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Athanasiou N, Diamantopoulos A, Keskinidou C, Katsaounou P, Angelousi A, Jahaj E, Mourelatos P, Vrettou CS, Botoula E, Vassiliou AG, Kotanidou A, Tsagarakis S, Dimopoulou I, Vassiliadi DA. Adrenal function in relation to cytokines and outcome in non-critically ill patients with COVID-19. J Endocrinol Invest 2024; 47:721-728. [PMID: 37702927 DOI: 10.1007/s40618-023-02189-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/18/2023] [Indexed: 09/14/2023]
Abstract
PURPOSE We aimed to identify whether hypothalamic-pituitary-adrenal (HPA) axis dysfunction is related to deterioration in a percentage of patients who progress to severe COVID-19. METHODS In this cohort observational study, we evaluated HPA axis activation by measuring cortisol, adrenocorticotropic hormone (ACTH), dehydroepiandrosterone sulfate (DHEA-S) levels, whole blood expression levels of the key glucocorticoid receptor, GCR-α, and the glucocorticoid-induced leucine zipper (GILZ), and cytokines, as markers of the inflammatory phase, in 149 patients with respiratory infection admitted in the ward, without known adrenal disease and/or confounding medications (glucocorticoids). One hundred and four (104) patients were SARS-CoV-2 positive (C +) and controls consisted of 45 SARS-CoV-2-negative patients (NC). RESULTS No differences in cortisol levels were observed between the C + and the NC patients. Cortisol levels correlated with ACTH (r = 0.284, p = 0.001) and IL-6 (r = 0.289, p = 0.04). In C + patients, cortisol levels mainly correlated with IL-6 levels (r = 0.28; p = 0.017). GCR-α expression was significantly higher in C + patients compared to NC. Patients with higher cortisol levels were more likely to progress to respiratory function deterioration or die. Both GCR-α and GILZ expression were significantly higher in C + non-survivors. CONCLUSION Our findings indicate that cortisol serves as an indicator of disease severity. GILZ expression appears to be a more effective marker of mortality prediction in moderate COVID-19 cases. However, routine measurement of GILZ levels is currently unavailable. Elevated levels of cortisol may be indicative of patients with moderate COVID-19 who are at a higher risk of deterioration. This information can aid in identifying individuals who require early medical attention.
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Affiliation(s)
- N Athanasiou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - A Diamantopoulos
- Department of Endocrinology Diabetes and Metabolism, National and European Expertise Center for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece
| | - C Keskinidou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - P Katsaounou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - A Angelousi
- First Department of Internal Medicine, Unit of Endocrinology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - E Jahaj
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - P Mourelatos
- Department of Endocrinology Diabetes and Metabolism, National and European Expertise Center for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece
| | - C S Vrettou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - E Botoula
- Department of Endocrinology Diabetes and Metabolism, National and European Expertise Center for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece
| | - A G Vassiliou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - A Kotanidou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - S Tsagarakis
- Department of Endocrinology Diabetes and Metabolism, National and European Expertise Center for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece
| | - I Dimopoulou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - D A Vassiliadi
- Department of Endocrinology Diabetes and Metabolism, National and European Expertise Center for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece.
