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de Freminville JB, Amar L, Azizi M, Mallart-Riancho J. Endocrine causes of hypertension: literature review and practical approach. Hypertens Res 2023; 46:2679-2692. [PMID: 37821565 DOI: 10.1038/s41440-023-01461-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/05/2023] [Accepted: 09/09/2023] [Indexed: 10/13/2023]
Abstract
Hypertension (HTN) affects more than 30% of adults worldwide. It is the most frequent modifiable cardiovascular (CV) risk factor, and is responsible for more than 10 million death every year. Among patients with HTN, we usually distinguish secondary HTN, that is HTN due to an identified cause, and primary HTN, in which no underlying cause has been found. It is estimated that secondary hypertension represents between 5 and 15% of hypertensive patients [1]. Therefore, routine screening of patients for secondary HTN would be too costly and is not recommended. In addition to the presence of signs suggesting a specific secondary cause, screening is based on specific criteria. Identifying secondary HTN can be beneficial for patients in certain situations, because it may lead to specific treatments, and allow better control of blood pressure and sometimes even a cure. Besides, it is now known that secondary HTN are more associated with morbidity and mortality than primary HTN. The main causes of secondary HTN are endocrine and renovascular (mainly due to renal arteries abnormalities). The most frequent endocrine cause is primary aldosteronism, which diagnosis can lead to specific therapies. Pheochromocytoma and Cushing syndrome also are important causes, and can have serious complications. Other causes are less frequent and can be suspected on specific situations. In this article, we will describe the endocrine causes of HTN and discuss their treatments.
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Affiliation(s)
- Jean-Baptiste de Freminville
- Hypertension Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France.
- Université Paris Cité,, F-75015, Paris, France.
| | - Laurence Amar
- Hypertension Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
- Université Paris Cité,, F-75015, Paris, France
| | - Michel Azizi
- Hypertension Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
- Université Paris Cité,, F-75015, Paris, France
| | - Julien Mallart-Riancho
- Hypertension Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
- Université Paris Cité,, F-75015, Paris, France
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2
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Baskin L, Sinclair A, Derpinghaus A, Cao M, Li Y, Overland M, Aksel S, Cunha GR. Estrogens and development of the mouse and human external genitalia. Differentiation 2020; 118:82-106. [PMID: 33092894 DOI: 10.1016/j.diff.2020.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 09/18/2020] [Indexed: 01/02/2023]
Abstract
The Jost hypothesis states that androgens are necessary for normal development of the male external genitalia. In this review, we explore the complementary hypothesis that estrogens can elicit abnormal development of male external genitalia. Herein, we review available data in both humans and mice on the deleterious effects of estrogen on external genitalia development, especially during the "window of susceptibility" to exogenous estrogens. The male and female developing external genitalia in both the human and mouse express ESR1 and ESR2, along with the androgen receptor (AR). Human clinical data suggests that exogenous estrogens can adversely affect normal penile and urethral development, resulting in hypospadias. Experimental mouse data also strongly supports the idea that exogenous estrogens cause penile and urethral defects. Despite key differences, estrogen-induced hypospadias in the mouse displays certain morphogenetic homologies to human hypospadias, including disruption of urethral fusion and preputial abnormalities. Timing of estrogenic exposure, or the "window of susceptibility," is an important consideration when examining malformations of the external genitalia in both humans and mice. In addition to a review of normal human and mouse external genital development, this article aims to review the present data on the role of estrogens in normal and abnormal development of the mouse and human internal and external genitalia. Based on the current literature for both species, we conclude that estrogen-dependent processes may play a role in abnormal genital development.
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Affiliation(s)
- Laurence Baskin
- University of California, San Francisco, Division of Pediatric Urology, Department of Urology, 550 16th St, 5th Floor, Mission Hall Pediatric Urology, San Francisco, CA, 94158, USA.
