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Ravichandran L, Asha HS, Mathai S, Thomas N, Chapla A. Congenital Adrenal Hyperplasia - A Comprehensive Review of Genetic Studies on 21-Hydroxylase Deficiency from India. Indian J Endocrinol Metab 2024; 28:117-128. [PMID: 38911104 PMCID: PMC11189293 DOI: 10.4103/ijem.ijem_303_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/23/2023] [Accepted: 02/06/2024] [Indexed: 06/25/2024] Open
Abstract
Congenital adrenal hyperplasia (CAH) comprises a heterogeneous group of autosomal recessive disorders impairing adrenal steroidogenesis. Most cases are caused by mutations in the CYP21A2 gene resulting in 21-hydroxylase (21-OH) deficiency (21-OHD). The genetics of 21-OH CAH is complexed by a highly homologous pseudogene CYP21A1P imposing several limitations in the molecular analysis. Therefore, genetic testing is still not a part of routine CAH diagnosis and is mainly dependent on 17-hydroxy progesterone (OHP) measurements. There are very few reports of CYP21A2 gene analysis from India and there is no comprehensive review available on genetic testing and the spectrum of CYP21A2 mutations from the country. This review focuses on the molecular aspects of 21-OHD and the genetic studies on CYP21A2 gene reported from India. The results of these studies insist the compelling need for large-scale CYP21A2 genetic testing and newborn screening (NBS) in India. With a high disease prevalence and consanguinity rates, robust and cost-effective genetic testing for 21-OH CAH would enable an accurate diagnosis in routine clinical practice. Whereas establishing affordable genotyping assays even in secondary care or resource-poor settings of the country can identify 90% of the mutations that are pseudogene derived, initiatives on reference laboratories for CAH across the nation with comprehensive genetic testing facilities will be beneficial in those requiring extended analysis of CYP21A2 gene. Further to this, incorporating genetic testing in NBS and carrier screening programmes will enable early diagnosis, better risk assessment and community-based management.
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Affiliation(s)
- Lavanya Ravichandran
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
- DBT-Regional Centre for Biotechnology (RCB), Faridabad, Haryana, India
| | - Hesarghatta S. Asha
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sarah Mathai
- Department of Pediatric Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
- DBT-Regional Centre for Biotechnology (RCB), Faridabad, Haryana, India
| | - Aaron Chapla
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
- DBT-Regional Centre for Biotechnology (RCB), Faridabad, Haryana, India
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Ben Simon A, Brener A, Segev-Becker A, Yackobovitch-Gavan M, Uretzky A, Schachter Davidov A, Alaev A, Oren A, Eyal O, Weintrob N, Lebenthal Y. Body composition in children and adolescents with non-classic congenital adrenal hyperplasia and the risk for components of metabolic syndrome: An observational study. Front Endocrinol (Lausanne) 2022; 13:1022752. [PMID: 36353234 PMCID: PMC9639453 DOI: 10.3389/fendo.2022.1022752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/26/2022] [Indexed: 01/19/2023] Open
Abstract
Background Treated or untreated non-classic congenital adrenal hyperplasia (NCCAH) diagnosed in childhood could pose an increased risk of obesity and metabolic derangements in adolescence and early adulthood. We aimed to explore the interaction between muscle-to-fat ratio (MFR) and components of metabolic syndrome in pediatric subjects with NCCAH. Methods This retrospective observational study was conducted in the Tel Aviv Medical Center from January 2018 to January 2022. The study group comprised 75 subjects (26 males) with NCCAH (61 hydrocortisone-treated [21 males] and 14 untreated [5 males]) and 134 healthy sex- and age-matched subjects (41 males) with normal puberty served as controls. Body composition was measured by bioelectrical impedance analysis (BIA) and muscle-to-fat ratio (MFR) z-scores were calculated. Stepwise linear regression models were applied to evaluate explanatory variables for MFR z-scores, blood pressure percentiles, lipid profiles, and glucose metabolism. Results The median age [interquartile range] was 7.5 years [5.3, 8.8] at NCCAH diagnosis and 12.3 years [8.9, 15.4] at BIA. The median cumulative hydrocortisone dose was 7620 mg/m2 [2547, 12903]. Subjects with NCCAH had higher mean BMI z-scores and lower median MFR z-scores compared to controls [(0.47 ± 0.97 vs. -0.19 ± 1.04, p<0.001) and (-0.74 [-1.06, -0.14] vs.-0.37 [-0.99, 0.15], p=0.045), respectively]. The linear regression models dependent variables and their explanatory variables were: MFR z-score (R2= 0.253, p<0.001) - socioeconomic position index (β=0.348, p=0.003), birthweight z-score (β=-0.258, p=0.013), and duration of hydrocortisone treatment in years (β=0.048, p=0.023); systolic blood pressure percentile (R2 = 0.166, p<0.001) - MFR z-score (β=-9.75, p<0.001); TG/HDL ratio (R2 = 0.116, p=0.024) - MFR z-score (β=-0.300, p=0.024). No significant variables were found for glucose. Conclusions Children and adolescents with NCCAH have a body composition characterized by an imbalance between muscle and fat tissues, which may place them at increased risk for early-onset cardiometabolic derangements. It is reassuring that glucocorticoid therapy aimed to alleviate androgen overproduction does not appear to adversely affect their body composition.
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Affiliation(s)
- Asaf Ben Simon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avivit Brener
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Anat Segev-Becker
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Michal Yackobovitch-Gavan
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Uretzky
- The Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Anita Schachter Davidov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Angelika Alaev
- The Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Nursing Services, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Asaf Oren
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ori Eyal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Naomi Weintrob
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Lebenthal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Zhang Q, Zhan M, Wu H, Feng P, Jin X, Wan Z, Yan J, Zhang P, Ke P, Zhuang J, Zhou J, Han L, Huang X. Simultaneous quantitation of 17 endogenous adrenal corticosteroid hormones in human plasma by UHPLC-MS/MS and their application in congenital adrenal hyperplasia screening. Front Chem 2022; 10:961660. [PMID: 36034654 PMCID: PMC9403142 DOI: 10.3389/fchem.2022.961660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
Accurate investigation of adrenal hormone levels plays a vital role in pediatric endocrinology for the detection of steroid-related disorders. This study aims to develop a straightforward, sensitive UHPLC-MS/MS method to quantify 17 endogenous adrenal corticosteroid hormones in human plasma. These hormones are the main ingredients in the synthetic and metabolic pathways of adrenal corticosteroid hormones. Chromatographic separation was achieved on a C18 column before electrospray ionization triple-quadrupole mass spectrometry in multiple reaction monitoring mode with a run time of 7 min. The samples were extracted by liquid-liquid extraction and required no derivatization. Analytical performance was evaluated, including linearity, analytical sensitivity, accuracy, precision, and specificity. Plasma specimens from 32 congenital adrenal hyperplasia (CAH) patients and 30 healthy volunteers were analyzed to further reveal the diagnostic value of multiple steroid hormones in the synthetic and metabolic pathways of adrenal corticosteroid in CAH diagnosis. All hormones were effectively extracted and separated using our method. The method was essentially free from potential interference of isomers or structural analogues. The imprecisions were <10%. The lower limits of quantification varied from 0.05 to 15.0 ng/ml. Good linearity coefficients (r2 > 0.998) were also obtained for most hormones in the required concentration range, except for 21-deoxycortisol (r2 = 0.9967) and androstenediol (r2 = 0.9952). The recoveries for the steroid hormones ranged from 91.7 to 109.8%. We developed the UHPLC-MS/MS method for the simultaneous measurement of steroid hormones. The results showed that measurement of steroid hormones simultaneously could improve the diagnostic efficiency of CAH.
