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Koren I, Weintrob N, Kebesch R, Majdoub H, Stein N, Naor S, Segev-Becker A. Genotype-Specific Cortisol Reserve in a Cohort of Subjects With Nonclassic Congenital Adrenal Hyperplasia (NCCAH). J Clin Endocrinol Metab 2024; 109:852-857. [PMID: 37715965 DOI: 10.1210/clinem/dgad546] [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: 06/03/2023] [Revised: 08/22/2023] [Accepted: 09/15/2023] [Indexed: 09/18/2023]
Abstract
CONTEXT Recent guidelines suggest that patients with nonclassic congenital adrenal hyperplasia (NCCAH) stop glucocorticoid therapy after achieving adult height. However, these guidelines do not differentiate between NCCAH genotype groups. OBJECTIVE Compare ACTH-stimulated cortisol and 17-hydroxyprogesterone (17OHP) levels, and the rate of partial cortisol insufficiency in subjects with NCCAH carrying one mild and one severe (mild/severe) mutation vs subjects with biallelic mild (mild/mild) mutations. METHODS Retrospective evaluation of the medical records of 122 patients who presented with postnatal virilization and were diagnosed with NCCAH. Patients underwent standard intravenous 0.25 mg/m2 ACTH stimulation testing. Those with stimulated 17OHP level â„40 nmol/L were screened for the 9 most frequent CYP21A2 gene mutations followed by multiplex ligation-dependent probe amplification. A stimulated cortisol level below 500 nmol/L was defined as partial cortisol deficiency. RESULTS Patients were subdivided into 3 genotype groups: 77 carried the mild/mild genotype, mainly homozygous for p.V281L mutation; 29 were compound heterozygous for mild/severe mutation, mainly p.V281L/p.I2Splice, and 16 were heterozygous for p.V281L, and were excluded from statistical evaluation. Stimulated cortisol levels were significantly lower in the mild/severe than in the mild/mild group (mean ± SD, 480 ± 90 vs 570 ± 125 nmol/L, P < .001). The mild/severe group exhibited a significantly higher rate of partial cortisol insufficiency (21/28, 75% vs 28/71, 39%, P = .004). Peak 17OHP was significantly higher in the mild/severe group (198 ± 92 vs 118 ± 50 nmol/L, P < .001). CONCLUSION The high rate of partial adrenal insufficiency in the mild/severe group underscores the need to carefully consider the value of glucocorticoid therapy cessation and the importance of stress coverage in this group.
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Affiliation(s)
- Ilana Koren
- Pediatric Endocrinology Unit, Carmel Medical Center, Clalit Health Services, Haifa 3436212, Israel
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Naomi Weintrob
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Rebekka Kebesch
- Pediatric Endocrinology Unit, Carmel Medical Center, Clalit Health Services, Haifa 3436212, Israel
| | - Hussein Majdoub
- Pediatric Endocrinology Unit, Carmel Medical Center, Clalit Health Services, Haifa 3436212, Israel
| | - Nili Stein
- Statistics Unit, Carmel Medical Center, Clalit Health Services, Haifa 3436212, Israel
| | - Shulamit Naor
- Endocrine laboratory, Clalit Health Services, Haifa 3688847, Israel
| | - Anat Segev-Becker
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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Balagamage C, Arshad A, Elhassan YS, Ben Said W, Krone RE, Gleeson H, Idkowiak J. Management aspects of congenital adrenal hyperplasia during adolescence and transition to adult care. Clin Endocrinol (Oxf) 2023. [PMID: 37964596 DOI: 10.1111/cen.14992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/11/2023] [Accepted: 11/03/2023] [Indexed: 11/16/2023]
Abstract
The adolescent period is characterised by fundamental hormonal changes, which affect sex steroid production, cortisol metabolism and insulin sensitivity. These physiological changes have a significant impact on patients with congenital adrenal hyperplasia (CAH). An essential treatment aim across the lifespan in patients with CAH is to replace glucocorticoids sufficiently to avoid excess adrenal androgen production but equally to avoid cardiometabolic risks associated with excess glucocorticoid intake. The changes to the hormonal milieu at puberty, combined with poor adherence to medical therapy, often result in unsatisfactory control exacerbating androgen excess and increasing the risk of metabolic complications due to steroid over-replacement. With the physical and cognitive maturation of the adolescent with CAH, fertility issues and sexual function become a new focus of patient care in the paediatric clinic. This requires close surveillance for gonadal dysfunction, such as irregular periods/hirsutism or genital surgery-associated symptoms in girls and central hypogonadism or testicular adrenal rest tumours in boys. To ensure good health outcomes across the lifespan, the transition process from paediatric to adult care of patients with CAH must be planned carefully and early from the beginning of adolescence, spanning over many years into young adulthood. Its key aims are to empower the young person through education with full disclosure of their medical history, to ensure appropriate follow-up with experienced physicians and facilitate access to multispecialist teams addressing the complex needs of patients with CAH.