| | - Adriane Sinclair
- University of California, San Francisco, Division of Pediatric Urology, Department of Urology, 550 16th St, 5th Floor, Mission Hall Pediatric Urology, San Francisco, CA, 94158, USA
| | - Amber Derpinghaus
- University of California, San Francisco, Division of Pediatric Urology, Department of Urology, 550 16th St, 5th Floor, Mission Hall Pediatric Urology, San Francisco, CA, 94158, USA
| | - Mei Cao
- University of California, San Francisco, Division of Pediatric Urology, Department of Urology, 550 16th St, 5th Floor, Mission Hall Pediatric Urology, San Francisco, CA, 94158, USA
| | - Yi Li
- University of California, San Francisco, Division of Pediatric Urology, Department of Urology, 550 16th St, 5th Floor, Mission Hall Pediatric Urology, San Francisco, CA, 94158, USA
| | - Maya Overland
- University of California, San Francisco, Division of Pediatric Urology, Department of Urology, 550 16th St, 5th Floor, Mission Hall Pediatric Urology, San Francisco, CA, 94158, USA
| | - Sena Aksel
- University of California, San Francisco, Division of Pediatric Urology, Department of Urology, 550 16th St, 5th Floor, Mission Hall Pediatric Urology, San Francisco, CA, 94158, USA
| | - Gerald R Cunha
- University of California, San Francisco, Division of Pediatric Urology, Department of Urology, 550 16th St, 5th Floor, Mission Hall Pediatric Urology, San Francisco, CA, 94158, USA
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Chaudhari M, Johnson EK, DaJusta D, Nahata L. Testicular adrenal rest tumor screening and fertility counseling among males with congenital adrenal hyperplasia. J Pediatr Urol 2018; 14:155.e1-155.e6. [PMID: 29330018 DOI: 10.1016/j.jpurol.2017.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 11/10/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Reduced fertility is a common potential problem among males with congenital adrenal hyperplasia (CAH), with nearly half experiencing impaired sperm production. The major cause of oligo/azoospermia in CAH is testicular adrenal rest tumors (TARTs). Studies indicate that ultrasound screening for TARTs should begin during childhood, yet it remains unclear whether boys with CAH are routinely screened for TARTs and/or counseled about infertility risk and potential interventions such as fertility testing and/or preservation. OBJECTIVE The purpose of this study was to examine TART screening and fertility counseling practices among boys with CAH. STUDY DESIGN An IRB-approved retrospective chart review was conducted of all males with ICD-9/10 codes for CAH (2007-2016) at a large pediatric academic center to examine: age and indication for diagnosis; age at first and last documented pediatric endocrinology and urology visit; history of ultrasound examinations; and documentation of fertility counseling. RESULTS Forty-six patients were included, of whom 38 had 21-hydroxylase deficiency. Median age at diagnosis was 2 weeks (range 7 days-10 years). Median age at the most recent pediatric endocrinology clinic visit was 14 years (range 2-42 years). Twenty-nine patients were >11 years old (63% of the sample) at the time of the study and 14 of these were >18 years old (30% of the sample). Seven patients (15%) had a screening ultrasound at some point in their care, of whom three had TARTs. Fertility was mentioned in the records of six subjects (13% of the sample). Six of the subjects (13%) had any mention of fertility in their records. None of the patients had biochemical testing or semen analysis to assess gonadal function, and none were offered fertility preservation. Only one patient was seen by a pediatric urologist. DISCUSSION Despite the limitations of a single-center retrospective design, our findings highlight that TART screening and fertility counseling remain underutilized in boys with CAH. There is a need for increased awareness and development of practice guidelines within pediatric urology and endocrinology to address this common and understudied problem. CONCLUSION In addition to a screening ultrasound in puberty and consideration of semen analysis after puberty, these boys may benefit from seeing a pediatric urologist independently or in an interdisciplinary program. Boys with CAH and their families should be educated about infertility risk and potential interventions, with the goal of improving reproductive outcomes in this population.
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Affiliation(s)
- Monika Chaudhari
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology and Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Daniel DaJusta
- Division of Pediatric Urology, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Leena Nahata
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
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4
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Miller AJ, Malek R. Management of Pregnancy in a Patient with Nonclassical Congenital Adrenal Hyperplasia. AACE Clin Case Rep 2018. [DOI: 10.4158/ep171958.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Fleming L, Van Riper M, Knafl K. Management of Childhood Congenital Adrenal Hyperplasia-An Integrative Review of the Literature. J Pediatr Health Care 2017; 31:560-577. [PMID: 28416079 PMCID: PMC5654644 DOI: 10.1016/j.pedhc.2017.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/10/2017] [Accepted: 02/10/2017] [Indexed: 12/13/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is an endocrine condition that requires parents to administer steroids up to three times daily, supplementing maintenance doses with oral or injectable doses during times of illness. The purpose of this integrative review was to explore the management, care, and associated health issues for children with CAH and the family response to the condition. Four literature indexes were searched, with 39 articles included. Four themes emerged: (a) Health- and Development-Related Issues, (a) Effects of Excess Androgens, (c) Life Experience of CAH, and (d) Managing and Averting Adrenal Crisis. Families having a child with CAH face complex concerns related their child's growth, the fear of adrenal crisis events, and the consequences of atypical genitalia for affected girls. Future studies should focus on interventions that provide guidelines to increase parental preparedness in managing adrenal crises and creating support systems for affected girls.
