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Furman K, Gut P, Sowińska A, Ruchała M, Fichna M. Predictors of bone mineral density in patients receiving glucocorticoid replacement for Addison's disease. Endocrine 2024; 84:711-719. [PMID: 38334892 DOI: 10.1007/s12020-024-03709-3] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/18/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE Patients receiving long-term glucocorticoid (GC) treatment are at risk of osteoporosis, while bone effects of substitution doses in Addison's disease (AD) remain equivocal. The project was aimed to evaluate serum bone turnover markers (BTMs): osteocalcin, type I procollagen N-terminal propeptide (PINP), collagen C-terminal telopeptide (CTX), sclerostin, DKK-1 protein, and alkaline phosphatase (ALP) in relation to bone mineral density (BMD) during GC replacement. METHODS Serum BTMs and hormones were assessed in 80 patients with AD (22 males, 25 pre- and 33 postmenopausal females) on hydrocortisone (HC) substitution for ≥3 years. Densitometry with dual-energy X-ray absorptiometry covered the lumbar spine (LS) and femoral neck (FN). RESULTS Among BTMs, only PINP levels were altered in AD. BMD Z-scores remained negative except for FN in males. Considering T-scores, osteopenia was found in LS in 45.5% males, 24% young and 42.4% postmenopausal females, while osteoporosis in 9.0%, 4.0% and 21.1%, respectively. Lumbar BMD correlated positively with body mass (p = 0.0001) and serum DHEA-S (p = 9.899 × 10-6). Negative correlation was detected with HC dose/day/kg (p = 0.0320), cumulative HC dose (p = 0.0030), patient's age (p = 1.038 × 10-5), disease duration (p = 0.0004), ALP activity (p = 0.0041) and CTX level (p = 0.0105). However, only age, body mass, ALP, serum CTX, and sclerostin remained independent predictors of LS BMD. CONCLUSION Standard HC substitution does not considerably accelerate BMD loss in AD patients and their serum BTMs: CTX, osteocalcin, sclerostin, DKK-1, and ALP activity remain within the reference ranges. Independent predictors of low lumbar spine BMD, especially ALP activity, serum CTX and sclerostin, might be monitored during GC substitution.
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Affiliation(s)
- Katarzyna Furman
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
- Ludwik Perzyna Regional Hospital, Kalisz, Poland
| | - Paweł Gut
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
| | - Anna Sowińska
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poznan, Poland
| | - Marek Ruchała
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
| | - Marta Fichna
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland.
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Wolff AB, Breivik L, Hufthammer KO, Grytaas MA, Bratland E, Husebye ES, Oftedal BE. The natural history of 21-hydroxylase autoantibodies in autoimmune Addison's disease. Eur J Endocrinol 2021; 184:607-615. [PMID: 34665570 PMCID: PMC8052519 DOI: 10.1530/eje-20-1268] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The most common cause of primary adrenal failure (Addison's disease) in the Western world is autoimmunity characterized by autoantibodies against the steroidogenic enzyme 21-hydroxylase (CYP21A2, 21OH). Detection of 21OH-autoantibodies is currently used for aetiological diagnosis, but how levels of 21OH-autoantibodies vary over time is not known. SETTING Samples from the national Norwegian Addison's Registry and Biobank established in 1996 (n = 711). Multi-parameter modelling of the course of 21OH-autoantibody indices over time. RESULTS 21OH-autoantibody positivity is remarkably stable, and >90% of the patients are still positive 30 years after diagnosis. Even though the antibody levels decline with disease duration, it is only rarely that this downturn reaches negativity. 21OH-autoantibody indices are affected by age at diagnosis, sex, type of Addison's disease (isolated vs autoimmune polyendocrine syndrome type I or II) and HLA genotype. CONCLUSION 21OH-autoantibodies are reliable and robust markers for autoimmune Addison's disease, linked to HLA risk genotype. However, a negative test in patients with long disease duration does not exclude autoimmune aetiology.
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Affiliation(s)
- Anette Boe Wolff
- Department of Clinical Science, University of Bergen, Norway
- K.G. Jebsen Center for autoimmune disorders, University of Bergen, Norway
- Department of Medicine, University of Bergen, Norway
| | - Lars Breivik
- Department of Clinical Science, University of Bergen, Norway
- K.G. Jebsen Center for autoimmune disorders, University of Bergen, Norway
- Department of Medicine, University of Bergen, Norway
| | | | - Marianne Aardal Grytaas
- K.G. Jebsen Center for autoimmune disorders, University of Bergen, Norway
- Department of Medicine, University of Bergen, Norway
| | - Eirik Bratland
- Department of Clinical Science, University of Bergen, Norway
- K.G. Jebsen Center for autoimmune disorders, University of Bergen, Norway
- Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Eystein Sverre Husebye
- Department of Clinical Science, University of Bergen, Norway
- K.G. Jebsen Center for autoimmune disorders, University of Bergen, Norway
- Department of Medicine, University of Bergen, Norway
- Correspondence should be addressed to E S Husebye;
| | - Bergithe Eikeland Oftedal
- Department of Clinical Science, University of Bergen, Norway
- K.G. Jebsen Center for autoimmune disorders, University of Bergen, Norway
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Penna-Martinez M, Meyer G, Wolff AB, Skinningsrud B, Betterle C, Falorni A, Ollier W, Undlien D, Husebye E, Pearce S, Mitchell AL, Badenhoop K. Vitamin D status and pathway genes in five European autoimmune Addison's disease cohorts. Eur J Endocrinol 2021; 184:373-381. [PMID: 33444227 DOI: 10.1530/eje-20-0956] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/12/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE While vitamin D regulates immune cells, little is known about it in autoimmune Addison's disease (AAD). We investigated the vitamin D status in AAD patients from five European populations to assess its deficiency. In addition, we studied two case-control cohorts for vitamin D metabolism and pathway genes. DESIGN Cross-sectional study. METHODS A total of 1028 patients with AAD from Germany (n = 239), Italy (n = 328), Norway (n = 378), UK (n = 44) and Poland (n = 39) and 679 controls from Germany (n = 301) and Norway (n = 378) were studied for 25(OH)D3 (primary objective). Secondary objectives (1,25(OH)2D3 and pathway genes) were examined in case-controls from Germany and Norway correlating 25(OH)D3 and single nucleotide polymorphisms within genes encoding the vitamin D receptor (VDR), 1-α-hydroxylase (CYP27B1), 25-hydroxylase (CYP2R1), 24-hydroxylase (CYP24A1) and vitamin D binding protein (GC/DBP). RESULTS Vitamin D deficiency (25(OH)D3 10-20 ng/mL) was highly prevalent in AAD patients (34-57%), 5-22% were severely deficient (<10 ng/mL), 28-38% insufficient (20-30 ng/mL) and only 7-14% sufficient (>30 ng/mL). Lower 25(OH)D3 and 1,25(OH)2D3 levels were observed both in Norwegian and German AAD (P = 0.03/0.003 and P = 1 × 10-5/< 1 × 10-7, respectively) the former was associated with CYP2R1 (rs1553006) genotype G. Whereas controls achieved sufficient median 25(OH)D3 in summers (21.4 to 21.9 ng/mL), AAD patients remained largely deficient (18.0 to 21.2 ng/mL) and synthesize less 1,25(OH)2D3. CONCLUSION Vitamin D deficiency and insufficiency are highly prevalent in AAD patients. The vitamin D status of AAD may be influenced by genetic factors and suggests individual vitamin D requirements throughout the year.
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Affiliation(s)
- Marissa Penna-Martinez
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine I, University Hospital Frankfurt, Goethe-University, Germany
| | - Gesine Meyer
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine I, University Hospital Frankfurt, Goethe-University, Germany
| | - Anette Boe Wolff
- Department of Clinical Science and KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Beate Skinningsrud
- Department of Medical Genetics, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Corrado Betterle
- Department of Medicine (DIMED), University of Padua School of Medicine, Padua, Italy
| | - Alberto Falorni
- Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - William Ollier
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
| | - Dag Undlien
- Department of Medical Genetics, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Eystein Husebye
- Department of Clinical Science and KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Simon Pearce
- Translational & Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Anna L Mitchell
- Translational & Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Klaus Badenhoop
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine I, University Hospital Frankfurt, Goethe-University, Germany
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Sævik ÅB, Åkerman AK, Methlie P, Quinkler M, Jørgensen AP, Höybye C, Debowska AJ, Nedrebø BG, Dahle AL, Carlsen S, Tomkowicz A, Sollid ST, Nermoen I, Grønning K, Dahlqvist P, Grimnes G, Skov J, Finnes T, Valland SF, Wahlberg J, Holte SE, Simunkova K, Kämpe O, Husebye ES, Bensing S, øksnes M. Residual Corticosteroid Production in Autoimmune Addison Disease. J Clin Endocrinol Metab 2020; 105:5835888. [PMID: 32392298 PMCID: PMC7274491 DOI: 10.1210/clinem/dgaa256] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/07/2020] [Indexed: 01/26/2023]
Abstract
CONTEXT Contrary to current dogma, growing evidence suggests that some patients with autoimmune Addison disease (AAD) produce corticosteroids even years after diagnosis. OBJECTIVE To determine frequencies and clinical features of residual corticosteroid production in patients with AAD. DESIGN Two-staged, cross-sectional clinical study in 17 centers (Norway, Sweden, and Germany). Residual glucocorticoid (GC) production was defined as quantifiable serum cortisol and 11-deoxycortisol and residual mineralocorticoid (MC) production as quantifiable serum aldosterone and corticosterone after > 18 hours of medication fasting. Corticosteroids were analyzed by liquid chromatography-tandem mass spectrometry. Clinical variables included frequency of adrenal crises and quality of life. Peak cortisol response was evaluated by a standard 250 µg cosyntropin test. RESULTS Fifty-eight (30.2%) of 192 patients had residual GC production, more common in men (n = 33; P < 0.002) and in shorter disease duration (median 6 [0-44] vs 13 [0-53] years; P < 0.001). Residual MC production was found in 26 (13.5%) patients and associated with shorter disease duration (median 5.5 [0.5-26.0] vs 13 [0-53] years; P < 0.004), lower fludrocortisone replacement dosage (median 0.075 [0.050-0.120] vs 0.100 [0.028-0.300] mg; P < 0.005), and higher plasma renin concentration (median 179 [22-915] vs 47.5 [0.6-658.0] mU/L; P < 0.001). There was no significant association between residual production and frequency of adrenal crises or quality of life. None had a normal cosyntropin response, but peak cortisol strongly correlated with unstimulated cortisol (r = 0.989; P < 0.001) and plasma adrenocorticotropic hormone (ACTH; r = -0.487; P < 0.001). CONCLUSION In established AAD, one-third of the patients still produce GCs even decades after diagnosis. Residual production is more common in men and in patients with shorter disease duration but is not associated with adrenal crises or quality of life.
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Affiliation(s)
- Åse Bjorvatn Sævik
- Department of Clinical Science, University of Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Anna-Karin Åkerman
- Department of Medicine, Örebro University Hospital, Örebro, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Paal Methlie
- Department of Clinical Science, University of Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | | | | | - Charlotte Höybye
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | | | - Bjørn Gunnar Nedrebø
- Department of Clinical Science, University of Bergen, Norway
- Department of Internal Medicine, Haugesund Hospital, Haugesund, Norway
| | - Anne Lise Dahle
- Department of Internal Medicine, Haugesund Hospital, Haugesund, Norway
| | - Siri Carlsen
- Department of Endocrinology, Stavanger University Hospital, Stavanger, Norway
| | - Aneta Tomkowicz
- Department of Medicine, Sørlandet Hospital, Kristiansand, Norway
| | - Stina Therese Sollid
- Department of Medicine, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Ingrid Nermoen
- Department of Endocrinology, Akershus University Hospital, Lørenskog, Norway
| | - Kaja Grønning
- Department of Endocrinology, Akershus University Hospital, Lørenskog, Norway
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Guri Grimnes
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
- Tromsø Endocrine Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Jakob Skov
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Trine Finnes
- Section of Endocrinology, Innlandet Hospital Trust, Hamar, Norway
| | | | - Jeanette Wahlberg
- Department of Endocrinology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | | | | | - Olle Kämpe
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Eystein Sverre Husebye
- Department of Clinical Science, University of Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne øksnes
- Department of Clinical Science, University of Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
- Correspondence and Reprint Requests: Marianne Øksnes, University of Bergen, Klinisk Institutt 2, Laboratoriebygget, 8. et., Jonas Lies vei 91B, 5021 Bergen, Norway, E-mail:
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Napier C, Allinson K, Gan EH, Mitchell AL, Gilligan LC, Taylor AE, Arlt W, Pearce SHS. Natural History of Adrenal Steroidogenesis in Autoimmune Addison's Disease Following Diagnosis and Treatment. J Clin Endocrinol Metab 2020; 105:5821191. [PMID: 32300791 PMCID: PMC7250207 DOI: 10.1210/clinem/dgaa187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 12/04/2019] [Accepted: 04/15/2020] [Indexed: 01/02/2023]
Abstract
CONTEXT The natural history of adrenal function in autoimmune Addison disease once diagnosed and treated has not been systematically studied, but several case reports of recovery from established adrenal failure suggest it may not be uniform. OBJECTIVE To ascertain steroidogenic function in autoimmune Addison disease immediately following diagnosis and during prolonged treatment. DESIGN We studied peak serum cortisol in response to ACTH1-24 in 20 newly diagnosed autoimmune Addison disease patients at first presentation and then again within a month. We also studied 37 patients with established Addison disease (for between 7 months and 44 years) in a medication-free state, measuring peak serum cortisol responses to ACTH1-24 and the urine LC-MS steroid metabolome. RESULTS Adrenal steroidogenesis declined rapidly after steroid replacement treatment for newly diagnosed Addison disease was started, with a peak serum cortisol falling from 138 ± 19 nmol/L (SEM) at presentation to 63 ± 13 nmol/L over 4 weeks (P < 0.003).Six of 37 participants (16%) with established Addison disease had detectable serum cortisol and urine glucocorticoid and mineralocorticoid metabolites during repeat testing, indicating variable degrees of residual adrenal function. CONCLUSION Autoimmune Addison disease is a heterogeneous condition, showing a rapid decline in adrenal steroidogenesis during the first few weeks following diagnosis, but low-level residual function in a minority of patients, which appears to persist for many years.
