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McCracken C, Kaabi O, Crawford M, Gardner MD, Getahun D, Goodman M, Sorouri Khorashad B, Lash TL, Roblin D, Vupputuri S, Yacoub R, Speiser PW, Lee PA, Sandberg DE. Anthropometric Measures Among Children and Teens With Classic 46,XX Congenital Adrenal Hyperplasia in Relation to Improvements in Diagnosis and Care. Endocr Pract 2024:S1530-891X(24)00671-2. [PMID: 39277085 DOI: 10.1016/j.eprac.2024.09.005] [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: 06/03/2024] [Revised: 09/02/2024] [Accepted: 09/09/2024] [Indexed: 09/17/2024]
Abstract
OBJECTIVES To examine anthropometric changes of patients with classic 46,XX congenital adrenal hyperplasia (CAH) and matched referents; and 2) To investigate the impact of improvements in diagnosis and care on growth patterns in these patients by comparing changes in anthropometric parameters before and after CAH consensus guidelines. METHODS This was a retrospective cohort study nested within 3 large integrated health-systems. Seventy-six patients with classic 46XX CAH and 1102 matched referents <21 years of age were identified. Anthropometric measurements including age-specific percentiles for height, weight, and body mass index were examined and compared between groups using linear mixed-effect models. Anthropometric trajectories were explored using latent class analyses. RESULTS CAH patients had lower height percentiles than referents at all time points. Differences ranged from 10.7% to 28.4%. After age 5, differences in height were only significant among study participants born before the publication of CAH consensus guidelines. Latent class analyses of height detected a "gradual growth increase" pattern in 28% of CAH cases and only 4% of referents, and a "growth stunting" pattern was observed in 13% of CAH cases and 6% of referents. Height percentile measures did not differ in CAH patients with or without evidence of hormonal interventions (growth hormone and/or puberty blockers) used to increase adult height. CONCLUSIONS There is substantial heterogeneity in growth trajectories of CAH patients. Although stunting may affect CAH patients, advances in diagnosis and care improved anthropometric outcomes in this population. Understanding the disease- and therapy-related mechanisms that explain the different growth patterns requires additional research.
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Affiliation(s)
- Courtney McCracken
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia.
| | - Oumaima Kaabi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Mackenzie Crawford
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia
| | - Melissa D Gardner
- Susan B. Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, Michigan
| | - Darios Getahun
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Behzad Sorouri Khorashad
- Susan B. Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, Michigan
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Douglas Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlanta States, Rockville, Maryland
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlanta States, Rockville, Maryland
| | - Rami Yacoub
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Phyllis W Speiser
- Division of Pediatric Endocrinology, Steven and Alexandra Cohen Children's Medical Center of New York; Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York
| | - Peter A Lee
- Division of Endocrinology, Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| | - David E Sandberg
- Susan B. Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, Michigan
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Amais DSR, da Silva TER, Barros BA, de Andrade JGR, de Lemos-Marini SHV, de Mello MP, Marques-de-Faria AP, Mazzola TN, Guaragna MS, Fabbri-Scallet H, Vieira TAP, Viguetti-Campos NL, Morcillo AM, Hiort O, Maciel-Guerra AT, Guerra-Junior G. Sex dimorphism of weight and length at birth: evidence based on disorders of sex development. Ann Hum Biol 2022; 49:274-279. [PMID: 36218438 DOI: 10.1080/03014460.2022.2134452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Males have higher weight and length at birth than females. AIM To verify the influence of the Y chromosome and the action of intrauterine androgens on weight and length at birth of children with Disorders of Sex Development (DSD). SUBJECTS AND METHODS A cross-sectional and retrospective study. Patients with Turner syndrome (TS), complete (XX and XY), mixed (45,X/46,XY) and partial (XY) gonadal dysgenesis (GD), complete (CAIS) and partial (PAIS) androgen insensitivity syndromes and XX and XY congenital adrenal hyperplasia (CAH) were included. Weight and length at birth were evaluated. RESULTS Weight and length at birth were lower in TS and mixed GD when compared to XY and XX DSD cases. In turn, patients with increased androgen action (117 cases) had higher weight and length at birth when compared to those with absent (108 cases) and decreased (68 cases) production/action. In birthweight, there was a negative influence of the 45,X/46,XY karyotype and a positive influence of increased androgen and gestational age. In birth length, there was a negative influence of the 45,X and 45,X/46,XY karyotypes and also a positive influence of increased androgen and gestational age. CONCLUSIONS The sex dimorphism of weight and length at birth could possibly be influenced by intrauterine androgenic action.
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Affiliation(s)
- D S R Amais
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil
| | - T E R da Silva
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil
| | - B A Barros
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil
| | - J G R de Andrade
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil
| | | | - M P de Mello
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil.,Human Molecular Genetics Laboratory, Molecular Biology and Genetic Engineering Center (CBMEG), UNICAMP, Campinas, Brazil
| | - A P Marques-de-Faria
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil
| | - T N Mazzola
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil.,Human Molecular Genetics Laboratory, Molecular Biology and Genetic Engineering Center (CBMEG), UNICAMP, Campinas, Brazil
| | - M S Guaragna
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil.,Human Molecular Genetics Laboratory, Molecular Biology and Genetic Engineering Center (CBMEG), UNICAMP, Campinas, Brazil
| | - H Fabbri-Scallet
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil.,Human Molecular Genetics Laboratory, Molecular Biology and Genetic Engineering Center (CBMEG), UNICAMP, Campinas, Brazil
| | - T A P Vieira
- Department of Medical Genetics and Genomic Medicine and Cytogenetics Laboratory, FCM, UNICAMP, Campinas, Brazil
| | - N L Viguetti-Campos
- Department of Medical Genetics and Genomic Medicine and Cytogenetics Laboratory, FCM, UNICAMP, Campinas, Brazil
| | - A M Morcillo
- Department of Pediatrics, FCM, UNICAMP, Campinas, Brazil
| | - O Hiort
- Division of Experimental Pediatric Endocrinology and Diabetes, University of Lübeck, Lübeck, Germany
| | - A T Maciel-Guerra
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil
| | - G Guerra-Junior
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil
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3
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Pitsava G, Stratakis CA. Adrenal hyperplasias in childhood: An update. Front Endocrinol (Lausanne) 2022; 13:937793. [PMID: 35992119 PMCID: PMC9382287 DOI: 10.3389/fendo.2022.937793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
Pediatric adrenocortical hyperplasias are rare; they usually present with Cushing syndrome (CS); of them, isolated micronodular adrenal disease and its variant, primary pigmented adrenocortical disease are the most commonly encountered. Most cases are due to defects in the cyclic AMP/protein kinase A (cAMP/PKA) pathway, although a few cases remain without an identified genetic defect. Another cause of adrenal hyperplasia in childhood is congenital adrenal hyperplasia, a group of autosomal recessive disorders that affect steroidogenic enzymes in the adrenal cortex. Clinical presentation varies and depends on the extent of the underlying enzymatic defect. The most common form is due to 21-hydroxylase deficiency; it accounts for more than 90% of the cases. In this article, we discuss the genetic etiology of adrenal hyperplasias in childhood.
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Affiliation(s)
- Georgia Pitsava
- Division of Intramural Research, Division of Population Health Research, Eunice Kennedy Shriver National Institutes of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
- *Correspondence: Georgia Pitsava,
| | - Constantine A. Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
- Human Genetics and Precision Medicine, Institute of Molecular Biology and Biotechnology of the Foundation for Research and Technology Hellas (IMBB-FORTH), Heraklion, Greece
- ELPEN Research Institute, ELPEN, Athens, Greece
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Kamrath C, Hartmann MF, Pons-Kühnemann J, Wudy SA. Urinary GC-MS steroid metabotyping in treated children with congenital adrenal hyperplasia. Metabolism 2020; 112:154354. [PMID: 32916150 DOI: 10.1016/j.metabol.2020.154354] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/24/2020] [Accepted: 09/01/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Treatment of children with classic congenital adrenal hyperplasia (CAH) is a difficult balance between hypercortisolism and hyperandrogenism. Biochemical monitoring of treatment is not well defined. OBJECTIVE Cluster analysis of the urinary steroid metabolome obtained by targeted gas chromatography-mass spectrometry (GC-MS) for treatment monitoring of children with CAH. METHODS We evaluated 24-h urinary steroid metabolome analyses of 109 prepubertal children aged 7.0 ± 1.6 years with classic CAH due to 21-hydroxylase deficiency treated with hydrocortisone and fludrocortisone. 24-h urinary steroid metabolite excretions were transformed into CAH-specific z-scores. Subjects were divided into groups (metabotypes) by k-means clustering algorithm. Urinary steroid metabolome and clinical data of patients of each metabotype were analyzed. RESULTS Four unique metabotypes were generated. Metabotype 1 (N = 21 (19%)) revealed adequate metabolic control with low cortisol metabolites (mean: -0.57z) and suppressed androgen and 17α-hydroxyprogesterone (17OHP) metabolites (-0.79z). Metabotype 2 (N = 23 (21%)) showed overtreatment consisting of a constellation of elevated urinary cortisol metabolites (0.62z) and low metabolites of androgens and 17OHP (-0.75z). Metabotype 3 (N = 32 (29%)) demonstrated undertreated patients with low cortisol metabolites (-0.69z) and elevated metabolites of androgens and 17OHP (0.50z). Metabotype 4 (N = 33 (30%)) presented patients with treatment failure reflected by unsuppressed androgen- and 17OHP metabolites (0.71z) despite elevated urinary cortisol metabolites (0.39z). CONCLUSION Metabotyping, which means grouping metabolically similar individuals, helps to monitor treatment of children with CAH using GC-MS urinary steroid metabolome analysis. This method allows classification in adequately-, over-, or undertreated children as well as identification of patients with treatment failure.
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Affiliation(s)
- Clemens Kamrath
- Division of Pediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Michaela F Hartmann
- Division of Pediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Jörn Pons-Kühnemann
- Medical Statistics, Institute of Medical Informatics, Justus Liebig University, Giessen, Germany
| | - Stefan A Wudy
- Division of Pediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany.
