Pediatric Cushing's disease: Case reports and retrospective review

BACKGROUND

We report four pediatric subjects with Cushing's disease (CD) diagnosed in the Czech Republic. We focus on initial symptoms of Cushing's syndrome (CS) which can lead to early diagnosis, on typical symptoms of CS in children, their age and sex distribution, the mean length of symptoms prior to diagnosis, indication for examination, post-cure growth, sexual development and pituitary function in our four CD patients after transsphenoidal pituitary surgery (TSS). We describe the diagnostic process leading to confirmation of CD and we emphasize the biochemical and radiological diagnostic difficulties.

CONCLUSIONS

Pediatric CD has a number of features distinct from adult CD. Our retrospective analysis confirmed the presence of growth retardation and change in facial appearance with development of moon face as the first symptoms of CS. According to our observation, growth retardation is prior to development of moon face. The other typical symptoms frequently seen in pediatric patients are pseudo-precocious puberty in both sexes, hirsutism in pubertal girls due to excessive adrenal androgen secretion and pubertal delay. A corticotropin-releasing hormone (CRH) test and especially bilateral inferior petrosal sinus sampling for ACTH (BIPSS) contribute to confirming the diagnosis of CD and excluding ectopic ACTH syndrome in children with unvisible adenoma on pituitary magnetic resonance imaging (MRI).

Rabies in the world and the Zero by 30 strategy

Rabies is a viral disease that occurs in more than 150 countries worldwide. According to the World Health Organisation, this zoonotic disease causes an estimated 59 000 human deaths each year, with 95% occuring in Africa and Asia. The most common route of transmission is through the bite of an infected dog. The disease is preventable by vaccination, and effective prophylaxis is also available after animal bite injury. However, if the patient develops clinical signs, the disease is almost always fatal. The aim of this brief report is to summarise information on the global impact of rabies and to present the Zero by 30 strategy, which aims to achieve the elimination of human deaths due to rabies transmission from infected dogs by 2030.

Current trends in the epidemiology of malaria

Malaria is one of the worlds most important infectious diseases, occurring in many tropical and subtropical countries. The causative agent is a parasitic protozoan of the genus Plasmodium, transmitted to humans by infected mosquitoes. More than 200 million people get malaria every year worldwide, and hundreds of thousands of them, mostly children under 5 years of age, die of it. Thanks to prevention programmes implemented by various organisations headed by the World Health Organisation (WHO) with the aim of eliminating malaria, cases have been declining in recent years. However, particularly in African countries, malaria continues to be a health and economic issue.

A Consensus on the Diagnosis and Treatment of Acromegaly Comorbidities: An Update

OBJECTIVE

The aim of the Acromegaly Consensus Group was to revise and update the consensus on diagnosis and treatment of acromegaly comorbidities last published in 2013.

PARTICIPANTS

The Consensus Group, convened by 11 Steering Committee members, consisted of 45 experts in the medical and surgical management of acromegaly. The authors received no corporate funding or remuneration.

EVIDENCE

This evidence-based consensus was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence following critical discussion of the current literature on the diagnosis and treatment of acromegaly comorbidities.

CONSENSUS PROCESS

Acromegaly Consensus Group participants conducted comprehensive literature searches for English-language papers on selected topics, reviewed brief presentations on each topic, and discussed current practice and recommendations in breakout groups. Consensus recommendations were developed based on all presentations and discussions. Members of the Scientific Committee graded the quality of the supporting evidence and the consensus recommendations using the GRADE system.

CONCLUSIONS

Evidence-based approach consensus recommendations address important clinical issues regarding multidisciplinary management of acromegaly-related cardiovascular, endocrine, metabolic, and oncologic comorbidities, sleep apnea, and bone and joint disorders and their sequelae, as well as their effects on quality of life and mortality.

Point-of-care ultrasound in internal medicine: A position paper by the ultrasound working group of the European federation of internal medicine

Point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. It has many uses in daily clinical practice, including improved diagnostic timeliness and accuracy, and providing information about a patient's prognosis and follow-up. It has been integrated into numerous specialities, but remains relatively undefined in internal medicine training programs. Ultrasonography is a useful tool in the standard clinical practice of internists in numerous clinical scenarios (Emergency Department, hospital ward, general and specific consultations, and home care). Although POCUS has been recently included in the European curriculum of internal medicine, there are differences between European internists in its use, ranging from not at all to well structured educational programs. The use of POCUS needs to be widespread in internal medicine departments, and to accomplish this we must encourage structured training. This document details the consensus-based recommendations by the European Federation of Internal Medicine (EFIM) Ultrasound working group. We establish POCUS core competencies and clinical settings for internists in a symptom-based approach. We also propose training requirements, providing a framework for training programs at a national level.

Early versus late Gamma Knife radiosurgery for Cushing's disease after prior resection: results of an international, multicenter study

OBJECTIVE

The optimal time to perform stereotactic radiosurgery after incomplete resection of adrenocorticotropic hormone (ACTH)-producing pituitary adenoma in patients with Cushing's disease (CD) remains unclear. In patients with persistent CD after resection of ACTH-producing pituitary adenoma, the authors evaluated the association of the interval between resection and Gamma Knife radiosurgery (GKRS) with outcomes.

METHODS

Pooled data from 10 institutions participating in the International Radiosurgery Research Foundation were used in this study.

RESULTS

Data from 255 patients with a mean follow-up of 65.59 ± 49.01 months (mean ± SD) were analyzed. Seventy-seven patients (30%) underwent GKRS within 3 months; 46 (18%) from 4 to 6 months; 34 (13%) from 7 to 12 months; and 98 (38%) at > 12 months after the resection. Actuarial endocrine remission rates were higher in patients who underwent GKRS ≤ 3 months than when treatment was > 3 months after the resection (78% and 65%, respectively; p = 0.017). Endocrine remission rates were lower in patients who underwent GKRS at > 12 months versus ≤ 12 months after the resection (57% vs 76%, respectively; p = 0.006). In multivariate Cox regression analyses adjusted for clinical and treatment characteristics, early GKRS was associated with increased probability of endocrine remission (hazard ratio [HR] 1.518, 95% CI 1.039-2.218; p = 0.031), whereas late GKRS (HR 0.641, 95% CI 0.448-0.919; p = 0.015) was associated with reduced probability of endocrine remission. The incidence of some degree of new pituitary deficiency (p = 0.922), new visual deficits (p = 0.740), and other cranial nerve deficits (p = 0.610) was not significantly related to time from resection to GKRS.

CONCLUSIONS

Early GKRS is associated with an improved endocrine remission rate, whereas later GKRS is associated with a lower rate of endocrine remission after pituitary adenoma resection. Early GKRS should be considered for patients with CD after incomplete pituitary adenoma resection.

Characteristic CT features of pheochromocytomas - probability model calculation tool based on a multicentric study

OBJECTIVES

The aim of the study was to evaluate the CT features of adrenal tumors in an effort to identify features specific to pheochromocytomas and second, to define a feasible probability calculation model.

METHODS

This multicentric retrospective study included patients from the period 2003 to 2017 with an appropriate CT examination and a histological diagnosis of an adrenal adenoma, pheochromocytoma, adrenocortical carcinoma, or metastasis. In total, 346 patients were suitable for the CT image analysis, which included evaluation of the largest diameter, the shape of the lesion, the presence of central necrosis and its margins, and the presence of an enhancing peripheral rim ("ring sign").

RESULTS

Pheochromocytomas have a significantly more spherical shape (P<0.001), whereas an elliptical shape significantly reduces the probability of a pheochromocytoma (odds ratio = 0.015), as does another shape (odds ratio = 0.006). A "ring sign" is also more frequent in pheochromocytomas compared to other adrenal tumors (P=0.001, odds ratio = 6.49). A sharp necrosis also increases the probability of a pheochromocytoma more than unsharp necrosis (odds ratio 231.6 vs. 20.2). The probability calculation model created on the basis of the results confirms a high sensitivity and specificity (80% and 95%).

CONCLUSION

This study confirms the value of anatomical features in the assessment of adrenal masses with the ability to significantly improve the identification of pheochromocytomas. Advanced assessment of the tumor shape was defined and a original comprehensive calculating tool of the pheochromocytoma probability was created on the basis of the results presented here and could be used in clinical routine.