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Affiliation(s)
- Catherine Napier
- Institute of Genetic Medicine, International Centre for Life, Newcastle University, Newcastle upon Tyne
- Newcastle upon Tyne Hospitals NHS Trust, Royal Victoria Infirmary, UK
| | - Kathleen Allinson
- Institute of Genetic Medicine, International Centre for Life, Newcastle University, Newcastle upon Tyne
- Newcastle upon Tyne Hospitals NHS Trust, Royal Victoria Infirmary, UK
| | - Earn H Gan
- Institute of Genetic Medicine, International Centre for Life, Newcastle University, Newcastle upon Tyne
- Newcastle upon Tyne Hospitals NHS Trust, Royal Victoria Infirmary, UK
| | - Anna L Mitchell
- Institute of Genetic Medicine, International Centre for Life, Newcastle University, Newcastle upon Tyne
- Newcastle upon Tyne Hospitals NHS Trust, Royal Victoria Infirmary, UK
| | - Lorna C Gilligan
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Angela E Taylor
- Institute of Metabolism and Systems Research (IMSR), 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 (IMSR), University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Simon H S Pearce
- Institute of Genetic Medicine, International Centre for Life, Newcastle University, Newcastle upon Tyne
- Newcastle upon Tyne Hospitals NHS Trust, Royal Victoria Infirmary, UK
- Correspondence and Reprint Requests: Dr. Catherine Napier, Endocrine Unit, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals, Queen Victoria Road, NE1 4LP, UK. E-mail:
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Fichna M, Małecki PP, Młodzikowska M, Gębarski B, Ruchała M, Fichna P. Increased risk of endocrine autoimmunity in first-degree relatives of patients with autoimmune Addison's disease. Eur J Endocrinol 2020; 183:73-81. [PMID: 32487775 DOI: 10.1530/eje-20-0150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 02/23/2020] [Accepted: 04/29/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Autoimmune conditions tend to cluster in subjects with Addison's disease (AD) and probably also among their relatives. The aim of the study was to estimate the frequency of the endocrine gland-specific autoantibodies in first-degree relatives of patients with AD. METHODS Autoantibodies were investigated in 113 family members using RIA and ELISA assays. The control group comprised 143 age-matched volunteers. RESULTS Autoimmune diseases were diagnosed in 38.1% relatives. Hashimoto's thyroiditis was found in 20.3%, Graves' disease in 8.0%, vitiligo and type 1 diabetes in 3.5%, whereas AD, rheumatoid arthritis and atrophic gastritis with pernicious anaemia in 2.7% each. All studied antibodies except for islet antigen-2 (P = 0.085) were significantly more frequent in AD relatives than in controls (P < 0.05). Antibodies to 21-hydroxylase were detected in 6.2% relatives, thyroid peroxidase in 28.3%, thyroglobulin in 19.5%, glutamic acid decarboxylase in 8.0%, and zinc transporter-8 in 7.1%. Two and more autoantibodies were detected in 18.6% subjects. Significant gender difference was revealed only for aTPO, more common in female relatives (P = 0.014; OR: 3.16; 95% CI: 1.23-8.12). Circulating autoantibodies were found more frequently in the relatives of affected males (P = 0.008; OR: 3.31; 95% CI: 1.33-8.23), and in family members of patients with polyendocrine autoimmunity (P = 0.009; OR: 3.55; 95% CI: 1.31-9.57). CONCLUSIONS This study provides evidence of increased susceptibility for the endocrine autoimmunity, especially thyroid disease, in close relatives of patients with AD. Relatives of the male AD patients and of those with autoimmune polyendocrine syndrome are at particular risk and should undergo periodic screening for autoimmune endocrine disorders.
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Affiliation(s)
- Marta Fichna
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznan, Poland
| | - Piotr P Małecki
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznan, Poland
| | - Mirela Młodzikowska
- Central Laboratory of the Poznan University of Medical Sciences Paediatric Hospital, Poznan, Poland
| | | | - Marek Ruchała
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznan, Poland
| | - Piotr Fichna
- Department of Paediatric Diabetes and Obesity, Poznan University of Medical Sciences, Poznan, Poland
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Fichna M, Czarnywojtek A, Sowińska A, Gryczyńska M, Gut P, Ruchała M. Serum Visfatin does not seem to be a Useful Marker to Guide Glucocorticoid Substitution in Adrenal Insufficiency. Horm Metab Res 2020; 52:322-328. [PMID: 32252104 DOI: 10.1055/a-1135-9715] [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: 10/24/2022]
Abstract
Primary adrenal insufficiency (Addison's disease, AD) requires lifelong steroid substitution. Excess exogenous glucocorticoids promote abdominal obesity, insulin-glucose imbalance, and hypertension. Reliable markers of the adequate glucocorticoid replacement are lacking. Visfatin is a pro-inflammatory adipokine, with enzymatic activity of nicotinamide phosphoribosyltransferase. It enhances leukocyte function and synthesis of tumour necrosis factor α (TNFα) and interleukin-6 (IL-6). Serum visfatin is elevated in autoimmunity, but also in obesity, insulin resistance, and metabolic syndrome. This study was aimed to investigate whether serum visfatin could guide the glucocorticoid substitution in AD. Biochemical analyses were performed in 96 patients with AD (mean age 43.3±14.9 years) and 91 controls (43.5±12.5 years). Visfatin level was significantly elevated in patients with AD compared to controls (p<0.0001). Higher circulating IL-6 was also detected among subjects with AD (p=0.006). In AD, visfatin level was positively correlated with IL-6 (p=0.014), TNFα (p=0.001), body mass (p=0.015), fasting insulin (p=0.001) and HOMA-IR (p=0.001). No relationship was noticed with daily hydrocortisone (p=0.096) and urinary free cortisol excretion (p=0.499). Only the correlations with IL-6 and fasting insulin survived multiple regression analysis (p=0.049 and p=0.005, respectively). Additionally, positive correlation between visfatin and autoantibodies to 21-hydroxylase was noted (p=0.005). In the control group serum visfatin was correlated with IL-6 (p=0.009) and TNFα (p=0.0002). The current study reveals elevated serum visfatin in autoimmune AD. Visfatin does not seem a useful marker of the glucocorticoid replacement, although it correlates with fasting insulin and pro-inflammatory molecules. Further functional analyses are warranted to elucidate the role of visfatin in autoimmunity.
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Affiliation(s)
- Marta Fichna
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
| | - Agata Czarnywojtek
- Department of Pharmacology, Poznań University of Medical Sciences, Poznań, Poland
| | - Anna Sowińska
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poznań, Poland
| | - Maria Gryczyńska
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
| | - Paweł Gut
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
| | - Marek Ruchała
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
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Melvin A, Chantzichristos D, Kyle CJ, Mackenzie SD, Walker BR, Johannsson G, Stimson RH, O’Rahilly S. GDF15 Is Elevated in Conditions of Glucocorticoid Deficiency and Is Modulated by Glucocorticoid Replacement. J Clin Endocrinol Metab 2020; 105:dgz277. [PMID: 31853550 PMCID: PMC7105349 DOI: 10.1210/clinem/dgz277] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/17/2019] [Indexed: 02/08/2023]
Abstract
CONTEXT GDF15 is a stress-induced hormone acting in the hindbrain that activates neural circuitry involved in establishing aversive responses and reducing food intake and body weight in animal models. Anorexia, weight loss, nausea and vomiting are common manifestations of glucocorticoid deficiency, and we hypothesized that glucocorticoid deficiency may be associated with elevated levels of GDF15. OBJECTIVE To determine the impact of primary adrenal insufficiency (PAI) and glucocorticoid replacement on circulating GDF15 levels. METHODS AND RESULTS We measured circulating concentrations of GDF15 in a cohort of healthy volunteers and Addison's disease patients following steroid withdrawal. Significantly higher GDF15 (mean ± standard deviation [SD]) was observed in the Addison's cohort, 739.1 ± 225.8 pg/mL compared to healthy controls, 497.9 ± 167.7 pg/mL (P = 0.01). The effect of hydrocortisone replacement on GDF15 was assessed in 3 independent PAI cohorts with classical congenital adrenal hyperplasia or Addison's disease; intravenous hydrocortisone replacement reduced GDF15 in all groups. We examined the response of GDF15 to increasing doses of glucocorticoid replacement in healthy volunteers with pharmacologically mediated cortisol deficiency. A dose-dependent difference in GDF15 (mean ± SD) was observed between the groups with values of 491.0 ± 157.7 pg/mL, 427.0 ± 152.1 pg/mL and 360 ± 143.1 pg/mL, in the low, medium and high glucocorticoid replacement groups, respectively, P < .0001. CONCLUSIONS GDF15 is increased in states of glucocorticoid deficiency and restored by glucocorticoid replacement. Given the site of action of GDF15 in the hindbrain and its effects on appetite, further study is required to determine the effect of GDF15 in mediating the anorexia and nausea that is a common feature of glucocorticoid deficiency.
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Affiliation(s)
- Audrey Melvin
- MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Addenbrookes Treatment Centre, UK
| | - Dimitrios Chantzichristos
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology-Diabetes-Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Catriona J Kyle
- University/ BHF Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, UK
| | - Scott D Mackenzie
- University/ BHF Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, UK
| | - Brian R Walker
- University/ BHF Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, UK
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology-Diabetes-Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roland H Stimson
- University/ BHF Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, UK
| | - Stephen O’Rahilly
- MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Addenbrookes Treatment Centre, UK
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9
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Abstract
A young man endures many years with classic symptoms of Addison’s disease due to difficulties in distinguishing this rare condition, whose features are non-specific and insidious in nature. With all facts on hand, the patient’s notable history of psychiatric disorders, namely depression, anxiety and social isolation, as well as signs of extreme fatigue and syncope may well have been caused by a gradual onset of primary adrenal insufficiency. Long delays in diagnosis are not uncommon, as in this case where the actual condition was identified just in time when the patient presented with a life-threatening cardiovascular collapse.
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Affiliation(s)
- Philippa Joersjö
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Linda Block
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
- Anaesthesiology and Intensive Care, University of Gothenburg Institute of Clinical Sciences, Gothenburg, Sweden
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10
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Affiliation(s)
- Fahmy W F Hanna
- University Hospital of North Midlands, Stoke-on-Trent, UK
- Staffordshire University, Stoke-on-Trent, UK
| | - Basil G Issa
- Manchester University Foundation Trust, Manchester, UK
| | - Brian Kevil
- Manchester University Foundation Trust, Manchester, UK
| | - Anthony A Fryer
- University Hospital of North Midlands, Stoke-on-Trent, UK
- Institute for Applied Clinical Sciences, Keele University, Stoke-on-Trent, UK
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11
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Wolf P, Beiglböck H, Fellinger P, Pfleger L, Aschauer S, Gessl A, Marculescu R, Trattnig S, Kautzky-Willer A, Luger A, Winhofer Y, Krššák M, Krebs M. Plasma renin levels are associated with cardiac function in primary adrenal insufficiency. Endocrine 2019; 65:399-407. [PMID: 31177424 PMCID: PMC6656897 DOI: 10.1007/s12020-019-01974-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/28/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite adequate glucocorticoid (GC) and mineralocorticoid (MC) replacement therapy, primary adrenal insufficiency (AI) is associated with an increased mortality, mainly due to cardiovascular disease. The role of MC replacement is not known. Therefore, we assessed whether renin concentrations during routine GC and MC substitution therapy are associated with heart function and morphology. METHODS Thirty two patients with primary AI were included in a cross-sectional case-control study. In total, 17 patients and 34 healthy controls (age: 48 ± 12 vs. 46 ± 18 years; BMI: 23 ± 3 vs. 24 ± 3 kg/m2) underwent magnetic resonance spectroscopy and imaging measurements to assess cardiac function, morphology, ectopic lipids, and visceral/subcutaneous fat mass. Patients were divided according to their actual plasma renin concentration at the study visit (Actual-Reninlow vs. Actual-Reninhigh) and their median plasma renin concentration of previous visits (Median-Reninlow vs. Median-Reninhigh). RESULTS Ejection fraction was higher (67 ± 5 vs. 55 ± 3%; p = 0.001) and left ventricular mass was lower (60 ± 9 vs. 73 ± 10 g/m2; p = 0.025) in Actual-Reninhigh. Median-Reninhigh was associated with lower cardiac mass (64 ± 9 vs. 76 ± 11 g/m2; p = 0.029). Blood pressure, glucose, and lipid metabolism, as well as ectopic lipid content, pericardial fat mass, and visceral/subcutaneous fat were not different between the groups. Compared with controls, ejection fraction was significantly lower in patients with AI (56 ± 4 vs. 63 ± 8%; p = 0.019). No differences were found in patients with ≤20 mg compared with >20 mg of hydrocortisone per day. CONCLUSIONS Higher renin concentrations are associated with more favorable cardiac function and morphology in patients with primary AI.
