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Ichihara A, Shibata H, Hayashi K, Saito I. In memoriam; a tribute to Takao Saruta, MD, PhD. Hypertens Res 2024; 47:255-256. [PMID: 37985740 DOI: 10.1038/s41440-023-01527-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023]
Affiliation(s)
- Atsuhiro Ichihara
- Department of Medicine, Tokyo Women's Medical University, Tokyo, Japan.
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Oita, Japan
| | - Kaori Hayashi
- Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ikuo Saito
- Japan Bank Association and Keio University, Tokyo, Japan
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Fernandes-Rosa FL, Boulkroun S, Fedlaoui B, Hureaux M, Travers-Allard S, Drossart T, Favier J, Zennaro MC. New advances in endocrine hypertension: from genes to biomarkers. Kidney Int 2023; 103:485-500. [PMID: 36646167 DOI: 10.1016/j.kint.2022.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 01/15/2023]
Abstract
Hypertension (HT) is a major cardiovascular risk factor that affects 10% to 40% of the general population in an age-dependent manner. Detection of secondary forms of HT is particularly important because it allows the targeted management of the underlying disease. Among hypertensive patients, the prevalence of endocrine HT reaches up to 10%. Adrenal diseases are the most frequent cause of endocrine HT and are associated with excess production of mineralocorticoids (mainly primary aldosteronism), glucocorticoids (Cushing syndrome), and catecholamines (pheochromocytoma). In addition, a few rare diseases directly affecting the action of mineralocorticoids and glucocorticoids in the kidney also lead to endocrine HT. Over the past years, genomic and genetic studies have allowed improving our knowledge on the molecular mechanisms of endocrine HT. Those discoveries have opened new opportunities to transfer knowledge to clinical practice for better diagnosis and specific treatment of affected subjects. In this review, we describe the physiology of adrenal hormone biosynthesis and action, the clinical and biochemical characteristics of different forms of endocrine HT, and their underlying genetic defects. We discuss the impact of these discoveries on diagnosis and management of patients, as well as new perspectives related to the use of new biomarkers for improved patient care.
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Affiliation(s)
| | | | | | - Marguerite Hureaux
- Université Paris Cité, PARCC, Inserm, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France
| | - Simon Travers-Allard
- Université Paris Cité, PARCC, Inserm, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Physiologie, Paris, France
| | - Tom Drossart
- Université Paris Cité, PARCC, Inserm, Paris, France; Université de Paris Cité, PARCC, Inserm, Equipe Labellisée par la Ligue contre le Cancer, Paris, France
| | - Judith Favier
- Université Paris Cité, PARCC, Inserm, Paris, France; Université de Paris Cité, PARCC, Inserm, Equipe Labellisée par la Ligue contre le Cancer, Paris, France
| | - Maria-Christina Zennaro
- Université Paris Cité, PARCC, Inserm, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France.
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Cardiac Hypertrophy and Related Dysfunctions in Cushing Syndrome Patients-Literature Review. J Clin Med 2022; 11:jcm11237035. [PMID: 36498610 PMCID: PMC9739690 DOI: 10.3390/jcm11237035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 11/29/2022] Open
Abstract
The survival rate of adrenal Cushing syndrome patients has been greatly increased because of the availability of appropriate surgical and pharmacological treatments. Nevertheless, increased possibility of a heart attack induced by a cardiovascular event remains a major risk factor for the survival of affected patients. In experimental studies, hypercortisolemia has been found to cause cardiomyocyte hypertrophy via glucocorticoid receptor activation, including the possibility of cross talk among several hypertrophy signals related to cardiomyocytes and tissue-dependent regulation of 11β-hydroxysteroid dehydrogenase type 1. However, the factors are more complex in clinical cases, as both geometric and functional impairments leading to heart failure have been revealed, and their associations with a wide range of factors such as hypertension are crucial. In addition, knowledge regarding such alterations in autonomous cortisol secretion, which has a high risk of leading to heart attack as well as overt Cushing syndrome, is quite limited. When considering the effects of treatment, partial improvement of structural alterations is expected, while functional disorders are controversial. Therefore, whether the normalization of excess cortisol attenuates the risk related to cardiac hypertrophy has yet to be fully elucidated.
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Fallo F, Di Dalmazi G, Beuschlein F, Biermasz NR, Castinetti F, Elenkova A, Fassnacht M, Isidori AM, Kastelan D, Korbonits M, Newell-Price J, Parati G, Petersenn S, Pivonello R, Ragnarsson O, Tabarin A, Theodoropoulou M, Tsagarakis S, Valassi E, Witek P, Reincke M. Diagnosis and management of hypertension in patients with Cushing's syndrome: a position statement and consensus of the Working Group on Endocrine Hypertension of the European Society of Hypertension. J Hypertens 2022; 40:2085-2101. [PMID: 35950979 DOI: 10.1097/hjh.0000000000003252] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Endogenous/exogenous Cushing's syndrome is characterized by a cluster of systemic manifestations of hypercortisolism, which cause increased cardiovascular risk. Its biological basis is glucocorticoid excess, acting on various pathogenic processes inducing cardiovascular damage. Hypertension is a common feature in Cushing's syndrome and may persist after normalizing hormone excess and discontinuing steroid therapy. In endogenous Cushing's syndrome, the earlier the diagnosis the sooner management can be employed to offset the deleterious effects of excess cortisol. Such management includes combined treatments directed against the underlying cause and tailored antihypertensive drugs aimed at controlling the consequences of glucocorticoid excess. Experts on endocrine hypertension and members of the Working Group on Endocrine Hypertension of the European Society of Hypertension (ESH) prepared this Consensus document, which summarizes the current knowledge in epidemiology, genetics, diagnosis, and treatment of hypertension in Cushing's syndrome.
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Affiliation(s)
- Francesco Fallo
- Clinica Medica 3, Department of Medicine, University of Padova, Padova
| | - Guido Di Dalmazi
- Unit of Endocrinology and Diabetes Prevention and Care, Department of Medical and Surgical Sciences, University of Bologna
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Nienke R Biermasz
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | - Frederic Castinetti
- Aix Marseille Université, Marseille Medical Genetics, INSERM
- Assistance Publique Hopitaux de Marseille
- Department of Endocrinology, La Conception Hospital, Marseille, France
| | - Atanaska Elenkova
- Department of Endocrinology, University Specialized Hospital for Active Treatment in Endocrinology (USHATE) "Acad. Ivan Penchev", Medical University - Sofia, Sofia, Bulgaria
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb University School of Medicine, Zagreb, Croatia
| | - Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London
| | - John Newell-Price
- Department of Oncology and Metabolism, Medical School, University of Sheffield
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences Istituto Auxologico Italiano, IRCCS
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany and University of Duisburg-Essen, Essen, Germany
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli
- Unesco Chair for Health Education and Sustainable Development, "Federico II" University, Naples, Italy
| | - Oskar Ragnarsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Antoine Tabarin
- CHU de Bordeaux, Hôpital Haut Lévêque, University of Bordeaux, Bordeaux, France
| | - Marily Theodoropoulou
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Elena Valassi
- Endocrinology Unit, Hospital Germans Trias i Pujol, Badalona
- Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Mazovian Bródno Hospital, Medical University of Warsaw, Warsaw, Poland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
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Characteristics of aldosterone-producing adenomas in patients without plasma renin activity suppression. PLoS One 2022; 17:e0267732. [PMID: 35482752 PMCID: PMC9049528 DOI: 10.1371/journal.pone.0267732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 04/13/2022] [Indexed: 01/13/2023] Open
Abstract
Primary aldosteronism (PA) usually accompanies suppressed plasma renin activity (PRA) through a negative feedback mechanism. While some cases of PA with unsuppressed PRA were reported, there have been no studies about the characteristics of PA with unsuppressed PRA; thus, these characteristics were examined herein. Nine patients with unsuppressed PRA and 86 patients with suppressed PRA were examined. All patients underwent segmental adrenal venous sampling (sAVS) and adrenalectomy, and were pathologically confirmed to have cytochrome P450 11B2 (CYP11B2)-positive aldosterone-producing adenoma according to international histopathology consensus criteria. Unsuppressed and suppressed PRA were defined as PRA levels of > 1.0 and ≤ 1.0 ng/mL/hr, respectively, in multiple blood samples obtained in the resting position. The unsuppressed PRA group had higher morning cortisol levels (12.6 [8.5, 13.5] vs. 8.5 [7.1, 11.0] μg/dL, P = 0.03) and higher cortisol levels after a 1 mg dexamethasone suppression test (DST) (2.2 [1.6, 2.5] vs. 1.3 [1.0, 1.9] μ g/dL, P = 0.004) than the suppressed PRA group. The unsuppressed PRA group also showed higher aldosterone levels on the non-surgical side during sAVS (P = 0.02 before adrenocorticotropic hormone (ACTH) stimulation, P = 0.002 after ACTH stimulation), a higher intensity of CYP17 expression in the resected adrenal gland (P = 0.02), and a lower clinical complete success rate 1 year after surgery (P = 0.04) compared with those in the suppressed PRA group. These findings suggest that PA should not be ruled out by unsuppressed PRA among patients with hypertension, particularly when their cortisol levels remain unsuppressed in the 1 mg DST. Meanwhile, it should be acknowledged that patients with unsuppressed PRA have higher aldosterone levels on the non-surgical side, and a lower likelihood of postoperative complete clinical success is to be expected.
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Esteves GP, Mazzolani BC, Smaira FI, Mendes ES, de Oliveira GG, Roschel H, Gualano B, Pereira RMR, Dolan E. Nutritional recommendations for patients undergoing prolonged glucocorticoid therapy. Rheumatol Adv Pract 2022; 6:rkac029. [PMID: 35539442 PMCID: PMC9080102 DOI: 10.1093/rap/rkac029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/05/2022] [Indexed: 11/14/2022] Open
Abstract
Glucocorticoid (GC) therapy is a common treatment used in rheumatic and autoimmune diseases, owing to its anti-inflammatory and immunosuppressive effects. However, GC therapy can also induce a number of adverse effects, including muscle and bone loss, hypertension, metabolic perturbations and increased visceral adiposity. We review available evidence in this area and provide nutritional recommendations that might ameliorate these adverse effects. Briefly, optimizing calcium, vitamin D, sodium and protein intake and increasing consumption of unprocessed and minimally processed foods, while decreasing the consumption of ultra-processed foods, might counteract some of the specific challenges faced by these patients. Importantly, we identify a dearth of empirical data on how nutritional intervention might impact health-related outcomes in this population. Further research is required to investigate the clinical and therapeutic efficacy of these theory-based recommendations.
