(CP) 8.05 - Evaluation of Endocrine Function

8.
05 CLINICAL
EVALUATION
PATHOLOGY OF ENDOCRINE
Dr. John Tawasil
PITUITARY FUNCTIONS
PITUITARY GLAND HYPOPROLACTENEMIA
 Located within the sella tursica  Inability to lactate postpartum
 Contiguous to vascular and neurologic structures  No milk letdown
o Cavernous sinuses  Often manifested as Sheehan’s syndrome
o Cranial nerves (postpartum blues)
o Optic chiasm o Can lead to psychosis and first manifestation
of prolactin deficiency.
ANTERIOR PITUITARY GLAND  GnRH release is decreased in direct response to
 Secrete various trophic hormones elevated prolactin, leading to decreased production of
 Disease in this region may result in syndromes of LH and FSH
hormone excess or deficiency  In women: Amenorrhea (present earlier), Hirsutism
 Production of important hormones  In men: Impotence, tend to present later, large
tumors, sign of mass effect
POSTERIOR PITUITARY GLAND  Reference value for serum PRL is 1–25 ng/mL (1–25
 More of a terminus of axons of neurons in the μg/L) for women and 1–20 ng/mL (1–20 μg/L) for men
supraoptic and paraventricular nuclei of the  PRL deficiency can be seen with pituitary necrosis or
hypothalamus infarction and in some cases of
 Storehouse for the hormones pseudohypoparathyroidism
 The main consequence of disease in this area is
disordered water homeostasis GROWTH HORMONE DEFICIENCY
 Does not synthesize hormone – storage only SCREENING TEST
PITUITARY TUMOR
 Quantitate first if deficient or excess - GH
measurements
 Classifications:
o microadenomas (<1 cm in greatest diameter  Pharmacologic stimulation and GH suppression –
Oral Glucose Load
and confined to the sella)
o macroadenomas (≥1 cm in greatest diameter)
CONFIRMATORY: INSULIN TOLERANCE TEST (ITT)
 subcategorized into secretory and nonsecretory
 “gold standard” for diagnosing GHD
varieties
 Needs attendance of a physician
 All tumors have the potential to grow
 Contraindicated with seizures or cardiac or
o It can compress the optic chiasm, resulting in
cerebrovascular disease
visual field defects
 bitemporal hemianopia is the most
SECOND CONFIRMATORY TEST: ARGININE
frequent presentation STIMULATION
 Invasion into the cavernous sinus can lead to:  Combination testing with GHRH + arginine
o compression of cranial nerves III, IV, VI, V1,
 Adults will fail stimulation with arginine alone
and V2 and the intracavernous portion of the
internal carotid artery GROWTH HORMONE EXCESSS
o hydrocephalus caused by obstruction of the  Screened by failure of GH suppression ff. An oral
third ventricle glucose load.
o hormonal deficiency due to compression of  If the condition develops before closure of the
other cell lineages within the pituitary gland epiphyses, these individuals may be exceedingly tall -
GIGANTISM.
PROLACTIN
 Goal is to normalize IGF-I suppress the GH response
 Produced by lactotrophs to OGTT to <1 ng/mL (<1 μg/L).
 For initiation and maintenance of lactation  Growth hormone overproduction can result in the
 Secreted in a circadian fashion condition called acromegaly.
o Highest during sleep  Characteristic features include prognathism,frontal
o Nadir between 10am-noon bossing, and spadelike hands.
 Half-life: 26-47 minutes  The screening test for clinically suspected acromegaly
 It is recommended that when a patient is screened for is a randomly collected IGF-1.
hyperprolactinemia, three specimens should be  If the level of IGF-1 is elevated or borderline with
obtained at 20 to 30 minute intervals respect to the appropriate age- and gender-related
 Major circulating form is the non-glycosylated reference range, it becomes necessary to confirm the
monomer diagnosis using an oral glucose tolerance test
 PRL is measured by immunometric assay (5ug/L) (OGTT).
 PRL acts on breast tissue, where, in the setting of
estrogen priming, it
 stimulates lactation. ORAL GLUCOSE TOLERANCE TEST
 PRL also acts at the hypothalamus to inhibit the  Administering 75 g of glucose
secretion of gonadotropin-releasing hormone (GnRH)
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8
EVALUATION OF ENDOCRINE FUNCTION 8.05
 Obtaining blood samples at baseline and every 30  Excessive or inappropriate production predisposes to
minutes over the next 2 hours for glucose and GH. hyponatremia if water intake is not reduced in parallel
 Patient with gigantism has a normal suppression of with urine output
GH to <1 ng/mL (1 μg/L) at any time during the OGTT
process. DIABETES INSIPIDUS
 If GH fails to drop to below 1 ng/mL (1 μg/L), the  2 CLASSIFICATIONS
patient is diagnosed having acromegaly o Central – absent or decreased ADH from the
hypothalamus or neurophysis
POSTERIOR PITUITARY HORMONES o Nephrogenic – due to renal resistance to the
actions of ADH
 both variants are characterized by the passage of
large volumes of dilute urine (>2.5 L/day) in the face
of inappropriately elevated plasma osmolality
 Water deprivation test – diagnostic test for DI.
o In neurogenic DI, ADH levels are low and the
kidney rapidly acts to conserve water in
response to exogenous ADH administration
o In nephrogenic DI, the ADH levels are normal or
increased and exogenous ADH administration
has little or no effect on renal water absorption
NEPHROGENIC DI
 most common congenital etiology: X-linked receptor
defect
 most common acquired etiology: medications
(Lithium, demeclocycline, methoxyflurane)
NEUROGENIC DI
 congenital: autosomal dominant mutation in the ADH
OXYTOCIN
signal peptide or in the exons that code for
 Contributes to uterine contractions late in labor by neurophysins
direct action and by stimulation of prostaglandin  acquired: (more common) due to lesions affecting the
secretion hypothalamus (metastatic tumor, trauma or
 Plays a role in hemostasis at the placental site granulomatous disorders) or medications (phenytoin,
following delivery chlorpromazine, a-adrenergic agonists)
 Stimulates the myoepithelial cells surrounding the  idiopathic: presence of autoantibodies directed
mammary glands and lactiferous ducts to contract, against ADH-producing cells of the hypothalamus
resulting in milk ejection
 Its function in males remains unknown. SIADH – DYNDROME OF INAPPROPRIATE ADH
 Fergusson reflex - stimulation of oxytocin by  euvolemic hypoosmolar hyponatremia associated with
stretching of the cervix and vagina during parturition hyperosmolar urine
 cannot be diagnosed until nonosmotic stimuli for ADH
ARGININE VASOPRESSIN (AVP) secretion and other pathologies interfere with free
 Anti Diuretic Hormone water clearance have been excluded
 synthesized within the paraventricular and supraoptic  Water load test – in the absence of medication or
nuclei of the hypothalamus other conditions that might impair diuresis, failure to
 Major function: to maintain osmotic homeostasis by excrete 80 – 90% of the administered water load
regulating water balance within 4 hours and to suppress Uosm to <100
o by stimulating theV2 receptors on principal mOsm/kg is indicative of SIADH
epithelial cells that line the cortical collecting  In the right clinical setting, a spot urine Na less than
ducts of the kidney 30 mmol/L can generally distinguish those with
 Other Functions: hyponatremia due to volume depletion from those
 induces an increase in the production of cyclic with SIADH in whom urine Na is greates than
adenosine monophosphate (cAMP), increasing water 30mmol/L.
permeability and reabsorption.  Cause of renal salt wasting (2-fold process):
 a potent pressor by causing vasoconstriction (V1 1. At the onset of disease, volume expansion
receptor) inhibits RAAS axis and leads to greater
 stimulates ACTH secretion from the anterior pituitary improved delivery to the distal tubules
gland 2. Continued sodium loss due to secretion of
 stimulates the production of clotting factor VIII. Atrial natriuretic peptide
 Deficiency: Diabetic Insipidus – large amounts of
dilute urine THYROID FUNCTION
REVIEW OF THE THYROID
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 Has 2 lobes connected by a narrow isthmus decarboxylation to form acetic acid analog tetrac and
 Lobes are divided into lobules composed of 20 to 40 by ether link conjugated with sulfate to form T3-sulfate
follicles each and can be converted to acetic acid analog, triac.
 Follicles are ring-shaped, in which a single band of  Enzymes responsible: phenolsulfotransferases and L-
follicular cells surrounds a closed cavity containing aminotranferases
colloid, thyroid hormone (TH), and thyroglobulin (Tg)  After formation from T4, both T3 and rT3 undergo
 Follicular cells rest on a basement membrane that is deiodination to form 3,3’-diiodothyronine (T2)
rich in glycoprotein  Protein-bound thyroid hormones that do not enter the
 Apex of the follicular cells have microvilli that extend cells, are considered biologically inert and function as
into the colloid where initial phase of hormone a storage reservoirs for circulating thyroid hormones
secretion occurs  Free thyroid hormones, on the other hand, readily
 Also contains parafollicular cells (C cells) which enter the cell by a specific transport mechanisms to
synthesize calcitonin exert their biological effects, which are mediated by
T3 receptors located in the nucleus of the cell
THYROID FUNCTION  4 isoforms of the T3 receptors: α1, α2, β1 and β2; α1
 Normal function requires: intact hypothalamic- and β1 present in most tissues, which binds to the T3
pituitary-thyroid (HPT) axis and a ready source of to promote thyroid hormone action: increasing mRNA
iodide and protein synthesis; In contrast, α2 is inhibitory and
o Hypothalamus secretes TRH → TRH stimulates acts as a negative regulator of thyroid hormone
thyrotrophs of anterior pituitary to secrete action. On the other hand, β2 is unique in pituitary
thyrotropin (TSH) → TSH stimulates the thyroid gland and is the central in negative feedback
to synthesize and secrete hormones regulation of TSH by thyroid hormone.
 Thyroid hormones exerts negative feedback on the  Mutations in the β2 receptors have been described in
hypothalamus and pituitary gland to maintain a the syndrome of thyroid hormone resistance,
minimal TSH concentration; it also mediates various characterized by growth and mental retardations of
metabolic activities varying degrees, as well as hypothyroidism.
 Through TSH, inorganic iodine enters the follicular
cells, undergoes a series of metabolic steps and is
transformed into thyroid hormones, thyroxine (T4) and
3,5,3’-triiodothyronine (T3)
 100% of circulating T4 is of thyroidal origin, while 20%
of T3 is of thyroidal origin.
o Approximately 110 nmol (85µg) of T4 and 10
nmol (8.5 µg) of T3 are produced daily by the
thyroid
 Thyroid hormones circulate while attached to plasma
proteins
o T4 - 70% is bound to thyroxine-binding globulin
(TBG), 20% to transthyretin, 10% to albumin
o T3 - most are bound to TBG, but has a 10-fold
reduced affinity compared to T4
o Small percentages of both T4 (0.03%) and T3
(0.3%) remain unbound to plasma
 Thyroid diseases are functionally classified into 3:
o Hyperthyroidism
o Hypothyroidism *APPENDIX
o Euthyroidism
HYPOTHALAMIC-PITUITARY-THYROID AXIS
 Intro
THYROID HORMONE SYNTHESIS AND METABOLISM
 TRH
 Iodine is a major component of thyroid hormone; the
main source of iodine is dietary intake.  TSH
 Inorganic iodide is transported into the follicular cell  Thyroxine
by the sodium-iodide symporter (NIS) located in the  Free Thyroxine
basolateral membrane  Triiodothyronine
 TSH modulates NIS activity: An increase in TSH  Reverse Triiodothyronine
secretion augments the uptake of iodide into the  Thyroglobulin
follicular cell  Thyroxine Binding Globulin
 Thyroglobulin is a glycoprotein synthesized by the  Thyroid Autoantibodies
rough endoplasmic reticulum in the basal and  Physiologic regulators responsible for integrating the
perinuclear regions of the follicular cell function of the thyroid gland and the periphery
 70% of T4 peripheral metabolism are from include:
monodeiodination of T4 to T3 and rT3; 30 % are from o TRH- the hypothalamic hormone
conjugation of T4 to sulfate, deamination, and o TRH enhances TSH synthesis
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o Stimulates the secretion of any pre- formed  reference range is 5 to 12.5 μg/dL in adults
TSH from the thyrotrophs  used along with TSH and can be important in
o Modulates the bioactivity of TSH interpreting TSH results.
o Under the negative-feedback influence of  Primary Hypothyroidism
circulating thyroid hormones o low T4 , increased TSH
 TSH- the pituitary hormone  Primary Hyperthyroidism
 Serum free T3 and T4 concentrations o elevated T4 and T3, decreased TSH
 Hyperthyroidism
THYROTROPIN-RELEASING HORMONE (TRH) o Elevated serum T4 but with serum T3 levels
 Found in the: within the reference range or low.
o hypothalamus  T4 thyrotoxicosis
o brain o patients with iodine-induced thyrotoxicosis; in
o C cells of the thyroid gland patients on beta blockers, amiodarone, or large
o β cells of the pancreas doses of steroids; and in thyrotoxic patients
o myocardium with NTI
o prostate and testis  T3 thyrotoxicosis
o spinal cord o suppressed TSH level associated with a
 Thyroid hormones regulate their own production by normal to low-normal T4 and a high T3;
feedback inhibition to synthesis of TRH and TSH in o more common in a toxic nodule
the hypothalamus and pituitary gland  Low T4 and T3 syndrome
 Acts also on the production of other pituitary o Severe nonthyroidal illness is associated with
hormones, especially prolactin low T4 and low T3; an adaptive response to
 Leptin plays a significant role in the regulation of the reduce metabolic demands and conserve
TRH gene which affects the individual’s appetite for protein stores; arises from a maladjusted
food intake. central inhibition of TRH
 difficult to develop a specific antibody for TRH,assays  Euthyroid hyperthyroxinemia
are not clinically useful o increased serum T4 level in association with a
normal TSH in an otherwise euthyroid
THYROID STIMULATING HORMONE (TSH) individual; caused by increased binding
 a glycoprotein consisting of two monocovalently Proteins as may be seen with certain drugs
linked α and β subunits (e.g., estrogen) or medical conditions (e.g.,
 α subunit: liver disease). It is also seen in patients who
o has the same amino acid sequences as LH, are acutely hospitalized for psychiatric illness
FSH, and human chorionic gonadotropin (hCG) and in patients with familial dysalbuminemia
 β subunit:  Free T4 correlates better with thyroid functional status
o carries specific information to the binding than does serum total T4 – because it is the free
receptors for expression of hormonal activities hormone, not the protein-bound component, that is
 Due to the improvements in the sensitivity of the TSH bioactive.
assay, it can identify all instances of hyperthyroidism  T3 uptake (T3-UP) test - classical method of adjusting
and hypothyroidism, except when there is damage to a total T4 measurement for alterations in binding
the hypothalamus or pituitary gland, thyroid hormone protein; relative measurement of the unoccupied
resistance, or interference with normal functioning of binding sites of all circulating proteins.
the HPT axis due to medication
 Most individuals with hypothyroidism, serum TSH FREE THYROXINE
results are clearly elevated  Biologically active fraction of thyroxine in circulating
 Subclinical Hypothyroidism: blood
o elevated TSH  Traditional reference method for FT4 is equilibrium
o normal levels of T4, T3, and FT4 dialysis – a method that is not affected by changes in
binding protein concentration
 More accurate measurement using: ultrafiltration and
symmetrical dialysis
 Mass spectrometry – well suited for thyroid hormone
measurement
 Increases or decreases in serum FT4 without
concomitant changes in metabolic state have been
reported in pregnancy with NTI, and in patients being
treated with certain drugs.
*APPENDIX
 Prolonged administration of phenytoin or
THYROXINE
carbamazepine results in a 15% to 30% decrease in
 bind to various proteins in the blood (thyroid-binding
both serum T4 and FT4
globulin, albumin, thyretin) after release from thyroid
follicles. TRIIODOTHYRONINE (T3)
 measured by immunoassay
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 Generally measured by IMMUNOASSAY. Reference REVERSE TRIIODOTHYRONINE (rT3)