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Pelsma ICM, Fassnacht M, Tsagarakis S, Terzolo M, Tabarin A, Sahdev A, Newell-Price J, Marina L, Lorenz K, Bancos I, Arlt W, Dekkers OM. Comorbidities in mild autonomous cortisol secretion and the effect of treatment: systematic review and meta-analysis. Eur J Endocrinol 2023; 189:S88-S101. [PMID: 37801655 DOI: 10.1093/ejendo/lvad134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/12/2023] [Accepted: 09/04/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVE To assess (1) comorbidities associated with and (2) treatment strategies for patients with adrenal incidentalomas and mild autonomous cortisol secretion (MACS; > 1.8 µg/dL (>50 nmol/L) cortisol level cut-off following the 1 mg dexamethasone suppression test). DESIGN Systematic review and meta-analysis. METHODS Seven databases were searched up to July 14, 2022. Eligible studies were (randomized) trials, cohort studies, and cross-sectional studies assessing comorbidities potentially attributable to cortisol excess or mortality in patients with adrenal incidentaloma with or without MACS or the effects of conservative or surgical management of MACS. Random-effects meta-analysis was performed to estimate pooled proportions (with 95% CIs). RESULTS In 30 cross-sectional and 16 cohort studies (n = 17 156 patients in total), patients with MACS had a higher prevalence of diabetes (relative risk [RR] 1.44 [1.23-1.69]), hypertension (RR = 1.24 [1.16-1.32]), and dyslipidemia (RR = 1.23 [1.13-1.34]). All-cause mortality (adjusted for confounders) in patients with MACS, assessed in 4 studies (n = 5921), was increased (hazard ratio [HR] = 1.54 [1.27-1.81]). Nine observational studies (n = 856) and 2 randomized trials (n = 107) suggest an improvement in glucometabolic control (RR = 7.99 [2.95-21.90]), hypertension (RR = 8.75 [3.99-19.18]), and dyslipidemia (RR = 3.24 [1.19-8.82]) following adrenalectomy. CONCLUSIONS The present systematic review and meta-analysis highlight the relevance of MACS, since both cardiometabolic morbidities and mortality appeared to have increased in patients with MACS compared to patients with non-functioning incidentalomas. However, due to heterogeneous definitions, various outcomes, selective reporting, and missing data, the reported pooled estimates need to be interpreted with caution. The small number of patients in randomized trials prevents any strong conclusion on the causality between MACS and these comorbidities.
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Affiliation(s)
- Iris C M Pelsma
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Oberdürrbacherstrasse 6, Würzburg 97080, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Josef-Schneider-Straße 2, Würzburg 97080, Germany
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Ipsilantou 45-47, Athens 106 76, Greece
| | - Massimo Terzolo
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Hospital University of Turin, Regione Gonzole, Orbassano-Torrino 10 10043, Italy
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University and CHU of Bordeaux, Pl. Amélie Raba Léon, Bordeaux 33000, France
| | - Anju Sahdev
- Department of Imaging, St Bartholomew's Hospital, Barts Health, London EC1A 7BE, United Kingdom
| | - John Newell-Price
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield S10 2RX, United Kingdom
- Endocrine Services, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, United Kingdom
| | - Ljiljana Marina
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Dr Subotića 8, Belgrade 11000, Serbia
| | - Kerstin Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale) 06108, Germany
| | - Irina Bancos
- Division of Endocrinology, Metabolism, Nutrition and Diabetes, Mayo Clinic, Rochester, MN 55905, United States
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, United Kingdom
| | - Olaf M Dekkers
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2333 ZA, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Olof Palmes Allé 43-45, Aarhus N 8200, Denmark
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Papalou O, Tavernaraki E, Tsagarakis S, Vassiliadi DA. Post-Thyroidectomy Development of Posterior Reversible Encephalopathy Syndrome (PRES) Due to Calcium Over-Replacement. JCEM Case Rep 2023; 1:luad116. [PMID: 37908204 PMCID: PMC10580489 DOI: 10.1210/jcemcr/luad116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Indexed: 11/02/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) represents a distinct neurological entity characterized by a range of neurological signs and symptoms (seizures, headache, visual abnormalities, altered consciousness, and/or focal neurological signs) and typical neuroimaging findings reflecting reversible subcortical vasogenic edema, usually in the setting of blood pressure fluctuations, cytotoxic drugs, autoimmune disorders, and eclampsia. Here we present a case of a 61-year-old woman, with a history of recent total thyroidectomy and postoperative hypoparathyroidism, who was admitted to the Emergency Department with generalized seizures. Although in this clinical setting, hypocalcemia is expected as the most possible underlying pathogenic factor for triggering seizures, the patient was diagnosed with iatrogenic hypercalcemia and milk-alkali syndrome. A brain magnetic resonance imaging (MRI) demonstrated cortical swelling and fluid-attenuated inversion recovery (FLAIR) signal abnormalities in both occipital, parietal, and right frontal lobes, consistent with PRES. The patient's encephalopathy resolved after resolution of hypercalcemia; she had no neurological deficits on discharge, while she was restarted on lower doses of calcium for hypoparathyroidism. This case illustrates the challenges imposed by postoperative hypoparathyroidism and highlights that PRES is a rare but serious complication of hypercalcemia of which endocrinologists should be aware.