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Affiliation(s)
- Gabriel P Esteves
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Bruna Caruso Mazzolani
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Fabiana Infante Smaira
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Elizabeth Silva Mendes
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Gabriela Guimarães de Oliveira
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Hamilton Roschel
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Bruno Gualano
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Rosa Maria R Pereira
- Bone Metabolism Laboratory, Rheumatology Division; Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Eimear Dolan
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
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Immunomodulatory Potential of Diuretics. BIOLOGY 2021; 10:biology10121315. [PMID: 34943230 PMCID: PMC8698805 DOI: 10.3390/biology10121315] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/25/2021] [Accepted: 12/09/2021] [Indexed: 12/15/2022]
Abstract
In this review, diuretics and their immunomodulatory functions are described. The effects on the immune response of this group of drugs are reported in patients suffering from hypertension and under experimental conditions involving animal models and cell line studies. The pathogenesis of hypertension is strongly connected to chronic inflammation. The vast majority of diuretics modulate the immune response, changing it in favor of the anti-inflammatory response, but depending on the drug, these effects may differ. This topic is significantly important in medical practice regarding the treatment of patients who have coexisting diseases with chronic inflammatory pathogenesis, including hypertension or chronic heart failure. In patients with metabolic syndrome, allergies, or autoimmune disorders, the anti-inflammatory effect is favorable, because of the overstimulation of their immune system. Otherwise, in the geriatric population, it is important to find the proper anti- and pro-inflammatory balance to avoid an enhancement of immune response suppression, which can result in reducing the risk of serious infections that can occur due to the age-diminished function of the immune system. This article is intended to facilitate the selection of an antihypertensive drug that depends on the patient's immune situation.
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Jurek A, Krzesiński P, Gielerak G, Witek P, Zieliński G, Kazimierczak A, Wierzbowski R, Banak M, Uziębło-Życzkowska B. Cushing's Disease: Assessment of Early Cardiovascular Hemodynamic Dysfunction With Impedance Cardiography. Front Endocrinol (Lausanne) 2021; 12:751743. [PMID: 34659130 PMCID: PMC8517395 DOI: 10.3389/fendo.2021.751743] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cushing's disease is a rare condition associated with a high cardiovascular risk and hypercortisolemia-related hemodynamic dysfunction, the extent of which can be assessed with a noninvasive method, called impedance cardiography. The standard methods for hemodynamic assessment, such as echocardiography or ambulatory blood pressure monitoring may be insufficient to fully evaluate patients with Cushing's disease; therefore, impedance cardiography is being currently considered a new modality for assessing early hemodynamic dysfunction in this patient population. The use of impedance cardiography for diagnosis and treatment of Cushing's disease may serve as personalized noninvasive hemodynamic status assessment and provide a better insight into the pathophysiology of Cushing's disease. The purpose of this study was to assess the hemodynamic profile of Cushing's disease patients and compare it with that in the control group. MATERIAL AND METHODS This observational prospective clinical study aimed to compare 54 patients with Cushing's disease (mean age 41 years; with 64.8% of this population affected with arterial hypertension) and a matched 54-person control group (mean age 45 years; with 74.1% of this population affected with arterial hypertension). The hemodynamic parameters assessed with impedance cardiography included the stroke index (SI), cardiac index (CI), systemic vascular resistance index (SVRI), velocity index (VI), (ACI), Heather index (HI), and thoracic fluid content (TFC). RESULTS The Cushing's disease group was characterized by a higher diastolic blood pressure and a younger age than the control group (82.9 vs. 79.1 mmHg, p=0.045; and 41.1 vs. 44.9 years, p=0.035, respectively). Impedance cardiography parameters in the Cushing's disease group showed: lower values of SI (42.1 vs. 52.8 ml/m2; p ≤ 0.0001), CI (2.99 vs. 3.64 l/min/m2; p ≤ 0,0001), VI (42.9 vs. 52.1 1/1000/s; p=0.001), ACI (68.7 vs. 80.5 1/100/s2; p=0,037), HI (13.1 vs. 15.2 Ohm/s2; p=0.033), and TFC (25.5 vs. 27.7 1/kOhm; p=0.006) and a higher SVRI (2,515 vs. 1,893 dyn*s*cm-5*m2; p ≤ 0.0001) than those in the control group. CONCLUSIONS Cushing's disease is associated with significantly greater vasoconstriction and left ventricular systolic dysfunction. An individual assessment with impedance cardiography may be useful in Cushing's disease patients in order to identify subclinical cardiovascular complications of chronic hypercortisolemia as potential therapeutic targets.
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Affiliation(s)
- Agnieszka Jurek
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
- *Correspondence: Agnieszka Jurek,
| | - Paweł Krzesiński
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Grzegorz Gielerak
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Zieliński
- Department of Neurosurgery, Military Institute of Medicine, Warsaw, Poland
| | - Anna Kazimierczak
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Robert Wierzbowski
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Małgorzata Banak
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
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Tinklenberg RL, Murphy SD, Mochel JP, Seo YJ, Mahaffey AL, Yan Y, Ward JL. Evaluation of dose-response effects of short-term oral prednisone administration on clinicopathologic and hemodynamic variables in healthy dogs. Am J Vet Res 2020; 81:317-325. [PMID: 32228253 DOI: 10.2460/ajvr.81.4.317] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether a dose-response relationship exists between short-term oral prednisone administration and common clinicopathologic variables, cardiovascular biomarkers, and systolic arterial blood pressure (SAP) in healthy dogs. ANIMALS 8 healthy Beagles. PROCEDURES Dogs underwent five 5-day experiments (no prednisone treatment [control condition] and prednisone administration at 0.5, 1, 2, and 4 mg/kg, PO, q 24 h), with a 9-day washout period between protocols. Analyses performed before and after treatments included a CBC, serum biochemical analysis, and determination of SAP, fractional excretion of electrolytes, urine protein-to-creatinine ratio, glomerular filtration rate (GFR), serum N-terminal pro B-type natriuretic peptide (NT-proBNP) and plasma cortisol concentrations, and plasma renin activity. Linear mixed-effects modeling was used to compare changes in variables from baseline (day 1 for the same experiment) among treatment conditions. RESULTS Changes in serum glucose concentration and GFR were significantly greater after administration of prednisone at 4 mg/kg than for the control condition. Fractional excretion of sodium was decreased from baseline when dogs received 0.5, 1, or 4 mg of prednisone/kg, compared with results for the control condition. Several expected changes in clinicopathologic values were observed after prednisone administration at any dose. Changes in serum NT-proBNP concentration, plasma renin activity, and SAP did not differ from changes for the control condition at any prednisone dose. CONCLUSIONS AND CLINICAL RELEVANCE Oral prednisone administration did not affect SAP, NT-proBNP concentration, or measures of renin-angiotensin-aldosterone system activation in healthy laboratory-housed dogs but was associated with relative increases in GFR and serum glucose concentration.
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Li D, El Kawkgi OM, Henriquez AF, Bancos I. Cardiovascular risk and mortality in patients with active and treated hypercortisolism. Gland Surg 2020; 9:43-58. [PMID: 32206598 DOI: 10.21037/gs.2019.11.03] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients with hypercortisolism demonstrate high cardiovascular morbidity and mortality, especially if diagnosis is delayed. Hypercortisolism-induced cardiovascular and metabolic comorbidities include hypertension, impaired glucose metabolism, dyslipidemia, and obesity. High prevalence of cardiovascular risk factors leads to increased rate of cardiovascular events and mortality. This risk is reduced, albeit not reversed even after successful treatment of hypercortisolism. In this review we will describe prevalence and mechanisms of cardiovascular comorbidities in patients with hypercortisolism. In addition, we will summarize the effect of therapy on cardiovascular risk factors, events, as well as mortality.
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Affiliation(s)
- Dingfeng Li
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Omar M El Kawkgi
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Andres F Henriquez
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
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11
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Jha S, Sinaii N, McGlotten RN, Nieman LK. Remission of hypertension after surgical cure of Cushing's syndrome. Clin Endocrinol (Oxf) 2020; 92:124-130. [PMID: 31721265 DOI: 10.1111/cen.14129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/17/2019] [Accepted: 11/10/2019] [Indexed: 11/27/2022]
Abstract
CONTEXT Hypertension associated with Cushing's syndrome (CS) increases cardiovascular risk. The time-course of improvement after cure is unclear. OBJECTIVE To describe the time-course and predictors of blood pressure (BP) normalization during one year after surgical cure of CS. DESIGN Retrospective chart review of 75 hypertensive adults cured of CS (72 with ACTH-dependent CS; 3 with adrenal adenoma). Hypertension was defined as current use of antihypertensives, a systolic BP >130 mm Hg, or diastolic BP >80 mm Hg. MAIN OUTCOME MEASURE(S) Remission of hypertension: BP ≤130/80 mm Hg and no antihypertensive medications. Improvement in hypertension: BP >130/80 mm Hg and decreased number or dose of medications, or blood pressure ≤130/80 with continued use of medications at constant dose. RESULTS At postoperative discharge, 17 (23%, P < .001), 51 (68%, P < .001) and 7 (9%) patients had remission, improvement in hypertension or no change. Twenty-nine had no follow-up. Others achieved remission at 3 (n = 5), 6 (n = 6), or 12-months (n = 5). At the last evaluation, 33/75 (44%) had remission, 36/75 (48%) had improved hypertension and 6 were unchanged. Patients with improvement discontinued a median of one medication (P < .001). At 12-months, 27/42 (64%) patients had normal BP (P < .002). Longer estimated duration of CS (P = .0106), younger age (P = .0022), and lower baseline body mass index (P = .0413) predicted hypertension remission. CONCLUSIONS About 80% of CS patients experienced BP normalization or improvement within 10 days of cure, but about half failed to normalize BP by one year. BP should be monitored after cure, and antihypertensive medications adjusted to avoid unwanted cardiovascular effects.
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Affiliation(s)
- Smita Jha
- Diabetes, Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
- Clinical and Investigative Orthopedics Surgery Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Raven N McGlotten
- Diabetes, Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Lynnette K Nieman
- Diabetes, Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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Carbajal-García A, Reyes-García J, Montaño LM. Androgen Effects on the Adrenergic System of the Vascular, Airway, and Cardiac Myocytes and Their Relevance in Pathological Processes. Int J Endocrinol 2020; 2020:8849641. [PMID: 33273918 PMCID: PMC7676939 DOI: 10.1155/2020/8849641] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/17/2020] [Accepted: 10/20/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Androgen signaling comprises nongenomic and genomic pathways. Nongenomic actions are not related to the binding of the androgen receptor (AR) and occur rapidly. The genomic effects implicate the binding to a cytosolic AR, leading to protein synthesis. Both events are independent of each other. Genomic effects have been associated with different pathologies such as vascular ischemia, hypertension, asthma, and cardiovascular diseases. Catecholamines play a crucial role in regulating vascular smooth muscle (VSM), airway smooth muscle (ASM), and cardiac muscle (CM) function and tone. OBJECTIVE The aim of this review is an updated analysis of the role of androgens in the adrenergic system of vascular, airway, and cardiac myocytes. Body. Testosterone (T) favors vasoconstriction, and its concentration fluctuation during life stages can affect the vascular tone and might contribute to the development of hypertension. In the VSM, T increases α1-adrenergic receptors (α 1-ARs) and decreases adenylyl cyclase expression, favoring high blood pressure and hypertension. Androgens have also been associated with asthma. During puberty, girls are more susceptible to present asthma symptoms than boys because of the increment in the plasmatic concentrations of T in young men. In the ASM, β 2-ARs are responsible for the bronchodilator effect, and T augments the expression of β 2-ARs evoking an increase in the relaxing response to salbutamol. The levels of T are also associated with an increment in atherosclerosis and cardiovascular risk. In the CM, activation of α 1A-ARs and β 2-ARs increases the ionotropic activity, leading to the development of contraction, and T upregulates the expression of both receptors and improves the myocardial performance. CONCLUSIONS Androgens play an essential role in the adrenergic system of vascular, airway, and cardiac myocytes, favoring either a state of health or disease. While the use of androgens as a therapeutic tool for treating asthma symptoms or heart disease is proposed, the vascular system is warmly affected.
