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Savage MO. Linear growth in children and adolescents with congenital adrenal hyperplasia. Curr Opin Pediatr 2024; 36:463-466. [PMID: 38747200 DOI: 10.1097/mop.0000000000001361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW Congenital adrenal hyperplasia (CAH) is a relatively common disorder and one of the most challenging conditions seen by pediatric endocrinologists. Poor linear growth in CAH has been recognized for many years. There are new insights to explain this abnormality and shed light on strategies to promote normal growth. RECENT FINDINGS Published data suggest that the dose of hydrocortisone during two critical periods of rapid growth, namely infancy and at puberty, has a fundamental effect on growth velocity, and by definition adult height. To prevent over-treatment, hydrocortisone dosage should remain within the range of 10-15 mg/m 2 body surface area per day. Precursor steroids such as 17-hydroxy progesterone (17OHP) should not be suppressed to undetectable levels. In fact, 17OHP should always be measurable, as complete suppression suggests over-treatment. SUMMARY CAH is a challenging disorder. High-quality compliance within the consultation setting, with the patient seeing the same specialist at every visit, will be rewarded by improved long-term growth potential. Quality auxological monitoring can avoid phases of growth suppression. New therapy with CRH receptor antagonists may lead to a more nuanced approach by allowing fine tuning of hydrocortisone replacement without the need to suppress ACTH secretion.
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Affiliation(s)
- Martin O Savage
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary, University of London, London, UK
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2
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Swart AC, van Rooyen D, du Toit T, Heyns B, Molphy J, Wilson M, Leahy R, Atkin SL. Circulating adrenal and gonadal steroid hormones heterogeneity in active young males and the contribution of 11-oxy androgens. Sci Rep 2024; 14:16226. [PMID: 39003307 PMCID: PMC11246537 DOI: 10.1038/s41598-024-66749-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 07/03/2024] [Indexed: 07/15/2024] Open
Abstract
The classical androgens, testosterone and dihydrotestosterone, together with dehydroepiandrosterone, the precusrsor to all androgens, are generally included in diagnostic steroid evaluations of androgen excess and deficiency disorders and monitored in androgen replacement and androgen suppressive therapies. The C11-oxy androgens also contribute to androgen excess disorders and are still often excluded from clinical and research-based steroids analysis. The contribution of the C11-oxy androgens to the androgen pool has not been considered in androgen deficiency. An exploratory investigation into circulating adrenal and gonadal steroid hormones in men was undertaken as neither the classical androgens nor the C11-oxy androgens have been evaluated in the context of concurrent measurement of all adrenal steroid hormones. Serum androgens, mineralocorticoids, glucocorticoids, progesterones and androgens were assessed in 70 healthy young men using ultra high performance supercritical fluid chromatography and tandem mass spectrometry. Testosterone, 24.5 nmol/L was the most prominent androgen detected in all participants while dihydrotestosterone, 1.23 nmol/L, was only detected in 25% of the participants. The 11-oxy androgens were present in most of the participants with 11-hydroxyandrostenedione, 3.37 nmol, in 98.5%, 11-ketoandrostenedione 0.764 in 77%, 11-hydroxytestosterone, 0.567 in 96% and 11-ketotestosterone: 0.440 in 63%. A third of the participants with normal testosterone and comparable 11-ketotestosterone, had significantly lower dehydroepiandrosterone (p < 0.001). In these males 11-hydroxyandrostenedione (p < 0.001), 11-ketoandrostenedione (p < 0.01) and 11-hydroxytestosterone (p < 0.006) were decreased. Glucocorticoids were also lower: cortisol (p < 0.001), corticosterone (p < 0.001), cortisone (p < 0.006) 11-dehydrocorticosterone (p < 0.001) as well as cortisol:cortisone (p < 0.001). The presence of dehydroepiandrosterone was associated with 16-hydroxyprogesterone (p < 0.001), which was also significantly lower. Adrenal and gonadal steroid analysis showed unexpected steroid heterogeneity in normal young men. Testosterone constitutes 78% of the circulating free androgens with the 11-oxy androgens abundantly present in all participants significantly contributing 22%. In addition, a subset of men were identified with low circulating dehydroepiandrosterone who showed altered adrenal steroids with decreased glucocorticoids and decreased C11-oxy androgens. Analysis of the classical and 11-oxy androgens with the additional measurement of dehydroepiandrosterone and 16-hydroxyprogesterone may allow better diagnostic accuracy in androgen excess or deficiency.
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Affiliation(s)
- Amanda C Swart
- Department of Biochemistry, Stellenbosch University, Stellenbosch, 7600, South Africa.
- Department of Chemistry and Polymer Science, Stellenbosch University, Stellenbosch, 7600, South Africa.
| | - Desmaré van Rooyen
- Department of Biochemistry, Stellenbosch University, Stellenbosch, 7600, South Africa
| | - Therina du Toit
- Department of Biochemistry, Stellenbosch University, Stellenbosch, 7600, South Africa
| | - Bianca Heyns
- Department of Biochemistry, Stellenbosch University, Stellenbosch, 7600, South Africa
- Department of Chemistry and Polymer Science, Stellenbosch University, Stellenbosch, 7600, South Africa
| | - John Molphy
- Research Institute of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Mathew Wilson
- Institute of Sport, Exercise and Health, University College London, London, WC1E 6BT, UK
| | - Roisin Leahy
- Data Science Centre, School of Population Health, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Stephen L Atkin
- Royal College of Surgeons in Ireland, Busaiteen, Bahrain
- Weill Cornell Medicine Qatar, Doha, Qatar
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3
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Dubinski I, Bechtold-Dalla Pozza S, Bidlingmaier M, Hawley J, Keevil B, Kunz S, Nowotny HF, Reisch N, Schiergens K, Tschaidse L, Schmidt H. Diurnal 11-ketotestosterone and 17-hydroxyprogesterone saliva profiles in paediatric classical congenital adrenal hyperplasia. J Pediatr Endocrinol Metab 2024; 37:419-424. [PMID: 38557593 DOI: 10.1515/jpem-2024-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES The most suitable biochemical markers for therapy adjustment in patients with congenital adrenal hyperplasia are controversial. 11-Oxygenated androgens are a promising new approach. The objective of this study was to investigate the diurnal rhythm of 11-ketotestosterone in children and adolescents in saliva and to correlate it with salivary 17-hydroxyprogesterone. METHODS Fifty-one samples of steroid day-profiles from 17 patients were additionally analysed for 11-ketotestosterone, retrospectively. All patients were treated in our university outpatient clinic for paediatric endocrinology between 2020 and 2022. Steroid day-profiles of 17 patients could be examined. The cohort showed a balanced sex ratio. The median age was 13 years. The measurements for 17-hydroxyprogesterone were carried out during routine care by immunoassay. The measurements of 11-ketotestosterone were performed from frozen saliva samples using an implemented in-house protocol for liquid chromatography-tandem mass spectrometry (LC-MS/MS). The most important outcome were the absolute values for 11-ketotestosterone, their diurnal rhythmicity and the correlation with 17-hydroxyprogesterone. RESULTS Both steroids show a circadian diurnal rhythm. 17-hydroxyprogesterone and 11-ketotestosterone correlate significantly. 11-Ketotestosterone showed a positive correlation with BMI at all times of the day. CONCLUSIONS 11-Ketotestosterone shows circadian rhythmicity in our cohort and correlates with 17-hydroxyprogesterone. These findings serve as an important basis for prospective research into 11-oxygenated androgens as therapeutic markers in paediatrics. However, 11-ketotestosterone appears to be very dependent on BMI.
