Changes in Cortisol Secretion and Corticosteroid Receptors in Critically Ill Patients with Sepsis/Septic Shock and Scope for Treatment

Sepsis is associated with dysregulated cortisol secretion, leading to abnormal levels of cortisol in the blood. In the early stages of sepsis, cortisol levels are typically elevated due to increased secretion from the adrenal glands. However, as the disease progresses, cortisol levels may decline due to impaired adrenal function, leading to relative adrenal insufficiency. The latter is thought to be caused by a combination of factors, including impaired adrenal function, decreased production of corticotropin-releasing hormone (CRH) and adrenocorticotropic hormone (ACTH) by the hypothalamus and pituitary gland, and increased breakdown of cortisol by enzymes such as 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2). The dysregulation of cortisol secretion in sepsis is thought to contribute to the pathophysiology of the disease by impairing the body's ability to mount an appropriate inflammatory response. The actions of cortisol are mediated through two types of corticosteroid receptors: the mineralocorticoid receptor (MR) and the glucocorticoid receptor (GCR). In sepsis, the expression and activity of GCR is altered, contributing to the pathophysiology of the disease. GCR expression and activity are typically downregulated in sepsis, impairing the body's ability to mount an appropriate inflammatory response. Given the dysregulation of cortisol secretion and corticosteroid receptors in sepsis, there has been considerable interest in the use of steroids as a treatment for sepsis. The rationale for steroid-based treatment is to supplement the body's endogenous cortisol production, restore normal cortisol levels, and improve the body's ability to mount an appropriate inflammatory response. However, the use of steroids in sepsis remains controversial, and clinical trials have yielded mixed results. Some studies have shown that steroid-based treatment can improve shock reversal, reduce the need for vasopressors, and improve overall survival in patients with septic shock, whereas other studies have found no benefit or even harm from steroid-based treatment in sepsis.