1
|
Baudin E, Goichot B, Berruti A, Hadoux J, Moalla S, Laboureau S, Nölting S, de la Fouchardière C, Kienitz T, Deutschbein T, Zovato S, Amar L, Haissaguerre M, Timmers H, Niccoli P, Faggiano A, Angokai M, Lamartina L, Luca F, Cosentini D, Hahner S, Beuschlein F, Attard M, Texier M, Fassnacht M. Sunitinib for metastatic progressive phaeochromocytomas and paragangliomas: results from FIRSTMAPPP, an academic, multicentre, international, randomised, placebo-controlled, double-blind, phase 2 trial. Lancet 2024; 403:1061-1070. [PMID: 38402886 DOI: 10.1016/s0140-6736(23)02554-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 10/04/2023] [Accepted: 11/13/2023] [Indexed: 02/27/2024]
Abstract
BACKGROUND No randomised controlled trial has ever been done in patients with metastatic phaeochromocytomas and paragangliomas. Preclinical and first clinical evidence suggested beneficial effects of sunitinib. We aimed to evaluate the safety and efficacy of sunitinib in patients with metastatic phaeochromocytomas and paragangliomas. METHODS FIRSTMAPPP is a multicentre, international, randomised, placebo-controlled, double-blind, phase 2 trial done at 14 academic centres across four European countries. Eligible participants were adults (aged ≥18 years) with sporadic or inherited progressive metastatic phaeochromocytomas and paragangliomas. Patients were randomly assigned (1:1) to receive either oral sunitinib (37·5 mg per day) or placebo. Randomisation was stratified according to SDHB status (mutation present vs wild type) and number of previous systemic therapies (0 vs ≥1). Primary endpoint was the rate of progression-free survival at 12 months according to real-time central review (Response Evaluation Criteria in Solid Tumours version 1.1). On the basis of a two-step Simon model, we aimed for the accrual of 78 patients, assuming a 20% improvement of the 12-month progression-free survival rate from 20% to 40%, to conclude that sunitinib is effective. Crossover from the placebo group was allowed. This trial is registered with ClinicalTrials.gov, number NCT01371201, and is closed for enrolment. FINDINGS From Dec 1, 2011, to Jan 31, 2019, a total of 78 patients with progressive metastatic phaeochromocytomas and paragangliomas were enrolled (39 patients per group). 25 (32%) of 78 patients had germline SDHx variants and 54 (69%) had used previous therapies. The primary endpoint was met, with a 12-month progression-free survival in 14 of 39 patients (36% [90% CI 23-50]) in the sunitinib group. In the placebo group, the 12-month progression-free survival in seven of 39 patients was 19% (90% CI 11-31), validating the hypotheses of our study design. The most frequent grade 3 or 4 adverse events were asthenia (seven [18%] of 39 and one [3%] of 39), hypertension (five [13%] and four [10%]), and back or bone pain (one [3%] and three [8%]) in the sunitinib and placebo groups, respectively. Three deaths occurred in the sunitinib group: these deaths were due to respiratory insufficiency, amyotrophic lateral sclerosis, and rectal bleeding. Only the latter event was considered drug related. Two deaths occurred in the placebo group due to aspiration pneumonia and septic shock. INTERPRETATION This first randomised trial supports the use of sunitinib as the medical option with the highest level of evidence for anti-tumour efficacy in progressive metastatic phaeochromocytomas and paragangliomas. FUNDING French Ministry of Health, through the National Institute for Cancer, German Ministry of Education and Research, and the German Research Foundation within the CRC/Transregio 205/2, EU Seventh Framework Programme, and a private donator grant.
Collapse
Affiliation(s)
- Eric Baudin
- Department of Imaging, Endocrine Oncology Unit, Gustave Roussy, University Paris Saclay, Villejuif, France.
| | - Bernard Goichot
- Department of Endocrinology, Hopital de Hautepierre-Hopitaux Universitaires de Strasbourg, Strasbourg, France
| | - Alfredo Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Azienda Ospedaliera Spedali Civili di Brescia, Brescia, Italy
| | - Julien Hadoux
- Department of Imaging, Endocrine Oncology Unit, Gustave Roussy, University Paris Saclay, Villejuif, France
| | - Salma Moalla
- Department of Imaging, Endocrine Oncology Unit, Gustave Roussy, University Paris Saclay, Villejuif, France
| | - Sandrine Laboureau
- Department of Endocrinology Diabetology Nutrition, Hopitaux Universitaires d'Angers, Angers, France
| | - Svenja Nölting
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | | | - Tina Kienitz
- Department of Endocrinology and Metabolism, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Stefania Zovato
- Familial Cancer Clinics, Istituto Oncologico Veneto, IRCCS, Padova, Italy
| | - Laurence Amar
- Department of Hypertension PARIS, Hopital Europeen Georges-Pompidou, Université Paris Cité, Paris, France
| | | | - Henri Timmers
- Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Patricia Niccoli
- Department of Medical Oncology, Institut Paoli Calmette, Marseille, France
| | - Antongiulio Faggiano
- Department of Clinical Medicine and Surgery, Endocrinology, Diabetology and Andrology Unit, Federico II University of Naples, Naples, Italy
| | - Moussa Angokai
- Office of Biostatistics and Epidemiology, Gustave Roussy, Université Paris-Saclay, Villejuif, France; Inserm, Université Paris-Saclay, CESP U1018, Oncostat, labeled Ligue Contre le Cancer, Villejuif, France
| | - Livia Lamartina
- Department of Imaging, Endocrine Oncology Unit, Gustave Roussy, University Paris Saclay, Villejuif, France
| | - Florina Luca
- Department of Endocrinology, Hopital de Hautepierre-Hopitaux Universitaires de Strasbourg, Strasbourg, France
| | - Deborah Cosentini
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Azienda Ospedaliera Spedali Civili di Brescia, Brescia, Italy
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Marie Attard
- Department of Imaging, Endocrine Oncology Unit, Gustave Roussy, University Paris Saclay, Villejuif, France
| | - Matthieu Texier
- Office of Biostatistics and Epidemiology, Gustave Roussy, Université Paris-Saclay, Villejuif, France; Inserm, Université Paris-Saclay, CESP U1018, Oncostat, labeled Ligue Contre le Cancer, Villejuif, France
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany; Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| |
Collapse
|
2
|
Kienitz T, Bechmann N, Deutschbein T, Hahner S, Honegger J, Kroiss M, Quinkler M, Rayes N, Reisch N, Willenberg HS, Meyer G. Adrenal Crisis - Definition, Prevention and Treatment: Results from a Delphi Survey. Horm Metab Res 2024; 56:10-15. [PMID: 37562416 DOI: 10.1055/a-2130-1938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Based on recent data, a total number of about 29 000 patients with adrenal insufficiency can be calculated for Germany, and about 1500 fatalities due to adrenal crises have to be expected within the next decade. Management of adrenal crises is still unsatisfactory. The objectives of this study were to establish consensus for diagnostic criteria, prevention strategies, and treatment recommendations for adrenal crises. The study was conducted from January 2022 to April 2023, using Delphi technique. Four rounds of questionnaires were sent to 45 experts, selected by a coordinating group on behalf of the adrenal section of the German Society of Endocrinology. The survey was implemented online using the REDCap web application. Responses were captured anonymously. During the Delphi process the expert panel developed diagnostic criteria to identify patients likely to have an adrenal crisis. Education about adrenal insufficiency among patients as well as non-endocrine medical personnel were regarded as highly important. It was suggested that recommendations for the management of adrenal insufficiency have to be simplified and made widely available. This study provides pragmatic strategies to identify and treat patients prone to adrenal crisis, thereby highlighting the need for an improved management of patients with adrenal insufficiency.
Collapse
Affiliation(s)
- Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| | - Nicole Bechmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Timo Deutschbein
- Medicover Oldenburg MVZ, Oldenburg, Germany
- Division of Endocrinology and Diabetes, University Hospital Wurzburg, Department of Internal Medicine I, Wurzburg, Germany
| | - Stefanie Hahner
- Division of Endocrinology and Diabetes, University Hospital Wurzburg, Department of Internal Medicine I, Wurzburg, Germany
| | - Jürgen Honegger
- Neurosurgery, Eberhard-Karls-Universitat Tubingen, Medizinische Fakultat, Tübingen, Germany
| | - Matthias Kroiss
- Department of Internal Medicine IV, University Hospital Munich, Munich, Germany
| | | | - Nada Rayes
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Nicole Reisch
- Department of Internal Medicine IV, University Hospital Munich, Munich, Germany
| | - Holger Sven Willenberg
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Rostock, Germany
| | - Gesine Meyer
- Goethe University Frankfurt, University Hospital, Medical Clinic 1, Division of Endocrinology, Frankfurt am Main, Germany
| |
Collapse
|
3
|
Meyer G, Gruendl M, Chifu I, Hahner S, Werner J, Weiß J, Kienitz T, Quinkler M, Badenhoop K, Herrmann E, Friedrich-Rust M, Bojunga J. Glucocorticoid Replacement for Adrenal Insufficiency and the Development of Non-Alcoholic Fatty Liver Disease. J Clin Med 2023; 12:6392. [PMID: 37835036 PMCID: PMC10573835 DOI: 10.3390/jcm12196392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/18/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023] Open
Abstract
Glucocorticoid excess is a known risk factor for non-alcoholic fatty liver disease (NAFLD). Our objective was to analyse the impact of glucocorticoid replacement therapy on the development of NAFLD and NAFLD-related fibrosis and, therefore, on cardiovascular as well as hepatic morbidity in patients with adrenal insufficiency. Two hundred and fifteen individuals with primary (n = 111) or secondary (n = 104) adrenal insufficiency were investigated for hepatic steatosis and fibrosis using the fatty liver index (FLI), NAFLD fibrosis score (NAFLD-FS), Fibrosis-4 Index (FiB-4) plus sonographic transient elastography. Results were correlated with glucocorticoid doses and cardiometabolic risk parameters. The median dose of hydrocortisone equivalent was 20 mg daily, with a median therapy duration of 15 years. The presence and grade of hepatic steatosis and fibrosis were significantly correlated with cardiometabolic risk factors. We could not find any significant correlations between single, daily or cumulative doses of glucocorticoids and the grade of liver steatosis, nor with fibrosis measured via validated sonographic techniques. In patients with adrenal insufficiency, glucocorticoid replacement within a physiological range of 15-25 mg hydrocortisone equivalent per day does not appear to pose an additional risk for the development of NAFLD, subsequent liver fibrosis, or the cardiovascular morbidity associated with these conditions.