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Affiliation(s)
- Peter Wolf
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Hannes Beiglböck
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Paul Fellinger
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lorenz Pfleger
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Centre of Excellence - High Field MR, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Stefan Aschauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Alois Gessl
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rodrig Marculescu
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Siegfried Trattnig
- Centre of Excellence - High Field MR, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Alexandra Kautzky-Willer
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Anton Luger
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Yvonne Winhofer
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Martin Krššák
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Centre of Excellence - High Field MR, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Michael Krebs
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
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12
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Singh M, Chandy DD, Bharani T, Marak RSK, Yadav S, Dabadghao P, Gupta S, Sahoo SK, Pandey R, Bhatia E. Clinical outcomes and cortical reserve in adrenal histoplasmosis-A retrospective follow-up study of 40 patients. Clin Endocrinol (Oxf) 2019; 90:534-541. [PMID: 30656706 DOI: 10.1111/cen.13935] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 11/07/2018] [Revised: 01/09/2019] [Accepted: 01/10/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Detailed studies of Addison's disease resulting from disseminated adrenal histoplasmosis (AH) are not available. We describe the presentation and prognosis of AH and cortisol status before and after antifungal therapy. DESIGN Single-centre retrospective hospital-based study of 40 consecutive adults with AH [39 males; age (mean ± SD) 53 ± 11 years] was conducted between 2006 and 2018. The median duration of follow-up was 2.5 years (range 0.2-12 years). PATIENTS AND METHODS AH was diagnosed by bilateral adrenal enlargement on CT scan and presence of Histoplasma by histology and/or culture of biopsied adrenal tissue. All patients received oral itraconazole and, if required, amphotericin B as per guidelines. ACTH-stimulated serum cortisol (normal > 500 nmol/L) was measured in 38 patients at diagnosis and re-tested after one year of antifungal therapy in 21 patients. RESULTS Seventy-three per cent of patients had primary adrenal insufficiency (PAI) and one-third had an adrenal crisis at presentation. HIV antibody was negative in all patients. Of the 29 patients who completed antifungal therapy, 25 (86%) were in remission at last follow-up. Overall, 8 (20%) patients died: three had a sudden death, four had severe histoplasmosis and one died due to adrenal crisis. No patient with PAI became eucortisolemic on re-testing after one year of antifungal therapy. Of the eight patients with normal cortisol at diagnosis, two developed adrenal insufficiency on follow-up. CONCLUSION All patients with AH tested negative for HIV antibody. While patients achieved a high rate of clinical remission after antifungal therapy, overall mortality was significant. Cortisol insufficiency did not normalize despite treatment.
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Affiliation(s)
- Mahaveer Singh
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - David D Chandy
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Tamnay Bharani
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rungmei S K Marak
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Subhash Yadav
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Preeti Dabadghao
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sushil Gupta
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Saroj K Sahoo
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rakesh Pandey
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Eesh Bhatia
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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13
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Venneri MA, Hasenmajer V, Fiore D, Sbardella E, Pofi R, Graziadio C, Gianfrilli D, Pivonello C, Negri M, Naro F, Grossman AB, Lenzi A, Pivonello R, Isidori AM. Circadian Rhythm of Glucocorticoid Administration Entrains Clock Genes in Immune Cells: A DREAM Trial Ancillary Study. J Clin Endocrinol Metab 2018; 103:2998-3009. [PMID: 29846607 DOI: 10.1210/jc.2018-00346] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [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: 02/11/2018] [Accepted: 05/22/2018] [Indexed: 01/08/2023]
Abstract
CONTEXT Adrenal insufficiency (AI) requires lifelong glucocorticoid (GC) replacement. Conventional therapies do not mimic the endogenous cortisol circadian rhythm. Clock genes are essential components of the machinery controlling circadian functions and are influenced by GCs. However, clock gene expression has never been investigated in patients with AI. OBJECTIVE To evaluate the effect of the timing of GC administration on circadian gene expression in peripheral blood mononuclear cells (PBMCs) of patients from the Dual Release Hydrocortisone vs Conventional Glucocorticoid Replacement in Hypocortisolism (DREAM) trial. DESIGN Outcome assessor-blinded, randomized, active comparator clinical trial. PARTICIPANTS AND INTERVENTION Eighty-nine patients with AI were randomly assigned to continue their multiple daily GC doses or switch to an equivalent dose of once-daily modified-release hydrocortisone and were compared with 25 healthy controls; 65 patients with AI and 18 controls consented to gene expression analysis. RESULTS Compared with healthy controls, 19 of the 68 genes were found modulated in patients with AI at baseline, 18 of which were restored to control levels 12 weeks after therapy was switched: ARNTL [BMAL] (P = 0.024), CLOCK (P = 0.016), AANAT (P = 0.021), CREB1 (P = 0.010), CREB3 (P = 0.037), MAT2A (P = 0.013); PRKAR1A, PRKAR2A, and PRKCB (all P < 0.010) and PER3, TIMELESS, CAMK2D, MAPK1, SP1, WEE1, CSNK1A1, ONP3, and PRF1 (all P < 0.001). Changes in WEE1, PRF1, and PER3 expression correlated with glycated hemoglobin, inflammatory monocytes, and CD16+ natural killer cells. CONCLUSIONS Patients with AI on standard therapy exhibit a dysregulation of circadian genes in PBMCs. The once-daily administration reconditions peripheral tissue gene expression to levels close to controls, paralleling the clinical outcomes of the DREAM trial (NCT02277587).
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Affiliation(s)
- Mary Anna Venneri
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Daniela Fiore
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Oxford Center for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Chiara Graziadio
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Claudia Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Mariarosaria Negri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Fabio Naro
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Ashley B Grossman
- Oxford Center for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom
- Centre for Endocrinology, Barts and the London School of Medicine, London, United Kingdom
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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14
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Morelli V, Minelli L, Eller-Vainicher C, Palmieri S, Cairoli E, Spada A, Arosio M, Chiodini I. Predictability of hypoadrenalism occurrence and duration after adrenalectomy for ACTH-independent hypercortisolism. J Endocrinol Invest 2018; 41:485-493. [PMID: 29151238 DOI: 10.1007/s40618-017-0788-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 05/19/2017] [Accepted: 10/29/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate if the parameters of hypothalamic-pituitary-adrenal (HPA) axis activity could predict the occurrence and duration of post-surgical hypocortisolism (PSH) in patients with Cushing's syndrome (CS) and with adrenal incidentaloma (AI). METHODS We studied 80 patients (54 females, age 53.3 ± 11 years), who underwent adrenalectomy for CS (17 patients) or for AI (53 patients). Before surgery, we measured adrenocorticotroph hormone (ACTH), urinary free cortisol (UFC) and serum cortisol after 1 mg dexamethasone suppression test (1 mg-DST) levels. After surgery, all patients were given a steroid replacement therapy, and PSH was searched after 2 months by a low-dose (1 µg, iv) corticotropin stimulation test, that was repeated every 6 months in PSH patients for at least 4 years. RESULTS The PSH occurred in 82.4 and 46% of CS and AI patients, respectively. In the whole sample and in AI patients separately considered, the PSH was independently predicted by the preoperative cortisol levels after 1 mg-DST, however, with a low (< 70%) accuracy. In AI patients the PSH occurrence was not ruled out even by the cortisol levels after 1 mg-DST lower than 1.8 μg/dL (50 nmol/L). In the 50% of CS patients and in 31% of AI patients the PSH lasted more than 18 months and in 35.7% of CS patients it persisted for more than 36 months. In AI patients, the PSH duration was not predictable by any parameter. However, a PSH duration of at least 12 months was significantly predicted before adrenalectomy (sensitivity 91.7%, specificity 41.2%, positive predictive value 52.4%, negative predictive value 87.5%, p = 0.05) by the presence of at least 2 out of low ACTH levels, increased UFC levels and cortisol levels after 1 mg-DST ≥ 3.0 µg/dL (83 nmol/L). CONCLUSION The PSH occurrence and its duration are hardly predictable before surgery. All patients undergoing unilateral adrenalectomy should receive a steroid substitutive therapy.
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Affiliation(s)
- V Morelli
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - L Minelli
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - C Eller-Vainicher
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Pad. Granelli, Via F. Sforza 35, 20122, Milan, Italy
| | - S Palmieri
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - E Cairoli
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - A Spada
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Arosio
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Pad. Granelli, Via F. Sforza 35, 20122, Milan, Italy
| | - I Chiodini
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Pad. Granelli, Via F. Sforza 35, 20122, Milan, Italy.
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15
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Abstract
In patients with acute adrenocortical insufficiency prompt recognition and treatment may be life-saving. Treatment should be initiated immediately before confirmation of the diagnosis. As shown by these case reports, junior staff on acute medical and surgical services, to whom these patients usually first present, may not appreciate that (a) hyponatraemia and hyperkalaemia, in the absence of renal failure, should immediately suggest the diagnosis of adrenal insufficiency and (b) treatment should precede confirmation of the diagnosis. Attempts to correct hyperkalaemia due to adrenocortical insufficiency with insulin and infusions of dextrose is inappropriate and potentially dangerous but seems to be a not unusual mistake.
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Affiliation(s)
- A Waise
- Department of Clinical Biochemistry, Hope Hospital, University of Manchester School of Medicine, Salford
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16
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Abstract
A 67-year-old Caucasian woman with no prior medical history was admitted to our hospital with complaints of generalised weakness, nausea, diarrhoea and weight loss. The patient suffered from tachycardia and hypotension. Blood tests revealed Graves' thyrotoxicosis and the patient was treated accordingly. However, patient's health continued to decline rapidly and further tests revealed a concomitant Addisonian crisis. Additional treatment with corticosteroids led to a full recovery. It is well known that autoimmune endocrine disorders tend to cluster. However, the presentation is usually sequential in time. This case reports the highly rare simultaneous presentation of Addison's disease and Graves' thyrotoxicosis. It also provides several suggestions to help establish the diagnoses.
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Affiliation(s)
- Ilias Attaye
- Department of Internal medicine, VU Medical Center, Amsterdam, The Netherlands
| | - Merel van Andel
- Endocrine Section, Department of Internal Medicine, VU Medical Center, Amsterdam, The Netherlands
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17
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Fichna M, Żurawek M, Budny B, Komarowska H, Niechciał E, Fichna P, Ruchała M. Elevated serum RANTES chemokine levels in autoimmune Addison disease. Pol Arch Intern Med 2018; 128:216-221. [PMID: 29498364 DOI: 10.20452/pamw.4221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Regulated on activation, normal T‑cell expressed and secreted chemokine (RANTES), the product of the CCL5 gene, is involved in trafficking immune cells into the inflammation site. It acts as coactivator of T cells and promotes polarization of the immune response towards the Th1 profile. In autoimmune Addison disease (AAD), the adrenal cortex is gradually destroyed by adrenal‑specific immune cell infiltration. RANTES might be implicated in autoimmune adrenal failure through recruitment and activation of the immune cells. Furthermore, the promoter CCL5 variant, rs2107538, seems to be associated with autoimmune endocrine conditions: diabetes and thyroid disease. OBJECTIVES Our analysis was designed to evaluate the prevalence of rs2107538 and serum RANTES levels in AAD. PATIENTS AND METHODS rs2107538 was genotyped using TaqMan technology in 239 individuals with AAD and 542 controls, while serum RANTES levels were evaluated by an enzyme‑linked immunosorbent assay in 114 patients with AAD and 111 healthy age- and sex‑matched individuals. RESULTS No differences were found in rs2107538 genotype or allele frequencies between patients and controls (P = 0.53 and P = 0.39, respectively), and no association was detected with age at AAD onset (P = 0.14). Serum RANTES levels were elevated in patients with AAD compared with controls (mean [SD], 59.2 [30.3] ng/ml vs 45.5 [20.4] ng/ml, P = 0.001). Healthy carriers of various rs2107538 genotypes demonstrated differences in serum RANTES levels (P = 0.02), whereas AAD patients did not (P = 0.26). No correlation was found between circulating RANTES levels and age, AAD duration, serum autoantibodies, hydrocortisone dose, and body mass (P >0.05). CONCLUSIONS This study demonstrates for the first time elevated serum RANTES levels in AAD and confirms that rs2107538 may affect serum chemokine levels.