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Affiliation(s)
- Olga Papalou
- Department of Endocrinology Diabetes and Metabolism, National Expertise Center for Rare Endocrine Disorders, Evangelismos Hospital, Athens 10676, Greece
| | | | - Stylianos Tsagarakis
- Department of Endocrinology Diabetes and Metabolism, National Expertise Center for Rare Endocrine Disorders, Evangelismos Hospital, Athens 10676, Greece
| | - Dimitra Argyro Vassiliadi
- Department of Endocrinology Diabetes and Metabolism, National Expertise Center for Rare Endocrine Disorders, Evangelismos Hospital, Athens 10676, Greece
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Upton TJ, Zavala E, Methlie P, Kämpe O, Tsagarakis S, Øksnes M, Bensing S, Vassiliadi DA, Grytaas MA, Botusan IR, Ueland G, Berinder K, Simunkova K, Balomenaki M, Margaritopoulos D, Henne N, Crossley R, Russell G, Husebye ES, Lightman SL. High-resolution daily profiles of tissue adrenal steroids by portable automated collection. Sci Transl Med 2023; 15:eadg8464. [PMID: 37343084 DOI: 10.1126/scitranslmed.adg8464] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/26/2023] [Indexed: 06/23/2023]
Abstract
Rhythms are intrinsic to endocrine systems, and disruption of these hormone oscillations occurs at very early stages of the disease. Because adrenal hormones are secreted with both circadian and ultradian periods, conventional single-time point measurements provide limited information about rhythmicity and, crucially, do not provide information during sleep, when many hormones fluctuate from nadir to peak concentrations. If blood sampling is attempted overnight, then this necessitates admission to a clinical research unit, can be stressful, and disturbs sleep. To overcome this problem and to measure free hormones within their target tissues, we used microdialysis, an ambulatory fraction collector, and liquid chromatography-tandem mass spectrometry to obtain high-resolution profiles of tissue adrenal steroids over 24 hours in 214 healthy volunteers. For validation, we compared tissue against plasma measurements in a further seven healthy volunteers. Sample collection from subcutaneous tissue was safe, well tolerated, and allowed most normal activities to continue. In addition to cortisol, we identified daily and ultradian variation in free cortisone, corticosterone, 18-hydroxycortisol, aldosterone, tetrahydrocortisol and allo-tetrahydrocortisol, and the presence of dehydroepiandrosterone sulfate. We used mathematical and computational methods to quantify the interindividual variability of hormones at different times of the day and develop "dynamic markers" of normality in healthy individuals stratified by sex, age, and body mass index. Our results provide insight into the dynamics of adrenal steroids in tissue in real-world settings and may serve as a normative reference for biomarkers of endocrine disorders (ULTRADIAN, NCT02934399).
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Affiliation(s)
- Thomas J Upton
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, Translational Health Sciences, Faculty of Health Sciences, University of Bristol, Bristol BS1 3NY, UK
| | - Eder Zavala
- Centre for Systems Modelling and Quantitative Biomedicine, University of Birmingham, Edgbaston B15 2TT, UK
| | - Paal Methlie
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen N-5021, Norway
- Department of Medicine, Haukeland University Hospital, Bergen N-5021, Norway
| | - Olle Kämpe
- Department of Endocrinology, Karolinska University Hospital, 171 76 Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, 171 77 Stockholm, Sweden
| | | | - Marianne Øksnes
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen N-5021, Norway
- Department of Medicine, Haukeland University Hospital, Bergen N-5021, Norway
| | - Sophie Bensing
- Department of Endocrinology, Karolinska University Hospital, 171 76 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden
| | | | - Marianne A Grytaas
- Department of Medicine, Haukeland University Hospital, Bergen N-5021, Norway
| | - Ileana R Botusan
- Department of Endocrinology, Karolinska University Hospital, 171 76 Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Grethe Ueland
- Department of Medicine, Haukeland University Hospital, Bergen N-5021, Norway
| | - Katarina Berinder
- Department of Endocrinology, Karolinska University Hospital, 171 76 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Katerina Simunkova