Collapse
Affiliation(s)
- Gesine Meyer
- Division of Endocrinology, Medical Clinic 1, University Hospital, Goethe University Frankfurt, 60590 Frankfurt, Germany (J.B.)
| | - Madeleine Gruendl
- Division of Endocrinology, Medical Clinic 1, University Hospital, Goethe University Frankfurt, 60590 Frankfurt, Germany (J.B.)
| | - Irina Chifu
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Stefanie Hahner
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Johanna Werner
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Johannes Weiß
- Division of Hepatology, Department of Medicine II, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Tina Kienitz
- Endocrinology in Charlottenburg, 10627 Berlin, Germany
| | | | - Klaus Badenhoop
- Division of Endocrinology, Medical Clinic 1, University Hospital, Goethe University Frankfurt, 60590 Frankfurt, Germany (J.B.)
| | - Eva Herrmann
- Institut for Biostatistics and Mathematic Modelling, Goethe University Frankfurt, 60590 Frankfurt, Germany
| | - Mireen Friedrich-Rust
- Division of Hepatology, Medical Clinic 1, University Hospital, Goethe University Frankfurt, 60590 Frankfurt, Germany
| | - Joerg Bojunga
- Division of Endocrinology, Medical Clinic 1, University Hospital, Goethe University Frankfurt, 60590 Frankfurt, Germany (J.B.)
- Division of Hepatology, Medical Clinic 1, University Hospital, Goethe University Frankfurt, 60590 Frankfurt, Germany
| |
Collapse
|
4
|
Kienitz T, Bechmann N, Deutschbein T, Hahner S, Honegger J, Kroiss M, Quinkler M, Rayes N, Reisch N, Willenberg HS, Meyer G. Correction: Adrenal Crisis - Definition, Prevention and Treatment: Results from a Delphi Survey. Horm Metab Res 2023. [PMID: 37625441 DOI: 10.1055/a-2157-2308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Affiliation(s)
- Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| | - Nicole Bechmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Timo Deutschbein
- Medicover Oldenburg MVZ, Oldenburg, Germany
- Division of Endocrinology and Diabetes, University Hospital Wurzburg, Department of Internal Medicine I, Wurzburg, Germany
| | - Stefanie Hahner
- Division of Endocrinology and Diabetes, University Hospital Wurzburg, Department of Internal Medicine I, Wurzburg, Germany
| | - Jürgen Honegger
- Neurosurgery, Eberhard-Karls-Universitat Tubingen, Medizinische Fakultat, Tübingen, Germany
| | - Matthias Kroiss
- Department of Internal Medicine IV, University Hospital Munich, Munich, Germany
| | | | - Nada Rayes
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Nicole Reisch
- Department of Internal Medicine IV, University Hospital Munich, Munich, Germany
| | - Holger Sven Willenberg
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Rostock, Germany
| | - Gesine Meyer
- Goethe University Frankfurt, University Hospital, Medical Clinic 1, Division of Endocrinology, Frankfurt am Main, Germany
| |
Collapse
|
5
|
Lang K, Quinkler M, Kienitz T. Mineralocorticoid replacement therapy in salt-wasting congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2023. [PMID: 37564007 DOI: 10.1111/cen.14959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Abstract
Patients with salt-wasting congenital adrenal hyperplasia (SW-CAH) usually show pronounced impairment of aldosterone secretion and, therefore, also require mineralocorticoid replacement. While a lot of research and discussion focusses on the glucocorticoid therapy in SW-CAH to replace the missing cortisol and to control adrenal androgen excess, very little research is dealing with mineralocorticoid replacement. However, recent data demonstrated an increased cardiovascular risk in adult CAH patients urging to reflect also on the current mineralocorticoid replacement therapy. In this review, we explain the role and function of the mineralocorticoid receptor, its ligands and inhibitors and its relevance for the therapy of patients with SW-CAH. We performed an extensive literature search and present data on mineralocorticoid therapy in SW-CAH patients as well as clinical advice how to monitor and optimise mineralocorticoid replacement therapy.
Collapse
Affiliation(s)
| | - Marcus Quinkler
- Endocrinology in Charlottenburg, Berlin, Germany
- Department of Endocrinology and Metabolism, Charite-Universitätsmedizin, Campus Mitte, Berlin, Germany
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| |
Collapse
|
6
|
Feldkamp L, Müller L, Deutschbein T, Detomas M, Hahner S, Strasburger CJ, Künzel H, Oßwald A, Braun L, Rubinstein G, Reincke M, Quinkler M, Kienitz T. Glucocorticoid receptor polymorphism BclI with increased glucocorticoid sensitivity has a positive influence on Quality of Life in Endogenous Cushing's syndrome in remission. Eur J Endocrinol 2023; 188:366-374. [PMID: 36995896 DOI: 10.1093/ejendo/lvad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/09/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023]
Abstract
CONTEXT Patients with endogenous Cushing's syndrome (CS) may suffer from a wide range of neuropsychiatric symptoms leading to impaired quality of life (QoL). OBJECTIVE Glucocorticoid receptor (GR) polymorphisms are associated with increased (BclI and N363S) or decreased (A3669G and ER22/23EK) GR sensitivity. HYPOTHESIS GR genotypes may modulate and affect QoL and recovery after remission differently via GR sensitivity. METHODS 295 patients with endogenous CS (81 active, 214 in remission) from 3 centers of the German Cushing's Registry were included for the cross-sectional analysis. All subjects were assessed with three questionnaires (CushingQoL, Tuebingen CD-25, SF-36). For the longitudinal part 120 patients of them were analyzed at baseline and after 1.5 ± 0.9 yrs of follow-up. DNA samples were obtained from peripheral blood leukocytes for GR genotyping. RESULTS Patients in remission scored significantly better than patients with active CS in the CushingQoL questionnaire and in the SF-36 sub-categories physical and social functioning, role-physical, bodily pain and vitality. In cross-sectional analysis, no differences in QoL between minor allele and wildtype carriers were detected for all polymorphisms in active or cured CS. In longitudinal analysis, however, carriers with BclI minor allele showed significant improvement in SF-36 sub-categories vitality (p = 0.038) and mental health (p = 0.013) compared to wildtype carriers (active CS at baseline vs. CS in remission at follow-up). The outcome of the two questionnaires CushingQoL and Tuebingen CD-25 improved significantly in both wildtype and minor allele carriers. CONCLUSION BclI minor allele carriers initially had the lowest QoL but recovered better from impaired QoL than wildtype carriers.
Collapse
Affiliation(s)
- Lara Feldkamp
- Endocrinology in Charlottenburg, 10627 Berlin, Germany
- Clinical Endocrinology CCM, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Lisa Müller
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
| | - Mario Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany
| | | | - Heike Künzel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Andrea Oßwald
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Leah Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | | | - Tina Kienitz
- Endocrinology in Charlottenburg, 10627 Berlin, Germany
- Clinical Endocrinology CCM, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| |
Collapse
|
7
|
Abstract
OBJECTIVE This study aimed to investigate the ability of the immune system assessment questionnaire (ISAQ) to predict adrenal crisis (AC) and infectious events in patients with primary adrenal insufficiency (PAI). DESIGN This was a prospective single-centre study over three years. METHODS Patients answered the ISAQ at baseline and were seen every 4-6 months in the endocrine outpatient clinic. At each visit previous infectious periods which required an increase in daily glucocorticoid dosage and AC were reported and documented. Seventy-five patients with PAI (53 women; 43 patients with autoimmune PAI, 20 patients with salt-wasting congenital adrenal hyperplasia and 12 patients who underwent bilateral adrenalectomy) were analysed. Due to the COVID-19 pandemic and consecutive lockdown measures, the data were analysed separately for March 2018 to March 2020 (period 1), and March 2020 to March 2021 (period 2). RESULTS During period 1 the ISAQ score significantly correlated with the number of reported infectious events (r=0.351; p<0.01), but not during period 2 (r=0.059, p=0.613), in which the number of infectious events per patient-year significantly decreased (1.1±0.1 vs 0.4±0.1; p<0.001). The frequency of AC decreased from 8.8 to 2.4 per 100 patient-years between the two study periods. The ISAQ score was not different between patients with or without AC. CONCLUSIONS The ISAQ score does not identify patients prone to ACs. The COVID-19 pandemic and consecutive lockdown measures significantly diminished the frequency of infectious events and ACs.
Collapse
Affiliation(s)
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| |
Collapse
|
8
|
Baudin E, Goichot B, Berruti A, Hadoux J, Moalla S, Laboureau S, Noelting S, De La Fouchardière C, Kienitz T, Deutschbein T, Zovato S, Amar L, Tabarin A, Timmers H, Niccoli P, Attard M. Essai randomisé en double aveugle du Sunitinib dans les phéochromocytomes et paragangliomes malins (PPGM) : résultats de l’étude internationale FIRSTMAPPP. Annales d'Endocrinologie 2021. [DOI: 10.1016/j.ando.2021.07.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
9
|
Kienitz T, Schwander J, Bogner U, Schwabe M, Steinmüller T, Quinkler M. Giant bilateral adrenal lipoma in a patient with congenital adrenal hyperplasia. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM200204. [PMID: 33845451 PMCID: PMC8052563 DOI: 10.1530/edm-20-0204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/11/2021] [Indexed: 11/17/2022] Open
Abstract
SUMMARY Apart from adrenal myelolipomas, adrenal lipomatous tumors are rare and only seldom described in the literature. We present the case of a 50-year-old man, with a classical form of congenital adrenal hyperplasia (CAH), which was well treated with prednisolone and fludrocortisone. The patient presented with pollakisuria and shortness of breath while bending over. On MRI, fat-equivalent masses were found in the abdomen (14 × 19 × 11 cm on the right side and 10 × 11 × 6 cm on the left side). The right adrenal mass was resected during open laparotomy and the pathohistological examination revealed the diagnosis of an adrenal lipoma. Symptoms were subdued totally postoperatively. This is the first report of a bilateral adrenal lipoma in a patient with CAH that we are aware of. LEARNING POINTS Macronodular hyperplasia is common in patients with congenital adrenal hyperplasia (CAH). Solitary adrenal tumors appear in approximately 10% of adult CAH patients and are often benign myelolipomas. The Endocrine Society Clinical Practice Guideline does not recommend routine adrenal imaging in adult CAH patients. Adrenal imaging should be performed in CAH patients with clinical signs for an adrenal or abdominal mass. Adrenal lipoma is rare and histopathological examinations should rule out a differentiated liposarcoma.