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Affiliation(s)
- Abril Carbajal-García
- Departamento de Farmacología, Facultad de Medicina, Universidad Nacional Autónoma de México, CDMX, Mexico
| | - Jorge Reyes-García
- Departamento de Farmacología, Facultad de Medicina, Universidad Nacional Autónoma de México, CDMX, Mexico
| | - Luis M. Montaño
- Departamento de Farmacología, Facultad de Medicina, Universidad Nacional Autónoma de México, CDMX, Mexico
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Nieman LK. Hypertension and Cardiovascular Mortality in Patients with Cushing Syndrome. Endocrinol Metab Clin North Am 2019; 48:717-725. [PMID: 31655772 DOI: 10.1016/j.ecl.2019.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Patients with Cushing syndrome have an increased mortality rate, primarily due to increased cardiovascular death, which is driven by hypertension, diabetes, obesity, and dyslipidemia. These should be evaluated before and after active hypercortisolism, and each should be treated specifically. Antihypertensives may be chosen based on probable pathophysiology. Thus, inhibitors of the renin-angiotensinogen system are recommended. Mineralocorticoid antagonists are helpful in hypokalemic patients. Other agents are often needed to normalize blood pressure. If medical treatment of Cushing syndrome is chosen, the goal should be to normalize cortisol (or its clinical action); if this is not achieved, it is more difficult to treat comorbidities.
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Affiliation(s)
- Lynnette K Nieman
- Diabetes, Endocrinology and Obesity Branch, The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Building 10, CRC, 1 East, Room 1-3140, 10 Center Drive, MSC 1109, Bethesda, MD 20892-1109, USA.
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Jain N, Kumar KM, Sachdeva N, Bhansali A, Walia R. Demystifying "Steroid Withdrawal" During Remission in Cushing's Disease: Is Mineralocorticoid Replacement the Answer? Indian J Endocrinol Metab 2019; 23:456-459. [PMID: 31741906 PMCID: PMC6844159 DOI: 10.4103/ijem.ijem_260_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To study renin-angiotensin-aldosterone axis status (RAAS) in patients of Cushing's disease (CD) at baseline and 6 weeks after curative trans-sphenoidal surgery and evaluate the role of mineralocorticoid replacement in the resolution of "steroid withdrawal syndrome" (SWS). Postoperative RAAS status had not been evaluated in previous studies, although aldosterone levels have been shown to be suppressed during medical therapy with pasireotide and cabergoline. MATERIALS AND METHODS This was a prospective, single-center study. Patients with CD, aged between 15-75 years, undergoing curative pituitary surgery were recruited. An 8 am and 11 pm cortisol and adrenocorticotropic hormone (ACTH) were measured at baseline. An 8 am cortisol was measured 6 weeks after surgery to demonstrate remission. Plasma-renin activity and plasma-aldosterone concentration were measured at baseline and 6 weeks after curative surgery. RESULTS A total of 14 patients (11 female, 3 male) were recruited initially, of these 8 patients completed the study. The plasma-renin activity was not suppressed at baseline and did not rise significantly after surgery (P = 0.717). However, plasma-aldosterone concentration was in the low-normal range at baseline and had risen significantly 6 weeks after surgery (P = 0.013). No difference was noted in subgroups with or without hypertension. CONCLUSION Curative pituitary surgery leads to normalization of plasma-aldosterone concentration in patients with CD just 6 weeks after surgery. Hence, mineralocorticoid replacement may not prove beneficial in alleviating the "SWS" in postsurgical CD patients who have achieved remission.
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Affiliation(s)
- Nimisha Jain
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K. Mahesh Kumar
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Naresh Sachdeva
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil Bhansali
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rama Walia
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
Vasodilatory shock is the most common type of circulatory shock in critically ill patients; sepsis the predominant cause. Steroid use in septic shock gained favor in the 1970s; however, studies of high-dose steroids demonstrated excess morbidity and mortality. Lower dosage steroid use was driven by trials demonstrating improved hemodynamic status and the possibility of relative adrenal insufficiency; however, divergent results led to uncertainty about hydrocortisone treatment. Two recent trials are likely to reinforce the role of steroids in septic shock and change the recommendation in future clinical practice guidelines. Future work could include elucidating mechanisms of shock reversal, interaction of hydrocortisone with other agents, identifying steroid responsiveness using biochemical or gene signatures, and clarifying the role of fludrocortisone.
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Affiliation(s)
- Balasubramanian Venkatesh
- Department of Intensive Care, The Wesley Hospital, Coronation Drive, QLD 4066, Australia; Department of Intensive Care, Princess Alexandra Hospital, Ipswich Road, University of Queensland, QLD 4102, Australia; Division of Critical Care, The George Institute for Global Health, University of New South Wales, King Street, NSW 2050, Australia.
| | - Jeremy Cohen
- Department of Intensive Care, The Wesley Hospital, Coronation Drive, QLD 4066, Australia; Department of Intensive Care, The Royal Brisbane and Women's Hospital, University of Queensland, Herston Road, QLD 4066, Australia; Division of Critical Care, The George Institute for Global Health, King Street, Sydney, NSW 2050, Australia
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Masters AK, Berger DJ, Ware WA, Langenfeld NR, Coetzee JF, Mochel JP, Ward JL. Effects of short-term anti-inflammatory glucocorticoid treatment on clinicopathologic, echocardiographic, and hemodynamic variables in systemically healthy dogs. Am J Vet Res 2018; 79:411-423. [DOI: 10.2460/ajvr.79.4.411] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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17
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Joukar S, Ebrahimi S, Khazaei M, Bashiri A, Shakibi MR, Naderi V, Shahouzehi B, Alasvand M. Co-administration of walnut (Juglans regia) prevents systemic hypertension induced by long-term use of dexamethasone: a promising strategy for steroid consumers. PHARMACEUTICAL BIOLOGY 2017; 55:184-189. [PMID: 27653214 PMCID: PMC7011871 DOI: 10.1080/13880209.2016.1233570] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 04/12/2016] [Accepted: 09/04/2016] [Indexed: 06/06/2023]
Abstract
CONTEXT The long-term consumption of glucocorticoids (GCs) may induce serious adverse effects such as hypertension. There is sufficient evidence related to the benefit of walnuts on the cardiovascular system. OBJECTIVE This study assesses the effect of methanol extract of walnut [Juglans regia L. (Juglandaceae)] on dexamethasone-induced hypertension and the possible mechanisms in Wistar rats. MATERIAL AND METHODS Animals were randomized into control, kernel extract (100 and 200 mg/kg/d, orally), dexamethasone (0.03 mg/kg/d, subcutaneously), dexamethasone + kernel (100 and 200 mg/kg/d, separately), and dexamethasone + captopril (25 mg/kg/d, orally) groups. Animals were treated with water, kernel extract or captopril by gavage 4 d before and during 11 d of saline or dexamethasone treatment. On the 16th day, blood pressure (BP) was recorded and blood samples were collected to measure nitric oxide (NO). Animal hearts were frozen for measurement of malondialdehyde (MDA) and glutathione peroxidase (GPX). RESULTS Dexamethasone increased the diastolic BP and MDA/GPX ratio in comparison with control group (128 ± 7 vs. 105 ± 3 mmHg, p < 0.05 and 0.2 ± 0.046 vs. 0.08 ± 0.02, p < 0.05). Combination of dexamethasone and walnut (200 mg/kg) prevented the dexamethasone-induced diastolic hypertension (109 ± 3 vs. 128 ± 7 mmHg; p < 0.05), increased the GPX level (14.8 ± 1.46 vs. 5.1 ± 0.64 unit/mg, p < 0.05), reduced the MDA/GPX ratio (0.16 ± 0.015 vs. 0.2 ± 0.046) and improved serum NO level. CONCLUSION Similar to captopril, walnut extract normalized dexamethasone-induced hypertension. A part of this beneficial effect apparently involves maintaining balance of the redox system and NO production.
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Affiliation(s)
- Siyavash Joukar
- Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
- Department of Physiology and Pharmacology, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
- Physiology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Sahar Ebrahimi
- Physiology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Majid Khazaei
- Neurogenic Inflammation Research Center and Department of Physiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Bashiri
- Faculty of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, Iran
| | - Mohammad Reza Shakibi
- Department of Internal Medicine, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Vida Naderi
- Physiology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Beydolah Shahouzehi
- Physiology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Masoud Alasvand
- Department of Physiology, Isfahan University of Medical Sciences, Isfahan, Iran
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Shah N, Ruiz HH, Zafar U, Post KD, Buettner C, Geer EB. Proinflammatory cytokines remain elevated despite long-term remission in Cushing's disease: a prospective study. Clin Endocrinol (Oxf) 2017; 86:68-74. [PMID: 27630017 DOI: 10.1111/cen.13230] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 08/04/2016] [Accepted: 09/07/2016] [Indexed: 11/30/2022]
Abstract
CONTEXT Inflammation contributes to the development of metabolic and cardiovascular disease. Cushing's disease (CD), a state of chronic glucocorticoid (GC) excess characterized by visceral obesity and insulin resistance, may be associated with increased systemic inflammation. Cardiovascular mortality in CD remains elevated even after successful remission. It is unclear whether a chronic low-grade inflammatory state persists even after remission of CD, which may account for the increased CVD mortality. PURPOSE (1) To assess circulating proinflammatory cytokines in patients with active CD and BMI-matched controls; (2) to prospectively follow plasma cytokine concentrations in patients with CD before and after surgical remission; and (3) to assess whether plasma cytokine concentrations correlate with adipose tissue distribution and ectopic lipid content in liver and muscle. METHODS Plasma cytokines from prospectively enrolled patients with CD (N = 31) were quantified during active disease (v1) vs controls (N = 18) and 19·5 ± 12·9 months after surgical remission (v2). Fasting plasma IL-6, IL-1β, TNF-α, IL-8, IL-17 and IL-10 were quantified using a multiplex assay. Total and regional fat masses were measured by whole-body MRI. RESULTS Circulating IL-6 and IL-1β were elevated in patients with active CD vs controls (P < 0·05) and remained elevated in CD after surgical remission, despite decreases in BMI (P < 0·001), HOMA-IR (P < 0·001), and visceral, hepatic and intermuscular fat (P < 0·001, <0·001 and 0·03, respectively). CONCLUSIONS Despite long-term remission and improvements in fat distribution and insulin sensitivity, patients with CD may suffer from a state of chronic low-grade inflammation, which could contribute to increased cardiovascular mortality.