interval of 60 to 160 µg/dL (0.9 to 2.46 nmol/L).  Major metabolite of thyroxine, is produced by 5-
 Total T3 concentrations measured by competitive deiodination of T4
immunoassay methods that are now mostly  Clinically, serum T3 and serum rT3 vary reciprocally
nonisotopic and use enzymes, fluorescence, or (serum rT3 measurements however is little clinical)
chemiluminescence molecules as signals  Increased Serum rT3 in:
 Less bound to serum protein than T4; Relatively o Patients with NTI (whose ↓ serum total T3)
greater proportion of T3 than T4 exists in the free, o Healthy newborns
diffusable state o Patients with hyperthyroidism (including
 Serum total T3 measurement aids in confirming the factitious hyperthyroidism)
diagnosis of hyperthyroidism, especially in patients o Patients taking certain drugs, including
with no or minimally elevated T4 or ambiguous clinical amiodarone and propranolol
manifestation
 Serum total T3 level can be in the reference range or THYROGLOBULIN
low in patients with hyperthyroidism if there is  Synthesized and secreted by the follicles
coexistent NTI, or if patients are on drugs that  Healthy indiviuals : 30 ng/mL
decrease the conversion of T4 to T3 (e.g.,  Serum Tg concentration reflects
propranolol, amiodarone) o Thyroid mass
 T3 thyrotoxicosis - Hyperthyroidism with elevated o Thyroid injury
serum T3 but normal T4 and free T4. o TSH receptor stimulation
 Generally, the measurement of serum T3 is not useful  Increased in Grave’s disease, thyroiditis, and nodular
in evaluating patients suspected of having goiter
hypothyroidism because serum T3 levels are within  Measurement is to follow patients with thyroid
the reference interval in 15% to 30% of hypothyroid malignancy postoperatively
patients
 Helpful in patients with well-differentiated thyroid
 Severe hypothyroidism - patients with serum T4 carcinoma but not in those who have undifferentiated
levels less than about 2 µg/dL (32 nmol/L), T3 serum tumors or medullary thyroid cancer.
levels are also decreased
 Well-differentiated tumors typically display about a 10-
 Low serum T3 may occur in patients with a wide fold increase in Tg in response to a high TSH.
variety of NTI, acute illness such as myocardial
infarction (occurs rapidly, declining to about 50% of THYROXINE-BINDING GLOBULIN
the reference value within days), cord blood (but Main serum carrier protein for both T3 and T4
increase rapidly during the first few hours of life)  Measurement of TBG is helpful in patients who have
 Serum total T3 measurement aids in confirming the serum T3 and T4 levels that do not agree with other
diagnosis of hyperthyroidism, especially in patients lab parameters of thyroid function or are not
with no or minimally elevated T4 or ambiguous clinical compatible with clinical findings.
manifestation  Inherited abnormalities include
 Patients receiving thyroid preparations containing T3 o Complete
such as desiccated thyroid and synthetic T3 and T4 o Partial deficiency
combinations and those treated with T3 will have
o TBG variants with decreased affinity for T4
uninterpretable serum T3 results unless the time of
or T3, and TBG excess
hormone administration is known.
 Acquired abnormalities include
 T3 (Ctyomel) administration - rapid rise in T3
o Medications - salicylates, phenytoin,
concentration that peaks within 2 to 4 hours and then
begins to drop off penicillin and heparin (displaces T4 from
binding to TBG)
 T4 (levothyroxine) treatment - stable levels of T3,
o Medical conditions
which is derived from the peripheral conversion of T4,
are reached after only a few weeks of therapy  Measured by: IMMUNOASSAY (NV: 13-39 ug/dL)
 Pharmacologic agents that are associated with low
THYROID ANTIBODIES
levels of T3 and free T3, and with normal or even high
levels of serum T4 and FT4 (these patients usually  Autoimmune thyroid disease causes cellular damage
have normal TSH results): and alters thyroid gland function.
o Glucocorticoids o Cellular damage occurs when the
o Amiodarone - can induce hyperthyroidism or autoantibodies or sensitized T lymphocytes
bind so thyroid cell membranes, causing cell
hypothyroidism (TSH values will be
lysis and inflammatory reactions.
suppressed or elevated, respectively)
 3 thyroid autoantigens responsible for the
o Propranolol (large doses)
autoimmune thyroid disorders:
 Low serum T3 may occur in patients with a wide
1. TPO antibodies (TPOAb): involved in the
variety of NTI, acute illness such as myocardial tissue destructive process associated with
infarction (occurs rapidly, declining to about 50% of hypothyroidism in Hashimoto’s and atrophic
the reference value within days), cord blood (but thyroiditis
increase rapidly during the first few hours of life) 2. Tg antibodies (TgAb): used to detect
autoimmune thyroid disease in patients with
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goiter and to monitor iodide therapy in  Genetically determined FT4 setpoint for each
endemic areas individual when the pituitary gland sense any
3. TSH receptor antibodies (TRAbs): Grave’s deviation from the setpoint, it will cause reciprocal
disease. Measurement has also been used change in TSH secretion
to predict the risk of thyroid dysfunction in  Serum TSH abnormality will precede the development
newborns of mothers with GD as a result of of an abnormal FT4 during early stages of developing
trans-placental passage of maternal TRAb. thyroid dysfunction
 Children: there is progressive maturation and
URINARY IODINE MEASUREMENT modulation of the hypothalamic-pituitary-thyroid axis
 Iodine deficiency disorders affect 2.2 billion persons → Higher TSH concentrations
throughout the world, including the United States  Midgestation to after puberty: continuous decline in
 Iodine measurements are used mainly to assess the the TSH/FT4 ratio
dietary iodine intake of certain populations.  Pregnancy: increased estrogen production
 Iodine is required for normal thyroid hormone progressively elevates TBG concentration which
production. results in increased total T4 and T3 reference range
 Because most of the ingested iodine is excreted in the to 1.5 times the nonpregnancy upper reference levely
urine, measurement of urinary iodine (UI) excretion by 16 weeks’ gestation. Serum FT4 and T3
provides an accurate estimate of dietary iodine intake concentrations remain unchanged
 Trimester-Specific Reference Range for TSH by
SCREENING PROGRAMS FOR DETECTION OF ATA:
NEONATAL HYPOTHYROIDISM
o First trimester TSH: 0.1 - 2.5 miu/L
 Prevalence in newborns id ~1 in 3000 to 1 in 5000
o Second trimester TSH: 0.2 - 2.5 miu/L
 Higher in certain ethincity and increased in iodine-
o Third trimester TSH: 0.3 - 3 miu/L
deficient regions
 Serum FT4 assessment during pregnancy: using
 Early detection of hypothyroidism: eliminate severe
online extraction/liquid chromatography/tandem mass
mental retardation
spectrometry (LC/MS/MS), T4 is measured in the
 Using dry blood spots or cord serum: TSH and T4
dialysate or ultrafiltrate of the serum sample. If this is
measurement for screening
not available, TSH is measured
o False postive results= low T4 levels occuring
 Elevation of TSH during pregnancy:
in premature infants and with congenital
o Subclinical Hypothyroidism: normal FT4, TSH
absence of TBG
is 2.5 - 10 miu/L
 Elevated TSH: the most sensitive test for the
o Overt Hypothyroidism: TSH is >10 miu/L, low
diagnosis of congenital hypothyroidism
FT4 or TSH 2.5 - 10 miu/L, low FT4
 For newborns:
 Thyroxine - only used drug for treating hypothyroid
o TSH value <10 mIU/L= no further action
pregnant women
needed
o TSH value 10-20 mIU/L= repeat test after 2- MEDICATIONS
6 weeks  Estrogen-induced TBG elevation causes
o TSH value >20 mIU/L= endocrinologic abnormally high total T4 and total T3, but has no
evaluation for hypothyroidism effect on TSH or FT4 and free T3.
 Glucocorticoids in large doses can suppress TSH
NONTHYROID ILLNESS
and decrease the conversion of T4 to T3
 Severe Illness - total and free T3 rapidly decline
 Dopamine suppresses TSH and can temper the
o Ex: Myocardial infarction and Sepsis
expected rise in TSH in hospitalized patients with
o Serum total T4 falls as the severity of the primary hypothyroidism
illness increases due to disruption of T4-  Propranolol suppresses the conversion of T4 to T3
binding protein by inhibitors in the circulation (this is one of the reasons it is used in the treatment
 Euthyroid Sick Syndrome or Low T4 Syndrome - of thyrotoxicosis).
thyroid function tests alterations seen in NTI  Iodide, found in iodide-containing contrast media
o Poor prognosis: patients with NTI whose T4 used in CT scans and coronary angiography or in
levels drop below 2ng/dL solution to sterilize skin, and radiopaque dyes can
o Patients with NTI: low or low-normal TSH, cause both hyperthyroidism and hypothyroidism in
normal or low-normal T4, very low T3 -- during susceptible patients.
Acute Illness  Iodine-containing drugs such as amiodarone (used
 Certain drugs that are used for underlying illness can as an antiarrhythmic agent) have complex effects on
suppress TSH and mask hypothyroid status thyroid function and can cause hypothyroidism or
o Ex: glucagon, dopamine, and high doses of hyperthyroidism
corticosteroids  Lithium inhibits thyroid hormone synthesis and
 Uremia - indoleacetic acid accumulation interferes release and can cause hypothyroidism; critical to the
with thyroid hormone binding development of hypothyroidism and goiter.
 Drugs such as phenytoin, carbamazepine,
PHYSIOLOGIC VARIABLES salicylate, salsalate, and furosemide competitively
inhibit thyroid binding to serum proteins. Therapeutic
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doses of phenytoin can induce acceleration of T4  An average replacement dose is 1.6 ug/kg body
disposal and perhaps can directly suppress TSH weight/day for adults
centrally, all of these mechanisms being responsible  4.0 ug/kg body weight/ day for children
for the reduced T4.  1.0 ug/kg body weight/ day for older adults
 Heparin can stimulate in vitro lipoprotein lipase and  The requirement might increase during pregnancy
can liberate free fatty acids, which inhibit T4 binding and in post-menopausal women starting hormonal
to serum proteins and falsely elevate FT4. replacement
 Medications such as phenobarbital, phenytoin,  A serum TSH between 0.5 to 2.0 mIU/ml is the
rifampin, and carbamazepine increase the rate of therapeutic goal level for L-T4 replacement in primary
thyroid hormone clearance by increasing the hypothyroidism
deiodination of T4 and T3. Hypothyroid patients  Serum FT4 concentration in the upper third of the
treated with any of these medications need to have reference intervals is therapeutic range in central
their hormone levels monitored closely. hypothyroidism.
 Somatostatin or its analog, octreotide, which is L-T4 is used to suppress TSH in patients with well-
used to treat acromegaly, and dopamine inhibit TSH differentiated thyroid carcinoma
synthesis to undetectable levels in patients with
severe NTI.
CALCITONIN
THYROID ILLNESS  Medullary thyroid carcinoma (MTC) originates from
 Hyperthyroid patients the C cells of the thyroid.
o present with one or all of the following signs  25% of MTC cases are hereditary (multiple endocrine
and symptoms:weight loss, sweating, heat neoplasia types 2A and 2B)
intolerance, palpitations, insomnia, increased o Autosomal dominant inherited multiglandular
bowel movement, tremors, infertility, or syndromes
amenorrhea o Recurring MTC genetic mutation = RET
o Secondary Hyperthyroidism: TSH is elevated oncogene located on the chromosome subband
along with T4 and T3; caused by TSH-producing 10q11.2
pituitary tumors, or other rare disorders such as o Recommended method of initial testing for
pituitary resistance to thyroid hormones. MEN2A is either a single or multi-tiered analysis
o Subclinical Hyperthyroidism is defined as low to detect RET mutation in exon 10 (codon 609,
TSH (<0.1 µIU/mL) with normal levels of T4 and 611, 618, 620), exon 11 (condon 630, 634) and
T3 exons 8, 13, 14, 15 and 16
 Primary hypothyroidism patients:  The current ATA risk categories for Hereditary MTC
o present with one or all of the following signs are:
and symptoms: cold intolerance, constipation, o Highest Risk (HST) - Patients with MEN2b and
water retention, hypercholesterolemia, RET codon M918T mutation
depression, pretibial myxedema, periorbittal o High Risk (H) - Patients with MEN2a and RET
edema, elevated TSH with low T4 and T3 codon c634 mutation
o In secondary hypothyroidism: TSH is low  Moderate Risk - Patients with hereditary MTC and
along with T4 and T3; caused by pituitary or RET codon mutations other than M918T and c634
hypothalamic disorders.  C cells secrete several hormones and biogenic
amines such as calcitonin and ACTH, B-melanocyte
o subclinical hypothyroidism have elevated stimulating hormone, somatostatin, chromogranin,
TSH levels (>4.5 µU/mL), but both T4 and T3 histaminase, neurotensin and carcinoembryonic
are within the reference range. antigen (CEA)
 Calcitonin and CEA are valuable tumor markers for
SCREENING FOR THYROID DISEASE patients with MTC
 ATA guidelines recommend screening at 35 years of o Elevated level of calcitonin in circulating blood
age and every 5 years thereafter. indicates presence of MTC
 Hashimoto’s thyroiditis o Measurement of calcitonin is done by two-site
o High TSH immunometric assays using monoclonal
o Positive TPOAb antibodies.
o Increasing prevalence with increasing age  One recognizes the N-terminal region
 Incidence of low TSH is also increased in older adults  The other one, recognizes the C-terminal
 Higher CV mortality rate in patients with chronically region
 This method is more specific and more
low TSH
sensitive
 Mild hypothyrodism in early pregnancy increases fetal
 This method eliminates any cross-reactivity
loss and impairs the IQ of offspring.
with procalcitonin that can be elevated
 Important to always confirm any TSH abnormality in a during sepsis or inflammatory conditions
fresh specimen drawn 3 weeks later before making
 The cutoff level in healthy adults is about 10 ng/L and
the diagnosis of mild abnormalities.
it is higher in children <3 years of age.
USES OF L-THYROXINE
CERVANTES
L8
 Some calcitonin measurements are used as tumor  The adrenal glands have a very rich arterial supply
markers for detecting residual thyroid tissue or that forms a subcapsular plexus and empties into a
metastasis in patients with MTC. central vein.
 It should be measured before and 6 months after  They have the highest perfusion of blood per gram of
surgery. tissue – a feature that ensures rapid dissemination of
 Presence of residual tissue or a recurrence of MTC hormones throughout the body in response to stress.
can be ruled out only if both basal and
postpentagastrin or calcium-stimulating calcitonin are
undetectable.
 Provocative stimuli, such as calcium and pentagastrin
or omeprazole, have been used to detect C cell
abnormalities, as they increase calcitonin levels at all
stages of MTC
 Pg (pentagastrin) stimulation test for the diagnosis of
MTC
o An intravenous infusion of Pg (0.5 ug/kg body
weight) is given over 5 seconds. HORMONES OF THE ADRENAL MEDULLA
o Blood samples are collected at baseline, 1, 2, 5  The adrenal medulla is part of the sympathoadrenal
and 10 minutes after the start of the infusion. axis. Being of neural crest origin, it possesses the
 Calcitonin stimulation test capability of synthesizing catecholamines through the
o Intravenous injection of 2.5 mg/kg of calcium process of amine precursor uptake and
gluconate is given over 30 seconds. decarboxylation.
o Blood samples are then collected at baseline, 1,
2 and 5 minutes.
o An increase in the plasma calcitonin level above
100 ng/L is an indication of C cell hyperplasia.
 Calcium infusion test is less sensitive than the Pg test
for the diagnosis of MTC, but if combined with the Pg
test, it enhances the sensitivity of the Pg test.
 The initial and rate-limiting step in catecholamine
INTREPRETATION OF THE PENTAGASTRIN (Pg) TEST synthesis is the conversion of tyrosine to 3,4-
dihydroxyphenyalanine (dopa) by the enzyme tyrosine
hydroxylase.
 Through a series of steps, L-dopa is converted to
dopamine, NE, and E.
 Epinephrine is almost exclusively produced and
secreted by the adrenal medulla.
 The catecholamines are either metabolized by either
catechol-O-methyl-transferase (COMT) or
monoamine oxidase (MAO).
 COMT – converts D to methoxytyramine, E to
metanephrine, and NE to normethanephrine, all of
which can be oxidized to vanillylmandelic acid
(VMA) by MAO.
 MAO – converts E and NE to 3,4-dihydroxymandelic
acid, which is acted upon by COMT to form VMA.
 3-Methoxy-4-hydroxyphenylacetic acid
(homovanillic acid [HVA]) is the final produce of
ADRENAL FUNCTION
dopamine metabolism.
 The adrenal glands are pyramidal structures located
above the kidney. PHEOCHROMOCYTOMA
 Anatomically divided into two parts: the medulla (inner  Arises from the chromaffin cells of the adrenal
layer) and the cortex (outer layer) medulla and account for 90% of catecholamine-
 Medulla – of neural crest origin (ectoderm); stores producing tumors.
and secretes catecholamines  Have an incidence of about 500 to 1600 per year and
 Cortex – of mesenchymal origin; further divided into account for <1% of all secondary causes of
three zones: hypertension.
o Outermost zona glomerulosa – produces  90% are benign
mineralocorticoids  Most pheochromocytomas are sporadic; however,
o Zona fasciculata – produces glucocorticoids 10% to 20% are familial
o Inner zona reticularis – produces  Sustained or paroxysmal hypertension is the most
androgens common manifestation
CERVANTES
L8
 Other symptoms include orthostatic hypotension, FACTORS THAT CAUSES FALSE POSITIVE RESULTS
labile blood pressure, excessive sweating, anxiety,  Patients should abstain from caffeinated beverages
nervousness, weight loss, fatigue, pallor, and tremor. and alcohol for 24 hours before testing.
 They should also avoid acetaminophen, tricyclic
antidepressants, phenoxybenzamine, α agonists (e.g.,
methyldopa [Aldomet]), and monoamine oxidase
inhibitors for at least 5 days before testing
 During testing for catecholamines, in addition to the
list of items to avoid when testing for metanephrines,
the patient should avoid nicotine, sympathomimetics
(theophylline, pseudoephedrine), α agonists (e.g.,
albuterol), and levodopa/carbidopa.
 Stressors such as an acute myocardial infarction,
congestive heart failure, surgery, and acute
cerebrovascular accident are all associated with
elevated levels of catecholamines.
 Plasma normetanephrine concentrations increase
with age; as a result, older adult patients are
particularly susceptible to having false-positive tests.
 10% to 20% are familial
 Genetic testing <50 y/o, physical traits suggestive of
one of the familial disorders, multifocal disease, or a
DIAGNOSIS positive family history.
 The products of COMT, metanephrine and  Tests:
normetanephrine, serve as specific markers of o Assaying for mutations in the gene for menin in
chromaffin tumors MEN 1
 Most recent guidelines recommend the measurement o RET oncogene in MEN 2A (Sipple’s disease)
of either plasma- free metanephrines or 24-hour urine and MEN 2B
collection for fractionated metanephrines via high- o neurofibromin in NF-1
pressure liquid o VHL in von Hippel–Lindau syndrome
 Plasma normetanephrines, and urine for fractionated  Familial paragangliomas are associated with various
catecholamines and VMA may also be obtained. defects in the gene for succinate dehydrogenase
 The plasma concentration of either free metanephrine  Pretest and posttest counseling is mandatory
is normetanephrine that is about four times the
upper reference limit. CHROMOGRANIN A (CGA)
 Samples are recommended to be collected after the  stored and secreted along with the catecholamines
patient has been supine for at least 30 minutes. from the adrenal medulla and sympathetic nervous
 In centers where this assay is not available the initial system.
test should be the chromatographic measurement of a  elevated in more than 80% of pheochromocytomas
24 hr urine collection for  high sensitivity of 86%; poor diagnostic specificity
normetanephrine,metanephrine, fractionated free o kidneys play a major role in the clearance of
catecholamines.
CgA from the circulation
 Metanephrine is the most sensitive and specific of o mild degrees of renal impairment can lead to
these metabolites.
significant increases in serum concentration of
 Another method of diagnosis is by measuring plasma CgA
catecholamines. But this method is only of used if
 Major use: Postoperative monitoring for recurrence of
the sample is collected during paroxysm.
these tumors.
 The value from 24hr urine collection or plasma
catecholamines that are 2 to 3 times above the upper NEUROBLASTOMA
limit of the normal are usually diagnostic of  Neural Crest in origin, arising within adrenal glands/
pheochromocytoma. sympathetic chain.
 Second most common solid malignant tumor in
SPORADIC PHEOCHROMOCYTOMA
childhood- (3-5yrs old)
 Choice and interpretation of the diagnostic tests  Symptoms relate primarily to tumor mass than
depends on the pretest level of suspicion for disease. hypertension which is mild or absent.
o A 24 hour urinary fractionated metanephrine and
 At time of diagnosis
fractionated catecholamine measurements are o -70% have distant metastasis
clinically acceptable than fractionated plasma
o (about 90% have elevated urinary HVA
free metanephrine values.
“homovanillic acid” levels)
o Fractionated plasma free metanephrines are
o (almost 75% have increased urinary
considered the biochemical test of choice in
vanilmandelic acid (VMA)levels)
pediatric population.
CERVANTES
L8
 Both test for HVA and VMA must be ordered for