Collapse
Affiliation(s)
- Tina Kienitz
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, Berlin, Germany
| | - Jörg Schwander
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, Berlin, Germany
| | - Ulrich Bogner
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, Berlin, Germany
| | | | - Thomas Steinmüller
- Department of Abdominal and Endocrine Surgery, DRK-Kliniken Westend, Berlin, Germany
| | - Marcus Quinkler
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, Berlin, Germany
| |
Collapse
|
10
|
Feldkamp LLI, Kaminsky E, Kienitz T, Quinkler M. Central Diabetes Insipidus Caused by Arginine Vasopressin Gene Mutation: Report of a Novel Mutation and Review of Literature. Horm Metab Res 2020; 52:796-802. [PMID: 32629514 DOI: 10.1055/a-1175-1307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Familial neurohypophyseal diabetes insipidus (FNDI) is an autosomal dominant hereditary disorder characterized by severe polydipsia and polyuria that usually presents in early childhood. In this study, we describe a new arginine vasopressin (AVP) gene mutation in an ethnic German family with FNDI and provide an overview of disease-associated AVP-gene mutations that are already described in literature. Three members of a German family with neurohypophyseal diabetes insipidus were studied. Isolated DNA from peripheral blood samples was used for mutation analysis by sequencing the whole coding region of AVP-NPII gene. Furthermore, we searched the electronic databases MEDLINE (Pubmed) as well as HGMD, LOVD-ClinVar, db-SNP and genomAD in order to compare our cases to that of other patients with FNDI. Genetic analysis of the patients revealed a novel heterozygote missense mutation in exon 2 of the AVP gene (c.274T>G), which has not yet been described in literature. We identified reports of more than 90 disease-associated mutations in the AVP gene in literature. The novel mutation of the AVP gene seems to cause FNDI in the presented German family. Similar to our newly detected mutation, most mutations causing FNDI are found in exon 2 of the AVP gene coding for neurophysin II. Clinically, it is important to think of FNDI in young children presenting with polydipsia and polyuria.
Collapse
Affiliation(s)
- Lara L I Feldkamp
- Endocrinology in Charlottenburg, Berlin, Germany
- Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| | | |
Collapse
|
11
|
Bancos I, Taylor AE, Chortis V, Sitch AJ, Jenkinson C, Davidge-Pitts CJ, Lang K, Tsagarakis S, Macech M, Riester A, Deutschbein T, Pupovac ID, Kienitz T, Prete A, Papathomas TG, Gilligan LC, Bancos C, Reimondo G, Haissaguerre M, Marina L, Grytaas MA, Sajwani A, Langton K, Ivison HE, Shackleton CHL, Erickson D, Asia M, Palimeri S, Kondracka A, Spyroglou A, Ronchi CL, Simunov B, Delivanis DA, Sutcliffe RP, Tsirou I, Bednarczuk T, Reincke M, Burger-Stritt S, Feelders RA, Canu L, Haak HR, Eisenhofer G, Dennedy MC, Ueland GA, Ivovic M, Tabarin A, Terzolo M, Quinkler M, Kastelan D, Fassnacht M, Beuschlein F, Ambroziak U, Vassiliadi DA, O'Reilly MW, Young WF, Biehl M, Deeks JJ, Arlt W. Urine steroid metabolomics for the differential diagnosis of adrenal incidentalomas in the EURINE-ACT study: a prospective test validation study. Lancet Diabetes Endocrinol 2020; 8:773-781. [PMID: 32711725 PMCID: PMC7447976 DOI: 10.1016/s2213-8587(20)30218-7] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Cross-sectional imaging regularly results in incidental discovery of adrenal tumours, requiring exclusion of adrenocortical carcinoma (ACC). However, differentiation is hampered by poor specificity of imaging characteristics. We aimed to validate a urine steroid metabolomics approach, using steroid profiling as the diagnostic basis for ACC. METHODS We did a prospective multicentre study in adult participants (age ≥18 years) with newly diagnosed adrenal masses. We assessed the accuracy of diagnostic imaging strategies based on maximum tumour diameter (≥4 cm vs <4 cm), imaging characteristics (positive vs negative), and urine steroid metabolomics (low, medium, or high risk of ACC), separately and in combination, using a reference standard of histopathology and follow-up investigations. With respect to imaging characteristics, we also assessed the diagnostic utility of increasing the unenhanced CT tumour attenuation threshold from the recommended 10 Hounsfield units (HU) to 20 HU. FINDINGS Of 2169 participants recruited between Jan 17, 2011, and July 15, 2016, we included 2017 from 14 specialist centres in 11 countries in the final analysis. 98 (4·9%) had histopathologically or clinically and biochemically confirmed ACC. Tumours with diameters of 4 cm or larger were identified in 488 participants (24·2%), including 96 of the 98 with ACC (positive predictive value [PPV] 19·7%, 95% CI 16·2-23·5). For imaging characteristics, increasing the unenhanced CT tumour attenuation threshold to 20 HU from the recommended 10 HU increased specificity for ACC (80·0% [95% CI 77·9-82·0] vs 64·0% [61·4-66.4]) while maintaining sensitivity (99·0% [94·4-100·0] vs 100·0% [96·3-100·0]; PPV 19·7%, 16·3-23·5). A urine steroid metabolomics result indicating high risk of ACC had a PPV of 34·6% (95% CI 28·6-41·0). When the three tests were combined, in the order of tumour diameter, positive imaging characteristics, and urine steroid metabolomics, 106 (5·3%) participants had the result maximum tumour diameter of 4 cm or larger, positive imaging characteristics (with the 20 HU cutoff), and urine steroid metabolomics indicating high risk of ACC, for which the PPV was 76·4% (95% CI 67·2-84·1). 70 (3·5%) were classified as being at moderate risk of ACC and 1841 (91·3%) at low risk (negative predictive value 99·7%, 99·4-100·0). INTERPRETATION An unenhanced CT tumour attenuation cutoff of 20 HU should replace that of 10 HU for exclusion of ACC. A triple test strategy of tumour diameter, imaging characteristics, and urine steroid metabolomics improves detection of ACC, which could shorten time to surgery for patients with ACC and help to avoid unnecessary surgery in patients with benign tumours. FUNDING European Commission, UK Medical Research Council, Wellcome Trust, and UK National Institute for Health Research, US National Institutes of Health, the Claire Khan Trust Fund at University Hospitals Birmingham Charities, and the Mayo Clinic Foundation for Medical Education and Research.
Collapse
Affiliation(s)
- Irina Bancos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Vasileios Chortis
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alice J Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Carl Jenkinson
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | | | - Katharina Lang
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Magdalena Macech
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Anna Riester
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Ivana D Pupovac
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Thomas G Papathomas
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Lorna C Gilligan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Cristian Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe Reimondo
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Turin, Turin, Italy
| | - Magalie Haissaguerre
- Department of Endocrinology, Hôpital Haut Lévêque, CHU de Bordeaux, Pessac, France
| | - Ljiljana Marina
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marianne A Grytaas
- Department of Clinical Science, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ahmed Sajwani
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Katharina Langton
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technical University, Dresden, Germany
| | - Hannah E Ivison
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Cedric H L Shackleton
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; UCSF Benioff Children's Hospital Oakland Research Institute, Oakland, CA, USA
| | - Dana Erickson
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Miriam Asia
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sotiria Palimeri
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Agnieszka Kondracka
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Ariadni Spyroglou
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Cristina L Ronchi
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Bojana Simunov
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Danae A Delivanis
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Robert P Sutcliffe
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ioanna Tsirou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Martin Reincke
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Stephanie Burger-Stritt
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Richard A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Letizia Canu
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Harm R Haak
- Department of Internal Medicine, Maxima Medisch Centrum, Eindhoven, Netherlands; Department of Health Services Research and CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technical University, Dresden, Germany
| | - M Conall Dennedy
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Grethe A Ueland
- Department of Clinical Science, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Miomira Ivovic
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Antoine Tabarin
- Department of Endocrinology, Hôpital Haut Lévêque, CHU de Bordeaux, Pessac, France
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Turin, Turin, Italy
| | | | - Darko Kastelan
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany; Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, University of Würzburg, Würzburg, Germany; Central Laboratory, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Felix Beuschlein
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany; Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zurich, Switzerland
| | - Urszula Ambroziak
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Michael W O'Reilly
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Michael Biehl
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, Netherlands
| | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK.
| |
Collapse
|
12
|
Abstract
Adrenal insufficiency (AI) requires life-long treatment with glucocorticoid
replacement therapy. Over- or under-substitution carries the risk of
increased morbidity in the form of side effects or adrenal crises.
Glucocorticoid replacement therapy needs to be flexible with dose adaptation
in special situations. This could not be managed by medical personnel on a
daily basis, but requires an educated patient who has a good knowledge of
the disease, understands his medical therapy and is able to perform
situational dose adaptation. The rarity of the disease in combination with
the need to respond to stressful situations with rapid glucocorticoid dose
adjustment underlines that a well-trained patient is crucial for optimal
management of the disease. In this literature review we provide background information further
clarifying the need of education in patients with AI including the current
shortcomings of medical therapy and of the treatment of patients with AI. We
outline the aims of therapeutic patient education, present the concept of
structured patient education in Germany, and discuss available results of
patient group education programs. Furthermore, we propose strategies how
therapeutic patient education for adrenal insufficiency can be organized
under COVID-19 pandemic conditions.
Collapse
Affiliation(s)
- Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| | - Stefanie Hahner
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Stephanie Burger-Stritt
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | | |
Collapse
|
13
|
Burger-Stritt S, Eff A, Quinkler M, Kienitz T, Stamm B, Willenberg HS, Meyer G, Klein J, Reisch N, Droste M, Hahner S. Standardised patient education in adrenal insufficiency: a prospective multi-centre evaluation. Eur J Endocrinol 2020; 183:119-127. [PMID: 32580144 DOI: 10.1530/eje-20-0181] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/06/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Patients with adrenal insufficiency (AI) suffer from impaired quality of life and are at risk of adrenal crisis (AC) despite established replacement therapy. Patient education is regarded an important measure for prevention of AC and improvement of AI management. A standardized education programme was elaborated for patients with chronic AI in Germany. DESIGN Longitudinal, prospective, questionnaire-based, multi-centre study. METHODS During 2-h sessions, patients (n = 526) were provided with basic knowledge on AI, equipped with emergency cards and sets and trained in self-injection of hydrocortisone. To evaluate the education programme, patients from eight certified centres completed questionnaires before, immediately after and 6-9 months after training. RESULTS 399 completed data sets were available for analysis. Questionnaire score-values were significantly higher after patient education, indicating successful knowledge transfer (baseline: 17 ± 7.1 of a maximum score of 29; after training: 23 ± 4.2; P < 0.001), and remained stable over 6-9 months. Female sex, younger age and primary cause of AI were associated with higher baseline scores; after education, age, cause of AI and previous adrenal crisis had a significant main effect on scores. 91% of patients would dare performing self-injection after training, compared to 68% at baseline. An improvement of subjective well-being through participation in the education programme was indicated by 95% of the patients 6-9 months after participation. CONCLUSION Patient group education in chronic AI represents a helpful tool for the guidance of patients, their self-assurance and their knowledge on prevention of adrenal crises. Repeated training and adaptation to specific needs, for example, of older patients is needed.
