Chronic Renal Disease and Endocrinopathies

International Journal of Endocrinology, 2014

Adrenal function might be impaired in patients with primary hypothyroidism. The objective was to evaluate adrenocortical function using the low-dose cosyntropin test in patients with primary hypothyroidism. Consequently a prospective, longitudinal, controlled study of sixty adult patients with primary hypothyroidism was carried out. Patients naïve to L-T4 treatment were compared with control participants. A low-dose cosyntropin test was done before and after L-T4 therapy. Thirty and sixty minutes after the lowdose cosyntropin, the mean cortisol values were lower in the cases group (612.6 ± 133.1 and 603.4 ± 153.7 nmol/L) when compared to the control group (677.0 ± 82.4 and 669.9 ± 83.7 nmol/L) ( = 0.001 and 0.003), respectively. After L-T4 therapy, this difference was lost. Four out of 60 cases (6.7%) taking a cortisol cutoff value of 500 mmol/L and 11 out of 60 (18.3%) having 550 mmol/L as the cutoff had adrenal insufficiency before L-T4 therapy. After L-T4 therapy, 50% and 81% of the cases had normal cortisol response. In conclusion, patients with different degrees of intensity of primary hypothyroidism had improved cortisol response after reaching euthyroidism. The incidence of adrenal insufficiency was 6.7-18.3% and more than 50% of the cases had a normal cortisol response after L-T4 therapy.

Frontiers in Endocrinology, 2022

Introduction: Hypoaldosteronism can be congenital or acquired, isolated or part of primary adrenal insufficiency, and caused by an aldosterone deficit, resistance, or a combination of both. Reduced mineralocorticoid action can induce a decrease in urine K+ and H+ excretion and an increase in urine Na+ excretion, leading to hyperkalemia, and/or hyponatremia, often combined with metabolic acidosis. We aimed to characterize the clinical manifestations of hypoaldosteronism, and their associated factors. Methods: Retrospective analysis of 112 episodes of hypoaldosteronism diagnosed in 86 adult patients from 2012-2019 by the Endocrinology and Nutrition Department of a tertiary hospital. The frequency of hyperkalemia, hypovolemic hyponatremia (HH) and metabolic acidosis (MA), and their associated factors were evaluated. Results: Patients had a median age of 77 [65-84], 55.4% were male. 94.6% cases showed hyperkalemia, 54.5% HH, and 60.3% MA. The mean serum K+ of all cases was 5.4 ± 0.5 mmol/L, Na+: 132.1 ± 6.3 mmol/L, HCO3: 22.6 ± 3.3 mmol/L. Hypoaldosteronism was isolated in the majority of cases: only 6/112 (5%) had primary adrenal insufficiency. Hypovolemia was associated with hyponatremia and a more florid clinical presentation. HH was associated with a combined presence of aldosterone-lowering and mineralocorticoid resistance factors. MA was associated with the presence of mineralocorticoid resistance factors.

American Journal of Kidney Diseases, 1987

2008

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Turkiye Klinikleri Journal of Medical Sciences, 2012

Hypothalamo-pituitary-adrenal (HPA) axis is affected by thyroid hormones. The present study was designed to compare the level of salivary cortisol, serum cortisol, plasma adrenocorticotropic hormone (ACTH) and urinary free cortisol (UFC) levels in patients with subclinical and overt thyrotoxicosis and hypothyroidism. M Ma at te er ri ia al l a an nd d M Me et th ho od ds s: : We analyzed the salivary cortisol, serum cortisol, plasma ACTH and UFC levels in 123 patients with thyroid dysfunction. The patients were classified into four groups; overt thyrotoxicosis (n= 32), subclinical thyrotoxicosis (n= 29), overt hypothyroidism (n= 28) and subclinical hypothyroidism (n= 34). R Re es su ul lt ts s: : There were no significant differences in terms of salivary cortisol, serum cortisol, plasma ACTH and UFC levels in patients with subclinical and overt thyrotoxicosis (p> 0.05). Similarly, no significant differences could be detected in terms of salivary cortisol, serum cortisol, plasma ACTH and UFC levels in patients with subclinical and overt hypothyroidism (p> 0.05). The comparison of patients with hypothyroidism and thyrotoxicosis also did not yield any significant difference in terms of salivary cortisol, serum cortisol, plasma ACTH and UFC levels (p> 0.05). C Co on nc cl lu us si io on n: : Similar salivary cortisol, serum cortisol, plasma ACTH and UFC levels were detected in patients with hypothyroidism and thyrotoxicosis. Thus, we may suggest that thyroid hormone status does not play a role in the HPA axis. The major limitation of this study was the absence of a healthy control group. Further studies with large numbers of patients are required to clarify the association between thyroid hormone dysfunction and glucocorticoid levels. K Ke ey y W Wo or rd ds s: : Thyrotoxicosis, hypothyroidism; cortisol; ACTH Ö ÖZ ZE ET T A Am ma aç ç: : Hipotalamo-hipofizer-adrenal (HPA) aks, tiroit hormonları tarafından etkilenir. Bu çalışma, klinik ve subklinik tirotoksik hastalarda ve hipotiroidi olgularında serum ve üriner serbest kortizol (UFC) ve plazma ACTH düzeylerinin yanı sıra, tükürük kortizol düzeylerini karşılaştırmak amacıyla tasarlandı. G Ge er re eç ç v ve e Y Yö ön nt te em ml le er r: : Tiroit disfonksiyonu olan 123 hastada tükürük kortizol, serum kortizol, plazma ACTH ve idrar serbest kortizol düzeyleri ölçüldü. Bu hastalar dört grupta sınıflandı; klinik tirotoksikozlu grup 32 hastadan, subklinik tirotoksikozlu grup 29 hastadan, klinik hipotiroidi grubu 28 hastadan ve subklinik hipotiroidi grubu da 34 hastadan oluşmaktaydı. B Bu ul lg gu u-l la ar r: : Klinik tirotoksikozlu ve subklinik tirotoksikozlu hastalarda tükürük kortizol, serum kortizol, plazma ACTH ve idrar serbest kortizol düzeyleri arasında anlamlı fark tespit edilmedi (p> 0,05). Klinik hipotiroidili ve subklinik hipotiroidili hastaların tükürük kortizol, serum kortizol, plazma ACTH ve idrar serbest kortizol düzeyleri de birbirinden anlamlı ölçüde farklı bulunmadı (p> 0,05). Benzer şekilde, tirotoksikozlu ve hipotiroidili hastalar arasında yapılan karşılaştırma, tükürük kortizol, serum kortizol, serum ACTH ve idrar serbest kortizol düzeyleri arasında anlamlı bir fark olmadığını ortaya koydu (p> 0,05). S So on nu uç ç: : Klinik ve subklinik hipotiroidili, klinik ve subklinik tirotoksikozlu hastalarda benzer serum kortizol, plazma ACTH, idrar serbest kortizol ve tükürük kortizol düzeyleri saptandı. Çalışmamızdaki bu sonuçlar, değişik düzeylerdeki tiroit disfonksiyonunun hipotalamo-hipofizer adrenal aks üzerinde etkisi olmadığını göstermektedir. Sağlıklı kontrol grubunun olmaması çalışmamızın en önemli kısıtlayıcı faktörüydü. Tiroit disfonksiyonu ve glukokortikoit düzeyleri arasındaki ilişkiyi ortaya koymak için daha geniş çaplı yeni çalışmalara ihtiyaç vardır.