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Affiliation(s)
- Chamila Balagamage
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Amynta Arshad
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- The Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yasir S Elhassan
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Wogud Ben Said
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ruth E Krone
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Helena Gleeson
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jan Idkowiak
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Adriaansen BPH, Schröder MAM, Span PN, Sweep FCGJ, van Herwaarden AE, Claahsen-van der Grinten HL. Challenges in treatment of patients with non-classic congenital adrenal hyperplasia. Front Endocrinol (Lausanne) 2022; 13:1064024. [PMID: 36578966 PMCID: PMC9791115 DOI: 10.3389/fendo.2022.1064024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) due to 21α-hydroxylase deficiency (21OHD) or 11ÎČ-hydroxylase deficiency (11OHD) are congenital conditions with affected adrenal steroidogenesis. Patients with classic 21OHD and 11OHD have a (nearly) complete enzyme deficiency resulting in impaired cortisol synthesis. Elevated precursor steroids are shunted into the unaffected adrenal androgen synthesis pathway leading to elevated adrenal androgen concentrations in these patients. Classic patients are treated with glucocorticoid substitution to compensate for the low cortisol levels and to decrease elevated adrenal androgens levels via negative feedback on the pituitary gland. On the contrary, non-classic CAH (NCCAH) patients have more residual enzymatic activity and do generally not suffer from clinically relevant glucocorticoid deficiency. However, these patients may develop symptoms due to elevated adrenal androgen levels, which are most often less elevated compared to classic patients. Although glucocorticoid treatment can lower adrenal androgen production, the supraphysiological dosages also may have a negative impact on the cardiovascular system and bone health. Therefore, the benefit of glucocorticoid treatment is questionable. An individualized treatment plan is desirable as patients can present with various symptoms or may be asymptomatic. In this review, we discuss the advantages and disadvantages of different treatment options used in patients with NCCAH due to 21OHD and 11OHD.
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Affiliation(s)
- Bas P. H. Adriaansen
- Radboud Institute of Health Sciences, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Pediatric Endocrinology, Amalia Childrenâs Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Mariska A. M. Schröder
- Department of Pediatric Endocrinology, Amalia Childrenâs Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Paul N. Span
- Radiotherapy & OncoImmunology Laboratory, Radboud Institute of Molecular Life Sciences, Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Fred C. G. J. Sweep
- Radboud Institute of Health Sciences, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Antonius E. van Herwaarden
- Radboud Institute of Health Sciences, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hedi L. Claahsen-van der Grinten
- Department of Pediatric Endocrinology, Amalia Childrenâs Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Hedi L. Claahsen-van der Grinten,
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Ntali G, Charisis S, Kylafi CF, Vogiatzi E, Michala L. The way toward adulthood for females with nonclassic congenital adrenal hyperplasia. Endocrine 2021; 73:16-30. [PMID: 33855677 DOI: 10.1007/s12020-021-02715-z] [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: 09/20/2020] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
Females with NC21OHD may present as asymptomatic or develop a wide range of androgen excess expression. Clinical manifestations may become evident in childhood and adolescence and include premature pubarche, precocious puberty, acne, hirsutism, and menstrual disorders or present later in life as oligo-ovulation and infertility. Glucocorticoids have been the mainstay of treatment as they regulate excess androgen expression by dampening ACTH activation. Their use requires a careful dose monitoring to avoid overtreatment and subsequently the risk of obesity, type 2 diabetes, dyslipidemia, hypertension, and osteoporosis. Women with NC21OHD need regular follow up throughout their life in order to overcome the physical and psychological burden of hyperandrogenism.