Upfront Gamma Knife radiosurgery for Cushing’s disease and acromegaly: a multicenter, international study

OBJECTIVE

Gamma Knife radiosurgery (GKS) is typically used after failed resection in patients with Cushing’s disease (CD) and acromegaly. Little is known about the upfront role of GKS for patients with CD and acromegaly. In this study, the authors examine the outcome of upfront GKS for patients with these functioning adenomas.

METHODS

An international group of 7 Gamma Knife centers sent pooled data from 46 patients (21 with CD and 25 with acromegaly) undergoing upfront GKS to the coordinating center of the study for analysis. Diagnosis was established on the basis of clinical, endocrine, and radiological studies. All patients were treated on a common radiosurgical platform and longitudinally followed for tumor control, endocrine remission, and hypopituitarism. Patients received a tumor median margin dose of 25 Gy (range 12–40.0 Gy) at a median isodose of 50%.

RESULTS

The median endocrine follow-up was 69.5 months (range 9–246 months). Endocrine remission was achieved in 51% of the entire cohort, with 28% remission in acromegaly and 81% remission for those with CD at the 5-year interval. Patients with CD achieved remission earlier as compared to those with acromegaly (p = 0.0005). In patients post-GKS, the pituitary adenoma remained stable (39%) or reduced (61%) in size. Hypopituitarism occurred in 9 patients (19.6%), and 1 (2.2%) developed third cranial nerve (CN III) palsy. Eight patients needed further intervention, including repeat GKS in 6 and transsphenoidal surgery in 2.

CONCLUSIONS

Upfront GKS resulted in good tumor control as well as a low rate of adverse radiation effects in the whole group. Patients with CD achieved a faster and far better remission rate after upfront GKS in comparison to patients with acromegaly. GKS can be considered as an upfront treatment in carefully selected patients with CD who are unwilling or unable to undergo resection, but it has a more limited role in acromegaly.

Outcomes After Gamma Knife Stereotactic Radiosurgery in Pediatric Patients with Cushing Disease or Acromegaly: A Multi-Institutional Study

OBJECTIVE

Pituitary adenomas comprise about 3% of all intracranial tumors in pediatric patients. This study examines the role of stereotactic radiosurgery in the management of pediatric acromegaly or patients with Cushing disease (CD).

METHODS

From an international consortium, we retrospectively collected treatment and outcome data on pediatric adrenocorticotrophic hormone and growth hormone-secreting pituitary adenomas treated with Gamma Knife radiosurgery (GKRS). There were a total of 36 patients including 24 with CD and 12 with acromegaly. The data were analyzed to assess outcomes including tumor control, endocrine remission, and adverse effects. Statistical analysis was performed to determine correlation between clinical/treatment parameters and outcomes.

RESULTS

At the last follow-up after GKRS, endocrine remission rates for CD and acromegaly were 80% and 42%, respectively. Tumor control was achieved in 87.5% of patients with CD and in 42% of patients with acromegaly. New pituitary hormone deficiency occurred in 7 of the 36 patients at a median time of 18 months after GKRS (range, 12-81 months). The predictive factors for endocrine remission were age <15 years (P = 0.015) and margin dose (P = 0.042). The median endocrine follow-up was 63.7 months (range, 7-246 months).

CONCLUSIONS

GKRS affords reasonable rates of endocrine remission and tumor control in most pediatric patients with functioning adenomas. The most common post-GKRS complication was hypopituitarism, although this occurred in only a few patients. Given the larger at-risk period for pediatric patients, further study is required to evaluate for delayed recurrences and hypopituitarism.

Hypopituitarism after Gamma Knife radiosurgery for pituitary adenomas: a multicenter, international study

OBJECTIVE

Recurrent or residual adenomas are frequently treated with Gamma Knife radiosurgery (GKRS). The most common complication after GKRS for pituitary adenomas is hypopituitarism. In the current study, the authors detail the timing and types of hypopituitarism in a multicenter, international cohort of pituitary adenoma patients treated with GKRS.

METHODS

Seventeen institutions pooled clinical data obtained from pituitary adenoma patients who were treated with GKRS from 1988 to 2016. Patients who had undergone prior radiotherapy were excluded. A total of 1023 patients met the study inclusion criteria. The treated lesions included 410 nonfunctioning pituitary adenomas (NFPAs), 262 cases of Cushing’s disease (CD), and 251 cases of acromegaly. The median follow-up was 51 months (range 6–246 months). Statistical analysis was performed using a Cox proportional hazards model to evaluate factors associated with the development of new-onset hypopituitarism.

RESULTS

At last follow-up, 248 patients had developed new pituitary hormone deficiency (86 with NFPA, 66 with CD, and 96 with acromegaly). Among these patients, 150 (60.5%) had single and 98 (39.5%) had multiple hormone deficiencies. New hormonal changes included 82 cortisol (21.6%), 135 thyrotropin (35.6%), 92 gonadotropin (24.3%), 59 growth hormone (15.6%), and 11 vasopressin (2.9%) deficiencies. The actuarial 1-year, 3-year, 5-year, 7-year, and 10-year rates of hypopituitarism were 7.8%, 16.2%, 22.4%, 27.5%, and 31.3%, respectively. The median time to hypopituitarism onset was 39 months. In univariate analyses, an increased rate of new-onset hypopituitarism was significantly associated with a lower isodose line (p = 0.006, HR = 8.695), whole sellar targeting (p = 0.033, HR = 1.452), and treatment of a functional pituitary adenoma as compared with an NFPA (p = 0.008, HR = 1.510). In multivariate analyses, only a lower isodose line was found to be an independent predictor of new-onset hypopituitarism (p = 0.001, HR = 1.38).

CONCLUSIONS

Hypopituitarism remains the most common unintended effect of GKRS for a pituitary adenoma. Treating the target volume at an isodose line of 50% or greater and avoiding whole-sellar radiosurgery, unless necessary, will likely mitigate the risk of post-GKRS hypopituitarism. Follow-up of these patients is required to detect and treat latent endocrinopathies.

Worse Health-Related Quality of Life at long-term follow-up in patients with Cushing's disease than patients with cortisol producing adenoma. Data from the ERCUSYN

OBJECTIVE

Hypercortisolism in Cushing's syndrome (CS) is associated with impaired health-related quality of life (HRQoL), which may persist despite remission. We used the data entered into the European Registry on Cushing's syndrome (ERCUSYN) to evaluate if patients with CS of pituitary origin (PIT-CS) have worse HRQoL, both before and after treatment than patients with adrenal causes (ADR-CS).

METHODS

Data from 595 patients (492 women; 83%) who completed the CushingQoL and/or EQ-5D questionnaires at baseline and/or following treatment were analysed.

RESULTS

At baseline, HRQoL did not differ between PIT-CS (n = 293) and ADR-CS (n = 120) on both EuroQoL and CushingQoL. Total CushingQoL score in PIT-CS and ADR-CS was 41 ± 18 and 44 ± 20, respectively (P = .7). At long-time follow-up (>1 year after treatment) total CushingQoL score was however lower in PIT-CS than ADR-CS (56 ± 20 vs 62 ± 23; P = .045). In a regression analysis, after adjustment for baseline age, gender, remission status, duration of active CS, glucocorticoid dependency and follow-up time, no association was observed between aetiology and HRQoL. Remission was associated with better total CushingQoL score (P < .001), and older age at diagnosis with worse total score (P = .01). Depression at diagnosis was associated with worse total CushingQoL score at the last follow-up (P < .001).

CONCLUSION

PIT-CS patients had poorer HRQoL than ADR-CS at long-term follow-up, despite similar baseline scoring. After adjusting for remission status, no interaetiology differences in HRQoL scoring were found. Age and presence of depression at diagnosis of CS may be potential predictors of worse HRQoL regardless of CS aetiology.

Preoperative medical treatment in Cushing's syndrome: frequency of use and its impact on postoperative assessment: data from ERCUSYN

BACKGROUND

Surgery is the definitive treatment of Cushing's syndrome (CS) but medications may also be used as a first-line therapy. Whether preoperative medical treatment (PMT) affects postoperative outcome remains controversial.

OBJECTIVE

(1) Evaluate how frequently PMT is given to CS patients across Europe; (2) examine differences in preoperative characteristics of patients who receive PMT and those who undergo primary surgery and (3) determine if PMT influences postoperative outcome in pituitary-dependent CS (PIT-CS).