The Journal of Clinical Endocrinology & Metabolism

2009

Objective: Cyclical Cushing's syndrome may render the diagnosis and management of Cushing's disease difficult. The aim of the present study was to investigate the prevalence of cyclicity and variability in patients with Cushing's disease, and to identify putative distinctive features. Design: Retrospective case-note study. Methods: We analysed the case-records of 201 patients with Cushing's disease in a retrospective case-note study. Cyclicity was considered as the presence of at least one cycle, defined as a clinical and/or biochemical hypercortisolaemic peak followed by clinical and biochemical remission, and by a new clinical and/or biochemical hypercortisolaemic peak. The fluctuations of mean serum cortisol levels, as assessed by a 5-point cortisol day curve, defined the variability. Results: Thirty (14.9%; 26 females) patients had evidence of cyclicity/variability. 'Cycling' patients were older but no difference in sex or paediatric distribution was revealed between 'cycling' and 'non-cycling' patients. The median number of cycles was 2 for each patient, and 4 years was the median intercyclic period. A trend to lower cure rate post-neurosurgery and lower adenoma identification was observed in 'cycling' compared to 'non-cycling' patients. In multivariate analysis, older patients, longer follow-up, female sex, and no histological identification of the adenoma were associated with an increased risk of cyclic disease. Conclusions: This large population study reveals that cyclicity/variability is not an infrequent phenomenon in patients with Cushing's disease, with a minimum prevalence of 15%. Physicians should be alert since it can lead to frequent problems in diagnosis and management, and no specific features can be used as markers.

Evaluating children or adolescents with central adrenal insufficiency (CAI) is a difficult task in clinical practice, especially in subjects with hypothalamic-pituitary diseases and partial ACTH deficiency, or in those with recent pituitary surgery or brain irradiation when the adrenal cortex may still be responsive to stress. In 2008, a meta-analysis reported a three-step approach for evaluating patients at risk for CAI with no acute illness. In particular, the authors recommended the evaluation of morning cortisol, a low dose ACTH test (LDST) and the “gold standard” insulin tolerance test or metyrapone test if the low LDCT was not diagnostic. Cortisol and ACTH secretion exhibit significant fluctuation throughout the day. The reference ranges supplied by labs are so wide that they only flag up extremely low cortisol levels. Interpreting the results correctly can be difficult for a physician without an experience in adrenal dysfunctions. The lack of uniformity in these cut-off levels could in part be attributed to differences in study populations, variability of dynamic tests, the use of different serum cortisol assays and dissimilar cut-off peak serum cortisol response indicative of a normal axis response and the difference in the clinical context in which the studies were done. Therefore, laboratories have to advertise the need to establish reference values for given populations, both for basal or stimulated hormone levels. Failure to apply this rule may elicit false-positive and more critically, falsenegative results. LDST (1 μg synthetic ACTH as iv bolus with measurement of serum cortisol) has been proposed as a sensitive test for the diagnosis of CAI. However, the advantage of LDST compared with the high dose test may be offset by the technical difficulties inherent to dilution of 250 μg ampoules. Clinical judgement remains imperative especially regarding the use of glucocorticoid supplementation during extreme stress.