Collapse
Affiliation(s)
- Stephanie Burger-Stritt
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Annemarie Eff
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | | | - Tina Kienitz
- Department of Endocrinology, Diabetes and Nutrition, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Bettina Stamm
- Medical practice for Endocrinology, Saarbrücken, Germany
| | - Holger S Willenberg
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Rostock, Germany
| | - Gesine Meyer
- Endocrinology & Diabetes Unit, Department of Internal Medicine 1, Goethe-University Hospital Frankfurt, Frankfurt/Main, Germany
| | | | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - Michael Droste
- Medical Practice for Endocrinology & Diabetes, Oldenburg, Germany
| | - Stefanie Hahner
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| |
Collapse
|
14
|
Bothou C, Anand G, Li D, Kienitz T, Seejore K, Simeoli C, Ebbehoj A, Ward EG, Paragliola RM, Ferrigno R, Badenhoop K, Bensing S, Oksnes M, Esposito D, Bergthorsdottir R, Drake W, Wahlberg J, Reisch N, Hahner S, Pearce S, Trainer P, Etzrodt-Walter G, Thalmann SP, Sævik ÅB, Husebye E, Isidori AM, Falhammar H, Meyer G, Corsello SM, Pivonello R, Murray R, Bancos I, Quinkler M, Beuschlein F. Current Management and Outcome of Pregnancies in Women With Adrenal Insufficiency: Experience from a Multicenter Survey. J Clin Endocrinol Metab 2020; 105:5840404. [PMID: 32424397 PMCID: PMC7320831 DOI: 10.1210/clinem/dgaa266] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/15/2020] [Indexed: 12/31/2022]
Abstract
CONTEXT Appropriate management of adrenal insufficiency (AI) in pregnancy can be challenging due to the rarity of the disease and lack of evidence-based recommendations to guide glucocorticoid and mineralocorticoid dosage adjustment. OBJECTIVE Multicenter survey on current clinical approaches in managing AI during pregnancy. DESIGN Retrospective anonymized data collection from 19 international centers from 2013 to 2019. SETTING AND PATIENTS 128 pregnancies in 113 women with different causes of AI: Addison disease (44%), secondary AI (25%), congenital adrenal hyperplasia (25%), and acquired AI due to bilateral adrenalectomy (6%). RESULTS Hydrocortisone (HC) was the most commonly used glucocorticoid in 83% (97/117) of pregnancies. Glucocorticoid dosage was increased at any time during pregnancy in 73/128 (57%) of cases. In these cases, the difference in the daily dose of HC equivalent between baseline and the third trimester was 8.6 ± 5.4 (range 1-30) mg. Fludrocortisone dosage was increased in fewer cases (7/54 during the first trimester, 9/64 during the second trimester, and 9/62 cases during the third trimester). Overall, an adrenal crisis was reported in 9/128 (7%) pregnancies. Cesarean section was the most frequent mode of delivery at 58% (69/118). Fetal complications were reported in 3/120 (3%) and minor maternal complications in 15/120 (13%) pregnancies without fatal outcomes. CONCLUSIONS This survey confirms good maternal and fetal outcome in women with AI managed in specialized endocrine centers. An emphasis on careful endocrine follow-up and repeated patient education is likely to have reduced the risk of adrenal crisis and resulted in positive outcomes.
Collapse
Affiliation(s)
- Christina Bothou
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
| | - Gurpreet Anand
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
| | - Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| | - Khyatisha Seejore
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds, UK
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Andreas Ebbehoj
- Department of Clinical Medicine, Department of Endocrinology and Diabetes, Aarhus University, Aarhus, Denmark
| | - Emma G Ward
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds, UK
| | - Rosa Maria Paragliola
- Unit of Endocrinology, Università Cattolica del Sacro Cuore – Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Klaus Badenhoop
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital, Frankfurt, Germany
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Inflammation and Infection Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne Oksnes
- Endocrinology in Charlottenburg, Berlin, Germany
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Jonas Liesvei, Bergen, Norway
| | - Daniela Esposito
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska, University Hospital, Gothenburg, Sweden
| | - Ragnhildur Bergthorsdottir
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska, University Hospital, Gothenburg, Sweden
| | - William Drake
- Department of Endocrinology, St Bartholomew’s Hospital, London, UK
| | - Jeanette Wahlberg
- Department of Endocrinology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Nicole Reisch
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Stefanie Hahner
- Department of Internal Medicine I, Endocrinology and Diabetes Unit, University Hospital of Würzburg, University of Würzburg, Germany
| | - Simon Pearce
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter Trainer
- The Christie NHS Foundation, MAHSC, Wilmslow Road, Manchester, UK
| | | | | | - Åse B Sævik
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Jonas Liesvei, Bergen, Norway
| | - Eystein Husebye
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Jonas Liesvei, Bergen, Norway
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Inflammation and Infection Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gesine Meyer
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital, Frankfurt, Germany
| | - Salvatore M Corsello
- Unit of Endocrinology, Università Cattolica del Sacro Cuore – Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Robert Murray
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds, UK
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Felix Beuschlein
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
- Correspondence and Reprint Requests: Prof. Felix Beuschlein, MD, Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Raemistrasse 100, CH-8091 Zürich, Switzerland. E-mail:
| |
Collapse
|
15
|
Altieri B, Sbiera S, Herterich S, De Francia S, Della Casa S, Calabrese A, Pontecorvi A, Quinkler M, Kienitz T, Mannelli M, Canu L, Angelousi A, Chortis V, Kroiss M, Terzolo M, Fassnacht M, Ronchi CL. Effects of Germline CYP2W1*6 and CYP2B6*6 Single Nucleotide Polymorphisms on Mitotane Treatment in Adrenocortical Carcinoma: A Multicenter ENSAT Study. Cancers (Basel) 2020; 12:cancers12020359. [PMID: 32033200 PMCID: PMC7072643 DOI: 10.3390/cancers12020359] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/19/2020] [Accepted: 01/31/2020] [Indexed: 02/06/2023] Open
Abstract
Mitotane is the only approved drug for advanced adrenocortical carcinoma (ACC) and no biomarkers are available to predict attainment of therapeutic plasma concentrations and clinical response. Aim of the study was to evaluate the suitability of cytochrome P450(CYP)2W1 and CYP2B6 single nucleotide polymorphisms (SNPs) as biomarkers. A multicenter cohort study including 182 ACC patients (F/M = 121/61) treated with mitotane monotherapy after radical resection (group A, n = 103) or in not completely resectable, recurrent or advanced disease (group B, n = 79) was performed. CYP2W1*2, CYP2W1*6, CYP2B6*6 and CYP2B6 rs4803419 were genotyped in germline DNA. Mitotane blood levels were measured regularly. Response to therapy was evaluated as time to progression (TTP) and disease control rate (DCR). Among investigated SNPs, CYP2W1*6 and CYP2B6*6 correlated with mitotane treatment only in group B. Patients with CYP2W1*6 (n = 21) achieved less frequently therapeutic mitotane levels (>14 mg/L) than those with wild type (WT) allele (76.2% vs 51.7%, p = 0.051) and experienced shorter TTP (HR = 2.10, p = 0.019) and lower DCR (chi-square = 6.948, p = 0.008). By contrast, 55% of patients with CYP2B6*6 vs. 28.2% WT (p = 0.016) achieved therapeutic range. Combined, a higher rate of patients with CYP2W1*6WT+CYP2B6*6 (60.6%) achieved mitotane therapeutic range (p = 0.034). In not completely resectable, recurrent or advanced ACC, CYP2W1*6 SNP was associated with a reduced probability to reach mitotane therapeutic range and lower response rates, whereas CYP2B6*6 correlated with higher mitotane levels. The association of these SNPs may predict individual response to mitotane.
Collapse
Affiliation(s)
- Barbara Altieri
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, 97080 Würzburg, Germany; (B.A.); (S.S.); (M.K.); (M.F.)
- Division of Endocrinology and Metabolic Diseases, Catholic University of the Sacred Heart, 00168 Rome, Italy; (S.D.C.); (A.P.)
| | - Silviu Sbiera
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, 97080 Würzburg, Germany; (B.A.); (S.S.); (M.K.); (M.F.)
| | - Sabine Herterich
- Central Laboratory, University Hospital of Würzburg, 97080 Würzburg, Germany;
| | - Silvia De Francia
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, 10043 Turin, Italy;
| | - Silvia Della Casa
- Division of Endocrinology and Metabolic Diseases, Catholic University of the Sacred Heart, 00168 Rome, Italy; (S.D.C.); (A.P.)
| | - Anna Calabrese
- Division of Internal Medicine I, University of Turin, San Luigi Gonzaga Hospital, Orbassano, 10043 Turin, Italy; (A.C.); (M.T.)
| | - Alfredo Pontecorvi
- Division of Endocrinology and Metabolic Diseases, Catholic University of the Sacred Heart, 00168 Rome, Italy; (S.D.C.); (A.P.)
| | - Marcus Quinkler
- Endocrinology in Charlottenburg, 10627 Berlin, Germany; (M.Q.)
| | - Tina Kienitz
- Endocrinology in Charlottenburg, 10627 Berlin, Germany; (M.Q.)
- Department of Endocrinology, Diabetes and Nutrition, Charité-Universitätsmedizin Berlin, Campus Mitte, 10117 Berlin, Germany
| | - Massimo Mannelli
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50134 Florence, Italy; (M.M.); (L.C.)
| | - Letizia Canu
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50134 Florence, Italy; (M.M.); (L.C.)
| | - Anna Angelousi
- 1st Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Laiko Hospital, 11527 Goudi, Greece;
| | - Vasileios Chortis
- Institute of Metabolism and System Research, University of Birmingham, Birmingham B152TT, UK;
- Centre for Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham B152TT, UK
| | - Matthias Kroiss
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, 97080 Würzburg, Germany; (B.A.); (S.S.); (M.K.); (M.F.)