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7
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Noppe G, de Rijke YB, Koper JW, van Rossum EFC, van den Akker ELT. Scalp hair 17-hydroxyprogesterone and androstenedione as a long-term therapy monitoring tool in congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2016; 85:522-7. [PMID: 27061431 DOI: 10.1111/cen.13078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 02/23/2016] [Accepted: 04/05/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Glucocorticoid replacement therapy in congenital adrenal hyperplasia (CAH) is challenging, especially in children, because both over- and under-dosing may have profound and long-lasting adverse effects. Clinical follow-up parameters are largely nonspecific and slow to develop. Steroid concentrations in scalp hair may be a useful monitoring tool, as it provides information on both long-term steroid precursor and glucocorticoid exposure. AIM We aimed to evaluate scalp hair steroid precursor concentrations as a monitoring tool for treatment follow-up in children with CAH. METHODS Scalp hair 17-hydroxyprogesterone (17-OHP) and androstenedione concentrations, measured by LC-MS/MS, of children with CAH (N = 26) were correlated with concentrations in serum and saliva, and compared to scalp hair concentrations in patient controls with adrenal insufficiency (AI) (N = 12) and healthy controls (N = 293). RESULTS Hair cortisol concentrations were higher in children with CAH, compared to both healthy controls (P < 0·001) and patient controls (P = 0·05), and did not differ significantly between patient controls with AI and healthy controls. Concentrations of androstenedione in scalp hair were strongly correlated with concentrations in serum (ρ = 0·72, P < 0·001) and saliva (ρ = 0·82, P = 0·002). This was also seen for 17-OHP in hair with serum (ρ = 0·94, P < 0·001) and saliva (ρ = 0·69, P = 0·009). Both hair 17-OHP and androstenedione were higher in CAH patients (mean concentration 17-OHP 2·9 pg/mg; androstenedione 1·3 pg/mg), when compared to healthy controls (17-OHP 0·44 pg/mg; androstenedione 0·65 pg/mg) and when compared to patients with AI (17-OHP 0·12 pg/mg; androstenedione 0·32 pg/mg). CONCLUSION This study shows that scalp hair 17-hydroxyprogesterone and androstenedione concentrations seem to be a promising parameter for treatment monitoring in patients with CAH.
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Affiliation(s)
- Gerard Noppe
- Department of Pediatrics, Division of Endocrinology, Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Internal Medicine, Division of Endocrinology, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Yolanda B de Rijke
- Department of Internal Medicine, Division of Endocrinology, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan W Koper
- Department of Internal Medicine, Division of Endocrinology, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Elisabeth F C van Rossum
- Department of Internal Medicine, Division of Endocrinology, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erica L T van den Akker
- Department of Pediatrics, Division of Endocrinology, Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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8
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Alonso-Fernández JR. Pregnanetriolone in paper-borne urine for neonatal screening for 21-hydroxylase deficiency: The place of urine in neonatal screening. Mol Genet Metab Rep 2016; 8:99-102. [PMID: 27570738 PMCID: PMC4992010 DOI: 10.1016/j.ymgmr.2016.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 08/08/2016] [Indexed: 10/26/2022] Open
Abstract
The standard method of primary neonatal screening for congenital adrenal hyperlasia (CAH), determination of 17-hydroxyprogesterone (17OHP) in heelprick blood, is the object of recurrent controversy because of its poor diagnostic and economic efficiency. The superior ability of urinary pregnanetriolone levels to discriminate between infants with and without classical CAH has been known for some time, but has not hitherto been exploited for primary screening. Here we propose an economical neonatal CAH-screening system based on fluorimetric determination of the product of reaction between urinary pregnanetriolone and phosphoric acid.
