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Hepsen S, Gul U, Bostan H, Akhanli P, Sencar ME, Kizilgul M, Unsal IO, Cakal E. Cushing's syndrome screening with the 1-mg dexamethasone suppression test in metabolically healthy and unhealthy obesity phenotypes. Int J Obes (Lond) 2024:10.1038/s41366-024-01598-0. [PMID: 39122909 DOI: 10.1038/s41366-024-01598-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 07/14/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND The ongoing debate regarding the need for screening Cushing's syndrome (CS) in patients with obesity continues. The objectives of this study were to establish the prevalence of CS in the population with obesity and assess how metabolic health status influences cortisol levels following the 1 mg dexamethasone suppression test (DST). METHODS This retrospective study included 1008 patients with obesity who underwent screening with the 1 mg DST for CS. These patients were categorized into two groups as metabolically healthy obesity (MHO) and unhealthy obesity (MUO). RESULTS Out of the 1008 patients, 779 (77.3%) belonged to the MUO group. Within the entire study cohort, 12 (1.2%) patients exhibited a cortisol level of ≥ 1.8 after the 1 mg DST. Cortisol levels following the 1 mg DST were also significantly higher in the MUO group than in the MHO group (p = 0.001). Among these 12 patients, 11 were presenting a MUO phenotype. Hypercortisolism was definitively diagnosed in two patients, resulting in an overall prevalence of 0.2%. The 1 mg DST demonstrated a specificity of 99% and 100% sensitivity for screening for CS. CONCLUSIONS While the 1 mg DST is a practical screening test for CS with high specificity in obesity, the number of CS cases detected remains relatively low. Therefore, it may be more reasonable and applicable to screen patients with MUO phenotype rather than all individuals with obesity.
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Affiliation(s)
- Sema Hepsen
- Ankara Etlik City Hospital, Department of Endocrinology and Metabolism, Ankara, Turkey.
| | - Umran Gul
- Ankara Etlik City Hospital, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Hayri Bostan
- Canakkale Mehmet Akif Ersoy State Hospital, Department of Endocrinology and Metabolism, Canakkale, Turkey
| | - Pinar Akhanli
- Erzurum Regional Training and Research Hospital, Department of Endocrinology and Metabolism, Erzurum, Turkey
| | - Muhammed Erkam Sencar
- Medicana International Ankara Hospital, Department of Endocrinology and Metabolism Ankara, Ankara, Turkey
| | - Muhammed Kizilgul
- Ankara Etlik City Hospital, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Ilknur Ozturk Unsal
- Ankara Etlik City Hospital, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Erman Cakal
- Ankara Etlik City Hospital, Department of Endocrinology and Metabolism, Ankara, Turkey
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Di Dalmazi G, Goi J, Burrello J, Tucci L, Cicero AFG, Mancusi C, Coletti Moia E, Iaccarino G, Borghi C, Muiesan ML, Ferri C, Mulatero P. Screening of hypercortisolism among patients with hypertension: an Italian nationwide survey. J Endocrinol Invest 2024:10.1007/s40618-024-02387-2. [PMID: 38913251 DOI: 10.1007/s40618-024-02387-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 04/25/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE Screening of Cushing Syndrome (CS) and Mild Autonomous Cortisol Secretion (MACS) in hypertensive patients is crucial for proper treatment. The aim of the study was to investigate screening and management of hypercortisolism among patients with hypertension in Italy. METHODS A 10 item-questionnaire was delivered to referral centres of European and Italian Society of Hypertension (ESH and SIIA) in a nationwide survey. Data were analyzed according to type of centre (excellence vs non-excellence), geographical area, and medical specialty. RESULTS Within 14 Italian regions, 82 centres (30% excellence, 78.790 patients during the last year, average 600 patients/year) participated to the survey. Internal medicine (44%) and cardiology (31%) were the most prevalent medical specialty. CS and MACS were diagnosed in 313 and 490 patients during the previous 5 years. The highest number of diagnoses was reported by internal medicine and excellence centres. Screening for hypercortisolism was reported by 77% in the presence of specific features of CS, 61% in resistant hypertension, and 38% in patients with adrenal mass. Among screening tests, the 24 h urinary free cortisol was the most used (66%), followed by morning cortisol and ACTH (54%), 1 mg-dexamethasone suppression test (49%), adrenal CT or MRI scans (12%), and late night salivary cortisol (11%). Awareness of referral centres with expertise in management of CS was reported by 67% of the participants, which reduced to 44% among non-excellence centres. CONCLUSIONS Current screening of hypercortisolism among hypertensive patients is unsatisfactory. Strategies tailored to different medical specialties and type of centres should be conceived.
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Affiliation(s)
- G Di Dalmazi
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy.
| | - J Goi
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Turin, Italy
| | - J Burrello
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Turin, Italy
| | - L Tucci
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - A F G Cicero
- Hypertension and Cardiovascular Risk Research Unit, Medical and Surgery Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - C Mancusi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini 5, 80131, Naples, Italy
| | - E Coletti Moia
- ARCA (Associazioni Regionali Cardiologi Ambulatoriali) sezione Piemonte, Turin, Italy
| | - G Iaccarino
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini 5, 80131, Naples, Italy
| | - C Borghi
- Hypertension and Cardiovascular Risk Research Unit, Medical and Surgery Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - M L Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - C Ferri
- Department of Life, Health and Environmental Sciences University of L'Aquila, L'Aquila, Italy
| | - P Mulatero
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Turin, Italy
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Chu S, Yang W, Lu Y, Li J, Peng J, Liu W, Jiang M, Bai G. Tetrandrine inhibits aldosterone synthesis by covalently targeting CYP11A1 to attenuate hypertension. Front Pharmacol 2024; 15:1387756. [PMID: 38948468 PMCID: PMC11211567 DOI: 10.3389/fphar.2024.1387756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/15/2024] [Indexed: 07/02/2024] Open
Abstract
Introduction Tetrandrine (Tet) is the main pharmacological component of Stephania tetrandra S. Moore, which is a well-documented traditional Chinese medicine known for its diuretic and antihypertensive properties. Unraveling the specific targets and mechanisms of Tet involved in inducing diuresis and mitigating hypertension can provide valuable insights into its therapeutic effects. This study aimed to explore the diuretic and antihypertensive targets and mechanisms of Tet using chemical biology coupled with activity analyses in vivo and in vitro. Methods The diuretic effects of Tet were evaluated using a water-loaded mouse model. The direct target proteins for the diuretic and antihypertensive effects of Tet were determined using chemical biology. Furthermore, the molecular mechanism of Tet binding to target proteins was analyzed using a multidisciplinary approach based on the structure and function of the proteins. Finally, the effects of the Tet-targeted protein on downstream signaling pathways and blood pressure were evaluated in hypertensive model rats. Results Tet exhibited significant antihypertensive and potassium-preserving diuretic effects. The mechanism underlying these effects involves the modulation of the enzyme activity by covalent binding of Tet to Cys423 of CYP11A1. This interaction alters the stability of heme within CYP11A1, subsequently impeding electron transfer and inhibiting aldosterone biosynthesis. Discussion This study not only revealed the mechanism of the diuretic and antihypertensive effects of Tet but also discovered a novel covalent inhibitor of CYP11A1. These findings contribute significantly to our understanding of the therapeutic potential of Tet and provide a foundation for future research in the development of targeted treatments for hypertension.