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Affiliation(s)
- Ilja Dubinski
- Department of Paediatrics, Division of Paediatric Endocrinology, 74939 Dr. von Hauner Children's Hospital, University Hospital, LMU Munich , Munich, Germany
| | - Susanne Bechtold-Dalla Pozza
- Department of Paediatrics, Division of Paediatric Endocrinology, 74939 Dr. von Hauner Children's Hospital, University Hospital, LMU Munich , Munich, Germany
| | - Martin Bidlingmaier
- Department of Medicine IV, 74939 University Hospital, LMU Munich , Munich, Germany
| | - James Hawley
- Department of Clinical Biochemistry, 5293 Manchester University Foundation NHS Trust, Manchester Academic Health Sciences Centre , Manchester, UK
| | - Brian Keevil
- Department of Clinical Biochemistry, 5293 Manchester University Foundation NHS Trust, Manchester Academic Health Sciences Centre , Manchester, UK
| | - Sonja Kunz
- Department of Medicine IV, 74939 University Hospital, LMU Munich , Munich, Germany
| | | | - Nicole Reisch
- Department of Medicine IV, 74939 University Hospital, LMU Munich , Munich, Germany
| | - Katharina Schiergens
- Department of Paediatrics, Division of Paediatric Endocrinology, 74939 Dr. von Hauner Children's Hospital, University Hospital, LMU Munich , Munich, Germany
| | - Lea Tschaidse
- Department of Medicine IV, 74939 University Hospital, LMU Munich , Munich, Germany
| | - Heinrich Schmidt
- Department of Paediatrics, Division of Paediatric Endocrinology, 74939 Dr. von Hauner Children's Hospital, University Hospital, LMU Munich , Munich, Germany
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Тюльпаков МА, Нагаева ЕВ, Калинченко НЮ, Безлепкина ОБ. [A promising approach for therapy control in congenital adrenal hyperplasia. Problems of Endocrinology]. PROBLEMY ENDOKRINOLOGII 2024; 69:102-108. [PMID: 38311999 PMCID: PMC10848187 DOI: 10.14341/probl13328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/23/2023] [Accepted: 08/31/2023] [Indexed: 02/06/2024]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders requiring lifelong glucocorticoid replacement (GC) therapy. Lack of GC therapy leads to precocious puberty in boys, heterosexual development in girls, accelerated bone maturation and short final height in both sexes. In adolescence, the lack of GC therapy is the cause of menstrual disorders in girls and the development of TART in boys, as a result reducing the reproductive potential in both sexes. On the other hand, an overdose of GC leads to drug-induced Itsenko-Cushing's syndrome. In order to select adequate doses of GC in childhood and adolescence, multiple determinations of 17-hydroxyprogesterone, androstenedione, and testosterone in blood plasma, and thus multiple venous blood sampling are required. The blood sampling requires specially trained medical staff and can effect on the results due to stress reaction especially in young patients. Hence, the development and implementation of a non-invasive method for determining the steroid profile is extremely important in monitoring GC therapy in children. In addition, the currently used immunofluorescence assay cannot determine other adrenal steroids, has a high variation due to the «cross-reaction» of steroids that are similar in structure, which inflates the results. Unlike immunofluorescence assay, liquid chromatography and tandem mass spectrometry is more preferable method, since it is more specific and accurate. In this literature review, saliva presented as an alternative substrate and the non-invasive method for determining the steroid profile. This method can solve the above disadvantages, simplify and make more accurate the selection of GC therapy in patients with CAH, which is especially important in childhood.
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Affiliation(s)
- М. А. Тюльпаков
- Национальный медицинский исследовательский центр эндокринологии
| | - Е. В. Нагаева
- Национальный медицинский исследовательский центр эндокринологии
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5
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Bacila IA, Lawrence NR, Badrinath SG, Balagamage C, Krone NP. Biomarkers in congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2023. [PMID: 37608608 DOI: 10.1111/cen.14960] [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: 05/09/2023] [Revised: 07/25/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
Monitoring of hormone replacement therapy represents a major challenge in the management of congenital adrenal hyperplasia (CAH). In the absence of clear guidance and standardised monitoring strategies, there is no consensus among clinicians regarding the relevance of various biochemical markers used in practice, leading to wide variability in their application and interpretation. In this review, we summarise the published evidence on biochemical monitoring of CAH. We discuss temporal variations of the most commonly measured biomarkers throughout the day, the interrelationship between different biomarkers, as well as their relationship with different glucocorticoid and mineralocorticoid treatment regimens and clinical outcomes. Our review highlights significant heterogeneity across studies in both aims and methodology. However, we identified key messages for the management of patients with CAH. The approach to hormone replacement therapy should be individualised, based on the individual hormonal profile throughout the day in relation to medication. There are limitations to using 17-hydroxyprogesterone, androstenedione and testosterone, and the role of additional biomarkers such 11-oxygenated androgens which are more disease specific should be further established. Noninvasive monitoring via salivary and urinary steroid measurements is becoming increasingly available and should be considered, especially in the management of children with CAH. Additionally, this review indicates the need for large scale longitudinal studies analysing the interrelation between different monitoring strategies used in clinical practice and health outcomes in children and adults with CAH.
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Affiliation(s)
| | - Neil R Lawrence
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Chamila Balagamage
- Department of Endocrinology, Birmingham Women's & Children's Hospital, Birmingham, UK
- Department of Endocrinology, Sheffield Children's Hospital, Sheffield, UK
| | - Nils P Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Endocrinology, Sheffield Children's Hospital, Sheffield, UK
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Dahmani C, Caron P, Simonyan D, Turcotte V, Grégoire J, Plante M, Guillemette C. Circulating adrenal 11-oxygenated androgens are associated with clinical outcome in endometrial cancer. Front Endocrinol (Lausanne) 2023; 14:1156680. [PMID: 37288302 PMCID: PMC10242140 DOI: 10.3389/fendo.2023.1156680] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/10/2023] [Indexed: 06/09/2023] Open
Abstract
Context Recent evidence support that androgens play an important role in the etiology of endometrial cancer (EC). Adrenal-derived 11-oxygenated androgens are highly potent agonists of the androgen receptor (AR), comparable to testosterone (T) and dihydrotestosterone (DHT) that have not been studied in the context of EC. Methodology We studied a cohort of 272 newly diagnosed postmenopausal EC cases undergoing surgical treatment. Circulating concentrations of seven 11-oxygenated androgens including precursors, potent androgens and their metabolites were established in serum samples collected before and 1 month after surgery using a validated liquid chromatography tandem mass spectrometry method (LC-MS/MS). Free (unconjugated) and total (free + sulfate and glucuronide conjugates following enzymatic hydrolysis) were analyzed in relation to clinicopathological features, recurrence and disease-free survival (DFS). Results Levels of 11-oxygenated androgens were weakly correlated to those of canonical androgens such as testosterone (T) and dihydrotestosterone (DHT), with no evidence of their association with clinicopathological features. Levels of 11-oxygenated androgens declined after surgery but remained higher in overweight and obese compared to normal weight cases. Higher levels of preoperative free 11-ketoandrosterone (11KAST) were associated with an increased risk of recurrence (Hazard ratio (HR) of 2.99 (95%CI=1.09-8.18); P=0.03). Postoperative free 11β-hydroxyandrosterone (11OHAST) levels were adversely associated with recurrence and DFS (HR = 3.23 (1.11-9.40); P=0.03 and 3.27 (1.34-8.00); P=0.009, respectively). Conclusion 11-oxygenated androgen metabolites emerge as potential prognostic markers of EC.