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Affiliation(s)
- Qiaoxuan Zhang
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Min Zhan
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Huihui Wu
- Anhui Prevention and Treatment Center for Occupational Disease, Anhui No. 2 Provincial People’s Hospital, Hefei, China
| | - Pinning Feng
- Department of Laboratory Medicine, Sun Yat-Sen University First Affiliated Hospital, Guangzhou, China
| | - Xing Jin
- The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Zemin Wan
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Jun Yan
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Pengwei Zhang
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Peifeng Ke
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Junhua Zhuang
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Jiuyao Zhou
- Department of Pharmacology, School of Pharmaceutical Sciences, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Liqiao Han
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
- *Correspondence: Liqiao Han, ; Xianzhang Huang,
| | - Xianzhang Huang
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
- *Correspondence: Liqiao Han, ; Xianzhang Huang,
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Agnani H, Bachelot G, Eguether T, Ribault B, Fiet J, Le Bouc Y, Netchine I, Houang M, Lamazière A. A proof of concept of a machine learning algorithm to predict late-onset 21-hydroxylase deficiency in children with premature pubic hair. J Steroid Biochem Mol Biol 2022; 220:106085. [PMID: 35292353 DOI: 10.1016/j.jsbmb.2022.106085] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 02/27/2022] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
In children with premature pubarche (PP), late onset 21-hydroxylase deficiency (21-OHD), also known as non-classical congenital adrenal hyperplasia (NCCAH), can be routinely ruled out by an adrenocorticotropic hormone (ACTH) test. Using liquid chromatography-tandem mass spectrometry (LC-MS/MS), a quantitative assay of the circulating steroidome can be obtained from a single blood sample. We hypothesized that, by applying multivariate machine learning (ML) models to basal steroid profiles and clinical parameters of 97 patients, we could distinguish children with PP from those with NCCAH, without the need for ACTH testing. Every child presenting with PP at the Trousseau Pediatric Endocrinology Unit between 2016 and 2018 had a basal and stimulated steroidome. Patients with central precocious puberty were excluded. The first set of patients (year 1, training set, n = 58), including 8 children with NCCAH verified by ACTH test and genetic analysis, was used to train the model. Subsequently, a validation set of an additional set of patients (year 2, n = 39 with 5 NCCAH) was obtained to validate our model. We designed a score based on an ML approach (orthogonal partial least squares discriminant analysis). A metabolic footprint was assigned for each patient using clinical data, bone age, and adrenal steroid levels recorded by LC-MS/MS. Supervised multivariate analysis of the training set (year 1) and validation set (year 2) was used to validate our score. Based on selected variables, the prediction score was accurate (100%) at differentiating premature pubarche from late onset 21-OHD patients. The most significant variables were 21-deoxycorticosterone, 17-hydroxyprogesterone, and 21-deoxycortisol steroids. We proposed a new test that has excellent sensitivity and specificity for the diagnosis of NCCAH, due to an ML approach.
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Affiliation(s)
- Héléna Agnani
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Sorbonne Université, Paris, France; Explorations Fonctionnelles Endocriniennes, Hôpital Armand Trousseau, AP-HP, 26 Av Dr Netter, Paris 75012, France
| | - Guillaume Bachelot
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP/Sorbonne Université, Paris, France
| | - Thibaut Eguether
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP/Sorbonne Université, Paris, France
| | - Bettina Ribault
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP/Sorbonne Université, Paris, France
| | - Jean Fiet
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP/Sorbonne Université, Paris, France
| | - Yves Le Bouc
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Sorbonne Université, Paris, France; Explorations Fonctionnelles Endocriniennes, Hôpital Armand Trousseau, AP-HP, 26 Av Dr Netter, Paris 75012, France
| | - Irène Netchine
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Sorbonne Université, Paris, France; Explorations Fonctionnelles Endocriniennes, Hôpital Armand Trousseau, AP-HP, 26 Av Dr Netter, Paris 75012, France
| | - Muriel Houang
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Sorbonne Université, Paris, France; Explorations Fonctionnelles Endocriniennes, Hôpital Armand Trousseau, AP-HP, 26 Av Dr Netter, Paris 75012, France
| | - Antonin Lamazière
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP/Sorbonne Université, Paris, France.