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen N-5021, Norway
| | - Maria Balomenaki
- Department of Endocrinology, Evangelismos Hospital, Athens 106 76, Greece
| | | | - Nina Henne
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen N-5021, Norway
| | | | - Georgina Russell
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, Translational Health Sciences, Faculty of Health Sciences, University of Bristol, Bristol BS1 3NY, UK
| | - Eystein S Husebye
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen N-5021, Norway
- Department of Medicine, Haukeland University Hospital, Bergen N-5021, Norway
| | - Stafford L Lightman
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, Translational Health Sciences, Faculty of Health Sciences, University of Bristol, Bristol BS1 3NY, UK
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Fassnacht M, Tsagarakis S, Terzolo M, Tabarin A, Sahdev A, Newell-Price J, Pelsma I, Marina L, Lorenz K, Bancos I, Arlt W, Dekkers OM. European Society of Endocrinology Clinical Practice Guidelines on the management of adrenal incidentalomas, in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2023:lvad066. [PMID: 37318239 DOI: 10.1093/ejendo/lvad066] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023]
Abstract
Adrenal incidentalomas are adrenal masses detected on imaging performed for reasons other than suspected adrenal disease. In most cases, adrenal incidentalomas are non-functioning adrenocortical adenomas, but may also require therapeutic intervention including that for adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastases. Here, we provide a revision of the first international, interdisciplinary guidelines on incidentalomas. We followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system and updated systematic reviews on four predefined clinical questions crucial for the management of incidentalomas: A) How to assess risk of malignancy? ; B) How to define and manage mild autonomous cortisol secretion? ; C) Who should have surgical treatment and how should it be performed? ; D) What follow-up is indicated if the adrenal incidentaloma is not surgically removed? Selected Recommendations: 1) Each adrenal mass requires dedicated adrenal imaging. Recent advances now allow discrimination between risk categories: Homogeneous lesions with HU ≤ 10 on unenhanced CT are benign and do not require any additional imaging independent of size. All other patients should be discussed in a multidisciplinary expert meeting, but only lesions >4 cm that are inhomogeneous or have HU >20 have sufficiently high risk of malignancy that surgery will be the usual management of choice. 2) Every patient needs a thorough clinical and endocrine work-up to exclude hormone excess including the measurement of plasma or urinary metanephrines and a 1-mg overnight dexamethasone suppression test (applying a cutoff value of serum cortisol ≤50 nmol/l (≤1.8 µg/dl)). Recent studies have provided evidence that most patients without clinical signs of overt Cushing's syndrome but serum cortisol levels post dexamethasone >50 nmol/l (>1.8 µg/dl) harbor increased risk of morbidity and mortality. For this condition, we propose the term 'mild autonomous cortisol secretion' (MACS). 3) All patients with MACS should be screened for potential cortisol-related comorbidities that are potentially attributably to cortisol (e.g. hypertension and type 2 diabetes mellitus), to ensure these are appropriately treated. 4) In patients with MACS who also have relevant comorbidities surgical treatment should be considered in an individualized approach. 5) The appropriateness of surgical intervention should be guided by the likelihood of malignancy, the presence and degree of hormone excess, age, general health and patient preference. We provide guidance on which surgical approach should be considered for adrenal masses with radiological findings suspicious of malignancy. 6) Surgery is not usually indicated in patients with an asymptomatic, non-functioning unilateral adrenal mass and obvious benign features on imaging studies. Furthermore, we offer recommendations for the follow-up of non-operated patients, management of patients with bilateral incidentalomas, for patients with extra-adrenal malignancy and adrenal masses, and for young and elderly patients with adrenal incidentalomas. Finally, we suggest ten important research questions for the future.