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Affiliation(s)
- Simeng Chu
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, China
| | - Wei Yang
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, China
| | - Yujie Lu
- College of Life Health, Dalian University, Dalian, China
| | - Junjie Li
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, China
| | - Jiamin Peng
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, China
| | - Wenjuan Liu
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, China
| | - Min Jiang
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, China
| | - Gang Bai
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, China
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Park S, Shin J, Ihm SH, Kim KI, Kim HL, Kim HC, Lee EM, Lee JH, Ahn SY, Cho EJ, Kim JH, Kang HT, Lee HY, Lee S, Kim W, Park JM. Resistant hypertension: consensus document from the Korean society of hypertension. Clin Hypertens 2023; 29:30. [PMID: 37908019 PMCID: PMC10619268 DOI: 10.1186/s40885-023-00255-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/09/2023] [Indexed: 11/02/2023] Open
Abstract
Although reports vary, the prevalence of true resistant hypertension and apparent treatment-resistant hypertension (aTRH) has been reported to be 10.3% and 14.7%, respectively. As there is a rapid increase in the prevalence of obesity, chronic kidney disease, and diabetes mellitus, factors that are associated with resistant hypertension, the prevalence of resistant hypertension is expected to rise as well. Frequently, patients with aTRH have pseudoresistant hypertension [aTRH due to white-coat uncontrolled hypertension (WUCH), drug underdosing, poor adherence, and inaccurate office blood pressure (BP) measurements]. As the prevalence of WUCH is high among patients with aTRH, the use of out-of-office BP measurements, both ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), is essential to exclude WUCH. Non-adherence is especially problematic, and methods to assess adherence remain limited and often not clinically feasible. Therefore, the use of HBPM and higher utilization of single-pill fixed-dose combination treatments should be emphasized to improve drug adherence. In addition, primary aldosteronism and symptomatic obstructive sleep apnea are quite common in patients with hypertension and more so in patients with resistant hypertension. Screening for these diseases is essential, as the treatment of these secondary causes may help control BP in patients who are otherwise difficult to treat. Finally, a proper drug regimen combined with lifestyle modifications is essential to control BP in these patients.
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Affiliation(s)
- Sungha Park
- Division of Cardiology, Severance Cardiovascular Hospital, Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jinho Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, South Korea
| | - Sang Hyun Ihm
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea.
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital327 Sosa-Ro, Wonmi-guGyunggi-do, Bucheon-si, 14647, Republic of Korea.
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeon Chang Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Mi Lee
- Division of Cardiology, Department of Internal Medicine, Wonkwang University Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Republic of Korea
| | - Jang Hoon Lee
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, South Korea
- School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Shin Young Ahn
- Division of Nephrology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Eun Joo Cho
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ju Han Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Hee-Taik Kang
- Department of Family Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sunki Lee
- Hallym University, Dongtan Hospital, Gyeonggi-do, Korea
| | - Woohyeun Kim
- Division of Cardiology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, South Korea
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5
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Fallo F, Di Dalmazi G, Beuschlein F, Biermasz NR, Castinetti F, Elenkova A, Fassnacht M, Isidori AM, Kastelan D, Korbonits M, Newell-Price J, Parati G, Petersenn S, Pivonello R, Ragnarsson O, Tabarin A, Theodoropoulou M, Tsagarakis S, Valassi E, Witek P, Reincke M. Diagnosis and management of hypertension in patients with Cushing's syndrome: a position statement and consensus of the Working Group on Endocrine Hypertension of the European Society of Hypertension. J Hypertens 2022; 40:2085-2101. [PMID: 35950979 DOI: 10.1097/hjh.0000000000003252] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Endogenous/exogenous Cushing's syndrome is characterized by a cluster of systemic manifestations of hypercortisolism, which cause increased cardiovascular risk. Its biological basis is glucocorticoid excess, acting on various pathogenic processes inducing cardiovascular damage. Hypertension is a common feature in Cushing's syndrome and may persist after normalizing hormone excess and discontinuing steroid therapy. In endogenous Cushing's syndrome, the earlier the diagnosis the sooner management can be employed to offset the deleterious effects of excess cortisol. Such management includes combined treatments directed against the underlying cause and tailored antihypertensive drugs aimed at controlling the consequences of glucocorticoid excess. Experts on endocrine hypertension and members of the Working Group on Endocrine Hypertension of the European Society of Hypertension (ESH) prepared this Consensus document, which summarizes the current knowledge in epidemiology, genetics, diagnosis, and treatment of hypertension in Cushing's syndrome.
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Affiliation(s)
- Francesco Fallo
- Clinica Medica 3, Department of Medicine, University of Padova, Padova
| | - Guido Di Dalmazi
- Unit of Endocrinology and Diabetes Prevention and Care, Department of Medical and Surgical Sciences, University of Bologna
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Nienke R Biermasz
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | - Frederic Castinetti
- Aix Marseille Université, Marseille Medical Genetics, INSERM
- Assistance Publique Hopitaux de Marseille
- Department of Endocrinology, La Conception Hospital, Marseille, France
| | - Atanaska Elenkova
- Department of Endocrinology, University Specialized Hospital for Active Treatment in Endocrinology (USHATE) "Acad. Ivan Penchev", Medical University - Sofia, Sofia, Bulgaria
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb University School of Medicine, Zagreb, Croatia
| | - Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London
| | - John Newell-Price
- Department of Oncology and Metabolism, Medical School, University of Sheffield
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences Istituto Auxologico Italiano, IRCCS
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany and University of Duisburg-Essen, Essen, Germany
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli
- Unesco Chair for Health Education and Sustainable Development, "Federico II" University, Naples, Italy
| | - Oskar Ragnarsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Antoine Tabarin
- CHU de Bordeaux, Hôpital Haut Lévêque, University of Bordeaux, Bordeaux, France
| | - Marily Theodoropoulou
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Elena Valassi
- Endocrinology Unit, Hospital Germans Trias i Pujol, Badalona
- Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Mazovian Bródno Hospital, Medical University of Warsaw, Warsaw, Poland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
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6
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Tabarin A, Assié G, Barat P, Bonnet F, Bonneville JF, Borson-Chazot F, Bouligand J, Boulin A, Brue T, Caron P, Castinetti F, Chabre O, Chanson P, Corcuff JB, Cortet C, Coutant R, Dohan A, Drui D, Espiard S, Gaye D, Grunenwald S, Guignat L, Hindie E, Illouz F, Kamenicky P, Lefebvre H, Linglart A, Martinerie L, North MO, Raffin-Samson ML, Raingeard I, Raverot G, Raverot V, Reznik Y, Taieb D, Vezzosi D, Young J, Bertherat J. Consensus statement by the French Society of Endocrinology (SFE) and French Society of Pediatric Endocrinology & Diabetology (SFEDP) on diagnosis of Cushing's syndrome. ANNALES D'ENDOCRINOLOGIE 2022; 83:119-141. [PMID: 35192845 DOI: 10.1016/j.ando.2022.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cushing's syndrome is defined by prolonged exposure to glucocorticoids, leading to excess morbidity and mortality. Diagnosis of this rare pathology is difficult due to the low specificity of the clinical signs, the variable severity of the clinical presentation, and the difficulties of interpretation associated with the diagnostic methods. The present consensus paper by 38 experts of the French Society of Endocrinology and the French Society of Pediatric Endocrinology and Diabetology aimed firstly to detail the circumstances suggesting diagnosis and the biologic diagnosis tools and their interpretation for positive diagnosis and for etiologic diagnosis according to ACTH-independent and -dependent mechanisms. Secondly, situations making diagnosis complex (pregnancy, intense hypercortisolism, fluctuating Cushing's syndrome, pediatric forms and genetically determined forms) were detailed. Lastly, methods of surveillance and diagnosis of recurrence were dealt with in the final section.