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Nakhleh A, Saiegh L, Shehadeh N, Weintrob N, Sheikh-Ahmad M, Supino-Rosin L, Alboim S, Gendelman R, Zloczower M. Screening for non-classic congenital adrenal hyperplasia in women: New insights using different immunoassays. Front Endocrinol (Lausanne) 2022; 13:1048663. [PMID: 36704043 PMCID: PMC9871807 DOI: 10.3389/fendo.2022.1048663] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
CONTEXT The 250µg-cosyntropin stimulation test (CST) is used to diagnose non-classic congenital adrenal hyperplasia (NCCAH). The current recommendation is to perform CST when follicular 17-hydroxyprogesterone (17OHP) is 6-30 nmol/L, a cutoff derived from radioimmunoassay (RIA). Recently, enzyme-linked immunosorbent assay (ELISA) has replaced RIA. OBJECTIVES We aimed to (1) determine the RIA and ELISA-based 17OHP cutoffs at which CST should be performed, (2) identify predictors of NCCAH. METHODS A retrospective study at an Israeli Health Maintenance Organization. Data were retrieved from women with suspected NCCAH, referred for CST during 2001-2020. NCCAH was defined as a stimulated 17OHP >30 nmol/L. Serum 17OHP levels were assayed by RIA from 1/2000-3/2015, and by ELISA from 4/2015-12/2020. ROC curves were generated and optimal 17OHP thresholds were determined. Multivariate analysis was performed. RESULTS CST was performed in 2409 women (1564 in RIA, 845 in ELISA). NCCAH was diagnosed in 4.7% of the RIA group and 7.5% of the ELISA group. The optimal basal 17OHP cutoff values predicting NCCAH were 6.1 nmol/L in RIA (sensitivity=93.2%, specificity=91.7%) and 8.2 nmol/L in ELISA (sensitivity=93.7%, specificity=92.3%). In multivariate analysis, higher basal 17OHP, lower LH: FSH ratio, and oligomenorrhea were predictors of NCCAH in RIA. Higher basal 17OHP, androstenedione, and total testosterone were predictors of NCCAH in ELISA. A lower LH: FSH ratio showed similar trend in ELISA. CONCLUSIONS Optimal RIA-based basal 17OHP cutoff was comparable with that recommended in guidelines. The results suggest adopting a higher 17OHP cutoff when using ELISA. LH : FSH ratio improves the negative predictive value of basal 17OHP.
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Affiliation(s)
- Afif Nakhleh
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, Haifa, Israel
- Diabetes and Endocrinology Clinic, Maccabi Healthcare Services, Haifa, Israel
- *Correspondence: Afif Nakhleh,
| | - Leonard Saiegh
- Ruth & Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
- Department of Endocrinology, Bnai Zion Medical Center, Haifa, Israel
| | - Naim Shehadeh
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, Haifa, Israel
- Diabetes and Endocrinology Clinic, Maccabi Healthcare Services, Haifa, Israel
- Ruth & Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Naomi Weintrob
- Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | | | - Lia Supino-Rosin
- Central Laboratory, Maccabi Healthcare Services, Rehovot, Israel
| | - Sandra Alboim
- Central Laboratory, Maccabi Healthcare Services, Rehovot, Israel
| | - Raya Gendelman
- The Endocrine Laboratory, Rambam Health Care Campus, Haifa, Israel
| | - Moshe Zloczower
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, Haifa, Israel
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Abstract
Adrenarche is the maturational increase in adrenal androgen production that normally begins in early childhood. It results from changes in the secretory response to adrenocorticotropin (ACTH) that are best indexed by dehydroepiandrosterone sulfate (DHEAS) rise. These changes are related to the development of the zona reticularis (ZR) and its unique gene/enzyme expression pattern of low 3ß-hydroxysteroid dehydrogenase type 2 with high cytochrome b5A, sulfotransferase 2A1, and 17ß-hydroxysteroid dehydrogenase type 5. Recently 11-ketotestosterone was identified as an important bioactive adrenarchal androgen. Birth weight, body growth, obesity, and prolactin are related to ZR development. Adrenarchal androgens normally contribute to the onset of sexual pubic hair (pubarche) and sebaceous and apocrine gland development. Premature adrenarche causes ≥90% of premature pubarche (PP). Its cause is unknown. Affected children have a significantly increased growth rate with proportionate bone age advancement that typically does not compromise growth potential. Serum DHEAS and testosterone levels increase to levels normal for early female puberty. It is associated with mildly increased risks for obesity, insulin resistance, and possibly mood disorder and polycystic ovary syndrome. Between 5% and 10% of PP is due to virilizing disorders, which are usually characterized by more rapid advancement of pubarche and compromise of adult height potential than premature adrenarche. Most cases are due to nonclassic congenital adrenal hyperplasia. Algorithms are presented for the differential diagnosis of PP. This review highlights recent advances in molecular genetic and developmental biologic understanding of ZR development and insights into adrenarche emanating from mass spectrometric steroid assays.
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Affiliation(s)
- Robert L Rosenfield
- University of Chicago Pritzker School of Medicine, Section of Adult and Pediatric Endocrinology, Metabolism, and Diabetes, Chicago, IL, USA.,Department of Pediatrics, University of California, San Francisco, CA, USA
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Andrisse S, Feng M, Wang Z, Awe O, Yu L, Zhang H, Bi S, Wang H, Li L, Joseph S, Heller N, Mauvais-Jarvis F, Wong GW, Segars J, Wolfe A, Divall S, Ahima R, Wu S. Androgen-induced insulin resistance is ameliorated by deletion of hepatic androgen receptor in females. FASEB J 2021; 35:e21921. [PMID: 34547140 DOI: 10.1096/fj.202100961r] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/23/2021] [Accepted: 08/31/2021] [Indexed: 12/16/2022]
Abstract
Androgen excess is one of the most common endocrine disorders of reproductive-aged women, affecting up to 20% of this population. Women with elevated androgens often exhibit hyperinsulinemia and insulin resistance. The mechanisms of how elevated androgens affect metabolic function are not clear. Hyperandrogenemia in a dihydrotestosterone (DHT)-treated female mouse model induces whole body insulin resistance possibly through activation of the hepatic androgen receptor (AR). We investigated the role of hepatocyte AR in hyperandrogenemia-induced metabolic dysfunction by using several approaches to delete hepatic AR via animal-, cell-, and clinical-based methodologies. We conditionally disrupted hepatocyte AR in female mice developmentally (LivARKO) or acutely by tail vein injection of an adeno-associated virus with a liver-specific promoter for Cre expression in ARfl/fl mice (adLivARKO). We observed normal metabolic function in littermate female Control (ARfl/fl ) and LivARKO (ARfl/fl ; Cre+/- ) mice. Following chronic DHT treatment, female Control mice treated with DHT (Con-DHT) developed impaired glucose tolerance, pyruvate tolerance, and insulin tolerance, not observed in LivARKO mice treated with DHT (LivARKO-DHT). Furthermore, during an euglycemic hyperinsulinemic clamp, the glucose infusion rate was improved in LivARKO-DHT mice compared to Con-DHT mice. Liver from LivARKO, and primary hepatocytes derived from LivARKO, and adLivARKO mice were protected from DHT-induced insulin resistance and increased gluconeogenesis. These data support a paradigm in which elevated androgens in females disrupt metabolic function via hepatic AR and insulin sensitivity was restored by deletion of hepatic AR.