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5
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Pussard E, Travers S, Bouvattier C, Xue QY, Cosson C, Viengchareun S, Martinerie L, Lombès M. Urinary steroidomic profiles by LC-MS/MS to monitor classic 21-Hydroxylase deficiency. J Steroid Biochem Mol Biol 2020; 198:105553. [PMID: 31778802 DOI: 10.1016/j.jsbmb.2019.105553] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/21/2019] [Accepted: 11/24/2019] [Indexed: 12/26/2022]
Abstract
21-hydroxylase deficiency, the most common enzyme defect associated with congenital adrenal hyperplasia (CAH) is characterized by an impairment of both aldosterone and cortisol biosynthesis. Close clinical and biological monitoring of Hydrocortisone (HC) and 9α-Fludrocortisone (FDR) replacement therapies is required to achieve an optimal treatment. As frequent and repeated reassessments of plasma steroids, 17-hydroxyprogesterone (17-OHP), androstenedione (Δ4-A) and testosterone (TESTO) is needed in childhood, urine steroid profiling could represent an interesting non-invasive alternative. We developed and validated a LC-MS/MS method for the measurement of 23-urinary mineralocorticoids, glucocorticoids and adrenal androgens. The usefulness of steroid profiling was investigated on single 08h00 am-collected spot urine for discriminating between 61 CAH patients and their age- and sex-matched controls. CAH patients were split into two groups according to their 08h00 am-plasma concentrations of 17-OHP: below (controlled patients, n = 26) and above 20 ng/mL (uncontrolled patients, n = 35). The lower limit of quantification and the wide analytical range allows to assay both free and total concentrations of the main urinary adreno-corticoids and their tetra-hydrometabolites. Extraction recoveries higher than 75% and intra-assay precision below 20% were found for most steroids. Urinary steroids upstream of the 21-hydroxylase defect were higher in uncontrolled CAH patients. Among CAH patients, plasma and urinary 17-OHP were closely correlated. As compared to controls, steroids downstream of the enzyme defect collapsed in CAH patients. This fall was more pronounced in controlled than in uncontrolled patients. Androgens (Δ4-A, TESTO and the sum etiocholanolone + androsterone) accumulated in uncontrolled CAH patients. A strong relationship was observed between plasma and urinary levels of androstenedione. Daily doses and urinary excretion of both FDR and HC were similar in both CAH groups. Urinary FDR was inversely related to the sodium-to-potassium ratio in urine. A partial least squares discriminant analysis model allowed to classify the patient's classes unaffected, controlled and un-controlled CAH patients based on urinary steroidomic profiles. Our LC-MS/MS method successfully established steroid profiling in urine and represents a useful and non-invasive tool for discriminating CAH patients according to treatment efficiency.
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Affiliation(s)
- Eric Pussard
- Inserm, U1185, Le Kremlin-Bicêtre, F-94276, France; Fac Med Paris-Sud, Univ. Paris-Sud, Université Paris Saclay, UMR-S 1185, Le Kremlin-Bicêtre, F-94276, France; Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, F-94275, France.
| | - Simon Travers
- Inserm, U1185, Le Kremlin-Bicêtre, F-94276, France; Fac Med Paris-Sud, Univ. Paris-Sud, Université Paris Saclay, UMR-S 1185, Le Kremlin-Bicêtre, F-94276, France; Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, F-94275, France
| | - Claire Bouvattier
- Département d'Endocrinologie Pédiatrique, Hôpital de Bicêtre, Hôpitaux Universitaires Paris Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, F-94275, France; Centre de Référence des Maladies Rares du Développement Génital (DEVGEN), Le Kremlin Bicêtre, F-94275, France
| | - Qiong-Yao Xue
- Inserm, U1185, Le Kremlin-Bicêtre, F-94276, France; Fac Med Paris-Sud, Univ. Paris-Sud, Université Paris Saclay, UMR-S 1185, Le Kremlin-Bicêtre, F-94276, France; Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, F-94275, France
| | - Claudine Cosson
- Service de Biochimie, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin Bicêtre, F-94275, France
| | - Say Viengchareun
- Inserm, U1185, Le Kremlin-Bicêtre, F-94276, France; Fac Med Paris-Sud, Univ. Paris-Sud, Université Paris Saclay, UMR-S 1185, Le Kremlin-Bicêtre, F-94276, France
| | - Laetitia Martinerie
- Inserm, U1185, Le Kremlin-Bicêtre, F-94276, France; Fac Med Paris-Sud, Univ. Paris-Sud, Université Paris Saclay, UMR-S 1185, Le Kremlin-Bicêtre, F-94276, France; Service d'Endocrinologie Pédiatrique, Hôpital Robert Debré, Assistance Publique Hôpitaux de Paris, Paris, F-75019, France; Université Paris Diderot, Sorbonne Paris Cité, Paris, F-75019, France
| | - Marc Lombès
- Inserm, U1185, Le Kremlin-Bicêtre, F-94276, France; Fac Med Paris-Sud, Univ. Paris-Sud, Université Paris Saclay, UMR-S 1185, Le Kremlin-Bicêtre, F-94276, France
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Pijnenburg-Kleizen KJ, Thomas CMG, Otten BJ, Roeleveld N, Claahsen-van der Grinten HL. Long-term follow-up of children with classic congenital adrenal hyperplasia: suggestions for age dependent treatment in childhood and puberty. J Pediatr Endocrinol Metab 2019; 32:1055-1063. [PMID: 31573958 DOI: 10.1515/jpem-2019-0006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 06/17/2019] [Indexed: 11/15/2022]
Abstract
Background In congenital adrenal hyperplasia (CAH), achieving the balance between overtreatment and undertreatment remains challenging. Final height (FH) can serve as a long-term outcome measure. We aimed to identify age-dependent factors that influence FH in CAH patients, resulting in age-specific treatment goals. Methods We retrospectively evaluated longitudinal data of 39 pediatric CAH patients born between 1980 and 1997 from the Radboudumc CAH database. We analyzed height and bone age (BA) at diagnosis or 4 years of age, at the start of puberty and at FH. Height data were corrected for parental height and secular trend. Hydrocortisone (HC) use and salivary steroid concentrations were studied longitudinally throughout childhood and puberty. Results Median FH standard deviation scores (SDSs) corrected for target height SDSs (THSDSs) was -1.63. Median height SDS corrected for THSDS (HSDS-THSDS) decreased from diagnosis/age 4 years to FH in both salt wasting (SW) CAH and simple virilizing (SV) CAH, and in both male and female patients. However, when height was corrected for BA, no height loss occurred from diagnosis/age 4 years to FH in any of the subgroups, while a height gain was seen in SV males. In the combined model analyzing both HC dose and salivary steroid concentrations, in childhood the androstenedione (A) concentration was negatively associated with FH, while in puberty the HC dose was negatively associated with FH. Conclusions In CAH, loss of growth potential already occurs in early childhood. In prepubertal children, exposure to elevated androgens is associated with decreased FH. In puberty, the growth suppressing effects of HC outweigh the negative effects of elevated androgens. Therefore, we suggest different treatment approaches in prepubertal and pubertal patients.
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Affiliation(s)
- Karijn J Pijnenburg-Kleizen
- Department of Pediatric Endocrinology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands, Phone: +0031-24-3614430, Fax: +0031-24-3614427
| | - Chris M G Thomas
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Barto J Otten
- Department of Pediatric Endocrinology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands
| | - Nel Roeleveld
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hedi L Claahsen-van der Grinten
- Department of Pediatric Endocrinology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands
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Kamrath C, Wettstaedt L, Hartmann MF, Wudy SA. Height Velocity defined metabolic Control in Children with Congenital Adrenal Hyperplasia using urinary GC-MS Analysis. J Clin Endocrinol Metab 2019; 104:4214-4224. [PMID: 31112272 DOI: 10.1210/jc.2019-00438] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/15/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Treatment of children with classic congenital adrenal hyperplasia (CAH) with glucocorticoids is a difficult balance between hypercortisolism and hyperandrogenism. Biochemical monitoring of treatment is not well defined. Achievement of a normal growth rate is the most important therapeutic goal. METHODS We retrospectively evaluated 123 24-h GC-MS urinary steroid metabolome analyses together with their corresponding one-year height velocity (HV) z-scores in 63 prepubertal children aged 7.2 ± 1.6 years with classic CAH due to 21-hydroxylase deficiency treated with hydrocortisone and fludrocortisone. RESULTS Multivariate linear mixed effects model analysis revealed a positive influence of CAH-specific z-scores of summed urinary androgen metabolites (B= 0.97 ± 0.20, t-value = 4.97, P < 0.0001) and a negative influence of the cortisol metabolite tetrahydrocortisol (B= -1.75 ± 0.79, t-value = -2.20, P = 0.03) on HV z-scores. ROC analysis demonstrated that adrenal androgen excess, defined as HV > 1.5 z, was best determined by a z-score of all urinary androgen metabolites of > 0.512 (accuracy 66.2%, sensitivity 57.1 %, specificity 74.4%, positive prediction values (PPV) 66.7%, negative prediction values (NPV) 65.9%). Tetrahydrocortisol excretion > 1480 µg/ m2 BSA/ d in conjunction with suppressed urinary androgen metabolites < 0.163 z indicated overtreatment, defined as HV < -1.5 z (accuracy 79.6 %, sensitivity 40.0 %, specificity 94.9%, PPV 75.0%, NPV 80.4%). CONCLUSION We could establish target values for urinary steroid metabolite excretions in children with CAH based on their growth rate. Urinary steroid metabolome analysis represents a highly suitable method for monitoring metabolic control in CAH children.
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Affiliation(s)
- Clemens Kamrath
- Division of Pediatric Endocrinology and Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Lisa Wettstaedt
- Division of Pediatric Endocrinology and Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Michaela F Hartmann
- Division of Pediatric Endocrinology and Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Stefan A Wudy
- Division of Pediatric Endocrinology and Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
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8
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Al Shaikh A, AlGhanmi Y, Awidah S, Bahha A, Ahmed ME, Soliman AT. Clinical Patterns and Linear Growth in Children with Congenital Adrenal Hyperplasia, an 11-Year Experience. Indian J Endocrinol Metab 2019; 23:298-306. [PMID: 31641631 PMCID: PMC6683700 DOI: 10.4103/ijem.ijem_99_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE An important goal in treating children with congenital adrenal hyperplasia (CAH) is to achieve a normal final adult height (FH). The aim of this study was to describe the clinical presentations and evaluate linear growth and possible factors affecting it in children with CAH. METHODS This is a retrospective study of 56 patients with CAH followed up in a tertiary center for 11 years. Patient's data including demographics, clinical, anthropometric, and laboratory information at presentation and during follow-up period were collected from medical records. RESULTS Fifty-six children (31 females) with CAH were seen at KAMC-Jeddah over 11-year period and 91% were 21-hydroxylase deficient. Of these, 46.4% had hyponatremia and 28.6% had hyperkalemia (21.4% had hyponatremia and hyperkalemia) at presentation. Positive family history was documented in 53.6%. Ambiguous genitalia were present in 72% of females and the majority required corrective surgery. Males had significantly decreased HtSDS versus females and females had significantly higher body mass index. The HtSDS of children who had had higher 17OHP or salt-losing crisis during treatment was significantly lower than those who had normal 17OHP and those who did not have salt-losing crisis, respectively. CONCLUSION The final height outcome in our patients with CAH treated with glucocorticoids is lower than the population norm. Proper control of the disease clinically and biochemically through strict compliance to medical therapy as well as close clinical and laboratory monitoring is an important key to achieve normal final adult height in these patients. Side effects, including overweight, obesity, and hypertension are true risk associations and need timely diagnosis and early management.
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Affiliation(s)
- Adnan Al Shaikh
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Yasser AlGhanmi
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Saniah Awidah
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Abdullah Bahha
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Mohamed E. Ahmed
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Ashraf T. Soliman
- Department of Pediatrics, Division of Endocrinology, University of Alexandria, Egypt
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Dörr HG, Penger T, Albrecht A, Marx M, Völkl TMK. Birth Size in Neonates with Congenital Adrenal Hyperplasia due to 21-hydroxylase Deficiency. J Clin Res Pediatr Endocrinol 2019; 11:41-45. [PMID: 30178749 PMCID: PMC6398197 DOI: 10.4274/jcrpe.galenos.2018.2018.0149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Classic congenital adrenal hyperplasia (CAH) secondary to 21-hydroxylase deficiency is characterized by increased prenatal adrenal androgen secretion. There are a small number of reports in the literature showing higher birth weight and length in CAH newborns. METHODS We analyzed birth weight and length data of 116 German newborns (48 boys, 68 girls) with classic CAH who were born during the period from 1990 to 2017. All children have been followed or are currently treated as outpatients in our clinic. All children were born at term. The mothers were healthy and their pregnancies were uneventful. The diagnosis of CAH was confirmed by molecular analyses of the CYP21A2 gene. Birth data were calculated as standard deviation (SD) scores according to German reference values. RESULTS Weight and length in male CAH newborns (mean ± SD) (3601±576 g; 52.4±2.85 cm) were significantly higher than in female CAH newborns (3347±442 g; 51.2±2.55 cm), but male-female differences in the CAH cohort were lost when the data were converted into SD scores. The birth sizes of the CAH newborns did not differ from the reference group. The birth sizes also did not differ between the different CAH genotypes. Maternal age, mode of delivery and maternal parity had no influence on birth size. CONCLUSION Our data show that prenatal hyperandrogenism does not affect fetal growth.
