospitalization, creatinine variability, and acute kidney injury.
Conclusions:
- Increased corticosteroid exposure is associated with lower MC levels and a higher incidence of AI in PKT recipients.
- AI in PKT patients is linked to greater medical complexity and kidney function instability.
- Systematic clinical surveillance for AI is recommended for PKT recipients on corticosteroid therapy.
Background:
Immunosuppression of pediatric kidney transplant (PKT) recipients often includes corticosteroids. Prolonged corticosteroid exposure has been associated with secondary adrenal insufficiency (AI); however, little is known about its impact on PKT recipients.
Methods:
This was a retrospective cohort review of PKT recipients to evaluate AI prevalence, risk factors, and adverse effects. AI risk was assessed using morning cortisol (MC) and diagnosis confirmed by an ACTH stimulation test. Potential risk factors and adverse effects were tested for associations with MC levels and AI diagnosis.
Results:
Fifty-one patients (60.8% male, age 7.4 (IQR 3.8, 13.1) years; 1 patient counted twice for repeat transplant) were included. Patients at risk for AI (MC < 240 nmol/L) underwent definitive ACTH stimulation testing, confirming AI in 13/51 (25.5%) patients. Identified risk factors for AI included current prednisone dosage (p = .001), 6-month prednisone exposure (p = .02), daily prednisone administration (p = .002), and rejection episodes since transplant (p = .001). MC level (2.5 years (IQR 1.1, 5.1) post-transplant) was associated with current prednisone dosage (p < .001), 6-month prednisone exposure (p = .001), daily prednisone administration (p = .006), rejection episodes since transplant (p = .003), greater number of medications (β = -16.3, p < .001), 6-month hospitalization days (β = -3.3, p = .013), creatinine variability (β = -2.4, p = .025), and occurrence of acute kidney injury (β = -70.6, p = .01).
Conclusion:
Greater corticosteroid exposure was associated with a lower MC level and confirmatory diagnosis of AI noted with an ACTH stimulation test. Adverse clinical findings with AI included greater medical complexity and kidney function lability. These data support systematic clinical surveillance for AI in PKT recipients treated with corticosteroids.
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