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Affiliation(s)
- Stanley Andrisse
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Physiology and Biophysics, Howard University, Washington, District of Columbia, USA
| | - Mingxiao Feng
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zhiqiang Wang
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Olubusayo Awe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Cellular and Molecular Physiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lexiang Yu
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Haiying Zhang
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sheng Bi
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hongbing Wang
- Department of Pharmaceutical Sciences, University of Maryland, Baltimore, Maryland, USA
| | - Linhao Li
- Department of Pharmaceutical Sciences, University of Maryland, Baltimore, Maryland, USA
| | - Serene Joseph
- Department of Cardiovascular Sciences/Center for Metabolic Disease Research, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nicola Heller
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Franck Mauvais-Jarvis
- Department of Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA.,Tulane Center of Excellence in Sex-Based Biology & Medicine, New Orleans, Louisiana, USA.,VA Medical Center, New Orleans, Louisiana, USA
| | - Guang William Wong
- Department of Cellular and Molecular Physiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James Segars
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew Wolfe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara Divall
- Department of Pediatrics, Seattle's Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Rexford Ahima
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sheng Wu
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Cellular and Molecular Physiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Cardiovascular Sciences/Center for Metabolic Disease Research, Temple University School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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8
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Oriolo C, Fanelli F, Castelli S, Mezzullo M, Altieri P, Corzani F, Pelusi C, Repaci A, Di Dalmazi G, Vicennati V, Baldazzi L, Menabò S, Dormi A, Nardi E, Brillanti G, Pasquali R, Pagotto U, Gambineri A. Steroid biomarkers for identifying non-classic adrenal hyperplasia due to 21-hydroxylase deficiency in a population of PCOS with suspicious levels of 17OH-progesterone. J Endocrinol Invest 2020; 43:1499-1509. [PMID: 32236851 DOI: 10.1007/s40618-020-01235-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/20/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We aimed at defining the most effective routine immunoassay- or liquid chromatography-tandem mass spectrometry (LC-MS/MS)-determined steroid biomarkers for identifying non-classic adrenal hyperplasia due to 21-hydroxylase deficiency (21-NCAH) in a PCOS-like population before genotyping. METHODS Seventy PCOS-like patients in reproductive age with immunoassay-determined follicular 17OH-progesterone (17OHP) ≥ 2.00 ng/mL underwent CYP21A2 gene analysis and 1-24ACTH test. Serum steroids were measured by immunoassays at baseline and 60 min after ACTH stimulation; basal steroid profile was measured by LC-MS/MS. RESULTS Genotyping revealed 23 21-NCAH, 15 single allele heterozygous CYP21A2 mutations (21-HTZ) and 32 PCOS patients displaying similar clinical and metabolic features. Immunoassays revealed higher baseline 17OHP and testosterone, and after ACTH stimulation, higher 17OHP (17OHP60) and lower cortisol, whereas LC-MS/MS revealed higher 17OHP (17OHPLC-MS/MS), progesterone and 21-deoxycortisol and lower corticosterone in 21-NCAH compared with both 21-HTZ and PCOS patients. Steroid thresholds best discriminating 21-NCAH from 21-HTZ and PCOS were estimated, and their diagnostic accuracy in identifying 21-NCAH from PCOS was established by ROC analysis. The highest accuracy was observed for 21-deoxycortisol ≥ 0.087 ng/mL, showing 100% sensitivity, while the combination of 17OHPLC-MS/MS ≥ 1.79 ng/mL and corticosterone ≤ 8.76 ng/mL, as well as the combination of ACTH-stimulated 17OHP ≥ 6.77 ng/mL and cortisol ≤ 240 ng/mL by immunoassay, showed 100% specificity. CONCLUSIONS LC-MS/MS measurement of basal follicular 21-deoxycortisol, 17OHP and corticosterone seems the most convenient method for diagnosing 21-NCAH in a population of PCOS with a positive first level screening, providing high accuracy and reducing the need for ACTH stimulation test.
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Affiliation(s)
- C Oriolo
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - F Fanelli
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - S Castelli
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - M Mezzullo
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - P Altieri
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - F Corzani
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - C Pelusi
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - A Repaci
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - G Di Dalmazi
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - V Vicennati
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - L Baldazzi
- Medical Genetic Unit, Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - S Menabò
- Medical Genetic Unit, Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - A Dormi
- Biostatistics Laboratory, Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - E Nardi
- Biostatistics Laboratory, Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - G Brillanti
- Biostatistics Laboratory, Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - R Pasquali
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - U Pagotto
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - A Gambineri
- Endocrinology Unit and Centre for Applied Biomedical Research (CRBA), Department of Medical and Surgical Sciences, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
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9
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Debeljak Ž, Marković I, Pavela J, Lukić I, Mandić D, Mandić S, Horvat V, Šerić V. Analytical bias of automated immunoassays for six serum steroid hormones assessed by LC-MS/MS. Biochem Med (Zagreb) 2020; 30:030701. [PMID: 32774123 PMCID: PMC7394251 DOI: 10.11613/bm.2020.030701] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/26/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction There is a growing amount of evidence showing the significant analytical bias of steroid hormone immunoassays, but large number of available immunoassays makes conduction of a single comprehensive study of this issue hardly feasible. Aim of this study was to assess the analytical bias of six heterogeneous immunoassays for serum aldosterone, cortisol, dehydroepiandrosterone sulphate (DHEAS), testosterone, 17-hydroxyprogesterone (OHP) and progesterone using the liquid chromatography coupled to the tandem mass spectrometry (LC-MS/MS). Materials and methods This method comparison study included 49 serum samples. Testosterone, DHEAS, progesterone and cortisol immunoassays were performed on the Abbott Architect i2000SR or Alinity i analysers (Abbott Diagnostics, Chicago, USA). DiaSorin’s Liaison (DiaSorin, Saluggia, Italy) and DIAsource’s ETI-Max 3000 analysers (DIAsource ImmunoAssays, Louvain-La-Neuve, Belgium) were chosen for aldosterone and OHP immunoassay testing, respectively. All immunoassays were evaluated against the LC-MS/MS assay relying on the commercial kit (Chromsystems, Gräfelfing, Germany) and LCMS-8050 analyser (Shimadzu, Kyoto, Japan). Analytical biases were calculated and method comparison was conducted using weighted Deming regression analysis. Results Depending on the analyte and specific immunoassay, mean relative biases ranged from -31 to + 137%. Except for the cortisol, immunoassays were positively biased. For none of the selected steroids slope and intercept 95% confidence intervals simultaneously contained 0 and 1, respectively. Conclusions Evaluated immunoassays failed to satisfy requirements for methods’ comparability and produced significant analytical biases in respect to the LC-MS/MS assay, especially at low concentrations.
