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Uijl E, Ye D, Ren L, Mirabito Colafella KM, van Veghel R, Garrelds IM, Lu HS, Daugherty A, Hoorn EJ, Nioi P, Foster D, Danser AHJ. Conventional Vasopressor and Vasopressor-Sparing Strategies to Counteract the Blood Pressure-Lowering Effect of Small Interfering RNA Targeting Angiotensinogen. J Am Heart Assoc 2022; 11:e026426. [PMID: 35876413 PMCID: PMC9375483 DOI: 10.1161/jaha.122.026426] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background A single dose of small interfering RNA (siRNA) targeting liver angiotensinogen eliminates hepatic angiotensinogen and lowers blood pressure. Angiotensinogen elimination raises concerns for clinical application because an angiotensin rise is needed to maintain perfusion pressure during hypovolemia. Here, we investigated whether conventional vasopressors can raise arterial pressure after angiotensinogen depletion. Methods and Results Spontaneously hypertensive rats on a low‐salt diet were treated with siRNA (10 mg/kg fortnightly) for 4 weeks, supplemented during the final 2 weeks with fludrocortisone (6 mg/kg per day), the α‐adrenergic agonist midodrine (4 mg/kg per day), or a high‐salt diet (all groups n=6–7). Pressor responsiveness to angiotensin II and norepinephrine was assessed before and after siRNA administration. Blood pressure was measured via radiotelemetry. Depletion of liver angiotensinogen by siRNA lowered plasma angiotensinogen concentrations by 99.2±0.1% and mean arterial pressure by 19 mm Hg. siRNA‐mediated blood pressure lowering was rapidly reversed by intravenous angiotensin II or norepinephrine, or gradually reversed by fludrocortisone or high salt intake. Midodrine had no effect. Unexpectedly, fludrocortisone partially restored plasma angiotensinogen concentrations in siRNA‐treated rats, and nearly abolished plasma renin concentrations. To investigate whether this angiotensinogen originated from nonhepatic sources, fludrocortisone was administered to mice lacking hepatic angiotensinogen. Fludrocortisone did not increase angiotensinogen in these mice, implying that the rise in angiotensinogen in the siRNA‐treated rats must have depended on the liver, most likely reflecting diminished cleavage by renin. Conclusions Intact pressor responsiveness to conventional vasopressors provides pharmacological means to regulate the blood pressure–lowering effect of angiotensinogen siRNA and may support future therapeutic implementation of siRNA.
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Affiliation(s)
- Estrellita Uijl
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands.,Division of Nephrology and Transplantation, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands
| | - Dien Ye
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands.,Saha Cardiovascular Research Center and Department of Physiology University of Kentucky Lexington KY
| | - Liwei Ren
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands.,Department of Pharmacy Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital Southern University of Science and Technology) Shenzhen China
| | - Katrina M Mirabito Colafella
- Cardiovascular Program, Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne Australia
| | - Richard van Veghel
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands
| | - Ingrid M Garrelds
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands
| | - Hong S Lu
- Saha Cardiovascular Research Center and Department of Physiology University of Kentucky Lexington KY
| | - Alan Daugherty
- Saha Cardiovascular Research Center and Department of Physiology University of Kentucky Lexington KY
| | - Ewout J Hoorn
- Division of Nephrology and Transplantation, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands
| | - Paul Nioi
- Alnylam Pharmaceuticals Cambridge MA
| | | | - A H Jan Danser
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands
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2
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Braun LT, Vogel F, Reincke M. Long-term morbidity and mortality in patients with Cushing's syndrome. J Neuroendocrinol 2022; 34:e13113. [PMID: 35312199 DOI: 10.1111/jne.13113] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 11/28/2022]
Abstract
Increased multisystem morbidity and mortality in patients with Cushing's syndrome comprise clinical problems and challenges, both at the time of diagnosis and in remission. Relevant comorbidities and clinical problems include hypertension, diabetes, overweight, myopathy and a high risk for acute complications such as infections and venous thrombembolism. Although there are therapy recommendations for most of these comorbidities, there is a lack of large, prospective studies to confirm and optimise them. Mortality is especially high during active disease and within the first year after diagnosis, as a result of cardiovascular events, infections and suicide. All in all, interdisciplinary therapy management is important for reducing morbidity and mortality over the long-term.