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Affiliation(s)
- Antoine Tabarin
- Service Endocrinologie, Diabète et Nutrition, Université, Hôpital Haut-Leveque CHU de Bordeaux, 33604 Pessac, France.
| | - Guillaume Assié
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Pascal Barat
- Unité d'Endocrinologie-Diabétologie-Gynécologie-Obésité Pédiatrique, Hôpital des Enfants CHU Bordeaux, Bordeaux, France
| | - Fidéline Bonnet
- UF d'Hormonologie Hôpital Cochin, Université de Paris, Institut Cochin Inserm U1016, CNRS UMR8104, Paris, France
| | | | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Hôpital Louis-Pradel, Hospices Civils de Lyon, INSERM U1290, Université Lyon1, 69002 Lyon, France
| | - Jérôme Bouligand
- Faculté de Médecine Paris-Saclay, Unité Inserm UMRS1185 Physiologie et Physiopathologie Endocriniennes, Paris, France
| | - Anne Boulin
- Service de Neuroradiologie, Hôpital Foch, 92151 Suresnes, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Philippe Caron
- Service d'Endocrinologie et Maladies Métaboliques, Pôle Cardiovasculaire et Métabolique, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France
| | - Frédéric Castinetti
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Olivier Chabre
- Université Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Le Kremlin-Bicêtre, France
| | - Jean Benoit Corcuff
- Laboratoire d'Hormonologie, Service de Médecine Nucléaire, CHU Bordeaux, Laboratoire NutriNeuro, UMR 1286 INRAE, Université de Bordeaux, Bordeaux, France
| | - Christine Cortet
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, CHU de Lille, Lille, France
| | - Régis Coutant
- Service d'Endocrinologie Pédiatrique, CHU Angers, Centre de Référence, Centre Constitutif des Maladies Rares de l'Hypophyse, CHU Angers, Angers, France
| | - Anthony Dohan
- Department of Radiology A, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Delphine Drui
- Service Endocrinologie-Diabétologie et Nutrition, l'institut du Thorax, CHU Nantes, 44092 Nantes cedex, France
| | - Stéphanie Espiard
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, INSERM U1190, Laboratoire de Recherche Translationnelle sur le Diabète, 59000 Lille, France
| | - Delphine Gaye
- Service de Radiologie, Hôpital Haut-Lêveque, CHU de Bordeaux, 33604 Pessac, France
| | - Solenge Grunenwald
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Laurence Guignat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Elif Hindie
- Service de Médecine Nucléaire, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frédéric Illouz
- Centre de Référence Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Service Endocrinologie-Diabétologie-Nutrition, CHU Angers, 49933 Angers cedex 9, France
| | - Peter Kamenicky
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Hervé Lefebvre
- Service d'Endocrinologie, Diabète et Maladies Métaboliques, CHU de Rouen, Rouen, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, and Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Service d'Endocrinologie Pédiatrique, CHU Robert-Debré, AP-HP, Paris, France; Université de Paris, Paris, France
| | - Marie Odile North
- Service de Génétique et Biologie Moléculaire, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Marie Laure Raffin-Samson
- Service d'Endocrinologie Nutrition, Hôpital Ambroise-Paré, GHU Paris-Saclay, AP-HP Boulogne, EA4340, Université de Versailles-Saint-Quentin, Paris, France
| | - Isabelle Raingeard
- Maladies Endocriniennes, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires, "Groupement Hospitalier Est", Hospices Civils de Lyon, Lyon, France
| | - Véronique Raverot
- Hospices Civils de Lyon, LBMMS, Centre de Biologie Est, Service de Biochimie et Biologie Moléculaire, 69677 Bron cedex, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte-de-Nacre, 14033 Caen cedex, France; University of Caen Basse-Normandie, Medical School, 14032 Caen cedex, France
| | - David Taieb
- Aix-Marseille Université, CHU La Timone, AP-HM, Marseille, France
| | - Delphine Vezzosi
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Jacques Young
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Jérôme Bertherat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
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7
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Sagmeister MS, Harper L, Hardy RS. Cortisol excess in chronic kidney disease - A review of changes and impact on mortality. Front Endocrinol (Lausanne) 2022; 13:1075809. [PMID: 36733794 PMCID: PMC9886668 DOI: 10.3389/fendo.2022.1075809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/27/2022] [Indexed: 01/18/2023] Open
Abstract
Chronic kidney disease (CKD) describes the long-term condition of impaired kidney function from any cause. CKD is common and associated with a wide array of complications including higher mortality, cardiovascular disease, hypertension, insulin resistance, dyslipidemia, sarcopenia, osteoporosis, aberrant immune function, cognitive impairment, mood disturbances and poor sleep quality. Glucocorticoids are endogenous pleiotropic steroid hormones and their excess produces a pattern of morbidity that possesses considerable overlap with CKD. Circulating levels of cortisol, the major active glucocorticoid in humans, are determined by a complex interplay between several processes. The hypothalamic-pituitary-adrenal axis (HPA) regulates cortisol synthesis and release, 11β-hydroxysteroid dehydrogenase enzymes mediate metabolic interconversion between active and inactive forms, and clearance from the circulation depends on irreversible metabolic inactivation in the liver followed by urinary excretion. Chronic stress, inflammatory states and other aspects of CKD can disturb these processes, enhancing cortisol secretion via the HPA axis and inducing tissue-resident amplification of glucocorticoid signals. Progressive renal impairment can further impact on cortisol metabolism and urinary clearance of cortisol metabolites. Consequently, significant interest exists to precisely understand the dysregulation of cortisol in CKD and its significance for adverse clinical outcomes. In this review, we summarize the latest literature on alterations in endogenous glucocorticoid regulation in adults with CKD and evaluate the available evidence on cortisol as a mechanistic driver of excess mortality and morbidity. The emerging picture is one of subclinical hypercortisolism with blunted diurnal decline of cortisol levels, impaired negative feedback regulation and reduced cortisol clearance. An association between cortisol and adjusted all-cause mortality has been reported in observational studies for patients with end-stage renal failure, but further research is required to assess links between cortisol and clinical outcomes in CKD. We propose recommendations for future research, including therapeutic strategies that aim to reduce complications of CKD by correcting or reversing dysregulation of cortisol.