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Affiliation(s)
- Željko Debeljak
- Clinical Institute of Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Ivana Marković
- Clinical Institute of Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Jasna Pavela
- Clinical Institute of Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Iva Lukić
- Clinical Institute of Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Dario Mandić
- Clinical Institute of Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Sanja Mandić
- Clinical Institute of Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Vesna Horvat
- Clinical Institute of Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Vatroslav Šerić
- Clinical Institute of Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
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10
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Dörr HG, Schulze N, Bettendorf M, Binder G, Bonfig W, Denzer C, Dunstheimer D, Salzgeber K, Schmidt H, Schwab KO, Voss E, Wabitsch M, Wölfle J. Genotype-phenotype correlations in children and adolescents with nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Mol Cell Pediatr 2020; 7:8. [PMID: 32647925 PMCID: PMC7347723 DOI: 10.1186/s40348-020-00100-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 07/02/2020] [Indexed: 01/13/2023] Open
Abstract
Background Nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency is caused by mutations in the active 21-hydroxylase gene (CYP21A2). The clinical symptoms can vary greatly. To date, no systematic studies have been undertaken in Germany. Aims Description of the phenotype, evaluation of the diagnostics and genotype-phenotype correlation Patients and methodology Retrospective analysis of the data of 134 patients (age range 0.1–18.6 years) in a multicentre study covering 10 paediatric endocrinology centres in Bavaria and Baden-Württemberg. The data was gathered on site from the medical records. Two hundred and thirty-three alleles with a mutation of the CYP21A2 gene were identified in 126 patients. A genotype-phenotype correlation of the mutation findings was undertaken (C1, severe/mild; C2, mild/mild). Individuals with a heterozygous mutation of the CYP21A2 were also included (C3). The data was collected with the approval of the ethics committee of the University Hospital of Erlangen during the period of 2014 and 2015. Results (MW ± SD) One hundred and seventeen out of 134 patients (115 f, 29 m) were symptomatic. The chronological age (CA) at diagnosis was 7.1 ± 4.4 years. The most frequent symptom (73.5%) was premature pubarche. The height-SDS on diagnosis was 0.8 ± 1.3 and the BMI-SDS was 0.8 ± 1.2. Bone age (BA) was ascertained in 82.9% of the symptomatic patients. The difference between BA and CA was 1.9 ± 1.4 years. Basal 17OHP concentrations were 14.5 ± 19.1 ng/ml (18 patients < 2 ng/ml). In total, 58.1% mild and 34.7% severe mutations were found. The most common mutation was p.Val281Leu (39.1%); 65.8% of the patients could be allocated to group C1. No phenotypical differences were found between the 3 mutation groups. The 17OHP levels (basal and after ACTH) in the standard ACTH stimulation test were highest in group C1 and also significantly higher in group C2 as in C3, the ACTH-stimulated cortisol levels (ng/ml) were significantly lower in groups C1 (192.1 ± 62.5) and C2 (218 ± 50) than in C3 (297.3 ± 98.7). Conclusion Most of the patients have symptoms of mild androgenisation. Male patients are underdiagnosed. Diagnostics are not standardised. Differences between the types of mutations are found in the hormone concentrations but not in phenotype. We speculate that further, as yet not clearly defined, factors are responsible for the development of the respective phenotypes.
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Affiliation(s)
| | - Nadja Schulze
- Paediatric Endocrinology, University Children's Hospital, Erlangen, Germany
| | - Markus Bettendorf
- Paediatric Endocrinology, University Children's Hospital, Heidelberg, Germany
| | - Gerhard Binder
- Paediatric Endocrinology, University Children's Hospital, Tübingen, Germany
| | - Walter Bonfig
- Departement of Paediatrics, Hospital Wels-Grieskirchen, Wels, Austria
| | - Christian Denzer
- Paediatric Endocrinology, University Children's Hospital, Ulm, Germany
| | | | | | - Heinrich Schmidt
- Paediatric Endocrinology, University Children's Hospital, Munich, Germany
| | | | - Egbert Voss
- Departament of Paediatrics, Cnopfsche Kinderklinik, Nuremberg, Germany
| | - Martin Wabitsch
- Paediatric Endocrinology, University Children's Hospital, Ulm, Germany
| | - Joachim Wölfle
- Paediatric Endocrinology, University Children's Hospital, Erlangen, Germany
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11
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Genotyp-Phänotyp-Korrelationen bei Kindern und Jugendlichen mit nichtklassischem adrenogenitalen Syndrom mit 21-Hydroxylase-Defekt. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-00976-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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EMQN best practice guidelines for molecular genetic testing and reporting of 21-hydroxylase deficiency. Eur J Hum Genet 2020; 28:1341-1367. [PMID: 32616876 PMCID: PMC7609334 DOI: 10.1038/s41431-020-0653-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 11/25/2022] Open
Abstract
Molecular genetic testing for congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21-OHD) is offered worldwide and is of importance for differential diagnosis, carrier detection and adequate genetic counseling, particularly for family planning. In 2008 the European Molecular Genetics Quality Network (EMQN) for the first time offered a European-wide external quality assessment scheme for CAH (due to 21-OH deficiency). The interest was great and over the last years at about 60 laboratories from Europe, USA and Australia regularly participated in that scheme. These best practice guidelines were drafted on the basis of the extensive knowledge and experience got from those annually organized CAH-schemes. In order to obtain the widest possible consultation with practicing laboratories the draft was therefore circulated twice by EMQN to all laboratories participating in the EQA-scheme for CAH genotyping and was updated by that input. The present guidelines address quality requirements for diagnostic molecular genetic laboratories, as well as criteria for CYP21A2 genotyping (including carrier-testing and prenatal diagnosis). A key aspect of that article is the use of appropriate methodologies (e.g., sequencing methods, MLPA (multiplex ligation dependent probe amplification), mutation specific assays) and respective limitations and analytical accuracy. Moreover, these guidelines focus on classification of variants, and the interpretation and standardization of the reporting of CYP21A2 genotyping results. In addition, the article provides a comprehensive list of common as well as so far unreported CYP21A2-variants.