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Affiliation(s)
- Nirali Shah
- Division of Endocrinology, Metabolism and Diabetes, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Henry H Ruiz
- Division of Endocrinology, Metabolism and Diabetes, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Usman Zafar
- Division of Endocrinology, Metabolism and Diabetes, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kalmon D Post
- Department of Neurosurgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christoph Buettner
- Division of Endocrinology, Metabolism and Diabetes, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eliza B Geer
- Division of Endocrinology, Metabolism and Diabetes, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neurosurgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Henley D, Brown S, Pennell C, Lye S, Torpy DJ. Evidence for central hypercortisolism and elevated blood pressure in adolescent offspring of mothers with pre-eclampsia. Clin Endocrinol (Oxf) 2016; 85:583-9. [PMID: 27144974 DOI: 10.1111/cen.13092] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 01/04/2016] [Accepted: 04/29/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Maternal total and free cortisol concentrations are reduced in pre-eclampsia (PE) and gestational hypertension (GH). However, the effect of this on the hypothalamic-pituitary-adrenal (HPA) axis function in the offspring is unknown. We examined the basal HPA axis activity in adolescent offspring of mothers with pre-pregnancy hypertension/GH/PE. DESIGN AND SUBJECTS A total of 1182 participants (mean age 17·1 years) recruited from the Western Australian Pregnancy Cohort (Raine) Study provided fasting morning blood samples for basal HPA axis and concomitant clinical assessments, including blood pressure. MEASUREMENTS Plasma ACTH, total cortisol, corticosteroid-binding globulin (CBG) and free cortisol calculated by Coolens' equation were measured from the blood samples collected at home before 10:00 am. RESULTS Total plasma cortisol (689 ± 153 nmol/l vs 583 ± 172 nmol/l, P = 0·024), ACTH (15·5 ± 13 pmol/l vs 10·8 ± 5·1 pmol/l, P = 0·040) and calculated free cortisol (52 ± 21 nmol/l vs 42 ± 22 nmol/l, P = 0·052) were higher in the PE offspring than in controls. The pre-pregnancy hypertension group had evidence of a lower ACTH/plasma free cortisol ratio (0·22 vs 0·33 P = 0·020) and lower CBG (713 nmol/l vs 821 nmol/l, P = 0·004) compared with controls. Systolic blood pressure was elevated in the GH/PE group compared with controls (120 mmHg vs 116 mmHg, P = 0·006). CONCLUSIONS Hypothalamic-pituitary-adrenal axis activity is increased in the adolescent offspring of mothers with pre-eclampsia. This may be an adaptation resulting from the reduced maternal cortisol during foetal life. The resulting mild hypercortisolism may have implications for long-term health outcomes and warrants further investigation.
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Affiliation(s)
- David Henley
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.
- School of Medicine and Pharmacology, The University of Western Australia, Crawley, WA, Australia.
| | - Suzanne Brown
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Craig Pennell
- School of Women's and Infants' Health, The University of Western Australia, Crawley, WA, Australia
| | - Stephen Lye
- Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- School of Medicine, University of Adelaide, Adelaide, SA, Australia
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The hypertension of Cushing's syndrome: controversies in the pathophysiology and focus on cardiovascular complications. J Hypertens 2016; 33:44-60. [PMID: 25415766 PMCID: PMC4342316 DOI: 10.1097/hjh.0000000000000415] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cushing's syndrome is associated with increased mortality, mainly due to cardiovascular complications, which are sustained by the common development of systemic arterial hypertension and metabolic syndrome, which partially persist after the disease remission. Cardiovascular diseases and hypertension associated with endogenous hypercortisolism reveal underexplored peculiarities. The use of exogenous corticosteroids also impacts on hypertension and cardiovascular system, especially after prolonged treatment. The mechanisms involved in the development of hypertension differ, whether glucocorticoid excess is acute or chronic, and the source endogenous or exogenous, introducing inconsistencies among published studies. The pleiotropic effects of glucocorticoids and the overlap of the several regulatory mechanisms controlling blood pressure suggest that a rigorous comparison of in-vivo and in-vitro studies is necessary to draw reliable conclusions. This review, developed during the first ‘Altogether to Beat Cushing's syndrome’ workshop held in Capri in 2012, evaluates the most important peculiarities of hypertension associated with CS, with a particular focus on its pathophysiology. A critical appraisal of most significant animal and human studies is compared with a systematic review of the few available clinical trials. A special attention is dedicated to the description of the clinical features and cardiovascular damage secondary to glucocorticoid excess. On the basis of the consensus reached during the workshop, a pathophysiology-oriented therapeutic algorithm has been developed and it could serve as a first attempt to rationalize the treatment of hypertension in Cushing's syndrome.
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Prediction of Adrenal Adenomas With Hypercortisolism by Using Adrenal Computed Tomography: Emphasis on Contralateral Adrenal Thinning. J Comput Assist Tomogr 2015; 39:741-6. [PMID: 26035405 DOI: 10.1097/rct.0000000000000269] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE To analyze computed tomography (CT) characteristics of adrenal adenomas with hypercortisolism on adrenal CT compared to adenomas with hyperaldosteronism. MATERIALS AND METHODS Thirty-two adrenal adenomas, consisting of group A (hypercortisolism, n = 16) and group B (hyperaldosteronism, n = 16), were evaluated with adrenal CT. Thirty-four patients without adrenal nodule on CT and hormonal abnormality (group C) were selected for comparison. In adenomas, lesion size, attenuation value, and absolute and relative washout were compared between groups A and B. The mean adrenal thickness was compared quantitatively and qualitatively between groups. RESULTS All of adenomas satisfied absolute (≥60%) or relative (≥40%) washout criteria of adrenal CT. The mean adrenal thickness was 1.6 ± 0.3 mm in group A, 2.9 ± 0.5 mm in group B, and 3.0 ± 0.4 mm in group C (group A versus B or C, P < 0.001; group B versus C, P = 0.775). For differentiating group A from B, the area under the curve of quantitative and qualitative analyses for contralateral adrenal thickness was 0.982 and 0.934, respectively. Both sensitivity and specificity with cutoff of 2.0 mm or less in thickness and probably thin or more in visual score were 93.7% and 93.7%, and 87.5% and 93.7%, respectively, for predicting group A. CONCLUSIONS Contralateral adrenal thinning on CT helps predict adrenal adenomas with hypercortisolism.
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van Moorsel D, van Greevenbroek MMJ, Schaper NC, Henry RMA, Geelen CC, van Rossum EFC, Nijpels G, 't Hart LM, Schalkwijk CG, van der Kallen CJH, Sauerwein HP, Dekker JM, Stehouwer CDA, Havekes B. BclI glucocorticoid receptor polymorphism in relation to cardiovascular variables: the Hoorn and CODAM studies. Eur J Endocrinol 2015; 173:455-64. [PMID: 26139210 DOI: 10.1530/eje-15-0381] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 07/02/2015] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Excess glucocorticoids are known to cause hypertension and cardiovascular disease (CVD). The BclI glucocorticoid receptor (GR) polymorphism increases glucocorticoid sensitivity and is associated with adverse metabolic effects. Previous studies investigating cardiovascular implications have shown inconsistent results. Therefore, the aim of the present study was to investigate the association of the BclI polymorphism with blood pressure, atherosclerosis, low-grade inflammation, endothelial dysfunction, and prevalent CVD. DESIGN Observational cohort study, combining two cohort studies designed to investigate genetic and metabolic determinants of CVD. METHODS We genotyped 1228 individuals (aged 64.7 years±8.5) from the Cohort on Diabetes and Atherosclerosis Maastricht (CODAM) study and Hoorn study for the BclI polymorphism. We measured blood pressure, ankle-brachial index (ABI), and carotid intima-media thickness (cIMT). Low-grade inflammation and endothelial dysfunction scores were computed by averaging Z-scores of six low-grade inflammation markers and four endothelial dysfunction markers respectively. Prevalent CVD was assessed with questionnaires, hospital records, ECG, and ABI. RESULTS Homozygous carriers (GG) had higher mean arterial pressure (103.8±12.4 mmHg vs 101.6±12.2 mmHg (mean±S.D.); P<0.05) compared with non-carriers (CC). Homozygous carriers had lower ABI compared with heterozygous carriers (CG) (1.08±0.13 vs 1.11±0.14; P<0.05). After adjustment for all covariates in the full model, the association with ABI was no longer significant. BclI was not associated with systolic blood pressure, cIMT, low-grade inflammation, endothelial dysfunction, and prevalent CVD. CONCLUSIONS The BclI polymorphism of the GR gene may contribute to an unfavorable cardiovascular profile; however, the effects on cardiovascular variables appear to be limited and partly mediated by the metabolic phenotype exerted by BclI.