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Affiliation(s)
- Cylia Dahmani
- Centre Hospitalier Universitaire de Québec (CHU de Québec) Research Center, Cancer Research Center (CRC) of Université Laval and Faculty of Pharmacy, Université Laval, Québec, QC, Canada
| | - Patrick Caron
- Centre Hospitalier Universitaire de Québec (CHU de Québec) Research Center, Cancer Research Center (CRC) of Université Laval and Faculty of Pharmacy, Université Laval, Québec, QC, Canada
| | - David Simonyan
- Statistical and Clinical Research Platform, CHU de Québec Research Center, Québec, QC, Canada
| | - Véronique Turcotte
- Centre Hospitalier Universitaire de Québec (CHU de Québec) Research Center, Cancer Research Center (CRC) of Université Laval and Faculty of Pharmacy, Université Laval, Québec, QC, Canada
| | - Jean Grégoire
- Gynecologic Oncology Service, CHU de Québec, and Department of Obstetrics, Gynecology, Reproduction, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Marie Plante
- Gynecologic Oncology Service, CHU de Québec, and Department of Obstetrics, Gynecology, Reproduction, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Chantal Guillemette
- Centre Hospitalier Universitaire de Québec (CHU de Québec) Research Center, Cancer Research Center (CRC) of Université Laval and Faculty of Pharmacy, Université Laval, Québec, QC, Canada
- Canada Research Chair in Pharmacogenomics, Université Laval, Québec, QC, Canada
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7
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Gregory S, Denham SG, Lee P, Simpson JP, Homer NZM. Using LC-MS/MS to Determine Salivary Steroid Reference Intervals in a European Older Adult Population. Metabolites 2023; 13:metabo13020265. [PMID: 36837884 PMCID: PMC9963097 DOI: 10.3390/metabo13020265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/26/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023] Open
Abstract
A number of steroids, including glucocorticoids and sex hormones, have been associated with neurodegenerative and cardiovascular conditions common in aging populations. The application of liquid chromatography tandem mass spectrometry (LC-MS/MS) steroid analysis offers an opportunity to conduct simultaneous multiplex steroid analysis within a given sample. In this paper, we describe the application of an LC-MS/MS steroid analysis method for the assessment of reference ranges of steroids in human saliva samples (200 µL) collected from older adults (age 50 years and above) enrolled in a European cohort investigating the risk for Alzheimer's dementia. Saliva samples were prepared using supported liquid extraction (SLE) along with a calibration curve and analysed using a Waters I-Class UPLC (Ultra Performance Liquid Chromatography) and a Sciex QTrap 6500+ mass spectrometer. Mass spectrometry parameters of steroids were optimised for each steroid and a method for the chromatographic separation of 19 steroids was developed. Lower limits of quantitation (LLOQs), linearity and other method criteria were assessed. In total, data from 125 participants (500 samples) were analysed and assessed for reference ranges (64 male, 61 female). A total of 19 steroids were detected in saliva within the range of the method. There were clear diurnal patterns in most of the steroid hormones detected. Sex differences were observed for androstenedione (A4), testosterone (T), cortisone (E) and aldosterone (Aldo). In the first sample of the day, dehydroepiandrosterone (DHEA) was significantly higher in healthy volunteers compared to those with Alzheimer's disease biomarkers. This LC-MS/MS method is suitable for the analysis of 19 steroids in saliva in adults.
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Affiliation(s)
- Sarah Gregory
- Edinburgh Dementia Prevention, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh EH4 2XU, UK
| | - Scott G. Denham
- Mass Spectrometry Core, Edinburgh Clinical Research Facility, Queens Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Patricia Lee
- Mass Spectrometry Core, Edinburgh Clinical Research Facility, Queens Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Joanna P. Simpson
- Mass Spectrometry Core, Edinburgh Clinical Research Facility, Queens Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Natalie Z. M. Homer
- Mass Spectrometry Core, Edinburgh Clinical Research Facility, Queens Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, UK
- BHF/Centre for Cardiovascular Sciences, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, EH16 4TJ, UK
- Correspondence:
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8
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Schiffer L, Kempegowda P, Sitch AJ, Adaway JE, Shaheen F, Ebbehoj A, Singh S, McTaggart MP, O'Reilly MW, Prete A, Hawley JM, Keevil BG, Bancos I, Taylor AE, Arlt W. Classic and 11-oxygenated androgens in serum and saliva across adulthood: a cross-sectional study analyzing the impact of age, body mass index, and diurnal and menstrual cycle variation. Eur J Endocrinol 2023; 188:lvac017. [PMID: 36651154 DOI: 10.1093/ejendo/lvac017] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 09/28/2022] [Accepted: 12/08/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE 11-oxygenated androgens significantly contribute to the circulating androgen pool. Understanding the physiological variation of 11-oxygenated androgens and their determinants is essential for clinical interpretation, for example, in androgen excess conditions. We quantified classic and 11-oxygenated androgens in serum and saliva across the adult age and body mass index (BMI) range, also analyzing diurnal and menstrual cycle-dependent variation. DESIGN Cross-sectional. Morning serum samples were collected from 290 healthy volunteers (125 men, 22-95 years; 165 women, 21-91 years). Morning saliva samples were collected by a sub-group (51 women and 32 men). Diurnal saliva profiles were collected by 13 men. Twelve women collected diurnal saliva profiles and morning saliva samples on 7 consecutive days during both follicular and luteal menstrual cycle phases. METHODS Serum and salivary steroids were quantified by liquid chromatography-tandem mass spectrometry profiling assays. RESULTS Serum classic androgens decreased with age-adjusted BMI, for example, %change kg/m2 for 5α-dihydrotestosterone: men -5.54% (95% confidence interval (CI) -8.10 to -2.98) and women -1.62% (95%CI -3.16 to -0.08). By contrast, 11-oxygenated androgens increased with BMI, for example, %change kg/m2 for 11-ketotestosterone: men 3.05% (95%CI 0.08-6.03) and women 1.68% (95%CI -0.44 to 3.79). Conversely, classic androgens decreased with age in both men and women, while 11-oxygenated androgens did not. Salivary androgens showed a diurnal pattern in men and in the follicular phase in women; in the luteal phase, only 11-oxygenated androgens showed diurnal variation. CONCLUSIONS Classic androgens decrease while active 11-oxygenated androgens increase with increasing BMI, pointing toward the importance of adipose tissue mass for the activation of 11-oxygenated androgens. Classic but not 11-oxygenated androgens decline with age.