PATIENTS AND METHODS

1143 CS patients entered into the ERCUSYN database from 57 centers in 26 countries. Sixty-nine percent had PIT-CS, 25% adrenal-dependent CS (ADR-CS), 5% CS from an ectopic source (ECT-CS) and 1% were classified as having CS from other causes (OTH-CS).

RESULTS

Twenty per cent of patients took PMT. ECT-CS and PIT-CS were more likely to receive PMT compared to ADR-CS (P < 0.001). Most commonly used drugs were ketoconazole (62%), metyrapone (16%) and a combination of both (12%). Median (interquartile range) duration of PMT was 109 (98) days. PIT-CS patients treated with PMT had more severe clinical features at diagnosis and poorer quality of life compared to those undergoing primary surgery (SX) (P < 0.05). Within 7 days of surgery, PIT-CS patients treated with PMT were more likely to have normal cortisol (P < 0.01) and a lower remission rate (P < 0.01). Within 6 months of surgery, no differences in morbidity or remission rates were observed between SX and PMT groups.

CONCLUSIONS

PMT may confound the interpretation of immediate postoperative outcome. Follow-up is recommended to definitely evaluate surgical results.

Stereotactic Radiosurgery for Cushing Disease: Results of an International, Multicenter Study

CONTEXT

Cushing disease (CD) due to adrenocorticotropic hormone-secreting pituitary tumors can be a management challenge.

OBJECTIVE

To better understand the outcomes of stereotactic radiosurgery (SRS) for CD and define its role in management.

DESIGN

International, multicenter, retrospective cohort analysis.

SETTING

Ten medical centers participating in the International Gamma Knife Research Foundation.

PATIENTS

Patients with CD with >6 months endocrine follow-up.

INTERVENTION

SRS using Gamma Knife radiosurgery.

MAIN OUTCOME MEASURES

The primary outcome was control of hypercortisolism (defined as normalization of free urinary cortisol). Radiologic response and adverse radiation effects (AREs) were recorded.

RESULTS

In total, 278 patients met inclusion criteria, with a mean follow-up of 5.6 years (0.5 to 20.5 years). Twenty-two patients received SRS as a primary treatment of CD. Mean margin dose was 23.7 Gy. Cumulative initial control of hypercortisolism was 80% at 10 years. Mean time to cortisol normalization was 14.5 months. Recurrences occurred in 18% with initial cortisol normalization. Overall, the rate of durable control of hypercortisolism was 64% at 10 years and 68% among patients who received SRS as a primary treatment. AREs included hypopituitarism (25%) and cranial neuropathy (3%). Visual deficits were related to treatment of tumor within the suprasellar cistern (P = 0.01), whereas both visual (P < 0.0001) and nonvisual cranial neuropathy (P = 0.02) were related to prior pituitary irradiation.

CONCLUSIONS

SRS for CD is well tolerated and frequently results in control of hypercortisolism. However, recurrences can occur. SRS should be considered for patients with persistent hypercortisolism after pituitary surgery and as a primary treatment in those unfit for surgery. Long-term endocrine follow-up is essential after SRS.

Diagnostic tests for Cushing's syndrome differ from published guidelines: data from ERCUSYN

OBJECTIVE

To evaluate which tests are performed to diagnose hypercortisolism in patients included in the European Registry on Cushing's syndrome (ERCUSYN), and to examine if their use differs from the current guidelines.

PATIENTS AND METHODS

We analyzed data on the diagnostic tests performed in 1341 patients with Cushing's syndrome (CS) who have been entered into the ERCUSYN database between January 1, 2000 and January 31, 2016 from 57 centers in 26 European countries. Sixty-seven percent had pituitary-dependent CS (PIT-CS), 24% had adrenal-dependent CS (ADR-CS), 6% had CS from an ectopic source (ECT-CS) and 3% were classified as having CS from other causes (OTH-CS).

RESULTS

Of the first-line tests, urinary free cortisol (UFC) test was performed in 78% of patients, overnight 1 mg dexamethasone suppression test (DST) in 60% and late-night salivary cortisol (LSaC) in 25%. Use of LSaC increased in the last five years as compared with previous years (P < 0.01). Use of HDDST was slightly more frequent in the last 5 years as compared with previous years (P < 0.05). Of the additional tests, late-night serum cortisol (LSeC) was measured in 62% and 48-h 2 mg/day low-dose dexamethasone suppression test (LDDST) in 33% of cases. ACTH was performed in 78% of patients. LSeC and overnight 1 mg DST supported the diagnosis of both PIT-CS and ADR-CS more frequently than UFC (P < 0.05).

CONCLUSIONS

Use of diagnostic tests for CS varies across Europe and partly differs from the currently available guidelines. It would seem pertinent that a European consensus be established to determine the best diagnostic approach to CS, taking into account specific inter-country differences with regard to the availability of diagnostic tools.

The role of early cortisol level in the assessment of the radicality of resection in central Cushing's disease

INTRODUCTION

To increase radicality and avoid surgical complications new treatment options are under investigation. One of the promising possibilities is to assess early morning cortisol levels on the first and second postoperative day.

MATERIAL AND METHODS

We enrolled 34 patients (9 males, 25 females) diagnosed with Cushing's disease. Blood samples to determine cortisol level were taken always at 06:00 and sent to the lab. The samples were taken on the first and second postoperative day. For all patients, standard four-handed, a bi-nostril endoscopic endonasal technique was used. Endocrinological follow-up (6-34 months) was performed using morning cortisol sampling.

RESULTS

In total, 36 patients (88%) were disease-free post-surgery. In the group with early postoperative levels of morning cortisol of less than 463 nmol/L, only 2 of 29 patients (7%) exceeded the final morning level of cortisol at follow-up. In patients with early postoperative cortisol levels between 17 nmol/l and 234 nmol/l all subjects showed normal postoperative cortisol levels.

DISCUSSION

In 30 of 34 patients (88%), the level of cortisol was within normal limits. The prediction importance of early measurement of cortisol is 93% for patients with early postoperative cortisol levels of less than 463 nmol/L. The prediction importance of early measurement of cortisol is 100% for patients with early postoperative cortisol levels from 17 to 234 nmol/L.

CONCLUSION

The monitoring of early morning cortisol levels seems to be an important tool in the management of central Cushing's disease.

Is it possible to avoid hypopituitarism after irradiation of pituitary adenomas by the Leksell gamma knife?

OBJECTIVE

Radiation therapy is one of the treatment options for pituitary adenomas. The most common side effect associated with Leksell gamma knife (LGK) irradiation is the development of hypopituitarism. The aim of this study was to verify that hypopituitarism does not develop if the maximum mean dose to pituitary is kept under 15 Gy and to evaluate the influence of maximum distal infundibulum dose on the development of hypopituitarism.

DESIGN AND METHODS

We followed the incidence of hypopituitarism in 85 patients irradiated with LGK in 1993-2003. The patients were divided in two subgroups: the first subgroup followed prospectively (45 patients), irradiated with a mean dose to pituitary <15 Gy; the second subgroup followed retrospectively 1993-2001 and prospectively 2001-2009 (40 patients), irradiated with a mean dose to pituitary >15 Gy. Serum TSH, free thyroxine, testosterone or 17β-oestradiol, IGF1, prolactin and cortisol levels were evaluated before and every 6 months after LGK irradiation.

RESULTS

Hypopituitarism after LGK irradiation developed only in 1 out of 45 (2.2%) patients irradiated with a mean dose to pituitary <15 Gy, in contrast to 72.5% patients irradiated with a mean dose to pituitary >15 Gy. The radiation dose to the distal infundibulum was found as an independent factor of hypopituitarism with calculated maximum safe dose of 17 Gy.

CONCLUSION

Keeping the mean radiation dose to pituitary under 15 Gy and the dose to the distal infundibulum under 17 Gy prevents the development of hypopituitarism following LGK irradiation.