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Affiliation(s)
- Michael S. Sagmeister
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- *Correspondence: Michael S. Sagmeister,
| | - Lorraine Harper
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Rowan S. Hardy
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Research into Inflammatory Arthritis Centre Versus Arthritis, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Institute of Clinical Science, University of Birmingham, Birmingham, United Kingdom
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8
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Giovanelli L, Aresta C, Favero V, Bonomi M, Cangiano B, Eller-Vainicher C, Grassi G, Morelli V, Pugliese F, Falchetti A, Gennari L, Scillitani A, Persani L, Chiodini I. Hidden hypercortisolism: a too frequently neglected clinical condition. J Endocrinol Invest 2021; 44:1581-1596. [PMID: 33394454 DOI: 10.1007/s40618-020-01484-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/07/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE Classic Cushing's syndrome (CS) is a severe disease characterized by central obesity, hypertension, easy bruising, striae rubrae, buffalo hump, proximal myopathy and hypertricosis. However, several CS cases have also been reported with unusual or camouflaged manifestations. In recent years, several authors investigated the prevalence of "hidden hypercortisolism" (HidHyCo) among subjects affected with bone fragility, hypertension and type 2 diabetes mellitus (DM2). The prevalence of the HidHyCo is estimated to be much higher than that of classic CS. However, similarly to classic CS, HidHyCo is known to increase the risk of fractures, cardiovascular disease and mortality. METHODS We reviewed all published cases of unusual presentations of hypercortisolism and studies specifically assessing the HidHyCo prevalence in diabetic, osteoporotic and hypertensive patients. RESULTS We found 49 HidHyCo cases, in whom bone fragility, hypertension and diabetes were the presenting manifestations of an otherwise silent hypercortisolism. Amongst these cases, 34.7%, 32.7%, 6.1% and 19.0%, respectively, had bone fragility, hypertension, DM2 or hypertension plus DM2 as the sole clinical manifestations of HidHyCo. Overall, 25% of HidHyCo cases were of pituitary origin, and bone fragility was the very prevalent first manifestation among them. In population studies, it is possible to estimate that 1-4% of patients with apparent primary osteoporosis has a HidHyCo and the prevalence of this condition among diabetics ranges between 3.4 and 10%. CONCLUSION These data indicate that patients with resistant or suddenly worsening hypertension or DM2 or unexplainable bone fragility should be screened for HidHyCo using the most recently approved sensitive cut-offs.
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Affiliation(s)
- L Giovanelli
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - C Aresta
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - V Favero
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Bonomi
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - B Cangiano
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - C Eller-Vainicher
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - G Grassi
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - V Morelli
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - F Pugliese
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, FG, Italy
| | - A Falchetti
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
| | - L Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - A Scillitani
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, FG, Italy
| | - L Persani
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - I Chiodini
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
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9
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Campana G, Loizzo S, Fortuna A, Rimondini R, Maroccia Z, Scillitani A, Falchetti A, Spampinato SM, Persani L, Chiodini I. Early post-natal life stress induces permanent adrenocorticotropin-dependent hypercortisolism in male mice. Endocrine 2021; 73:186-195. [PMID: 33630246 DOI: 10.1007/s12020-021-02659-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/10/2021] [Indexed: 01/06/2023]
Abstract
PURPOSE It has been hypothesized that specific early-life stress (ES) procedures on CD-1 male mice produce diabetes-like alterations due to the failure of negative feedback of glucocorticoid hormone in the pituitary. The aim of this study is to investigate the possible mechanism that leads to this pathological model, framing it in a more specific clinical condition. METHODS Metabolic and hypothalamic-pituitary-adrenal-related hormones of stressed mice (SM) have been analyzed immediately after stress procedures (21 postnatal days, PND) and after 70 days of a peaceful (unstressed) period (90 PND). These data have been compared to parameters from age-matched controls (CTR), and mice treated during ES procedures with oligonucleotide antisense for pro-opiomelanocortin (AS-POMC). RESULTS At 21 PND, SM presented an increased secretion of hypothalamic CRH and pituitary POMC-derived peptides, as well as higher plasmatic levels of ACTH and corticosterone vs. CTR. At 90 PND, SM showed hyperglycemia, with suppression of hypothalamic CRH, while pituitary and plasmatic ACTH levels, as well as plasma corticosterone, were constantly higher than in CTR. These values are accompanied by a progressive acceleration in gaining total body weight, which became significant vs. CTR at 90 PND together with a higher pituitary weight. Treatment with AS-POMC prevented all hormonal and metabolic alterations observed in SM, both at 21 and 90 PND. CONCLUSIONS These findings show that these specific ES procedures affect the negative glucocorticoid feedback in the pituitary, but not in the hypothalamus, suggesting a novel model of ACTH-dependent hypercortisolism that can be prevented by silencing the POMC gene.
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Affiliation(s)
- Gabriele Campana
- Department of Pharmacy and Biotechnology, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
| | - Stefano Loizzo
- Department of Cardiovascular and Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy.
| | - Andrea Fortuna
- Department of Cardiovascular and Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
| | - Roberto Rimondini
- Department of Medical and Clinical Sciences, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
| | - Zaira Maroccia
- Department of Cardiovascular and Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
| | - Alfredo Scillitani
- Endocrinology and Diabetology, Ospedale "Casa Sollievo della sofferenza" IRCCS, Viale Cappuccini 1, 71013, San Giovanni Rotondo, Foggia, Italy
| | - Alberto Falchetti
- Department of Clinical Sciences and Community Health, University of Milan, Via della Commenda 19, 20122, Milan, Italy
| | - Santi Mario Spampinato
- Department of Pharmacy and Biotechnology, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
| | - Luca Persani
- Department of Clinical Sciences and Community Health, University of Milan, Via della Commenda 19, 20122, Milan, Italy
- Division of Endocrine and Metabolic Diseases & Laboratory of Endocrine and Metabolic Research, IRCCS Istituto Auxologico Italiano, Piazzale Brescia 20, 20149, Milan, Italy
| | - Iacopo Chiodini
- Department of Clinical Sciences and Community Health, University of Milan, Via della Commenda 19, 20122, Milan, Italy
- Division of Endocrine and Metabolic Diseases & Laboratory of Endocrine and Metabolic Research, IRCCS Istituto Auxologico Italiano, Piazzale Brescia 20, 20149, Milan, Italy
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10
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Aresta C, Favero V, Morelli V, Giovanelli L, Parazzoli C, Falchetti A, Pugliese F, Gennari L, Vescini F, Salcuni A, Scillitani A, Persani L, Chiodini I. Cardiovascular complications of mild autonomous cortisol secretion. Best Pract Res Clin Endocrinol Metab 2021; 35:101494. [PMID: 33814301 DOI: 10.1016/j.beem.2021.101494] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Adrenal incidentalomas (AI) may be associated with a mild autonomous cortisol secretion (MACS) in up to one third of cases. There is growing evidence that MACS patients actually present increased risk of cardiovascular disease and higher mortality rate, driven by increased prevalence of known cardiovascular risk factors, as well as accelerated cardiovascular remodelling. Adrenalectomy seems to have cardiometabolic beneficial effects in MACS patients but their management is still a debated topic due to the lack of high-quality studies. Several studies suggested that so called "non-functioning" AI may be actually "functioning" with an associated increased cardiovascular risk. Although the individual cortisol sensitivity and peripheral activation have been recently suggested to play a role in influencing the cardiovascular risk even in apparently eucortisolemic patients, to date the degree of cortisol secretion, as mirrored by the cortisol levels after dexamethasone suppression test remains the best predictor of an increased cardiovascular risk in AI patients. However, whether or not the currently used cut-off set at 50 nmol/L for cortisol levels after dexamethasone suppression could be considered completely reliable in ruling out hypercortisolism remains unclear.
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Affiliation(s)
- Carmen Aresta
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy.
| | - Vittoria Favero
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
| | - Valentina Morelli
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy.
| | - Luca Giovanelli
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
| | - Chiara Parazzoli
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy.
| | - Alberto Falchetti
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy.
| | - Flavia Pugliese
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo (FG), Italy.