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Affiliation(s)
- José Ramón Alonso-Fernández
- Laboratorio de Tría Neonatal en Galicia, Laboratorio de Metabolopatías, Departamento de Pediatria, Hospital Clínico (CHUS) e Universidade de Santiago de Compostela, Galicia. Spain
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9
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Webb EA, Krone N. Current and novel approaches to children and young people with congenital adrenal hyperplasia and adrenal insufficiency. Best Pract Res Clin Endocrinol Metab 2015; 29:449-68. [PMID: 26051302 DOI: 10.1016/j.beem.2015.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Congenital adrenal hyperplasia (CAH) represents a group of autosomal recessive conditions leading to glucocorticoid deficiency. CAH is the most common cause of adrenal insufficiency (AI) in the paediatric population. The majority of the other forms of primary and secondary adrenal insufficiency are rare conditions. It is critical to establish the underlying aetiology of each specific condition as a wide range of additional health problems specific to the underlying disorder can be found. Following the introduction of life-saving glucocorticoid replacement sixty years ago, steroid hormone replacement regimes have been refined leading to significant reductions in glucocorticoid doses over the last two decades. These adjustments are made with the aim both of improving the current management of children and young persons and of reducing future health problems in adult life. However despite optimisation of existing glucocorticoid replacement regimens fail to mimic the physiologic circadian rhythm of glucocorticoid secretion, current efforts therefore focus on optimising replacement strategies. In addition, in recent years novel experimental therapies have been developed which target adrenal sex steroid synthesis in patients with CAH aiming to reduce co-morbidities associated with sex steroid excess. These developments will hopefully improve the health status and long-term outcomes in patients with congenital adrenal hyperplasia and adrenal insufficiency.
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Affiliation(s)
- Emma A Webb
- School of Clinical & Experimental Medicine, University of Birmingham, Institute of Biomedical Research, Birmingham B15 2TT, UK.
| | - Nils Krone
- School of Clinical & Experimental Medicine, University of Birmingham, Institute of Biomedical Research, Birmingham B15 2TT, UK.
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10
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Yau M, Pina C, Khattab A, Barhen A, New MI. Prenatal diagnosis of congenital adrenal hyperplasia owing to 21-hydroxylase deficiency. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1035254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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11
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van Rossum HH, Bergman AM, Lentjes E. Analytical Challenges and Potential Applications of Sex Steroid Hormone Analysis in Breast and Prostate Cancer Patients. Chromatographia 2014. [DOI: 10.1007/s10337-014-2797-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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12
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Sarafoglou K, Addo OY, Turcotte L, Otten N, Wickremasinghe A, Pittock S, Kyllo J, Lteif AN, Himes JH, Miller BS. Impact of hydrocortisone on adult height in congenital adrenal hyperplasia-the Minnesota cohort. J Pediatr 2014; 164:1141-1146.e1. [PMID: 24560184 DOI: 10.1016/j.jpeds.2014.01.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 12/04/2013] [Accepted: 01/06/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To estimate the impact of the average daily dose of hydrocortisone (HC) on the amount of growth attained in children with congenital adrenal hyperplasia (CAH). The effect of glucocorticoid therapy on adult height (AH) in children with CAH has yet to be elucidated. STUDY DESIGN Triple-logistic models estimating components of growth and maturation were fitted to longitudinal records of 104 patients with classic CAH from 3 pediatric medical centers in Minnesota between 1955 and 2012. A total of 3664 clinical encounters were examined. Random-effects longitudinal models with time-related covariates were used to estimate the effect of HC therapy on linear growth. RESULTS The predicted AH z-score (-0.7) was similar between the sexes and among CAH subtypes. The mean growth period HC dose was 18.9 ± 5.6 mg/m(2)/day. In the final regression model, HC dose was negatively associated with predicted AH, with each mg/m(2)/day increase in average growth period HC dose predicting a 0.37-cm decrease in AH (P < .004). CONCLUSION This study has quantified the fractional reduction in predicted final AH with an incremental increase in HC dose. These findings have important clinical implications in the decision making balance between HC replacement dose and adrenal androgen suppression in children with CAH.