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Affiliation(s)
- Leah T Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Frederick Vogel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
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3
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Zhou Y, Fu X, Zheng Z, Ren Y, Zheng Z, Zhang B, Yuan M, Duan J, Li M, Hong T, Lu G, Zhou D. Identification of gene co-expression modules and hub genes associated with the invasiveness of pituitary adenoma. Endocrine 2020; 68:377-389. [PMID: 32342269 DOI: 10.1007/s12020-020-02316-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
Abstract
In pituitary adenoma (PA), invasiveness is the main cause of recurrence and poor prognosis. Thus, identifying specific biomarkers for diagnosis and effective treatment of invasive PAs is of great clinical significance. In this study, from the Gene Expression Omnibus database, we obtained and combined several microarrays of PA by the "sva" R package. Weighted gene co-expression network analysis was performed to construct a scale-free topology model and analyze the relationships between the modules and clinical traits. Our analysis results indicated that three key modules (dark turquoise, saddle brown, and steel blue) were associated with the invasiveness of PA. Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis and Gene Ontology analysis were performed for the functional annotation of the key modules. In addition, the hub genes in the three modules were identified and screened by differential expression analysis between normal samples and PA samples. Three upregulated differentially expressed genes (DGAT2, PIGZ, and DHRS2) were identified. The Fisher's exact test and receiver operating characteristic curve were used to validate the capability of these genes to distinguish invasive traits, and transcription factor interaction networks were used to further explore the underlying mechanisms of the three genes. Moreover, a lower expression level of DGAT2 in invasive PA tissue than in noninvasive PA tissue was validated by quantitative reverse transcription-polymerase chain reaction. In general, this study contributes to potential molecular biomarkers of invasive PAs and provides a broader perspective for diagnosis and new therapeutic targets for the invasive PAs.
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Affiliation(s)
- Yuancheng Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
- The First Clinical Medical College of Nanchang University, Nanchang, Jiangxi, PR China
| | - Xiaorui Fu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
- Medical Department, Queen Mary College , Nanchang University, Nanchang, Jiangxi, China
| | - Zhicheng Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
- The Fourth Clinical Medical College of Nanchang University, Nanchang, Jiangxi, PR China
| | - Yu Ren
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
- The First Clinical Medical College of Nanchang University, Nanchang, Jiangxi, PR China
| | - Zijian Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
- The First Clinical Medical College of Nanchang University, Nanchang, Jiangxi, PR China
| | - Bohan Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
- The First Clinical Medical College of Nanchang University, Nanchang, Jiangxi, PR China
| | - Min Yuan
- Shanggao County People's Hospital, Yichun, Jiangxi, PR China
| | - Jian Duan
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
| | - Meihua Li
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
| | - Tao Hong
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
| | - Guohui Lu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China.
| | - Dongwei Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China.