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18
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Eriksson D, Dalin F, Eriksson GN, Landegren N, Bianchi M, Hallgren Å, Dahlqvist P, Wahlberg J, Ekwall O, Winqvist O, Catrina SB, Rönnelid J, Hulting AL, Lindblad-Toh K, Alimohammadi M, Husebye ES, Knappskog PM, Rosengren Pielberg G, Bensing S, Kämpe O. Cytokine Autoantibody Screening in the Swedish Addison Registry Identifies Patients With Undiagnosed APS1. J Clin Endocrinol Metab 2018; 103:179-186. [PMID: 29069385 DOI: 10.1210/jc.2017-01957] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 09/03/2017] [Accepted: 10/16/2017] [Indexed: 12/30/2022]
Abstract
CONTEXT Autoimmune polyendocrine syndrome type 1 (APS1) is a monogenic disorder that features autoimmune Addison disease as a major component. Although APS1 accounts for only a small fraction of all patients with Addison disease, early identification of these individuals is vital to prevent the potentially lethal complications of APS1. OBJECTIVE To determine whether available serological and genetic markers are valuable screening tools for the identification of APS1 among patients diagnosed with Addison disease. DESIGN We systematically screened 677 patients with Addison disease enrolled in the Swedish Addison Registry for autoantibodies against interleukin-22 and interferon-α4. Autoantibody-positive patients were investigated for clinical manifestations of APS1, additional APS1-specific autoantibodies, and DNA sequence and copy number variations of AIRE. RESULTS In total, 17 patients (2.5%) displayed autoantibodies against interleukin-22 and/or interferon-α4, of which nine were known APS1 cases. Four patients previously undiagnosed with APS1 fulfilled clinical, genetic, and serological criteria. Hence, we identified four patients with undiagnosed APS1 with this screening procedure. CONCLUSION We propose that patients with Addison disease should be routinely screened for cytokine autoantibodies. Clinical or serological support for APS1 should warrant DNA sequencing and copy number analysis of AIRE to enable early diagnosis and prevention of lethal complications.
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Affiliation(s)
- Daniel Eriksson
- Center for Molecular Medicine, Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Frida Dalin
- Center for Molecular Medicine, Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden
- Science for Life Laboratory, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Nils Landegren
- Center for Molecular Medicine, Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden
- Science for Life Laboratory, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Matteo Bianchi
- Science for Life Laboratory, Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Åsa Hallgren
- Center for Molecular Medicine, Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden
- Science for Life Laboratory, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Jeanette Wahlberg
- Department of Endocrinology, Linköping University, Linköping, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Olov Ekwall
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ola Winqvist
- Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden
| | - Sergiu-Bogdan Catrina
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Johan Rönnelid
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Anna-Lena Hulting
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Kerstin Lindblad-Toh
- Science for Life Laboratory, Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, Massachusetts
| | | | - Eystein S Husebye
- Center for Molecular Medicine, Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, University of Bergen, Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, Bergen, Norway
| | - Per Morten Knappskog
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, Bergen, Norway
| | - Gerli Rosengren Pielberg
- Science for Life Laboratory, Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Sophie Bensing
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Olle Kämpe
- Center for Molecular Medicine, Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Science for Life Laboratory, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- K.G. Jebsen Center for Autoimmune Disorders, Bergen, Norway
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Blanco JA, Gutiérrez LS, Caballero MGR. Photoclinic. Arch Iran Med 2017; 20:716-717. [PMID: 29480738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Jessica Ares Blanco
- Department of Endocrinology and Nutrition, Faculty of Medicine, Hospital Universitario Central de Asturias (Oviedo), Oviedo University, Spain
| | - Lorena Suárez Gutiérrez
- Department of Endocrinology and Nutrition, Faculty of Medicine, Hospital Universitario Central de Asturias (Oviedo), Oviedo University, Spain
| | - María Galiana Rodríguez Caballero
- Department of Endocrinology and Nutrition, Faculty of Medicine, Hospital Universitario Central de Asturias (Oviedo), Oviedo University, Spain
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De Bellis A, Bellastella G, Falorni A, Aitella E, Barrasso M, Maiorino MI, Bizzarro E, Bellastella A, Giugliano D, Esposito K. Natural history of autoimmune primary ovarian insufficiency in patients with Addison's disease: from normal ovarian function to overt ovarian dysfunction. Eur J Endocrinol 2017; 177:329-337. [PMID: 28733292 DOI: 10.1530/eje-17-0152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 02/21/2017] [Revised: 07/14/2017] [Accepted: 07/21/2017] [Indexed: 11/08/2022]
Abstract
CONTEXT Women with autoimmune Addison's disease with normal ovulatory cycles but positive for steroid cell antibodies (StCA) have been considered at risk of premature ovarian insufficiency (POI). DESIGN Thirty-three women younger than 40 years, with subclinical-clinical autoimmune Addison's disease but with normally ovulatory menses, were followed up for 10 years to evaluate the long-term time-related variations of StCA, ovarian function and follicular reserve. All patients and 27 control women were investigated at the start and every year for the presence and titre of StCA (by indirect immunofluorescence), serum concentrations of anti-Mullerian hormone (AMH) and ovarian function at four consecutive menses every year. RESULTS At the start of the study StCA were present in 16 women (group 1), at low/middle titres (≤1:32) in seven of them (43.8%, group 1A), at high titres (>1:32) in the remaining nine patients (group 1B, 56.2%), while they were absent from 17 patients (group 2). During the follow-up period, all women in group 1A remained StCA-positive at low/middle titres with normal ovulatory menses and normal gonadotrophin and AMH levels, while all patients in group 1B showed a further increase of StCA titres (1:128-1:256) and progressed through three stages of ovarian function. None of the patients in group 2 and controls showed the appearance of StCA or ovarian dysfunction during the follow-up. CONCLUSIONS The presence of StCA at high titres can be considered a good predictive marker of subsequent development of autoimmune POI. To single out the stages of autoimmune POI may allow a timely therapeutic choice in the subclinical and early clinical stages.
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Affiliation(s)
- Annamaria De Bellis
- Endocrinology and Metabolic Diseases Unit, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Giuseppe Bellastella
- Endocrinology and Metabolic Diseases Unit, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Alberto Falorni
- Section of Internal Medicine and Endocrine and Metabolic Sciences, Department of Medicine, University of Perugia, Perugia, Italy
| | - Ernesto Aitella
- Department of Clinical and Experimental Medicine, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Mariluce Barrasso
- Endocrinology and Metabolic Diseases Unit, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Maria Ida Maiorino
- Endocrinology and Metabolic Diseases Unit, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Elio Bizzarro
- Division of Obstetrics and Gynecology, Department of Public Health, School of Medicine and Surgery Department of Public Health 'Federico II' University of Naples, Naples, Italy
| | - Antonio Bellastella
- Endocrinology and Metabolic Diseases Unit, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Dario Giugliano
- Endocrinology and Metabolic Diseases Unit, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Katherine Esposito
- Diabetes Unit, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, University of Campania 'L. Vanvitelli', Naples, Italy
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Altieri B, Muscogiuri G, Barrea L, Mathieu C, Vallone CV, Mascitelli L, Bizzaro G, Altieri VM, Tirabassi G, Balercia G, Savastano S, Bizzaro N, Ronchi CL, Colao A, Pontecorvi A, Della Casa S. Does vitamin D play a role in autoimmune endocrine disorders? A proof of concept. Rev Endocr Metab Disord 2017; 18:335-346. [PMID: 28070798 DOI: 10.1007/s11154-016-9405-9] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [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] [Indexed: 12/13/2022]
Abstract
In the last few years, more attention has been given to the "non-calcemic" effect of vitamin D. Several observational studies and meta-analyses demonstrated an association between circulating levels of vitamin D and outcome of many common diseases, including endocrine diseases, chronic diseases, cancer progression, and autoimmune diseases. In particular, cells of the immune system (B cells, T cells, and antigen presenting cells), due to the expression of 1α-hydroxylase (CYP27B1), are able to synthesize the active metabolite of vitamin D, which shows immunomodulatory properties. Moreover, the expression of the vitamin D receptor (VDR) in these cells suggests a local action of vitamin D in the immune response. These findings are supported by the correlation between the polymorphisms of the VDR or the CYP27B1 gene and the pathogenesis of several autoimmune diseases. Currently, the optimal plasma 25-hydroxyvitamin D concentration that is necessary to prevent or treat autoimmune diseases is still under debate. However, experimental studies in humans have suggested beneficial effects of vitamin D supplementation in reducing the severity of disease activity. In this review, we summarize the evidence regarding the role of vitamin D in the pathogenesis of autoimmune endocrine diseases, including type 1 diabetes mellitus, Addison's disease, Hashimoto's thyroiditis, Graves' disease and autoimmune polyendocrine syndromes. Furthermore, we discuss the supplementation with vitamin D to prevent or treat autoimmune diseases.
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Affiliation(s)
- Barbara Altieri
- Division of Endocrinology and Metabolic Diseases, Institute of Medical Pathology, Catholic University of the Sacred Heart, Rome, Italy.
| | - Giovanna Muscogiuri
- Ios and Coleman Medicina Futura Medical Center, University Federico II, Naples, Italy
| | - Luigi Barrea
- Ios and Coleman Medicina Futura Medical Center, University Federico II, Naples, Italy
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Carla V Vallone
- Emergency Department, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Luca Mascitelli
- Comando Brigata Alpina Julia/Multinational Land Force, Medical Service, Udine, Italy
| | | | | | - Giacomo Tirabassi
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Giancarlo Balercia
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Silvia Savastano
- Department of Clinical Medicine and Surgery, University "Federico II", Naples, Italy
| | - Nicola Bizzaro
- Laboratory of Clinical Pathology, San Antonio Hospital, Tolmezzo, Italy
| | - Cristina L Ronchi
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Annamaria Colao
- Department of Clinical Medicine and Surgery, University "Federico II", Naples, Italy
| | - Alfredo Pontecorvi
- Division of Endocrinology and Metabolic Diseases, Institute of Medical Pathology, Catholic University of the Sacred Heart, Rome, Italy
| | - Silvia Della Casa
- Division of Endocrinology and Metabolic Diseases, Institute of Medical Pathology, Catholic University of the Sacred Heart, Rome, Italy
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Martínez-Cabriales SA, González-Moreno EI, Ocampo-Candiani J. A man with abdominal pain and skin pigmentation. Eur J Intern Med 2017; 37:e1-e2. [PMID: 27557599 DOI: 10.1016/j.ejim.2016.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 08/04/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Sylvia Aide Martínez-Cabriales
- Department of Dermatology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Emmanuel I González-Moreno
- Department of Gastroenterology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León , Monterrey, Mexico
| | - Jorge Ocampo-Candiani
- Department of Dermatology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Mexico.
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Falorni A, Bini V, Betterle C, Brozzetti A, Castaño L, Fichna M, Kämpe O, Mellgren G, Peterson P, Chen S, Rönnelid J, Seissler J, Tiberti C, Uibo R, Yu L, Lernmark Å, Husebye E. Determination of 21-hydroxylase autoantibodies: inter-laboratory concordance in the Euradrenal International Serum Exchange Program. Clin Chem Lab Med 2016; 53:1761-70. [PMID: 25811668 DOI: 10.1515/cclm-2014-1106] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 02/11/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND 21-Hydroxylase autoantibodies (21OHAb) are markers of an adrenal autoimmune process that identifies individuals with autoimmune Addison's disease (AAD). Quality and inter-laboratory agreement of various 21OHAb tests are incompletely known. The objective of the study was to determine inter-laboratory concordance for 21OHAb determinations. METHODS Sixty-nine sera from 51 patients with AAD and 51 sera from 51 healthy subjects were blindly coded by a randomization center and distributed to 14 laboratories that determined 21OHAb, either by an "in-house" assay (n=9) using in vitro-translated (35)S-21OH or luciferase-labeled 21OH or a commercial kit with (125)I-21OH (n=5). Main outcome measures were diagnostic accuracy of each participating laboratory and inter-laboratory agreement of 21OHAb assays. RESULTS Intra-assay coefficient of variation ranged from 2.6% to 5.3% for laboratories using the commercial kit and from 5.1% to 23% for laboratories using "in-house" assays. Diagnostic accuracy, expressed as area under ROC curve (AUC), varied from 0.625 to 0.947 with the commercial kit and from 0.562 to 0.978 with "in-house" methods. Cohen's κ of inter-rater agreement was 0.603 among all 14 laboratories, 0.691 among "in-house" laboratories, and 0.502 among commercial kit users. Optimized cutoff levels, calculated on the basis of AUCs, increased the diagnostic accuracy of every laboratory (AUC >0.9 for 11/14 laboratories) and increased the Cohen's κ of inter-rater agreement. Discrepancies in quantitation of 21OHAb levels among different laboratories increased with increasing autoantibody levels. CONCLUSIONS The quality of 21OHAb analytical procedures is mainly influenced by selection of cutoff value and correct handling of assay materials. A standardization program is needed to identify common standard sera and common measuring units.