- Comprehensive Cancer Center Mainfranken, University of Würzburg, 97080 Würzburg, Germany
| | - Massimo Terzolo
- Division of Internal Medicine I, University of Turin, San Luigi Gonzaga Hospital, Orbassano, 10043 Turin, Italy; (A.C.); (M.T.)
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, 97080 Würzburg, Germany; (B.A.); (S.S.); (M.K.); (M.F.)
- Central Laboratory, University Hospital of Würzburg, 97080 Würzburg, Germany;
- Comprehensive Cancer Center Mainfranken, University of Würzburg, 97080 Würzburg, Germany
| | - Cristina L. Ronchi
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, 97080 Würzburg, Germany; (B.A.); (S.S.); (M.K.); (M.F.)
- Institute of Metabolism and System Research, University of Birmingham, Birmingham B152TT, UK;
- Centre for Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham B152TT, UK
- Correspondence: ; Tel.: +49-0931-20139720
| |
Collapse
|
16
|
Müller LM, Kienitz T, Deutschbein T, Riester A, Hahner S, Burger-Stritt S, Berr CM, Oßwald A, Braun L, Rubinstein G, Reincke M, Quinkler M. Glucocorticoid Receptor Polymorphisms Influence Muscle Strength in Cushing's Syndrome. J Clin Endocrinol Metab 2020; 105:5587858. [PMID: 31613324 DOI: 10.1210/clinem/dgz052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 09/24/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT An important clinical feature of Cushing's syndrome (CS) is proximal muscle myopathy caused by glucocorticoid induced protein metabolism. However, interindividual differences cannot be explained solely by the pure extent of hypercortisolemia. OBJECTIVE To evaluate the effects of glucocorticoid receptor (GR) polymorphisms (BclI, N363S, ER22/23EK and A3669G), which influence peripheral glucocorticoid sensitivity on muscular function in endogenous CS. METHODS 205 patients with proven endogenous CS (128 central, 77 adrenal) from 3 centers of the German Cushing's Registry and 125 subjects, in whom CS was ruled out, were included. All subjects were assessed for grip strength (via hand grip dynamometer) and performed a chair-rising test (CRT). DNA samples were obtained from peripheral blood leukocytes for GR genotyping. RESULTS In patients with active CS, normalized handgrip strength of the dominant and nondominant hand was higher in A3669G minor allele than in wildtype carriers (P = .006 and P = .021, respectively). CS patients in remission and ruled-out CS showed no differences in handgrip strength regarding A3669G minor allele and wildtype carriers. Male CS patients harboring the ER22/23EK wildtype presented lower hand grip strength than minor allele carriers (P = .049 dominant hand; P = .027 nondominant hand). The other polymorphisms did not influence handgrip strength. CRT showed no differences regarding GR polymorphisms carrier status. CONCLUSION Handgrip strength seems to be more susceptible to hypercortisolism in A3669G wildtype than in A3669G minor allele carriers. This might partially explain the inter-individual differences of glucocorticoid-induced myopathy in patients with endogenous CS. ER22/23EK polymorphism seems to exert sex-specific differences.
Collapse
Affiliation(s)
- Lisa Marie Müller
- Endocrinology in Charlottenburg, Berlin, Germany
- Clinical Endocrinology CCM, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
- Clinical Endocrinology CCM, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, Würzburg, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, Würzburg, Germany
| | - Stephanie Burger-Stritt
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, Würzburg, Germany
| | - Christina M Berr
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Andrea Oßwald
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Leah Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | | |
Collapse
|
17
|
Schöfl C, Mayr B, Maison N, Beuschlein F, Meyer G, Badenhoop K, Kienitz T, Quinkler M. Daily adjustment of glucocorticoids by patients with adrenal insufficiency. Clin Endocrinol (Oxf) 2019; 91:256-262. [PMID: 31050815 DOI: 10.1111/cen.14004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 04/17/2019] [Accepted: 05/02/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with adrenal insufficiency (AI) require lifelong glucocorticoid (GC) replacement. AI patients need to adjust GC dosage in response to stressful events and illness in order to prevent life-threatening adrenal crisis (AC). AIM To evaluate self-management of patients with AI. METHODS Four German centres, which are using patient's diary as part of their routine clinical practice, instructed AI patients to prospectively document any discomfort, intercurrent illness or stressful events as well as changes in GC therapy on a daily basis. Diaries of 80 patients (44 females, 52.9 ± 15.9 years, 34 primary AI) were collected and analysed. A symptom score sheet was used to evaluate severity of discomfort. RESULTS In total, 34 074 patient days (93.4 years) were recorded. 4622 days with discomfort were documented. On 35% of those days (n = 1621), patients increased their GC dose (4.8% of all days). Patients who recorded discomfort had a median of four episodes of discomfort, which lasted a median of 2 days. Women documented significantly more episodes of discomfort than men (P = 0.014). Low-to-median symptom scores resulted in GC increase by 50%-60%, whereas high symptom scores and/or fever resulted in doubling GC daily dose. However, dose increase was only 55% in situations indicating gastrointestinal (GI) infection. CONCLUSION Severe discomfort did not always result in dose increase, especially in GI infection. However, low symptom scores resulted in an inappropriate GC increase in some patients. This underscores an urgent need for improved training methods. Keeping daily records might be a useful tool for continued and individualized patient education.
Collapse
Affiliation(s)
- Christof Schöfl
- Centers of Endocrinology and Metabolism, Bamberg and Erlangen, Bamberg, Germany
| | - Bernhard Mayr
- Division of Endocrinology and Diabetes, Department of Medicine I, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Nicole Maison
- Endocrine Research, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität, Munich, Germany
| | - Felix Beuschlein
- Endocrine Research, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zurich, Zurich, Switzerland
| | - Gesine Meyer
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Klaus Badenhoop
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| | | |
Collapse
|
18
|
Broersen LHA, van Haalen FM, Kienitz T, Dekkers OM, Strasburger CJ, Pereira AM, Biermasz NR. The incidence of adrenal crisis in the postoperative period of HPA axis insufficiency after surgical treatment for Cushing's syndrome. Eur J Endocrinol 2019; 181:201-210. [PMID: 31167165 DOI: 10.1530/eje-19-0202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/05/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Adrenal crisis, the most feared complication of adrenal insufficiency, is a potentially life-threatening state of acute glucocorticoid deficiency. After successful surgery for Cushing's syndrome, many patients develop (transient) adrenal insufficiency. The incidence of adrenal crisis in patients treated for hypercortisolism is unknown. METHODS Cohort study included consecutive patients with Cushing's syndrome with adrenal insufficiency after surgery from Leiden and Berlin from 2000 to 2015. We summarized the incidence of adrenal crisis, compared patients with and without adrenal crisis regarding potential risk factors for its occurrence and assessed the effect of better education in time on incidence of adrenal crisis. RESULTS We included 106 patients, of whom 19 patients had a total of 41 adrenal crises. There were 9.0 crises per 100 patient-years at risk (95% confidence interval (CI): 6.7-12.0). All crises occurred while on hydrocortisone replacement. The risk ratio for a recurrent crisis was 2.3 (95% CI: 1.2-4.6). No clear change in incidence of adrenal crisis due to better education in time was observed. There was no difference in recurrence rate between patients with, and without any crisis, but patients with adrenal crisis had more often pituitary deficiencies. CONCLUSIONS The incidence of adrenal crises after treatment for Cushing's syndrome is substantial, and patients who suffered from an adrenal crisis have higher risk for recurrent crisis. Adrenal crisis tends to present early after remission of Cushing's syndrome, which is probably the period of severest HPA axis suppression, despite in general higher hydrocortisone replacement doses for withdrawal complaints in this period. Additional pituitary hormone deficiencies may be a risk marker for increased risk of adrenal crisis. However, further risk factor analysis is needed to identify risks for a first crisis. Effective education methods to prevent adrenal crises should be identified and implemented, including stress instructions by trained nursing staff before hospital discharge.
Collapse
Affiliation(s)
- Leonie H A Broersen
- Department of Medicine, Division of Endocrinology
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, The Netherlands
- Department of Endocrinology, Diabetes and Nutrition, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Femke M van Haalen
- Department of Medicine, Division of Endocrinology
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, The Netherlands
| | - Tina Kienitz
- Department of Endocrinology, Diabetes and Nutrition, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Olaf M Dekkers
- Department of Medicine, Division of Endocrinology
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Christian J Strasburger
- Department of Endocrinology, Diabetes and Nutrition, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alberto M Pereira
- Department of Medicine, Division of Endocrinology
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke R Biermasz
- Department of Medicine, Division of Endocrinology
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
19
|
Broersen LHA, van Haalen FM, Kienitz T, Biermasz NR, Strasburger CJ, Dekkers OM, Pereira AM. Sex Differences in Presentation but Not in Outcome for ACTH-Dependent Cushing's Syndrome. Front Endocrinol (Lausanne) 2019; 10:580. [PMID: 31543864 PMCID: PMC6730597 DOI: 10.3389/fendo.2019.00580] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/08/2019] [Indexed: 01/19/2023] Open
Abstract
Background: Sex differences in clinical picture of ACTH-dependent Cushing's syndrome are controversial, except for the known higher prevalence in females. We compared a broad range of potential differences to enable a more accurate understanding of the clinical picture of sex-specific ACTH-dependent Cushing's syndrome. Methods: Cohort study including consecutive patients with ACTH-dependent Cushing's syndrome from Leiden and Berlin diagnosed between 2000 and 2016. We compared clinical presentation, biochemical parameters, diagnostic tests, surgical outcome, and comorbidities between men and women. Results: We included 130 patients: 37 males and 93 females. With similar cortisol concentrations, ACTH concentrations were higher in males than females at time of diagnosis (median: 116 vs. 57 ng/L). The prevalence of osteoporosis was higher in males than in females (48.6 vs. 25.0%), persisting after surgery, with more vertebral fractures (16.2 vs. 5.4%) before surgery. Males showed more anemia (75.9 vs. 36.8%) after surgery. There were no differences in etiology, pituitary tumor size, diagnostic and therapeutic strategy, or surgical outcome between sexes. Conclusions: Based on this study, males and females with ACTH-dependent Cushing's syndrome present different clinical patterns. However, these differences do not justify different diagnostic strategies or treatment based on sex, considering the similar surgical outcome. Clinicians should be alert to diagnose accompanying osteoporosis (with fractures) in male patients with ACTH-dependent Cushing's syndrome.