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Affiliation(s)
- Lina Schiffer
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Punith Kempegowda
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Alice J Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Joanne E Adaway
- Department of Clinical Biochemistry, Wythenshawe Hospital, Manchester, United Kingdom
| | - Fozia Shaheen
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Andreas Ebbehoj
- Division of Endocrinology, Metabolism, Diabetes and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Sumitabh Singh
- Division of Endocrinology, Metabolism, Diabetes and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Malcom P McTaggart
- Department of Clinical Biochemistry, Wythenshawe Hospital, Manchester, United Kingdom
| | - Michael W O'Reilly
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Endocrinology Research Group, Department of Medicine, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - James M Hawley
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Department of Clinical Biochemistry, Wythenshawe Hospital, Manchester, United Kingdom
| | - Brian G Keevil
- Department of Clinical Biochemistry, Wythenshawe Hospital, Manchester, United Kingdom
| | - Irina Bancos
- Division of Endocrinology, Metabolism, Diabetes and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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9
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Nowotny HF, Braun L, Vogel F, Bidlingmaier M, Reincke M, Tschaidse L, Auer MK, Lottspeich C, Wudy SA, Hartmann MF, Hawley J, Adaway JE, Keevil B, Schilbach K, Reisch N. 11-Oxygenated C19 steroids are the predominant androgens responsible for hyperandrogenemia in Cushing's disease. Eur J Endocrinol 2022; 187:663-673. [PMID: 36074938 PMCID: PMC9578081 DOI: 10.1530/eje-22-0320] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/08/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Symptoms of hyperandrogenism are common in patients with Cushing's disease (CD), yet they are not sufficiently explained by androgen concentrations. In this study, we analyzed the contribution of 11-oxygenated C19 steroids (11oxC19) to hyperandrogenemia in female patients with CD. METHODS We assessed saliva day profiles in females with CD pre (n = 23) and post (n = 13) successful transsphenoidal surgery, 26 female controls, 5 females with CD treated with metyrapone and 5 treated with osilodrostat for cortisol, cortisone, androstenedione (A4), 11-hydroxyandrostenedione (11OHA4), testosterone (TS), 11-ketotestosterone (11KT), as well as metabolites of classic and 11-oxygenated androgens in 24-h urine. In addition, morning baseline levels of gonadotropins and estradiol, sex hormone-binding globulin, cortisol and dehydroepiandrosterone sulfate (DHEAS) in serum and adrenocorticotrophic hormone in plasma in patients and controls were investigated. RESULTS Treatment-naïve females with CD showed a significantly elevated area under the curve of 11OHA4 and 11KT in saliva throughout the day compared to controls (11OHA4 mean rank difference (mrd) 18.13, P = 0.0002; 11KT mrd 17.42; P = 0.0005), whereas A4, TS and DHEAS were comparable to controls. Gonadotropin concentrations were normal in all patients with CD. After transsphenoidal surgery, 11oxC19 and their metabolites dropped significantly in saliva (11OHA4 P < 0.0001; 11KT P = 0.0010) and urine (11-oxo-androsterone P = 0.0011; 11-hydroxy-androsterone P < 0.0001), treatment with osilodrostat and metyrapone efficaciously blocked 11oxC19 synthesis. CONCLUSION Hyperandrogenemia in CD is predominantly caused by excess of 11oxC19 steroids.
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Affiliation(s)
- Hanna F Nowotny
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Leah Braun
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Frederick Vogel
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Martin Bidlingmaier
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Lea Tschaidse
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Matthias K Auer
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Christian Lottspeich
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Stefan A Wudy
- Division of Pediatric Endocrinology & 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 & 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
| | - James Hawley
- Department of Clinical Biochemistry, Manchester University Foundation NHS Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Joanne E Adaway
- Department of Clinical Biochemistry, Manchester University Foundation NHS Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Brian Keevil
- Department of Clinical Biochemistry, Manchester University Foundation NHS Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Katharina Schilbach
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Nicole Reisch
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
- Correspondence should be addressed to N Reisch;
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10
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Schiffer L, Shaheen F, Gilligan LC, Storbeck KH, Hawley JM, Keevil BG, Arlt W, Taylor AE. Multi-steroid profiling by UHPLC-MS/MS with post-column infusion of ammonium fluoride. J Chromatogr B Analyt Technol Biomed Life Sci 2022; 1209:123413. [PMID: 35988498 DOI: 10.1016/j.jchromb.2022.123413] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 07/21/2022] [Accepted: 08/06/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Multi-steroid profiling is a powerful analytical tool that simultaneously quantifies steroids from different biosynthetic pathways. Here we present an ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) assay for the profiling of 23 steroids using post-column infusion of ammonium fluoride. METHODS Following liquid-liquid extraction, steroids were chromatographically separated over 5 min using a Phenomenex Luna Omega C18 column and a water (0.1 % formic acid) methanol gradient. Quantification was performed on a Waters Acquity UHPLC and Xevo® TQ-XS mass spectrometer. Ammonium fluoride (6 mmol/L, post-column infusion) and formic acid (0.1 % (vol/vol), mobile phase additive) were compared as additives to aid ionisation. RESULTS Post-column infusion of ammonium fluoride enhanced ionisation in a steroid structure-dependent fashion compared to formic acid (122-140 % for 3βOH-Δ5 steroids and 477-1274 % for 3-keto-Δ4 steroids). Therefore, we analytically validated post-column infusion of ammonium fluoride. Lower limits of quantification ranged from 0.3 to 3 nmol/L; All analytes were quantifiable with acceptable accuracy (bias range -14 % to 11.9 % for 21/23, -21 % to 11.9 % for all analytes). Average recovery ranged from 91.6 % to 113.6 % and average matrix effects from -29.9 % to 19.9 %. Imprecision ranged from 2.3 % to 23 % for all analytes and was < 15 % for 18/23 analytes. The serum multi-steroid profile of 10 healthy men and 10 healthy women was measured. CONCLUSIONS UHPLC-MS/MS with post-column infusion of ammonium fluoride enables comprehensive multi-steroid profiling through enhanced ionisation particularly benefiting the detection of 3-keto-Δ4 steroids.
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Affiliation(s)
- Lina Schiffer
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
| | - Fozia Shaheen
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
| | - Lorna C Gilligan
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
| | - Karl-Heinz Storbeck
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK; Department of Biochemistry, Stellenbosch University, Stellenbosch, South Africa
| | - James M Hawley
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK; Department of Clinical Biochemistry, Wythenshawe Hospital, Manchester NHS Foundation Trust, Manchester, UK
| | - Brian G Keevil
- Department of Clinical Biochemistry, Wythenshawe Hospital, Manchester NHS Foundation Trust, Manchester, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
| | - Angela E Taylor
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK.
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11
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Fariha R, Jabrah M, Hill C, Spooner A, Deshpande P, Tripathi A. Simultaneous detection of salivary cortisol and cortisone using an automated high-throughput sample preparation method for LC-MS/MS. SLAS Technol 2022; 27:237-246. [DOI: 10.1016/j.slast.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/27/2021] [Accepted: 01/13/2022] [Indexed: 12/17/2022]
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12
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Abstract
Androgens are essential sex steroid hormones for both sexes. Testosterone (T) is the predominant androgen in males, while in adult females, T concentrations are about 15-fold lower and androgen precursors are converted to estrogens. T is produced primarily in testicular Leydig cells in men, while in women precursors are biosynthesised in the adrenal cortex and ovaries and converted into T in the periphery. The biosynthesis of T occurs via a series of enzymatic reactions in steroidogenic organs. Notably, the more potent androgen, dihydrotestosterone, may be synthesized from T in the classic pathway, however, alternate metabolic pathways also exist. The classic action of androgens on target organs is mediated through the androgen receptor, which regulates nuclear receptor gene transcription. However, the androgen-androgen receptor complex may also interact directly with membrane proteins or signaling molecules to exert more rapid effects. This review summarizes the current knowledge of androgen biosynthesis, mechanisms of action and endocrine effects in human biology, and relates these effects to respective human congenital and acquired disorders.
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Affiliation(s)
- Rawda Naamneh Elzenaty
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Bern University Hospital, University of Bern, Switzerland; Department of Biomedical Research, University of Bern, Switzerland; Graduate School of Cellular and Biomedical Sciences, University of Bern, Switzerland.
| | - Therina du Toit
- Department of Biomedical Research, University of Bern, Switzerland.
| | - Christa E Flück
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Bern University Hospital, University of Bern, Switzerland; Department of Biomedical Research, University of Bern, Switzerland.