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Affiliation(s)
- Georgia Ntali
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece.
| | - Sokratis Charisis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Christo F Kylafi
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | | | - Lina Michala
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
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5
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Dörr HG, Schulze N, Bettendorf M, Binder G, Bonfig W, Denzer C, Dunstheimer D, Salzgeber K, Schmidt H, Schwab KO, Voss E, Wabitsch M, Wölfle J. Genotype-phenotype correlations in children and adolescents with nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Mol Cell Pediatr 2020; 7:8. [PMID: 32647925 PMCID: PMC7347723 DOI: 10.1186/s40348-020-00100-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 07/02/2020] [Indexed: 01/13/2023] Open
Abstract
Background Nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency is caused by mutations in the active 21-hydroxylase gene (CYP21A2). The clinical symptoms can vary greatly. To date, no systematic studies have been undertaken in Germany. Aims Description of the phenotype, evaluation of the diagnostics and genotype-phenotype correlation Patients and methodology Retrospective analysis of the data of 134 patients (age range 0.1â18.6âyears) in a multicentre study covering 10 paediatric endocrinology centres in Bavaria and Baden-WĂŒrttemberg. The data was gathered on site from the medical records. Two hundred and thirty-three alleles with a mutation of the CYP21A2 gene were identified in 126 patients. A genotype-phenotype correlation of the mutation findings was undertaken (C1, severe/mild; C2, mild/mild). Individuals with a heterozygous mutation of the CYP21A2 were also included (C3). The data was collected with the approval of the ethics committee of the University Hospital of Erlangen during the period of 2014 and 2015. Results (MW ± SD) One hundred and seventeen out of 134 patients (115 f, 29 m) were symptomatic. The chronological age (CA) at diagnosis was 7.1 ± 4.4âyears. The most frequent symptom (73.5%) was premature pubarche. The height-SDS on diagnosis was 0.8 ± 1.3 and the BMI-SDS was 0.8 ± 1.2. Bone age (BA) was ascertained in 82.9% of the symptomatic patients. The difference between BA and CA was 1.9 ± 1.4âyears. Basal 17OHP concentrations were 14.5 ± 19.1âng/ml (18 patients <â2âng/ml). In total, 58.1% mild and 34.7% severe mutations were found. The most common mutation was p.Val281Leu (39.1%); 65.8% of the patients could be allocated to group C1. No phenotypical differences were found between the 3 mutation groups. The 17OHP levels (basal and after ACTH) in the standard ACTH stimulation test were highest in group C1 and also significantly higher in group C2 as in C3, the ACTH-stimulated cortisol levels (ng/ml) were significantly lower in groups C1 (192.1 ± 62.5) and C2 (218 ± 50) than in C3 (297.3 ± 98.7). Conclusion Most of the patients have symptoms of mild androgenisation. Male patients are underdiagnosed. Diagnostics are not standardised. Differences between the types of mutations are found in the hormone concentrations but not in phenotype. We speculate that further, as yet not clearly defined, factors are responsible for the development of the respective phenotypes.