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Fichna M, Rogowicz-Frontczak A, Żurawek M, Fichna P, Gryczyńska M, Zozulińska-Ziółkiewicz D, Ruchała M. Positive autoantibodies to ZnT8 indicate elevated risk for additional autoimmune conditions in patients with Addison's disease. Endocrine 2016; 53:249-57. [PMID: 26972575 PMCID: PMC4901090 DOI: 10.1007/s12020-016-0916-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 03/02/2016] [Indexed: 01/09/2023]
Abstract
Autoimmune Addison's disease (AAD) associates with exceptional susceptibility to develop other autoimmune conditions, including type 1 diabetes (T1D), marked by positive serum autoantibodies to insulin (IAA), glutamic acid decarboxylase (GADA) and insulinoma-associated protein 2 (IA-2A). Zinc transporter 8 (ZnT8) is a new T1D autoantigen, encoded by the SLC30A8 gene. Its polymorphic variant rs13266634C/T seems associated with the occurrence of serum ZnT8 antibodies (ZnT8A). This study was designed to determine the prevalence of serum ZnT8A and their clinical implication in 140 AAD patients. Other beta cell and thyroid-specific autoantibodies were also investigated, and ZnT8A results were confronted with the rs13266634 genotype. ZnT8A were detectable in 8.5 %, GADA in 20.7 %, IA-2A in 5.7 %, IAA in 1.6 % and various anti-thyroid antibodies in 7.1-67.8 % individuals. Type 1 diabetes was found in 10 % AAD patients. ZnT8A were positive in 57.1 % of T1D patients and 3.4 % non-diabetic AAD. Analysis of ZnT8A enabled to identify autoimmunity in two (14.3 %) T1D individuals previously classified as autoantibody-negative. ZnT8A-positive patients revealed significantly higher number of autoimmune conditions (p < 0.001), increased prevalence of T1D (p < 0.001) and other beta cell-specific autoantibodies. Carriers of the rs13266634 T-allele displayed increased frequency (p = 0.006) and higher titres of ZnT8A (p = 0.002). Our study demonstrates high incidence of ZnT8A in AAD patients. ZnT8A are associated with coexisting T1D and predictive of T1D in non-diabetic subjects. Moreover, positive ZnT8A in AAD indicate elevated risk for additional autoimmune conditions. Autoantibodies to beta cell antigens, comprising ZnT8, could be included in routine screening panels in AAD.
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Affiliation(s)
- Marta Fichna
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 49 Przybyszewskiego, 60-355, Poznan, Poland.
- Institute of Human Genetics, Polish Academy of Sciences, Poznan, Poland.
| | - Anita Rogowicz-Frontczak
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznan, Poland
| | - Magdalena Żurawek
- Institute of Human Genetics, Polish Academy of Sciences, Poznan, Poland
| | - Piotr Fichna
- Department of Paediatric Diabetes and Obesity, Poznan University of Medical Sciences, Poznan, Poland
| | - Maria Gryczyńska
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 49 Przybyszewskiego, 60-355, Poznan, Poland
| | | | - Marek Ruchała
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 49 Przybyszewskiego, 60-355, Poznan, Poland
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Gan EH, MacArthur K, Mitchell AL, Joshi A, Crock P, Pearce SHS. Spontaneous and tetracosactide-induced anti-ACTH antibodies in man. Clin Endocrinol (Oxf) 2016; 84:489-95. [PMID: 25880719 PMCID: PMC4949547 DOI: 10.1111/cen.12795] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 03/04/2015] [Accepted: 04/10/2015] [Indexed: 11/30/2022]
Abstract
CONTEXT During a clinical trial of regular tetracosactide depot injections, four of 13 patients with autoimmune Addison's disease (AAD) developed adverse reactions immediately following tetracosactide injections. We wished to investigate whether these adverse effects could be due to the production of circulating antitetracosactide (ACTH1-24 ) antibodies. DESIGN Anti-ACTH binding activity was investigated using immunoblotting and ELISA on sera from participants in the trial (n = 13; baseline and after tetracosactide exposure), 131 unrelated patients with AAD, 92 patients with Graves' disease (GD), 15 patients with isolated ACTH deficiency and 102 controls. Immunohistochemistry of human pituitary tissue sections was also performed using pooled sera. RESULTS Bands at approximately 4 and 6 kDa, corresponding to ACTH1-24 and full-length ACTH1-39, respectively, were found in 10 of 13 (77%) of sera from trial patients exposed to tetracosactide, including all those who had an adverse reaction. This is in contrast with healthy control sera, which showed no binding. The same 10 subjects also showed high levels of binding to tetracosactide by ELISA, along with 21% of patients with AAD, 14% of patients with GD (both P < 0·001 compared to controls) and 1 isolated ACTH deficiency patient (7% of 15). These sera also recognized native ACTH in human pituitary sections. CONCLUSION Our study demonstrates that repeated administration of depot tetracosactide can lead to anti-ACTH1-24 autoreactivity. In addition, a significant number of patients with AAD and GD also had similar, spontaneous, anti-ACTH reactivity. The presence of these antibodies could mediate some of the adverse effects or explain the well-described phenomenon of resistance to chronic ACTH therapy.
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Affiliation(s)
- Earn H. Gan
- Institute of Genetic MedicineNewcastle UniversityNewcastle upon TyneUK
- Endocrine UnitRoyal Victoria InfirmaryNewcastle upon TyneUK
| | - Katie MacArthur
- Institute of Genetic MedicineNewcastle UniversityNewcastle upon TyneUK
| | - Anna L. Mitchell
- Institute of Genetic MedicineNewcastle UniversityNewcastle upon TyneUK
- Endocrine UnitRoyal Victoria InfirmaryNewcastle upon TyneUK
| | - Abhijit Joshi
- Cellular Pathology DepartmentRoyal Victoria InfirmaryNewcastle upon TyneUK
| | - Patricia Crock
- John Hunter Children's HospitalUniversity of NewcastleNewcastleNSWAustralia
| | - Simon H. S. Pearce
- Institute of Genetic MedicineNewcastle UniversityNewcastle upon TyneUK
- Endocrine UnitRoyal Victoria InfirmaryNewcastle upon TyneUK
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Rauschecker M, Abraham SB, Abel BS, Wesley R, Saverino E, Trivedi A, Heller T, Nieman LK. Cosyntropin-Stimulated Serum Free Cortisol in Healthy, Adrenally Insufficient, and Mildly Cirrhotic Populations. J Clin Endocrinol Metab 2016; 101:1075-81. [PMID: 26647150 PMCID: PMC4803155 DOI: 10.1210/jc.2015-2285] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Serum free cortisol (SFF) responses to cosyntropin simulation test (CST) may more accurately assess adrenal function than total cortisol (TF). OBJECTIVE The objective of the study was to evaluate the diagnostic utility of SFF responses during a 250-μg CST. DESIGN We recruited healthy volunteers (HV; n = 27), patients with primary and secondary adrenal insufficiency (n = 19 and n = 24, respectively), and subjects with Child-Pugh class A cirrhosis (CH; n = 15). Each received 250 μg cosyntropin with measurement of ACTH and corticosteroid binding globulin (CBG) at time 0 and TF and SFF at 0, 30, and 60 minutes. Salivary cortisol was measured at all time points in CH subjects. RESULTS Peak SFF and TF were significantly higher in HVs vs both AI groups (P < .05). Peak SFF and TF (6.8 μg/dL vs 2.2 μg/dL; [188 nmol/L vs 62 nmol/L]; P < .01) were significantly higher in the secondary adrenal insufficiency vs primary adrenal insufficiency patients. The optimal peak SFF criterion to identify adrenal insufficiency patients vs HV was 0.9 μg/dL (25 nmol/L) (sensitivity of 95%, specificity of 100%). Mean CBG and albumin levels were similar among all four groups. CH patients had a higher peak SFF than HV (2.4 vs 2.0 μg/dL; P = .02. In the CH patients, peak salivary cortisol levels correlated well with peak SFF (rs = 0.84, P = .005). CBG levels were similar among the groups. CONCLUSION We provide normative data for SFF values in HV and AI during the CST. Normal CBG levels in mild cirrhosis did not affect the interpretation of the CST.
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Affiliation(s)
- Mitra Rauschecker
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Smita Baid Abraham
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Brent S Abel
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Robert Wesley
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Elizabeth Saverino
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Apurva Trivedi
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Theo Heller
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Lynnette K Nieman
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
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Boag AM, Christie MR, McLaughlin KA, Syme HM, Graham P, Catchpole B. Autoantibodies against Cytochrome P450 Side-Chain Cleavage Enzyme in Dogs (Canis lupus familiaris) Affected with Hypoadrenocorticism (Addison's Disease). PLoS One 2015; 10:e0143458. [PMID: 26618927 PMCID: PMC4664467 DOI: 10.1371/journal.pone.0143458] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 11/04/2015] [Indexed: 12/15/2022] Open
Abstract
Canine hypoadrenocorticism likely arises from immune-mediated destruction of adrenocortical tissue, leading to glucocorticoid and mineralocorticoid deficiency. In humans with autoimmune Addison's disease (AAD) or autoimmune polyendocrine syndrome (APS), circulating autoantibodies have been demonstrated against enzymes associated with adrenal steroid synthesis. The current study investigates autoantibodies against steroid synthesis enzymes in dogs with spontaneous hypoadrenocorticism. Coding regions of canine CYP21A2 (21-hydroxylase; 21-OH), CYP17A1 (17-hydroxylase; 17-OH), CYP11A1 (P450 side-chain cleavage enzyme; P450scc) and HSD3B2 (3β hydroxysteroid dehydrogenase; 3βHSD) were amplified, cloned and expressed as 35S-methionine radiolabelled recombinant protein. In a pilot study, serum samples from 20 dogs with hypoadrenocorticism and four unaffected control dogs were screened by radio-immunoprecipitation assay. There was no evidence of reactivity against 21-OH, 17-OH or 3βHSD, but five dogs with hypoadrenocorticism showed immunoreactivity to P450scc compared with controls. Serum samples were subsequently obtained from 213 dogs diagnosed with hypoadrenocorticism and 110 dogs from a hospital control population. Thirty control dogs were randomly selected to establish a threshold for antibody positivity (mean + 3 × standard deviation). Dogs with hypoadrenocorticism were more likely to be P450scc autoantibody positive than hospital controls (24% vs. 1.2%, respectively; p = 0.0016). Sex was significantly associated with the presence of P450scc autoantibodies in the case population, with 30% of females testing positive compared with 17% of males (p = 0.037). Significant associations with breed (p = 0.015) and DLA-type (DQA1*006:01 allele; p = 0.017) were also found. This cross-sectional study indicates that P450scc autoantibodies are present in a proportion of dogs affected with hypoadrenocorticism.
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Affiliation(s)
- Alisdair M. Boag
- The Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush Campus, Midlothian, United Kingdom
| | - Michael R. Christie
- Division of Diabetes & Nutritional Sciences, King’s College London, Hodgkin Building, Guy’s Campus, London, United Kingdom
- School of Life Sciences, University of Lincoln, Lincoln, United Kingdom
| | - Kerry A. McLaughlin
- Division of Diabetes & Nutritional Sciences, King’s College London, Hodgkin Building, Guy’s Campus, London, United Kingdom
| | - Harriet M. Syme
- Department of Clinical Sciences and Services, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire, United Kingdom
| | - Peter Graham
- Faculty of Medicine and Health Sciences, University of Nottingham, Sutton Bonington, Leicestershire, United Kingdom
| | - Brian Catchpole
- Department of Pathology and Pathogen Biology, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire, United Kingdom
- * E-mail:
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Inder WJ, Meyer C, Hunt PJ. Management of hypertension and heart failure in patients with Addison's disease. Clin Endocrinol (Oxf) 2015; 82:789-92. [PMID: 25138826 DOI: 10.1111/cen.12592] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 06/03/2014] [Revised: 07/23/2014] [Accepted: 08/12/2014] [Indexed: 01/25/2023]
Abstract
Addison's disease may be complicated by hypertension and less commonly by heart failure. We review the pathophysiology of the renin-angiotensin-aldosterone axis in Addison's disease and how this is altered in the setting of hypertension and heart failure. An essential first step in management in both conditions is optimizing glucocorticoid replacement and considering dose reduction if excessive. Following this, if a patient with Addison's disease remains hypertensive, the fludrocortisone dose should be reviewed and reduced if there are clinical and/or biochemical signs of mineralocorticoid excess. In the absence of such signs, where the renin is towards the upper end of the normal range or elevated, an angiotensin II (AII) receptor antagonist or angiotensin converting enzyme (ACE) inhibitor is the treatment of choice, and the fludrocortisone dose should remain unchanged. Dihydropyridine calcium channel blockers are clinically useful as second line agents, but diuretics should be avoided. In the setting of heart failure, there is an increase in total body sodium and water; therefore, it is appropriate to reduce and rarely consider ceasing the fludrocortisone. Loop diuretics may be used, but not aldosterone antagonists such as spironolactone or eplerenone. Standard treatment with ACE inhibitors, or as an alternative, AII receptor antagonists, are appropriate. Measurements of renin are no longer helpful in heart failure to determine the volume status but plasma levels of brain natriuretic peptide (BNP/proBNP) may help guide therapy.