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13
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Adriaansen BPH, Kamphuis JS, Schröder MAM, Olthaar AJ, Bock C, Brandt A, Stikkelbroeck NMML, Lentjes EGWM, Span PN, Sweep FCGJ, Claahsen‐van der Grinten HL, van Herwaarden AE. Diurnal salivary androstenedione and 17-hydroxyprogesterone levels in healthy volunteers for monitoring treatment efficacy of patients with congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2022; 97:36-42. [PMID: 35150157 PMCID: PMC9542109 DOI: 10.1111/cen.14690] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/13/2021] [Accepted: 12/19/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Treatment of congenital adrenal hyperplasia (CAH) patients with glucocorticoids is often challenging since there is a delicate balance between over- and undertreatment. Treatment can be monitored noninvasively by measuring salivary androstenedione (A4) and 17-hydroxyprogesterone (17-OHP). Optimal treatment monitoring requires the establishment of reference values in saliva. DESIGN A descriptive study. PATIENTS For this study saliva of 255 healthy paediatric and adult volunteers with an age range of 4-75 years old was used. MEASUREMENTS We developed a sensitive liquid chromatography-tandem mass spectrometry method, assessed salivary A4 and 17-OHP stability, and measured A4 and 17-OHP concentrations in saliva collected in the morning, afternoon, and evening. RESULTS We quantified A4 and 17-OHP concentrations in the morning, afternoon, and evening and demonstrated that there is a significant rhythm with the highest levels in the morning and decreasing levels over the day. A4 and 17-OHP concentrations display an age-dependent pattern. These steroids remain stable in saliva at ambient temperature for up to 5 days. CONCLUSIONS Good stability of the steroids in saliva enables saliva collection by the patient at home. Since salivary A4 and 17-OHP display a diurnal rhythm and age-dependent pattern, we established reference values for both children and adults at three time points during the day. These reference values support treatment monitoring of children and adults with CAH.
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Affiliation(s)
- Bas P. H. Adriaansen
- Department of Laboratory Medicine, Radboud Institute of Health SciencesRadboud University Medical CentreNijmegenThe Netherlands
- Department of Paediatric Endocrinology, Amalia Children's HospitalRadboud University Medical CentreNijmegenThe Netherlands
| | - Johannes S. Kamphuis
- Department of Clinical Chemistry and HaematologyGelre HospitalsApeldoornThe Netherlands
| | - Mariska A. M. Schröder
- Department of Paediatric Endocrinology, Amalia Children's HospitalRadboud University Medical CentreNijmegenThe Netherlands
- Department of Laboratory Medicine, Radboud Institute of Molecular Life SciencesRadboud University Medical CentreNijmegenThe Netherlands
| | - André J. Olthaar
- Department of Laboratory Medicine, Radboud Institute of Health SciencesRadboud University Medical CentreNijmegenThe Netherlands
| | - Carina Bock
- Department of Laboratory Medicine, Radboud Institute of Health SciencesRadboud University Medical CentreNijmegenThe Netherlands
| | - André Brandt
- Department of Laboratory Medicine, Radboud Institute of Health SciencesRadboud University Medical CentreNijmegenThe Netherlands
| | | | - Eef G. W. M. Lentjes
- Central Diagnostic LaboratoryUniversity Medical Centre UtrechtUtrechtThe Netherlands
| | - Paul N. Span
- Department of Radiation OncologyRadboud University Medical CentreNijmegenThe Netherlands
| | - Fred C. G. J. Sweep
- Department of Laboratory Medicine, Radboud Institute of Health SciencesRadboud University Medical CentreNijmegenThe Netherlands
| | | | - Antonius E. van Herwaarden
- Department of Laboratory Medicine, Radboud Institute of Health SciencesRadboud University Medical CentreNijmegenThe Netherlands
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14
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Schröder MAM, van Herwaarden AE, Span PN, van den Akker ELT, Bocca G, Hannema SE, van der Kamp HJ, de Kort SWK, Mooij CF, Schott DA, Straetemans S, van Tellingen V, van der Velden JA, Sweep FCGJ, Claahsen-van der Grinten HL. Optimizing the Timing of Highest Hydrocortisone Dose in Children and Adolescents With 21-Hydroxylase Deficiency. J Clin Endocrinol Metab 2022; 107:e1661-e1672. [PMID: 34788830 PMCID: PMC8947312 DOI: 10.1210/clinem/dgab826] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Indexed: 11/20/2022]
Abstract
CONTEXT Hydrocortisone treatment of young patients with 21-hydroxylase deficiency (21OHD) is given thrice daily, but there is debate about the optimal timing of the highest hydrocortisone dose, either mimicking the physiological diurnal rhythm (morning), or optimally suppressing androgen activity (evening). OBJECTIVE We aimed to compare 2 standard hydrocortisone timing strategies, either highest dosage in the morning or evening, with respect to hormonal status throughout the day, nocturnal blood pressure (BP), and sleep and activity scores. METHODS This 6-week crossover study included 39 patients (aged 4-19 years) with 21OHD. Patients were treated for 3 weeks with the highest hydrocortisone dose in the morning, followed by 3 weeks with the highest dose in the evening (n = 21), or vice versa (n = 18). Androstenedione (A4) and 17-hydroxyprogesterone (17OHP) levels were quantified in saliva collected at 5 am; 7 am; 3 pm; and 11 pm during the last 2 days of each treatment period. The main outcome measure was comparison of saliva 17OHP and A4 levels between the 2 treatment strategies. RESULTS Administration of the highest dose in the evening resulted in significantly lower 17OHP levels at 5 am, whereas the highest dose in the morning resulted in significantly lower 17OHP and A4 levels in the afternoon. The 2 treatment dose regimens were comparable with respect to averaged daily hormone levels, nocturnal BP, and activity and sleep scores. CONCLUSION No clear benefit for either treatment schedule was established. Given the variation in individual responses, we recommend individually optimizing dose distribution and monitoring disease control at multiple time points.
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Affiliation(s)
- Mariska A M Schröder
- Amalia Children’s Hospital, Department of Pediatrics, Radboud University Medical Center, HB Nijmegen, the Netherlands
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Antonius E van Herwaarden
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Paul N Span
- Radiotherapy & OncoImmunology Laboratory, Department of Radiation Oncology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Erica L T van den Akker
- Department of Pediatrics, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, DR Rotterdam, the Netherlands
| | - Gianni Bocca
- Beatrix Children’s Hospital, Department of Pediatrics, University Medical Center Groningen, RB Groningen, the Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Centre, RC Leiden, the Netherlands
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, MB Amsterdam, the Netherlands
| | - Hetty J van der Kamp
- Wilhelmina Children’s Hospital, Utrecht University Medical Center, EA Utrecht, the Netherlands
| | - Sandra W K de Kort
- Department of Pediatrics, Haga Teaching Hospital/Juliana Children’s Hospital, AA The Hague, the Netherlands
| | - Christiaan F Mooij
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, AZ Amsterdam, the Netherlands
| | - Dina A Schott
- Department of Pediatrics Endocrinology, Zuyderland medical center, PC Heerlen, the Netherlands
| | - Saartje Straetemans
- Department of Pediatric Endocrinology, Maastricht university medical center, HX Maastricht, the Netherlands
| | - Vera van Tellingen
- Department of Pediatrics, Catharina Hospital, EJ Eindhoven, the Netherlands
| | - Janiëlle A van der Velden
- Amalia Children’s Hospital, Department of Pediatrics, Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Hedi L Claahsen-van der Grinten
- Amalia Children’s Hospital, Department of Pediatrics, Radboud University Medical Center, HB Nijmegen, the Netherlands
- Correspondence: Hedi L. Claahsen-van der Grinten, MD, PhD, Amalia Children’s Hospital, Radboud University Medical Center, Department of Pediatrics, Geert Grooteplein Zuid 10, 6500 HB, Nijmegen, the Netherlands.