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4
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Jain N, Kumar KM, Sachdeva N, Bhansali A, Walia R. Demystifying "Steroid Withdrawal" During Remission in Cushing's Disease: Is Mineralocorticoid Replacement the Answer? Indian J Endocrinol Metab 2019; 23:456-459. [PMID: 31741906 PMCID: PMC6844159 DOI: 10.4103/ijem.ijem_260_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To study renin-angiotensin-aldosterone axis status (RAAS) in patients of Cushing's disease (CD) at baseline and 6 weeks after curative trans-sphenoidal surgery and evaluate the role of mineralocorticoid replacement in the resolution of "steroid withdrawal syndrome" (SWS). Postoperative RAAS status had not been evaluated in previous studies, although aldosterone levels have been shown to be suppressed during medical therapy with pasireotide and cabergoline. MATERIALS AND METHODS This was a prospective, single-center study. Patients with CD, aged between 15-75 years, undergoing curative pituitary surgery were recruited. An 8 am and 11 pm cortisol and adrenocorticotropic hormone (ACTH) were measured at baseline. An 8 am cortisol was measured 6 weeks after surgery to demonstrate remission. Plasma-renin activity and plasma-aldosterone concentration were measured at baseline and 6 weeks after curative surgery. RESULTS A total of 14 patients (11 female, 3 male) were recruited initially, of these 8 patients completed the study. The plasma-renin activity was not suppressed at baseline and did not rise significantly after surgery (P = 0.717). However, plasma-aldosterone concentration was in the low-normal range at baseline and had risen significantly 6 weeks after surgery (P = 0.013). No difference was noted in subgroups with or without hypertension. CONCLUSION Curative pituitary surgery leads to normalization of plasma-aldosterone concentration in patients with CD just 6 weeks after surgery. Hence, mineralocorticoid replacement may not prove beneficial in alleviating the "SWS" in postsurgical CD patients who have achieved remission.
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Affiliation(s)
- Nimisha Jain
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K. Mahesh Kumar
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Naresh Sachdeva
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil Bhansali
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rama Walia
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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5
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Luo A, El Gierari ETM, Nally LM, Sturmer LR, Dodd D, Shi RZ. Clinical utility of an ultrasensitive urinary free cortisol assay by tandem mass spectrometry. Steroids 2019; 146:65-69. [PMID: 30951757 DOI: 10.1016/j.steroids.2019.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND 24 h urinary free cortisol measurement is a clinically important first-line screening test for Cushing's syndrome (CS). Tandem mass spectrometry (LC-MS/MS) assays have superior sensitivity and specificity compared to immunoassays. Our goal was to improve and validate a LC-MS/MS method to measure urinary free cortisol in both adult and pediatric patients and to characterize its clinical diagnostic performance of CS by chart review. METHODS We improved a LC-MS/MS method previously reported for urinary free cortisol to be able to measure urinary and salivary cortisol in the same batch for increased efficiency. The sample preparation was by liquid-liquid extraction using dichloromethane followed by stepwise washing with acidic, basic and neutral solutions. The assay's analytical performance was characterized, and a retrospective patient chart review was conducted to evaluate the assay's clinical performance in diagnosing CS. RESULTS The LC-MS/MS assay demonstrated enhanced sensitivity and was linear within an analytical measurement range of 10-10,000 ng/dL. Assay accuracy was satisfactory as determined by spike and recovery studies and highly correlated with a reference LC-MS/MS method. The assay's clinical diagnostic sensitivity and specificity in detecting CS was 96% and 91%, respectively, when compared to a urinary cortisol excretion of at least 50 µg/24 h. CONCLUSIONS The improved LC-MS/MS method is both sensitive and specific with enhanced analytical performance and clinical diagnostic utility to screen for CS. The clinical diagnostic sensitivity and specificity were superior based on retrospective patient chart review.
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Affiliation(s)
- Amy Luo
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, United States
| | | | - Laura M Nally
- Yale School of Medicine, New Heaven, CT, United States
| | - Lillian R Sturmer
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Dylan Dodd
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Run-Zhang Shi
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, United States.