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Affiliation(s)
- Dirk van Moorsel
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht
| | - Marleen M J van Greevenbroek
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht
| | - Nicolaas C Schaper
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht
| | - Ronald M A Henry
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht
| | - Charlotte C Geelen
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands
| | - Elisabeth F C van Rossum
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands
| | - Giel Nijpels
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands
| | - Leen M 't Hart
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht
| | - Casper G Schalkwijk
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht
| | - Carla J H van der Kallen
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht
| | - Hans P Sauerwein
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht
| | - Jacqueline M Dekker
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands
| | - Coen D A Stehouwer
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht
| | - Bas Havekes
- Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht University Medical Center, 6200 MD Maastricht, The NetherlandsSection Molecular EpidemiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsSchool of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht, The NetherlandsSchool for Cardiovascular Diseases Maastricht (CARIM)Maastricht, The Netherlands andSchool for Public Health and Primary Care (CAPHRI)Maastricht, The Netherlands Department of Internal MedicineDivision of Endocrinology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The NetherlandsDepartment of Internal MedicineMaastricht University Medical Center, 6202 AZ Maastricht, The NetherlandsAdelante Center of Expertise in Rehabilitation and Audiology6432 CC Adelante, Hoensbroek, The NetherlandsDepartment of Internal MedicineDivision of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The NetherlandsDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchVU University Medical Center, 1007 MB Amsterdam, The NetherlandsDepartment of Molecular Cell BiologyLeiden University Medical Center, 2300 RC Leiden, The NetherlandsDepartment of Human BiologyMaastricht
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Kitterer D, Latus J, Henes J, Birkmeier S, Backes M, Braun N, Sechtem U, Dominik Alscher M, Mahrholdt H, Greulich S. Impact of long-term steroid therapy on epicardial and pericardial fat deposition: a cardiac MRI study. Cardiovasc Diabetol 2015; 14:130. [PMID: 26419433 PMCID: PMC4588496 DOI: 10.1186/s12933-015-0289-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 09/11/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Increased cardiac fat has been identified as a risk factor for coronary artery disease. Metabolic syndrome is associated with increased cardiac fat deposition. Steroids are known to imitate some effects of metabolic syndrome and are frequently used in patients with rheumatic disorders. Primary aim was to evaluate the impact of long-term steroid use on cardiac fat deposition in patients with rheumatic disorders. In addition, we sought to investigate if this effect might be dose-dependent. METHODS Patients were enrolled as follows: (1) rheumatic disorder; and (2) long-term steroid therapy, and (3) underwent cardiovascular magnetic resonance (CMR) imaging. Patients were stratified in a high-dose (>7.5 mg prednisone equivalent/day for at least 6 months) and a low-dose steroid group (<7.5 mg prednisone equivalent/day) and compared to steroid-naïve controls without rheumatic disorders. RESULTS 122 patients were included (n = 61 steroid patients, n = 61 controls). N = 36 were classified as high-dose, n = 25 as low-dose steroid group. Steroid patients showed larger epicardial 5.7 [3.5-9.1] cm(2) and pericardial 13.0 [6.1-26.8] cm(2) areas of fat than controls 4.2 [1.3-5.8] cm(2)/6.4 [1.6-15.4] cm(2), p < 0.001, p < 0.01, respectively. High-dose steroid patients had more epi- and pericardial fat both than controls: 7.2 [4.2-11.1] cm(2) vs. 4.4 [1.0-6.0] cm(2), p < 0.001; 18.6 [8.9-38.2] cm(2) vs. 10.7 [4.7-26.8] cm(2), p < 0.05, and patients in the low-dose steroid group (p < 0.01, p < 0.001, respectively). CONCLUSION The present data suggest increased cardiac fat deposition in steroid-treated patients with rheumatic disorders. Furthermore, this accumulation of cardiac fat seems to be dose-dependent, pointing towards a cumulative effect of steroids.
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Affiliation(s)
- Daniel Kitterer
- Division of Nephrology, Department of Internal Medicine, Robert-Bosch-Medical Center, Auerbachstrasse 110, 70376, Stuttgart, Germany.
| | - Joerg Latus
- Division of Nephrology, Department of Internal Medicine, Robert-Bosch-Medical Center, Auerbachstrasse 110, 70376, Stuttgart, Germany.
| | - Joerg Henes
- Division of Rheumatology, Department of Internal Medicine II, Universitätsklinik Tübingen, Tübingen, Germany.
| | - Stefan Birkmeier
- Department of Cardiology, Robert-Bosch-Medical Center, Auerbachstrasse 110, 70376, Stuttgart, Germany.
| | - Maik Backes
- Department of Radiology, Robert-Bosch-Medical Center, Auerbachstrasse 110, 70376, Stuttgart, Germany.
| | - Niko Braun
- Division of Nephrology, Department of Internal Medicine, Robert-Bosch-Medical Center, Auerbachstrasse 110, 70376, Stuttgart, Germany.
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Medical Center, Auerbachstrasse 110, 70376, Stuttgart, Germany.
| | - M Dominik Alscher
- Division of Nephrology, Department of Internal Medicine, Robert-Bosch-Medical Center, Auerbachstrasse 110, 70376, Stuttgart, Germany.
| | - Heiko Mahrholdt
- Department of Cardiology, Robert-Bosch-Medical Center, Auerbachstrasse 110, 70376, Stuttgart, Germany.
| | - Simon Greulich
- Department of Cardiology, Robert-Bosch-Medical Center, Auerbachstrasse 110, 70376, Stuttgart, Germany.
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24
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Bartz SK, Karaviti LP, Brandt ML, Lopez ME, Masand P, Devaraj S, Hicks J, Anderson L, Lodish M, Keil M, Stratakis CA. Residual manifestations of hypercortisolemia following surgical treatment in a patient with Cushing syndrome. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2015; 2015:19. [PMID: 26322079 PMCID: PMC4551381 DOI: 10.1186/s13633-015-0014-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 07/07/2015] [Indexed: 11/26/2022]
Abstract
Context Cushing Syndrome is difficult to diagnose, and the comorbidities and persistent late effects of hypercortisolemia after treatment of the primary disease are challenging for the patient and the endocrinologist. Objective To report the case of a girl with obesity and hypertension, ultimately diagnosed with Cushing syndrome due to primary pigmented nodular adrenocortical disease. In this case, the complications of hypercortisolism persisted short term despite surgical intervention. Patient A 4 year old morbidly obese African-American girl with developmental delay presented with hypertensive emergency in the ER and 18-month history of progressive weight gain. Her previous history included premature adrenarche, hypertension, seizures and a random high cortisol with suppressed ACTH. She was subsequently stabilized, and a diagnostic work-up persistently demonstrated elevated cortisol and suppressed ACTH. An abdominal MRI showed bilateral adrenal multinodular disease, consistent with multinodular hyperplasia of the adrenal glands. Based on these findings the patient underwent a bilateral adrenalectomy, which confirmed primary pigmented nodular adrenocortical disease. The patient had a complicated, protracted post-operative course requiring adjustment of therapy for persistent hypertension. Two months after surgery, she was readmitted to the Emergency Department with hyperpyrexia and hypertension and succumbed to the complications of sepsis. Conclusions and outcome This case highlights the significant diagnostic and therapeutic challenges in treating children with Cushing syndrome. Resolution of the source of hypercortisolemia does not imply regression of hypertension or recovery of the immune system. Although the child underwent bilateral adrenalectomy, persistent consequences of prolonged severe hypercortisolism contributed to her death two months later.
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Affiliation(s)
- Sara K Bartz
- Department of Pediatric Endocrinology and Metabolism, Texas Children's Hospital, Houston, TX USA
| | - Lefkothea P Karaviti
- Department of Pediatric Endocrinology and Metabolism, Texas Children's Hospital, Houston, TX USA
| | - Mary L Brandt
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX USA
| | - Monica E Lopez
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX USA
| | - Prakash Masand
- Department of Radiology, Texas Children's Hospital, Houston, TX USA
| | - Sridevi Devaraj
- Medical Director of Clinical Chemistry and POCT, Texas Children's Hospital and Baylor College of Medicine, Houston, TX USA
| | - John Hicks
- Department of Pathology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX USA
| | | | - Maya Lodish
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), NIH, Houston, TX USA
| | - Meg Keil
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), NIH, Houston, TX USA
| | - Constantine A Stratakis
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), NIH, Houston, TX USA
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25
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Liu X, Zhu X, Zeng M, Zhuang Y, Zhou Y, Zhang Z, Yang Y, Wang Y, Ye H, Li Y. Gender-Specific Differences in Clinical Profile and Biochemical Parameters in Patients with Cushing's Disease: A Single Center Experience. Int J Endocrinol 2015; 2015:949620. [PMID: 26064114 PMCID: PMC4438174 DOI: 10.1155/2015/949620] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 04/23/2015] [Accepted: 04/26/2015] [Indexed: 01/08/2023] Open
Abstract
Cushing's disease (CD) is remarkably prevalent among females; however, more severe clinical presentation and adverse outcomes have been found in males. The purpose of this study was to investigate the overall clinical profile and biochemical parameters in patients with CD to identify the gender differences. Here we describe our series of CD patients referred to our medical center during 2012-2013. Among 73 cases, females presented a marked preponderance compared to males. Males had significantly higher ACTH, BMI, HbA1c, systolic blood pressure, and hemoglobin than females. For the first time, the incidence of fatty liver and hepatic function was also shown to be elevated in males. Multiple linear regression analysis was performed to further investigate the correlation of risk factors with hypokalemia, HbA1c, and systolic blood pressure. Gender and serum cortisol were associated with hypokalemia. Age, gender, and serum cortisol were significantly associated with HbA1c. Additionally, only gender was significantly associated with systolic blood pressure. Regarding clinical presentation, purple striae seemed to occur more frequently in males than in females. Thus, more severe clinical presentation, biochemical parameters, and complications were found in males than in females. Clinical professionals should pay more attention to the diagnosis and management of males with CD.
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Affiliation(s)
- Xiaoxia Liu
- Division of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Xiaoming Zhu
- Division of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Meifang Zeng
- Division of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Yan Zhuang
- Division of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Yiting Zhou
- Division of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Zhaoyun Zhang
- Division of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Yehong Yang
- Division of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Yongfei Wang
- Division of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Hongying Ye
- Division of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
- *Hongying Ye: and
| | - Yiming Li
- Division of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
- *Yiming Li:
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26
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van der Pas R, van Esch JHM, de Bruin C, Danser AHJ, Pereira AM, Zelissen PM, Netea-Maier R, Sprij-Mooij DM, van den Berg-Garrelds IM, van Schaik RHN, Lamberts SWJ, van den Meiracker AH, Hofland LJ, Feelders RA. Cushing's disease and hypertension: in vivo and in vitro study of the role of the renin-angiotensin-aldosterone system and effects of medical therapy. Eur J Endocrinol 2014; 170:181-91. [PMID: 24165019 DOI: 10.1530/eje-13-0477] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE/METHODS Cushing's disease (CD) is often accompanied by hypertension. CD can be treated surgically and, given the expression of somatostatin subtype 5 and dopamine 2 receptors by corticotroph pituitary adenomas, pharmacologically. Indeed, we recently observed that stepwise medical combination therapy with the somatostatin-analog pasireotide, the dopamine-agonist cabergoline, and ketoconazole (which directly suppresses steroidogenesis) biochemically controlled CD patients and lowered their blood pressure after 80 days. Glucocorticoids (GC) modulate the renin-angiotensin-aldosterone system (RAAS) among others by increasing hepatic angiotensinogen expression and stimulating mineralocorticoid receptors (MR). This study therefore evaluated plasma RAAS components in CD patients before and after drug therapy. In addition, we studied whether cabergoline/pasireotide have direct relaxant effects in angiotensin II (Ang II)-constricted iliac arteries of spontaneously hypertensive rats, with and without concomitant GR/MR stimulation with dexamethasone or hydrocortisone. RESULTS Baseline concentrations of angiotensinogen were elevated, while renin and aldosterone were low and suppressed, respectively, even in patients treated with RAAS-blockers. This pattern did not change after 80 days of treatment, despite blood pressure normalization, nor after 4 years of remission. In the presence of dexamethasone, pasireotide inhibited Ang II-mediated vasoconstriction. CONCLUSIONS The low plasma renin concentrations, even under RAAS blockade, in CD may be the consequence of increased GC-mediated MR stimulation and/or the elevated angiotensinogen levels in such patients. The lack of change in RAAS-parameters despite blood pressure and cortisol normalization suggests persisting consequences of long-term exposure to cortisol excess. Finally, pasireotide may have a direct vasodilating effect contributing to blood pressure lowering.