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15
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 172] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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16
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Nowotny HF, Auer MK, Lottspeich C, Schmidt H, Dubinski I, Bidlingmaier M, Adaway J, Hawley J, Keevil B, Reisch N. Salivary Profiles of 11-oxygenated Androgens Follow a Diurnal Rhythm in Patients With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2021; 106:e4509-e4519. [PMID: 34165575 PMCID: PMC8530726 DOI: 10.1210/clinem/dgab446] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Indexed: 11/30/2022]
Abstract
CONTEXT Several studies have highlighted the importance of the 11-oxygenated 19-carbon (11oxC19) adrenal-derived steroids as potential biomarkers for monitoring patients with 21-hydroxylase deficiency (21OHD). OBJECTIVE To analyze circadian rhythmicity of 11oxC19 steroids in saliva profiles and evaluate their relevance as potential monitoring parameters in 21OHD. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional single-center study including 59 patients with classic 21OHD (men = 30; women = 29) and 49 body mass index- and age-matched controls (men = 19; women = 30). OUTCOME MEASURES Salivary concentrations of the following steroids were analyzed by liquid chromatography-tandem mass spectrometry: 17-hydroxyprogesterone (17OHP), androstenedione (A4), testosterone (T), 11β-hydroxyandrostenedione (11OHA4), and 11-ketotestosterone (11KT). RESULTS Similar to the previously described rhythmicity of 17OHP, 11OHA4 and 11KT concentrations followed a distinct diurnal rhythm in both patients and controls with highest concentrations in the early morning and declining throughout the day (11-OHA4: mean reduction of hormone concentrations between timepoint 1 and 5 (Δ mean) in male patients = 66%; male controls Δ mean = 83%; female patients Δ mean = 47%; female controls Δ mean = 86%; 11KT: male patients Δ mean = 57%; male controls Δ mean = 63%; female patients Δ mean = 50%; female controls Δ mean = 76%). Significant correlations between the area under the curve for 17OHP and 11KT (rpmale = 0.773<0.0001; rpfemale = 0.737<0.0001), and 11OHA4 (rpmale = 0.6330.0002; rpfemale = 0.5640.0014) were observed in patients but not present or reduced in controls. CONCLUSIONS Adrenal 11oxC19 androgens are secreted following a diurnal pattern. This should be considered when evaluating their utility for monitoring treatment control.
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Affiliation(s)
- Hanna Franziska Nowotny
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Matthias K Auer
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Christian Lottspeich
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Heinrich Schmidt
- Department of Pediatric Endocrinology, Dr. von Haunersches Children’s Hospital, Klinikum der Universität München, LMU München, Munich, Germany
| | - Ilja Dubinski
- Department of Pediatric Endocrinology, Dr. von Haunersches Children’s Hospital, Klinikum der Universität München, LMU München, Munich, Germany
| | - Martin Bidlingmaier
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Jo Adaway
- Department of Clinical Biochemistry, Manchester University Foundation NHS Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - James Hawley
- Department of Clinical Biochemistry, Manchester University Foundation NHS Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Brian Keevil
- Department of Clinical Biochemistry, Manchester University Foundation NHS Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Nicole Reisch
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
- Correspondence: Nicole Reisch, Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, Ziemssenstr. 1, 80336 München, Germany.
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17
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Barnard L, du Toit T, Swart AC. Back where it belongs: 11β-hydroxyandrostenedione compels the re-assessment of C11-oxy androgens in steroidogenesis. Mol Cell Endocrinol 2021; 525:111189. [PMID: 33539964 DOI: 10.1016/j.mce.2021.111189] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/22/2021] [Accepted: 01/24/2021] [Indexed: 12/29/2022]
Abstract
Adrenal steroidogenesis has, for decades, been depicted as three biosynthesis pathways -the mineralocorticoid, glucocorticoid and androgen pathways with aldosterone, cortisol and androstenedione as the respective end products. 11β-hydroxyandrostenedione was not included as an adrenal steroid despite the adrenal output of this steroid being twice that of androstenedione. While it is the end of the line for aldosterone and cortisol, as it is in these forms that they exhibit their most potent receptor activities prior to inactivation and conjugation, 11β-hydroxyandrostenedione is another matter entirely. The steroid, which is weakly androgenic, has its own designated pathway yielding 11-ketoandrostenedione, 11β-hydroxytestosterone and the potent androgens, 11-ketotestosterone and 11-ketodihydrotestosterone, primarily in the periphery. Over the last decade, these C11-oxy C19 steroids have once again come to the fore with the rising number of studies contradicting the generally accepted notion that testosterone and it's 5α-reduced product, dihydrotestosterone, are the principal potent androgens in humans. These C11-oxy androgens have been shown to contribute to the androgen milieu in adrenal disorders associated with androgen excess and in androgen dependant disease progression. In this review, we will highlight these overlooked C11-oxy C19 steroids as well as the C11-oxy C21 steroids and their contribution to congenital adrenal hyperplasia, polycystic ovarian syndrome and prostate cancer. The focus is on new findings over the past decade which are slowly but surely reshaping our current outlook on human sex steroid biology.
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Affiliation(s)
- Lise Barnard
- Department of Biochemistry, Stellenbosch University, Private Bag X1, Matieland, 7602, South Africa
| | - Therina du Toit
- Department of Biochemistry, Stellenbosch University, Private Bag X1, Matieland, 7602, South Africa
| | - Amanda C Swart
- Department of Biochemistry, Stellenbosch University, Private Bag X1, Matieland, 7602, South Africa; Department of Chemistry and Polymer Science, Stellenbosch University, Private Bag X1, Matieland, 7602, South Africa.
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18
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Schiffer L, Bossey A, Kempegowda P, Taylor AE, Akerman I, Scheel-Toellner D, Storbeck KH, Arlt W. Peripheral blood mononuclear cells preferentially activate 11-oxygenated androgens. Eur J Endocrinol 2021; 184:353-363. [PMID: 33444228 PMCID: PMC7923147 DOI: 10.1530/eje-20-1077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/12/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Androgens are important modulators of immune cell function. The local generation of active androgens from circulating precursors is an important mediator of androgen action in peripheral target cells or tissues. We aimed to characterize the activation of classic and 11-oxygenated androgens in human peripheral blood mononuclear cells (PBMCs). METHODS PBMCs were isolated from healthy male donors and incubated ex vivo with precursors and active androgens of the classic and 11-oxygenated androgen pathways. Steroids were quantified by liquid chromatography-tandem mass spectrometry. The expression of genes encoding steroid-metabolizing enzymes was assessed by quantitative PCR. RESULTS PBMCs generated eight-fold higher amounts of the active 11-oxygenated androgen 11-ketotestosterone than the classic androgen testosterone from their respective precursors. We identified the enzyme AKR1C3 as the major reductive 17β-hydroxysteroid dehydrogenase in PBMCs responsible for both conversions and found that within the PBMC compartment natural killer cells are the major site of AKRC13 expression and activity. Steroid 5α-reductase type 1 catalyzed the 5α-reduction of classic but not 11-oxygenated androgens in PBMCs. Lag time prior to the separation of cellular components from whole blood increased serum 11-ketotestosterone concentrations in a time-dependent fashion, with significant increases detected from two hours after blood collection. CONCLUSIONS 11-Oxygenated androgens are the preferred substrates for androgen activation by AKR1C3 in PBMCs, primarily conveyed by natural killer cell AKR1C3 activity, yielding 11-ketotestosterone the major active androgen in PBMCs. Androgen metabolism by PBMCs can affect the results of serum 11-ketotestosterone measurements, if samples are not separated in a timely fashion. SIGNIFICANCE STATEMENT We show that human peripheral blood mononuclear cells (PBMCs) preferentially activate 11-ketotestosterone rather than testosterone when incubated with precursors of both the classic and the adrenal-derived 11-oxygenated androgen biosynthesis pathways. We demonstrate that this activity is catalyzed by the enzyme AKR1C3, which we found to primarily reside in natural killer cells, major contributors to the anti-viral immune defense. This potentially links intracrine 11-oxygenated androgen generation to the previously observed decreased NK cell cytotoxicity and increased infection risk in primary adrenal insufficiency. In addition, we show that PBMCs continue to generate 11-ketotestosterone if the cellular component of whole blood samples is not removed in a timely fashion, which could affect measurements of this active androgen in routine clinical biochemistry.