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Marques P, Tufton N, Bhattacharya S, Caulfield M, Akker SA. Hypertension due to a deoxycorticosterone-secreting adrenal tumour diagnosed during pregnancy. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180164. [PMID: 31051469 PMCID: PMC6499913 DOI: 10.1530/edm-18-0164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/11/2019] [Indexed: 11/25/2022] Open
Abstract
Mineralocorticoid hypertension is most often caused by autonomous overproduction of aldosterone, but excess of other mineralocorticoid precursors can lead to a similar presentation. 11-Deoxycorticosterone (DOC) excess, which can occur in 11-β hydroxylase or 17-α hydroxylase deficiencies, in DOC-producing adrenocortical tumours or in patients taking 11-β hydroxylase inhibitors, may cause mineralocorticoid hypertension. We report a 35-year-old woman who in the third trimester of pregnancy was found to have a large adrenal mass on routine obstetric ultrasound. On referral to our unit, persistent hypertension and long-standing hypokalaemia was noted, despite good compliance with multiple antihypertensives. Ten years earlier, she had hypertension noted in pregnancy which had persisted after delivery. A MRI scan confirmed the presence of a 12 cm adrenal mass and biochemistry revealed high levels of DOC and low/normal renin, aldosterone and dehydroepiandrosterone, with normal catecholamine levels. The patient was treated with antihypertensives until obstetric delivery, following which she underwent an adrenalectomy. Histology confirmed a large adrenal cortical neoplasm of uncertain malignant potential. Postoperatively, blood pressure and serum potassium normalised, and the antihypertensive medication was stopped. Over 10 years of follow-up, she remains asymptomatic with normal DOC measurements. This case should alert clinicians to the possibility of a diagnosis of a DOC-producing adrenal tumours in patients with adrenal nodules and apparent mineralocorticoid hypertension in the presence of low or normal levels of aldosterone. The associated diagnostic and management challenges are discussed. Learning points: Hypermineralocorticoidism is characterised by hypertension, volume expansion and hypokalaemic alkalosis and is most commonly due to overproduction of aldosterone. However, excess of other mineralocorticoid products, such as DOC, lead to the same syndrome but with normal or low aldosterone levels. The differential diagnosis of resistant hypertension with low renin and low/normal aldosterone includes congenital adrenal hyperplasia, syndrome of apparent mineralocorticoid excess, Cushing's syndrome, Liddle's syndrome and 11-deoxycorticosterone-producing tumours. DOC is one intermediate product in the mineralocorticoid synthesis with weaker activity than aldosterone. However, marked DOC excess seen in 11-β hydroxylase or 17-α hydroxylase deficiencies in DOC-producing adrenocortical tumours or in patients taking 11-β hydroxylase inhibitors, may cause mineralocorticoid hypertension. Excessive production of DOC in adrenocortical tumours has been attributed to reduced activity of the enzymes 11-β hydroxylase and 17-α hydroxylase and increased activity of 21-α hydroxylase. The diagnosis of DOC-producing adrenal tumours is challenging because of its rarity and poor availability of DOC laboratory assays.
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Affiliation(s)
- Pedro Marques
- Department of Endocrinology, St. Bartholomew’s Hospital, West Smithfield, London, UK
| | - Nicola Tufton
- Department of Endocrinology, St. Bartholomew’s Hospital, West Smithfield, London, UK
| | - Satya Bhattacharya
- Hepatobiliary and Pancreatic Surgery Unit, The Royal London Hospital, London, UK
| | - Mark Caulfield
- Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Scott A Akker
- Department of Endocrinology, St. Bartholomew’s Hospital, West Smithfield, London, UK
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7
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Barbot M, Ceccato F, Scaroni C. The Pathophysiology and Treatment of Hypertension in Patients With Cushing's Syndrome. Front Endocrinol (Lausanne) 2019; 10:321. [PMID: 31164868 PMCID: PMC6536607 DOI: 10.3389/fendo.2019.00321] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/02/2019] [Indexed: 12/19/2022] Open
Abstract
When hypertension, a pathology that is frequently found in the general population, presents in a young patient, secondary causes such as Cushing's syndrome (CS), a rare disease characterized by long-term elevated cortisol levels, should be considered. Present in ~80% of CS patients independently of their age and sex, hypertension is one of the pathology's most prevalent, alarming features. Its severity is principally associated with the duration and intensity of elevated cortisol levels. Prompt diagnosis and rapid initiation of treatment are important for reducing/delaying the consequences of hypercortisolism. Glucocorticoid excess leads to hypertension via a variety of mechanisms including mineralocorticoid mimetic activity, alterations in peripheral and renovascular resistance, and vascular remodeling. As hypertension in CS patients is caused by cortisol excess, treating the underlying pathology generally contributes to reducing blood pressure (BP) levels, although hypertension tends to persist in approximately 30% of cured patients. Surgical removal of the pituitary tumor remains the first-line treatment for both adrenocorticotropin hormone (ACTH) dependent and independent forms of the syndrome. In light of the fact that surgery is not always successful in curing the underlying disease, it is essential that other treatments be considered and prescribed as needed. This article discusses the mechanisms involved in the pathogenesis of CS and the pros and the cons of the various antihypertensive agents that are presently available to treat these patients.