Plasma concentrations of fibroblast growth factors 21 and 19 in patients with Cushing's syndrome

The objective of this study was to measure plasma fibroblast growth factor 21 and 19 (FGF21 and FGF19) levels in patients with Cushing's syndrome (CS) and to compare it with those of lean control subjects (C) and patients with obesity (OB). Fourteen untreated patients with CS, 19 patients with OB and 36 controls were included in the study. Plasma FGF21 and FGF19 levels were measured by ELISA kits, other hormonal and biochemical parameters were measured by standard laboratory methods. Plasma FGF19 did not significantly differ among the studied groups. Plasma FGF21 levels were significantly higher in both CS and OB groups relative to C group but they did not differ between CS and OB groups. In a combined population of all three groups FGF21 levels positively correlated with BMI, waist circumference and percentage of total and truncal fat mass. Less prominent inverse relationship with these parameters was found for FGF19. Neither FGF21 nor FGF19 were significantly related to cortisol concentrations. Increased FGF21 concentrations in both patients with CS and OB relative to lean subjects suggest that excessive body fat and/or related metabolic abnormalities rather than direct effects of cortisol are responsible. In contrast neither obesity nor hypercortisolism significantly affected FGF19 concentrations.

[120 laparoscopic adrenalectomies with a harmonic scalpel]

BACKGROUND

Presently the laparoscopic adrenalectomy (LA) becomes most popular since 1992 when it was performed for the first time by laparoscopic method by Gagner. Typical indication for LA is the aldosteron-secreting adenoma, Cushing's syndrome, feochromocytoma or scarcity tumors such as adrenal cyst or myelolipomas.

AIM

The evaluation of the laparoscopic adrenalectomy as safe method for adrenals tumout's extirpation to the sizes 10 cm.

METHODS

LA is provided with transperitoneal lateral approach most frequently then in back side position. Retroperitoneal approach is used less commonly.

RESULTS

Since 2006, firstly at the 1st Surgical department of 1st Medical School of Charles University and General Faculty Hospital and lastly at the Surgical department 2nd Medical School of Charles University and Central Military Hospital, has been performed on the whole 120 LA in 114 patients. The bilateral LA was performed in 6 patients. The conversion from the laparoscopic to open adrenalectomy was necessary by reason of the king size of the tumor (13/14 cm) in two cases. The lateral position and transperitoneal approach was used in all cases. The harmonie scalpel was used with advantage. Average length of the operation was 82 minutes (40-154 min), respective 180 minutes (130-270 min) in the case of the bilateral LA. The median size of the adrenal tumor was 4.9 cm (1.5-12.5 cm) with average weight 44 g (18-421 g). All of the patients after LA were monitored for 24 hours in the Intensive care units. The average time of the hospitalization was 3.7 days (2-6 days).

CONCLUSION

Laparoscopic adrenalectomy presently becomes as the "gold standard" for the treatment of adrenal tumors to the size 10 cm namely and in the event of malignancy. The harmonie scalpel is useful and sparing advice for the LA.

Use of the Leksell gamma knife in the treatment of prolactinoma patients

OBJECTIVE

Pharmacological treatment with dopaminergic agonists (DA) is the treatment of choice for prolactinomas. Surgical and radiation treatment is also indicated in certain situations. We describe our 12-year experience in treating prolactinomas with the Leksell gamma knife (LGK).

DESIGN

We followed 35 prolactinoma patients (25.7% microprolactinomas, 74.3% macroprolactinomas) treated with LGK irradiation. The mean follow-up period was 75.5 months. Prior to LGK irradiation, patients were treated with DA and 10 of them (28.6%) underwent neurosurgery. Indications for LGK irradiation were: DA intolerance (31.4%), DA resistance (45.7%) and efforts to reduce the DA dose or shorten the period of administration (22.9%). Pituitary function was monitored regularly at 6-month intervals. The central radiation dose range was 40-80 Gy (median 70 Gy), and the minimal peripheral dose was 20-49 Gy (median 34 Gy).

RESULTS

Normoprolactinaemia was achieved in 37.1% of the patients who discontinued DA and in 42.9% of patients who continued DA treatment after LGK irradiation. The median time to prolactin normalization after discontinuation of DA was 96 months. No relapse was seen in any patient. After LGK irradiation, the prolactinoma stopped growing or decreased in size in all but one patient (97.1%).

CONCLUSION

LGK treatment resulted in normoprolactinaemia in 80.0% of the patients, all of whom had failed pharmacological treatment due to DA resistance or intolerance. After achieving normoprolactinaemia, no relapse of hyperprolactinaemia was observed in any patient. The size of the adenoma decreased even in those patients in whom it was not changed by previous DA treatment.

[Adrenal cancer]

Adrenal cancer is a rare disease which is often diagnosed at a late stage and usually has a poor prognosis. This review article gives a current knowledge on the etiopathogenesis, which could lead to the improvement of therapeutic strategies and possibly outcomes of therapy. Further, clinical presentation, diagnostic approach and current treatment options in patients with adrenal cancer are summarized. The multidisciplinary approach as well as centralized care is necessary for successful management of patients with adrenal cancer and for improvement of their poor prognosis.

Cytosine-Adenosine (CA)n repeats polymorphism in IGF-I gene and early growth in infants born appropriate and small for gestational age

BACKGROUND

IGF-I gene polymorphisms might alter IGF-I level resulting in decreased foetal and postnatal growth and increased risk for diabetes mellitus type 2 and cardiovascular diseases in adulthood.

OBJECTIVES

We analyzed the association between Cytosine-Adenosine (CA)10-24 repeats polymorphism in promoter region of the IGF-I gene and early growth in infants with birth weight appropriate for gestational age (AGA) and small for gestational age (SGA).

DESIGN AND METHODS

All neonates were born at term, 196 of them were AGA and 26 SGA. Blood for DNA analyses was obtained from placental part of umbilical vein. Genotyping was performed using fragment analyses of IGF-I gene promoter region. The data about postnatal growth in the group of AGA children were obtained at the age of 18 months, in SGA children at 12 months.

RESULTS

No differences in the frequency of wild type allele with (CA)19 repeats and polymorphisms with (CA)<19 or (CA)>19 repeats were observed between AGA and SGA children. The average birth weight and length in AGA wild type (CA)19 homozygotes were lower in comparison with AGA carriers of various (CA)n polymorphisms but all observed anthropometric differences disappeared at the age of 18 months. In SGA children, no differences were found between number of (CA)n repeats and anthropometric parameters both at birth and at the age of 12 months.

CONCLUSIONS

Although (CA)n repeats polymorphism in IGF-I gene might affect prenatal growth in AGA children, our results have not shown any impact of variable number of (CA) n repeats in IGF-I gene on postnatal growth.

[Pathogenesis of insulin resistance in different endocrinopathies]

Visceral obesity, insulin resistance and increased cardiovascular morbidity and mortality are strongly related. Development of visceral obesity and regulation of body fat distribution in general are influenced by many factors. This article is a summary of current knowledge about pathogenesis of insulin resistance in different endocrinopathies, particularly in the Cushing's syndrome and acromegaly, as they are both connected with the pathological conditions mentioned above.

Adrenocortical changes and arterial hypertension in lipoatrophic A-ZIP/F-1 mice

The A-ZIP/F-1 transgenic mouse is a model of lipoatrophic diabetes with severe insulin resistance, hyperglycemia and hyperlipidemia. Recently, a regulatory role of adipose tissue on adrenal gland function and blood pressure has been suggested. To further explore the importance of adipose tissue in the regulation of adrenal function and blood pressure, we studied this mouse model of lipodystrophy. A-ZIP/F-1 mice exhibit significantly elevated systolic and diastolic blood pressure values despite lack of white adipose tissue and its hormones. Furthermore, A-ZIP/F-1 lipoatrophic mice have a significant reduction of adrenal zona glomerulosa, while plasma aldosterone levels and aldosterone synthase mRNA expression remain unchanged. On the other hand, lipoatrophic mice present elevated corticosterone levels but no adrenocortical hyperplasia. Ultrastructural analysis of adrenal gland show significant alterations in adrenocortical cells, with conformational changes of mitochondrial internal membranes and high amounts of liposomes. In conclusion, lipodystrophy in A-ZIP/F-1 mice is associated with hypertension, possibly due to hypercorticosteronemia and/or others metabolic-vascular changes.