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Affiliation(s)
- Lina Schiffer
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Alicia Bossey
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Punith Kempegowda
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Ildem Akerman
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | | | - Karl-Heinz Storbeck
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Biochemistry, Stellenbosch University, Stellenbosch, South Africa
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
- Correspondence should be addressed to W Arlt;
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19
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Ramirez Alcantara J, Halper A. Adrenal insufficiency updates in children. Curr Opin Endocrinol Diabetes Obes 2021; 28:75-81. [PMID: 33278125 DOI: 10.1097/med.0000000000000591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The current article will review the newest diagnostic tools, genetic causes, and treatment of adrenal insufficiency in children. RECENT FINDINGS It is common practice to perform an adrenocorticotropin hormone (ACTH) stimulation test when adrenal insufficiency is suspected. The indications for use of a high-dose or low-dose of synthetic ACTH in children have been refined. In addition, newer studies propose adding 15 and 30-min serum or salivary cortisol levels to the low-dose ACTH stimulation test to correctly identify adrenal insufficiency. Recent identification of genetic mutations in children with non-classic steroidogenic acute regulatory protein and other mutations associated with primary and secondary adrenal insufficiency have expanded the cause and pathophysiology of monogenic adrenal insufficiency. In addition, newer hydrocortisone formulations and delivery methods and medications to use in combination with hydrocortisone are being explored to improve treatment for children with adrenal insufficiency. SUMMARY Improved diagnostic aids, detection of newer genetic mutations, and better treatment options and delivery systems will help correctly identify and manage children with adrenal insufficiency to improve health outcomes and quality of life. VIDEO ABSTRACT http://links.lww.com/COE/A21.
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Affiliation(s)
- Jonanlis Ramirez Alcantara
- Division of Pediatric Endocrinology, Department of Pediatrics, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts, USA
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20
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Auchus RJ. An Innovative Approach to Noninvasive Dynamic Adrenal Testing. J Clin Endocrinol Metab 2020; 105:5885054. [PMID: 32766761 DOI: 10.1210/clinem/dgaa455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 07/09/2020] [Indexed: 02/13/2023]
Affiliation(s)
- Richard J Auchus
- Division of Metabolism, Endocrinology, & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Department of Pharmacology, University of Michigan, Ann Arbor, MI
- Veterans Affairs Medical Center, Ann Arbor, MI
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21
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du Toit T, van Rooyen D, Stander MA, Atkin SL, Swart AC. Analysis of 52 C19 and C21 steroids by UPC2-MS/MS: Characterising the C11-oxy steroid metabolome in serum. J Chromatogr B Analyt Technol Biomed Life Sci 2020; 1152:122243. [DOI: 10.1016/j.jchromb.2020.122243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/22/2020] [Accepted: 06/11/2020] [Indexed: 02/04/2023]
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22
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Kocova M, Anastasovska V, Falhammar H. Clinical outcomes and characteristics of P30L mutations in congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Endocrine 2020; 69:262-277. [PMID: 32367336 PMCID: PMC7392929 DOI: 10.1007/s12020-020-02323-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/18/2020] [Indexed: 01/07/2023]
Abstract
Despite numerous studies in the field of congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, some clinical variability of the presentation and discrepancies in the genotype/phenotype correlation are still unexplained. Some, but not all, discordant phenotypes caused by mutations with known enzyme activity have been explained by in silico structural changes in the 21-hydroxylase protein. The incidence of P30L mutation varies in different populations and is most frequently found in several Central and Southeast European countries as well as Mexico. Patients carrying P30L mutation present predominantly as non-classical CAH; however, simple virilizing forms are found in up to 50% of patients. Taking into consideration the residual 21-hydroxulase activity present with P30L mutation this is unexpected. Different mechanisms for increased androgenization in patients carrying P30L mutation have been proposed including influence of different residues, accompanying promotor allele variability or mutations, and individual androgene sensitivity. Early diagnosis of patients who would present with SV is important in order to improve outcome. Outcome studies of CAH have confirmed the uniqueness of this mutation such as difficulties in phenotype classification, different fertility, growth, and psychologic issues in comparison with other genotypes. Additional studies of P30L mutation are warranted.
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Affiliation(s)
- Mirjana Kocova
- Medical Faculty, University"Cyril&Methodius", Skopje, Republic of North Macedonia
| | - Violeta Anastasovska
- Genetic Laboratory, University Pediatric Hospital, Skopje, Republic of North Macedonia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.
- Departement of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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23
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Minnetti M, Caiulo S, Ferrigno R, Baldini-Ferroli B, Bottaro G, Gianfrilli D, Sbardella E, De Martino MC, Savage MO. Abnormal linear growth in paediatric adrenal diseases: Pathogenesis, prevalence and management. Clin Endocrinol (Oxf) 2020; 92:98-108. [PMID: 31747461 DOI: 10.1111/cen.14131] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 11/10/2019] [Accepted: 11/18/2019] [Indexed: 12/13/2022]
Abstract
Abnormal adrenal function can interfere with linear growth, potentially causing either acceleration or impairment of growth in paediatric patients. These abnormalities can be caused by direct effects of adrenal hormones, particularly glucocorticoids and sex steroids, or be mediated by indirect mechanisms such as the disturbance of the growth hormone-insulin-like growth factor-1 axis and aromatization of androgens to oestrogens. The early diagnosis and optimal treatment of adrenal disorders can prevent or minimize growth disturbance and facilitate improved height gain. Mechanisms of growth disturbance in the following abnormal states will be discussed; hypercortisolaemia, hyperandrogenaemia and obesity. Prevalence and features of growth disturbance will be discussed in ACTH-dependent and ACTH-independent Cushing's syndrome, adrenocortical tumours, premature adrenarche, congenital adrenal hyperplasia and adrenal insufficiency disorders. Recommendations for management have been included.