screening.
o In healthy children until age of 15 VMA and
metanephrines usually higher than adults.
o Metanephrines also can be elevated in
neuroblastoma but not sensitive measure of
residual tumor.
o HVA is increased in familial dysautonomia
(Riley-Day syndrome) and pheochromocytoma
MINERALOCORTICOID AXIS
ALDOSTERONE
 Chief mineralocorticoid that promotes reabsorption of
Na+ and H2O by the kidney to help maintain blood
pressure and tonicity.
 May respond to acute changes in ACTH
 Under the control of the Renin-Angiotensin System
CONGENITAL DISORDERS OF ADRENAL CORTICAL

ENZYME DEFICIENCIES
 The hormones of the adrenal cortex are steroid
derivatives, synthesized from low-density lipoprotein
(LDL) cholesterol.
 LDL is delivered to the adrenals where it is taken up
by LDL receptors.
 Steroid acute regulatory protein (StAR) shuttles LDL
 Expression of the enzyme CYP11B2 (aldosterone
across the mitochondrial membrane, where it begins
synthase) is site-specific to the zona glomerulosa. its journey down the steroidogenic pathway
 11-deoxycorticosterone (DOC) and 11-deoxycortisol  The enzymes that catalyze these synthetic reactions
as well as precursor molecules to aldosterone can be are of four general types:
synthesized in both zona glomerulosa and zona o Hydroxylases
fasciculata.
o Dehydrogenases
 Zona fasciculata - responsible for the synthesis and
o Desmolases
secretion of glucocorticoids
o Isomerases
 Zona reticularis - produces androgens and estrogens
 Because most of the inborn errors of metabolism
CORTISOL affecting steroid hormone synthesis in the adrenal
 Key glucocorticoid that regulates its own secretion cortex involve de ciencies of hydroxylases, they
through negative feedback from HPA axis constitute the most clinically important group of
 Inhibits corticotropin-releasing hormone (CRH) from enzymes.
hypothalamus  At least eight different metabolic defects in the
 Inhibits ACTH release from pituitary gland synthesis of cortisol and aldosterone have been
 It is needed in times of stress to maintain blood described, each characterized by a deficiency of a
pressure and blood sugar, and to prevent shock. specific adrenal enzyme.
 CORTICOSTERONE also possesses a glucocorticoid  A vast majority of these enzymatic deficiencies are
activity inherited as an autosomal recessive trait with variable
degrees of penetrance. Those enzymatic defects that
uniquely affect the biosynthesis of cortisol are
grouped together under the rubric of congenital
adrenal hyperplasia (CAH).
 These five enzymes are P450scc (defect in StAR), 3-
β-hydroxysteroid dehydrogenase, 21-hydroxylase, 11-
hydroxylase, and 17-hydroxylase
 In CAH, defects in the enzymes necessary for cortisol
production lead to cortisol deficiency; cortisol
deficiency results in disinhibition of negative feedback
on CRH and ACTH production.
 CRH and ACTH levels rise, inducing adrenal
hyperplasia and a forward push in steroidogenesis, as
the body tries to compensate and normalize cortisol
production.
CERVANTES
L8
 Not only does this result in a buildup of hormonal Therefore, a deficiency in 21-OH leads to an increase in:
precursors directly preceding the enzymatic defect, it 17-OHP in serum
also causes massive shunting of these precursors Pregnanetriol in urine
down the remaining functional pathways. Clinical symptoms depend on severity of the deficiency.
CLASSIC FORM VS NON-CLASSIC FORM