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy.
| | - Fabio Vescini
- Endocrinology and Metabolism Unit, University-Hospital S. Maria della Misericordia, Udine, Italy.
| | - Antonio Salcuni
- Endocrinology and Metabolism Unit, University-Hospital S. Maria della Misericordia, Udine, Italy.
| | - Alfredo Scillitani
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo (FG), Italy.
| | - Luca Persani
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
| | - Iacopo Chiodini
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
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11
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Landmann E, Brugger M, Blank V, Wudy SA, Hartmann M, Strauch K, Rudloff S. Adrenal Steroid Metabolism and Blood Pressure in 5- to 7-Year-Old Children Born Preterm as Compared to Peers Born at Term. Front Pediatr 2021; 9:754989. [PMID: 34917560 PMCID: PMC8669960 DOI: 10.3389/fped.2021.754989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 10/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Previous studies indicated preterm birth to be a risk factor for hypertension in adolescence and adulthood. However, studies in children investigating the underlying mechanisms are scarce. Objective: We hypothesized children born preterm to have higher excretion of cortisol and/or androgen metabolites per day concomitantly with higher blood pressure as compared to peers born at term. We thus aimed to compare urinary steroid profiles and blood pressure between 5- to 7-year-old children born preterm and peers born at term. Furthermore, aldosterone precursor excretion per day was compared between both groups. Methods: Blood pressure was measured in 236 children (preterms n = 116; gestational age 29.8 ± 2.6 (30; 24-33) weeks [mean ± standard deviation (median; range)]) using an automatic oscillometric device. Urinary steroid profiles were determined in 24-h urine samples (preterms n = 109; terms n = 113) using gas chromatographic-mass spectrometric analysis. To assess excretion of cortisol and androgen metabolites per day, major cortisol and androgen metabolites were summed, respectively. To assess aldosterone excretion per day tetrahydrocorticosterone, 5α-tetrahydrocorticosterone, and tetrahydro-11-deydrocorticosterone were summed. Results: Multiple regression analyses showed prematurity to be associated with systolic but not with diastolic blood pressure. When adjusted for potential confounders (prematurity, gender, age at day of examination, being born small for gestational age, breastfeeding, accelerated weight gain during infancy, family history of cardiovascular disease, parental hypertension, and body mass index) prematurity was shown to be associated with an increase in systolic blood pressure by 2.87 mmHg (95% confidence interval 0.48-5.27; p = 0.02). Cortisol, androgen metabolite, and aldosterone precursor excretion per day were not higher in individuals born preterm. In contrast to our hypothesis, multiple regression analysis showed prematurity to independently decrease cortisol and aldosterone precursor excretion per day (p < 0.001 and 0.04, respectively). Conclusion: This study provides further evidence for systolic blood pressure to be higher after preterm birth as early as at the age of 5 to 7 years. However, this seems not to be explained by elevated excretion of cortisol and/or androgen metabolites.
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Affiliation(s)
- Eva Landmann
- Department of Pediatric Hematology and Oncology, Center of Child and Adolescent Medicine, Justus Liebig University Giessen, Giessen, Germany
| | - Markus Brugger
- Institute of Medical Biometry and Epidemiology, Philipps-University Marburg, Marburg, Germany.,Institute of Genetic Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany.,Institute of Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Genetic Epidemiology, LMU Munich, Munich, Germany.,Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Verena Blank
- Department of Neuropediatrics, Center of Child and Adolescent Medicine, Justus Liebig University Giessen, Giessen, Germany
| | - Stefan A Wudy
- Department of Pediatrics and Neonatology, Justus Liebig University Giessen, Giessen, Germany.,Steroid Research and Mass Spectrometry Unit, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus-Liebig-University Giessen, Giessen, Germany
| | - Michaela Hartmann
- Department of Pediatrics and Neonatology, Justus Liebig University Giessen, Giessen, Germany.,Steroid Research and Mass Spectrometry Unit, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus-Liebig-University Giessen, Giessen, Germany
| | - Konstantin Strauch
- Institute of Medical Biometry and Epidemiology, Philipps-University Marburg, Marburg, Germany.,Institute of Genetic Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany.,Institute of Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Genetic Epidemiology, LMU Munich, Munich, Germany.,Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Silvia Rudloff
- Department of Pediatrics and Neonatology, Justus Liebig University Giessen, Giessen, Germany.,Institute of Nutritional Science, Justus Liebig University Giessen, Giessen, Germany
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12
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Abstract
PURPOSE OF REVIEW To discuss the current definition as well as recommendations for diagnosis and treatment of resistant hypertension (RH) based on the 2018 American Heart Association (AHA) guidelines and recent literature. RECENT FINDINGS RH is defined as uncontrolled blood pressure (BP) on ≥ 3 anti-hypertensives, one of which should be a diuretic, prescribed at maximally tolerated doses and appropriate dosing frequency. The diagnosis of RH requires exclusion of white coat effect and medication non-adherence, underscoring the importance of out-of-office BP measurements. Secondary causes of hypertension must be excluded in all patients with RH. A step-wise approach to treatment focusing on lifestyle modifications and medication optimization can be effective in > 50% of the patients with RH. Device-based interventional therapies for RH are currently investigational. Out-of-office BP measurements are central to the diagnosis of RH. Medication optimization is successful in most patients. Further studies are needed to define the role of device-based interventions.
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Affiliation(s)
- Irene Chernova
- Yale School of Medicine/Section of Nephrology, New Haven, CT, USA
| | - Namrata Krishnan
- Yale School of Medicine/Section of Nephrology, New Haven, CT, USA. .,Veterans Affairs Medical Center, 950 Campbell Ave., West Haven, CT, 06516, USA.
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13
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Carey RM, Calhoun DA, Bakris GL, Brook RD, Daugherty SL, Dennison-Himmelfarb CR, Egan BM, Flack JM, Gidding SS, Judd E, Lackland DT, Laffer CL, Newton-Cheh C, Smith SM, Taler SJ, Textor SC, Turan TN, White WB. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension 2019; 72:e53-e90. [PMID: 30354828 DOI: 10.1161/hyp.0000000000000084] [Citation(s) in RCA: 572] [Impact Index Per Article: 114.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the "white-coat effect" (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.
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14
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Chiodini I, Ramos-Rivera A, Marcus AO, Yau H. Adrenal Hypercortisolism: A Closer Look at Screening, Diagnosis, and Important Considerations of Different Testing Modalities. J Endocr Soc 2019; 3:1097-1109. [PMID: 31069279 PMCID: PMC6500795 DOI: 10.1210/js.2018-00382] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 04/05/2019] [Indexed: 11/19/2022] Open
Abstract
Although prolonged hypercortisolism is associated with increased mortality and substantial morbidity, the clinical signs and symptoms are wide ranging and often nonspecific, contributing to challenges in diagnosis, as well as treatment delays. Greater awareness is needed among clinicians to help identify which patients should undergo biochemical screening for excess cortisol. Several biochemical tests are available, each with important caveats that should be considered in the context of the individual patient. Cortisol secretion varies widely, further complicating the biochemical diagnosis of hypercortisolism, which relies on the use of definitive cutoff values. Patients with hypercortisolism resulting from adrenal adenomas, including those discovered incidentally, often do not present with overt Cushingoid features (plethora, striae, muscle weakness, moon facies, etc.). However, the consequences of prolonged exposure to even slight elevations in cortisol levels are profound, including increased risk of diabetes, hypertension, fractures, cardiovascular events, and mortality. Because most cases of hypercortisolism resulting from an adrenal adenoma can be managed, it is imperative to identify patients at risk and initiate testing early for the best outcomes. The aim of this report is to increase awareness of the indications for screening for hypercortisolism and to review the biochemical screening tests and diagnosis for hypercortisolism associated with adrenal adenomas.