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Affiliation(s)
| | - Nadja Schulze
- Paediatric Endocrinology, University Children's Hospital, Erlangen, Germany
| | - Markus Bettendorf
- Paediatric Endocrinology, University Children's Hospital, Heidelberg, Germany
| | - Gerhard Binder
- Paediatric Endocrinology, University Children's Hospital, TĂŒbingen, Germany
| | - Walter Bonfig
- Departement of Paediatrics, Hospital Wels-Grieskirchen, Wels, Austria
| | - Christian Denzer
- Paediatric Endocrinology, University Children's Hospital, Ulm, Germany
| | | | | | - Heinrich Schmidt
- Paediatric Endocrinology, University Children's Hospital, Munich, Germany
| | | | - Egbert Voss
- Departament of Paediatrics, Cnopfsche Kinderklinik, Nuremberg, Germany
| | - Martin Wabitsch
- Paediatric Endocrinology, University Children's Hospital, Ulm, Germany
| | - Joachim Wölfle
- Paediatric Endocrinology, University Children's Hospital, Erlangen, Germany
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6
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Genotyp-PhÀnotyp-Korrelationen bei Kindern und Jugendlichen mit nichtklassischem adrenogenitalen Syndrom mit 21-Hydroxylase-Defekt. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-00976-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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KamenickĂœ P, Blanchard A, Lamaziere A, Piedvache C, Donadille B, Duranteau L, Bry H, Gautier JF, Salenave S, Raffin-Sanson ML, Genc S, Pietri L, Christin-Maitre S, Thomas J, Lorthioir A, Azizi M, Chanson P, Le Bouc Y, Brailly-Tabard S, Young J. Cortisol and Aldosterone Responses to Hypoglycemia and Na Depletion in Women With Non-Classic 21-Hydroxylase Deficiency. J Clin Endocrinol Metab 2020; 105:5569997. [PMID: 31529070 DOI: 10.1210/clinem/dgz005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 09/06/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Non-classic 21-hydroxylase deficiency is usually diagnosed in post-pubertal women because of androgen excess. Indication of systematic steroid replacement therapy is controversial because the risk of acute adrenal insufficiency is unknown. In order to specify this risk we evaluated the cortisol and aldosterone secretions in response to appropriate pharmacologic challenges. METHODS In this prospective case-control non-inferiority study we investigated 20 women with non-classic 21-hydroxylase deficiency carrying biallelic CYP21A2 mutations and with serum 17-hydroxyprogesterone (17OHP) >10 ng/mL after stimulation with SynacthenÂź (tetracosactrin) and 20 age- and body mass index-matched healthy women with 17OHP after SynacthenÂź <2 ng/mL. Each participant underwent sequentially an insulin tolerance test to evaluate cortisol secretion and a sodium depletion test, obtained by oral administration of 40 mg of furosemide under low sodium diet (<20 mmol during 24 hours), to evaluate renin and aldosterone secretion. FINDINGS The peak serum cortisol concentration after insulin hypoglycemia was lower in patients than in controls (mean difference -47 ng/mL, 90% CI, -66, P = 0.0026). A peak serum cortisol above a cutoff value of 170 ng/mL was obtained in all controls but only in 55% of patients (P = 0.0039). Twenty-four hours after sodium depletion, blood pressure, plasma sodium, potassium, and serum aldosterone concentrations were comparable between the two groups, but patients had higher stimulated renin concentrations than controls (P = 0.0044). INTERPRETATION Patients with non-classic 21-hydroxylase deficiency frequently display partial cortisol insufficiency and compensated defect in aldosterone secretion. Their clinical management should systematically include assessment of adrenal functions.