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A V R. Inhalational Steroids and Iatrogenic Cushing's Syndrome. Open Respir Med J 2014; 8:74-84. [PMID: 25674177 PMCID: PMC4319196 DOI: 10.2174/1874306401408010074] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 10/21/2014] [Accepted: 10/21/2014] [Indexed: 11/22/2022] Open
Abstract
Bronchial asthma (BA) and Allergic rhinitis (AR) are common clinical problems encountered in day to day practice, where inhalational corticosteroids (ICS) or intranasal steroids (INS) are the mainstay of treatment. Iatrogenic Cushing syndrome (CS) is a well known complication of systemic steroid administration. ICS /INS were earlier thought to be safe, but now more and more number of case reports of Iatrogenic Cushing syndrome have been reported, especially in those who are taking cytochrome P450 (CYP 450) inhibitors. Comparing to the classical clinical features of spontaneous Cushing syndrome, iatrogenic Cushing syndrome is more commonly associated with osteoporosis, increase in intra-ocular pressure, benign intracranial hypertension, aseptic necrosis of femoral head and pancreatitis, where as hypertension, hirsuitisum and menstrual irregularities are less common. Endocrine work up shows low serum cortisol level with evidence of HPA (hypothalamo-pituitary-adrenal) axis suppression. In all patients with features of Cushing syndrome with evidence of adrenal suppression always suspect iatrogenic CS. Since concomitant administration of cytochrome P450 inhibitors in patients on ICS/INS can precipitate iatrogenic CS, avoidance of CYP450 inhibitors, its dose reduction or substitution of ICS are the available options. Along with those, measures to prevent the precipitation of adrenal crisis has to be taken. An update on ICS-/INS- associated iatrogenic CS and its management is presented here.
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Affiliation(s)
- Raveendran A V
- Department of Internal Medicine, Government Medical College & Hospitals, Kottayam, Kerala-686008, India
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Chennareddy S, Adapa R, Kishore BKV, Rajasekhar L. Posterior reversible encephalopathy syndrome in systemic lupus erythematosus following methylprednisolone: report of two cases. Int J Rheum Dis 2013; 16:786-8. [PMID: 24131800 DOI: 10.1111/1756-185x.12148] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Srinivasa Chennareddy
- Department of Rheumatology, Nizams Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
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29
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Shibusawa N, Yamada M, Hashida T, Hashimoto K, Satoh T, Horiguchi J, Oyama T, Takeyoshi I, Mori M. Dilated cardiomyopathy as a presenting feature of Cushing's syndrome. Intern Med 2013; 52:1067-71. [PMID: 23676592 DOI: 10.2169/internalmedicine.52.9051] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Cardiovascular complications, including cardiomegaly, myocardial ischemia and left ventricular hypertrophy, are some of the major determinants of the mortality rate in patients with Cushing's syndrome. We herein report the case of a patient with Cushing's syndrome caused by an adrenal adenoma who presented with congestive heart failure secondary to dilated cardiomyopathy. Follow-up echocardiography showed a marked improvement in the left ventricular cardiac function, and the plasma B-type natriuretic peptide (BNP) levels regressed after successful treatment. "Reversible" dilated cardiomyopathy is rarely associated with Cushing's syndrome; however, it should be recognized. Administering appropriate treatment in a timely manner can reverse this cardiomyopathy along with the other symptoms of Cushing's syndrome.
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Affiliation(s)
- Nobuyuki Shibusawa
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Japan.
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30
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Keen JA, McGorum BC, Hillier C, Nally JE. Short-term incubation of equine laminar veins with cortisol and insulin alters contractility in vitro: possible implications for the pathogenesis of equine laminitis. J Vet Pharmacol Ther 2012; 36:382-8. [PMID: 22943152 DOI: 10.1111/j.1365-2885.2012.01429.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 07/07/2012] [Indexed: 11/25/2022]
Abstract
This study investigated the effects of cortisol and insulin, hormones that affect both glycaemic status and vascular function, on the in vitro contractility of isolated healthy equine small laminar veins. Small veins (150-500 μm) draining the digital laminae from healthy horses or ponies were investigated by wire myography. Concentration response curves were constructed for noradrenaline (NA), phenylephrine (PE), endothelin-1 (ET-1) and 5-hydroxytryptamine (5-HT) in the presence of either cortisol (10(-6 ) m) or insulin (1000 μIU/mL). Cortisol significantly increased the maximum contractility of laminar veins to the vasoconstrictors NA and 5-HT but decreased the maximal contraction to ET-1. Insulin decreased the contractility of vessels to PE and ET-1. It is possible that short-term cortisol excess could enhance venoconstrictor responses to 5-HT and NA in laminar veins in vivo, thereby predisposing to laminitis. Additionally, a reduction in the ability of insulin to counteract alpha-adrenoreceptor and ET-1-mediated contraction, likely to occur in subjects with insulin resistance, may further exacerbate venoconstriction in animals prone to laminitis. These mechanisms may also predispose horses with disorders such as equine Cushing's disease and equine metabolic syndrome to laminitis.
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Affiliation(s)
- J A Keen
- Department of Biological and Biochemical Science, Glasgow Caledonian University, Glasgow, UK.
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31
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Valassi E, Biller BMK, Klibanski A, Misra M. Adipokines and cardiovascular risk in Cushing's syndrome. Neuroendocrinology 2012; 95:187-206. [PMID: 22057123 DOI: 10.1159/000330416] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 06/25/2011] [Indexed: 01/01/2023]
Abstract
Cushing's syndrome (CS) is associated with increased cardiovascular morbidity and mortality. Recent evidence also suggests that increased cardiovascular risk may persist even after long-term remission of CS. Increased central obesity, a typical feature of CS, is associated with altered production of adipokines, which contributes to the pathogenesis of several metabolic and cardiovascular complications observed in this condition. In vitro and in vivo studies have shown a relationship between cortisol and adipokines in several experimental settings. In patients with either active or 'cured' CS, an increase in leptin and resistin levels as well as the release of pro-inflammatory cytokines, such as tumor necrosis factor-α and interleukin-6, may be associated with increased cardiovascular risk. For other adipokines, including adiponectin, results are inconclusive. Studies are needed to further elucidate the interactions between clinical and subclinical increases in cortisol production and altered adipokine release in CS.
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Affiliation(s)
- Elena Valassi
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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32
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Yiu KH, Marsan NA, Delgado V, Biermasz NR, Holman ER, Smit JWA, Feelders RA, Bax JJ, Pereira AM. Increased myocardial fibrosis and left ventricular dysfunction in Cushing's syndrome. Eur J Endocrinol 2012; 166:27-34. [PMID: 22004909 DOI: 10.1530/eje-11-0601] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Active Cushing's syndrome (CS) is associated with cardiomyopathy, characterized by myocardial structural, and ultrastructural abnormalities. The extent of myocardial fibrosis in patients with CS has not been previously evaluated. Therefore, the objective of this study was to assess myocardial fibrosis in CS patients, its relationship with left ventricular (LV) hypertrophy and function, and its reversibility after surgical treatment. DESIGN AND METHODS Fifteen consecutive CS patients (41±12 years) were studied together with 30 hypertensive (HT) patients (matched for LV hypertrophy) and 30 healthy subjects. Echocardiography was performed in all patients including i) LV systolic function assessment by conventional measures and by speckle tracking-derived global longitudinal strain, ii) LV diastolic function assessment using E/E', and iii) myocardial fibrosis assessment using calibrated integrated backscatter (IBS). Echocardiography was repeated after normalization of cortisol secretion (14±3 months). RESULTS CS patients showed the highest value of calibrated IBS (-15.1±2.5 dB) compared with HT patients (-20.0±2.6 dB, P<0.01) and controls (-23.8±2.4 dB, P<0.01), indicating increased myocardial fibrosis independent of LV hypertrophy. Moreover, calibrated IBS in CS patients was significantly related to both diastolic function (E/E', r=0.79, P<0.01) and systolic function (global longitudinal strain, r=0.60, P=0.02). After successful surgical treatment, calibrated IBS normalized (-21.0±3.8 vs -15.1±2.5 dB, P<0.01), suggestive of regression of myocardial fibrosis. CONCLUSIONS Patients with CS have increased myocardial fibrosis, which is related to LV systolic and diastolic dysfunction. Successful treatment of CS normalizes the extent of myocardial fibrosis. Therefore, myocardial fibrosis appears to be an important factor in the development and potential regression of CS cardiomyopathy.
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Affiliation(s)
- Kai Hang Yiu
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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33
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Peppa M, Krania M, Raptis SA. Hypertension and other morbidities with Cushing's syndrome associated with corticosteroids: a review. Integr Blood Press Control 2011; 4:7-16. [PMID: 21949634 PMCID: PMC3172078 DOI: 10.2147/ibpc.s9486] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Indexed: 01/08/2023] Open
Abstract
Corticosteroids constitute an ideal treatment for various inflammatory and autoimmune disorders due to their anti-inflammatory and immunomodulatory actions. However, corticosteroids have a considerable number of side effects, including hypertension, diabetes, lipid disorders, sleep apnea, osteoporosis, myopathy, and disorders of coagulation and fibrinolysis, which are components of Cushing’s syndrome (CS). Corticosteroid-induced side effects are dependent on the formulation, route, dose, and time of exposure. However, the underlying pathogenetic mechanisms have not been clearly defined. A large body of evidence supports the role of an imbalance between vasoconstriction and vasodilation with possible links to nitric oxide, prostanoids, angiotensin II, arginine vasopressin, endothelins, catecholamines, neuropeptide Y, and atrial natriuretic peptide. Increased oxidative stress, renin–angiotensin system activation, increased pressor response, metabolic syndrome, and sleep apnea appear to be pathogenetically involved as well. The ideal treatment is the withdrawal of corticosteroids, which is most often impossible due to the exacerbation of the underlying disease. Alternatively, a careful plan, including the proper selection of the formulation, time, and route, should be made, and each side effect should be treated properly. The focus of the research should be to develop synthetic corticosteroids with anti-inflammatory effects but fewer metabolic effects, which so far has been unsuccessful.