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13
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Sumińska M, Bogusz-Górna K, Wegner D, Fichna M. Non-Classic Disorder of Adrenal Steroidogenesis and Clinical Dilemmas in 21-Hydroxylase Deficiency Combined with Backdoor Androgen Pathway. Mini-Review and Case Report. Int J Mol Sci 2020; 21:E4622. [PMID: 32610579 PMCID: PMC7369945 DOI: 10.3390/ijms21134622] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/27/2020] [Accepted: 06/28/2020] [Indexed: 12/19/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) is the most common cause of primary adrenal insufficiency in children and adolescents. It comprises several clinical entities associated with mutations in genes, encoding enzymes involved in cortisol biosynthesis. The mutations lead to considerable (non-classic form) to almost complete (classic form) inhibition of enzymatic activity, reflected by different phenotypes and relevant biochemical alterations. Up to 95% cases of CAH are due to mutations in CYP21A2 gene and subsequent 21α-hydroxylase deficiency, characterized by impaired cortisol synthesis and adrenal androgen excess. In the past two decades an alternative ("backdoor") pathway of androgens' synthesis in which 5α-androstanediol, a precursor of the 5α-dihydrotestosterone, is produced from 17α-hydroxyprogesterone, with intermediate products 3α,5α-17OHP and androsterone, in the sequence and with roundabout of testosterone as an intermediate, was reported in some studies. This pathway is not always considered in the clinical assessment of patients with hyperandrogenism. The article describes the case of a 17-year-old female patient with menstrual disorders and androgenization (persistent acne, advanced hirsutism). Her serum dehydroepiandrosterone sulfate and testosterone were only slightly elevated, along with particularly high values for 5α-dihydrotestosterone. In 24 h urine collection, an increased excretion of 16α-OHDHEA-a dehydroepiandrosterone metabolite-and pregnanetriolone-a 17α-hydroxyprogesterone metabolite-were observed. The investigations that we undertook provided evidence that the girl suffered from non-classic 21α-hydroxylase deficiency with consequent enhancement of the androgen "backdoor" pathway in adrenals, peripheral tissues or both, using adrenal origin precursors. The paper presents diagnostic dilemmas and strategies to differentiate between various reasons for female hyperandrogenism, especially in childhood and adolescence.
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Affiliation(s)
- Marta Sumińska
- Department of Pediatric Diabetes and Obesity, Poznan University of Medical Sciences, 60-527 Poznan, Poland; (K.B.-G.); (D.W.)
| | - Klaudia Bogusz-Górna
- Department of Pediatric Diabetes and Obesity, Poznan University of Medical Sciences, 60-527 Poznan, Poland; (K.B.-G.); (D.W.)
| | - Dominika Wegner
- Department of Pediatric Diabetes and Obesity, Poznan University of Medical Sciences, 60-527 Poznan, Poland; (K.B.-G.); (D.W.)
| | - Marta Fichna
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 60-653 Poznan, Poland;
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14
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Wang Z, Feng M, Awe O, Ma Y, Shen M, Xue P, Ahima R, Wolfe A, Segars J, Wu S. Gonadotrope androgen receptor mediates pituitary responsiveness to hormones and androgen-induced subfertility. JCI Insight 2019; 5:127817. [PMID: 31393859 DOI: 10.1172/jci.insight.127817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Many women with hyperandrogenemia suffer from irregular menses and infertility. However, it is unknown whether androgens directly affect reproduction. Since animal models of hyperandrogenemia-induced infertility are associated with obesity, which may impact reproductive function, we have created a lean mouse model of elevated androgen using implantation of low dose dihydrotestosterone (DHT) pellets to separate the effects of elevated androgen from obesity. The hypothalamic-pituitary-gonadal axis controls reproduction. While we have demonstrated that androgen impairs ovarian function, androgen could also disrupt neuroendocrine function at the level of brain and/or pituitary to cause infertility. To understand how elevated androgens might act on pituitary gonadotropes to influence reproductive function, female mice with disruption of the androgen receptor (Ar) gene specifically in pituitary gonadotropes (PitARKO) were produced. DHT treated control mice with intact pituitary Ar (Con-DHT) exhibit disrupted estrous cyclicity and fertility with reduced pituitary responsiveness to GnRH at the level of both calcium signaling and LH secretion. These effects were ameliorated in DHT treated PitARKO mice. Calcium signaling controls GnRH regulation of LH vesicle exotocysis. Our data implicated upregulation of GEM (a voltage-dependent calcium channel inhibitor) in the pituitary as a potential mechanism for androgen's pathological effects. These results demonstrate that gonadotrope AR, as an extra-ovarian regulator, plays an important role in reproductive pathophysiology.
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Affiliation(s)
- Zhiqiang Wang
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mingxiao Feng
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Olubusayo Awe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yaping Ma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Mingjie Shen
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Gynecology and Obstetrics, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ping Xue
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Andrew Wolfe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Molecular and Cellular Physiology, and
| | - James Segars
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sheng Wu
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Molecular and Cellular Physiology, and.,Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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15
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Livadas S, Bothou C. Management of the Female With Non-classical Congenital Adrenal Hyperplasia (NCCAH): A Patient-Oriented Approach. Front Endocrinol (Lausanne) 2019; 10:366. [PMID: 31244776 PMCID: PMC6563652 DOI: 10.3389/fendo.2019.00366] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 05/22/2019] [Indexed: 12/02/2022] Open
Abstract
Non-classical congenital adrenal hyperplasia (NCCAH) is considered to be a common monogenic inherited disease, with an incidence range from 1:500 to 1:100 births worldwide. However, despite the high incidence, there is a low genotype-phenotype correlation, which explains why NCCAH diagnosis is usually delayed or even never carried out, since many patients remain asymptomatic or are misdiagnosed as suffering from other hyperandrogenic disorders. For affected adolescent and adult women, it is crucial to investigate any suspicion of NCCAH and determine a firm and accurate diagnosis. The Synacthen test is a prerequisite in the event of clinical suspicion, and molecular testing will establish the diagnosis. In most cases occurring under 8 years of age, the first symptom is premature pubarche. In some cases, due to advanced bone age and/or severe signs of hyperandrogenism, initiation of hydrocortisone treatment prepubertally may be considered. Our unifying theory of the hyperandrogenic signs system and its regulation by internal (hormones, enzymes, tissue sensitivity) and external (stress, insulin resistance, epigenetic, endocrine disruptors) factors is presented in an attempt to elucidate both the prominent genotype-phenotype heterogeneity of this disease and the resultant wide variation of clinical findings. Treatment should be initiated not only to address the main cause of the patient's visit but additionally to decrease abnormally elevated hormone concentrations. Goals of treatment include restoration of regular menstrual cyclicity, slowing the progression of hirsutism and acne, and improvement of fertility. Hydrocortisone supplementation, though not dexamethasone administration, could, as a general rule, be helpful, however, at minimum doses, and also for a short period of time and, most likely, not lifelong. On the other hand, in cases where severe hirsutism and/or acne are present, prescription of oral contraceptives and/or antiandrogens may be advisable. Furthermore, women with NCCAH commonly experience subfertility, therefore, there will be analysis of the appropriate approach for these patients, including during pregnancy, based mainly on genotype. Besides, we should keep in mind that since the same patient will have changing requirements through the years, the attending physician should undertake a tailor-made approach in order to cover her specific needs at different stages of life.