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Affiliation(s)
- Iacopo Chiodini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Unit for Bone Metabolism Diseases and Diabetes and Laboratory of Endocrine and Metabolic Research, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Auxologico Italiano, Milan, Italy
| | - Arelys Ramos-Rivera
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida
| | - Alan O Marcus
- South Orange County Endocrinology, Laguna Hills, California
| | - Hanford Yau
- Division of Endocrinology, University of California, San Francisco (UCSF Fresno), Fresno, California
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15
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Koracevic G, Stojkovic M, Lovic D, Pavlovic M, Kostic T, Kutlesic M, Micic S, Koracevic M, Djordjevic M. Should Cushing's Syndrome be Considered as a Disease with High Cardiovascular Risk in Relevant Guidelines? Curr Vasc Pharmacol 2018; 18:12-24. [PMID: 30289080 DOI: 10.2174/1570161116666181005122339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/29/2018] [Accepted: 09/29/2018] [Indexed: 12/27/2022]
Abstract
A considerable amount of data supports a 1.8-7.4-fold increased mortality associated with Cushing's syndrome (CS). This is attributed to a high occurrence of several cardiovascular disease (CVD) risk factors in CS [e.g. adiposity, arterial hypertension (AHT), dyslipidaemia and type 2 diabetes mellitus (T2DM)]. Therefore, practically all patients with CS have the metabolic syndrome (MetS), which represents a high CVD risk. Characteristically, despite a relatively young average age, numerous patients with CS display a 'high' or 'very high' CVD risk (i.e. risk of a major CVD event >20% in the following 10 years). Although T2DM is listed as a condition with a high CVD risk, CS is not, despite the fact that a considerable proportion of the CS population will develop T2DM or impaired glucose tolerance. CS is also regarded as a risk factor for aortic dissection in current guidelines. This review considers the evidence supporting listing CS among high CVD risk conditions.
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Affiliation(s)
- Goran Koracevic
- Department for Cardiovascular Diseases, Clinical Centre, Nis, Serbia.,Medical Faculty, University of Nis, Nis, Serbia
| | | | - Dragan Lovic
- Clinic for Internal Medicine Intermedica, Nis, Serbia
| | - Milan Pavlovic
- Department for Cardiovascular Diseases, Clinical Centre, Nis, Serbia.,Medical Faculty, University of Nis, Nis, Serbia
| | - Tomislav Kostic
- Department for Cardiovascular Diseases, Clinical Centre, Nis, Serbia.,Medical Faculty, University of Nis, Nis, Serbia
| | | | | | | | - Milan Djordjevic
- Health Centre Jagodina, Emergency Medical Service, Jagodina, Serbia
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Reimondo G, Puglisi S, Pia A, Terzolo M. Autonomous hypercortisolism: definition and clinical implications. MINERVA ENDOCRINOL 2018; 44:33-42. [PMID: 29963828 DOI: 10.23736/s0391-1977.18.02884-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In current practice, an adrenal adenoma usually comes as an unexpected byproduct of an imaging study performed for unrelated reasons, without any prior suspect of adrenal disease. Therefore, these tumors currently represent a public health challenge because they are increasingly recognized due to the widespread use of high-resolution cross-sectional imaging for diagnostic purposes. In radiology series, the prevalence of adrenal adenomas increases steeply with age, from around 3% below the age of 50 years up to 10% in the ageing population. These tumors may have clinical relevance because they are able to secrete cortisol autonomously, independently from the pituitary control, in up to 20-30% of patients. In most of the cases the resulting cortisol excess is insufficient to produce a typical Cushing phenotype but may have clinical consequences, such as hypertension, diabetes, obesity, dyslipidemia and osteoporosis. Despite some controversy on the most effective diagnostic algorithm to define this subtle hypercortisolism, there is mounting evidence that a simple approach by using the 1-mg overnight dexamethasone suppression test (DST) may stratify patients for their cardiovascular risk. Cross-sectional, retrospective studies showed that patients with increasingly higher cortisol following DST have an adverse cardiovascular risk profile and are at increased risk of death. Therefore, also a subtle autonomous cortisol excess is associated with increased morbidity and mortality, mainly of cardiovascular origin.
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Affiliation(s)
- Giuseppe Reimondo
- Unit of Internal Medicine and Endocrinology, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Turin, Orbassano, Turin, Italy -
| | - Soraya Puglisi
- Unit of Internal Medicine and Endocrinology, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Turin, Orbassano, Turin, Italy
| | - Anna Pia
- Unit of Internal Medicine and Endocrinology, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Turin, Orbassano, Turin, Italy
| | - Massimo Terzolo
- Unit of Internal Medicine and Endocrinology, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Turin, Orbassano, Turin, Italy
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Chiodini I, Vainicher CE, Morelli V, Palmieri S, Cairoli E, Salcuni AS, Copetti M, Scillitani A. MECHANISMS IN ENDOCRINOLOGY: Endogenous subclinical hypercortisolism and bone: a clinical review. Eur J Endocrinol 2016; 175:R265-R282. [PMID: 27412441 DOI: 10.1530/eje-16-0289] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 07/13/2016] [Indexed: 01/11/2023]
Abstract
In recent years, the condition of subclinical hypercortisolism (SH) has become a topic of growing interest. This is due to the fact that SH prevalence is not negligible (0.8-2% in the general population) and that, although asymptomatic, this subtle cortisol excess is not harmless, being associated with an increased risk of complications, in particular of osteoporosis and fragility fractures. As specific symptoms of hypercortisolism are absent in SH, the SH diagnosis relies only on biochemical tests and it is a challenge for physicians. As a consequence, even the indications for the evaluation of bone involvement in SH patients are debatable and guidelines are not available. Finally, the relative importance of bone density, bone quality and glucocorticoid sensitivity in SH is a recent field of research. On the other hand, SH prevalence seems to be increased in osteoporotic patients, in whom a vertebral fracture may be the presenting symptom of an otherwise asymptomatic cortisol excess. Therefore, the issue of who and how to screen for SH among the osteoporotic patients is widely debated. The present review will summarize the available data regarding the bone turnover, bone mineral density, bone quality and risk of fracture in patients with endogenous SH. In addition, the role of the individual glucocorticoid sensitivity in SH-related bone damage and the problem of diagnosing and managing the bone consequences of SH will be reviewed. Finally, the issue of suspecting and screening for SH patients with apparent primary osteoporosis will be addressed.
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Affiliation(s)
- I Chiodini
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - C Eller Vainicher
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - V Morelli
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - S Palmieri
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - E Cairoli
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - A S Salcuni
- Endocrine UnitDepartment of Medical Sciences, University of Cagliari, Cagliari, Italy
| | | | - A Scillitani
- Unit of Endocrinology"Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
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Jurca SJ, Elliott WJ. Common Substances That May Contribute to Resistant Hypertension, and Recommendations for Limiting Their Clinical Effects. Curr Hypertens Rep 2016; 18:73. [DOI: 10.1007/s11906-016-0682-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Costa DS, Conceição FL, Leite NC, Ferreira MT, Salles GF, Cardoso CRL. Prevalence of subclinical hypercortisolism in type 2 diabetic patients from the Rio de Janeiro Type 2 Diabetes Cohort Study. J Diabetes Complications 2016; 30:1032-8. [PMID: 27210052 DOI: 10.1016/j.jdiacomp.2016.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/16/2016] [Accepted: 05/04/2016] [Indexed: 12/29/2022]
Abstract
AIMS Subclinical hypercortisolism was reported to be more prevalent among diabetic, obese and hypertensive patients. Our primary aim was to investigate the prevalence of subclinical hypercortisolism in patients from the Rio de Janeiro Type 2 Diabetes (RIO-T2D) Cohort; and secondarily to assess its associated factors. METHODS From May 2013 to August 2014, 393 diabetic outpatients underwent overnight 1mg dexamethasone suppression test (DST). Patients with non-suppressive morning cortisol (≥1.8μg/dl) were further evaluated with nocturnal salivary cortisol, two readings >0.35μg/dl were considered confirmatory for subclinical hypercortisolism. RESULTS One-hundred twenty-eight patients (32.6%) failed to suppress morning cortisol, and in 33 patients (8.6%) subclinical hypercortisolism was confirmed. Independent correlates of a positive DST were older age (OR: 1.04; 95% CI: 1.01-1.07; p=0.007), number of anti-hypertensive drugs in use (OR: 1.26; 95% CI: 1.05-1.50; p=0.012), longer diabetes duration (OR: 1.03; 95% CI: 1.004-1.06; p=0.023), and presence of diabetic nephropathy (OR: 1.70; 95% CI: 1.01-2.87; p=0.047). Independent correlates of confirmed subclinical hypercortisolism were a greater number of anti-hypertensive medications (OR: 1.54; 95% CI: 1.14-2.06; p=0.004), shorter diabetes duration (OR: 0.92; 95% CI: 0.87-0.98; p=0.006), and increased aortic stiffness (OR: 2.81; 95% CI: 1.20-6.57; p=0.017); metformin use was protective (OR: 0.27; 95% CI: 0.10-0.73; p=0.010). CONCLUSION Patients with type 2 diabetes had a high prevalence of subclinical hypercortisolism, and its presence was associated with more severe hypertension and increased aortic stiffness.