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Affiliation(s)
- Helmuth G. Dörr
- University Hospital of Erlangen, Department of Paediatrics, Division of Paediatrics Endocrinology, Erlangen, Germany,* Address for Correspondence: University Hospital of Erlangen, Department of Paediatrics, Division of Paediatrics Endocrinology, Erlangen, Germany Phone: +49(0)91318533732 E-mail:
| | - Theresa Penger
- University Hospital of Erlangen, Department of Paediatrics, Division of Paediatrics Endocrinology, Erlangen, Germany
| | - Andrea Albrecht
- University Hospital of Erlangen, Department of Paediatrics, Division of Paediatrics Endocrinology, Erlangen, Germany
| | - Michaela Marx
- University Hospital of Erlangen, Department of Paediatrics, Division of Paediatrics Endocrinology, Erlangen, Germany
| | - Thomas M. K. Völkl
- University Hospital of Erlangen, Department of Paediatrics, Division of Paediatrics Endocrinology, Erlangen, Germany
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Maheshwari A, Khadilkar V, Gangodkar P, Khadilkar A. Long-term Growth in Congenital Adrenal Hyperplasia. Indian J Pediatr 2019; 86:154-158. [PMID: 30097840 DOI: 10.1007/s12098-018-2753-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 07/19/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To retrospectively assess growth of children with congenital adrenal hyperplasia (CAH) with special reference to puberty and to assess longitudinal growth and final height of subset of children with CAH. METHODS A retrospective analysis of 30 children (14 boys) with classic CAH (11 salt wasters, 19 simple virilisers) followed up for a mean duration of 9.9 ± 2.4 y (Study period December 2002 through December 2016) was performed. Height Z scores, target height Z scores, height velocities and laboratory parameters were analysed. RESULTS Children were treated with hydrocortisone in a mean dose of 15.7 ± 3.3 mg/m2/d. Mean 17-hydroxy progesterone in boys and girls were 10.8 ± 6.7 ng/ml and 11.3 ± 9.3 ng/ml respectively. Fifteen children (7 boys) developed central precocious puberty at mean age of 7.6 ± 1.8 y and 13 were treated with GnRH analogues for 3.5 y. Of all patients, 18 (10 girls, 8 boys) reached final height at a mean age of 14.2 ± 1.6 y. Mean final height achieved was 158.0 ± 8.5 cm in boys [target height (TH) -165.5 ± 3.8 cm] and in girls it was 149.9 ± 6.7 cm [target height (TH) 154.7 ± 6.4 cm]. Final height standard deviation scores (SDS) for boys and girls were - 2.06 ± 1.1 (TH-SDS -1.06 ± 0.5) and - 1.47 ± 1.1 (TH-SDS -0.56 ± 1.2) respectively and were not significantly different from target height Z scores (p > 0.05). Growth velocity was attenuated during pubertal years. CONCLUSIONS Monitoring growth and puberty in children with CAH is critical for optimizing final height.
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Affiliation(s)
- Ankita Maheshwari
- Growth and Pediatric Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, 32 Sassoon Road, Pune, 411001, India
| | - Vaman Khadilkar
- Growth and Pediatric Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, 32 Sassoon Road, Pune, 411001, India
| | - Priyanka Gangodkar
- Growth and Pediatric Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, 32 Sassoon Road, Pune, 411001, India
| | - Anuradha Khadilkar
- Growth and Pediatric Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, 32 Sassoon Road, Pune, 411001, India.
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11
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Mooij CF, Webb EA, Claahsen van der Grinten HL, Krone N. Cardiovascular health, growth and gonadal function in children and adolescents with congenital adrenal hyperplasia. Arch Dis Child 2017; 102:578-584. [PMID: 27974295 DOI: 10.1136/archdischild-2016-311910] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/21/2016] [Indexed: 11/04/2022]
Abstract
After the introduction of replacement therapy with glucocorticoids and mineralocorticoids in the 1950s, congenital adrenal hyperplasia (CAH) is no longer a life-limiting condition. However, due to the successful introduction of medical steroid hormone replacement, CAH has become a chronic condition, with associated comorbidities and long-term health implications. The aim of treatment is the replacement of mineralocorticoids and glucocorticoids and the normalisation of elevated androgen concentrations. Long-term consequences of the condition and current treatment regimens include unfavourable changes in the cardiovascular risk profile, impaired growth, testicular adrenal rest tumours (TART) in male and subfertility in both male and female patients with CAH. Optimising replacement therapy in patients with CAH remains challenging. On one hand, treatment with supraphysiological doses of glucocorticoids might be required to normalise androgen concentrations and decrease size or presence of TARTs. On the other hand, treatment with supraphysiological doses of glucocorticoids is associated with an increased prevalence of unfavourable cardiovascular and metabolic risk profiles as well as impaired longitudinal growth and gonadal function. Therefore, treatment of children and adults with CAH requires an individualised approach. Careful monitoring for early signs of complications is already warranted during paediatric healthcare provision to prevent and reduce the impact of comorbidities in later life.
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Affiliation(s)
- Christiaan F Mooij
- Institute of Metabolism and Systems Research, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, UK.,Department of Paediatric Endocrinology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Emma A Webb
- Institute of Metabolism and Systems Research, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, UK
| | - Hedi L Claahsen van der Grinten
- Department of Paediatric Endocrinology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nils Krone
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield Children's Hospital, Sheffield, UK
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12
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Bizzarri C, Improda N, Maggioli C, Capalbo D, Roma S, Porzio O, Salerno M, Cappa M. HYDROCORTISONE THERAPY AND GROWTH TRAJECTORY IN CHILDREN WITH CLASSICAL CONGENITAL ADRENAL HYPERPLASIA. Endocr Pract 2017; 23:546-556. [PMID: 28225306 DOI: 10.4158/ep171751.or] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Poor linear growth is one of the main concerns in children with congenital adrenal hyperplasia (CAH). We aimed to analyze factors affecting growth trajectory in children with classical CAH. METHODS Clinical records of children followed from infancy up to the end of growth at two Italian tertiary referral hospitals were reviewed. Fifty-seven patients (31 males), treated with hydrocortisone and fludrocortisone only, were included. Clinical observations were divided into three groups: 0 to 2 years, 172 observations; from 2 years to puberty onset, 813 observations; after puberty onset, 527 observations. Height velocity, pubertal growth spurt, and final height were evaluated as outcomes. RESULTS Final height standard deviation score (SDS) was lower than target height SDS (-0.74 ± 1.1 versus -0.31 ± 1.01; P<.001). Target-adjusted final height SDS was -0.44 ± 1.8 in males and -0.13 ± 1.1 in females (P = .001). Total pubertal growth was 21.9 ± 7.3 cm in males and 19.2 ± 8.2 cm in females (P = .19). Hydrocortisone dose increased and height-velocity SDS decreased during puberty. At multivariable analysis, height-velocity SDS was adversely affected by hydrocortisone dose (P = .038) and directly related to adrenocorticotropic hormone (ACTH) levels (P = .023). Target-adjusted final-height SDS was adversely affected by hydrocortisone dose (P<.001) and positively related to mineralocorticoid therapy (P = .001) and ACTH levels (P = .02). Total pubertal growth (cm) was positively related to ACTH levels (P = .01). CONCLUSION Height outcome of CAH patients is now better than previously reported. During puberty, the lowest effective dose of hydrocortisone should be used to optimize pubertal growth spurt and final height. ABBREVIATIONS 17-OHP = 17-alpha-hydroxyprogesterone ACTH = adrenocorticotropic hormone BMI = body mass index CAH = congenital adrenal hyperplasia GH = growth hormone HPA = hypothalamus-pituitary-adrenal PRA = plasma renin activity SDS = standard deviation score SV = simple virilizing SW = salt-wasting.
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13
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Hawton K, Walton-Betancourth S, Rumsby G, Raine J, Dattani M. Growth Hormone With Aromatase Inhibitor May Improve Height in CYP11B1 Congenital Adrenal Hyperplasia. Pediatrics 2017; 139:peds.2016-0730. [PMID: 28126912 DOI: 10.1542/peds.2016-0730] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2016] [Indexed: 11/24/2022] Open
Abstract
With an estimated prevalence of 1 in 100 000 births, 11β-hydroxylase deficiency is the second most common form of congenital adrenal hyperplasia (CAH) and is caused by mutations in CYP11B1 Clinical features include virilization, early gonadotropin-independent precocious puberty, hypertension, and reduced stature. The current mainstay of management is with glucocorticoids to replace deficient steroids and to minimize adrenal sex hormone overproduction, thus preventing virilization and optimizing growth. We report a patient with CAH who had been suboptimally treated and presented to us at 6 years of age with precocious puberty, hypertension, tall stature, advanced bone age, and a predicted final height of 150 cm. Hormonal profiles and genetic analysis confirmed a diagnosis of 11β-hydroxylase deficiency. In addition to glucocorticoid replacement, the patient was commenced on growth hormone and a third-generation aromatase inhibitor, anastrozole, in an attempt to optimize his growth. After the initiation of this treatment, the patient's growth rate improved significantly and bone age advancement slowed. The patient reached a final height of 177.5 cm (0.81 SD score), 11.5 cm above his mid-parental height. This patient is only the second reported case of the use of an aromatase inhibitor in combination with growth hormone to optimize height in 11β-hydroxylase-deficient CAH. This novel treatment proved to be highly efficacious, with no adverse effects. It may therefore provide a promising option to promote growth in exceptional circumstances in individuals with 11β-hydroxylase deficiency presenting late with advanced skeletal maturation and consequent short stature.