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Affiliation(s)
- Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
- *Correspondence: Mattia Barbot
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
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The Low-Renin Hypertension Phenotype: Genetics and the Role of the Mineralocorticoid Receptor. Int J Mol Sci 2018; 19:ijms19020546. [PMID: 29439489 PMCID: PMC5855768 DOI: 10.3390/ijms19020546] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 01/31/2018] [Accepted: 02/08/2018] [Indexed: 12/22/2022] Open
Abstract
A substantial proportion of patients with hypertension have a low or suppressed renin. This phenotype of low-renin hypertension (LRH) may be the manifestation of inherited genetic syndromes, acquired somatic mutations, or environmental exposures. Activation of the mineralocorticoid receptor is a common final mechanism for the development of LRH. Classically, the individual causes of LRH have been considered to be rare diseases; however, recent advances suggest that there are milder and "non-classical" variants of many LRH-inducing conditions. In this regard, our understanding of the underlying genetics and mechanisms accounting for LRH, and therefore, potentially the pathogenesis of a large subset of essential hypertension, is evolving. This review will discuss the potential causes of LRH, with a focus on implicated genetic mechanisms, the expanding recognition of non-classical variants of conditions that induce LRH, and the role of the mineralocorticoid receptor in determining this phenotype.
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9
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Sapouckey SA, Deng G, Sigmund CD, Grobe JL. Potential mechanisms of hypothalamic renin-angiotensin system activation by leptin and DOCA-salt for the control of resting metabolism. Physiol Genomics 2017; 49:722-732. [PMID: 28986397 DOI: 10.1152/physiolgenomics.00087.2017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/22/2017] [Indexed: 02/07/2023] Open
Abstract
The renin-angiotensin system (RAS), originally described as a circulating hormone system, is an enzymatic cascade in which the final vasoactive peptide angiotensin II (ANG) regulates cardiovascular, hydromineral, and metabolic functions. The RAS is also synthesized locally in a number of tissues including the brain, where it can act in a paracrine fashion to regulate blood pressure, thirst, fluid balance, and resting energy expenditure/resting metabolic rate (RMR). Recent studies demonstrate that ANG AT1A receptors (Agtr1a) specifically in agouti-related peptide (AgRP) neurons of the arcuate nucleus (ARC) coordinate autonomic and energy expenditure responses to various stimuli including deoxycorticosterone acetate (DOCA)-salt, high-fat feeding, and leptin. It remains unclear, however, how these disparate stimuli converge upon and activate this specific population of AT1A receptors in AgRP neurons. We hypothesize that these stimuli may act to stimulate local expression of the angiotensinogen (AGT) precursor for ANG, or the expression of AT1A receptors, and thereby local activity of the RAS within the (ARC). Here we review mechanisms that may control AGT and AT1A expression within the central nervous system, with a particular focus on mechanisms activated by steroids, dietary fat, and leptin.