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Affiliation(s)
- Sarantis Livadas
- Metropolitan Hospital, Pireas, Greece
- *Correspondence: Sarantis Livadas
| | - Christina Bothou
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
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16
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Deshmukh H, Papageorgiou M, Kilpatrick ES, Atkin SL, Sathyapalan T. Development of a novel risk prediction and risk stratification score for polycystic ovary syndrome. Clin Endocrinol (Oxf) 2019; 90:162-169. [PMID: 30339716 DOI: 10.1111/cen.13879] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/10/2018] [Accepted: 10/13/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to develop a simple phenotypic algorithm that can capture the underlying clinical and hormonal abnormalities to help in the diagnosis and risk stratification of polycystic ovary syndrome (PCOS). METHODS The study consisted of 111 women with PCOS fulfilling the Rotterdam diagnostic criteria and 67 women without PCOS. A Firth's penalized logistic regression model was used for independent variable section. Model optimism, discrimination and calibration were assessed using bootstrapping, area under the curve (AUC) and Hosmer-Lemeshow statistics, respectively. The prognostic index (PI) and risk score for developing PCOS were calculated using independent variables from the regression model. RESULTS Firth penalized logistic regression model with backward selection identified four independent predictors of PCOS namely free androgen index [β 0.30 (0.12), P = 0.008], 17-OHP [β = 0.20 (0.01), P = 0.026], anti-mullerian hormone [AMH; β = 0.04 (0.01) P < 0.0001] and waist circumference [β = 0.08 (0.02), P < 0.0001]. The model estimates indicated high internal validity (minimal optimism on 1000-fold bootstrapping), good discrimination ability (bias corrected c-statistic = 0.90) and good calibration (Hosmer-Lemeshow χ2 = 3.7865). PCOS women with a high-risk score (q1 + q2 + q3 vs q4) presented with a worse metabolic profile characterized by a higher 2-hour glucose (P = 0.01), insulin (P = 0.0003), triglycerides (P = 0.0005), C-reactive protein (P < 0.0001) and low HDL-cholesterol (P = 0.02) as compared to those with lower risk score for PCOS. CONCLUSIONS We propose a simple four-variable model, which captures the underlying clinical and hormonal abnormalities in PCOS and can be used for diagnosis and metabolic risk stratification in women with PCOS.
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Affiliation(s)
- Harshal Deshmukh
- Department of Academic Diabetes, Endocrinology and Metabolism, Hull York Medical School, University of Hull, Hull, UK
| | - Maria Papageorgiou
- Department of Academic Diabetes, Endocrinology and Metabolism, Hull York Medical School, University of Hull, Hull, UK
| | - Eric S Kilpatrick
- Department of Pathology, Sidra Medical and Research Center, Doha, Qatar
| | | | - Thozhukat Sathyapalan
- Department of Academic Diabetes, Endocrinology and Metabolism, Hull York Medical School, University of Hull, Hull, UK
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17
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Han L, Tavakoli NP, Morrissey M, Spink DC, Cao Z(T. Liquid chromatography-tandem mass spectrometry analysis of 17-hydroxyprogesterone in dried blood spots revealed matrix effect on immunoassay. Anal Bioanal Chem 2018; 411:395-402. [DOI: 10.1007/s00216-018-1449-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/09/2018] [Accepted: 10/23/2018] [Indexed: 10/27/2022]
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18
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Grandone A, Marzuillo P, Luongo C, Toraldo R, Mariani M, Miraglia Del Giudice E, Perrone L. Basal levels of 17-hydroxyprogesterone can distinguish children with isolated precocious pubarche. Pediatr Res 2018; 84:533-536. [PMID: 29976972 DOI: 10.1038/s41390-018-0096-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 06/08/2018] [Accepted: 06/16/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND Basal levels of androgens, in particular 17-hydroxyprogesterone (17OHP), are widely debated as predictors of non-classical congenital adrenal hyperplasia (NCCAH) among patients with precocious pubarche (PP). Many authors have recommended the use of adrenocorticotropic hormone (ACTH) stimulation test in children with PP. The aim of our study was to identify clinical and biochemical predictors of NCCAH in children with PP. METHODS We conducted a prospective study of 92 patients with PP undergoing an ACTH stimulation test. We tested the association of basal clinical and biochemical parameters with NCCAH diagnosis. Patients were suspected to have NCCAH if their stimulated 17OHP plasma levels were >10 ng/mL. In these patients, the diagnosis was confirmed by genetic test. RESULTS Seven (7.6%) patients resulted having NCCAH. The best basal biochemical predictor for NCCAH was 17OHP level >2 ng/mL. In fact, a basal 17OHP level >2 ng/mL had 100% (95% confidence interval (CI), 59.04-100) sensitivity and 93% (95% CI, 85.3-97.37) specificity. The area under the receiver-operating characteristic curve for 17OHP was 0.99 (95% CI, 0.98-1.007). CONCLUSIONS Basal 17OHP cut-off of 2 ng/mL was very effective in predicting NCCAH among our patients with PP. Assay-specific cut-off would probably be the best strategy to avoid unnecessary ACTH test.
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Affiliation(s)
- Anna Grandone
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
| | - Pierluigi Marzuillo
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy.
| | - Caterina Luongo
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
| | - Roberto Toraldo
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
| | - Michela Mariani
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
| | - Emanuele Miraglia Del Giudice
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
| | - Laura Perrone
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
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Martin KA, Anderson RR, Chang RJ, Ehrmann DA, Lobo RA, Murad MH, Pugeat MM, Rosenfield RL. Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018. [PMID: 29522147 DOI: 10.1210/jc.2018-00241] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To update the "Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline," published by the Endocrine Society in 2008. PARTICIPANTS The participants include an Endocrine Society-appointed task force of seven medical experts and a methodologist. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS Group meetings, conference calls, and e-mail communications facilitated consensus development. Endocrine Society committees, members, and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines. CONCLUSION We suggest testing for elevated androgen levels in all women with an abnormal hirsutism score. We suggest against testing for elevated androgen levels in eumenorrheic women with unwanted local hair growth (i.e., in the absence of an abnormal hirsutism score). For most women with patient-important hirsutism despite cosmetic measures (shaving, plucking, waxing), we suggest starting with pharmacological therapy and adding direct hair removal methods (electrolysis, photoepilation) for those who desire additional cosmetic benefit. For women with mild hirsutism and no evidence of an endocrine disorder, we suggest either pharmacological therapy or direct hair removal methods. For pharmacological therapy, we suggest oral combined estrogen-progestin contraceptives for the majority of women, adding an antiandrogen after 6 months if the response is suboptimal. We recommend against antiandrogen monotherapy unless adequate contraception is used. We suggest against using insulin-lowering drugs. For most women who choose hair removal therapy, we suggest laser/photoepilation.