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Affiliation(s)
| | - Sandra Walton-Betancourth
- Genetics and Epigenetics in Health and Disease Section, Genetics and Genomic Medicine Programme, UCL Institute of Child Health and Great Ormond Street Hospital, London, United Kingdom
| | - Gill Rumsby
- University College London Hospital, London, United Kingdom; and
| | | | - Mehul Dattani
- Genetics and Epigenetics in Health and Disease Section, Genetics and Genomic Medicine Programme, UCL Institute of Child Health and Great Ormond Street Hospital, London, United Kingdom
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14
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Kamrath C, Wettstaedt L, Boettcher C, Hartmann MF, Wudy SA. The urinary steroidome of treated children with classic 21-hydroxylase deficiency. J Steroid Biochem Mol Biol 2017; 165:396-406. [PMID: 27544322 DOI: 10.1016/j.jsbmb.2016.08.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 08/11/2016] [Accepted: 08/15/2016] [Indexed: 11/22/2022]
Abstract
Monitoring treatment of children with classic congenital adrenal hyperplasia (CAH) is difficult and biochemical targets are not well defined. We retrospectively analysed 576 daily urinary steroid hormone metabolite profiles determined by gas chromatography-mass spectrometry of 150 children aged 3.0-17.9 years with classic 21-hydroxylase deficiency (21-OHD) on hydrocortisone and fludrocortisone treatment. Daily urinary excretion of glucocorticoid-, 17α-hydroxyprogesterone (17-OHP)-, and androgen metabolites as well as growth and weight gain are presented. Children with classic CAH exhibited increased height velocity during prepubertal age, which was then followed by diminished growth velocity during pubertal age until final height was reached. Final height was clearly below the population mean. 11β-Hydroxyandrosterone was the dominant urinary adrenal-derived androgen metabolite in CAH children. Adrenarche is blunted in children with CAH under hydrocortisone treatment and androgen metabolites except 11β-hydroxyandrosterone were suppressed. Cortisol metabolite excretion reflected supraphysiological hydrocortisone treatment dosage, which resulted in higher body-mass-indices in children with CAH. Reference values of daily urinary steroid metabolite excretions of treated children with CAH allow the clinician to adequately classify the individual patient regarding the androgen-, 17-OHP-, and glucocorticoid status in the context of the underlying disorder. Additionally, urinary 21-OHD-specific reference ranges will be important for research studies in children with CAH.
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Affiliation(s)
- Clemens Kamrath
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Lisa Wettstaedt
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Claudia Boettcher
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Michaela F Hartmann
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany.
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15
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Kiviranta P, Kuiri-Hänninen T, Saari A, Lamidi ML, Dunkel L, Sankilampi U. Transient Postnatal Gonadal Activation and Growth Velocity in Infancy. Pediatrics 2016; 138:peds.2015-3561. [PMID: 27283013 DOI: 10.1542/peds.2015-3561] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Transient activation of the hypothalamic-pituitary-gonadal axis with a sex steroid surge is observed in boys and girls during the first months of life. However, the role of sex steroids in the regulation of growth has not been substantiated in infancy. We tested the hypothesis that testosterone (T) surge, known to be higher in infant boys than in girls during the transient postnatal gonadal activation regulates linear growth in infants. METHODS To characterize in detail the linear growth velocity (GV) differences between genders in the normal population in early infancy, we evaluated growth of 18 570 healthy infants (51.0% boys) with 162 003 height measurements from birth to 12 months of age. GV was monitored and compared with serially measured urinary T and estradiol levels and serum insulin-like growth factor 1 levels in 84 healthy infants (45% boys) during the first 6 months of life. RESULTS GV was significantly faster from birth to 6 months of age in boys than in girls (P ≤ .01). The greatest GV difference, 4.1 cm per year, was observed at 1 month of age, simultaneously with the peak of postnatal gonadal activation. In the mixed model analysis, GV showed a significant positive association with T in both genders (parameter estimate up to 0.62, 95% confidence interval 0.44-0.81). CONCLUSIONS These results provide a new insight into the regulation of growth in infants and elucidate a novel biological role of the transient postnatal gonadal activation in growth regulation.
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Affiliation(s)
- Panu Kiviranta
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland; Department of Pediatrics and
| | - Tanja Kuiri-Hänninen
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland; Department of Pediatrics and
| | - Antti Saari
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland; Department of Pediatrics and
| | - Marja-Leena Lamidi
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland; and
| | - Leo Dunkel
- William Harvey Research Institute, Barts and the London, Queen Mary University of London, London, United Kingdom
| | - Ulla Sankilampi
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland; Department of Pediatrics and
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16
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Juan L, Huamei M, Zhe S, Yanhong L, Hongshan C, Qiuli C, Jun Z, Song G, Minlian D. Near-final height in 82 Chinese patients with congenital adrenal hyperplasia due to classic 21-hydroxylase deficiency: a single-center study from China. J Pediatr Endocrinol Metab 2016; 29:841-8. [PMID: 27054598 DOI: 10.1515/jpem-2015-0406] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 01/22/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND The objective of this study was to identify variables that might interfere with reaching the near final height (NFH) in Congenital adrenal hyperplasia (CAH) due to classic 21-hydroxylase deficiency (21-OHD). METHODS A cross-sectional study of 82 (24 males and 58 females) classic (23 salt-wasting form [SW] and 59 simple-virilizing form [SV]) CAH 21-OHD patients seen in our institution between 1989 and 2015 with 10.6 (0.5~25.5) years of follow-up who reached their NFH was conducted. The variables related to NFH were explored. RESULTS NFH (153.35±8.31) cm, (-1.9±1.1) SD was significantly lower than the normal population (p<0.001). The treated patients reached a significantly higher NFH (-1.7±1.1) SD than those untreated (-2.6±1.0) SD (p<0.05). Both of early treatment and late treatment group were taller than untreated group (p<0.001, p=0.013, respectively), and early treatment group had a taller height trend than late treatment group (p=0.089). A better height outcome was observed in patients with advantage in target height, good compliance, and low hydrocortisone dose by multivariate Cox regression analysis in 62 treatment patients. NFH and hydrocortisone dose was negatively correlated (r=-0.23, p=0.078) in treated group. Patients complicated by central precocious puberty (CPP) received gonadotropin-releasing hormone analogue (GnRHa) plus letrozole had increased NFH with height SD for bone age and Ht SD improved after treatment compare to no intervention group (p=0.001, p=0.035). CONCLUSIONS Patients with classic 21-OHD have blunted final height, as compared with their target height and the population norm, not-treated even worse. Careful treatment adjustments have a favorable influence on growth. Alternative treatments, such as the use of puberty inhibitors GnRHa in addition to anti-estrogen therapy letrozole can somewhat improve NFH in children with 21-OHD complicated by CPP.
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MESH Headings
- Adolescent
- Adrenal Hyperplasia, Congenital/ethnology
- Adrenal Hyperplasia, Congenital/physiopathology
- Adrenal Hyperplasia, Congenital/therapy
- Body Height/ethnology
- Child
- Child, Preschool
- China
- Cohort Studies
- Combined Modality Therapy
- Cross-Sectional Studies
- Female
- Follow-Up Studies
- Growth Disorders/ethnology
- Growth Disorders/etiology
- Growth Disorders/physiopathology
- Growth Disorders/prevention & control
- Hospitals, University
- Humans
- Infant
- Infant, Newborn
- Male
- Outpatient Clinics, Hospital
- Proportional Hazards Models
- Puberty, Precocious/ethnology
- Puberty, Precocious/etiology
- Puberty, Precocious/physiopathology
- Puberty, Precocious/prevention & control
- Retrospective Studies
- Severity of Illness Index
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17
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Abstract
Adrenal steroidogenesis is a dynamic process, reliant on de novo synthesis from cholesterol, under the stimulation of ACTH and other regulators. The syntheses of mineralocorticoids (primarily aldosterone), glucocorticoids (primarily cortisol), and adrenal androgens (primarily dehydroepiandrosterone and its sulfate) occur in separate adrenal cortical zones, each expressing specific enzymes. Congenital adrenal hyperplasia (CAH) encompasses a group of autosomal-recessive enzymatic defects in cortisol biosynthesis. 21-Hydroxylase (21OHD) deficiency accounts for more than 90% of CAH cases and, when milder or nonclassic forms are included, 21OHD is one of the most common genetic diseases.
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Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology, & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; Department of Pharmacology, University of Michigan, Room 5560A MSRBII, 1150 West Medical Center Drive, Ann Arbor, MI 48109, USA.
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18
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Webb EA, Krone N. Current and novel approaches to children and young people with congenital adrenal hyperplasia and adrenal insufficiency. Best Pract Res Clin Endocrinol Metab 2015; 29:449-68. [PMID: 26051302 DOI: 10.1016/j.beem.2015.04.002] [Citation(s) in RCA: 24] [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] [Indexed: 12/11/2022]
Abstract
Congenital adrenal hyperplasia (CAH) represents a group of autosomal recessive conditions leading to glucocorticoid deficiency. CAH is the most common cause of adrenal insufficiency (AI) in the paediatric population. The majority of the other forms of primary and secondary adrenal insufficiency are rare conditions. It is critical to establish the underlying aetiology of each specific condition as a wide range of additional health problems specific to the underlying disorder can be found. Following the introduction of life-saving glucocorticoid replacement sixty years ago, steroid hormone replacement regimes have been refined leading to significant reductions in glucocorticoid doses over the last two decades. These adjustments are made with the aim both of improving the current management of children and young persons and of reducing future health problems in adult life. However despite optimisation of existing glucocorticoid replacement regimens fail to mimic the physiologic circadian rhythm of glucocorticoid secretion, current efforts therefore focus on optimising replacement strategies. In addition, in recent years novel experimental therapies have been developed which target adrenal sex steroid synthesis in patients with CAH aiming to reduce co-morbidities associated with sex steroid excess. These developments will hopefully improve the health status and long-term outcomes in patients with congenital adrenal hyperplasia and adrenal insufficiency.
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Affiliation(s)
- Emma A Webb
- School of Clinical & Experimental Medicine, University of Birmingham, Institute of Biomedical Research, Birmingham B15 2TT, UK.
| | - Nils Krone
- School of Clinical & Experimental Medicine, University of Birmingham, Institute of Biomedical Research, Birmingham B15 2TT, UK.
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19
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Nour MA, Pacaud D. Height augmentation in 11β-hydroxylase deficiency congenital adrenal hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2015; 2015:12. [PMID: 25983757 PMCID: PMC4432823 DOI: 10.1186/s13633-015-0008-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 02/23/2015] [Indexed: 11/10/2022]
Abstract
Context 11β-hydroxylase deficiency is the second most common form of congenital adrenal hyperplasia. Untreated, this enzyme deficiency leads to virilization, hypertension, and significant height impairment. Patient We describe a patient from abroad who first presented to us at age 7 years for follow-up of ambiguous genitalia. He had been investigated and treated in Pakistan at 3-years-of-age following presentation for bilateral cryptorchidism. He was found to have 46, XX karyotype, elevated 17-OH progesterone and was diagnosed with congenital adrenal hyperplasia. In Pakistan, the patient had abdominal hysterectomy, bilateral salpingoophrectomy, and was started on corticosteroid replacement. At 7 years, shortly after immigrating to Canada, height was 138 cm and BMI 19.3 kg/m2 (+2.9 SDS and +1.7 SDS, respectively, male growth chart) and blood pressure was greater than the 99th percentile for age and height. The patient had Prader stage III - IV genital anatomy. Bone age was significantly advanced, yielding a severely compromised predicted final adult height. Biochemical evaluation was consistent with 11β-hydroxylase deficiency congenital adrenal hyperplasia. Intervention and outcome In an attempt to improve final height, in addition to glucocorticoid replacement, this patient was treated with recombinant growth hormone and a third generation aromatase inhibitor (Letrozole) with an improvement in final height attained as compared with predicted height. Conclusions This case of a 46,XX patient raised as male with congenital adrenal hyperplasia due to 11β-hydroxylase deficiency highlights a number of unique and difficult treatment challenges; specifically, the role of new therapeutic options for optimization of growth in the context of prior suboptimal disease management.