[Randomly discovered enlargement in the region of sella turcica]

Computer tomography (CT) and magnetic resonance imaging (MRI) quite often detect unexpected cases of enlargement in the hypothalamus-hypophysial region, without the above methods being indicated for clinical manifested symptomatology provoked by the tumour. This is not surprising if we consider that autopsies show the presence of hypophysial adenomas of 10-15% of population on an average. X ray, CT or MRI are indicated in the case of head traumas, lateral nasal cavity inflammations, headaches, strokes, neurological diseases and other disorders. A number of tumours of diverse etiology occur in the hypothalamus-hypophysial region, but hypophysial adenomas are by far the most frequent among all (above 90 %). Among other primary enlargements, the most frequent are craniopharyngeomas and meningeomas, while other enlargements are by fare less common. Such randomly detected tumours are mostly asymptomatic, but targeted anamnesis may show some of the symptoms quite clearly. The symptomatology can be linked with possible slight hormonal overproduction of hypophysial adenomas, a deficit of hypophysial hormones or local manifestations of expansion. Exact assessment of MRI results, of hormonal activity of the enlargement, of the relation to surrounding structures, especially the optic nerves, and the assessment of hypophysial functions are important for the therapeutic decision. Depending on the type and extension of the tumour the options considered are pharmacotherapy (the treatment of choice in the case of prolactinomas), surgery, radiotherapy (today prevailingly using the gamma knife), and if no intervention is necessary, follow up with regular MRI examinations. Tumorous growth is more often observed in "macroadenomas" than in "microadenomas" (up to 10 mm).

[Adrenal incidentalomas]

Adrenal incidentalomas are called as a disease of modern technology because increased availability and accuracy of imaging techniques lead to increased incidence of incidentally discovered adrenal masses. Adrenal incidentalomas are found in about 0.35-4.36% of abdominal CT scans performed for purpose other than suspicion of adrenal diseases. However, in autoptic studies the percentage of incidentally discovered adrenal tumours in much higher, in some of then being even more than 20%. Important component of differential diagnosis is endocrinological examination aimed to reveal potential autonomous hormonal overproduction. Approximately more than 10% of adrenal incidentalomas is characterized by autonomous cortisol production, 5-10% is phaeochromocytomas and 5-7% is aldosteron producing adenomas. Vast majority of adrenal incidentalomas are nonfunctioning tumours, mainly adenomas. Rational ways and recommendations for screening of hormonal activity of adrenal incidentalomas is discussed. Very important issue is to distinguish between benign and malignant lesions and between adenomas and non-adenomas. The accuracy of CT, MR, and fine needle aspiration cytology in distinguishing between adenomas from non-adenomas is comparable, in general not exceeding 90%. Particular characteristics of particular adrenal tumours are discussed. From the relationship between the tumour size and probability of malignancy, current recommendations are derived, that non-functioning tumours smaller than 4 cm are indicated for further follow-up, size over 6 cm is indication for adrenalectomy and in tumours between 4-6 cm decision process is complex.

[How corticoids, growth hormone and oestrogens influence lipids and atherosclerosis]

The hormones with a strong influence on the lipid spectrum and the development of atherosclerosis include cortisol, growth hormone and oestrogens. Cortisol accelerates atherosclerosis both through dyslipidemia and through an increase in visceral fat, hypertension, increased insulin resistance and the development of reduced glucose tolerance which may result in diabetes mellitus. Even when a cortisol excess disappears, as is the case of patients cured of Cushing syndrome, arterial walls remain permanently vulnerable to the atherosclerotic process. In conditions involving a lack of growth hormone, dyslipidemia develops and increases the burden on the cardiovascular system if not treated in a timely manner by the substitution of growth hormone. Oestrogens have a double effect: they have an anti-atherogenic effect on artery walls that are not yet damaged by an atherosclerotic process, but where atherosclerosis has already developed they have a prothrombotic effect and destabilise the atheromatous plaques. If oestrogen is to be used as protection against the onset of atherogenesis, it is necessary to start in a period when the atherosclerotic process has not yet begun to damage the woman's arterial walls and it is best to use natural hormones (estradiol) and to prevent endometriosis it should be combined with crystalline progesterone applied locally--inravaginally. Oestrogens should be given in small doses, preferably parenterally. Even this will not prevent genetic oestrogen effects though.

Impaired microvascular reactivity and endothelial function in patients with Cushing's syndrome: influence of arterial hypertension

The aim of the study was to evaluate skin microvascular reactivity (MVR) and possible influencing factors (fibrinolysis, oxidative stress, and endothelial function) in patients with Cushing's syndrome. Twenty-nine patients with active Cushing's syndrome (ten of them also examined after a successful operation) and 16 control subjects were studied. Skin MVR was measured by laser Doppler flowmetry during post-occlusive (PORH) and thermal hyperemia (TH). Malondialdehyde and Cu,Zn-superoxide dismutase were used as markers of oxidative stress. Fibrinolysis was estimated by tissue plasminogen activator (tPA) and its inhibitor (PAI-1). N-acetyl-beta-glucosaminidase, E-selectin, P-selectin, and ICAM-1 were used as markers of endothelial function. Oxidative stress and endothelial dysfunction was present in patients with hypercortisolism, however, increased concentration of ICAM-1 was also found in patients after the operation as compared to controls (290.8+/-74.2 vs. 210.9+/-56.3 ng.ml(-1), p<0.05). Maximal perfusion was significantly lower in patients with arterial hypertension during PORH and TH (36.3+/-13.0 vs. 63.3+/-32.4 PU, p<0.01, and 90.4+/-36.6 vs. 159.2+/-95.3 PU, p<0.05, respectively) and similarly the velocity of perfusion increase during PORH and TH was lower (3.2+/-1.5 vs. 5.2+/-3.4 PU.s(-1), p<0.05, and 0.95+/-0.6 vs. 1.8+/-1.1 PU.s(-1), p<0.05, respectively). The most pronounced impairment of microvascular reactivity was present in patients with combination of arterial hypertension and diabetes mellitus.

Increased lipolysis of subcutaneous abdominal adipose tissue and altered noradrenergic activity in patients with Cushing's syndrome: an in-vivo microdialysis study

Cushing's syndrome is associated with typical central redistribution of adipose tissue. The aim of the study was to assess lipolysis and catecholamines and their metabolites in subcutaneous abdominal adipose tissue using an in-vivo microdialysis technique. Nine patients with Cushing's syndrome and nine age-, gender- and body mass index (BMI)-matched control subjects were included in the study. Local glycerol concentrations were significantly increased in subcutaneous adipose tissue of patients with Cushing's syndrome (p<0.001). Plasma noradrenaline, dihydroxyphenylglycol and dihydroxyphenylalanine were decreased in patients with Cushing's syndrome (p<0.02, p<0.05, and p<0.02, respectively). Adrenaline, noradrenaline, dihydroxyphenylglycol and dihydroxyphenylalanine concentrations in subcutaneous abdominal adipose were non-significantly higher in patients with Cushing's syndrome. In conclusion, we showed that lipolysis in subcutaneous adipose tissue of patients with Cushing's syndrome is significantly increased as compared to healthy subjects. This finding together with non-significantly increased local catecholamine concentrations in these patients suggests a possible link between increased lipolysis and catecholaminergic activity in subcutaneous adipose tissue.

Gamma knife radiosurgery for acromegaly--long-term experience

OBJECTIVE

The Leksell gamma knife (LGK) is one of the treatment options for pituitary adenomas. We report on our long-term experience treating acromegaly using LGK.

DESIGN

Since 1993 we have followed 96 acromegaly patients through periods of from 12 to 120 months. The mean follow-up period was 53.7 +/- 26.8 months. Seventy-two patients were treated with neurosurgery prior to LGK; for 24 LGK was the primary treatment. Thirteen patients were irradiated twice, due to persistent activity of the adenoma or its residue. Pituitary functions were tested at 6-month intervals, post-irradiation. The target tumour volume for radiosurgery was between 93.3 and 12 700 mm3 (median 1350 mm3).

RESULTS

Fifty per cent of the patients achieved mean GH < 2.5 microg/l within 42 months, normalized their IGF-I within 54 months, and achieved GH suppression in the oral glucose tolerance test (oGTT) < 1 microg/l with normal IGF-I within 66 months. LGK effectiveness was dependent on initial adenoma hormonal activity (GH and IGF-I serum levels), not on the size of the adenoma. Patients with primary neurosurgery followed by LGK irradiation had better outcomes than those with LGK alone. Irradiation arrested all adenoma growth, causing tumour shrinkage in 62.3% of patients. Twenty-six developed hypopituitarism when irradiated by 15 Gy (or more) on functional peritumoral pituitary tissue. No hypopituitarism appeared using lower doses.