 Symptoms range from shock, salt-wasting, and
CLASSIC FORM (CYP21A1)
anomalous sexual development in infancy, to
hirsutism and infertility in the adult.  Presents during newborn period or early childhood
 Adrenal insufficiency and virilization
 May or may not have salt wasting
 In a study of 38 children:
o 40%-80% lowering of plasma epinephrine,
metanephrine, and urinary epinephrine levels.
 In another study:
o Significant decrease in catecholamine response
to exercise that was unaffected by the
administration of stress doses of glucocorticoid
NON-CLASSIC FORM
 Late childhood = early adrenarche
*appendix  Young adulthood = hirsutism, amenorrhea, and
infertility
 The diagnosis is made by measuring the various  In females: may present as PCOS
serum hormone levels and assessing which steroids  In males: precocious puberty, adrenal rests within the
are produced in excess and which are deficient, and testes, and infertility
by calculating the precursor/product ratio and
comparing these results to age- and sex-matched DIAGNOSIS
normative data. PRENATAL DIAGNOSIS
 If hormone levels return as borderline, but the clinical  Suppressive treatment with steroids can abrogate the
suspicion for CAH remains high, the steroid levels development of virilization of the female fetus.
should be remeasured 60 minutes after intravenous  Measuring 17-OHP in amniotic fluid
administration of 0.25 mg of ACTH. ACTH drives  Genotyping cells obtained by chorionic villous
steroidogenesis forward, accentuating the block. sampling
 CAH is categorized according to severity of disease
into classic (neonatal, severe) and nonclassic (late- NEONATAL SCREENING
onset, cryptogenic) forms.  Mandatory in the US
 The classic form is further subdivided into salt-losing  Measuring 17-OHP (using automated time resolved
and non–salt-losing (simple virilizing) variants. dissociation-enhanced lanthanide fluoroimmunoassay
[DELFIA])
21-HYDROXYLASE DEFICIENCY
 Genotyping blood from heel stick and collected on
 The most common cause of CAH (95% of all cases)
filter paper
 21-hydroxylase (aka CYP21, CYP21A2, P450c21)  CYP21 (CYP21A2) >>>> Located on
o Located in mitochondrial endoplasmic reticulum
 CYP21P (CYP21A) >>>> Chromosome 6
 Screening:  CYP21 is active
o Capillary heel blood on paper filter disks
 Mutations in CYP21P interfere with normal gene
 Classic Form expression
o Detected in 1 in 16,000 live births  These mutations are identified by PCR and Southern
 Non-Classic Form blotting on chorionic villous samples
o 0.2% of the general Caucasian population  In the newborn with salt wasting, unstimulated 17-
 Dysplasia of medulla OHP levels are typically greater than 8000 ng/dL,
 Catecholamine hyposecretion rising to 100,000 ng/dL (3000 nmol/L) following
 Degree of medullary impairment: biomarker for CAH administration of ACTH
severity  Levels in the simple virilizing variant range from
10,000 to 30,000 ng/dL (300 to 1000 nmol/L).
 Those with nonclassic disease typically have 17-OHP
levels ranging from 1500 to 10,000 ng/dL (50 to 300
nmol/L) (New et al, 1983)
 The diagnosis can be confirmed by comparing serum
17-OHP levels before and 60 minutes after
administration of 0.25 mg ACTH (Cortrosyn).
DIFFERENT VALUES
CERVANTES
L8
 Normal:  Deficiency Leads to blockage in the conversion of Δ5