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Affiliation(s)
- Denise S Costa
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Rodolpho Paulo Rocco 255, Cidade Universitária-Ilha do Fundão Rio de Janeiro-RJ, Brazil, CEP: 21941-913
| | - Flavia L Conceição
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Rodolpho Paulo Rocco 255, Cidade Universitária-Ilha do Fundão Rio de Janeiro-RJ, Brazil, CEP: 21941-913
| | - Nathalie C Leite
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Rodolpho Paulo Rocco 255, Cidade Universitária-Ilha do Fundão Rio de Janeiro-RJ, Brazil, CEP: 21941-913
| | - Marcel T Ferreira
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Rodolpho Paulo Rocco 255, Cidade Universitária-Ilha do Fundão Rio de Janeiro-RJ, Brazil, CEP: 21941-913
| | - Gil F Salles
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Rodolpho Paulo Rocco 255, Cidade Universitária-Ilha do Fundão Rio de Janeiro-RJ, Brazil, CEP: 21941-913
| | - Claudia R L Cardoso
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Rodolpho Paulo Rocco 255, Cidade Universitária-Ilha do Fundão Rio de Janeiro-RJ, Brazil, CEP: 21941-913.
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Cushing’s Syndrome: Screening and Diagnosis. High Blood Press Cardiovasc Prev 2016; 23:209-15. [DOI: 10.1007/s40292-016-0153-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/25/2016] [Indexed: 10/21/2022] Open
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Belen E, Sungur A, Sungur MA, Erdoğan G. Increased Neutrophil to Lymphocyte Ratio in Patients With Resistant Hypertension. J Clin Hypertens (Greenwich) 2015; 17:532-7. [PMID: 25807989 PMCID: PMC8031939 DOI: 10.1111/jch.12533] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 12/30/2014] [Accepted: 01/02/2015] [Indexed: 11/27/2022]
Abstract
Resistant hypertension (RHT) is an important disease that causes an increase in cardiovascular risk, yet its etiology remains unclear. The authors aimed to investigate neutrophil/lymphocyte ratio (NLR) as an inflammation marker in patients with RHT. A total of 150 patients were included in the study and grouped according to their office and ambulatory blood pressure measurements. They were classified as having normotension (NT), controlled hypertension (CHT), or RHT. The RHT group had a significantly higher NLR than the CHT group (P=.03), and NLRs of both hypertension groups were significantly higher than those in the NT group (P<.001, for both). NLR and neutrophil count were found to be independent correlates for RHT in multivariate analysis (P<.001). NLR and neutrophil count are increased in RHT patients than both CHT and NT patients. This finding, which is defined for the first time in patients with RHT, may imply the importance of inflammation in blood pressure control.
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Affiliation(s)
- Erdal Belen
- Department of CardiologyOkmeydanı Training and Research HospitalIstanbulTurkey
| | - Aylin Sungur
- Department of CardiologyKahramanmaras Necip Fazıl City HospitalKahramanmarasTurkey
| | - Mustafa Azmi Sungur
- Department of CardiologyKahramanmaras Necip Fazıl City HospitalKahramanmarasTurkey
| | - Güney Erdoğan
- Department of CardiologyOrdu Training and Research HospitalOrduTurkey
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Abstract
INTRODUCTION Cushing's syndrome (CS) is a rare disease characterized by a collection of signs and symptoms, also common in the general population without elevated cortisol secretion. During the last years more patients with CS are identified earlier and with milder disease. Many of these patients are diagnosed during screening efforts performed for certain or isolated complaints like weight gain, diabetes mellitus (DM), hypertension, osteoporosis, elevated white blood cell counts and more. METHODS In this review article the most popular screening test performed in the studies cited was the 1-mg dexamethasone suppression test. CONCLUSIONS Cushing is not frequent enough to support the use of routine screening in patients with morbid obesity and type 2 DM. Also only 1% of hypertensive patients have secondary hypertension due to CS. However, screening should be considered in young patients with resistant DM and/or hypertension. Among patients with osteoporosis and vertebral fractures up to 5% were diagnosed with subclinical hypercortisolism; most of these had adrenal adenoma. Screening for CS is important in subjects with adrenal incidentaloma, and many studies show a high prevalence (~10%) of Cushing or subclinical CS in these patients.
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Affiliation(s)
- Ilan Shimon
- Rabin Medical Center, Institute of Endocrinology and Metabolism, Beilinson Hospital, 49100, Petach Tikva, Israel,
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Fülöp T, Tapolyai M. Beauty in Simplicity: Abnormal Neutrophil to Lymphocyte Ratio in Resistant Hypertension. J Clin Hypertens (Greenwich) 2015; 17:538-40. [PMID: 25810379 DOI: 10.1111/jch.12526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Tibor Fülöp
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Mihály Tapolyai
- Fresenius Medical Care Hungary, Semmelweis University, Budapest, Hungary
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Zhang R, Bo T, Shen L, Luo S, Li J. Effect of dexamethasone on intelligence and hearing in preterm infants: a meta-analysis. Neural Regen Res 2014; 9:637-45. [PMID: 25206867 PMCID: PMC4146231 DOI: 10.4103/1673-5374.130085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2014] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE A meta-analysis of published randomized controlled trials investigating the long-term effect of dexamethasone on the nervous system of preterm infants. DATA SOURCES Online literature retrieval was conducted using The Cochrane Library (from January 1993 to June 2013), EMBASE (from January 1980 to June 2013), MEDLINE (from January 1963 to June 2013), OVID (from January 1993 to June 2013), Springer (from January 1994 to June 2013) and Chinese Academic Journal Full-text Database (from January 1994 to June 2013). Key words were preterm infants and dexamethasone in English and Chinese. STUDY SELECTION Selected studies were randomized controlled trials assessing the effect of intravenous dexamethasone in preterm infants. The quality of the included papers was evaluated and those without the development of the nervous system and animal experiments were excluded. Quality assessment was performed through bias risk evaluation in accordance with Cochrane Handbook 5.1.0 software in the Cochrane Collaboration. The homogeneous studies were analyzed and compared using Revman 5.2.6 software, and then effect model was selected and analyzed. Those papers failed to be included in the meta-analysis were subjected to descriptive analysis. MAIN OUTCOME MEASURES Nervous system injury in preterm infants. RESULTS Ten randomized controlled trials were screened, involving 1,038 subjects. Among them 512 cases received dexamethasone treatment while 526 cases served as placebo control group and blank control group. Meta-analysis results showed that the incidence of cerebral palsy, visual impairment and hearing loss in preterm infants after dexamethasone treatment within 7 days after birth was similar to that in the control group (RR = 1.47, 95%CI: 0.97-2.21; RR = 1.46, 95%CI: 0.97-2.20; RR = 0.80, 95%CI: 0.54-1.18; P > 0.05), but intelligence quotient was significantly decreased compared with the control group (MD = -3.55, 95%CI: -6.59 to -0.51; P = 0.02). Preterm infants treated with dexamethasone 7 days after birth demonstrated an incidence of cerebral palsy and visual impairment, and changes in intelligence quotient similar to those in the control group (RR = 1.26, 95%CI: 0.89-1.79; RR = 1.37, 95%CI: 0.73-2.59; RR = 0.53, 95%CI: 0.32-0.89; RR = 1.66, 95%CI: -4.7 to 8.01; P > 0.05). However, the incidence of hearing loss was significantly increased compared with that in the control group (RR = 0.53, 95%CI: 0.32-0.89; P = 0.02). CONCLUSION Dexamethasone may affect the intelligence of preterm infants in the early stages after birth, but may lead to hearing impairment at later stages after birth. More reliable conclusions should be made through large-size, multi-center, well-designed randomized controlled trials.