Collapse
Affiliation(s)
- Leonie H. A. Broersen
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, Netherlands
- Department of Endocrinology, Diabetes and Nutrition, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- *Correspondence: Leonie H. A. Broersen
| | - Femke M. van Haalen
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, Netherlands
| | - Tina Kienitz
- Department of Endocrinology, Diabetes and Nutrition, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Nienke R. Biermasz
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, Netherlands
| | - Cristian J. Strasburger
- Department of Endocrinology, Diabetes and Nutrition, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Olaf M. Dekkers
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Alberto M. Pereira
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|
20
|
Frey KR, Kienitz T, Schulz J, Ventz M, Zopf K, Quinkler M. Prednisolone is associated with a worse bone mineral density in primary adrenal insufficiency. Endocr Connect 2018; 7:811-818. [PMID: 29720511 PMCID: PMC5987359 DOI: 10.1530/ec-18-0160] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 12/30/2022]
Abstract
CONTEXT Patients with primary adrenal insufficiency (PAI) or congenital adrenal hyperplasia (CAH) receive life-long glucocorticoid (GC) therapy. Daily GC doses are often above the physiological cortisol production rate and can cause long-term morbidities such as osteoporosis. No prospective trial has investigated the long-term effect of different GC therapies on bone mineral density (BMD) in those patients. OBJECTIVES To determine if patients on hydrocortisone (HC) or prednisolone show changes in BMD after follow-up of 5.5 years. To investigate if BMD is altered after switching from immediate- to modified-release HC. DESIGN AND PATIENTS Prospective, observational, longitudinal study with evaluation of BMD by DXA at visit1, after 2.2 ± 0.4 (visit2) and after 5.5 ± 0.8 years (visit3) included 36 PAI and 8 CAH patients. Thirteen patients received prednisolone (age 52.5 ± 14.8 years; 8 women) and 31 patients received immediate-release HC (age 48.9 ± 15.8 years; 22 women). Twelve patients on immediate-release switched to modified-release HC at visit2. RESULTS Prednisolone showed significantly lower Z-scores compared to HC at femoral neck (-0.85 ± 0.80 vs -0.25 ± 1.16, P < 0.05), trochanter (-0.96 ± 0.62 vs 0.51 ± 1.07, P < 0.05) and total hip (-0.78 ± 0.55 vs 0.36 ± 1.04, P < 0.05), but not at lumbar spine, throughout the study. Prednisolone dose decreased by 8% over study time, but no significant effect was seen on BMD. BMD did not change significantly after switching from immediate- to modified-release HC. CONCLUSIONS The use of prednisolone as hormone replacement therapy results in significantly lower BMD compared to HC. Patients on low-dose HC replacement therapy showed unchanged Z-scores within the normal reference range during the study period.
Collapse
Affiliation(s)
- Kathrin R Frey
- Department of Medicine IEndocrine and Diabetes Unit, University Hospital, University of Würzburg, Würzburg, Germany
| | - Tina Kienitz
- Charité - Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Julia Schulz
- Charité - Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Manfred Ventz
- Charité - Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Kathrin Zopf
- Charité - Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | |
Collapse
|
21
|
Zopf K, Frey KR, Kienitz T, Ventz M, Bauer B, Quinkler M. BclI polymorphism of the glucocorticoid receptor and adrenal crisis in primary adrenal insufficiency. Endocr Connect 2017; 6:685-691. [PMID: 28954735 PMCID: PMC5655680 DOI: 10.1530/ec-17-0269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 09/26/2017] [Indexed: 02/03/2023]
Abstract
CONTEXT Patients with primary adrenal insufficiency (PAI) or congenital adrenal hyperplasia (CAH) are at a high risk of adrenal crisis (AC). Glucocorticoid sensitivity is at least partially genetically determined by polymorphisms of the glucocorticoid receptor (GR). OBJECTIVES To determine if a number of intercurrent illnesses and AC are associated with the GR gene polymorphism BclI in patients with PAI and CAH. DESIGN AND PATIENTS This prospective, longitudinal study over 37.7 ± 10.1 months included 47 PAI and 25 CAH patients. During the study period, intercurrent illness episodes and AC were documented. RESULTS The study period covered 223 patient years in which 21 AC occurred (9.4 AC/100 pat years). There were no significant differences between BclI polymorphisms (CC (n = 29), CG (n = 34) and GG (n = 9)) regarding BMI, hydrocortisone equivalent daily dose and blood pressure. We did not find a difference in the number of intercurrent illnesses/patient year among BclI polymorphisms (CC (1.5 ± 1.4/pat year), CG (1.2 ± 1.2/pat year) and GG (1.6 ± 2.2/pat year)). The occurrence of AC was not significantly different among the homozygous (GG) genotype (32.5 AC/100 pat years), the CC genotype (6.7 AC/100 pat years) and the CG genotype (4.9 AC/100 pat years). Concomitant hypothyroidism was the highest in the GG genotype group (5/9), compared to others (CC (11/29) and CG (11/34)). CONCLUSIONS Although sample sizes were relatively small and results should be interpreted with caution, this study suggests that the GR gene polymorphism BclI may not be associated with the frequencies of intercurrent illnesses and AC.
Collapse
Affiliation(s)
- Kathrin Zopf
- Department of EndocrinologyDiabetes and Nutrition, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Kathrin R Frey
- Department of Medicine IEndocrine and Diabetes Unit, University Hospital, University of Würzburg, Würzburg, Germany
| | - Tina Kienitz
- Department of EndocrinologyDiabetes and Nutrition, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Manfred Ventz
- Department of EndocrinologyDiabetes and Nutrition, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | | |
Collapse
|
22
|
Jumpertz von Schwartzenberg R, Elbelt U, Ventz M, Mai K, Kienitz T, Maurer L, Rose T, Rückert JC, Strasburger CJ, Spranger J. Palliative treatment of uncontrollable hypercalcemia due to parathyrotoxicosis: denosumab as rescue therapy. Endocrinol Diabetes Metab Case Rep 2015; 2015:150082. [PMID: 26605043 PMCID: PMC4653612 DOI: 10.1530/edm-15-0082] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 10/29/2015] [Indexed: 11/08/2022] Open
Abstract
Parathyroid carcinoma is a rare disease leading to severe hypercalcemia due to hyperparathyroidism. Surgery is the primary treatment option. A more progressive form of the disease is characterized by parathyrotoxicosis, and subsequent hypercalcemia is the most common cause of death. We report a case presenting with severe hypercalcemia due to parathyrotoxicosis from parathyroid carcinoma treated for the first time using the monoclonal antibody denosumab as a rescue therapy and present long-term follow-up data. The 71-year-old patient presented with severe hypercalcemia due to metastatic parathyroid carcinoma. Despite undergoing treatment with bisphosphonates, cinacalcet hydrochloride, and forced diuresis, the patient`s condition deteriorated rapidly due to resistant hypercalcemia. Surgery performed because of spinal metastasis and forced diuresis lowered calcium levels, albeit they remained in the hypercalcemic range and significantly increased when forced diuresis was stopped. Considering a palliative situation to overcome hypercalcemia, we decided to administer denosumab, a monoclonal antibody that binds to the receptor activator of nuclear factor-kappa B ligand. After a single subcutaneous administration of 60 mg denosumab, calcium levels normalized within one day. Subsequent denosumab injections led to permanent control of serum calcium for more than 2 years despite rising parathyroid hormone levels and repeated surgeries. Together with recent cases in the literature supporting our observation, we believe that denosumab is relevant for future trials and represents an effective tool to control hypercalcemia in patients with advanced stages of parathyroid cancer.
Collapse
Affiliation(s)
| | - Ulf Elbelt
- Department of Endocrinology and Metabolic Diseases, Charité - Universitätsmedizin , Charitéplatz 1, Berlin, 10117 , Germany
| | - Manfred Ventz
- Department of Endocrinology and Metabolic Diseases, Charité - Universitätsmedizin , Charitéplatz 1, Berlin, 10117 , Germany
| | - Knut Mai
- Department of Endocrinology and Metabolic Diseases, Charité - Universitätsmedizin , Charitéplatz 1, Berlin, 10117 , Germany
| | - Tina Kienitz
- Department of Endocrinology and Metabolic Diseases, Charité - Universitätsmedizin , Charitéplatz 1, Berlin, 10117 , Germany
| | - Lukas Maurer
- Department of Endocrinology and Metabolic Diseases, Charité - Universitätsmedizin , Charitéplatz 1, Berlin, 10117 , Germany
| | - Thomas Rose
- Division of Rheumatology and Clinical Immunology, Medical Department, Charité - Universitätsmedizin , Charitéplatz 1, Berlin, 10117 , Germany
| | - Jens C Rückert
- Department of General Visceral Vascular and Thoracic Surgery, Charité - Universitätsmedizin , Charitéplatz 1, Berlin, 10117 , Germany
| | - Christian J Strasburger
- Department of Endocrinology and Metabolic Diseases, Charité - Universitätsmedizin , Charitéplatz 1, Berlin, 10117 , Germany
| | - Joachim Spranger
- Department of Endocrinology and Metabolic Diseases, Charité - Universitätsmedizin , Charitéplatz 1, Berlin, 10117 , Germany
| |
Collapse
|
23
|
Kienitz T, Mönig H. [Endocrine changes in critically ill patients]. Dtsch Med Wochenschr 2014; 139:1565-7. [PMID: 25076306 DOI: 10.1055/s-0034-1370165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- T Kienitz
- Medizinische Klinik m.S. Endokrinologie, Diabetes und Ernährungsmedizin, Charité Universitätsmedizin Berlin
| | - H Mönig
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig-Holstein/ Campus Kiel
| |
Collapse
|
24
|
Hofmann PJ, Michaelis M, Gotz F, Bartel C, Kienitz T, Quinkler M. Flutamide increases aldosterone levels in gonadectomized male but not female Wistar rats. Am J Hypertens 2012; 25:697-703. [PMID: 22402471 DOI: 10.1038/ajh.2012.21] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Sex-specific differences in blood pressure (BP) suggest an important modulating role of testosterone in the kidney. However, little is known about the interaction between androgens and the mineralocorticoid aldosterone. Our objective was to determine the effects of testosterone in gonadectomized male and female rats on a low-salt diet, and to determine the effect of androgen receptor (AR) blockade by flutamide on BP and on aldosterone levels. METHODS Normotensive male and female Wistar rats were gonadectomized and put on a low-salt diet. They were treated for 16 days with testosterone or placebo. In addition, the animals received the AR antagonist flutamide or placebo, respectively. BP was measured by tail-cuff method, 24-h urine samples were collected in metabolic cages and blood was collected for hormonal measurements. RESULTS Testosterone increased BP in males and females, and this effect could be blocked by flutamide. Flutamide treatment itself significantly increased aldosterone levels in male but not in female rats. These elevated aldosterone levels could be lowered by testosterone treatment during AR blockade. Accordingly to aldosterone levels, flutamide increased in males the serum sodium/potassium to urinary sodium/potassium ratio, an in vivo indicator of renal aldosterone action. CONCLUSIONS Testosterone regulates BP in male and female gonadectomized rats via the AR. Flutamide by itself exerts influence over aldosterone in the absence of gonadal steroid replacement suggesting AR involvement in renal sodium handling. These flutamide effects were sex-specific and not seen in female rats.