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Affiliation(s)
- Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital and University of Queensland, Brisbane, Qld, Australia
| | - Caroline Meyer
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Melbourne, Vic., Australia
| | - Penny J Hunt
- Department of Endocrinology, Christchurch Hospital and University of Otago, Christchurch, New Zealand
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Bellastella G, Maiorino MI, Petrizzo M, De Bellis A, Capuano A, Esposito K, Giugliano D. Vitamin D and autoimmunity: what happens in autoimmune polyendocrine syndromes? J Endocrinol Invest 2015; 38:629-33. [PMID: 25576459 DOI: 10.1007/s40618-014-0233-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 10/10/2014] [Accepted: 12/18/2014] [Indexed: 12/27/2022]
Abstract
PURPOSE To evaluate the Vitamin D status of patients with a single autoimmune disease and of patients with several autoimmune diseases. METHODS We enrolled 35 patients with isolated type 1 diabetes mellitus (T1DM), 60 with autoimmune polyendocrine syndromes (APS) including T1DM and 72 control subjects. Among patients with APS, 10 were classified as type 2 (Addison's disease + T1DM), whereas the other 50 as type 3 (autoimmune thyroid disease + T1DM + other autoimmune diseases). Vitamin D (25-OHD) levels were assessed by a chemiluminescent immunoassay in all patients and controls on samples drawn in the morning of the same months. RESULTS Both groups of APS and T1DM patients showed 25-OHD levels significantly lower than healthy controls (p < 0.001 for both vs controls), without any significant difference between the two groups (p = 0.80). The highest prevalence of vitamin D deficiency (values <20 ng/ml) was observed in APS type 3 subgroup (8 out of 50 patients, 16%). CONCLUSIONS Patients with APS present reduced vitamin D circulating levels, but the vitamin D status is not different between patients with single or multiple autoimmune diseases. The kind of autoimmune disease, rather than the association of several autoimmune diseases, may influence negatively the levels of vitamin D. Further prospective studies are needed to clarify if impaired vitamin D level is a causal factor in the pathogenesis of autoimmune diseases or a consequence of them.
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Affiliation(s)
- G Bellastella
- Endocrinology and Metabolic Diseases Unit, Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, Second University of Naples, Piazza L. Miraglia 2, 80138, Naples, Italy.
| | - M I Maiorino
- Endocrinology and Metabolic Diseases Unit, Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, Second University of Naples, Piazza L. Miraglia 2, 80138, Naples, Italy
| | - M Petrizzo
- IOS and Coleman Medicina Futura Medical Center, Centro Direzionale, Naples, Italy
| | - A De Bellis
- Department of Cardio-Thoracic and Respiratory Sciences, Second University of Naples, Naples, Italy
| | - A Capuano
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - K Esposito
- Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - D Giugliano
- Endocrinology and Metabolic Diseases Unit, Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, Second University of Naples, Piazza L. Miraglia 2, 80138, Naples, Italy
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31
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Brozzetti A, Alimohammadi M, Morelli S, Minarelli V, Hallgren Å, Giordano R, De Bellis A, Perniola R, Kämpe O, Falorni A. Autoantibody response against NALP5/MATER in primary ovarian insufficiency and in autoimmune Addison's disease. J Clin Endocrinol Metab 2015; 100:1941-8. [PMID: 25734249 DOI: 10.1210/jc.2014-3571] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [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: 02/10/2023]
Abstract
CONTEXT NACHT leucine-rich-repeat protein 5 (NALP5)/maternal antigen that embryo requires (MATER) is an autoantigen in hypoparathyroidism associated with autoimmune polyendocrine syndrome type 1 (APS1) but is also expressed in the ovary. Mater is an autoantigen in experimental autoimmune oophoritis. OBJECTIVES The objectives of the study were to determine the frequency of NALP5/MATER autoantibodies (NALP5/MATER-Ab) in women with premature ovarian insufficiency (POI) and in patients with autoimmune Addison's disease (AAD) and to evaluate whether inhibin chains are a target for autoantibodies in POI. METHODS Autoantibodies against NALP5/MATER and inhibin chains-α and -βA were determined by radiobinding assays in 172 patients with AAD without clinical signs of gonadal insufficiency, 41 women with both AAD and autoimmune POI [steroidogenic cell autoimmune POI (SCA-POI)], 119 women with idiopathic POI, 19 patients with APS1, and 211 healthy control subjects. RESULTS NALP5/MATER-Ab were detected in 11 of 19 (58%) sera from APS1 patients, 12 of 172 (7%) AAD sera, 5 of 41 (12%) SCA-POI sera, 0 of 119 idiopathic POI sera and 1 of 211 healthy control sera (P < .001). None of 160 POI sera, including 41 sera from women with SCA-POI and 119 women with idiopathic POI, and none of 211 healthy control sera were positive for inhibin chain-α/βA autoantibodies. CONCLUSIONS NALP5/MATER-Ab are associated with hypoparathyroidism in APS1 but are present also in patients with AAD and in women with SCA-POI without hypoparathyroidism. Inhibin chains do not appear to be likely candidate targets of autoantibodies in human POI.
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Affiliation(s)
- Annalisa Brozzetti
- Department of Internal Medicine (A.B., S.M., V.M., A.F.), University of Perugia, 06126 Perugia, Italy; Department of Medical Sciences (M.A., O.K.), Science for Life Laboratory, Uppsala University, 750 03 Uppsala, Sweden; Centre of Molecular Medicine (M.A., A.H., O.K.), Department of Medicine (Solna), Karolinska Institutet, 171 76 Stockholm, Sweden; Division of Endocrinology, Diabetology, and Metabolism (R.G.), Department of Medical Sciences, University of Turin, 10126 Turin, Italy; Department of Cardio-Thoracic and Respiratory Science (A.D.B.), Endocrinology Unit, Second University of Naples, 80132 Naples, Italy; and Department of Pediatrics-Neonatal Intensive Care (R.P.), V. Fazzi Regional Hospital, 73100 Lecce, Italy
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Tanaka K, Nicholson WE, Orth DN. Molecular size and plasma levels of immunoreactive beta-MSH under physiological and pathological conditions in man. Front Horm Res 2015; 4:208-14. [PMID: 207598 DOI: 10.1159/000400368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Boscolo M, Bry-Gauillard H, Tardy V, Young J. Secondary amenorrhoea associated with high serum 17-hydroxyprogesterone levels revealing a heterozygous CYP21A2 mutation in a woman with Addison disease. Clin Endocrinol (Oxf) 2015; 82:620-2. [PMID: 25353971 DOI: 10.1111/cen.12646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Marina Boscolo
- Service d' Endocrinologie, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgique; Assistance Publique Hôpitaux de Paris, Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital de Bicêtre, Université Paris Sud, Le Kremlin Bicêtre, France
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Fichna M, Fichna P, Gryczyńska M, Czarnywojtek A, Żurawek M, Ruchała M. Steroid replacement in primary adrenal failure does not appear to affect circulating adipokines. Endocrine 2015; 48:677-85. [PMID: 25129652 PMCID: PMC4351438 DOI: 10.1007/s12020-014-0388-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 08/06/2014] [Indexed: 01/17/2023]
Abstract
Despite continuous efforts for an optimal steroid replacement, recent observations suggest increased cardiometabolic risk and related mortality in primary adrenal insufficiency (PAI). Adipokines are peptides from the adipose tissue, markers of cardiometabolic dysfunction. This study was aimed to evaluate serum levels of adipokines: leptin, adiponectin, and resistin in PAI during conventional steroid substitution. The analysis comprised 63 patients (mean age 42.7 ± 14.1 years) and 63 healthy controls. Serum adipokines, lipid profile, and plasma glucose were assessed in both cohorts. ACTH, serum insulin, HOMA-IR, DHEA-S, cortisol and 24 h urinary free cortisol were determined in PAI. Body mass composition was analyzed by Dual-Energy X-ray Absorptiometry. Mean BMI in the control group was 24.1 ± 3.9 kg/m(2) and 23.7 ± 3.9 kg/m(2) in the PAI cohort. Serum leptin and adiponectin levels were similar in both groups, whereas resistin appeared significantly lower among affected subjects (p = 0.0002). Its levels were weakly correlated with HOMA-IR (p = 0.048). Leptin was independently correlated with fasting insulin, HOMA-IR, BMI, and body fat (p < 0.001). At the multiple regression analysis only weight (p = 0.017), total and HDL cholesterol (p < 0.001) appeared significant predictors of adiponectin level. No adipokine correlations with serum cortisol or daily hydrocortisone dose were found. Patients receiving DHEA substitution displayed lower leptin and adiponectin levels (p < 0.05). In conclusion, our study did not provide evidence of an adverse adipokine profile in patients with PAI under conventional glucocorticoid replacement. Serum adipokines in treated PAI follow similar correlations to those reported in healthy subjects. Further prospective studies are warranted to verify and explain plausible excess of cardiovascular mortality in PAI.
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Affiliation(s)
- Marta Fichna
- Institute of Human Genetics, Polish Academy of Sciences, 32 Strzeszynska, 60-479, Poznan, Poland,
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Abstract
Patients with primary adrenal insufficiency usually show pronounced impairment of aldosterone secretion and, therefore, require also mineralocorticoid replacement for full recovery. Clinical signs of mineralocorticoid deficiency comprise hypotension, weakness, salt craving and electrolyte disturbances (hyperkalemia, hyponatremia). Mineralocorticoid deficiency is confirmed by demonstration of profoundly decreased aldosterone and highly elevated plasma renin activity (PRA). Standard replacement consists of 9α-fluorocortisol (fludrocortisone) given once daily as a single oral dose (0.05-0.2 mg). Monitoring of mineralocorticoid replacement consists of clinical assessment (well-being, physical examination, blood pressure, electrolyte measurements) and measurement of PRA aiming at a PRA level in the upper normal range. Current replacement regimens may often be associated with mild hypovolemia. Dose adjustments are frequently needed in pregnancy to compensate for the anti-mineralocorticoid activity of progesterone and in high ambient temperature to avoid sodium depletion. In arterial hypertension a dose reduction is usually recommended, but monitoring for hyperkalemia is required.
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Affiliation(s)
- Marcus Quinkler
- Endocrinology in Charlottenburg, Berlin, Germany; Charité University Medicine, Berlin, Germany.
| | | | - Hanna Remde
- Charité University Medicine, Berlin, Germany
| | - Bruno Allolio
- Endocrinology and Diabetes Unit, Department of Internal Medicine I, University Hospital of Wuerzburg, Germany.
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Abstract
Hypogonadism may complicate Addison's disease (primary hypoadrenalism), but prevalence and metabolic sequelae of hypogonadism in Addison's disease are poorly described. We recruited patients from the South African Addison's disease national registry who received stable replacement doses of hydrocortisone and had no acute illness. Male biochemical testosterone deficiency was defined as an early morning basal testosterone<9.9 nmol/l and premature ovarian failure (POF) when menopause occurred before 40 years of age. Cardiometabolic risk variables were measured in males only. Male hypogonadism prevalence was 33% (14/42), and 10 patients had newly diagnosed hypogonadism. Two untreated patients had elevated FSH or LH (>10 or 12 IU/l). Testosterone deficiency did not correlate with age, disease duration or hydrocortisone dose. Untreated male hypogonadal subjects had a higher (mean ± standard deviation) BMI compared to eugonadal subjects 29.2 ± 4.9 kg/m(2) vs. 24.7 ± 3.4 kg/m(2) (p=0.01) and a higher median (interquartile range) high-sensitive-CRP 6.4 (2.5-14.0) mg/l vs. 1.45 (0.6-2.8) mg/l (p=0.002). There were no differences between the 2 groups in lipids, lipoproteins and fasting glucose. The median (interquartile range) DHEAS was lower in the hypogonadal 0.31 (0.27-0.37) μmol/l, compared with the eugonadal group 0.75 (0.50-1.51) μmol/l (p=0.005). POF was documented in 11% of female patients. Male testosterone deficiency was highly prevalent in this cohort and was primarily due to secondary hypogonadism. Only BMI and hs-CRP were increased in untreated male hypogonadal subjects. Male and female hypogonadism appears to be a common complication of Addison's disease and may contribute to its morbidity.