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Affiliation(s)
- Peter KamenickĂœ
- Service d'Endocrinologie et des Maladies de la Reproduction, HĂŽpital de BicĂȘtre, Assistance Publique-HĂŽpitaux de Paris (AP-HP), Le Kremlin-BicĂȘtre, France
- Univ Paris-Sud, UniversitĂ© Paris-Saclay, Le Kremlin-BicĂȘtre, France
- Institut National de la SantĂ© et de la Recherche MĂ©dicale (Inserm) UMR_S1185, Le Kremlin BicĂȘtre, France
| | - Anne Blanchard
- Centre d'Investigation Clinique, HÎpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Antonin Lamaziere
- Plateforme de MĂ©tabolomique, Peptidomique et de Dosage de MĂ©dicaments, HĂŽpital Saint-Antoine, AP-HP, Paris, France
| | - CĂ©line Piedvache
- UnitĂ© de Recherche Clinique, HĂŽpital de BicĂȘtre, AP-HP, Le Kremlin-BicĂȘtre, France
| | - Bruno Donadille
- Service d'Endocrinologie et des Maladies de la Reproduction, HĂŽpital Saint-Antoine, AP-HP, Paris, France
| | - Lise Duranteau
- UF de GynĂ©cologie Adolescente et Jeune Adulte, HĂŽpital de BicĂȘtre, AP-HP, Le Kremlin-BicĂȘtre, France
| | - HĂ©lĂšne Bry
- Service d'Endocrinologie et des Maladies de la Reproduction, HĂŽpital de BicĂȘtre, Assistance Publique-HĂŽpitaux de Paris (AP-HP), Le Kremlin-BicĂȘtre, France
| | - Jean-François Gautier
- Centre Universitaire de Diabétologie et de ses Complications, HÎpital LariboisiÚre, AP-HP, Paris, France
| | - Sylvie Salenave
- Service d'Endocrinologie et des Maladies de la Reproduction, HĂŽpital de BicĂȘtre, Assistance Publique-HĂŽpitaux de Paris (AP-HP), Le Kremlin-BicĂȘtre, France
| | | | - Seray Genc
- Service d'Endocrinologie, HĂŽpital Jean Bernard, Valenciennes Cedex, France
| | - Laurence Pietri
- Service d'Endocrinologie, HĂŽpital Saint-Joseph, Paris, France
| | - Sophie Christin-Maitre
- Service d'Endocrinologie et des Maladies de la Reproduction, HĂŽpital Saint-Antoine, AP-HP, Paris, France
| | - Julien Thomas
- Plateforme de MĂ©tabolomique, Peptidomique et de Dosage de MĂ©dicaments, HĂŽpital Saint-Antoine, AP-HP, Paris, France
| | - Aurelien Lorthioir
- Centre d'Investigation Clinique, HÎpital Européen Georges Pompidou, AP-HP, Paris, France
- Unité d'Hypertension, HÎpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Michel Azizi
- Centre d'Investigation Clinique, HÎpital Européen Georges Pompidou, AP-HP, Paris, France
- Unité d'Hypertension, HÎpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Philippe Chanson
- Service d'Endocrinologie et des Maladies de la Reproduction, HĂŽpital de BicĂȘtre, Assistance Publique-HĂŽpitaux de Paris (AP-HP), Le Kremlin-BicĂȘtre, France
- Univ Paris-Sud, UniversitĂ© Paris-Saclay, Le Kremlin-BicĂȘtre, France
- Institut National de la SantĂ© et de la Recherche MĂ©dicale (Inserm) UMR_S1185, Le Kremlin BicĂȘtre, France
| | | | - Sylvie Brailly-Tabard
- Univ Paris-Sud, UniversitĂ© Paris-Saclay, Le Kremlin-BicĂȘtre, France
- Service de GĂ©nĂ©tique MolĂ©culaire, PharmacogĂ©nĂ©tique et Hormonologie, HĂŽpital de BicĂȘtre, AP-HP, Le Kremlin-BicĂȘtre, France
| | - Jacques Young
- Service d'Endocrinologie et des Maladies de la Reproduction, HĂŽpital de BicĂȘtre, Assistance Publique-HĂŽpitaux de Paris (AP-HP), Le Kremlin-BicĂȘtre, France
- Univ Paris-Sud, UniversitĂ© Paris-Saclay, Le Kremlin-BicĂȘtre, France
- Institut National de la SantĂ© et de la Recherche MĂ©dicale (Inserm) UMR_S1185, Le Kremlin BicĂȘtre, France
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Chesover AD, Millar H, Sepiashvili L, Adeli K, Palmert MR, Hamilton J. Screening for Nonclassic Congenital Adrenal Hyperplasia in the Era of Liquid Chromatography-Tandem Mass Spectrometry. J Endocr Soc 2019; 4:bvz030. [PMID: 32110745 PMCID: PMC7041698 DOI: 10.1210/jendso/bvz030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/17/2019] [Indexed: 12/31/2022] Open
Abstract