Collapse
|
25
|
Michaelis M, Hofmann PJ, Götz F, Bartel C, Kienitz T, Quinkler M. Sex-specific effects of spironolactone on blood pressure in gonadectomized male and female Wistar rats. Horm Metab Res 2012; 44:291-5. [PMID: 22266825 DOI: 10.1055/s-0031-1299774] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
A low-salt diet is known to decrease and salt excess to increase blood pressure in humans and rodents. Sex steroids seem to play a role in salt dependent hypertension. However, little is known about sex differences in mineralocorticoid receptor blockade between male and female rats. The objective of the work was at first to investigate the effects of a low-salt vs. a high-salt diet on blood pressure without the influence of gonadal steroids in male and female rats. Second, to determine the sex-specific effects of mineralocorticoid receptor blockade by spironolactone in high-salt and low-salt fed gonadectomized male and female animals. Normotensive male and female Wistar rats were gonadectomized and put on a low (NaCl<0.03%) or high (NaCl=4%) salt diet. On each diet animals received spironolactone or placebo. Blood pressure was measured by tail-cuff-method; 24-h urine samples were collected in metabolic cages and blood was collected for hormonal measurements. High-salt diet significantly increased systolic blood pressure in both sexes. This effect could be blocked effectively by spironolactone only in male rats. Spironolactone treatment significantly increased aldosterone levels in males and females independent of the sodium content of the diet. High sodium diet significantly increased relative kidney weight, which was not altered by spironolactone treatment. Independently of gonadal steroids a high-salt diet increased blood pressure in gonadectomized male and female rats. Spironolactone lowered blood pressure only in male not in female rats on a high-salt diet clearly indicating sex-specific effects of the mineralo-corticoid antagonist spironolactone.
Collapse
Affiliation(s)
- M Michaelis
- Clinical Endocrinology, Charité Campus Mitte, Charité Campus Virchow, Charité University Medicine Berlin, Berlin, Germany
| | | | | | | | | | | |
Collapse
|
26
|
Abstract
Glucose-6-phosphate transporter (G6PT) and microsomal glucose-6-phosphatase-α (G6Pase-α) perform the terminal step in glycogenolysis and gluconeogenesis. Deficiency of these proteins leads to glycogen storage diseases. Partial inhibition of G6Pase in rats results in increased hepatic triglyceride content and de novo lipogenesis leading to hepatic steatosis. Hepatic steatosis represents hepatic manifestation of the metabolic syndrome. We investigated molecular mechanisms that may explain the relationship between fatty liver and G6Pase-α in humans in detail. A total of 27 patients (11 men, 16 women) underwent liver biopsy. Histological diagnosis identified nonfatty liver in seven patients and nonalcoholic fatty liver in 20 patients. We quantified G6Pase-α and G6PT mRNA expression by real-time PCR. Anthropometric measurements and analysis of plasma lipids and liver enzymes were performed. Patients with fatty liver showed no significant differences in age, HOMA(IR) (homeostasis model assessment of insulin resistance), BMI, liver enzymes or waist-to-hip ratio compared to those with nonfatty liver, but total plasma cholesterol levels and liver fat content were higher in patients with fatty liver (P < 0.05). G6Pase-α and G6PT mRNA expressions were significantly downregulated in fatty compared to histologically normal liver (P < 0.05). G6Pase-α and G6PT mRNA expressions correlated positively (R(2) = 0.406 P < 0.05). Both expressions did not correlate with age, BMI, aspartate transaminase, alanine transaminase, alkaline phosphatase, γ-glutamyl transferase, triglycerides or glucose levels. Our data suggest that expression of hepatic G6Pase-α and G6PT are closely interlinked. Downregulation of G6Pase-α in fatty liver might be associated with hepatic fat accumulation and pathogenesis of hepatic steatosis.
Collapse
Affiliation(s)
- Sarah Konopelska
- Department of Clinical Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany.
| | | | | |
Collapse
|
27
|
Lepenies J, Eardley KS, Kienitz T, Hewison M, Ihl T, Stewart PM, Cockwell P, Quinkler M. Renal TLR4 mRNA expression correlates with inflammatory marker MCP-1 and profibrotic molecule TGF-β₁ in patients with chronic kidney disease. Nephron Clin Pract 2011; 119:c97-c104. [PMID: 21677444 DOI: 10.1159/000324765] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 01/31/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Toll-like receptor-4 (TLR4) has been implicated in the pathogenesis of different renal diseases in rodent models. However, in human kidney disease, TLR4 expression and regulation is not well understood. We hypothesized that renal TLR4 expression plays a role in chronic kidney disease (CKD) and is associated with proteinuria, kidney function, histological diagnosis, and inflammatory mediators. METHODS We quantified TLR4 mRNA as well as expression of macrophage chemoattractant protein-1 (MCP-1), transforming growth factor-β₁ (TGF-β₁) and interleukin-6 (IL-6) in human kidney biopsies from 70 patients with CKD. We measured kidney function, urinary MCP-1 protein excretion, and the amount of chronic damage. Macrophage load was quantified by CD68 and vascularization by CD34 immunostaining. RESULTS TLR4 expression correlated significantly with MCP-1 and TGF-β₁ expression. High TLR4 expression was associated with high IL-6 expression. TLR4 expression was significantly upregulated in patients with severe proteinuria, and in patients with chronic ischemic renal damage and IgA nephropathy, when compared to patients with thin glomerular basement membrane disease. TLR4 expression did not correlate with creatinine clearance, renal outcome, macrophage load or chronic damage. CONCLUSIONS We show for the first time that renal TLR4 expression was significantly associated with the pro-inflammatory marker MCP-1 and the profibrotic molecule TGF-β₁ in kidney biopsies from patients with CKD, suggesting that increased expression of TLR4 is an important feature of CKD.
Collapse
|
28
|
Kienitz T, Ventz M, Kaminsky E, Quinkler M. Novel PHEX Nonsense Mutation in a Patient with X-Linked Hypophosphatemic Rickets and Review of Current Therapeutic Regimens. Exp Clin Endocrinol Diabetes 2011; 119:431-5. [DOI: 10.1055/s-0031-1277162] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
29
|
Graul-Neumann LM, Kienitz T, Robinson PN, Baasanjav S, Karow B, Gillessen-Kaesbach G, Fahsold R, Schmidt H, Hoffmann K, Passarge E. Marfan syndrome with neonatal progeroid syndrome-like lipodystrophy associated with a novel frameshift mutation at the 3' terminus of the FBN1-gene. Am J Med Genet A 2011; 152A:2749-55. [PMID: 20979188 DOI: 10.1002/ajmg.a.33690] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
We report on a 25-year-old woman with pronounced generalized lipodystrophy and a progeroid aspect since birth, who also had Marfan syndrome (MFS; fulfilling the Ghent criteria) with mild skeletal features, dilated aortic bulb, dural ectasia, bilateral subluxation of the lens, and severe myopia in addition to the severe generalized lipodystrophy. She lacked insulin resistance, hypertriglyceridemia, hepatic steatosis, and diabetes. Mutation analysis in the gene encoding fibrillin 1 (FBN1) revealed a novel de novo heterozygous deletion, c.8155_8156del2 in exon 64. The severe generalized lipodystrophy in this patient with progeroid features has not previously been described in other patients with MFS and FBN1 mutations. We did not find a mutation in genes known to be associated with congenital lipodystrophy (APGAT2, BSCL2, CAV1, PTRF-CAVIN, PPARG, LMNB2) or with Hutchinson-Gilford progeria (ZMPSTE24, LMNA/C). Other progeria syndromes were considered unlikely because premature greying, hypogonadism, and scleroderma-like skin disease were not present. Our patient shows striking similarity to two patients who have been published in this journal by O'Neill et al. [O'Neill et al. (2007); Am J Med Genet Part A 143A:1421-1430] with the diagnosis of neonatal progeroid syndrome (NPS). This condition also known as Wiedemann-Rautenstrauch syndrome is a rare disorder characterized by accelerated aging and lipodystrophy from birth, poor postnatal weight gain, and characteristic facial features. The course is usually progressive with early lethality. However this entity seems heterogeneous. We suggest that our patient and the two similar cases described before represent a new entity, a subgroup of MFS with overlapping features to NPS syndrome.
Collapse
|
30
|
Koetz K, Kienitz T, Quinkler M. Management of steroid replacement in adrenal insufficiency. MINERVA ENDOCRINOL 2010; 35:61-72. [PMID: 20595936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Adrenal insufficiency is caused by either primary adrenal failure, mostly due to autoimmune adrenalitis, or by hypothalamic-pituitary impairment of the corticotropic axis, predominantly by long-term pharmacodynamic glucocorticoid treatment or by pituitary tumour growth and related treatment. Despite optimized life-saving glucocorticoid and mineralocorticoid replacement therapy, health-related quality of life in adrenal insufficiency is more severely impaired than previously thought and patients with adrenal insufficiency are also threatened by an increased mortality. Optimizing hormone replacement remains one of the most challenging tasks in endocrinology. Monitoring of glucocorticoid replacement quality is hampered by lack of objective assessment tools and therefore largely based on clinical grounds. Thus, long-term management of patients with adrenal insufficiency remains a continuous challenge asking for the experienced specialist. However, diagnosis and management of suspected acute adrenal failure is an important task for all physicians. This review explains the rationale behind the current hormone replacement scheme, points to the deficits and hints at possible future therapies.