o Post ACTH 17-OHP <330 ng/dL to Δ4 steroids
 Heterozygote Carrier  Increase Δ5 steroid but Δ4 remains normal
o 330-1000 ng/dL  Manifestations:
 Non-Classic CAH  Glucocorticoid deficiency due with or without salt
o >2000 ng/dL wasting
 Incomplete masculinization for males
MINERALOCORTICOID REPLACEMENT THERAPY  Females may have ambiguous genitalia
 In children:  Late onset: polycystic ovarian disease
o Attainment of normal growth  Diagnosis
o Attainment of normal weight o Previous: examine basal and ACTH stimulated
o Attain normal pubertal development Δ4/Δ5 ratios in urine or blood
o Optimization of final adult height o Revised: genotypic studies, ACTH stimulated
 In adults: Δ5-17 P levels and Δ5-17 P/cotisol ratios( shown
o Lessening of signs of virilization best indices in diagnosing 3-B-HSD deficiency)
o Resumption of fertility  Treatment:
 Normalization of 17-OHP should not be attempted o Glucocorticoids, mineralocorticoids as well as
because it requires supraphysiologic levels if sex steroids
glucocorticoids and may result in Cushing’s
Syndrome 17-HYDROXLASE DEFICIENCY
 21-Oh causes varying degrees of hypoaldosteronism  17-Hydroxylase (CYP17, P450c17) - expressed in the
 This is apparent due to elevated plasma renin activity adrenal glands and the gonads and encodes two
(PRA) and decreased aldosterone/PRA ration enzymes:
 The goal of mineralocorticoid replacement therapy is o 17α-hydroxylase - catalyzes the conversion of
to normalize the plasma renin activity pregnenolone and progesterone to their
respective 17-OH derivatives
11-β-HYDROXYLASE DEFICIENCY o 17,20-lyase - converts 17-OH pregnenolone to
 The second most common enzyme deficiency of the dihydroepiandosterone, and 17-OH
adrenal cortex, progesterone to androstenedione
 A defect in this enzyme blocks the final conversion of  CYP17 deficiency - blocks the conversion of
11-deoxycortisol to cortisol and DOC to corticosterone pregnenolone and progesterone to the 17-hydroxy
 11-OH deficiency is an autosomal recessive disorder derivatives, causing shunting from testosterone and
caused by mutations of the genes CYP11B1 and cortisol synthesis to aldosterone.
CYP11B2, on chromosome 8q21q22  Patients develop hypertension and hypokalemic
alkalosis in association with incomplete
DIAGNOSIS masculinization (in the male) and decreased
 In the neonate, high basal and a high ACTH- testosterone and cortisol levels.
stimulated 11-deoxycortisol, Concentrations of urine  17-OH deficiency Diagnosis: high DOC,
tetrahydro-11-deoxycortisol are also elevated pregnenolone, and progesterone levels, along with
 Childhood and in young adults, the diagnosis of 11- decreased urinary 17-ketosteroids and 17-
OH deficiency is made by the presence of elevated hydroxycorticosteroids.
early-morning and ACTH-stimulated serum levels of  Gene associated with this condition (CYP17) - located
11-deoxycortisol that are more than three times the on chromosome 10q, the same gene as 17,20-
upper limit for age-matched normals. desmolase
 Levels of DOC and adrenal androgens
CONGENITAL LIPID ADRENAL HYPERPLASIA
(androstenedione, dehydroepiandrosterone, and
dehydroepiandrosterone sulfate) are also elevated.  Most severe form of Congenital Adrenal hyperplasia
 Plasma renin activity and aldosterone are often  Condition in which all the synthesis of all gonadal and
suppressed as a result of salt and water retention adrenal cortical steroids is markedly impaired.
induced by elevations of DOC.  Maybe caused by a defect in the StAR or the P450
 Prenatal diagnosis of 11-OH deficiency is made by side chain cleavage (scc) which is located on
measuring levels of tetrahydro-11-deoxycortisol (THS) chromosome 8p11, controls the rate-limiting step in
in the maternal urine or amniotic fluid. These levels steroidogenesis.
begin to rise in the first trimester.  It is responsible for the shuttling of cholesterol from
 Pathologically, the adrenal cortex shows marked the outer to the inner mitochondrial membrane.
accumulation of cholesterol and other lipids, which is  20,22-Desmolase (CYP11A1, P450scc) converts
the primary distinguishing feature from congenital cholesterol to pregnenolone
adrenal hypoplasi  Pathologically, the adrenal cortex shows marked
accumulation of cholesterol and other lipids, which is
3-β-HYDROXYSTEROID DEHYDROGENASE the primary distinguishing feature from congenital
DEFICIENCY adrenal hypoplasia.
 3-B-HSD catalyze second enzymatic step in  Clinical presentation:
steroidogenesis
CERVANTES
L8
o Severe adrenal insufficiency with hypotension, o CRH is released in a circadian pattern and in
salt wasting, and feminization of external response to physiologic stimuli such as stress
genitalia in males. and hypoglycemia.
o Occasionally, females may not present until  The HPA axis consists of various feedback loops that
the onset of puberty. control cortisol synthesis and secretion. When plasma
 Diagnosis: cortisol increases, it suppresses the release of CRH,
o Presence of extremely low cortisol and ACTH, and AVP, which, in turn, leads to lowering of
aldosterone concentrations and elevated the cortisol level.
ACTH and plasma renin activity.  Conversely, when serum cortisol reaches a nadir, the
hypothalamus and pituitary gland respond by
ALDOSTERONE SYNTHETASE DEFICIENCY increasing CRH and ACTH production, leading to
 Aldosterone Synthetase (CYP11B2) = stimulation of cortisol formation and secretion.
 Final Step in Steroid synthetic pathway --> o By this mechanism, ACTH and cortisol control
Aldosterone the concentration of each other within a very
narrow range, and a small change in one results
11-Hydroxylation of DOC → Corticosterone → in a concomitant change in the other.
18-hydroxycortisone ⇏ Aldosterone  When the adrenal gland is unable to respond to
ACTH
o cortisol levels are low and ACTH levels are high.
 Causes Salt wasting, hyperkalemia and metabolic
acidosis  Damage to the hypothalamus is also associated with
 Dx=Demonstrating the presence of metabolites of low ACTH and cortisol levels;
o Synthetic forms of CRH are used in testing the
Corticosterone and 11-deoxycorticosterone in urine,
elevated DOC, and [↓corticosterone,18- anterior pituitary gland’s reserve of ACTH by
hydroxycorticosterone or aldosterone in the serum comparing plasma ACTH and cortisol before and
1 hour after CRH stimulation
CORTISOL AND GLUCOCORTICOIDS  In those conditions in which the pituitary gland is
 The adrenal cortex secretes cortisol in response to destroyed, ACTH is not formed and cortisol levels are
ACTH, a diurnal rhythm, and stress. consequently low.
 ACTH, synthesized in the adenohypophysis, is  testing with CRH may permit the distinction between
formed from the cleavage of a much larger precursor these two entities
molecule: POMC.  If the lesion is in the hypothalamus, after a time delay,
o cleavage of POMC releases β-LPH, which in ACTH levels rise following CRH administration. If it is
turn is cleaved to yield γ-LPH and β-endorphin. in the pituitary gland, no significant ACTH response
 Within the ACTH sequence are α-MSH and the occurs. With primary adrenal insufficiency,
corticotropin-like intermediate lobe protein. administration of CRH causes a further rise in an
 Endorphins, which act on neurons in the brain, already elevated ACTH level, but little or no rise in
constitute a distinct peptidergic system related to pain cortisol level.
perception. The significance of this remains unknown.  If the HPA axis is interrupted by the administration of
 Occasionally, POMC is incompletely processed; large quantities of exogenous glucocorticoids, they
leading to formation of other forms of ACTH that will exert an inhibitory effect on the hypothalamus and
usually have little biological activity. pituitary gland, suppressing CRH and ACTH
secretion.
 These forms may predominate in malignant
conditions such as ectopic production by primary or  If this suppression continues = leads to atrophy of the
metastatic lung cancer, and in some patients with adrenal glands;
Nelson’s syndrome o the HPA axis unable to secrete cortisol in times
 Defects in POMC cleavage enzymes may also be of stress.
responsible for the formation of rare forms of isolated o The HPA axis can fully recover after tapering off
ACTH deficiency of steroids.
 Nelson’s syndrome: a disorder characterized by the  The second influence on plasma cortisol levels is the
occurrence of a pituitary tumor and skin diurnal pattern, which is due to the circadian pattern
hyperpigmentation following bilateral adrenalectomy. of ACTH release.
 ACTH secretion is mediated by CRH and AVP o Major increases in secretion occur at between 4
(important) am and 8 am, followed by a decrease in ACTH
o Other factors: atrial natriuretic factor (ANF), during the rest of the day.
angiotensin II, IL-6, IL-1, and tumor necrosis o the lowest ACTH concentrations are found
factor-α. shortly after midnight.
 CRH is synthesized and released from the  Sudden changes in sleep-wake patterns have little
hypothalamus effect on the diurnal pattern but permanent changes
o acts to stimulate the synthesis and release of in daily sleep habits result in a gradual change in
ACTH from the pituitary gland. diurnal secretory patterns.
 Superimposed on the circadian periodicity is an
ultradian rhythm of 10 to 18 secretory bursts per 24
hours
CERVANTES
L8
 The third important influence on cortisol secretion is  ACTH secretion is inhibited and levels are low or
stress. undetectable in patients with increased levels of
o Stimuli such as surgical trauma, pyrogens, circulating glucocorticoids due to an adrenal adenoma
hypoglycemia, and hemorrhage are capable of or carcinoma, and those taking steroids
bringing about an acute increase in ACTH and  In patients with pituitary-induced adrenal hyperplasia,
cortisol secretion. plasma ACTH may be at or above the upper
 Response to stress may be absent or decreased in reference interval at 9 am, and fail to show the
magnitude in patients in whom large doses of steroids expected fall after midnight
have been administered for some time.  Another use of ACTH assays is in the determination
 The initiation of any stress response is dependent on of adequacy of cortisol replacement in congenital
an intact nervous system. adrenal hyperplasia
 Evidence suggests that the stress response of cortisol  When replacement therapy is optimal, ACTH values
is mediated through excitatory and inhibitory inputs are similar to those seen in a reference population
that integrate at the level of the hypothalamus and
modulate CRH secretion. PLASMA CORTICOTROPIN-RELEASING HORMONE
o Cortisol levels also rise after meals, especially  CRH measurements are performed by: liquid
those high in protein; it also rises in depression chromatography and tandem mass spectrometry
 For example, trauma normally results in the acute  Two forms: free and bound to CRH-binging protein
release of ACTH and cortisol; however, in patients  Reference range for men and pregnant women: <34
with spinal cord transections, the normal transmission pg/ml
of neurologic stimuli is interrupted, and as a result, the  CRH is increased in Cushing’s Syndrome due to
same trauma applied to an extremity will not elicit any ectopic production of CRH
ACTH or cortisol response.  CRH-binding protein: increases during pregnancy
 Most disorders of cortisol secretion can be classified o 1st trimester: <40 pg/ml
by the patterns of response of the following three o 2nd trimester: <153 pg/ml
hormones to suppression and stimulation: ACTH, o 3rd trimester: <847 pg/ml
plasma cortisol, and urinary free cortisol
SERUM CORTISOL MEASUERMENTS
LABORATORY MANAGEMENT OF ACTH  90% of circulating cortisol is bound to serum protein
 Plasma ACTH is measured using a two-site  Fluorometric assay: earliest and simplest method to
immunoradiometric assay or an determine serum cortisol concentration
immunochemiluminometric assay  Antibody-based Immunoassays: more specific
 To prevent degradation of ACTH, it is best to collect method for cortisol estimation
the sample in a pre-chilled EDTA lavender-top tube o Advantage: smaller specimen volume and more
 Specimen should be kept in an ice bath and rapid turnaround time
processed as soon as possible o Disadvantage: antibodies showed large degree
 Following centrifugation in a refrigerated centrifuge, of cross reactivity resulting in elevated cortisol
the specimen should be separated, transferred to a concentration
plastic tube, and kept frozen at −20° C until time of  High performance liquid chromatography with tandem
analysis mass spectrometry: has an ultimate specificity and it
 Normal: 2-12 pmol/L (9-52 pg/mL) between 7am and is where serum cortisol is collected in a no-additive
10am tube.
 Plasma ACTH is useful for distinguishing between  Reference values: M and F = 5-25 ug/dL at 8am to
primary (adrenal), secondary (pituitary) or tertiary 10am (peak), dropping to about 3-12 ug/dL by 4pm
(hypothalamic) adrenal insufficiency  Its diurnal and ultradian pattern of secretion are most
 Primary adrenal insufficiency useful when evaluated in the context of dynamic
o Low cortisol concentration manipulation
o Increased ACTH
 Secondary or Tertiary adrenal insufficiency SALIVARY CORTISOL
o Both ACTH and cortisol are low  Salivary cortisol is highly stable and easy to collect.
 ACTH best discriminates between healthy individuals o Useful tool for screening and for diagnosing
and those with adrenal insufficiency when collected instances of increased cortisol secretion.
between 8am and 10am  It does not appear to be affected by the rate of saliva
 ACTH is less useful in diseases of cortisol excess production.