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34
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Caccavale A, Romanazzi F, Imparato M, Negri A, Morano A, Ferentini F. Central serous chorioretinopathy: a pathogenetic model. Clin Ophthalmol 2011; 5:239-43. [PMID: 21386917 PMCID: PMC3046994 DOI: 10.2147/opth.s17182] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Indexed: 11/23/2022] Open
Abstract
Despite numerous studies describing predominantly its demography and clinical course, many aspects of central serous chorioretinopathy (CSCR) remain unclear. Perhaps the major impediment to finding an effective therapy is the difficulty of performing studies with large enough cohorts, which has meant that clinicians have focused more on therapy than on a deeper understanding of the pathogenesis of the disease. Hypotheses on the pathogenesis of CSCR have ranged from a basic alteration in the choroid to an involvement of the retinal pigment epithelium (RPE). Starting from evidence that affected subjects often present a personality prone to stress with altered pituitary–hypothalamic axis response (HPA) and that they have higher levels of serum and urinary cortisol and catecholamines than healthy subjects, we hypothesize a cascade of events that may lead to CSCR through hypercoagulability and augmented platelet aggregation. In particular we investigated the role of tissue plasminogen activator, increasing plasminogen activator inhibitor 1 (PAI-1), and plasmin-α2- plasmin inhibitor complexes. We reviewed the different therapeutic approaches, including adrenergic antagonists, carbonic anhydrase inhibitors, mifepristone, ketoconazole, laser photocoagulation, intravitreal injection of bevacizumab, and photodynamic therapy with verteporfin (PDT) and our model of pathogenesis seems to be in agreement with the clinical effects obtained from these treatments. In accord with our thesis, we began to treat a group of patients affected by CSCR with low-dose aspirin (75–100 mg), because of its effectiveness in other vascular diseases and its low ocular and general toxicity with prolonged use. The formulation of a causative model of CSCR enables us to understand how the therapeutic approach cannot be based on a generalized therapy but should be individualized for each patient, and that sometimes a combined strategy of treatment is required. Moreover a complete knowledge of the disease will help to identify patients prone to the most persistent forms of CSCR, and thus help to find a treatment.
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Affiliation(s)
- Antonio Caccavale
- Department of Ophthalmology, Neuropthalmology and Ocular Immunology Service
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35
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Smets P, Meyer E, Maddens B, Daminet S. Cushing's syndrome, glucocorticoids and the kidney. Gen Comp Endocrinol 2010; 169:1-10. [PMID: 20655918 DOI: 10.1016/j.ygcen.2010.07.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 07/08/2010] [Indexed: 11/18/2022]
Abstract
Glucocorticoids (GCs) affect renal development and function in fetal and mature kidneys both indirectly, by influencing the cardiovascular system, and directly, by their effects on glomerular and tubular function. Excess GCs due to endogenous GC overproduction in Cushing's syndrome or exogenous GC administration plays a pivotal role in hypertension and causes increased cardiac output, total peripheral resistance and renal blood flow. Glucocorticoids increase renal vascular resistance (RVR) in some species and experimental settings and decrease RVR in others. Short term administration of adrenocorticotrophic hormone or GCs causes an increased glomerular filtration rate (GFR) in humans, rats, sheep and dogs. Interestingly, chronic exposure may cause a decreased GFR in combination with a higher cardiovascular risk in human patients with Cushing's syndrome. Glomerular dysfunction leads to proteinuria and albuminuria in canine and human Cushing's patients, and some cases also show histological evidence of glomerulosclerosis. Tubular dysfunction is reflected by an impaired urinary concentrating ability and disturbed electrolyte handling, which can potentially result in increased sodium reabsorption, hypercalciuria and urolithiasis. Conversely, chronic kidney disease can also alter GC metabolism. More research needs to be performed to further evaluate the renal consequences of Cushing's syndrome because of its implications for therapeutic aspects as well as the general well-being of the patient. Because there is a high incidence of Cushing's syndrome in canines, which is similar to the syndrome in humans, dogs are an interesting animal model to investigate the link between hypercortisolism and renal function.
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Affiliation(s)
- Pascale Smets
- Small Animal Medicine and Clinical Biology, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium.
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36
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Yong TY, Li JYZ. Reversible dilated cardiomyopathy in a patient with Cushing's syndrome. ACTA ACUST UNITED AC 2010; 16:77-9. [PMID: 20412474 DOI: 10.1111/j.1751-7133.2009.00123.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Tuck Y Yong
- Department of General Medicine, Flinders Medical Centre, Flinders University, Adelaide, South Australia.
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37
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Reusch CE, Schellenberg S, Wenger M. Endocrine hypertension in small animals. Vet Clin North Am Small Anim Pract 2010; 40:335-52. [PMID: 20219493 DOI: 10.1016/j.cvsm.2009.10.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hypertension is classified as idiopathic or secondary. In animals with idiopathic hypertension, persistently elevated blood pressure is not caused by an identifiable underlying or predisposing disease. Until recently, more than 95% of cases of hypertension in humans were diagnosed as idiopathic. New studies have shown, however, a much higher prevalence of secondary causes, such as primary hyperaldosteronism. In dogs and cats, secondary hypertension is the most prevalent form and is subclassified into renal and endocrine hypertension. This review focuses on the most common causes of endocrine hypertension in dogs and cats.
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Affiliation(s)
- Claudia E Reusch
- Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, Winterthurerstrasse 260, 8057 Zurich, Switzerland.
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38
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Sherlock M, Ayuk J, Tomlinson JW, Toogood AA, Aragon-Alonso A, Sheppard MC, Bates AS, Stewart PM. Mortality in patients with pituitary disease. Endocr Rev 2010; 31:301-42. [PMID: 20086217 DOI: 10.1210/er.2009-0033] [Citation(s) in RCA: 253] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Pituitary disease is associated with increased mortality predominantly due to vascular disease. Control of cortisol secretion and GH hypersecretion (and cardiovascular risk factor reduction) is key in the reduction of mortality in patients with Cushing's disease and acromegaly, retrospectively. For patients with acromegaly, the role of IGF-I is less clear-cut. Confounding pituitary hormone deficiencies such as gonadotropins and particularly ACTH deficiency (with higher doses of hydrocortisone replacement) may have a detrimental effect on outcome in patients with pituitary disease. Pituitary radiotherapy is a further factor that has been associated with increased mortality (particularly cerebrovascular). Although standardized mortality ratios in pituitary disease are falling due to improved treatment, mortality for many conditions are still elevated above that of the general population, and therefore further measures are needed. Craniopharyngioma patients have a particularly increased risk of mortality as a result of the tumor itself and treatment to control tumor growth; this is a key area for future research in order to optimize the outcome for these patients.
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Affiliation(s)
- Mark Sherlock
- Centre for Endocrinology, Diabetes, and Metabolism, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, United Kingdom
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Bailey MA, Mullins JJ, Kenyon CJ. Mineralocorticoid and Glucocorticoid Receptors Stimulate Epithelial Sodium Channel Activity in a Mouse Model of Cushing Syndrome. Hypertension 2009; 54:890-6. [DOI: 10.1161/hypertensionaha.109.134973] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Experiments in Cushing patients and healthy control subjects receiving adrenocorticotropic hormone (ACTH) indicate that transient renal sodium retention may contribute to the generation of hypertension. Here we have investigated the effect of chronic ACTH infusion on renal sodium handling in adult male C57BL/6J mice using selective antagonists to dissect mineralocorticoid and glucocorticoid receptor–mediated pathways. Mice were infused via osmotic minipump with ACTH (2.5 μg/d) or saline for 2 weeks before being anesthetized for renal function experiments. ACTH caused an increase in blood pressure and a reduction in fractional sodium excretion associated with enhanced activity of the epithelial sodium channel. Given separately, spironolactone and RU38486 blunted the pressor response to ACTH and the increased epithelial sodium channel activity; combined mineralocorticoid and glucocorticoid receptor blockade was required to resolve the response to ACTH excess. Dietary sodium depletion also prevented ACTH-induced hypertension. The effect of increased sodium reabsorption in the distal nephron is offset by downregulation of Na-K-Cl cotransport in the loop of Henle. Sodium excretion is normalized chronically, but blood pressure remains high; acute blockade of V1 receptors and α1 adrenoceptors in combination restored blood pressure to control values. In summary, ACTH excess promotes renal sodium reabsorption, contributing to the increased blood pressure; both glucocorticoid and mineralocorticoid receptor pathways are involved. These data are relevant to conditions associated with overactivity of the hypothalamic-pituitary-adrenal axis, such as obesity and chronic stress.
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Affiliation(s)
- Matthew A. Bailey
- From the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - John J. Mullins
- From the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Christopher J. Kenyon
- From the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
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40
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Lodish MB, Sinaii N, Patronas N, Batista DL, Keil M, Samuel J, Moran J, Verma S, Popovic J, Stratakis CA. Blood pressure in pediatric patients with Cushing syndrome. J Clin Endocrinol Metab 2009; 94:2002-8. [PMID: 19293264 PMCID: PMC2690429 DOI: 10.1210/jc.2008-2694] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Hypertension (HTN) has been reported in up to 60% of children with Cushing syndrome (CS), but its course, side effects, and potential differences among various causes of CS have not been adequately studied. OBJECTIVE The objective of the study was to measure blood pressure in pediatric patients with CS before and after transphenoidal surgery or adrenalectomy and identify side effects and rates of residual HTN. DESIGN Data from 86 children with corticotropinomas [Cushing disease (CD)] and 27 children with ACTH-independent CS (AICS) were analyzed. RESULTS Patients with CD and AICS had significant HTN before surgery; more patients with AICS had systolic HTN (SHTN) than with CD (74 vs. 44%, P = 0.0077), but the rate of diastolic HTN (DHTN) was similar. Both groups experienced significant decreases in SHTN immediately after transphenoidal surgery and adrenalectomy. One year postoperatively, both SHTN and DHTN were lower than the preoperative values in all patients, but as many as 16 and 4% of the patients with CD and 21 and 5% of the patients with AICS still had SHTN and DHTN, respectively. Higher blood pressure preoperatively correlated with cortisol levels. Two patients suffered serious side effects: one with multiple infarcts and another with hypertensive encephalopathy. CONCLUSIONS Children with CS are at risk for residual HTN despite a significant improvement after surgical cure. HTN appears to correlate with the degree of hypercortisolemia. Serious HTN-related side effects, although rare, may occur during the perioperative period.
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Affiliation(s)
- Maya B Lodish
- Section on Endocrinology Genetics, Program on Developmental Endocrinology Genetics, National Institute of Child Health and Human Development, NIH, Building 10, CRC, 10 Center Drive, MSC1103, Bethesda, Maryland 20892, USA.