Collapse
Affiliation(s)
- K Koetz
- Clinical Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Charitéplatz 1, Berlin, Germany
| | | | | |
Collapse
|
31
|
Abstract
With the beginning of puberty blood pressure increases and is persistently higher in men than in premenopausal women. Sex steroids are known to have complex effects on the renal and cardiovascular system and are involved in blood pressure regulation. The epithelial sodium channel (ENaC) modulates sodium reabsorption in the kidney, but little is known about sex-specific regulation of ENaC subunit expression. Regulation of the androgen receptor (AR) is known to be tissue-specific and age-dependent, but not well studied in the kidney. We investigated the effects of sex steroids on ENaC subunits and renal AR expression in an in vivo rat model. Ovariectomized female Wistar rats were treated with placebo, testosterone, 5 alpha-dihydrotestosterone (DHT) or 17 beta-estradiol (E2) for 14 days, and quantitative PCR and Western immunoblots were performed. DHT significantly decreased expression of all ENaC subunits in female rats, whereas testosterone showed only a trend to lower ENaC expression. These results are in contrast to previous studies where stimulating effects of androgens on the alpha-subunit of ENaC were seen. AR mRNA expression showed a trend to lower levels in females after testosterone treatment in this study. However, estrogen treatment significantly downregulated AR mRNA expression. In male control animals we were able to show a significantly increased expression of AR mRNA upon testosterone treatment. Our data demonstrate that AR and ENaC are regulated by sex steroids. That way sex steroids might modulate renal sodium reabsorption and therefore provide a possible explanation for sex differences in blood pressure.
Collapse
Affiliation(s)
- T Kienitz
- Clinical Endocrinology, Department of Internal Medicine, Gastroenterology, Hepatology and Endocrinology, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Berlin 10117, Germany
| | | | | | | |
Collapse
|
32
|
Konopelska S, Kienitz T, Hughes B, Pirlich M, Bauditz J, Lochs H, Strasburger CJ, Stewart PM, Quinkler M. Hepatic 11beta-HSD1 mRNA expression in fatty liver and nonalcoholic steatohepatitis. Clin Endocrinol (Oxf) 2009; 70:554-60. [PMID: 18665910 DOI: 10.1111/j.1365-2265.2008.03358.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
CONTEXT Nonalcoholic fatty liver disease represents the hepatic manifestation of the metabolic syndrome. Nonalcoholic steatohepatitis (NASH) is the progressive form of liver injury. The pathophysiology that leads to NASH is not well understood. OBJECTIVE We hypothesize that an altered cortisol metabolism in the liver may be a pathogenetic factor. DESIGN AND PATIENTS 75 patients (28 men, 47 women) underwent liver biopsy for elevation in liver enzymes. Histological diagnosis identified normal liver in eight, fatty liver in 20, NASH grade 1 in 22, grade 2 in nine, grade 3 in three patients, and other forms of hepatitis or cirrhosis in 13 patients. We quantified hepatic 11beta-hydroxysteroid dehydrogenase type1 (11beta-HSD1) and hexose-6-phosphate-dehydrogenase (H6PDH) mRNA expression by real-time PCR. In addition, analysis of 24 h urinary excretion of cortisol metabolites using GCMS was performed and compared with healthy controls. RESULTS 11beta-HSD1 mRNA expression correlated significantly (R2= 0.809; P < 0.001) with H6PDH mRNA expression, negatively with waist-to-hip ratio in women (R2= 0.394; P= 0.005), but not with urinary (THF + 5alpha-THF)/THE ratio, total cortisol metabolite excretion, age, BMI, degree of fatty liver or NASH stages. Total cortisol metabolite excretion was increased in patients with fatty liver or NASH compared with healthy controls. CONCLUSIONS Our data suggest that expression of hepatic 11beta-HSD1 and H6PDH are closely interlinked. 11beta-HSD1 gene expression does not seem to be involved in the pathogenesis of fatty liver or NASH. However, those patients showed an increased 5alpha- and 5beta-reduction of cortisol leading to an increased cortisol turnover rate and an activation of the HPA axis.
Collapse
Affiliation(s)
- Sarah Konopelska
- Internal Medicine, Center for Gastroenterology, Hepatology, and Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
33
|
van der Klaauw AA, Kienitz T, Strasburger CJ, Smit JWA, Romijn JA. Malignant pituitary corticotroph adenomas: report of two cases and a comprehensive review of the literature. Pituitary 2009; 12:57-69. [PMID: 18176844 DOI: 10.1007/s11102-007-0080-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Corticotroph pituitary carcinomas are tumors, defined by the presence of distant metastases that determine their poor prognosis. The diagnosis and therapy of malignant corticotroph adenomas remains a clinical challenge. The molecular mechanisms of malignant transformation of pituitary adenomas are unclear, although they are believed to arise in an adenoma-to-carcinoma sequence. We describe two cases of malignant Cushing's disease with metastases in liver and bone, respectively. The primary pituitary tumors were treated by a combination of radiotherapy and transsphenoidal surgery, but recurred several times in both patients. The time interval between the diagnosis of Cushing's disease and the discovery of metastases was 32 and 17 years, respectively. In the first case the patient died within 6 months after diagnosis of metastasis, whereas the second patient is alive at a follow-up of 2 years after the discovery of the metastasis. Furthermore, we reviewed all available cases of corticotroph pituitary carcinomas reported in the literature and analyzed their clinical features and therapeutical management. In conclusion, frequent relapses of Cushing's disease, aggressive growth of macroadenoma, Nelson's syndrome after adrenalectomy or persistently high ACTH levels should prompt the clinician to consider the possibility of pituitary corticotroph carcinomas.
Collapse
Affiliation(s)
- Agatha A van der Klaauw
- Department of Endocrinology and Metabolism, C4-R, Leiden University Medical Center, P.O. Box 9600, Leiden 2300 RC, The Netherlands.
| | | | | | | | | |
Collapse
|
34
|
|
35
|
Kienitz T, Quinkler M, Strasburger CJ, Ventz M. Long-term management in five cases of TSH-secreting pituitary adenomas: a single center study and review of the literature. Eur J Endocrinol 2007; 157:39-46. [PMID: 17609400 DOI: 10.1530/eje-07-0098] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE TSH-secreting pituitary tumors (TSH-omas) are a rare cause of hyperthyroidism and account for <1% of all pituitary adenomas. Failure to recognize the presence of a TSH-oma may result in dramatic consequences such as thyroid ablation that may cause further growth in pituitary tumor. The primary goal of the treatment of TSH-omas is to remove the pituitary tumor. Medical treatment includes dopaminergic agonists or somatostatin analogs. METHODS AND RESULTS We report five cases of TSH-oma diagnosed between 1997 and 2006 and review the literature. All the patients are females with an age range from 54 to 65 years at diagnosis. Four of the five patients had at least one event of thyroid surgery due to goiter or nodule of unknown dignity. Three of the five patients had a stroke before the diagnosis of TSH-oma, probably due to hypertension, or smoking and contraceptive treatment. One patient with invasive tumor growth received stereotactic radiotherapy (and developed panhypopituitarism after operation), another patient received somatostatin analogs preoperatively and successfully underwent transsphenoidal operation. Three of the five patients received dopaminergic agonists (bromocriptine 5 mg daily or cabergoline 0.5-0.75 mg per week), because they refused surgical therapy or the tumor was stable under dopaminergic therapy. All patients have been followed-up for 2.5-8 years. A normalization of circulating thyroid hormone levels was achieved in all patients. The patient who underwent operation shows no recurrence of the disease. The other patients have a stable pituitary mass without signs of growth. CONCLUSION We report the successful long-term treatment of TSH-omas with different therapies.
Collapse
Affiliation(s)
- Tina Kienitz
- Clinical Endocrinology, Department of Internal Medicine, Gastroenterology, Hepatology and Endocrinology, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1 D-10117, Berlin, Germany
| | | | | | | |
Collapse
|
36
|
Konopelska S, Kienitz T, Pirlich M, Bauditz J, Stewart PM, Lochs H, Strasburger CJ, Quinkler M. Hepatic mRNA expression of 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) in patients with non-alcoholic steatohepatitis (NASH). Exp Clin Endocrinol Diabetes 2007. [DOI: 10.1055/s-2007-972378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
37
|
Kienitz T, Quinkler M, Strasburger CJ, Ventz M. Long-term management in 5 cases of TSH-secreting pituitary adenomas: A single centre study. Exp Clin Endocrinol Diabetes 2007. [DOI: 10.1055/s-2007-972243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
38
|
Kienitz T, Allolio B, Strasburger C, Quinkler M. Testosterone treatment in rats increases expression of the alpha-subunit of the epithelial sodium channel (alpha-ENaC) in the kidney. Exp Clin Endocrinol Diabetes 2006. [DOI: 10.1055/s-2006-933061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
39
|
Dorn M, Kienitz T, Ryckmanns F. [Onychomycosis: experiences with atraumatic nail avulsion]. Hautarzt 1980; 31:30-4. [PMID: 6446529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Patients with onychomycosis (tinea) of finger- and toenails underwent combined treatment: avulsion of nail plate, local antimycotic and systemic griseofulvin treatment. Avulsion of the involved nails was performed by the patients themselves chemo-mechanically using 50% KI-ointment. 1,500 nails were successfully removed. Out of 250 patients 101 were clinically and mycologically cured after a median delay of 6.5 months. Only 50% of the 101 patients remained cured up to one year after cessation of therapy. Atraumatic nail avulsion in combination with chemotherapy is a reliable, inexpensive, painless, and effective alternative method to surgical excision treating onychomycosis.
Collapse
|
40
|
Kienitz T, Balda BR. [Lues in patients previously treated with antibiotics]. Ther Ggw 1979; 118:1820-9. [PMID: 549229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
41
|
Kienitz T. [Gynacomastia. Forms and diagnostic measures in andrologic patients]. Ther Ggw 1978; 117:756-72. [PMID: 663862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
42
|
Kienitz T, Schill WB. [Oral kallikrein-therapy of asthenozoospermia]. Fortschr Med 1977; 95:2102-5. [PMID: 903074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Over a period of 7 weeks 51 men with idiopathic asthenozoospermia were treated with Kallikrein (600 Kallikrein units per day). A statistically significant improvement of sperm motility was observed with a maximum 1 month after the therapy. The conception rate was 31%. Stimulation of sperm motility may be caused by a positive effect on spermatogenesis, by an improvement of the nutritional functions of the tubulus apparatus and by an improvement of sperm maturation in the eqididymis.
Collapse
|
43
|
Kienitz T. [Swimming-pool granuloma]. Hautarzt 1977; 28:489-90. [PMID: 914519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The swimming pool granuloma is a chronic granulomatous skin disease, caused by atypical quick growing mycobacteria in areas of minor injuries with high self-healing rate.
Collapse
|
44
|
Kienitz T, Braun-Falco O. [Circumscribed skin necroses following intramuscular injections. Review and case reports]. MMW Munch Med Wochenschr 1976; 118:1515-8. [PMID: 826786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In rare instances local hemorrhagic necroses may be observed after intramuscular injection. The clinical features of this side reaction - lividoid dermatitis progressing to hemorrhagic necrosis and prolonged wound healing - are presented in the light of four of our own observations. With regard to the etiology, functional vascular spasm, embolism or/and local thromboses are discussed.
Collapse
|