 Measurement of ACTH by plasma extraction may be o Reflect a change in serum cortisol in as rapid as
useful in distinguishing patients with cancer-related few minutes.
syndromes or ACTH-secreting tumors from those with  Due to alteration in circadian rhythm: not an
Cushing’s disease, as the former entities are more appropriate test for shift workers or those w/ highly
likely to produce these other forms of ACTH variable bed times.
 ACTH measurement using selective venous sampling  Measurement of bedtime salivary cortisol was a
has been proven useful in localization of the lesion practical and accurate screening test for the diagnosis
when ACTH-secreting neoplasms are occult of Cushing’s syndrome.
CERVANTES
L8
 Patient must avoid tobacco on the day of specimen o ↑ serum cortisol, urinary free cortisol, midnight
collection. salivary cortisol
o Loss of circadian rhythm of ACTH and cortisol.
URINARY FREE CORTISOL MEASUREMENTS o Loss of suppression of cortisol production by
 Only 1% of the total adrenal secretion appears in the administration of dexamethasone.
urine as cortisol, this fraction provides a valuable aid  Most commonly iatrogenic in origin.
in the diagnosis of adrenal disease. o May also be due to: primary adrenal malignancy,
 In the kidney, glomerular filtration of free cortisol ectopic production of CRH or ACTH by a tumor.
(unbound to CBG and albumin) is followed by passive o CUSHING’S DISEASE: Hypercortisolism due to
tubular reabsorption without a demonstrable an ACTH-secreting pituitary adenoma.
reabsorption maximum.  CUSHING SYNDROME: Global term for
 Unlike serum cortisol, UFC is not affected by hypercortisolemia.
conditions and medications that alter CBG and o Most commonly iatrogenic in origin.
albumin concentrations. o May also be due to: primary adrenal malignancy,
o Thus making it easier to differentiate patients
ectopic production of CRH or ACTH by a tumor.
with adrenal hyperfunction from a reference
population. 24-HOUR URINARY FREE CORTISOL
 UFC is the best specimen to submit because it  reflection of the unbound circulating cortisol that is
provides an integrated profile of total cortisol secretion freely filtered by the glomerulus
over a 24-hour period, which is most helpful in those  unaffected by the level of circulating CBG
with sporadic excess cortisol production.
 Best specificity - HPLC or gas chromatography
 Reliability of the test may be further improved by coupled with tandem mass spectrometry
submitting urine collected over 2 or 3 days
 Values greater than four times the upper limit of
 UFC is unreliable when CrCl is <20 mL/min, and is of normal are diagnostic of Cushing’s syndrome
reduced reliability when CrCl is <60 mL/min o From 10% to 15% of patients with Cushing’s
 Increased serum concentration of transcortin during syndrome will have at least one in four 24-hour
pregnancy and with estrogen therapy results in urine collections for free cortisol return as normal
increased serum cortisol levels. o If cortisol excretion is normal but clinical
 Conditions in which spuriously elevated levels occur suspicion is high, the study should be repeated
include starvation, use of topical steroids, and or a different screening method should be used
hydration in the form of water loading.
 Milder elevations of UFC can be seen in pseudo-
 Method Cushing’s and during normal pregnancy
o HPLC (High-performance liquid
chromatography) with mass spectrometry is OVERNIGHT DEXAMETHASONE SUPPRESION TEST
considered the current reference method for
measuring UFC; it has diagnostic sensitivity of patient
patient takes
takes 1
1 mg
mg of
of plasma
plasma cortisol
cortisol is
is drawn
drawn
dexamethasone orally the following morning
100% and specificity of 98% for distinguishing between
between the
the hours
hours of
of 11
11 between
between 8 8 am
am and
and 9 9 am,
am,
patients with Cushing’s syndrome from normal pm and 12 midnight respectively
individuals (Rudd, 1985).
o Normal range varies according to the assay  original criterion for an abnormal response was failure
technique used; values that are four times the to suppress the morning cortisol level to <5 μg/ dL
upper reference limit are diagnostic for (138 nmol/L);
Cushing’s syndrome. o revised downward to <1.8 μg/dL (50 nmol/L)
o A low urinary free cortisol value is suggestive of o provides a greater than 95 % sensitivity and 80%
adrenal hypofunction; however, because there specificity and minimize the number of false-
is great overlap with the normal reference positive results
interval, this test is not used to make the  False positivity can be due to:
diagnosis of adrenal insufficiency. o Dexamethasone was taken too early
o Patient was on phenobarbital, phenytoin, or
HYPERCORTISOLISM: CUSHING’S SYNDROME another medication known to accelerate the
 Results from prolonged exposure to elevated metabolism of dexamethasone
concentrations of glucocorticoids. o Malabsorption; alcoholism; or morbid obesity
o Endogenous: secreted by adrenal zona o Pregnancy and drugs such as estrogen, which
fasciculata. increase serum transcortin (aka CBG), may also
o Exogenous: (Most common) Pharmacological result in elevated cortisol levels
administration of steroids.
 Patients w/ severe forms of syndrome presents: MIDNIGHT SALIVARY CORTISOL
Striae, Facial plethora, Proximal muscle weakness,
Stereotypical accumulation of fat.
 Signs and Symptoms: fatigue, weight gain, obesity,
diabetes, hypertension.
 Laboratory findings:
CERVANTES
L8
The
The patient
patient
can chew on
can chew on TEST FOR DEFINING THE CAUSE OF CUSHING’S
a cotton
a cotton The SYNDROME
pledget for 2 The sample
sample
pledget for 2 can be  Cushing’s is categorized as being ACTH dependent
to
to 33 minutes
minutes analyzed or ACTH independent; this is accomplished by
and then analyzed
and then either
either by
by measuring the plasma ACTH, or by performing a
place the
place the The sample is
The sample is
immunoassa
immunoassa high-dose DST or a CRH stimulation test
pledget
pledget intointo a
a then mailed
then mailed to
to
y or liquid
y or liquid
plastic
plastic tube
tube the reference
the reference chromatogra
chromatogra
laboratory
laboratory
or
or phy–mass
phy–mass
The spectrometr
spectrometr
The patient
patient y
can
can passively
passively y (LC-
(LC-
drool directly MS/MS)
drool directly
into a test
tube
 High diagnostic sensitivity and specificity, and has
been demonstrated to have an excellent correlation
with the plasma free cortisol concentration
(Papanicolaou et al, 2002; Yaneva et al, 2004; Alwani
et al, 2014)
 Using a cutoff of 9.3 nmol/L on a commercial ELISA
kit, MSC had a sensitivity of 100% specificity of 83%,
PPV of 94%, and NPV of 100% (Alwani et al, 2014)
 It performs slightly better than the 24-hour UFC in
distinguishing patients with Cushing’s syndrome from
obese subjects (Yaneva et al, 2004)
 Late-night (11 pm to 12 am) salivary cortisol (LNSC)
 Falsely elevated - smokers and users of chewing
tobacco, refraining from use for 24 hours prior to
collection is recommended. PSEUDO-CUSHING’S SYNDROME
 Excess activity of the hypothalamic-pituitary axis,
SCREENING IN SPECIAL POPULATIONS similar to the seen in pituitary Cushing’s syndrome
 Pregnancy – UFC  Seen in some patients with alcoholism, major
o UFC levels normally rise during the second and depression, and obesity; resolution of the
third trimesters, therefore UFC values greater underlying problem results in the normalization of the
than three times the upper limit of normal are HPA axis
considered consistent with Cushing’s syndrome  Serum cortisol above 7.5 ug/dL at midnight
 Renal Failure – 1-mg DST discriminates Cushing’s syndrome from pseudo-
o Because of the decrease in cortisol filtration with Cushing’s with 100% specificity
declining renal function,  More definitive test: combined dexamethasone-
 Suspected of cyclic Cushing’s – serial UFC or MSC oCRH test
o diagnostic thresholds for MSC during pregnancy o o-CRH is infused 2 hours after a low-dose
and in renal disease remain to be established dexamethasone test
 For an incidentally discovered adrenal mass, the 1- o Plasma cortisol concentration > 38 nmol/L at 15
mg DST has been shown to be superior to the UFC minutes following administration of oCRH =
and MSC identifies all cases of Cushing’s syndrome and
all cases of pseudo-Cushing’s with specificity,
CONFIRMATORY TESTS sensitivity, and diagnostic accuracy of 100%
 Repeat testing in 3 months - equivocal screening ADRENAL INSUFFICIENCY
 Midnight plasma cortisol - 100%specificity  Categorized according to dysfunction with in HPA
o 48 Hour hospital admission axis: Primary (adrenal), Secondary (pituitary) and
Tertiary(hypothalamic)
o IV insertion before 10 PM
 Major dysfunction: mineralocorticoid deficiency
o Blood is drawn while patient is sleeping at
 Most common cause of central adrenal insufficiency:
midnight
o HPA axis suppression due to prolonged steroid
o Cortisol>7.5ug/dL - diagnostic of Cushing’s
 2-day low dose DST (LDDST) PRIMARY ADRENAL INSUFFICIENCY (ADDISON’S
o 2 baseline 24-hr urine UFC is measured DISEASE)
o Administration of 0.5mg oral dexamethasone  Most commonly due to : Autoimmune adrenalitis
every 6hrs for 2 days  Other causes:
o 24-hr urine UFC is measured o TB, Granulomatous disorders, Metastatic
o Normal: decrease in UFC to <10ug per 24hrs disease, hemorrhage, HIV, acquired
(97-100% specificity) & suppresion of plasma immunodeficiency and infection
cortisol to <1.8ug/dL (95% specificity)
CERVANTES
L8
PRIMARY ADRENAL INSUFFICIENCY (ADDISON’S  A rise in 11-deoxycortisol to greater than 7 μg/dL (200
DISEASE) nmol/L) is NORMAL.
 Basal Hormone Measurements  An ABNORMAL RESPONSE is defined by 11-
o Cortisol levels are diurnal deoxycortisol less than 7 μg/dL accompanied by
o Cortisol of less than 3 ug/dl at 8 am to 9 am cortisol less than 5 μg/dL.
indicated adrenal insufficiency and needs further  Risk in factor:
testing. o Addisonian Crisis in those with Central
Hypocortisolism
ACTH o Metyrapone is currently only available on a
 Produced by the pituitary gland compassionate basis
 Stimulates the adrenal gland, which sit atop the
kidneys, to release two hormones: Cortisol and CORTICOTROPIN-REALEASING HORMONE TEST
Adrenaline (epinephrine)  Used to diagnose hypocortisolism and localize the
site of damage.
ACTH STIMULATION TEST
 Safe but expensive.
 Aka cosyntropin test
 After blood is drawn for baseline ACTH and cortisol,
 Done to test if the adrenal glands aren’t functioning 100 µg of oCRH is administered intravenously.
properly  Blood is then collected for cortisol and ACTH every 15
 Measures how your adrenal glands react to ACTH in minutes for 60 to 90 minutes.
your blood  A normal response is seen as cortisol greater than 20
 Used to diagnose adrenal insufficiency known as µg/dL.
Addison’s disease  Basal ACTH levels and their change in response to
 Requires to receive an injection of cosyntropin, a oCRH are used to localize the site of pathology.
synthetic portion of ACTH  Plasma corticotropin usually peaks at 15 to 30
 Two blood samples drawn: one before injection and minutes, and cortisol usually peaks at around 30 to 40
one after injection minutes post oCRH injection.
 Both the bound and free cortisol concentration show a
HOW IS AN ACTH (COSYNTROPIN) STIMULATION
progressive rise throughout pregnancy.
TEST PERFORMED?
 It has been recommended that higher cutoffs be used
 Take a blood sample. This blood sample will measure
to properly interpret the ACTH stimulation results in
your blood cortisol levels. You can use this sample as
pregnancy.
a baseline against which to compare the results of the
second blood test.
 You will receive an injection of cosyntropin, a RENIN-ALDOSTERONE AXIS
synthetic portion of ACTH. This hormone should  Maintain blood pressure within normal limits
trigger the adrenal glands to produce cortisol. You will  Renin
then wait for about an hour while your body reacts to o Released when there is a drop in renal
the cosyntropin injection. hydrostatic pressure, hyponatremia,
 Take a second blood sample after this first hour is up. hypokalemia, or a decrease in cathecholamines,
This sample will reflect your cortisol levels after your angitensin II, or atrial natriuretic hormome
body has had time to react to the injection.
 Both of your blood samples will be tested for their ISOENZYMES OF RENIN
cortisol levels.  Renin acts on angiotensinogen, converting it to
angiotensin I.
OVERNIGHT METYRAPONE TEST  ACE converts angiotensin I to angiotensin II
 What is Metyrapone?
o Metyrapone inhibits 11-β-hydroxylase,  Angiotensin II
preventing the conversion of 11-deoxycortisol o Responsible for physiologic effects on target
(compound S) to cortisol. tissue
o Under normal circumstances, the metyrapone- o Very potent vasoconstrictor
induced drop in cortisol is detected at the level of
the hypothalamus and pituitary gland; a RENIN RELEASE
compensatory increase in CRH and ACTH  Rate limiting step in Renin-Aldosterone axis.
secretion occurs, stimulating steroidogenesis  Dependent on changes in effective plasma volume
and leading to a buildup of 11-deoxycortisol, the  Dependent on tubular reabsorption of Na+
hormone preceding the block.  *Renin secretion is inhibited by hyperkalemia
 Measure the ability of pituitary gland to release ACTH
in response to decrease cortisol levels ALDOSTERONE AND GLUCOCORTICOIDS
 It is done when Metyrapone 30 mg/kg is administered  Mineralocorticoid receptor
orally at midnight; blood for cortisol and 11-
 Cause reabsorption of Na+, leading to increase
deoxycortisol is collected the following morning at 8
intravascular volume
am.
 Causes renal K+ loss
CERVANTES
L8
 Development of vasculopathy o is also associated with high plasma renin activity