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Affiliation(s)
- I L Ross
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - N S Levitt
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - D J Blom
- Division of Lipidology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - D Haarburger
- Ampath Laboratories, Pomona, Gauteng Province, South Africa
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Oksnes M, Björnsdottir S, Isaksson M, Methlie P, Carlsen S, Nilsen RM, Broman JE, Triebner K, Kämpe O, Hulting AL, Bensing S, Husebye ES, Løvås K. Continuous subcutaneous hydrocortisone infusion versus oral hydrocortisone replacement for treatment of addison's disease: a randomized clinical trial. J Clin Endocrinol Metab 2014; 99:1665-74. [PMID: 24517155 DOI: 10.1210/jc.2013-4253] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [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: 02/13/2023]
Abstract
CONTEXT Conventional glucocorticoid replacement therapy fails to mimic the physiological cortisol rhythm, which may have implications for morbidity and mortality in patients with Addison's disease. OBJECTIVE The objective of the study was to compare the effects of continuous sc hydrocortisone infusion (CSHI) with conventional oral hydrocortisone (OHC) replacement therapy. DESIGN, PATIENTS, AND INTERVENTIONS This was a prospective crossover, randomized, multicenter clinical trial comparing 3 months of treatment with thrice-daily OHC vs CSHI. From Norway and Sweden, 33 patients were enrolled from registries and clinics. All patients were assessed at baseline and after 8 and 12 weeks in each treatment arm. MAIN OUTCOME MEASURES The morning ACTH level was the primary outcome measure. Secondary outcome measures were effects on metabolism, health-related quality of life (HRQoL), sleep, and safety. RESULTS CSHI yielded normalization of morning ACTH and cortisol levels, and 24-hour salivary cortisol curves resembled the normal circadian variation. Urinary concentrations of glucocorticoid metabolites displayed a normal pattern with CSHI but were clearly altered with OHC. Several HRQoL indices in the vitality domain improved over time with CSHI. No benefit was found for either treatments for any subjective (Pittsburgh Sleep Quality Index questionnaire) or objective (actigraphy) sleep parameters. CONCLUSION CSHI safely brought ACTH and cortisol toward normal circadian levels without adversely affecting glucocorticoid metabolism in the way that OHC did. Positive effects on HRQoL were noted with CSHI, indicating that physiological glucocorticoid replacement therapy may be beneficial and that CSHI might become a treatment option for patients poorly controlled on conventional therapy.
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Affiliation(s)
- Marianne Oksnes
- Department of Clinical Science (M.Ø., P.M., K.T., K.L., E.S.H.), University of Bergen, N-5009 Bergen, Norway; Department of Medicine (M.Ø., K.L., E.S.H.) and Centre for Clinical Research, Haukeland University Hospital, N-5021 Bergen, Norway (R.M.N.); Department of Molecular Medicine and Surgery (S.Bj., A.-L.H., S.Be.), Karolinska Institutet, SE-171 77 Stockholm, Sweden; Departments of Medical Sciences (M.I., S.B., O.K.) and Neuroscience and Psychiatry (J.-E.B.), Uppsala University, SE-751 05 Uppsala, Sweden; and Department of Medicine (S.C.), Stavanger University Hospital, N-4068 Stavanger, Norway
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Ross IL, Bergthorsdottir R, Levitt N, Dave JA, Schatz D, Marais D, Johannsson G. Cardiovascular risk factors in patients with Addison's disease: a comparative study of South African and Swedish patients. PLoS One 2014; 9:e90768. [PMID: 24603607 PMCID: PMC3948337 DOI: 10.1371/journal.pone.0090768] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 02/04/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with Addison's disease (AD) in Scandinavia have an increased risk for premature death due to cardiovascular disease (CVD). Serum lipids are important risk factors for CVD and vascular mortality. Replacement doses of hydrocortisone have historically been higher in Sweden than South Africa. The primary aim was to study the lipid profiles in a large group of patients with AD with the hypothesis that the lipid profile in patients in Sweden would be worse than in South Africa. METHODS In a cross-sectional study, 110 patients with AD (55 from South Africa, 55 from Sweden) matched for age, gender, ethnicity and BMI were studied. Anthropometric measures, blood pressure, lipids, highly sensitive C-reactive protein (hs-CRP) and adiponectin were studied. RESULTS All patients were Caucasian and the majority were women N = 36 (65.5%). Mean (standard deviation; SD) ages of the Swedish and South African patients were 52.9 (13.0) and 52.6 (14.4) years and BMI 25.3 (3.2) and 25.8 (4.1) kg/m2, respectively. The mean total daily hydrocortisone dose was greater in the Swedish patients than the South African patients, [33.0 (8.1) versus 24.3 (8.0) mg; p<0.0001]. South African patients had higher median (interquartilerange; IQR) triglycerides (TG) [1.59 (1.1-2.46) versus 0.96 (0.74-1.6) mmol/l; p<0.001], total cholesterol (TC) [6.02(1.50) versus 5.13 (0.87) mmol/l; p<0.001], LDL-C [4.43 (1.44) versus 2.75 (0.80) mmol/l; p<0.001] and median hs-CRP [2.15 (0.93-5.45) versus 0.99 (0.57-2.10) mg/L; p<0.003] and lower HDL-C [0.80 (0.40) versus 1.86 (0.46) mmol/l; p<0.001] than the Swedish patients. Approximately 20% of the patients in both cohorts had hypertension and diabetes mellitus. CONCLUSIONS South African patients with AD have worse lipid profiles and higher hs-CRP compared to their matched Swedish patients, despite lower doses of hydrocortisone. It is uncertain at this time whether these are due to genetic or environmental factors.
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Affiliation(s)
- Ian Louis Ross
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ragnhildur Bergthorsdottir
- Department of Endocrinology, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Naomi Levitt
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Joel Alex Dave
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Desmond Schatz
- Department of Paediatrics, University of Florida, Gainesville, Florida, United States of America
| | - David Marais
- Division of Chemical Pathology, Clinical Laboratory Sciences, National Health Laboratory Service, University of Cape Town, Cape Town, South Africa
| | - Gudmundur Johannsson
- Department of Endocrinology, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
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Busch K, Wehner A, Dorsch R, Hartmann K, Unterer S. [Acute haemorrhagic diarrhoea as a presenting sign in a dog with primary hypoadrenocorticism]. Tierarztl Prax Ausg K Kleintiere Heimtiere 2014; 42:326-330. [PMID: 25323215] [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] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 05/13/2014] [Indexed: 06/04/2023]
Abstract
A 7-year-old male castrated mixed breed dog was presented because of acute haemorrhagic vomiting and watery haemorrhagic diarrhoea. According to clinical signs, nonspecific clinicopathological abnormalities, normal electrolytes and a rapid improvement with fluid therapy, haemorrhagic gastroenteritis (HGE) was suspected. One month later the dog was represented with weakness and electrolyte changes characteristic for typical hypoadrenocorticism (hyperkalaemia and hyponatraemia) were found. The tentative diagnosis was confirmed using an ACTH stimulation test. This case report highlights that dogs with hypoadrenocorticism may be presented with acute haemorrhagic diarrhoea. Electrolyte changes characteristic for hypoadrenocorticism may not be present in case of gastrointestinal potassium loss because of vomiting and diarrhoea. To rule out hypoadrenocorticism, a basal cortisol measurement should be performed in every dog with acute haemorrhagic diarrhoea of unknown cause.
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Affiliation(s)
| | | | | | | | - S Unterer
- Dr. Stefan Unterer, Medizinische Kleintierklinik der Ludwig-Maximilians-Universität München, Veterinärstraße 13, 80539 München, E-Mail:
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Ekman B, Alstrand N, Bachrach-Lindström M, Jenmalm MC, Wahlberg J. Altered chemokine Th1/Th2 balance in Addison's disease: relationship with hydrocortisone dosing and quality of life. Horm Metab Res 2014; 46:48-53. [PMID: 23918683 DOI: 10.1055/s-0033-1351291] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [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: 10/26/2022]
Abstract
The adrenalitis found in autoimmune Addison's disease (AAD) is considered having a Th1-driven pathogenesis. Circulating Th1- and Th2-associated chemokines responsible for the trafficking of leukocytes to inflammatory sites are markers for the Th1/Th2 balance. The aim of the study was to assess if the same daily hydrocortisone dose of 30 mg given in either 2 or 4 doses to patients with AAD could affect the Th1/Th2 balance of circulating chemokines.Fifteen patients (6 women) with AAD were included in this randomised, placebo controlled, double blind cross-over study. Samples for chemokines, Th1-associated (CXCL10, CXCL11) and Th2-associated (CCL17, CCL22), were drawn 5 times during a 24-h period at the end of each treatment period and analysed with Luminex. Seven control subjects did the same diurnal blood sampling once. Subjects with AAD had higher median diurnal levels of the Th1-associated chemokines than controls, CXCL10 [43 (33-56) pg/ml vs. 22 (19-34) pg/ml, p<0.01] and CXCL11 [37 (29-48) pg/ml vs. 16 (9-24) pg/ml, p<0.001], whereas no significant difference was found regarding the Th2-related chemokines. Similar chemokine levels were found when the same hydrocortisone dose of 30 mg was divided in 2 or 4 doses. Levels of CXCL11 correlated negatively with scores of SF-36 domains (high score indicate better health) of General Health (GH) and total score for Physical Component Summary (PCS), and these negative correlations were most pronounced at 04:00 h on the 2-dose regimen. Patients with AAD have a dominant Th1 chemokine profile that partially correlates to reduced quality of life.
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Affiliation(s)
- B Ekman
- Department of Medicine and Health Sciences, Division of Endocrinology, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - N Alstrand
- Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping, County Hospital, Kalmar, Sweden
| | - M Bachrach-Lindström
- Department of Medicine and Health Sciences, Division of Nursing Science, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - M C Jenmalm
- Department of Clinical and Experimental Medicine, Division of Inflammation Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - J Wahlberg
- Department of Medicine and Health Sciences, Division of Endocrinology, Faculty of Health Sciences, Linköping University, Linköping, Sweden
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Abstract
OBJECTIVE Routine delays in the diagnosis of primary adrenal insufficiency (PAI) are well known and conceivably attributable to the absence of cues, other than anti-adrenal autoantibodies, to pursue subclinical PAI. Subclinical PAI is latent unless the afflicted patient encounters stress such as an acute illness, surgery, psychosocial burden, etc. It remains to be demonstrated whether a history of stress-related health changes is a useful cue to pursue a diagnosis of latent PAI. METHODS The patients were selected for a history of recurrent symptoms, i.e., gastrointestinal symptoms, fatigue, or lassitude, aggravated by stress and alleviated by the removal of stress, and signs, i.e., weight loss, hypotension, and hyperpigmentation. As the early morning cortisol levels were low or low-normal and the adrenocorticotropic hormone (ACTH) levels were within the reference ranges, provocation tests, i.e., insulin-induced hypoglycemia tests and low-dose (1 μg) corticotropin tests (LDTs), were used to estimate the hypothalamus-pituitary-adrenal (HPA) axis status. Patients with the HPA axis dysfunction on two provocation tests were supplemented with physiologic doses of glucocorticoids (GCs). The effects of GC supplementation on stress-related health changes were observed. RESULTS The ACTH levels after insulin-induced hypoglycemia were higher and the cortisol levels were lower in the patients than in the control subjects. The cortisol levels in the patients were increased less significantly by LDT than those observed in the control subjects. Stress-related health changes ceased to recur and signs, i.e., a low body weight, hypotension, and hyperpigmentation, were ameliorated following GC supplementation. CONCLUSION A history of stress-related health changes is useful as a cue to pursue latent PAI in patients with low or low-normal early morning cortisol levels.
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Grossman A, Johannsson G, Quinkler M, Zelissen P. Therapy of endocrine disease: Perspectives on the management of adrenal insufficiency: clinical insights from across Europe. Eur J Endocrinol 2013; 169:R165-75. [PMID: 24031090 PMCID: PMC3805018 DOI: 10.1530/eje-13-0450] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Conventional glucocorticoid (GC) replacement for patients with adrenal insufficiency (AI) is inadequate. Patients with AI continue to have increased mortality and morbidity and compromised quality of life despite treatment and monitoring. OBJECTIVES i) To review current management of AI and the unmet medical need based on literature and treatment experience and ii) to offer practical advice for managing AI in specific clinical situations. METHODS The review considers the most urgent questions endocrinologists face in managing AI and presents generalised patient cases with suggested strategies for treatment. RESULTS Optimisation and individualisation of GC replacement remain a challenge because available therapies do not mimic physiological cortisol patterns. While increased mortality and morbidity appear related to inadequate GC replacement, there are no objective measures to guide dose selection and optimisation. Physicians must rely on experience to recognise the clinical signs, which are not unique to AI, of inadequate treatment. The increased demand for corticosteroids during periods of stress can result in a life-threatening adrenal crisis (AC) in a patient with AI. Education is paramount for patients and their caregivers to anticipate, recognise and provide proper early treatment to prevent or reduce the occurrence of ACs. CONCLUSIONS This review highlights and offers suggestions to address the challenges endocrinologists encounter in treating patients with AI. New preparations are being developed to better mimic normal physiological cortisol levels with convenient, once-daily dosing which may improve treatment outcomes.
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Affiliation(s)
| | - Gudmundur Johannsson
- Department of EndocrinologyInstitute of Medicine, Sahlgrenska Academy, University of GothenburgGothenburgSweden
| | - Marcus Quinkler
- Clinical Endocrinology, Charité Campus MitteCharité University MedicineBerlinGermany
| | - Pierre Zelissen
- Section of Endocrinology, Department of Internal MedicineUtrecht University Medical CenterUtrechtThe Netherlands
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43
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Abstract
Cortisol is quantitatively the major glucocorticoid product of the adrenal cortex. The main reason to measure cortisol is to diagnose human diseases characterised by deficiency of adrenal steroid excretion in Addison's disease or overproduction in Cushing's syndrome (CS). In both cases a sensitive, accurate and reproducible assay of cortisol is required. Several methods have been described for the quantitative measurement of cortisol in both serum and urine. The most widely used methods in routine clinical laboratories are immunoassays (IA) and enzyme immunoassays (EIA), luminescence and fluorescence assays, which are available in numerous commercial kits and on automated platforms. However, there remains a number of problems in the so-called direct immunoassays if extraction and prepurification are not carried out before the assay. Recently, more specific chromatographic methods have been introduced, such as high pressure liquid chromatographic (HPLC) or liquid chromatography tandem mass spectrometric assays (LC-MS/MS). The high specificity especially of LC-MS/MS facilitates reliable measurement of cortisol both in plasma, urine and saliva samples.