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Affiliation(s)
| | | | | | | | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minnesota
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20
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Carmina E, Dewailly D, Escobar-Morreale HF, Kelestimur F, Moran C, Oberfield S, Witchel SF, Azziz R. Non-classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency revisited: an update with a special focus on adolescent and adult women. Hum Reprod Update 2017; 23:580-599. [DOI: 10.1093/humupd/dmx014] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 05/12/2017] [Indexed: 01/29/2023] Open
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21
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Abstract
Congenital adrenal hyperplasia (CAH) is classified as classical CAH and non-classical CAH (NCCAH). In the classical type, the most severe form comprises both salt-wasting and simple virilizing forms. In the non-classical form, diagnosis can be more confusing because the patient may remain asymptomatic or the condition may be associated with signs of androgen excess in the postnatal period or in the later stages of life. This review paper will include information on clinical findings, symptoms, diagnostic approaches, and treatment modules of NCCAH.
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Affiliation(s)
- Selim Kurtoğlu
- Erciyes University Faculty of Medicine, Department of Pediatric Endocrinology, Kayseri, Turkey
| | - Nihal Hatipoğlu
- Erciyes University Faculty of Medicine, Department of Pediatric Endocrinology, Kayseri, Turkey Phone: +90 505 578 05 37 E-mail:
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22
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Andrisse S, Childress S, Ma Y, Billings K, Chen Y, Xue P, Stewart A, Sonko ML, Wolfe A, Wu S. Low-Dose Dihydrotestosterone Drives Metabolic Dysfunction via Cytosolic and Nuclear Hepatic Androgen Receptor Mechanisms. Endocrinology 2017; 158:531-544. [PMID: 27967242 PMCID: PMC5460775 DOI: 10.1210/en.2016-1553] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 12/13/2016] [Indexed: 12/14/2022]
Abstract
Androgen excess in women is associated with metabolic dysfunction (e.g., obesity, hyperinsulinemia, insulin resistance, and increased risk of type 2 diabetes) and reproductive dysfunction (e.g., polycystic ovaries, amenorrhea, dysregulated gonadotropin release, and infertility). We sought to identify the effects of androgen excess on glucose metabolic dysfunction and the specific mechanisms of action by which androgens are inducing pathology. We developed a mouse model that displayed pathophysiological serum androgen levels with normal body mass/composition to ensure that the phenotypes were directly from androgens and not an indirect consequence of obesity. We performed reproductive tests, metabolic tests, and hormonal assays. Livers were isolated and examined via molecular, biochemical, and histological analysis. Additionally, a low-dose dihydrotestosterone (DHT) cell model using H2.35 mouse hepatocytes was developed to study androgen effects on hepatic insulin signaling. DHT mice demonstrated impaired estrous cyclicity; few corpora lutea in the ovaries; glucose, insulin, and pyruvate intolerance; and lowered hepatic insulin action. Mechanistically, DHT increased hepatic androgen-receptor binding to phosphoinositide-3-kinase (PI3K)-p85, resulting in dissociation of PI3K-p85 from PI3K-p110, leading to reduced PI3K activity and decreased p-AKT and, thus, lowered insulin action. DHT increased gluconeogenesis via direct transcriptional regulation of gluconeogenic enzymes and coactivators. The hepatocyte model recapitulated the in vivo findings. The DHT-induced hepatocyte insulin resistance was reversed by the androgen-receptor antagonist, flutamide. These findings present a phenotype (i.e., impaired glucose tolerance and disrupted glucose metabolism) in a lean hyperandrogenemia model (low-dose DHT) and data to support 2 molecular mechanisms that help drive androgen-induced impaired glucose metabolism.
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Affiliation(s)
- Stanley Andrisse
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Shameka Childress
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Yaping Ma
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Katelyn Billings
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Yi Chen
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ping Xue
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ashley Stewart
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Momodou L Sonko
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Andrew Wolfe
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sheng Wu
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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23
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Hoehn T, Lukacs Z, Huckenbeck W, Torresani T, Blankenstein O, Bounnack S. Congenital Adrenal Hyperplasia with Non-functional Mutations in Both Alleles in a Clinically Unaffected Infant. J Trop Pediatr 2016; 62:158-60. [PMID: 26721550 PMCID: PMC4886113 DOI: 10.1093/tropej/fmv078] [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] [Indexed: 11/14/2022]
Abstract
BACKGROUND Results in neonatal screening programs aiming at detection of congenital adrenal hyperplasia (CAH) can only report elevated levels of 17-hydroxy-progesterone (17-OHP), without being able to differentiate presence or absence of salt loss. AIM To predict presence or absence of salt loss in newborn infants with CAH. METHODS The first specimen of suspected CAH in samples sent from People's Democratic Republic of Laos (Lao PDR) was investigated for known mutations in CAH associated with salt loss. RESULTS Molecular genetic diagnosis revealed mutations associated with loss of function in both alleles; however, the infant was clinically unaffected even without any corticosteroid substitution therapy. CONCLUSIONS Although molecular genetic methods can theoretically predict loss of function in CAH, our infant was clinically unaffected even without therapy at 6 years of age. We speculate that in CAH, remaining enzyme activity can be sufficiently high, despite the presence of loss of function mutations, which do not affect infants clinically.
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Affiliation(s)
- Thomas Hoehn
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Neonatology and Pediatric Intensive Care Medicine, Heinrich-Heine-University, Duesseldorf 40225, Germany
| | - Zoltan Lukacs
- Newborn Screening and Metabolic Diagnostics, Hamburg University Medical Center, Hamburg 20246, Germany
| | | | | | - Oliver Blankenstein
- Institute for Experimental Pediatric Endocrinology, Charité-Universitätsmedizin Berlin, Berlin 13353, Germany
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