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Affiliation(s)
- Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Massimo Terzolo
- Internal Medicine 1, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Antoine Tabarin
- Department of Endocrinology, diabetes and nutrition, University and CHU of Bordeaux, France
| | - Anju Sahdev
- Department of Imaging, St Bartholomew's Hospital, Barts Health, London, EC1A 7BE, UK
| | - John Newell-Price
- Department of Oncology and Metabolism, Medical School, University of Sheffield, S10 2RX, UK
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, S10 2JF, UK
| | - Iris Pelsma
- Departments of Clinical Epidemiology and Internal Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ljiljana Marina
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Serbia
| | - Kerstin Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Irina Bancos
- Division of Endocrinology, Metabolism, Nutrition and Diabetes, Mayo Clinic, Rochester, MN, USA
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Olaf M Dekkers
- Departments of Clinical Epidemiology and Internal Medicine, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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Vassiliou AG, Vassiliadi DA, Keskinidou C, Jahaj E, Botoula E, Tsagarakis S, Kotanidou A, Dimopoulou I. Down-Regulation of the Mineralocorticoid Receptor (MR) and Up-Regulation of Hydroxysteroid 11-Beta Dehydrogenase Type 2 (HSD11B2) Isoenzyme in Critically Ill Patients. Clin Med Res 2023; 21:6-13. [PMID: 37130784 PMCID: PMC10153682 DOI: 10.3121/cmr.2023.1743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 05/04/2023]
Abstract
Objective: The mineralocorticoid receptor (MR) has two ligands, aldosterone and cortisol. Hydroxysteroid 11-beta dehydrogenase (HSD11B) isoenzymes regulate which ligand will bind to MR. In this study we aimed to evaluate the expression of the MR and the HSD11B isozymes in peripheral polymorphonuclear cells (PMNs) in critical illness for a 13-day period.Design: Prospective studySetting: One multi-disciplinary intensive care unit (ICU)Participants: Forty-two critically ill patientsMethods: Messenger RNA (mRNA) expression of MR, HSD11B1, and HSD11B2, aldosterone levels, and plasma renin activity (PRA) were measured in 42 patients on ICU admission and on days 4, 8, and 13. Twenty-five age and sex-matched healthy subjects were used as controls.Results: Compared to healthy controls, MR expression in critically ill patients was lower during the entire study period. HSD11B1 expression was also lower, while HSD11B2 expression was higher. In patients, PRA, aldosterone, the aldosterone:renin ratio, and cortisol remained unaltered during the study period.Conclusion: Our results suggest that, in our cohort of critically ill patients, local endogenous cortisol availability is diminished, pointing towards glucocorticoid resistance. Aldosterone probably occupies the MR, raising the possibility that PMNs might be useful to study to gain insights into MR functionality during pathological states.
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Affiliation(s)
- Alice G Vassiliou
- 1 Department of Critical Care Medicine & Pulmonary Services, National & Kapodistrian University of Athens, "Evangelismos" Hospital, Athens, Greece
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, National Expertise Centre for Rare Endocrine Diseases, "Evangelismos" Hospital, Athens, Greece
| | - Chrysi Keskinidou
- 1 Department of Critical Care Medicine & Pulmonary Services, National & Kapodistrian University of Athens, "Evangelismos" Hospital, Athens, Greece
| | - Edison Jahaj
- 1 Department of Critical Care Medicine & Pulmonary Services, National & Kapodistrian University of Athens, "Evangelismos" Hospital, Athens, Greece
| | - Efi Botoula
- Department of Endocrinology, Diabetes and Metabolism, National Expertise Centre for Rare Endocrine Diseases, "Evangelismos" Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, National Expertise Centre for Rare Endocrine Diseases, "Evangelismos" Hospital, Athens, Greece
| | - Anastasia Kotanidou
- 1 Department of Critical Care Medicine & Pulmonary Services, National & Kapodistrian University of Athens, "Evangelismos" Hospital, Athens, Greece
| | - Ioanna Dimopoulou
- 1 Department of Critical Care Medicine & Pulmonary Services, National & Kapodistrian University of Athens, "Evangelismos" Hospital, Athens, Greece
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Amodru V, Ferriere A, Tabarin A, Castinetti F, Tsagarakis S, Toth M, Feelders RA, Webb SM, Reincke M, Netea-Maier R, Kastelan D, Elenkova A, Maiter D, Ragnarsson O, Santos A, Valassi E. Cushing's Syndrome in the Elderly: Data from the European Registry on Cushing's Syndrome. Eur J Endocrinol 2023; 188:395-406. [PMID: 36749009 DOI: 10.1093/ejendo/lvad008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/18/2022] [Accepted: 01/03/2023] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate whether age-related differences exist in clinical characteristics, diagnostic approach and management strategies in patients with Cushing's syndrome included in the European Registry on Cushing's Syndrome (ERCUSYN). DESIGN Cohort study. METHODS We analyzed 1791 patients with CS, of whom 1234 (69%) had pituitary-dependent CS (PIT-CS), 450 (25%) adrenal-dependent CS (ADR-CS) and 107 (6%) had an ectopic source (ECT-CS). According to the WHO criteria, 1616 patients (90.2%) were classified as younger (<65 years) and 175 (9.8%) as older (>65 years). RESULTS Older patients were more frequently males and had a lower BMI and waist circumference as compared with the younger. Older patients also had a lower prevalence of skin alterations, depression, hair loss, hirsutism and reduced libido, but a higher prevalence of muscle weakness, diabetes, hypertension, cardiovascular disease, venous thromboembolism and bone fractures than younger patients, regardless of sex (p<0.01 for all comparisons). Measurement of UFC supported the diagnosis of CS less frequently in older patients as compared with the younger (p<0.05). An extra-sellar macroadenoma (macrocorticotropinoma with extrasellar extension) was more common in older PIT-CS patients than in the younger (p<0.01). Older PIT-CS patients more frequently received cortisol-lowering medications and radiotherapy as a first-line treatment, whereas surgery was the preferred approach in the younger (p<0.01 for all comparisons). When transsphenoidal surgery was performed, the remission rate was lower in the elderly as compared with their younger counterpart (p<0.05). CONCLUSIONS Older CS patients lack several typical symptoms of hypercortisolism, present with more comorbidities regardless of sex, and are more often conservatively treated.
