Endocrinology (part 3 – adrenal glands)

Some observations from chapter 3 below.

“The normal adrenal gland weigh 4-5g. The cortex represents 90% of the normal gland and surrounds the medulla. […] Glucocorticoid (cortisol […]) production occurs from the zona fasciculata, and adrenal androgens arise from the zona reticularis. Both of these are under the control of ACTH [see also my previous post about the book – US], which regulates both steroid synthesis and also adrenocortical growth. […] Mineralocorticoid (aldosterone […]) synthesis occurs in zona glomerulosa, predominantly under the control of the renin-angiotensin system […], although ACTH also contributes to its regulation. […] The adrenal gland […] also produces sex steroids in the form of dehydroepiandrostenedione (DHEA) and androstenedione. The synthetic pathway is under the control of ACTH. Urinary steroid profiling provides quantitative information on the biosynthetic and catabolic pathways. […] CT is the most widely used modality for imaging the adrenal glands. […] MRI can also reliably detect adrenal masses >5-10mm in diameter and, in some circumstances, provides additional information to CT […] PET can be useful in locating tumours and metastases. […] Adrenal vein sampling (AVS) […] can be useful to lateralize an adenoma or to differentiate an adenoma from bilateral hyperplasia. […] AVS is of particular value in lateralizing small aldosterone-producing adenomas that cannot easily be visualized on CT or MRI. […] The procedure should only be undertaken in patients in whom surgery is feasible and desired […] [and] should be carried out in specialist centres only; centres with <20 procedures per year have been shown to have poor success rates”.

“The majority of cases of mineralocorticoid excess are due to excess aldosterone production, […] typically associated with hypertension and hypokalemia. *Primary hyperaldosteronism is a disorder of autonomous aldosterone hypersecretion with suppressed renin levels. *Secondary hyperaldosteronism occurs when aldosterone hypersecretion occurs 2° [secondary, US] to elevated circulating renin levels. This is typical of heart failure, cirrhosis, or nephrotic syndrome but can also be due to renal artery stenosis and, occasionally, a very rare renin-producing tumour (reninoma). […] Primary hyperaldosteronism is present in around 10% of hypertensive patients. It is the most prevalent form of secondary hypertension. […] Aldosterone causes renal sodium retention and potassium loss. This results in expansion of body sodium content, leading to suppression of renal renin synthesis. The direct action of aldosterone on the distal nephron causes sodium retention and loss and hydrogen and potassium ions, resulting in a hypokalaemic alkalosis, although serum potassium […] may be normal in up to 50% of cases. Aldosterone has pathophysiological effects on a range of other tissues, causing cardiac fibrosis, vascular endothelial dysfunction, and nephrosclerosis. […] hypertension […] is often resistant to conventional therapy. […] Hypokalaemia is usually asymptomatic. […] Occasionally, the clinical syndrome of hyperaldosteronism is not associated with excess aldosterone. […] These conditions are rare.”

“Bilateral adrenal hyperplasia [make up] 60% [of cases of primary hyperaldosteronism]. […] Conn’s syndrome (aldosterone-producing adrenal adenoma) [make up] 35%. […] The pathophysiology of bilateral adrenal hyperplasia is not understood, and it is possible that it represents an extreme end of the spectrum of low renin essential hypertension. […] Aldosterone-producing carcinoma[s] [are] [r]are and usually associated with excessive secretion of other corticosteroids (cortisol, androgen, oestrogen). […] Indications [for screening include:] *Patients resistant to conventional antihypertensive medication (i.e. not controlled on three agents). *Hypertension associated with hypokalaemia […] *Hypertension developing before age of 40 years. […] Confirmation of autonomous aldosterone production is made by demonstrating failure to suppress aldosterone in face of sodium/volume loading. […] A number of tests have been described that are said to differentiate between the various subtypes of 1° [primary, US] aldosteronism […]. However, none of these are sufficiently specific to influence management decisions”.