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Affiliation(s)
- Sarah A Sapouckey
- Department of Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, Iowa.,Molecular Medicine Graduate Program, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Guorui Deng
- Department of Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Curt D Sigmund
- Department of Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, Iowa.,Molecular Medicine Graduate Program, Carver College of Medicine, University of Iowa, Iowa City, Iowa.,Center for Hypertension Research, Carver College of Medicine, University of Iowa, Iowa City, Iowa.,Abboud Cardiovascular Research Center, Carver College of Medicine, University of Iowa, Iowa City, Iowa.,Fraternal Order of Eagles' Diabetes Research Center, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Justin L Grobe
- Department of Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, Iowa; .,Molecular Medicine Graduate Program, Carver College of Medicine, University of Iowa, Iowa City, Iowa.,Center for Hypertension Research, Carver College of Medicine, University of Iowa, Iowa City, Iowa.,Abboud Cardiovascular Research Center, Carver College of Medicine, University of Iowa, Iowa City, Iowa.,Fraternal Order of Eagles' Diabetes Research Center, Carver College of Medicine, University of Iowa, Iowa City, Iowa.,Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, Iowa; and.,Obesity Research & Education Initiative, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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10
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Ma L, Yin L, Hu Q. Therapeutic compounds for Cushing's syndrome: a patent review (2012-2016). Expert Opin Ther Pat 2016; 26:1307-1323. [PMID: 27454103 DOI: 10.1080/13543776.2016.1217331] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Endogenous Cushing's syndrome (CS) is a set of disorders caused by chronic exposure to excess glucocorticoids induced by neuroendocrine tumors in pituitary, adrenals, and infrequently other sites (ectopic ACTH syndrome). Due to various comorbidities, CS patients exhibit higher risks of cardiovascular diseases and thus increased mortality. Pharmaceutical therapy is an important constituent of treatment regimen. Areas covered: Patents published since 2012 are reviewed, which claim therapeutic compounds interfering with ACTH secretion and down-stream signal transduction, inhibiting cortisol biosynthesis and antagonizing glucocorticoid receptors. Advances focus on a) new analogues with improved efficacy and PK properties or less off-target toxicity; b) existing drugs (candidates) being repurposed to treat CS; and c) novel strategies such as selective inhibition of CYP11B1. Expert opinion: New compounds against established targets need to be developed because current drugs lack selectivity leading to off-target toxicity. Selective inhibition of CYP11B1 is a novel alternative strategy and is potentially versatile in controlling all types of hypercortisolism. Selective multi-targeting enzymes in steroidogenesis network is promising due to potential synergistic effects. However, doses toward each targets are not feasible to adjust because the corresponding intrinsic potencies are rigid. Targeting PRKACA mutations is promising in treating CS caused by adrenal adenomas.
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Affiliation(s)
- Li Ma
- a College of Pharmaceutical Sciences , Zhejiang University , Hangzhou , China PR
| | | | - Qingzhong Hu
- c Department of Chemistry , University of Cambridge , Cambridge , UK
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11
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Pivonello R, De Leo M, Cozzolino A, Colao A. The Treatment of Cushing's Disease. Endocr Rev 2015; 36:385-486. [PMID: 26067718 PMCID: PMC4523083 DOI: 10.1210/er.2013-1048] [Citation(s) in RCA: 288] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/13/2015] [Indexed: 12/23/2022]
Abstract
Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Monica De Leo
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Alessia Cozzolino
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Annamaria Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
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Abstract
Transsphenoidal surgery remains the first line therapy in Cushing's disease, but a large number of patients will not be cured or disease will recur over time. Repeat pituitary surgery, bilateral adrenalectomy, and radiation have limitations with respect to efficacy and/or side effects. Therefore, there is a clear need for an effective medical treatment. The studies reviewed here suggest a role for pituitary-directed therapies, applying multireceptor ligand somatostatin analogs like pasireotide or second-generation dopamine agonists. Retinoic acid has been also studied in a small prospective study. These compounds target ACTH-secretion at the pituitary level and possibly inhibit corticotrope proliferation. Specific side effects of these compounds need to be considered, especially when used as long-term therapy. These novel approaches could provide options for treatment of patients in whom surgery has failed or is not possible, and while awaiting effects of radiation therapy. Preoperative use to decrease cortisol excess, potentially reducing perioperative complications, needs to be further studied.
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Affiliation(s)
- Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Altonaer Str. 59, 20357, Hamburg, Germany,
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