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Affiliation(s)
- Munier A Nour
- Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan Canada ; Department of Pediatrics, College of Medicine, Royal University Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W8 Canada
| | - Danièle Pacaud
- Division of Pediatric Endocrinology, Alberta Children's Hospital, Calgary, Alberta Canada ; Faculty of Medicine, University of Calgary, Calgary, Alberta Canada
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20
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Kawano A, Kohno H, Miyako K. A Retrospective Analysis of the Growth Pattern in Patients with Salt-wasting 21-Hydroxylase Deficiency. Clin Pediatr Endocrinol 2014; 23:27-34. [PMID: 24790384 PMCID: PMC4004995 DOI: 10.1297/cpe.23.27] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 12/12/2013] [Indexed: 11/30/2022] Open
Abstract
The objective of this study was to investigate the growth pattern of children with the
salt-wasting form of congenital adrenal hyperplasia caused by 21-hydroxylase deficiency
(21-OHD). We reviewed the medical records of 13 patients in whom salt-wasting 21-OHD was
diagnosed during the first 2 mo of life at our hospital from 1980 through 2008. Six
reached adult height. Growth patterns, bone age, biochemical data, and the hydrocortisone
dose at each growth stage were analyzed retrospectively. The mean adult height was 155.1 ±
6.5 cm (mean ± SD) in females and 158.1 ± 7.1 cm in males. Although length at birth was
normal or longer than the national mean in almost all patients, the mean height SD score
of both boys and girls decreased to below 0 SD during infancy. Subsequently, both boys and
girls transiently showed growth acceleration and reached their peak growth velocity at
3–10 yr of age. In conclusion, in addition to suppression of growth during infancy, there
was inappropriate growth acceleration during childhood. Especially from 3 mo to 3 yr of
age, decreasing the hydrocortisone dose in patients who exhibit slower growth may lead to
satisfactory height outcomes. Also, strict adjustment of the hydrocortisone dose to avoid
accelerated growth from childhood to adolescence might improve adult height outcomes of
patients with 21-OHD.
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Affiliation(s)
- Atsuko Kawano
- Department of Endocrinology and Metabolism, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Hitoshi Kohno
- Department of Endocrinology and Metabolism, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Kenichi Miyako
- Department of Endocrinology and Metabolism, Fukuoka Children's Hospital, Fukuoka, Japan
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21
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Validation of automatic bone age determination in children with congenital adrenal hyperplasia. Pediatr Radiol 2013; 43:1615-21. [PMID: 24091922 DOI: 10.1007/s00247-013-2744-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 04/06/2013] [Accepted: 04/22/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Determination of bone age is routinely used for following up substitution therapy in congenital adrenal hyperplasia (CAH) but today is a procedure with significant subjectivity. OBJECTIVE The aim was to test the performance of automatic bone age rating by the BoneXpert software package in all radiographs of children with CAH seen at our clinic from 1975 to 2006. MATERIALS AND METHODS Eight hundred and ninety-two left-hand radiographs from 100 children aged 0 to 17 years were presented to a human rater and BoneXpert for bone age rating. Images where ratings differed by more than 1.5 years were each rerated by four human raters. RESULTS Rerating was necessary in 20 images and the rerating result was closer to the BoneXpert result than to the original manual rating in 18/20 (90 %). Bone age rating precision based on the smoothness of longitudinal curves comprising a total of 327 data triplets spanning less than 1.7 years showed BoneXpert to be more precise (P<0.001). CONCLUSION BoneXpert performs reliable bone age ratings in children with CAH.
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Koh JW, Kim GH, Yoo HW, Yu J. Clinical features of congenital adrenal insufficiency including growth patterns and significance of ACTH stimulation test. J Korean Med Sci 2013; 28:1650-6. [PMID: 24265530 PMCID: PMC3835509 DOI: 10.3346/jkms.2013.28.11.1650] [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: 07/31/2013] [Accepted: 09/05/2013] [Indexed: 12/18/2022] Open
Abstract
Congenital adrenal insufficiency is caused by specific genetic mutations. Early suspicion and definite diagnosis are crucial because the disease can precipitate a life-threatening hypovolemic shock without prompt treatment. This study was designed to understand the clinical manifestations including growth patterns and to find the usefulness of ACTH stimulation test. Sixteen patients with confirmed genotyping were subdivided into three groups according to the genetic study results: congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH, n=11), congenital lipoid adrenal hyperplasia (n=3) and X-linked adrenal hypoplasia congenita (n=2). Bone age advancement was prominent in patients with CAH especially after 60 months of chronologic age (n=6, 67%). They were diagnosed in older ages in group with bone age advancement (P<0.05). Comorbid conditions such as obesity, mental retardation, and central precocious puberty were also prominent in this group. In conclusion, this study showed the importance of understanding the clinical symptoms as well as genetic analysis for early diagnosis and management of congenital adrenal insufficiency. ACTH stimulation test played an important role to support the diagnosis and serum 17-hydroxyprogesterone levels were significantly elevated in all of the CAH patients. The test will be important for monitoring growth and puberty during follow up of patients with congenital adrenal insufficiency.
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MESH Headings
- 17-alpha-Hydroxyprogesterone/blood
- Adolescent
- Adrenal Hyperplasia, Congenital/drug therapy
- Adrenal Hyperplasia, Congenital/genetics
- Adrenal Insufficiency/congenital
- Adrenal Insufficiency/diagnosis
- Adrenal Insufficiency/drug therapy
- Adrenal Insufficiency/genetics
- Adrenocorticotropic Hormone/metabolism
- Bone Development/genetics
- Child
- Child, Preschool
- DAX-1 Orphan Nuclear Receptor/genetics
- Disorder of Sex Development, 46,XY/drug therapy
- Disorder of Sex Development, 46,XY/genetics
- Female
- Genetic Diseases, X-Linked/drug therapy
- Genetic Diseases, X-Linked/genetics
- Genotype
- Glucocorticoids/therapeutic use
- Humans
- Hypoadrenocorticism, Familial
- Intellectual Disability/complications
- Male
- Mineralocorticoids/therapeutic use
- Obesity/complications
- Phosphoproteins/genetics
- Puberty, Precocious/complications
- Retrospective Studies
- Steroid 21-Hydroxylase/genetics
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Affiliation(s)
- Ji Won Koh
- Department of Pediatrics, Dankook University College of Medicine, Cheonan, Korea
| | - Gu Hwan Kim
- Medical Genetics Center, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Han Wook Yoo
- Medical Genetics Center, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeesuk Yu
- Department of Pediatrics, Dankook University College of Medicine, Cheonan, Korea
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Ahmadi S, Alvi S, Urban RJ. Nonclassic congenital adrenal hyperplasia and the heterozygote carrier. Expert Rev Endocrinol Metab 2013; 8:239-246. [PMID: 30780815 DOI: 10.1586/eem.13.18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This article discusses the difficulty of differentiating three causes of adult androgen excess including nonclassic congenital adrenal hyperplasia caused by 21-hydroxylase deficiency, polycystic ovarian syndrome and heterozygote carrier of CYP21 mutations based on clinical findings. It also reviews the screening modalities that discriminate patients with nonclassic congenital adrenal hyperplasia and the heterozygote carrier of CYP21 mutations from the normal population. In addition, the current management of hyperandrogenism and ovulatory dysfunction in these patients is described.
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Affiliation(s)
- Sara Ahmadi
- a Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Saadia Alvi
- b Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, USA
| | - Randall J Urban
- c Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, USA.
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Hassan MM, Ibrahim A, Abdel-Salam A, Huthail H. Growth in infants with congenital adrenal hyperplasia due to 21-hydroxylase deficiency: An analysis of the factors affecting height. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2013. [DOI: 10.1016/j.epag.2013.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Cordeiro GV, Silva IN, Goulart EMA, Chagas AJD, Kater CE. Final height in congenital adrenal hyperplasia: the dilemma of hypercortisolism versus hyperandrogenism. ACTA ACUST UNITED AC 2013; 57:126-31. [DOI: 10.1590/s0004-27302013000200005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 09/22/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: The purpose of this study was to identify factors that might interfere with reaching the final height in patients with 21-hydroxylase deficiency (21-OHD). SUBJECTS AND METHODS: Thirty-one patients with classical 21-OHD who reached their FH in our Institution were evaluated in order to compare the Z score for final height (FHZ) with: (1) the target height, (2) the standard height for the population, and (3) the hydrocortisone treatment schedule. RESULTS: The FHZ of -2.13 ± 1.11 had a significant negative correlation with the hydrocortisone doses used throughout the period of study. Patients who reached FH within the normal population range were those who received lower doses of hydrocortisone, as compared to those whose FH remained below -2 SDS. CONCLUSION: We conclude that careful treatment adjustments have a major influence on growth of children with CAH, and that the dose range for hydrocortisone replacement that does not lead to side effects is relatively narrow. The better height outcome was achieved in 21-OHD patients who received lower doses of hydrocortisone.
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Janin C, Pascal Vigneron V, Weryha G, Leheup B. Clinical audit concerning the quality of management in patients with classic form of congenital adrenal hyperplasia. ANNALES D'ENDOCRINOLOGIE 2013; 74:13-26. [PMID: 23357572 DOI: 10.1016/j.ando.2012.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Accepted: 10/16/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE High Authority for Health (HAS) edited in April 2011 a national program of care and diagnostic (PNDS) concerning congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency in agreement with the international recommendation 2002 and 2010. To reduce long-term complications and improve the quality of life to our patients, we had tested our professional practices. PATIENTS All patients aged more than 18 years with classic CAH of the adult endocrine units in the Nancy's University Hospital Center. METHODS We have made a clinical audit. We checked all medical records to see whether the recommendation were applied or not between the last consultation before (Tour 1; T1) and after (Tour 2; T2) the introduction of the national guidelines. RESULTS Twenty-seven medicals records with classic CAH were analyzed. The collection of clinical data must be more systematic because if the weight appeared in 89% of cases, body mass index missed (26% only in T1), the measure of the blood pressure remained insufficient (74% in T2). Concerning the therapeutic balance, 17-hydroxyprogestérone, testosterone, renin were correctly prescribed (>80%), Delta4-androstènedione in improvement (from 67% to 100%) some in defect (stable with 68% sodium and potassium). The evaluation of the fertility considerably progressed on the other hand the markers of bone metabolism were still often too much lacking. CONCLUSIONS Change in compliance since national guidelines is a slow process.
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Affiliation(s)
- Cécile Janin
- Service d'endocrinologie adulte, CHU Brabois, 11, rue du morvan, 54500 Vandœuvre-lès-Nancy, France.
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Takasawa K, Ono M, Miyai K, Matsubara Y, Takizawa F, Onishi T, Kashimada K, Mizutani S. Initial high dose hydrocortisone (HDC) treatment for 21-hydroxylase deficiency (21-OHD) does not affect linear growth during the first three years of life. Endocr J 2012; 59:1001-6. [PMID: 22785554 DOI: 10.1507/endocrj.ej12-0036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
An initial high-dose treatment of glucocorticoid has been proposed to prevent chronic androgen excess, improving the final height prognosis of 21-hydroxylase deficiency (21-OHD) patients. In Japan, it is recommended to use an extremely high-dose of hydrocortisone (HDC) (100-200 mg/m(2)/day) for initial treatment by the Japanese Society for Pediatric Endocrinology. However, a precise evaluation of the treatment has not been carried out. In this study, we retrospectively analysed the effects of initial high-dose HDC therapy on the linear growth of classical 21-OHD patients discovered by newborn screening. Thirty patients (14 females) were eligible for this study, all of whom were initiated with high dose HDC therapy. The height standard deviation score (Ht-SDS) was 0.76 ± 0.65 at birth, and decreased to -1SD or less until the age of 12 months, subsequently catching up by 3 years of age (-0.56 ± 0.76). The growth pattern and the height at the age of two years were very similar to those previously observed in patients without initial high dose HDC therapy. We did not find any significant difference in growth retrospectively between the high- or low-dose HDC group (initial treatments of ≥150 mg/m(2)/day and 100 mg/m(2)/day, respectively). Bone ages did not exceed chronological ages at the ages of three and six years. Our data suggest that an initial high-dose HDC treatment does not profoundly affect linear growth during first three years of life and that the treatment could be a valuable option for 21-OHD patients without having an obvious adverse effect on linear growth.