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Affiliation(s)
- Kyriakie Sarafoglou
- Department of Pediatrics, University of Minnesota Amplatz Children's Hospital, Minneapolis, MN.
| | - O Yaw Addo
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Lucie Turcotte
- Department of Pediatrics, University of Minnesota Amplatz Children's Hospital, Minneapolis, MN
| | - Noelle Otten
- Department of Pediatrics, University of Minnesota Amplatz Children's Hospital, Minneapolis, MN
| | - Andrea Wickremasinghe
- Department of Pediatrics, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Siobhan Pittock
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Jennifer Kyllo
- Division of Diabetes and Endocrinology, Children's Hospitals of Minnesota, Minneapolis, MN
| | - Aida N Lteif
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - John H Himes
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Bradley S Miller
- Department of Pediatrics, University of Minnesota Amplatz Children's Hospital, Minneapolis, MN
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Han TS, Walker BR, Arlt W, Ross RJ. Treatment and health outcomes in adults with congenital adrenal hyperplasia. Nat Rev Endocrinol 2014; 10:115-24. [PMID: 24342885 DOI: 10.1038/nrendo.2013.239] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a genetic disorder caused by defective steroidogenesis that results in glucocorticoid deficiency; the most common underlying mutation is in the gene that encodes 21-hydroxylase. Life-saving glucocorticoid treatment was introduced in the 1950s, and the number of adult patients is now growing; however, no consensus has been reached on the management of CAH beyond childhood. Adult patients are prescribed a variety of glucocorticoids, including hydrocortisone, prednisone, prednisolone, dexamethasone and combinations of these drugs taken in either a circadian or reverse circadian regimen. Despite these personalized treatments, biochemical control of CAH is only achieved in approximately one-third of patients. Some patients have a poor health status, with an increased incidence of obesity and osteoporosis, and impaired fertility and quality of life. The majority of poor health outcomes seem to relate to inadequate treatment rather than the genotype of the patient. Patients receiving high doses of glucocorticoids and the more potent synthetic long-acting glucocorticoids are at an increased risk of obesity, insulin resistance and a reduced quality of life. Further research is required to optimize the treatment of adult patients with CAH and improve health outcomes.
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Affiliation(s)
- Thang S Han
- Department of Diabetes and Endocrinology, St Peter's NHS Foundation Trust, Guildford Road, Chertsey, Surrey KT16 0PZ, UK
| | - Brian R Walker
- BHF Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Wiebke Arlt
- Centre for Endocrinology, Diabetes and Metabolism, School of Clinical & Experimental Medicine, University of Birmingham, Birmingham B15 2TT, UK
| | - Richard J Ross
- Academic Unit of Diabetes, Endocrinology & Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, South Yorkshire S10 2RX, UK
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Gidlöf S, Falhammar H, Thilén A, von Döbeln U, Ritzén M, Wedell A, Nordenström A. One hundred years of congenital adrenal hyperplasia in Sweden: a retrospective, population-based cohort study. Lancet Diabetes Endocrinol 2013; 1:35-42. [PMID: 24622265 DOI: 10.1016/s2213-8587(13)70007-x] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Congenital adrenal hyperplasia due to 21-hydroxylase deficiency results in cortisol and aldosterone deficiency and is, in its most severe form, lethal. We aimed to assess the effect of historical medical improvements in the care of patients with this disorder over time and to assess the effects of neonatal screening in Sweden. METHODS For this retrospective, population-based cohort study, we collected data for all known patients with congenital adrenal hyperplasia in Sweden between 1910 and 2011 [corrected]. Data sources included the registry at the Swedish national screening laboratory, patients identified via the Swedish neonatal screening programme, late-diagnosed patients reported to the laboratory, and patients who underwent genetic diagnostics or became known to us through clinical contacts. All known patients were included in a population-based cohort study of the distribution of clinical severity, genotype, sex, and the effect of nationwide neonatal screening. FINDINGS We identified 606 patients with the disorder, born between 1915 and 2011. The CYP21A2 genotype (conferring deficiency of 21-hydroxylase) was known in 490 patients (81%). The female-to-male ratio was 1·25 in the whole cohort, but close to 1 in patients detected by the screening. We noted a sharp increase in the number of patients diagnosed in the 1960s and 1970s, and after the introduction of neonatal screening in 1986 the proportion of patients with the salt-wasting form of congenital adrenal hyperplasia increased in both sexes, from 114 (47%) of 242 individuals between 1950 and 1985 to 165 (57%) of 292 individuals between 1986 and 2011 (p=0·038). On average, five to ten children were missed every year before 1970. The non-classic form of the disorder was diagnosed more often in women than in men, which accounts for the female preponderance in our cohort. INTERPRETATION Our findings suggest that, contrary to current belief, boys and girls with salt-wasting congenital adrenal hyperplasia were equally missed clinically. Neonatal screening improved detection of the salt-wasting form in girls as well as boys, saving lives in both sexes. The non-classic form was diagnosed more often in women than it was in men, leading to the female preponderance in this cohort. FUNDING The Swedish Research Council, the Centre of Gender Medicine at Karolinska Institutet, the Stockholm County Council, the Sällskapet Barnavård Foundation, the Stiftelsen Samariten Foundation, the Stiftelsen Frimurare Barnhuset Foundation, and the Novo Nordisk Foundation.