“Laparoscopic adrenalectomy is the treatment of choice for aldosterone-secreting adenomas […] and laparoscopic adrenalectomy […] has become the procedure of choice for removal of most adrenal tumours. *Hypertension is cured in about 70%. *If it persists […], it is more amenable to medical treatment. *Overall, 50% become normotensive in 1 month and 70% within 1 year. […] Medical therapy remains an option for patients with bilateral disease and those with a solitary adrenal adenoma who are unlikely to be cured by surgery, who are unfit for operation, or who express a preference for medical management. *The mineralocorticoid receptor antagonist spironolactone […] has been used successfully for many years to treat hypertension and hypokalaemia associated with bilateral adrenal hyperplasia […] Side effects are common – particularly gynaecomastia and impotence in ♂, menstrual irregularities in ♀, and GI effects. […] Eplerenone […] is a mineralocorticoid receptor antagonist without antiandrogen effects and hence greater selectivity and less side effects than spironolactone. *Alternative drugs include the potassium-sparing diuretics amiloride and triamterene.”

“Cushing’s syndrome results from chronic excess cortisol [see also my second post in this series] […] The causes may be classified as ACTH-dependent and ACTH-independent. […] ACTH-independent Cushing’s syndrome […] is due to adrenal tumours (benign and malignant), and is responsible for 10-15% of cases of Cushing’s syndrome. […] Benign adrenocortical adenomas (ACA) are usually encapsulated and <4cm in diameter. They are usually associated with pure glucocorticoid excess. *Adrenocortical carcinomas (ACC) are usually >6cm in diameter, […] and are not infrequently associated with local invasion and metastases at the time of diagnosis. Adrenal carcinomas are characteristically associated with the excess secretion of several hormones; most frequently found is the combination of cortisol and androgen (precursors) […] ACTH-dependent Cushing’s results in bilateral adrenal hyperplasia, thus one has to firmly differentiate between ACTH-dependent and independent causes of Cushing’s before assuming bilateral adrenal hyperplasia as the primary cause of disease. […] It is important to note that, in patients with adrenal carcinoma, there may also be features related to excessive androgen production in ♀ and also a relatively more rapid time course of development of the syndrome. […] Patients with ACTH-independent Cushing’s syndrome do not suppress cortisol […] on high-dose dexamethasone testing and fail to show a rise in cortisol and ACTH following administration of CRH. […] ACTH-independent causes are adrenal in origin, and the mainstay of further investigation is adrenal imaging by CT”.

“Adrenal adenomas, which are successfully treated with surgery, have a good prognosis, and recurrence is unlikely. […] Bilateral adrenalectomy [in the context of bilateral adrenal hyperplasia] is curative. Lifelong glucocorticoid and mineralocorticoid treatment is [however] required. […] The prognosis for adrenal carcinoma is very poor despite surgery. Reports suggest a 5-year survival of 22% and median survival time of 14 months […] Treatment of adrenocortical carcinoma (ACC) should be carried out in a specialist centre, with expert surgeons, oncologists, and endocrinologists with extensive treatment in treating ACC. This improves survival.”

“Adrenal insufficiency [AI, US] is defined by the lack of cortisol, i.e. glucocorticoid deficiency, may be due to destruction of the adrenal cortex (1°, Addison’s disease and congenital adrenal hyperplasia (CAH) […] or due to disordered pituitary and hypothalamic function (2°). […] *Permanent adrenal insufficiency is found in 5 in 10,000 population. *The most frequent cause is hypothalamic-pituitary damage, which is the cause of AI in 60% of affected patients. *The remaining 40% of cases are due to primary failure of the adrenal to synthesize cortisol, almost equal prevalence of Addison’s disease (mostly of autoimmune origin, prevalence 0.9-1.4 in 10,000) and congenital adrenal hyperplasia (0.7-1.0 in 10,000). *2° adrenal insufficiency due to suppression of pituitary-hypothalamic function by exogenously administered, supraphysiological glucocorticoid doses for treatment of, for example, COPD or rheumatoid arthritis, is much more common (50-200 in 10,000 population). However, adrenal function in these patients can recover”.