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Affiliation(s)
- Kei Takasawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
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Lin-Su K, Harbison MD, Lekarev O, Vogiatzi MG, New MI. Final adult height in children with congenital adrenal hyperplasia treated with growth hormone. J Clin Endocrinol Metab 2011; 96:1710-7. [PMID: 21450983 PMCID: PMC3206397 DOI: 10.1210/jc.2010-2699] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency typically reach a final adult height well below their mid-parental target height. OBJECTIVE The objective of this study was to examine whether GH alone or in combination with an LHRH analog (LHRHa) improved the final adult height in patients with CAH. DESIGN The study was a nonrandomized prospective study. SETTING The study was conducted at two university hospitals in New York City, NY. PARTICIPANTS Thirty-four patients with CAH treated with GH participated in this study. Nineteen males and 15 females who were predicted to be more than 2 SD below their mid-parental target height or more than 2 SD below the population mean received GH until reaching final adult height. In addition to GH, 27 patients (16 males, 11 females) were also treated with an LHRHa. INTERVENTION The mean duration of GH treatment was 5.6 ± 1.8 yr in males and 4.5 ± 1.6 yr in females. The mean duration of LHRHa therapy was 3.7 ± 1.7 yr for both sexes. MAIN OUTCOME MEASURES The primary endpoint variables were final adult height, final height discrepancy, and gain in height. RESULTS Males reached a significantly higher final adult height (172.0 ± 4.8 cm) than their initial predicted height (162.8 ± 7.7 cm) (P < 0.00001). Females also reached a significantly higher final adult height (162.2 ± 5.3 cm) than initially predicted (151.7 ± 5.2 cm) (P < 0.0000001). Mean gain in height was 9.2 ± 6.7 cm in males and 10.5 ± 3.7 cm in females. CONCLUSION Our results indicate that GH alone or in combination with LHRHa improves final adult height in patients with CAH.
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Affiliation(s)
- Karen Lin-Su
- Department of Pediatric Endocrinology, Weill Medical College of Cornell University, New York, New York 10021, USA
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Sarafoglou K, Himes JH, Lacey JM, Netzel BC, Singh RJ, Matern D. Comparison of multiple steroid concentrations in serum and dried blood spots throughout the day of patients with congenital adrenal hyperplasia. Horm Res Paediatr 2011; 75:19-25. [PMID: 20798478 PMCID: PMC3202930 DOI: 10.1159/000315910] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 05/21/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM periodic measurement of plasma concentrations of cortisol precursors on a clinic visit may be of limited value in patients with congenital adrenal hyperplasia because it does not reflect a patient's circadian patterns of adrenal steroid secretion. Steroid profiling in dried blood spots (DBS) may allow for more frequent and sensitive monitoring. METHODS we compared the agreement between 17α-hydroxyprogesterone (17-OHP) and androstenedione (D4A) levels determined from DBS samples and concurrently collected serum samples. Blood was drawn from 9 congenital adrenal hyperplasia patients every 4 h over a 24-hour period. Serum and DBS steroid levels were measured by liquid chromatography tandem mass spectrometry. RESULTS DBS determinations of 17-OHP overestimated corresponding serum levels (mean difference 1.67 ng/ml), and underestimated D4A serum levels (mean difference 0.84 ng/ml). However, the DBS assay yielded excellent agreement (97%) with serum 17-OHP, but did considerably poorer for D4A (31%). CONCLUSIONS our results indicate an excellent agreement between DBS and serum 17-OHP measurements to identify the peaks and troughs associated with an individual's circadian pattern. Larger-scale studies are required to evaluate the utility of DBS for home monitoring and to determine if more frequent monitoring leads to improved clinical outcomes.
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Affiliation(s)
- Kyriakie Sarafoglou
- Department of Pediatrics, School of Public Health, University of Minnesota, Minneapolis, Minn. 55455, USA.
| | - John H. Himes
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minn., USA
| | - Jean M. Lacey
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minn., USA
| | - Brian C. Netzel
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minn., USA
| | - Ravinder J. Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minn., USA
| | - Dietrich Matern
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minn., USA
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Cavarzere P, Vincenzi M, Gaudino R, Franceschi R, Perlini S, Camilot M, Teofoli F, Antoniazzi F, Tatò L. Possible andrologic markers in elevated neonatal 17-hydroxyprogesterone. Fertil Steril 2010; 94:2350-2. [DOI: 10.1016/j.fertnstert.2010.04.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 04/10/2010] [Accepted: 04/16/2010] [Indexed: 10/19/2022]
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Speiser PW, Azziz R, Baskin LS, Ghizzoni L, Hensle TW, Merke DP, Meyer-Bahlburg HFL, Miller WL, Montori VM, Oberfield SE, Ritzen M, White PC. Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2010; 95:4133-60. [PMID: 20823466 PMCID: PMC2936060 DOI: 10.1210/jc.2009-2631] [Citation(s) in RCA: 659] [Impact Index Per Article: 47.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We developed clinical practice guidelines for congenital adrenal hyperplasia (CAH). PARTICIPANTS The Task Force included a chair, selected by The Endocrine Society Clinical Guidelines Subcommittee (CGS), ten additional clinicians experienced in treating CAH, a methodologist, and a medical writer. Additional experts were also consulted. The authors received no corporate funding or remuneration. CONSENSUS PROCESS Consensus was guided by systematic reviews of evidence and discussions. The guidelines were reviewed and approved sequentially by The Endocrine Society's CGS and Clinical Affairs Core Committee, members responding to a web posting, and The Endocrine Society Council. At each stage, the Task Force incorporated changes in response to written comments. CONCLUSIONS We recommend universal newborn screening for severe steroid 21-hydroxylase deficiency followed by confirmatory tests. We recommend that prenatal treatment of CAH continue to be regarded as experimental. The diagnosis rests on clinical and hormonal data; genotyping is reserved for equivocal cases and genetic counseling. Glucocorticoid dosage should be minimized to avoid iatrogenic Cushing's syndrome. Mineralocorticoids and, in infants, supplemental sodium are recommended in classic CAH patients. We recommend against the routine use of experimental therapies to promote growth and delay puberty; we suggest patients avoid adrenalectomy. Surgical guidelines emphasize early single-stage genital repair for severely virilized girls, performed by experienced surgeons. Clinicians should consider patients' quality of life, consulting mental health professionals as appropriate. At the transition to adulthood, we recommend monitoring for potential complications of CAH. Finally, we recommend judicious use of medication during pregnancy and in symptomatic patients with nonclassic CAH.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children's Medical Center of New York and Hofstra University School of Medicine, New Hyde Park, New York 11040, USA
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Schaeffer TL, Tryggestad JB, Mallappa A, Hanna AE, Krishnan S, Chernausek SD, Chalmers LJ, Reiner WG, Kropp BP, Wisniewski AB. An Evidence-Based Model of Multidisciplinary Care for Patients and Families Affected by Classical Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:692439. [PMID: 20339513 PMCID: PMC2842898 DOI: 10.1155/2010/692439] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Accepted: 01/19/2010] [Indexed: 11/18/2022]
Abstract
In 2002 a consensus statement pertaining to the management of classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency was jointly produced by the Lawson Wilkins Pediatric Endocrine Society and the European Society of Pediatric Endocrinology. One of the recommendations of this consensus was that centers should maintain multidisciplinary teams for providing care and support to these patients and their families. However, the specifics for how this should be accomplished were not addressed in the original consensus statement. Here we interpret and translate the 2002 consensus statement recommendations into medical, surgical and mental health protocols. Additionally, we provide preliminary evidence that such protocols result in improved care and support for patients and families.
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Affiliation(s)
- Traci L. Schaeffer
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Jeanie B. Tryggestad
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Ashwini Mallappa
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Adam E. Hanna
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Sowmya Krishnan
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Steven D. Chernausek
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Laura J. Chalmers
- Pediatric Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - William G. Reiner
- Pediatric Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Brad P. Kropp
- Pediatric Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Amy B. Wisniewski
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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Gonçalves EM, Lemos-Marini SHVD, Mello MPD, Baldin AD, Carvalho WRG, Farias ES, Guerra-Júnior G. Composição corporal em mulheres com deficiência da 21-hidroxilase: comparação dos métodos antropométricos e de impedância bioelétrica em relação a um grupo controle. ACTA ACUST UNITED AC 2010; 54:274-81. [DOI: 10.1590/s0004-27302010000300005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Accepted: 11/02/2009] [Indexed: 11/22/2022]
Abstract
OBJETIVO: Estimar a composição corporal avaliada pela espessura de dobras cutâneas (EDC) e pela impedância bioelétrica (BIA) em um grupo de mulheres com hiperplasia adrenal congênita, forma clássica por deficiência da enzima 21-hidroxilase (HAC-C-D21OH) e em relação ao um grupo controle. PACIENTES E MÉTODOS: Foram avaliadas 16 pacientes com HAC-C-D21OH e 26 controles, todas do sexo feminino, com idades de 8 a 18 anos. Foram estimadas as massas gorda (MG) e magra (MM) utilizando EDC e BIA. Os dados das MG e MM foram analisados de forma relativa (%), absoluta (kg) e em relação à estatura (IMG e IMM). RESULTADOS: Não foram encontradas diferenças significativas entre os dois métodos em cada grupo avaliado. Em relação ao grupo controle, as pacientes com HAC-C-D21OH apresentaram valores maiores de MG (%) BIA, IMG BIA e IMM EDC e menores de MM (%) BIA. Foi verificada correlação positiva e alta em todos os parâmetros analisados. CONCLUSÃO: Os resultados observados pelos métodos de EDC e BIA foram semelhantes nesta amostra de mulheres com HAC-CD21OH, porém controversos em relação ao grupo controle, sugerindo que se tenha cautela no uso desses métodos de avaliação da composição corporal nessa população.
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Growth and reproductive outcomes in congenital adrenal hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:298937. [PMID: 20148087 PMCID: PMC2817857 DOI: 10.1155/2010/298937] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 12/11/2009] [Indexed: 11/21/2022]
Abstract
The treatment of congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is complex. In addition to disease control, important therapeutic goals are the maintenance of normal growth and the acquisition of normal reproductive function. Here, data regarding final adult height (FH) in patients with CAH will be reviewed. Additional difficulties associated with CAH, including risks of obesity and hypertension, will be discussed. Information about fertility and reproductive outcomes in men and women with CAH will also be summarized. Although the treatment of each child with CAH needs to be individualized, close medical followup and laboratory monitoring along with good compliance can often result in positive clinical outcomes.