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Affiliation(s)
- Sebastian Gidlöf
- Department of Molecular Medicine and Surgery, Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynaecology, Karolinska University Hospital Huddinge, Stockholm, Sweden.
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Astrid Thilén
- Department of Paediatrics, Jönköping Hospital, Jönköping, Sweden
| | - Ulrika von Döbeln
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Martin Ritzén
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Anna Wedell
- Department of Molecular Medicine and Surgery, Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Anna Nordenström
- Department of Molecular Medicine and Surgery, Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden; Paediatric Endocrinology, Karolinska University Hospital Solna, Stockholm, Sweden
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15
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Ferraldeschi R, Sharifi N, Auchus RJ, Attard G. Molecular pathways: Inhibiting steroid biosynthesis in prostate cancer. Clin Cancer Res 2013; 19:3353-9. [PMID: 23470964 DOI: 10.1158/1078-0432.ccr-12-0931] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A significant proportion of castration-resistant prostate cancers (CRPC) remains driven by ligand activation of the androgen receptor. Although the testes are the primary source of testosterone, testosterone can also be produced from peripheral conversion of adrenal sex hormone precursors DHEA and androstenedione in the prostate and other tissues. CYP17A1 catalyzes two essential reactions in the production of DHEA and androstenedione: the hydroxylation (hydroxylase activity) and the subsequent cleavage of the C17-20 side chain (lyase activity). Potent and selective inhibition of CYP17A1 by abiraterone depletes residual nongonadal androgens and is an effective treatment for CRPC. Elucidation of the mechanisms that underlie resistance to abiraterone will inform the development of novel therapeutic strategies post-abiraterone. Preclinical evidence that androgen biosynthesis in prostate cancer cells does not necessarily follow a single dominant pathway, and residual androgens or alternative ligands (including administered glucocorticoids) can reactivate androgen receptor signaling, supports cotargeting of more than one enzyme involved in steroidogenesis and combining a CYP17A1 inhibitor with an antiandrogen. Furthermore, given the drawbacks of 17α-hydroxylase inhibition, there is considerable interest in developing new CYP17A1 inhibitors that more specifically inhibit lyase activity and are therefore less likely to require glucocorticoid coadministration.
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Affiliation(s)
- Roberta Ferraldeschi
- Prostate Cancer Targeted Therapy Group and Drug Development Unit, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, Sutton, Surrey, United Kingdom
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Fallat ME, Hertweck P, Ralston SJ. Surgical and ethical challenges in disorders of sexual development. Adv Pediatr 2012; 59:283-302. [PMID: 22789583 DOI: 10.1016/j.yapd.2012.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
A resolution to the difficulties faced by parents, physicians, and pediatric patients in treating DSDs will only come with better communication and improved research methodologies. Advocacy groups and the Internet have allowed the intersex community to have a larger role in guiding the research and the ethical frameworks that are used in treating these disorders. These disorders are unusual and collaboration across medical centers should be the rule rather than the exception. When possible, treatments that are innovative or experimental should be subjected to rigorous research oversight [29,30]. Defined periods of family crisis in which counseling and education become important are at the time of diagnosis [30,31], at the time of any surgical procedure, and at the beginning of major developmental stages. Historically, children were often left uninformed until someone judged them old and mature enough to comprehend how they were different. These attempts to protect individual children from their condition may have left them vulnerable to a personal crisis at an age when sexual identity and identity with a peer group are important. Both the needs of the child and the adult the child will become should be considered in making treatment decisions for children and adolescents with DSDs. It is best to counsel parents and educate developing children in a way that parallels chronologic and conceptual growth. When possible, the child should be involved in an age-appropriate fashion in the decision-making process and accurate information about the child's history and body should be made available. In addition, parents and families need as much information as possible and support systems that will help them navigate these challenging situations.
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Affiliation(s)
- Mary E Fallat
- Division of Pediatric Surgery, Department of Surgery, University of Louisville, KY 40202, USA.
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