 Stimulates gene for collagen synthesis, TGF, and aldosterone.
inflammatory factors, plasminogen activator inhibitor 3. Renal vascular hypertension,
type 1. o the renin and aldosterone levels are also
 Aldosterone synthetase(CYP11B2) elevated.
o Converts corticosterone to aldosterone o in contradistinction to malignant hypertension,
 Major stimuli for aldosterone secretion: treatment with ACEs usually results in further
o Angiotensin II and hyperkalemia deterioration of renal function.
 *ACTH much weaker stimulus 4. Chronic renal failure
 Inhibits aldosterone synthesis: o almost any renin level can be expected. A small
o Somatostatin, atrial natriuretic hormone, number of hypertensive patients on dialysis
dopamine, and heparin have intractable, accelerated hypertension.
 Cortisol a. Renal transplant patients
o Circulates at much higher concentration than  elevated plasma renin may be
indicative of renal ischemia and
aldosterone
rejection.
o Does not normally function as a major
5. Cushing’s syndrome
mineralocorticoid
o Systemic hypertension occurs
o Some patients have increased plasma renin and
11-B-HYDROXYSTEROID DEHYDROGENASE II
renin substrate.
 11-HSD-2, aka CYP11B2
o Other Cushing’s syndrome patients have
 Expressed by mineralocorticoid target cells in
hypokalemia associated with secretion of a
collecting tubules
minor mineralocorticoid (such as DOC or
 Acts to convert cortisol to cortisone
corticosterone) causes hypertension
 Cortisone o other patients, severely elevated cortisol levels
o An in active metabolite
overwhelm the capacity of 11-hydroxysteroid
dehydrogenase (11-HSD
RENIN AND HYPERTENSION
6. Treatment with medications
 Essential hypertension can be classified on the o diuretics, vasodilators, or other antihypertensive.
basis of renin measurements as high, low, or normal
o Hormonal agents such as glucocorticoids,
renin, and that drug selection
estrogen-containing oral contraceptives
 Renin profiling has shown renin to be an independent
o Even though plasma renin activity, aldosterone,
risk factor for myocardial infarction
and urinary sodium excretion may be normal in
 Increased aldosterone (secondary aldosteronism)
60% of hypertensive patients, evidence indicates
may contribute significantly to the symptoms and
that renin-angiotensin plays a significant part in
course of high-renin hypertension
normal-renin hypertension.
CAUSES OF HYPERTENSION SOOCIATED WITH HIGH