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Nebesio T, Eugster E. Growth and Reproductive Outcomes in Congenital Adrenal Hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-298937] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Schaeffer T, Tryggestad J, Mallappa A, Hanna A, Krishnan S, Chernausek S, Chalmers L, Reiner W, Kropp B, Wisniewski A. An Evidence-Based Model of Multidisciplinary Care for Patients and Families Affected by Classical Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-692439] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Bonfig W, Pozza SBD, Schmidt H, Pagel P, Knorr D, Schwarz HP. Hydrocortisone dosing during puberty in patients with classical congenital adrenal hyperplasia: an evidence-based recommendation. J Clin Endocrinol Metab 2009; 94:3882-8. [PMID: 19622620 DOI: 10.1210/jc.2009-0942] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with congenital adrenal hyperplasia (CAH) are at risk for early pubertal development and diminished pubertal growth. Liberal treatment with glucocorticoids will prevent early puberty but may inhibit growth outright. OBJECTIVE The aim of the study was to determine an optimal range for hydrocortisone dosing during puberty in children with classical CAH who were exclusively treated with hydrocortisone. METHODS The effects of glucocorticoid treatment for classical CAH were retrospectively analyzed in 92 patients (57 females). Growth pattern, final height (FH), and mean daily hydrocortisone dose were recorded. RESULTS Pubertal growth was significantly reduced in all patients: salt-wasting (SW) females, 13.8 +/- 7.4 cm; simple virilizing (SV) females, 13.1 +/- 6.2 cm; vs. reference, 20.3 +/- 6.8 cm (P < 0.05); and SW males, 17.7 +/- 6.7 cm; SV males, 16.2 +/- 5.7 cm; vs. reference, 28.2 +/- 8.2 cm (P < 0.05). Decreased pubertal growth resulted in FH at the lower limit of genetic potential (corrected FH in SW females, -0.6 +/- 0.9; SV females, -0.3 +/- 0.9; SW males, -0.8 +/- 0.8; and SV males, -1.0 +/- 1.0). During puberty, mean daily hydrocortisone dose was 17.2 +/- 3.4 mg/m(2) in females (SW, 17.0 +/- 3.3; SV, 17.4 +/- 3.5) and 17.9 +/- 2.5 mg/m(2) in males (SW, 17.4 +/- 2.0; SV, 18.7 +/- 3.1). In a logistic regression model, a significant correlation between hydrocortisone dose and FH was found (P < 0.01), and the positive predictive value for short stature rose from below 30% to above 60% when hydrocortisone dose exceeded 17 mg/m(2). CONCLUSION With conventional hydrocortisone treatment, pubertal growth is significantly reduced in both sexes, resulting in a FH at the lower limit of genetic potential. These deleterious effects on pubertal growth can be reduced if hydrocortisone does not exceed 17 mg/m(2).
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Affiliation(s)
- Walter Bonfig
- University Children's Hospital, Division of Endocrinology, Ludwig Maximilians University, D-80337 Munich, Germany.
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Armengaud JB, Charkaluk ML, Trivin C, Tardy V, Bréart G, Brauner R, Chalumeau M. Precocious pubarche: distinguishing late-onset congenital adrenal hyperplasia from premature adrenarche. J Clin Endocrinol Metab 2009; 94:2835-40. [PMID: 19454583 DOI: 10.1210/jc.2009-0314] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Because precocious pubarche (PP) reveals late-onset congenital adrenal hyperplasia (LO-CAH) in 5 to 20% of cases, an adrenal stimulation test is recommended in all patients presenting with it. This test is stressful and expensive, and results are normal in more than 80% of cases. OBJECTIVE Our objective was to identify clinical and plasma predictors of LO-CAH among patients presenting with PP. DESIGN, SETTING, AND PATIENTS We conducted a retrospective cohort study that included all patients seen for PP at our hospital between 1999 and 2006 (n = 238). All had undergone an ACTH test. MAIN OUTCOME MEASURE LO-CAH was defined by a post-ACTH 17-hydroxyprogesterone (17-OHP) plasma level greater than 10 ng/ml and confirmed by mutational analysis of the CYP21 gene. The association of standard clinical and laboratory indicators with LO-CAH was assessed. RESULTS Ten (4%) of 238 patients had LO-CAH. Basal 17-OHP, Delta4-androstenedione, and testosterone plasma levels were significantly higher in these patients. A 2-ng/ml threshold for basal 17-OHP plasma levels offered 100% (95% CI, 69-100) sensitivity for the diagnosis of LO-CAH and 99% (95% CI, 96-100) specificity. CONCLUSION We identified three plasma predictors of LO-CAH in patients presenting with PP. A selective strategy based on a 2-ng/ml basal 17-OHP plasma level threshold would have safely avoided 99% of the unnecessary ACTH tests among our patients.
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Utriainen P, Voutilainen R, Jääskeläinen J. Girls with premature adrenarche have accelerated early childhood growth. J Pediatr 2009; 154:882-7. [PMID: 19230905 DOI: 10.1016/j.jpeds.2008.12.038] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Revised: 11/14/2008] [Accepted: 12/18/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the effect of premature adrenarche (PA) on prepubertal growth. STUDY DESIGN The prepubertal growth of 54 girls with PA and 52 control girls was analyzed retrospectively. Birth measures were noted, and childhood length/height and weight were measured annually until age 5 years and at the current visit (at a median age of 7.6 years). The growth variables were correlated with serum insulin-like growth factor (IGF)-1, dehydroepiandrosterone sulfate, and insulin concentrations. RESULTS There were no significant differences in birth length or weight standard deviation scores (SDSs) between the 2 study groups. The girls with PA demonstrated a significant length SDS increment during the first 2 years of life (median +1.0 SDS; P < .001). Compared with controls, they were taller (median current height 1.2 vs 0 SDS; P < .001) and gained more weight throughout childhood. The difference in weight-for-height became significant at a later age compared with the difference in height. Median serum IGF-1 concentration adjusted for both age and body mass index SDS was higher in the PA group (24 vs 19 nmol/L; P < .031). CONCLUSIONS PA was not associated with small birth size in our population. Girls with PA had enhanced growth already in early childhood, which was not explained by weight gain. Enhanced IGF-1 production may contribute to the prepubertal growth acceleration in PA.
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Affiliation(s)
- Pauliina Utriainen
- Department of Pediatrics, University of Kuopio and Kuopio University Hospital, Kuopio, Finland.
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Abstract
Classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency leads to glucocorticoid and mineralocorticoid deficiency. Management should be viewed as a process of care which requires input from an interdisciplinary team. Glucocorticoid therapy should take the form of hydrocortisone in a starting dose of 15 mg/m(2)/day (divided into three doses), and the dose should be titrated to blood or urine profiles of cortisol and 17-hydroxyprogesterone. Mineralocorticoid replacement (9 alpha-fludrocortisone) requires higher doses in infancy and childhood than in adolescence. The starting dose should be 150 microg/m(2)/day, and the dose thereafter titrated to plasma renin activity and blood pressure. Despite adequate glucocorticoid substitution and concordance with medical therapy, control can be difficult during puberty due to alterations in the clearance of hydrocortisone, and dosing schedules may need to be adjusted to account for this. Follow-up should address the many facets of CAH, which should be assessed at an annual review, and a suggested protocol is presented.
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Affiliation(s)
- Peter C Hindmarsh
- Developmental Endocrinology Research Group, Institute of Child Health, University College London, London, UK.
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Dörr HG. Growth in patients with classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency. HORMONE RESEARCH 2007; 68 Suppl 5:93-9. [PMID: 18174719 DOI: 10.1159/000110587] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND One important goal in the management of children with classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is to achieve normal growth. Reviewing available data published over the last few years on growth and height outcomes in CAH patients, it becomes evident that an acceptable height can be achieved by many CAH patients. However, linear growth and final adult height may be stunted in some patients due to factors related to the timing of diagnosis, the age at therapy onset, the start of therapy, the adequacy of metabolic control, the quality of therapy, patient compliance and the experience of the treating physician. In children with CAH who have a poor height prognosis, additional treatment options should be considered. CONCLUSIONS Treatment of children with CAH requires individualized approaches to prevent long-term growth failure.
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Affiliation(s)
- Helmuth G Dörr
- Division of Pediatric Endocrinology, University Hospital for Children and Adolescents, Erlangen, Germany.
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Ramos CCA, Bento LR, Gonçalves EM, Mello MPD, Baptista MTM, Lemos-Marini SHVD, Guerra-Júnior G. Avaliação do crescimento, do controle laboratorial e da corticoterapia em um grupo de pacientes com a forma clássica da deficiência da 21-hidroxilase. REVISTA PAULISTA DE PEDIATRIA 2007. [DOI: 10.1590/s0103-05822007000400004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVO: Avaliar o padrão de crescimento de pacientes com hiperplasia adrenal congênita com a forma clássica da deficiência da 21-hidroxilase (21-OH), em relação ao controle hormonal e ao uso de corticóide no tratamento. MÉTODOS: Análise retrospectiva dos prontuários de 45 pacientes. Como padrão de crescimento, foi utilizado o ganho ou não de altura, avaliando-se a diferença entre o escore Z da estatura na última consulta (para idade óssea) em relação ao escore Z da estatura no início do tratamento (para a idade cronológica). Foram avaliadas todas as concentrações de 17-OH progesterona (17-OHP), androstenediona e renina, sendo considerados bem controlados os pacientes com 50% ou mais das dosagens normais. Em relação ao corticóide, foram analisados o tipo e a dose. RESULTADOS: A idade na última consulta variou de 2,8 a 26,6 anos (12,6+5,8 anos), sendo 31 do sexo feminino, 30 com a forma perdedora de sal; 62% foram considerados bem controlados para 17-OHP, 75% para androstenediona e 78% para renina. A hidrocortisona foi usada por 41 pacientes (20,2+2,6 mg/m²/dia) e, por 40, em associação com a 9a-fludrocortisona. Encontrou-se 14 pacientes com ganho, 20 com manutenção e 11 com perda estatural. Os pacientes perdedores de sal (p=0,01) e os bem controlados (p=0,0005) para 17-OHP e androstenediona apresentaram associação significativa com o ganho de estatura. CONCLUSÕES: Nesta amostra de pacientes com a forma clássica da deficiência da 21-OHD, o melhor crescimento apresentou associação com o bom controle laboratorial da 17-OHP e da androstenediona e com a forma perdedora de sal.