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Takagi S, Tanabe A, Tsuiki M, Naruse M, Takano K. Hypokalemia, diabetes mellitus, and hypercortisolemia are the major contributing factors to cardiac dysfunction in adrenal Cushing's syndrome. Endocr J 2009; 56:1009-18. [PMID: 19789419 DOI: 10.1507/endocrj.k09e-198] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Although cardiovascular complications are the major determinant of the prognosis of Cushing's syndrome (CS), factors contributing to the cardiovascular lesions are still unclear. We investigated clinical factors determining cardiac function in patients with adrenal CS. Fifty patients with adrenal CS were studied. Patients were divided into 3 groups based on their NYHA classification and electrocardiographic (ECG) findings: group A with NYHA grade 0 and normal ECG, group B with NYHA grade I and abnormal ECG, and group C with NYHA grade II or higher. Clinical and echocardiographic findings were compared between the groups. Heart failure of grade I or higher was seen in 40% and grade II or higher was seen in 8% of the patients. Age, HbA1c, and prevalence of diabetes mellitus were positively correlated and serum potassium levels were negatively correlated with the severity of cardiac dysfunction. Decreased ejection fraction (EF) and the ratio of the peak to late transmittal filling velocities (E/A), and increased left ventricular mass index (LVMI) were frequently observed. Multivariate analysis demonstrated that serum potassium and HbA1c levels were independent factors contributing to EF, while serum potassium and cortisol levels were independent factors contributing to LVMI. These results clearly demonstrated that hypokalemia, diabetes mellitus, and hypercortisolemia are the major contributing factors to cardiac dysfunction in adrenal CS. Strict control of these conditions is warranted for the prevention of cardiac dysfunction in adrenal CS.
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Affiliation(s)
- Sachiko Takagi
- Department of Medicine, Institute of Clinical Endocrinology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
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42
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Singer E, Strohm S, Göbel U, Bieringer M, Schmidt D, Schneider W, Kettritz R, Luft FC. Cushing's disease, hypertension, and other sequels. Hypertension 2008; 52:1001-5. [PMID: 18981320 DOI: 10.1161/hypertensionaha.108.121640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eugenia Singer
- Medical Faculty of the Charité, Franz-Volhard Clinic, HELIOS Klinikum-Berlin, Berlin, Germany
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43
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Panoulas VF, Metsios GS, Pace AV, John H, Treharne GJ, Banks MJ, Kitas GD. Hypertension in rheumatoid arthritis. Rheumatology (Oxford) 2008; 47:1286-98. [PMID: 18467370 DOI: 10.1093/rheumatology/ken159] [Citation(s) in RCA: 189] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
RA associates with an increased burden of cardiovascular disease, which is at least partially attributed to classical risk factors such as hypertension (HT) and dyslipidaemia. HT is highly prevalent, and seems to be under-diagnosed and under-treated among patients with RA. In this review, we discuss the mechanisms that may lead to increased blood pressure in such patients, paying particular attention to commonly used drugs for the treatment of RA. We also suggest screening strategies and management algorithms for HT, specific to the RA population, although it is clear that these need to be formally assessed in prospective randomized controlled trials designed specifically for the purpose, which, unfortunately, are currently lacking.
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Affiliation(s)
- V F Panoulas
- Department of Rheumatology, Dudley Group of Hospitals NHS Trust, Russells Hall Hospital, Pensnett Road, Dudley, West Midlands DY1 2HQ, UK
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44
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Abstract
Renal colic affects up to 12% of the population. Initial management of most patients is expectant. Acute symptom management of renal colic is best accomplished with a combination of parenteral opioids and NSAIDs. The elderly patient with a kidney stone should be screened for contraindications to NSAID therapy, such as renal failure or previous peptic ulcer disease. Use of parenteral opioids is often necessary during the acute setting, and downward-adjusted doses and monitoring are necessary to prevent associated confusion and respiratory depression. Novel therapy with desmopressin may also be effective for symptom control at the initial presentation, without the adverse effects of opioids or NSAIDs. However, use of desmopressin in the elderly must be undertaken cautiously, given the potential adverse effects of this agent. Many small, distal ureteral stones are treated initially with watchful waiting for the first 2-4 weeks after presentation. The patient should have effective, non-parenteral analgesics for use at home. Included in these agents are oral or suppository NSAIDs and oral opioids. Medical expulsion therapy with alpha-adrenoceptor antagonists or calcium channel antagonists is efficacious. alpha-Adrenoceptor antagonists such as the alpha(1A/)(1)(D)-selective tamsulosin are well tolerated in the elderly and increase the rate of spontaneous stone passage by approximately 50% for small distal stones. These agents also appear to decrease the severity of renal colic. Corticosteroids and calcium channel antagonists are also effective but their use in the elderly is not recommended as first-line therapy.
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Affiliation(s)
- Blayne K Welk
- Department of Urologic Sciences, University of British Columbia, Providence Healthcare, Vancouver, British Columbia, Canada
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45
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Romanholi DJ, Salgado LR. Síndrome de Cushing exógena e retirada de glicocorticóides. ACTA ACUST UNITED AC 2007; 51:1280-92. [DOI: 10.1590/s0004-27302007000800014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 08/21/2007] [Indexed: 11/22/2022]
Abstract
Glicocorticóides são amplamente utilizados na prática clínica para o controle da atividade de doenças auto-imunes, inflamatórias, alérgicas e outras entidades nosológicas. Doses terapêuticas de glicocorticóides são muita vezes administradas inapropriadamente e isto é um problema particular, pois a terapia crônica tem muitos efeitos colaterais que se estendem desde a supressão do eixo hipotálamo-hipofisário-adrenal e síndrome de Cushing até infecções e alterações do status mental. Fatores que influenciam tanto nos efeitos adversos quanto nos terapêuticos dos glicocorticóides incluem propriedades farmacocinéticas do glicocorticóide, dose diária, diferenças individuais no metabolismo esteróide e duração do tratamento. Quando utilizados para o controle da atividade destas doenças, quatro aspectos da retirada de glicocorticóide merecem atenção especial. Primeiro, a doença tratada pelo esteróide pode recorrer. Segundo, o eixo hipotálamo- hipófise-adrenal pode permanecer suprimido por um longo período. Terceiro, muitas vezes desenvolve-se dependência psicológica a esses hormônios. Quarto, uma síndrome de retirada inespecífica pode desenvolver mesmo enquanto os pacientes estão recebendo doses de reposição fisiológica de glicocorticóides. A gravidade da síndrome de retirada depende da fase e o grau de dependência e inclui sintomas tais como anorexia, náusea, vômitos, perda de peso, fadiga, mialgias, artralgias, cefaléia, dor abdominal, letargia, hipotensão postural, febre e descamação da pele.
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46
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Abstract
Cushing's syndrome is a consequence of primary or, more commonly, secondary oversecretion of cortisol. Cardiovascular disease is the major cause of morbidity and mortality in Cushing's syndrome, and excess risk remains even in effectively treated patients. The cardiovascular consequences of cortisol excess are protean and include, inter alia, elevation of blood pressure, truncal obesity, hyperinsulinemia, hyperglycemia, insulin resistance, and dyslipidemia. This review analyses the relationship of cortisol excess, both locally and at tissue level, to these cardiovascular risk factors, and to putative mechanisms for hypertension. Previous studies have examined correlations between cortisol, blood pressure, and other parameters in the general population and in Cushing's syndrome. This review also details changes induced by short-term cortisol administration in normotensive healthy men.
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Affiliation(s)
- Judith A Whitworth
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia.
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47
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Lavis VR, Picolos MK, Willerson JT. Endocrine Disorders and the Heart. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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48
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Tsuchiya K, Ohta K, Yoshimoto T, Doi M, Izumiyama H, Hirata Y. A Case of acromegaly associated with subclinical Cushing's disease. Endocr J 2006; 53:679-85. [PMID: 16926523 DOI: 10.1507/endocrj.k06-031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 54-year-old man with type 2 diabetes was referred to our hospital for endocrine evaluation of acromegaly. Physical examination showed typical acromegalic features without Cushingoid features. Magnetic resonance imaging of the brain revealed the presence of a pituitary macroadenoma. Basal plasma levels of GH and insulin-like growth factor-I under fasting hyperglycemia (202 mg/dl) were markedly elevated. Plasma GH levels paradoxically increased after stimulation with TRH and LH-RH, and decreased after bromocriptine and octreotide administration. Endocrine examination of the hypothalamo-pituitary-adrenal (HPA) axis showed a lack of circadian rhythm of ACTH and cortisol, non-suppressibility to low-dose (1 mg), but suppressibility to high-dose (8 mg) dexamethasone, and normal response to CRH stimulation. The tumor resected by transsphenoidal surgery was histopathologically consistent with the diagnosis of eosinophilic adenoma: positive immunoreactivities of GH, PRL and ACTH were demonstrated, but negative immunoreactivities of prohormone convertase (PC) 1/3 by immunohistochemical method. After surgery, plasma GH and IGF-I levels decreased along with normalization of HPA axis. Metabolic co-morbidities such as diabetes and hypertension disappeared after removal of the pituitary tumor. This is a very rare case of GH-producing pituitary adenoma causing typical acromegaly with concomitant production of ACTH causing subclinical Cushing's disease.
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Affiliation(s)
- Kyoichiro Tsuchiya
- Department of Clinical and Molecular Endocrinology, Tokyo Medical and Dental University Graduate School, Yushima, Tokyo, Japan
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49
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Abstract
Cushing's syndrome can be exogenous, resulting from the administration of glucocorticoids or adrenocorticotrophic hormone (ACTH), or endogenous, secondary to increased secretion of cortisol or ACTH. Hypertension is one of the most distinguishing features of endogenous Cushing's syndrome, as it is present in about 80% of adult patients and in almost half of children and adolescents patients. Hypertension results from the interplay of several pathophysiological mechanisms regulating plasma volume, peripheral vascular resistance and cardiac output, all of which may be increased. The therapeutic goal is to find and remove the cause of excess glucocorticoids, which, in most cases of endogenous Cushing's syndrome, is achieved surgically. Treatment of Cushing's syndrome usually results in resolution or amelioration of hypertension. However, some patients may not achieve normotension or may require a prolonged period of time for the correction of hypercortisolism. Therefore, therapeutic strategies for Cushing's-specific hypertension (to normalise blood pressure and decrease the duration of hypertension) are necessary to decrease the morbidity and mortality associated with this disorder. The various pathogenetic mechanisms that have been proposed for the development of glucocorticoid-induced hypertension in Cushing's syndrome and its management are discussed.
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Affiliation(s)
- Maria Alexandra Magiakou
- Unit of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, University of Athens Medical School, Agia Sophia Children's Hospital, 11527 Goudi, Athens, Greece.
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50
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Abstract
Cushing's syndrome results from prolonged exposure to excess glucocorticoids. Patients with Cushing's syndrome may develop multiple metabolic problems including obesity, hyperglycemia, hypertension, depression, low bone mass, muscle atrophy, and hypogonadism. Cutaneous manifestations of hypercortisolism include skin atrophy, excessive bruising, purple striations, poor wound healing, facial plethora, vellous hypertrichosis and hirsutism. Diagnostic tests used to screen for Cushing's syndrome include 24-hour urine cortisol, the 1 mg dexamethasone suppresion test, and late night salivary cortisol. A normal screening test excludes the diagnosis of Cushing's. Patients with an abnormal screening test should be referred to an endocrinologist for complete evaluation of the pituitary-adrenal axis.
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Affiliation(s)
- Amal Shibli-Rahhal
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
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