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Affiliation(s)
- Vincent Amodru
- IIB-Sant Pau and Department of Endocrinology, Hospital Sant Pau, Dept Medicine, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale INSERM U1251, Marseille Medical Genetics, Marseille, France and Assistance Publique Hôpitaux de Marseille (APHM), Hôpital de la Conception, Marseille, France
| | - Amandine Ferriere
- Department of Endocrinology, Diabetes and Nutrition, University of Bordeaux, Bordeaux, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University of Bordeaux, Bordeaux, France
| | - Frederic Castinetti
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale INSERM U1251, Marseille Medical Genetics, Marseille, France and Assistance Publique Hôpitaux de Marseille (APHM), Hôpital de la Conception, Marseille, France
| | | | - Miklos Toth
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | | | - Susan M Webb
- IIB-Sant Pau and Department of Endocrinology, Hospital Sant Pau, Dept Medicine, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Romana Netea-Maier
- Department of Internal Medicine, division of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Zagreb, Zagreb, Croatia
| | - Atanaska Elenkova
- Department of endocrinology, Medical University of Sofia, Sofia, Bulgaria
| | | | - Oskar Ragnarsson
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alicia Santos
- IIB-Sant Pau and Department of Endocrinology, Hospital Sant Pau, Dept Medicine, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - Elena Valassi
- Endocrinology and Nutrition Department, Germans Trias i Pujol Hospital and Research Institute, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER)
- Universitat Internacional de Catalunia (UIC), Barcelona, Spain
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8
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Pivonello R, Zacharieva S, Elenkova A, Tóth M, Shimon I, Stigliano A, Badiu C, Brue T, Georgescu CE, Tsagarakis S, Cohen F, Fleseriu M. Levoketoconazole in the treatment of patients with endogenous Cushing's syndrome: a double-blind, placebo-controlled, randomized withdrawal study (LOGICS). Pituitary 2022; 25:911-926. [PMID: 36085339 PMCID: PMC9675660 DOI: 10.1007/s11102-022-01263-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE The efficacy of levoketoconazole for endogenous Cushing's syndrome was demonstrated in a phase 3, open-label study (SONICS). This study (LOGICS) evaluated drug-specificity of cortisol normalization. METHODS LOGICS was a phase 3, placebo-controlled, randomized-withdrawal study with open-label titration-maintenance (14-19 weeks) followed by double-blind, randomized-withdrawal (~ 8 weeks), and restoration (~ 8 weeks) phases. RESULTS 79 patients received levoketoconazole during titration-maintenance; 39 patients on a stable dose (~ 4 weeks or more) proceeded to randomization. These and 5 SONICS completers who did not require dose titration were randomized to levoketoconazole (n = 22) or placebo (n = 22). All patients with loss of response (the primary endpoint) met the prespecified criterion of mean urinary free cortisol (mUFC) > 1.5 × upper limit of normal. During randomized-withdrawal, 21 patients withdrawn to placebo (95.5%) lost mUFC response compared with 9 patients continuing levoketoconazole (40.9%); treatment difference: - 54.5% (95% CI - 75.7, - 27.4; P = 0.0002). At the end of randomized-withdrawal, mUFC normalization was observed among 11 (50.0%) patients receiving levoketoconazole and 1 (4.5%) receiving placebo; treatment difference: 45.5% (95% CI 19.2, 67.9; P = 0.0015). Restoration of levoketoconazole reversed loss of cortisol control in most patients who had received placebo. Adverse events were reported in 89% of patients during treatment with levoketoconazole (dose-titration, randomized-withdrawal, and restoration phases combined), most commonly nausea (29%) and hypokalemia (26%). Prespecified adverse events of special interest with levoketoconazole were liver-related (10.7%), QT interval prolongation (10.7%), and adrenal insufficiency (9.5%). CONCLUSIONS Levoketoconazole reversibly normalized urinary cortisol in patients with Cushing's syndrome. No new risks of levoketoconazole treatment were identified.