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Bonfig W, Bechtold S, Schmidt H, Knorr D, Schwarz HP. Reduced final height outcome in congenital adrenal hyperplasia under prednisone treatment: deceleration of growth velocity during puberty. J Clin Endocrinol Metab 2007; 92:1635-9. [PMID: 17299071 DOI: 10.1210/jc.2006-2109] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
CONTEXT Normal to decreased final height (FH) has been reported in patients with congenital adrenal hyperplasia (CAH). OBJECTIVE The objective was to determine FH outcome and influences of steroid treatment. METHODS The effects of glucocorticoid treatment for classical CAH were retrospectively studied in 125 patients (77 females). Growth pattern, FH, and pubertal development were recorded. RESULTS Corrected FH was in the lower range of genetic potential [females with simple virilizing (SV)-CAH, -0.6 +/- 1.0 sd score (SDS) vs. females with salt-wasting (SW)-CAH, -0.6 +/- 0.9 SDS; males with SV-CAH, -1.1 +/- 0.9 SDS vs. males with SW-CAH, -0.9 +/- 0.9 SDS]. Total pubertal growth was significantly reduced in comparison with a reference population (females with SV-CAH, 11.9 +/- 6.5 cm, and females with SW-CAH, 13.8 +/- 7.6 cm vs. reference 20.3 +/- 6.8 cm, P < 0.01; and males with SV-CAH, 15.4 +/- 6.6 cm, and males with SW-CAH, 18.5 +/- 6.9 cm vs. reference 28.2 +/- 8.2 cm, P < 0.01). Thirty-three patients had been treated with prednisone, which resulted in reduced FH compared with patients (n = 92) treated with hydrocortisone (-1.0 +/- 0.9 SDS vs.-0.6 +/- 0.9 SDS; P < 0.05). FH correlated negatively with hydrocortisone dose given at the start of puberty (r = -0.3; P < 0.05). Pubertal development started early in boys [9.8 +/- 2.3 yr (SV) and 10.6 +/- 1.9 yr (SW)] and was timely in girls [9.8 +/- 1.9 yr (SV) and 10.3 +/- 1.5 yr (SW), menarche at 13.3 +/- 1.7 yr (SV) and 13.7 +/- 1.5 yr (SV)]. CONCLUSION Patients with CAH are able to achieve adequate FH with conventional therapy. Total pubertal growth is significantly decreased, and treatment with prednisone results in decreased FH. In addition to biochemical analysis, treatment should be adjusted to normal growth velocity, especially during puberty.
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Affiliation(s)
- Walter Bonfig
- University Children's Hospital, Department of Endocrinology, Ludwig Maximilians University, Lindwurmstrasse 4, D-80337 Munich, Germany.
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Falhammar H, Filipsson H, Holmdahl G, Janson PO, Nordenskjöld A, Hagenfeldt K, Thorén M. Metabolic profile and body composition in adult women with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. J Clin Endocrinol Metab 2007; 92:110-6. [PMID: 17032717 DOI: 10.1210/jc.2006-1350] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The chronic, often supraphysiological glucocorticoid doses used in congenital adrenal hyperplasia (CAH) might increase morbidity in cardiovascular disease and diabetes. OBJECTIVE Our aim was to assess risk factors for cardiovascular disease and diabetes in CAH women. SUBJECTS, METHODS, AND DESIGN: We compared 61 women, 18-63 yr, with CAH due to 21-hydroxylase deficiency with 61 age- and sex- matched controls. Twenty-seven were younger than 30 yr, and 34 were 30 yr or older. Anthropometry, fat and lean mass measured by dual-energy x-ray absorptiometry, serum lipids, insulin, and adrenocortical steroids were studied. MAIN OUTCOME MEASURE Body composition and cardiovascular risk factors were the main outcome measures. RESULTS Younger patients and controls had similar waist to hip ratio, lean and fat mass, and insulin. Older patients had higher waist to hip ratio, lean mass, and insulin than controls. Fat mass was similar to controls but higher than in younger patients. Lipid profiles were slightly more favorable in older patients than controls. Gestational diabetes was more common in patients (21% of pregnancies vs. 0, P < 0.026). Few older patients had hypertension, cardiovascular disease, or diabetes. Despite moderate glucocorticoid doses, most patients had suppressed androgens. CONCLUSIONS No clear evidence of unfavorable cardiovascular risk factors were found. Increased fat mass and higher insulin levels were, however, found in patients older than 30 yr. High frequency of gestational diabetes is a risk marker for future diabetes. Lifelong follow-up, lifestyle modifications, and attempts to adjust and reduce the glucocorticoid doses seem important.
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Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Metabolism, and Diabetes, D2:04, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
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Abstract
CONTEXT Nonclassical congenital adrenal hyperplasia (CAH) owing to steroid 21-hydroxylase deficiency (NC21OHD) is the most frequent of all autosomal recessive genetic diseases, occurring in one in 100 persons in the heterogeneous New York City population. NC21OHD occurs with increased frequency in certain ethnic groups, such as Ashkenazi Jews, in whom one in 27 express the disease. NC21OHD is underdiagnosed in both male and female patients with hyperandrogenic symptoms because hormonal abnormalities in NC21OHD are only mild to moderate, not severe as in the classical form of CAH. Unlike classical CAH, NC21OHD is not associated with ambiguous genitalia of the newborn female. MAIN OUTCOME MEASURES The hyperandrogenic symptoms include advanced bone age, early pubic hair, precocious puberty, tall stature, and early arrest of growth in children; infertility, cystic acne, and short stature in both adult males and females; hirsutism, frontal balding, polycystic ovaries, and irregular menstrual periods in females; and testicular adrenal rest tissue in males. CONCLUSIONS The signs and symptoms of hyperandrogenism are reversed with dexamethasone treatment.
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Affiliation(s)
- Maria I New
- Adrenal Steroid Disorders Program, Department of Pediatrics, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Balsamo A, Wasniewska M, Di Pasquale G, Salzano G, Baronio F, Bombaci S, De Luca F. Birth length and weight in congenital adrenal hyperplasia according to the different phenotypes. Eur J Pediatr 2006; 165:380-3. [PMID: 16520942 DOI: 10.1007/s00431-005-0075-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Accepted: 12/13/2005] [Indexed: 11/29/2022]
Abstract
UNLABELLED The aims of this study were to: (1) retrospectively investigate the birth length and weight of our patients with congenital adrenal hyperplasia (CAH); (2) compare these parameters with standards for birth length and weight recently assessed in an Italian control population; (3) evaluate whether neonatal auxological data may change depending on the different clinical forms of CAH. Birth length and weight were retrospectively evaluated in 101 children with different clinical forms of CAH and compared with standards for birth length and weight assessed in an Italian control population. In both sexes the average birth length of patients with classical CAH was greater than the mean birth length of the controls, and both length and weight were greater in children with classical CAH than in those with the non-classical form. Among the patients with classical CAH, those with the salt-wasting form were longer but also weighed less than those with the simple-virilizing form. CONCLUSIONS (1) fetal length velocity in patients with CAH may be increased only in those infants with classical forms of the syndrome, while it is unaffected in those with the non-classical form; (2) the greater the enzymatic activity impairment, the longer the birth length of newborns with CAH.
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Affiliation(s)
- Antonio Balsamo
- Department of Pediatrics, University of Bologna, Bologna, Italy
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Aycan Z, Ocal G, Berberoglu M, Cetinkaya E, Adiyaman P, Evliyaoglu O. Experience with long-term glucocorticoid treatment in congenital adrenal hyperplasia: growth pattern compared with genetic height potential. J Pediatr Endocrinol Metab 2006; 19:245-51. [PMID: 16607925 DOI: 10.1515/jpem.2006.19.3.245] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Long-term replacement treatment with high doses of steroids in congenital adrenal hyperplasia (CAH) is known to have a negative influence on growth. We evaluated the effects of long-term steroid treatment in patients with classical CAH on height development in relation to genetic height potential. PATIENTS AND METHODS Twenty-three patients with CAH (16 females, 7 males, mean age: 9.8 +/- 3.5 years) were included in this longitudinal study. The effect of steroid treatment on growth was determined by monitoring patients for 8.61 +/- 3.46 years (2-17 years) while they were treated with hydrocortisone at a mean dosage of 17.64 +/- 3.60 mg/m2/day. The height standard deviation scores (Ht-SDS), target Ht-SDS, and corrected Ht-SDS for target height was calculated for all patients. Predicted adult height according to bone age was calculated and it was determined whether height was developing according to the genetic height potential. In addition, patients were grouped as 'tight control' or 'poor control' according to their mean serum 17OH-progesterone or ACTH levels while on treatment. We evaluated whether height development was different for the tight and poor control groups. RESULTS The mean chronological age of our patients at the time of the study was 9.89 +/- 3.53 years, Ht-SDS -0.77 +/- 1.57, target height (TH) 161.03 +/- 6.54 cm, TH-SDS -0.60 +/- 0.90, predicted height (PH) 157.2 +/- 11.16 cm, PH-SDS -1.1 +/- 1.69, and corrected Ht-SDS -0.75 +/- 1.14. There was no significant difference between the actual Ht-SDS and TH-SDS of our patients (p >0.05) but the corrected Ht-SDS was less than zero. Only 28.5% of our patients had normal height according to their genetic potential while 71.5% were shorter than their genetic height potential. While the Ht-SDS and corrected Ht-SDS were similar in the tight and poor metabolic control groups, the predicted height was significantly greater in the tight control group. CONCLUSION We demonstrated that a hydrocortisone dose of 17.64 +/- 3.60 mg/m2/day in classical CAH had a negative influence on height development for genetic height potential in 8.5 years of follow-up and that it is necessary to use the lowest possible steroid dosage by individualizing the dose.
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Affiliation(s)
- Zehra Aycan
- Department of Pediatric Endocrinology, Ankara Dişkapi Children's Hospital, Turkey.
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Abstract
Individuals with congenital adrenal hyperplasia (CAH) are shorter, on an average, than the general population. A recent meta analysis of final height in CAH indicated that the height deficit is typically 1 to 2 standard deviations below the mean in both males and females. Growth in CAH due to 21-hydroxylase deficiency is influenced by a number of factors, related both to the underlying disease and its treatment. In general, males with the simple virilising form have the poorest height prognosis. This relates in part to late diagnosis and treatment and the bone age advancement seen in individuals with untreated postnatal androgen excess. Obesity in CAH patients also appears to be correlated with reduced height potential. Glucocorticoid treatment which is vital for cortisol replacement, prevention of adrenal crises and androgen suppression, results in growth inhibition when administered in larger doses. Current evidence suggests that infancy and peripubertal periods are the time periods where height outcome is most sensitive to glucocorticoid dose. More recent estimates of physiological cortisol secretion rates indicate that standard cortisol replacement schedules may result in overtreatment. In addition, dose titration to achieve complete androgen suppression and normalization of 17-hydroxyprogesterone is likely to result in overtreatment and consequent growth impairment. Optimization of current treatment may lead to further improvements in height prognosis. The potential benefits of more complex treatment regimes, using aromatase inhibitors and antiandrogens, in combination with a reduced glucocorticoid dose remain uncertain.
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Affiliation(s)
- An Tt Nguyen
- Department of Endocrinology and Diabetes, Murdoch Children's Research Institute, Royal Children's Hospital,Parkville, Victoria, Australia.
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Gallagher MP, Levine LS, Oberfield SE. A review of the effects of therapy on growth and bone mineralization in children with congenital adrenal hyperplasia. Growth Horm IGF Res 2005; 15 Suppl A:S26-S30. [PMID: 16039891 DOI: 10.1016/j.ghir.2005.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The medical management of children with congenital adrenal hyperplasia (CAH) can be challenging with regard to optimizing final height. Insufficient glucocorticoid suppression of adrenal hormone production will result in acceleration of bone maturation and premature epiphyseal fusion, while appropriate or excessive glucocorticoid therapy can be accompanied by suppression of the growth axis. The extent of the growth suppression appears to be affected by the type and dose of glucocorticoid. Some studies suggest that such growth suppression can be ameliorated through concomitant use of growth hormone (GH) therapy. Available data published over the last 10 years on height outcomes in CAH patients treated with glucocorticoids will be reviewed.
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Affiliation(s)
- Mary Pat Gallagher
- Division of Pediatric Endocrinology, Columbia University, College of Physicians & Surgeons, 622 West 168th Street, PH 5 East, Room 519, New York, NY 10032, USA.
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