“[In primary AI] [a]drenal gland destruction or dysfunction occurs due to a disease process which usually involves all three zones of the adrenal cortex, resulting in inadequate glucocorticoid, mineralocorticoid, and adrenal androgen precursor secretion. The manifestations of insufficiency do not usually appear until at least 90% of the gland has been destroyed and are usually gradual in onset […] Acute adrenal insufficiency may occur in the context of acute septicaemia […] Mineralocorticoid deficiency leads to reduced sodium retention and hyponatraemia and hypotension […] Androgen deficiency presents in ♀ with reduced axillary and pubic hair and reduced libido. (Testicular production of androgens is more important in ♂). [In secondary AI] [i]nadequate ACTH results in deficient cortisol production (and ↓ androgens in ♀). […] Mineralocorticoid secretion remains normal […] The onset is usually gradual, with partial ACTH deficiency resulting in reduced response to stress. […] Lack of stimulation of skin MC1R due to ACTH deficiency results in pale skin appearance. […] [In 1° adrenal insufficiency] hyponatraemia is present in 90% and hyperkalaemia in 65%. […] Undetectable serum cortisol is diagnostic […], but the basal cortisol is often in the normal range. A cortisol >550nmol/L precludes the diagnosis. At times of acute stress, an inappropriately low cortisol is very suggestive of the diagnosis.”

“Autoimmune adrenalitis[:] Clinical features[:] *Anorexia and weight loss (>90%). *Tiredness. *Weakness – generalized, no particular muscle groups. […] Dizziness and postural hypotension. *GI symptoms – nausea and vomiting, abdominal pain, diarrhea. *Arthralgia and myalgia. […] *Mediated by humoral and cell-mediated immune mechanisms. Autoimmune insufficiency associated with polyglandular autoimmune syndrome is more common in ♀ (70%). *Adrenal cortex antibodies are present in the majority of patients at diagnosis, and […] they are still found in approximately 70% of patients 10 years later. Up to 20% patients/year with [positive] antibodies develop adrenal insufficiency. […] *Antiadrenal antibodies are found in <2% of patients with other autoimmune endocrine disease (Hashimoto’s thyroiditis, diabetes mellitus, autoimmune hypothyroidism, hypoparathyroidism, pernicious anemia). […] antibodies to other endocrine glands are commonly found in patients with autoimmune adrenal insufficiency […] However, the presence of antibodies does not predict subsequent manifestation of organ-specific autoimmunity. […] Patients with type 1 diabetes mellitus and autoimmune thyroid disease only rarely develop autoimmune adrenal insufficiency. Approximately 60% of patients with Addison’s disease have other autoimmune or endocrine disorders. […] The adrenals are small and atrophic in chronic autoimmune adrenalitis.”

“Autoimmune polyglandular syndrome (APS) type 1[:] *Also known as autoimmune polyendocrinopathy, candidiasis, and ectodermal dystrophy (APECED). […] [C]hildhood onset. *Chronic mucocutaneous candidiasis. *Hypoparathyroidism (90%), 1° adrenal insufficiency (60%). *1° gonadal failure (41%) – usually after Addison’s diagnosis. *1° hypothyroidism. *Rarely hypopituitarism, diabetes insipidus, type 1 diabetes mellitus. […] APS type 2[:] *Adult onset. *Adrenal insufficiency (100%). 1° autoimmune thyroid disease (70%) […] Type 1 diabetes mellitus (5-20%) – often before Addison’s diagnosis. *1° gonadal failure in affected women (5-20%). […] Schmidt’s syndrome: *Addison’s disease, and *Autoimmune hypothyroidism. *Carpenter syndrome: *Addison’s disease, and *Autoimmune hypothyroidism, and/or *Type 1 diabetes mellitus.”

“An adrenal incidentaloma is an adrenal mass that is discovered incidentally upon imaging […] carried out for reasons other than a suspected adrenal pathology.  […] *Autopsy studies suggest incidence prevalence of adrenal masses of 1-6% in the general population. *Imagining studies suggest that adrenal masses are present 2-3% in the general population. Incidence increases with ageing, and 8-10% of 70-year olds harbour an adrenal mass. […] It is important to determine whether the incidentally discovered adrenal mass is: *Malignant. *Functioning and associated with excess hormonal secretion.”

January 17, 2018 - Posted by | Books, Cancer/oncology, Diabetes, Epidemiology, Immunology, Medicine, Nephrology, Pharmacology

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