CONCLUSIONS

In acromegaly, LGK is a useful adjunct to primary neurosurgery when treating post-surgical residues because it can limit the duration of medical therapy. It can be used as a primary therapy when neurosurgery is not possible.

Angiogenic factors are elevated in overweight and obese individuals

BACKGROUND

Adipose tissue produces both vascular growth factors and inhibitors. Since obesity is associated with expansion of the capillary bed in regional adipose depots the balance between these factors may favor angiogenesis.

OBJECTIVE

To investigate the relationship between body mass index and serum concentrations of vascular growth factors in human subjects.

METHODS

Vascular endothelial growth factor (VEGF), VEGF-C, VEGF-D, soluble VEGF receptor-2 (sVEGFr2), hepatocyte growth factor (HGF), angiopoietin-2, angiogenin and endostatin concentrations were measured in serum collected from 58 lean (24 males, 34 female, mean BMI, 22.2+/-0.3) and 42 overweight and obese (16 males and 26 females, mean BMI, 33.5+/-1.2) subjects after an overnight fast.

RESULTS

Sexual dimorphism was apparent in the serum concentrations of VEGF-C, VEFG-D and angiopoietin-2 with significantly higher levels in female compared to male subject. VEGF, VEGF-C, VEGF-D, soluble VEGF receptor-2, angiopoietin-2, angiogenin and endostatin but not HGF were significantly elevated in overweight and obese subjects. Positive correlations between BMI and the serum concentrations of VEGF-C, VEGF-D, sVEGF-R2, angiopoietin-2, angiogenin and endostatin were observed even after adjustment for gender and age.

CONCLUSIONS

Increased levels of vascular growth factors as well as the angiogenesis inhibitor endostatin are present in overweight and obese subjects and may contribute to previously documented increased risk of metastatic disease in obese subjects with cancer.

Plasma levels of total and active ghrelin in acromegaly and growth hormone deficiency

Ghrelin is an endogenous growth hormone (GH) secretagogue recently isolated from the stomach. Although it possesses a strong GH releasing activity in vitro and in vivo, its physiological significance in endogenous GH secretion remains unclear. The aim of this study was to characterize plasma ghrelin levels in acromegaly and growth hormone deficiency (GHD). We investigated plasma total and active ghrelin in 21 patients with acromegaly, 9 patients with GHD and 24 age-, sex- and BMI-matched controls. In all subjects, we further assessed the concentrations of leptin, soluble leptin receptor, insulin, IGF-I, free IGF-I and IGFBP-1, 2, 3 and 6. Patients with acromegaly and GHD as well as control subjects showed similar levels of total ghrelin (controls 2.004+/-0.18 ng/ml, acromegalics 1.755+/-0.16 ng/ml, p=0.31, GHD patients 1.704+/-0.17 ng/ml, p=0.35) and active ghrelin (controls 0.057+/-0.01 ng/ml, acromegalics 0.047+/-0.01 ng/ml, p=0.29, GHD patients 0.062+/-0.01 ng/ml, p=0.73). In acromegalic patients plasma total ghrelin values correlated negatively with IGF-I (p<0.05), in GHD patients active ghrelin correlated with IGF-I positively (p<0.05). In the control group, total ghrelin correlated positively with IGFBP-2 (p<0.05) and negatively with active ghrelin (p=0.05), BMI (p<0.05), WHR (p<0.05), insulin (p=0.01) and IGF-I (p=0.05). Plasma active ghrelin correlated positively with IGFBP-3 (p=0.005) but negatively with total ghrelin and free IGF-I (p=0.01). In conclusion, all groups of the tested subjects showed similar plasma levels of total and active ghrelin. In acromegaly and growth hormone deficiency plasma ghrelin does not seem to be significantly affected by changes in GH secretion.

Plasma levels of active and total ghrelin in renal failure: a relationship with GH/IGF-I axis

Ghrelin was originally isolated from the rat stomach and significant amounts were found also in the kidney. Present study was designed to examine changes in ghrelin levels in renal failure and their relationship to the GH/IGF-I axis. Fourty patients with mild-to-severe CRF (19 men, 21 women, aged 62.5 +/- 2.2 years, BMI 27.57 +/- 0.73 kg/m(2)) and 34 healthy control subjects (17 men, 17 women, aged 60 +/- 2.6 years, BMI 27.55 +/- 0.79 kg/m(2)) were included in the study. Total ghrelin levels were significantly increased in patients with chronic renal failure (CRF) (p < 0.0001). Total ghrelin in CRF correlated positively with active ghrelin (p < 0.001), GH (p < 0.05), IGF-I (p < 0.05), free IGF-I (p = 0.0001), IGFBP-3 (p < 0.01), IGFBP-2 and -6 (p < 0.05). Active ghrelin in CRF correlated positively with IGF-I (p < 0.001), free-IGF-I (p < 0.005), IGFBP-2 (p < 0.05) and IGFBP-3 (p < 0.05). However, most of the correlation were markedly reduced and the significance disappeared after adjustment for different creatinine levels. Hemodialysis in patients with end stage renal disease (ESRD) resulted in a significant reduction of plasma total and active ghrelin (p < 0.01 and p < 0.001 respectively). In conclusion we demonstrated elevated plasma levels of total ghrelin in CRF, and a reduction of total and active ghrelin after a single course of hemodialysis in ESRD. The elevation of ghrelin levels could be caused by impaired clearance and/or metabolism of ghrelin in the kidney. We did not prove clearly significant relationship between ghrelin serum levels and parameters of GH/IGF-I axis in study subjects.

The effects of growth hormone status on circulating levels of vascular growth factors

BACKGROUND

Vascular growth factors are important not only in angiogenesis but also for the maintenance of normal endothelial integrity and function. Elevated levels of vascular endothelial growth factor (VEGF), angiopoietin-2, hepatocyte growth factor (HGF), endostatin and angiogenin have been associated with endothelial dysfunction and atherosclerosis. Both acromegaly and growth hormone deficiency (GHD) are associated with endothelial dysfunction and changes in blood vessel morphology.

AIM

To investigate the effect of GH status on the circulating levels of angiogenic factors.

DESIGN

We measured the levels of six endothelial growth modulators, four angiogenic growth factors and two inhibitors of angiogenesis in 35 untreated acromegalics, 36 untreated GH-deficient subjects and 101 normal control subjects. Fifteen GH-deficient subjects were also studied before and 1 year after treatment with GH.

RESULTS

Mean angiogenin concentrations were increased in acromegaly and decreased in GH-deficient subjects compared to control subjects. Endostatin levels showed a similar pattern although the elevated levels in acromegalic subjects did not achieve statistical significance. Angiogenin and endostatin levels both correlated significantly with IGF-I levels (R = 0.61, P < 0.001 and R = 0.22, P < 0.01, respectively). The relationship between angiogenin and IGF-I levels remained significant even after correction for gender, age, body mass index (BMI) and insulin resistance. There were no significant differences in the levels of HGF, VEGF, VEGF-C or angiopoietin-2 between the three groups. VEGF-D levels were elevated in both acromegalic and GH-deficient male subjects. A similar pattern was apparent in female subjects. After GH treatment, a significant reduction in VEGF-D levels and a significant rise in endostatin levels were observed in GH-deficient subjects. A nonsignificant increase in angiogenin levels was also observed.

CONCLUSION

These data indicate that significant perturbations in the levels of vascular growth modulators are present in both acromegaly and GHD. While changes in endostatin and angiogenin levels appear to correlate with IGF-I levels, VEGF-D levels show similar perturbations in both acromegaly and GHD. Further studies are required to determine the relationship of the perturbations to endothelial dysfunction in these conditions.