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Affiliation(s)
- Ursula Turpeinen
- HUSLAB, Laboratory of Women's Clinic, Haartmaninkatu 2, 00290 Helsinki, Finland.
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Abstract
OBJECTIVE Evaluation of the pharmacokinetics and safety of s.c. hydrocortisone injection for use in adrenal emergency. DESIGN Single-center, open-label, sequence-randomized, crossover study in a tertiary care center. PATIENTS AND METHODS Twelve patients with chronic Addison's disease. Comparison of hydrocortisone pharmacokinetics after s.c. and i.m. injection (100 mg) and after s.c. administration of sodium chloride (0.9%) respectively at three different visits. MAIN OUTCOME MEASURE maximum serum cortisol (Cmax), time to Cmax (tmax), and time to serum cortisol >36 μg/dl (tserum cortisol >36 μg/dl) after s.c. administration compared with i.m. administration, safety, and patient preference. RESULTS Serum cortisol increased rapidly and substantially after both i.m. and s.c. injections (Cmax: 110±29 vs 97±28 μg/dl, P=0.27, tmax: 66±51 vs 91±34 min, P=0.17, and tserum cortisol >36 μg/dl: 11±5 vs 22±11 min, P=0.004 respectively). Both i.m. and s.c. injections were well tolerated. Eleven (91.7%) patients preferred s.c. injection, whereas one patient did not have any preference. CONCLUSIONS S.c. administration of 100 mg hydrocortisone shows excellent pharmacokinetics for emergency use with only a short delay in cortisol increase compared with i.m. injection. It has a good safety profile and is preferred by patients over i.m. injection.
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Affiliation(s)
- Stefanie Hahner
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Oberdürrbacher Strasse 6, D-97080 Wuerzburg, Germany.
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45
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Bratland E, Hellesen A, Husebye ES. Induction of CXCL10 chemokine in adrenocortical cells by stimulation through toll-like receptor 3. Mol Cell Endocrinol 2013; 365:75-83. [PMID: 22989785 DOI: 10.1016/j.mce.2012.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [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] [Received: 01/26/2012] [Revised: 09/07/2012] [Accepted: 09/08/2012] [Indexed: 12/01/2022]
Abstract
Addison's disease is a prototypic organ-specific autoimmune disease affecting the adrenal cortex. The CXC chemokine ligand 10 (CXCL10) is expressed early in viral infections, and is produced by primary adrenocortical cells stimulated by certain cytokines. CXCL10 is also elevated in the serum of Addison's disease patients. We therefore investigated if the viral RNA substitute polyinosine-polycytidylic acid (poly (I:C)) could influence the cytokine induced production of CXCL10 by adrenocortical cells. We found that poly (I:C) could induce CXCL10 in NCI-H295R adrenocortical carcinoma cells, either alone or synergistically along with cytokines interferon-γ and tumor necrosis factor-α. This effect was found to be mediated by toll-like receptor 3 and both nuclear factor κB (NFκB) and signal transducer and activator of transcription-1 (STAT1), but not type I interferons, seemed to be involved. We propose that the combination of environmental and endogenous factors presented here, could contribute to the multifactorial pathogenesis of autoimmune Addison's disease.
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Affiliation(s)
- Eirik Bratland
- Section for Endocrinology, Institute of Medicine, University of Bergen, N-5020 Bergen, Norway.
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46
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Krikke M, ten Wolde M, Smit N. [Addison's disease, primary adrenal insufficiency in adults]. Ned Tijdschr Geneeskd 2013; 157:A6078. [PMID: 24020621] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Adrenal insufficiency is a rare but fatal disease if left unrecognized. Symptoms often mimic more prevalent diseases. We discuss three patients with primary adrenal insufficiency. These cases illustrate that presenting symptoms such as syncope, nausea, vomiting, weight loss and hypoglycemia are often non-specific and, therefore, often not immediately recognized. When an adrenal crisis is suspected, glucocorticoids should be given promptly. The symptoms are caused by insufficient production of adrenal hormones due to destruction of the adrenal glands by auto-immune adrenalitis. An ACTH stimulation test should confirm the diagnosis when primary adrenal insufficiency is suspected. Treatment consists of glucocorticoid and mineralocorticoid replacement. Primary adrenal insufficiency is a 'master of disguise'. Unexplained syncope, vomiting, weight loss or hypoglycemia should prompt suspicion of this disease.
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47
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Fichna M, Zurawek M, Fichna P, Gryczynska M, Nowak J, Ruchala M. Increased serum osteoprotegerin in patients with primary adrenal insufficiency receiving conventional hydrocortisone substitution. J Physiol Pharmacol 2012; 63:677-682. [PMID: 23388484] [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] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 12/18/2012] [Indexed: 06/01/2023]
Abstract
Patients treated for primary adrenal insufficiency (PAI) are at risk of steroid over-replacement, which may affect their skeleton. The study was aimed to investigate the effect of steroid substitution on serum osteoprotegerin and receptor activator of nuclear factor kappa-beta ligand (RANKL) levels in relation to bone mineral density (BMD) in PAI. Eighty patients (mean age 47.2±14.5 years, mean hydrocortisone dose 0.49±0.14 mg/kg/day) and 63 healthy subjects were included. Serum osteoprotegerin, RANKL, 25-hydroxyvitamin D₃, calcium, phosphate, alkaline phosphatase, intact parathormone, and dehydroepiandrosterone-sulfate levels were evaluated in patients and controls. BMD was assessed in affected subjects using dual-energy X-ray absorptiometry. Mean osteoprotegerin concentration in PAI patients appeared significantly higher vs. controls (p=0.002), while RANKL levels were similar (p=0.430). Serum osteoprotegerin increased with age (p<0.001), but showed no correlation with daily hydrocortisone dose. Osteoprotegerin was negatively correlated with serum dehydroepiandrosterone-sulfate (p=0.008) and with BMD at the lumbar spine (p<0.001) and femoral neck (p=0.003). RANKL correlated negatively with PAI duration (p=0.029) and positively with daily hydrocortisone dose (p=0.018). Lumbar spine osteoporosis and osteopenia were found in 12 and 31 patients, respectively, whereas in femoral neck: in 5 and 33 individuals. Patients with osteoporosis displayed higher osteoprotegerin levels, but after the age-adjustment the correlation was lost. In conclusion, increased osteoprotegerin in PAI might reflect a compensatory response to enhanced bone resorption due to exogenous steroid excess and/or result from a deficit in adrenal androgens. RANKL levels remain within normal range on standard steroid replacement.
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Affiliation(s)
- M Fichna
- Department of Endocrinology and Metabolism, University of Medical Sciences, Poznan, Poland.
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Ekman B, Bachrach-Lindström M, Lindström T, Wahlberg J, Blomgren J, Arnqvist HJ. A randomized, double-blind, crossover study comparing two- and four-dose hydrocortisone regimen with regard to quality of life, cortisol and ACTH profiles in patients with primary adrenal insufficiency. Clin Endocrinol (Oxf) 2012; 77:18-25. [PMID: 22288685 DOI: 10.1111/j.1365-2265.2012.04352.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [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] [Indexed: 11/30/2022]
Abstract
CONTEXT Current guidelines on how to divide the daily cortisol substitution dose in patients with primary adrenal insufficiency (PAI) are controversial and mainly based on empirical data. OBJECTIVE To assess how an equal dose of hydrocortisone (HC) given either four times daily or twice daily influence diurnal profiles of cortisol and ACTH, patient preferences and health-related quality of life (HRQoL). DESIGN Double blind, crossover. METHODS Fifteen patients with PAI (six women) were included. Capsules of HC or placebo were given at 07:00, 12:00, 16:00 and 22:00 h in 4-week treatment periods: either one period with four doses (10 + 10 + 5 + 5 mg) or one period with two doses (20 + 0 + 10 + 0 mg). Diurnal profiles of cortisol and ACTH were collected, and area under the curve (AUC) was calculated. Questionnaires were used to evaluate patient preferences and HRQoL. RESULTS The four-dose regimen gave a higher serum cortisol before tablet intake in the morning (P = 0·027) and a higher 24-h cortisol(AUC) (P < 0·0001) compared with the two-dose period. In contrast, a lower median plasma ACTH in the morning before tablet intake (P = 0·003) and a lower 24-h ln(ACTH(AUC) ) were found during the four-dose period. The patients preferred the four-dose regimen (P = 0·03), and the HRQoL scores tended to be higher (high score indicates better HRQoL) for the four-dose period. In summary, a four-dose regimen gives increased availability of cortisol and an enhanced effect with a less elevated ACTH in the morning in comparison with a two-dose regimen but the effect on HRQoL remains inconclusive.
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Affiliation(s)
- Bertil Ekman
- Department of Medical and Health Sciences, Section of Endocrinology, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
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Meyer G, Hackemann A, Reusch J, Badenhoop K. Nocturnal hypoglycemia identified by a continuous glucose monitoring system in patients with primary adrenal insufficiency (Addison's Disease). Diabetes Technol Ther 2012; 14:386-8. [PMID: 22242902 PMCID: PMC3338953 DOI: 10.1089/dia.2011.0158] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [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: 11/12/2022]
Abstract
BACKGROUND Hypoglycemia can be a symptom in patients with Addison's disease. The common regimen of replacement therapy with oral glucocorticoids results in unphysiological low cortisol levels in the early morning, the time of highest insulin sensitivity. Therefore patients with Addison's disease are at risk for unrecognized and potentially severe nocturnal hypoglycemia also because of a disturbed counterregulatory function. Use of a continuous glucose monitoring system (CGMS) could help to adjust hydrocortisone treatment and to avoid nocturnal hypoglycemia in these patients. METHODS Thirteen patients with Addison's disease were screened for hypoglycemia wearing a CGMS for 3-5 days. RESULTS In one patient we identified a hypoglycemic episode at 3:45 a.m. with a blood glucose level of 46 mg/dL, clearly beneath the 95% tolerance interval of minimal glucose levels between 2 and 4 a.m. (53.84 mg/dL). After the hydrocortisone replacement scheme was changed, the minimum blood glucose level between 2 and 4 a.m. normalized to 87 mg/dL. CONCLUSIONS Continuous glucose monitoring can detect nocturnal hypoglycemia in patients with primary adrenal insufficiency and hence prevent in these patients an impaired quality of life and even serious adverse effects.
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Affiliation(s)
- Gesine Meyer
- Department of Endocrinology and Diabetes, University Hospital, Frankfurt, Germany.
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50
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Baker PR, Nanduri P, Gottlieb PA, Yu L, Klingensmith GJ, Eisenbarth GS, Barker JM. Predicting the onset of Addison's disease: ACTH, renin, cortisol and 21-hydroxylase autoantibodies. Clin Endocrinol (Oxf) 2012; 76:617-24. [PMID: 22066755 PMCID: PMC4963152 DOI: 10.1111/j.1365-2265.2011.04276.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
CONTEXT Autoantibodies to 21-hydroxylase (21OH-AA) precede onset of autoimmune Addison's disease (AD). Progression to AD can take months to years, and early detection of metabolic decompensation may prevent morbidity and mortality. OBJECTIVE To define optimal methods of predicting progression to overt AD (defined by subnormal peak cortisol response to Cosyntropin) in 21OH-AA+ individuals. DESIGN, SETTING AND PARTICIPANTS Individuals were screened for 21OH-AA at the Barbara Davis Center from 1993 to 2011. Subjects positive for 21OH-AA (n = 87) were tested, and the majority prospectively followed for the development of Addison's disease, including seven diagnosed with AD upon 21OH-AA discovery (discovered), seven who progressed to AD (progressors) and 73 nonprogressors. MAIN OUTCOME MEASURED Plasma renin activity (PRA), ACTH, baseline cortisol, peak cortisol and 21OH-AA were measured at various time points relative to diagnosis of AD or last AD-free follow-up. RESULTS Compared with nonprogressors, in the time period 2 months-2 years prior to the onset of AD, progressors were significantly more likely to have elevated ACTH (11-22 pM, P < 1E-4), with no significant differences in mean PRA (P = 0·07) or baseline cortisol (P = 0·08), and significant but less distinct differences seen with 21OH-AA levels (P < 1E-4) and poststimulation cortisol levels (P = 6E-3). CONCLUSION Moderately elevated ACTH is a more useful early indicator of impending AD than 21OH-AA, PRA or peak cortisol, in the 2 months-2 years preceding the onset of AD.
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Affiliation(s)
- Peter R. Baker
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
| | - Priyaanka Nanduri
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
| | - Peter A. Gottlieb
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
| | - Liping Yu
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
| | | | - George S. Eisenbarth
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
| | - Jennifer M. Barker
- Department of Pediatric Endocrinology, University of Colorado Denver, Aurora, CO, USA
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