Context Screening for and diagnosing non classic congenital adrenal hyperplasia (NCCAH) uses serum 17-hydroxyprogesterone (17OHP) thresholds established from immunoassay data; however, a new liquid-chromatography tandem mass spectrometry (LC-MS/MS) method results in lower 17OHP values. The evolution of immunoassays is also challenging our diagnostic cut-off for glucocorticoid insufficiency and few data re-evaluate the utility of testing for glucocorticoid insufficiency in NCCAH. Objective (1) Evaluate the 17OHP threshold that predicts NCCAH in children using LC-MS/MS, and (2) determine the prevalence of glucocorticoid insufficiency in NCCAH. Methods A retrospective chart review of pediatric patients who underwent ACTH stimulation tests with cortisol and 17OHP measurements from 2011 to 2018 for assessment of NCCAH. Other adrenal pathologies were excluded. A cortisol <â
415 nmol/L defined glucocorticoid insufficiency. Published correlation data determined a 17OHP of 3.3 nmol/L by LC-MS/MS was equivalent to 6 nmol/L by immunoassay. Data analysis was by measures of diagnostic accuracy. Results Of 188 patients included, 23 (12%) had NCCAH (21/23 had genetic confirmation); the remaining 2 had peak 17OHP >â
30 nmol/L. Baseline 17OHP â„â
6 nmol/L most accurately screened for NCCAHâsensitivity and specificity 96%. Almost all genetically confirmed NCCAH (20/21) had peak 17OHP >â
30 nmol/L; all subjects with other diagnoses peaked <â
30 nmol/L. Glucocorticoid insufficiency was present in 55% with NCCAH. Conclusions Despite the increased specificity of LC-MS/MS, a baseline 17OHP â„â
6 nmol/L most accurately screened for NCCAH; this supports current practice guidelines. This threshold identified all with glucocorticoid insufficiency, notably prevalent in our cohort and for whom glucocorticoid stress dosing should be considered.
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Affiliation(s)
- Alexander D Chesover
- Division of Endocrinology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto M5G 1H4, Canada
| | - Heather Millar
- Section of Gynaecology, Division of Endocrinology, Department of Obstetrics and Gynaecology, The Hospital for Sick Children, University of Toronto M5G 1H4, Toronto, Canada
| | - Lusia Sepiashvili
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto M5G 1H4, Canada
| | - Khosrow Adeli
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto M5G 1H4, Canada
| | - Mark R Palmert
- Division of Endocrinology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto M5G 1H4, Canada.,Department of Physiology, University of Toronto, Toronto M5S 1A8, Canada
| | - Jill Hamilton
- Division of Endocrinology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto M5G 1H4, Canada
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9
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White PC. Update on diagnosis and management of congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Curr Opin Endocrinol Diabetes Obes 2018; 25:178-184. [PMID: 29718004 DOI: 10.1097/med.0000000000000402] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is a relatively common inherited disorder of cortisol biosynthesis that can be fatal if untreated. RECENT FINDINGS The basic biochemistry and genetics of CAH have been known for decades but continue to be refined by the discoveries of an alternative 'backdoor' metabolic pathway for adrenal androgen synthesis and the secretion of 11-hydroxy and 11-keto analogs of known androgens, by the elucidation of hundreds of new mutations, and by the application of high-throughput sequencing techniques to noninvasive prenatal diagnosis. Although hydrocortisone is a mainstay of treatment, overtreatment may have adverse effects on growth, risk of obesity, and cardiovascular disease; conversely, undertreatment may increase risk of testicular adrenal rest tumors in affected men. SUMMARY Refinements to screening techniques may improve the positive predictive value of newborn screening programs. Alternative dosing forms of hydrocortisone and additional therapeutic modalities are under study. Although surgical treatment of virilized female genitalia is widely accepted by families and patients, it is not without complications or controversy, and some families choose to defer it.
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Affiliation(s)
- Perrin C White
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
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