Plasma ghrelin levels in patients with end-stage renal disease

Ghrelin is an acylated peptide stimulating secretion of the growth hormone (GH). It was originally isolated from the rat stomach as an endogenous ligand for the growth hormone secretagogue receptor. Although being predominantly produced by endocrine cells of the gastric fundus, its secretion has been found in various tissues including the kidney. To study the influence of renal failure on plasma ghrelin levels we examined 16 patients with end-stage renal disease (ESRD) receiving hemodialysis (8 men and 8 women) and 19 controls (10 men and 9 women). Both groups were comparable in age and BMI. In all subjects we assessed plasma levels of ghrelin, leptin, soluble leptin receptor, insulin, IGF-I, IGFBP-1, IGFBP-3 and IGFBP-6. Ghrelin levels were significantly higher in the group of dialyzed patients (4.49+/-0.74 vs. 1.79+/-0.15 ng/ml; p<0.001). These patients had significantly higher levels of GH, IGFBP-1, IGFBP-6, leptin and percentage of body fat (p<0.05). In the group of patients with ESRD plasma ghrelin levels positively correlated with IGFBP-1 (p<0.01). In the control group, ghrelin positively correlated with GH concentrations (p<0.01) and negatively correlated with the levels of insulin and creatinine (p<0.05). In conclusion, patients with ESRD have higher ghrelin concentrations, which might be caused by a decreased excretion/metabolism of ghrelin in the kidney during renal failure.

Endocrine and metabolic activities of a recently isolated peptide hormone ghrelin, an endogenous ligand of the growth hormone secretagogue receptor

Ghrelin is a member of the group of growth hormone secretagogues (GHSs). It is a peptide hormone, recently isolated from stomach as an endogenous ligand for the growth hormone secretagogue receptor (GHS-R). Ghrelin is mostly produced by the stomach, although its production has been proved in various tissues. It is a potent releaser of growth hormone (GH) from anterior pituitary cells, but it also stimulates the release of other hypophyseal hormones. Ghrelin stimulates food intake and induces metabolic changes leading to an increase in body weight and body fat mass. This effect seems to be independent of GH action and needs an intact NPY/AGRP (neuropeptide Y/agouti-related protein) system. Plasma ghrelin levels are decreased in obesity, elevated in cachexia and show a diurnal rhythm. Its preprandial elevation suggests, that it might be a signal for meal initiation. Ghrelin further stimulates the release of gastric acid and gastric motility and affects pancreatic functions. It has vasodilatatory, cardioprotective and antiproliferative effects. This article is focused on ghrelin's endocrine and metabolic functions.

Adipokine levels in Cushing's syndrome; elevated resistin levels in female patients with Cushing's syndrome

BACKGROUND

Cushing's syndrome (CS) is associated with central adiposity, insulin resistance and impaired glucose homeostasis. Adipose tissue is thought to regulates glucose homeostasis via circulating adipokines, such as resistin, leptin and adiponectin, although their role in the insulin resistance associated with CS has not been established.

DESIGN

We examined the relationship between insulin resistance and adipokine levels in CS patients. We compared plasma levels of resistin, leptin and adiponectin in 10 women and four men patients with CS, with 14 health subjects matched for age, gender and body mass index. A subgroup of three women and four men with pituitary-dependent CS were re-examined at least 9 months after curative surgery.

RESULTS

CS patients had significantly more truncal fat and less lean body mass as assessed by DEXA compared to control subjects. Total cholesterol, triglycerides and insulin resistance, as calculated using the homeostasis model assessment of insulin resistance (HOMA-R), was significantly increased in CS patients. Of the adipokines measured, only resistin was significantly different between female CS patients and female control subjects (5.05 +/- 0.56 vs. 2.91 +/- 0.39 micro g/l, P = 0.015). Curative surgery significantly reduced total body fat and truncal fat, leptin, total and low-density lipoprotein (LDL) cholesterol, glucose and HOMA-R. A reduction in both resistin and adiponectin was also observed but the differences between pre- and post-treatment levels did not achieve statistical significance.

CONCLUSION

Here we report for the first time that resistin levels are significantly elevated in CS patients and may be important in the insulin resistance associated with glucocorticoid excess.

Serum ghrelin levels in obese patients: the relationship to serum leptin levels and soluble leptin receptors levels

Ghrelin is a new endogenous ligand for the growth hormone secretagogue receptor. It activates the release of growth hormone from the pituitary and it also participates in the regulation of energy homeostasis. The aim of the study was to characterize changes in serum ghrelin levels in obese subjects and their relationship to the serum levels of leptin and soluble leptin receptor. Eight obese patients (6 women and 2 men) with body mass index (BMI) 40.3+/-13.4 kg.m(-2) and eight healthy controls (5 women and 3 men) with BMI 22.7+/-1.3 kg.m(-2) were examined. The ghrelin serum levels (165.0+/-58.1 vs. 343.37+/-81.96; p<0.001) and soluble leptin receptor serum levels (7.25+/-3.44 vs. 21.80+/-4.99; p<0.0001) were significantly lower in obese patients. The leptin serum levels (23.45+/-12.90 vs. 6.41+/-2.96; p<0.005) were significantly higher compared to the lean subject group. In both measured groups the levels of serum leptin significantly positively correlated with BMI. We proved a significantly lower serum ghrelin levels in the group of obese patients in comparison with the control group.

Plasma resistin, adiponectin and leptin levels in lean and obese subjects: correlations with insulin resistance

OBJECTIVE

Adipose tIssue regulates insulin sensitivity via the circulating adipocytokines, leptin, resistin and adiponectin. The objective of this study was to compare the levels of resistin, adiponectin and leptin in lean and obese subjects and determine the relationship between circulating adipocytokines and insulin resistance.

METHODS

We examined plasma levels of resistin, adiponectin and leptin in 17 lean subjects with a mean body mass index (BMI) of approximately 23 and 34 non-diabetic obese individuals with a mean BMI approximately 33. Insulin resistance was assessed using the homeostasis model assessment ratio (HOMA-R) formula derived from fasting insulin and glucose levels.

RESULTS

Resistin levels were not significantly different between the two groups but were significantly higher in women compared with men, 35.4+/-6.5 (s.e.) vs 15.4+/-2.9 microg/L, P<0.01. Resistin did not correlate with BMI but did significantly correlate with HOMA-R, P<0.01, and this correlation remained significant after adjustment for gender and BMI. Adiponectin levels were significantly lower in obese compared with lean subjects, P<0.005, and higher in women, P<0.001, but showed no significant correlation with HOMA-R. Leptin levels were significantly higher in obese subjects and women and correlated with HOMA-R and resistin.

DISCUSSION

In this small group of patients we demonstrated that insulin resistance correlated most strongly with leptin levels. A significant correlation between resistin levels and insulin resistance was also observed. Although a similar trend was apparent for adiponectin, the correlation with insulin resistance did not achieve statistical significance.

Plasma ghrelin levels and malnutrition: a comparison of two etiologies

Ghrelin is a peptide hormone that is involved in regulating growth hormone secretion as well as food intake and energy homeostasis. The aim of this study was to compare changes in plasma ghrelin levels in patients with malnutrition due to anorexia nervosa (AN) or short bowel syndrome (SBS). Blood samples for laboratory analyses were taken from 16 AN patients (plus 13 comparable healthy controls) and 27 SBS patients (plus 13 comparable healthy controls) after an overnight fast. In comparison with their respective control groups, plasma ghrelin levels were increased in the AN patients (p < 0.05) and significantly decreased in the patients with SBS (p < 0.01). These results suggest that quantitative ghrelin secretion in the gut wall is important in determining ghrelin concentrations in the systemic circulation.

[Total body composition in adult patients with growth hormone deficiency before and after its administration]

Effect of growth hormone (GH) on the growth and development of children is generally known. Effects of GH in adults are favorable, though. The aim of the work was to verify effects of GH administration on body composition in adult patients with GH deficit (GHD). The authors examined 15 adult patients with GHD originated in 13 of them in adulthood and in two of them in childhood. Their mean age was 43.9 +/- 11.3 years, the mean body mass was 80.0 +/- 15.2 kg. The GH deficit was verified by the stimulation insulin tolerance test. For the period of 12 months, they were subcutaneously administered recombinant human GH in a substitution dose of 0.5 to 1.5 IU/m2 body surface/day. A stable substitution of the hormone was applied for the period of at least six months in all these patients provided any deficit of other hormones had not been demonstrated. The examination by whole-body dosimeter Lunar DPX-L was made in the patients before the GH treatment began and after 12 months of therapy. It enabled to determine the amount of lean body mass (LBM) and fatty mass. After 12 months of GH treatment the mean level of insulin-like growth factor (IGF-I) was increased (P = 0.002). A statistically significant increase of total LBM (48.6 +/- 9.8 vs. 50.8 +/- 9.9 kg, P = 0.004) developed, the fatty mass did not change. Nine of these 15 patients were further followed and the administration of GH proceeded for six months. The densitometric examination was repeated, but no change of LBM was observed. The administration of GH was halted and after the period of 12 months the whole-body densitometric examination was done. The increase of LBM lasted. The amount of fat mass did not change, a decrease of fatty mass was observed after the GH administration ended. After 12 months of GH treatment there was also an increase of maximal output reached on bicycle ergometer (157.3 +/- 34.2 vs. 197.5 +/- 68.1 W, P = 0.006). A positive correlation between LBM and maximal output reached on bicycle ergometer before GH administration (r = 0.58, P = 0.02) was observed. A favorable effect of the substitution dose of GS administered to adult patients with GHD on the increase of LBM and physical output was confirmed.