LEVELS OF PLASMA RENIN
1. Renin-secreting tumors
o extremely rare and can be difficult to diagnose.
o can be benign or malignant, renal or extrarenal.
o most common location is in the juxtaglomerular  Primary aldosteronism is uncommon compared with
apparatus renin hypertension. It is characterized by (1) systolic
2. Malignant hypertension and diastolic hypertension caused
CERVANTES
L8
 by oversecretion of aldosterone by an adrenal o A PAC >6ng/dL with a PRA <1ng/mL/hour

adenoma (aldosteroneproducing adenoma [APA]) or confirms the diagnosis.
hyperplasia (idiopathic hyperaldosteronism [IHA]), (2) 4. Captopril challenge test
low renin or a high aldosterone/renin ratio (>50), (3) o Baseline blood is collected for PRA,PAC, and
renal potassium wasting, and (4) sodium retention. cortisol then a 25-50mg Captopril is given orally.
 A low-salt diet (<2 g/day), stress, upright posture, and PRA, PAC, and cortisol is measured again after
diuretics all increase plasma aldosterone, whereas a 1-2 hours. The patient is kept seated throughout
high-salt diet and lying in a supine position suppress the entire test.
aldosterone secretion in healthy subjects. o In primary hyperaldosteronism, PAC remains
elevated and PRA is suppressed.
PRIMARY HYPERALDOSTERONISM – SCREENING AND
CONFIRMATION TESTS DIFFERENTIATING AMONG THE DIFFERENT CAUSES
 Preferred screening test is “Plasma Aldosterone OF PRIMARY HYPERALDOSTERONISM
Concentration/Plasma Renin Activity Ratio (PAC/PRA  Difference of aldosterone-producing adenoma (APA)
ratio)” and idiopathic hyperaldosteronism (IHA), is that APA:
o A ratio >30 is suggestive of primary o has more extreme blood pressures
hyperaldosteronism, and a value of 50 can be o Greater potassium wasting
diagnostic. o Higher natriuretic peptide level
o Special Considerations:
 (+) postural stimulation test (plasma aldosterone:
 4-6 weeks prior the test spironolactone and ambulating rising to less than 130% of the supine
eplerenone should be discontinued and level) has moderate sensitivity and specificity for
other diuretics for at least 2 weeks. ADENOMA (but not for hyperplasia)
 Hypokalemia should be corrected, and
 The specificity of CT or MRI correctly categorize
patient should not be on a sodium-
patients as having APA versus IHA
restricted diet.
 BILATERAL ADRENAL VEIN SAMPLING is
 The diagnosis of hyperaldosteronism is confirmed by
recommended for >40 yrs old who are contemplating
one of the four ff confirmatory tests:
for surgery. This is bec. hyperplasia may present as a
o Oral sodium loading test
unilateral adenoma.
o Saline infusion test o It entails risk but still it is the GOLD STANDARD
o Fludrocortisone suppression test for distinguishing adenoma from hyperplasia
o Captopril challenge test o Procedure: pt is administered with ACTH at
 The choice of test depends on several factors: 50u/hr IV, 30 mins before the test and is
o Patient compliance continued throughout the procedure (to mitigate
o Uncontrolled HPN any stress-induced fluctuations in aldosterone
o Renal Insufficiency and maximize the difference in secretion of
o CHF aldosterone bet. right and left adrenal glands in
o Expertise instances of APA)
1. Oral sodium loading test  CORTISOL-CORRECTED ALDOSTERONE: correct
o Done by administering sodium chloride tablets dilutional effects.
10-12g daily for 3 days o No gradient is seen in hyperplasia whereas in
o On the last day of oral administration, a 24-hour APA, the ratio is 5-fold higher on the side with
urine is collected for aldosterone, creatinine, and the adenoma
sodium.  Syndrome of inapparent mineralocorticoid excess is
o An aldosterone >10mg/24hours ff the 3 days of due to dysfunction of 11-B-hydroxysteroid
sodium loading confirms the diagnosis. dehydrogenase type 2.
2. Saline infusion test o Cortisol can function as a potent
o Done by infusing 2L of 0.9%saline over 4 hours. mineralocorticoid, binding to the
o PAC is measured at the end of infusion: mineralocorticoid receptor in the kidney with the
 <5 ng/dL = negative same affinity as ALDOSTERONE.
 5-10ng/dL = considered intermediate and o ELEVATED CORTISOL/CORTISONE CONC.
may be seen with IHA. (24-hr urine) confirms the Dx.
 >10ng/dL = positive  There are 2 variants of familial hyperaldosteronism
3. Fludrocortisone suppression test (FH), FH-1 (aka glucocorticoid remedial
o Done by giving: hyperaldosteronism-GRA) and it is characterized by 3
 0.1mg fludrocortisone orally every 6 hours for H’s: hyperaldosteronism, hyporeninemia and severe
4 days. hypertension) and FH-2
 Slow-release potassium chloride o Confirmatory dx for FH-1: normalization of
supplements aldosterone (after 4-6 wks steroid suppression)
 Slow-release NaCl and liberilization of or Southern blot or long PCR.
sodium intake. o Unlike FH-1 aldosterone does not suppress in
o On the 4th day an upright plasma cortisol is response to glucocorticoid tx.
measured at 7am and 10am, then PAC and PRA
are measured at 10am.
CERVANTES
L8
 LIDDLE SYNDROME- rare autosomal dominant 1. Lecture Notes

disorder characterized by hypertension and 2. Lecturer’s PPT
hypokalemia.
o PRA and PAC are both low unlike in primary
hyperaldosteronism
o Dx test: Genetic testing or clinical response to
amiloride or triamterene, and by LACK of
response to dexamethasone or aldosterone
antagonist.
ALDOSTERONE MEASUREMENTS
 An isolated aldosterone measurement with no
attention to patient preparation is of “LITTLE
CLINICAL VALUE”.
 It is difficult to discriminate with certainty between
primary aldosteronism and other forms of
hypertension with the use of PLASMA
ALDOSTERONE MEASUREMENTS alone.
o Even when time of sampling, posture, and
dietary sodium and potassium are controlled.
 Interpretation of the aldosterone level must be done in
the context of a simultaneously collected plasma renin
and serum potassium.
ALDOSTERONE ASSAYS
 Performed on plasma using extraction to remove
aldosterone from plasma proteins,
o followed by chromatography and immunoassay
or, preferably, LC-MS/MS.
 Urine is assayed following acid hydrolysis and
extraction.
 Normative values exist for different age groups,
postures, and sodium intakes.
 HPLC with tandem mass spectrometry affords greater
consistency and is gradually replacing older methods.
RENIN MEASUREMENTS
 Renin is extremely labile and its release is controlled
by many physiologic and pharmacologic variables:
o upright posture
o Diuretic
o Low sodium diets (most potent)
 2 TYPES:
 PRA – most widely used method for determination of
renin.
o bioassay wherein a plasma specimen containing
renin is allowed to react with its substrate
(angiotensinogen) after a specfied period of
time, the reaction is terminated and generated
amgiotensin I is measured by RIA
o endogenous substrate is not eliminated
 PRC – immunoassay directed to the renin molecule
itself
o measured the effect of substrate eliminated
REFERENCES
CERVANTES
L8
CERVANTES
L8
CERVANTES
L8

(CP) 8.05 - Evaluation of Endocrine Function

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8.

 Generally measured by IMMUNOASSAY. Reference REVERSE TRIIODOTHYRONINE (rT3)

 Both test for HVA and VMA must be ordered for

CONGENITAL DISORDERS OF ADRENAL CORTICAL

CLASSIC FORM VS NON-CLASSIC FORM

 Normal:  Deficiency Leads to blockage in the conversion of Δ5

 Development of vasculopathy o is also associated with high plasma renin activity

CAUSES OF HYPERTENSION SOOCIATED WITH HIGH

 by oversecretion of aldosterone by an adrenal o A PAC >6ng/dL with a PRA <1ng/mL/hour

 LIDDLE SYNDROME- rare autosomal dominant 1. Lecture Notes

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