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Affiliation(s)
- Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvana Caiulo
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
| | - Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Federico II University, Naples, Italy
| | - Barbara Baldini-Ferroli
- Dipartimento Pediatrico Universitario Ospedaliero, Bambino Gesu' Children's Hospital, Rome, Italy
| | - Giorgia Bottaro
- Dipartimento Pediatrico Universitario Ospedaliero, Bambino Gesu' Children's Hospital, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Martin O Savage
- Endocrinology Centre, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, London, UK
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24
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Balsamo A, Baronio F, Ortolano R, Menabo S, Baldazzi L, Di Natale V, Vissani S, Cassio A. Congenital Adrenal Hyperplasias Presenting in the Newborn and Young Infant. Front Pediatr 2020; 8:593315. [PMID: 33415088 PMCID: PMC7783414 DOI: 10.3389/fped.2020.593315] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/23/2020] [Indexed: 12/25/2022] Open
Abstract
Congenital adrenal hyperplasia includes autosomal recessive conditions that affect the adrenal cortex steroidogenic enzymes (cholesterol side-chain cleavage enzyme; 3β-hydroxysteroid dehydrogenase; 17α-hydroxylase/17,20 lyase; P450 oxidoreductase; 21-hydroxylase; and 11β-hydroxylase) and proteins (steroidogenic acute regulatory protein). These are located within the three major pathways of the steroidogenic apparatus involved in the production of mineralocorticoids, glucocorticoids, and androgens. Many countries have introduced newborn screening program (NSP) based on 17-OH-progesterone (17-OHP) immunoassays on dried blood spots, which enable faster diagnosis and treatment of the most severe forms of 21-hydroxylase deficiency (21-OHD). However, in several others, the use of this diagnostic tool has not yet been implemented and clinical diagnosis remains challenging, especially for males. Furthermore, less severe classic forms of 21-OHD and other rarer types of CAHs are not identified by NSP. The aim of this mini review is to highlight both the main clinical characteristics and therapeutic options of these conditions, which may be useful for a differential diagnosis in the neonatal period, while contributing to the biochemical evolution taking place in the steroidogenic field. Currently, chromatographic techniques coupled with tandem mass spectrometry are gaining attention due to an increase in the reliability of the test results of NPS for detecting 21-OHD. Furthermore, the possibility of identifying CAH patients that are not affected by 21-OHD but presenting elevated levels of 17-OHP by NSP and the opportunity to include the recently investigated 11-oxygenated androgens in the steroid profiles are promising tools for a more precise diagnosis and monitoring of some of these conditions.
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Affiliation(s)
- Antonio Balsamo
- Pediatric Endocrinology Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Baronio
- Pediatric Endocrinology Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Rita Ortolano
- Pediatric Endocrinology Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Soara Menabo
- Genetic Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Lilia Baldazzi
- Genetic Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Valeria Di Natale
- Pediatric Endocrinology Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Sofia Vissani
- Pediatric Endocrinology Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Alessandra Cassio
- Pediatric Endocrinology Unit, Department of Medical and Surgical Sciences, Endo-ERN Centre IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
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25
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Bacila I, Adaway J, Hawley J, Mahdi S, Krone R, Patel L, Alvi S, Randell T, Gevers E, Dattani M, Cheetham T, Kyriakou A, Schiffer L, Ryan F, Crowne E, Davies JH, Ahmed SF, Keevil B, Krone N. Measurement of Salivary Adrenal-Specific Androgens as Biomarkers of Therapy Control in 21-Hydroxylase Deficiency. J Clin Endocrinol Metab 2019; 104:6417-6429. [PMID: 31361321 DOI: 10.1210/jc.2019-00031] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 07/22/2019] [Indexed: 02/12/2023]
Abstract
BACKGROUND Monitoring of hormonal control represents a key part of the management of congenital adrenal hyperplasia (CAH). Monitoring strategies remain suboptimal because they rely on frequent blood tests and are not specific for adrenal-derived hormones. Recent evidence suggests the crucial role of adrenal-specific 11-oxygenated-C19 androgens in the pathogenesis of CAH. OBJECTIVE To establish a correlation between plasma and salivary adrenal-specific androgens in CAH as a noninvasive monitoring strategy. DESIGN This prospective cross-sectional study recruited patients between 2015 and 2018. SETTING Multicenter study including 13 tertiary centers in the United Kingdom. PARTICIPANTS Seventy-eight children with CAH and 62 matched healthy controls. METHODS Using liquid chromatography-tandem mass spectrometry, plasma and salivary concentrations of five steroids were measured: 17-hydroxyprogesterone (17OHP), androstenedione (A4), testosterone (T), 11-hydroxyandrostenedione (11OHA4), and 11-ketotestosterone (11KT). The correlation between plasma and salivary steroids was analyzed to assess their use in clinical practice. RESULTS Strong correlations between plasma and salivary steroid concentrations in patients with CAH were detected: 17OHP (rs = 0.871; P < 0.001), A4 (rs = 0.931; P < 0.001), T (rs = 0.867; P < 0.001), 11OH4A (rs = 0.876; P < 0.001), and 11KT (rs = 0.944; P < 0.001). These results were consistent for patient subgroups based on sex and age. Analysis of patient subgroups based on 17OHP concentrations established clear correlations between plasma and salivary concentrations of the adrenal-specific androgen 11KT. CONCLUSIONS The current study identified tight correlations between plasma and saliva for the adrenal-derived 11-oxygenated C19 androgen 11KT, as well as 17OHP and A4, which are widely used for monitoring treatment in CAH. This combination of steroid hormones will serve as an improved noninvasive salivary test for disease monitoring in patients with CAH.
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Affiliation(s)
- Irina Bacila
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Jo Adaway
- Department of Biochemistry, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - James Hawley
- Department of Biochemistry, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Sundus Mahdi
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Ruth Krone
- Birmingham Women's & Children's Hospital, Birmingham, United Kingdom
| | - Leena Patel
- University of Manchester, Manchester, United Kingdom
| | - Sabah Alvi
- Leeds General Infirmary, Leeds, United Kingdom
| | | | - Evelien Gevers
- Queen Mary University London and Barts Health NHS Trust, The Royal London Hospital, London, United Kingdom
| | - Mehul Dattani
- Great Ormond Street Hospital, London, United Kingdom
| | - Timothy Cheetham
- Great North Children's Hospital, University of Newcastle, Newcastle, United Kingdom
| | - Andreas Kyriakou
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
| | - Lina Schiffer
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Fiona Ryan
- Oxford Children's Hospital, Oxford, United Kingdom
| | - Elizabeth Crowne
- Bristol Royal Hospital for Children, University Hospitals Bristol Foundation Trust, Bristol, United Kingdom
| | - Justin H Davies
- University Hospital Southampton, Southampton, United Kingdom
| | - Syed Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
| | - Brian Keevil
- Department of Clinical Biochemistry, Wythenshawe Hospital, Manchester, United Kingdom
| | - Nils Krone
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
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26
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46,XX DSD due to Androgen Excess in Monogenic Disorders of Steroidogenesis: Genetic, Biochemical, and Clinical Features. Int J Mol Sci 2019; 20:ijms20184605. [PMID: 31533357 PMCID: PMC6769793 DOI: 10.3390/ijms20184605] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 12/17/2022] Open
Abstract
The term 'differences of sex development' (DSD) refers to a group of congenital conditions that are associated with atypical development of chromosomal, gonadal, or anatomical sex. Disorders of steroidogenesis comprise autosomal recessive conditions that affect adrenal and gonadal enzymes and are responsible for some conditions of 46,XX DSD where hyperandrogenism interferes with chromosomal and gonadal sex development. Congenital adrenal hyperplasias (CAHs) are disorders of steroidogenesis that mainly involve the adrenals (21-hydroxylase and 11-hydroxylase deficiencies) and sometimes the gonads (3-beta-hydroxysteroidodehydrogenase and P450-oxidoreductase); in contrast, aromatase deficiency mainly involves the steroidogenetic activity of the gonads. This review describes the main genetic, biochemical, and clinical features that apply to the abovementioned conditions. The activities of the steroidogenetic enzymes are modulated by post-translational modifications and cofactors, particularly electron-donating redox partners. The incidences of the rare forms of CAH vary with ethnicity and geography. The elucidation of the precise roles of these enzymes and cofactors has been significantly facilitated by the identification of the genetic bases of rare disorders of steroidogenesis. Understanding steroidogenesis is important to our comprehension of differences in sexual development and other processes that are related to human reproduction and fertility, particularly those that involve androgen excess as consequence of their impairment.
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