[Effect of hypercortisolism on development of atherosclerotic changes in blood vessels]

Hypercortisolism is associated with a high risk of sickness rate and death rate particularly in view of facilitated arteriosclerotic processes. It is most frequently induced by drug therapy, but endogenous hypercortisolism (Cushing's syndrome) may serve as a suitable model of the effect of hypercortisolism on vascular wall. Our cohort included the following groups of patients and control individuals: 1. a group of patients with florid so far untreated Cushing's syndrome--14 patients, 2. a control group to these patients--16 individuals, 3. a group recently operated on and healed-up patients with Cushing's syndrome--8 patients, 4. a group of previous of previous cured-up patients with Cushing's syndrome--27 subjects, 5. a control group to those patients of group 4--17 persons. The following differences were found between the respective groups: 1. the ultrasonographic examination of carotid arteries demonstrated sclerotic plates or carotid stenosis in 21.3% of patients with florid Cushing's syndrome and 41.4% in patients with corticolism having been cured-up against 11.7% in the relevant control group; 2. the examination of skin microcirculation by the laser-doppler method revealed a lower velocity of perfusion increase during examination of postocclusion hyperemia in patients with florid Cushing's syndrome and hypercortisolism having been cured-up against a control group (CUSH., P < 0.04; previous cured-up, P < 0.02) as well as thermally-induced hyperemia (CUSH., P < 0.03; formerly cured-up, P < 0.04); 3. the laboratory examination of patients with florid Cushing's syndrome revealed higher values of LDL-cholesterol (P < 0.05) and total cholesterol (P < 0.001), malonyldialdehyde as an indicator of increased formation of oxygen radicals (P < 0.05) and oromucoid, the protein of acute phase, signaling a chronic inflammation (P < 0.05); 4. in patients who previously suffered from hypercortisolism increased levels of fibrinogen (P < 0.03) and the cytoadhesive molecule ICAM-1 (P < 0.05) were accompanied by decreased levels of the growth factor of vascular endothelia (VEGF) (P < 0.05) against patients with florid Cushing's syndrome.

CONCLUSION

The findings of the examinations performed indicate that increased incidence of arteriosclerotic processes is present in patients with the florid Cushing's syndrome as well as in those who have suffered from Cushing's syndrome before.

[Changes in IGF-I levels and its binding proteins in diabetes mellitus and obesity]

BACKGROUND

The system of IGF-I and its binding proteins is a complex system with many physiological functions including metabolic regulations. Present study was aimed to describe changes of its particular components in patients with type 1 and type 2 diabetic patients and patients with obesity.

METHODS AND RESULTS

We examined 21 patients with obesity, 13 patients with type 2 and 22 with type 1 diabetes in comparison with 16 age matched healthy controls. We performed clinical examination and estimation of serum concentrations of IGF-I, free-IGF-I, IGFBP-1, -2, -3 and -6, insulin, C-peptide and fasting glucose. Patients with obesity featured by decreased IGF-I (p < 0.05), free-IGF-I (p < 0.05), IGFBP-1 (p < 0.01) and IGFBP-3 (p < 0.05) serum levels. Type 2 diabetes were associated with a decline of IGF-I (p < 0.05) and IGFBP-2 (p < 0.05) serum levels. Type 1 diabetes was characterised by typical decrease in IGF-I (p < 0.05), free-IGF-I (p < 0.01) and IGFBP-3 (p < 0.01) serum levels as well as by increase in IGFBP-1 (p < 0.01) serum levels. Type 2 diabetic patients had lover IGFBP-2 and higher IGFBP-1 and IGFBP-6 levels than obese subjects.

CONCLUSIONS

The study showed a changes in the system of IGF-1 and its binding proteins associated with studied metabolic diseases that confirm active participations of this system in carbohydrate metabolism regulation.

[Microvascular reactivity in type 2 diabetes mellitus and its relation to IGF-I and its binding proteins]

BACKGROUND AND AIM

System of insulin-like growth factor-I (IGF-I) and its binding proteins (IGFBP) may be involved in the pathogenesis of vascular damage in Type 2 diabetes. Aim of the study was to analyse the relationship between this system and microvascular reactivity in Type 2 diabetes as measured by laser-Doppler flowmetry.

METHODS AND RESULTS

Thirteen Type 2 diabetic patients (8 women and 5 men) with microangiopathy and fifteen healthy subjects (8 women and 7 men) were examined clinically, underwent laser-Doppler flowmetry and intima-media thickness measurements. Fasting serum levels of IGF-I, IGFBP and lipids were examined. Percentage perfusion increase in the test with postocclusive reactive hyperaemia (PORH) as well as in that with thermal hyperaemia (TH) were significantly decreased in Type 2 diabetic patients (p < 0.05). Maximal perfusion after heating (THmax) was lower in Type 2 diabetic patients. Reaction of microcirculation after heating (THmax/t) was slower in Type 2 diabetic patients (p < 0.001). The changes in microvascular reactivity didn't significantly correlate with any of measured parameters of IGF-I/IGFBP system.

CONCLUSIONS

Microvascular reactivity is impaired in Type 2 diabetic patients. The function of microcirculation is not significantly related to the particular parameters of the IGF-I/IGFBP system.

Perturbations in adiponectin, leptin and resistin levels in acromegaly: lack of correlation with insulin resistance

BACKGROUND

Insulin resistance, impaired glucose tolerance and type 2 diabetes are common in acromegalic subjects. The mechanism underlying this insulin resistance is unclear.

DESIGN

We investigated the levels of the adipocytokines, resistin, adiponectin and leptin in a group of 18 acromegalic subjects and 18 control subjects matched for age, gender and body mass index.

RESULTS

Here we demonstrate for the first time significant elevation in adiponectin levels in acromegalic subjects compared to control subjects 12.5 +/- 1.2 vs. 8.97 +/- 1.1 mg/l, P = 0.029. The resistin levels were similar in acromegalic subjects and controls; 20.65 +/- 2.99 vs. 19.03 +/- 4.72 micro g/l. No evidence of a correlation between adiponectin and insulin resistance as calculated from HOMA-R was found. No correlation was observed either between adiponectin or resistin levels and GH levels, total IGF-I or free IGF-I levels. Leptin levels were significantly reduced in acromegalic subjects, 8.22 +/- 2.26 vs. 18.3 +/- 4.1 micro g/l, P = 0.004. In control subjects, significant correlations between leptin levels and HOMA-R and between resistin levels and HOMA-R were observed. These relationships were not apparent in acromegalic subjects.

CONCLUSION

From these data we conclude that changes in resistin and adiponectin levels are unlikely to account for the insulin resistance of acromegaly.

Ghrelin -- a new endogenous growth hormone secretagogue

Ghrelin is a new endogenous peptide, discovered in 1999 by Kojima et al., as the result of a search for an endogenous ligand for an orphan receptor of known structure and function. Ghrelin is composed of 28 amino acids and is produced mostly by cells of the stomach, hypothalamus, and hypophysis, but it has also been detected in other tissues. Its discovery is related to the development of a new hypothesis regarding the regulation of growth hormone secretion. It is an antagonist of somatostatin. Ghrelin activates the release of growth hormone from the somatotrophic cells of the hypophysis. It participates in the regulation of energy homeostasis, increases food intake, decreases energy output and exerts a lipogenetic effect. Its metabolic effects do not depend on the GH/IGF-I system, but are mediated by the NPY/Y1 and AGRP receptor system. Ghrelin influences the secretion and motility of the gastrointestinal tract, especially the stomach. The presence of ghrelin and its receptors has also been demonstrated in many other tissues. Its function in these tissues has not yet been studied, thus providing many possibilities for further research.