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Affiliation(s)
- Ruolin Zhang
- Department of Pediatrics, Second Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Tao Bo
- Department of Pediatrics, Second Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Li Shen
- Department of Pediatrics, Second Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Senlin Luo
- Department of Pediatrics, Second Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Jian Li
- Department of Pediatrics, Second Xiangya Hospital, Central South University, Changsha, Hunan Province, China
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Borsoi L, Ludvik B, Prager G, Luger A, Riedl M. Cushing's syndrome in a morbidly obese patient undergoing evaluation before bariatric surgery. Obes Facts 2014; 7:191-6. [PMID: 24903206 PMCID: PMC5644810 DOI: 10.1159/000363260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 10/10/2013] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Cushing's syndrome (CS) is extremely rare in morbidly obese patients. To date, no occurrences in obese patients with BMI above 60 kg/m2 have been reported in the literature. CASE REPORT This case report describes a patient who was admitted to the ward of the Clinical Division of Endocrinology and Metabolism of the Medical University of Vienna in preparation for bariatric surgery. The patient was a 49-year-old female who showed morbid obesity (BMI 61.6 kg/m2), hypertension, and substituted hypothyroidism. Preoperative work-up revealed CS due to an adrenal adenoma. Therefore, the patient underwent unilateral adrenalectomy followed by bariatric surgery 6 months later. CONCLUSION Since undiagnosed CS might result in severe perioperative complications in a population already at increased risk, this case report underlines the importance of careful endocrine evaluation of morbidly obese patients. After all, even rare endocrine causes should be excluded.
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Affiliation(s)
- Livia Borsoi
- Institute of Social Medicine, Centre for Public Health, Vienna, Austria
- Department of Endocrinology and Metabolism, Internal Medicine III, Vienna, Austria
- *Livia Borsoi, MD, MPH, Institute of Social Medicine, Centre for Public Health, Medical University of Vienna, Kinderspitalgasse 15, 1090 Vienna (Austria),
| | - Bernhard Ludvik
- Department of Endocrinology and Metabolism, Internal Medicine III, Vienna, Austria
| | - Gerhard Prager
- Department of Surgery, Medical University of Vienna, Austria
| | - Anton Luger
- Department of Endocrinology and Metabolism, Internal Medicine III, Vienna, Austria
| | - Michaela Riedl
- Department of Endocrinology and Metabolism, Internal Medicine III, Vienna, Austria
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The possibility of resistant hypertension during the treatment of hypertensive patients. Hypertens Res 2013; 36:924-9. [PMID: 24026036 DOI: 10.1038/hr.2013.107] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 07/22/2013] [Accepted: 07/25/2013] [Indexed: 02/07/2023]
Abstract
Patients with poorly controlled hypertension despite taking at least three different kinds of anti-hypertensive drugs, including diuretics, are considered to have resistant hypertension (RH). The prevalence of RH was reported to be 13% in the Japanese J-HOME study. The incidences of RH in younger and older Japanese individuals should be prospectively investigated in the near future. RH is associated with poor outcomes and various cardiovascular events. In addition, it is frequently associated with older age, obesity, sleep apnea, long-term hypertension, diabetes, dyslipidemia, reduced renal function, microalbuminuria and left ventricular hypertrophy. Some cases of RH exhibit high levels of aldosterone and cortisol, suggesting that endocrine hypertension should be ruled out among RH patients. Carotid baroreceptor activation and renal sympathetic denervation have recently been developed as treatments for RH. In conclusion, we should consider the possibility of RH during the treatment of hypertensive patients who do not achieve appropriate blood pressure control, in order to avoid the early onset of fatal cardiovascular events and reduce medical costs.
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Cardoso EML, Arregger AL, Monardes G, Contreras LN. An accurate, non-invasive approach to diagnose Cushing's syndrome in at-risk populations. Steroids 2013; 78:476-82. [PMID: 23485687 DOI: 10.1016/j.steroids.2013.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 01/30/2013] [Accepted: 02/04/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The prevalence of Cushing's syndrome (CS) in at-risk populations in developing countries remains uncertain. Evening urinary cortisol (UFC(22-23)) and salivary cortisol after treatment with 1-mg DST (SAFdex) have seldom been used as diagnostic tools in these populations. OBJECTIVES (1) To establish the prevalence of CS in adults with cortisol-related morbidities using UFC22-23 and SAFdex as markers along with all first-line diagnostic tests recommended for CS; and (2) to assess the performance of each test and define a non-invasive diagnostic approach for CS in at-risk outpatient subjects. METHODS A total of 128 outpatients were evaluated, including type 1 and 2 diabetic patients with poor metabolic control (DM1 and DM2), hypertensive subjects with central obesity (HBP) and premenopausal women with osteoporosis (OS). Controls included 100 healthy volunteers and 23 patients with CS. Total urinary cortisol (UFC), UFC(22-23), late-night salivary cortisol (SAF23) and suppression of cortisol levels in saliva (SAFdex) and serum (Fdex) after treatment with 1-mg DST were assessed. RESULTS CS was diagnosed in one DM2 and one HBP patient; both women exhibited central obesity. Among CS patients, UFC showed more within-person variability than UFC(22-23) or SAF23. UFC(22-23) and SAF23 were positively and significantly correlated in all groups (r > or = 0.70; p < or = 0.0001). UFC(22-23) > 44.0 ng/mg creatinine or SAF23 > 3.8 nM were 100% sensitive (S) and specific (E) for CS. Furthermore, SAFdex > 2.0 nM or Fdex > 50.0 nM were 100% S and 97.3% E for CS. CONCLUSION CS was diagnosed in 1.5% of at-risk patients. The combination of UFC(22-23) or SAF23 with SAFdex offers a non-invasive diagnostic tool to assess cortisol nadir and feed-back status in outpatients.
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Affiliation(s)
- Estela M L Cardoso
- Endocrine Research Department, Instituto de Investigaciones Médicas A. Lanari, University of Buenos Aires, Argentina
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