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Affiliation(s)
| | | | | | | | - Ilan Shimon
- Rabin Medical Center and Tel Aviv University, Tel Aviv, Israel
| | | | - Corin Badiu
- National Institute of Endocrinology CI Parhon and "C. Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Thierry Brue
- Aix-Marseille Université and Assistance Publique - Hôpitaux de Marseille, Hôpital de la Conception, Marseille, France
| | - Carmen Emanuela Georgescu
- Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Endocrinology Clinical Unit, Cluj County Emergency Hospital, Cluj-Napoca, Romania
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9
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Valassi E, Castinetti F, Ferriere A, Tsagarakis S, Feelders RA, Netea-Maier RT, Droste M, Strasburger CJ, Maiter D, Kastelan D, Chanson P, Webb SM, Demtröder F, Pirags V, Chabre O, Franz H, Santos A, Reincke M. Corticotroph tumor progression after bilateral adrenalectomy: data from ERCUSYN. Endocr Relat Cancer 2022; 29:681-691. [PMID: 36197784 DOI: 10.1530/erc-22-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022]
Abstract
Corticotroph tumor progression after bilateral adrenalectomy/Nelson's syndrome (CTP-BADX/NS) is a severe complication of bilateral adrenalectomy (BADX). The aim of our study was to investigate the prevalence, presentation and outcome of CTP-BADX/NS in patients with Cushing's disease (CD) included in the European Registry on Cushing's Syndrome (ERCUSYN). We examined data on 1045 CD patients and identified 85 (8%) who underwent BADX. Of these, 73 (86%) had follow-up data available. The median duration of follow-up since BADX to the last visit/death was 7 years (IQR 2-9 years). Thirty-three patients (45%) experienced CTP-BADX/NS after 3 years (1.5-6) since BADX. Cumulative progression-free survival was 73% at 3 years, 66% at 5 years and 46% at 10 years. CTP-BADX/NS patients more frequently had a visible tumor at diagnosis of CD than patients without CTP-BADX/NS (P < 0.05). Twenty-seven CTP-BADX/NS patients underwent surgery, 48% radiotherapy and 27% received medical therapy. The median time since diagnosis of CTP-BADX/NS to the last follow-up visit was 2 years (IQR, 1-5). Control of tumor progression was not achieved in 16 of 33 (48%) patients, of whom 8 (50%) died after a mean of 4 years. Maximum adenoma size at diagnosis of CD was associated with further tumor growth in CTP-BADX/NS despite treatment (P = 0.033). Diagnosis of CTP-BADX/NS, older age, greater UFC levels at diagnosis of CD and initial treatment predicted mortality. In conclusion, CTP-BADX/NS was reported in 45% of the ERCUSYN patients who underwent BADX, and control of tumor growth was reached in half of them. Future studies are needed to establish effective strategies for prevention and treatment.
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Affiliation(s)
- Elena Valassi
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
- Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Frédéric Castinetti
- Department of Endocrinology, Aix Marseille University, AP-HM, INSERM, Marseille Medical Genetics, Marmara Institute, La Conception Hospital, Marseille, France
| | - Amandine Ferriere
- Department of Endocrinology, Diabetes and Nutrition, University of Bordeaux, Bordeaux, France
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Richard A Feelders
- Erasmus Medical Center, Division of Endocrinology, Department of Internal Medicine, Rotterdam, The Netherlands
| | - Romana T Netea-Maier
- Division of Endocrinology, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michael Droste
- Praxis für Endokrinologie Dr. med. Michael Droste, Oldenburg, Germany
| | - Christian J Strasburger
- Division of Clinical Endocrinology, Department of Medicine CCM, Charité-Universitätsmedizin, Berlin, Germany
| | - Dominique Maiter
- Service d'Endocrinologie et Nutrition, Cliniques universitaires Saint Luc, Brussels, Belgium
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Zagreb, Zagreb, Croatia
| | - Philippe Chanson
- Institut National de la Santé et de la Recherche Médicale, U1185, Le Kremlin, Bicêtre, Paris, France
| | - Susan M Webb
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Frank Demtröder
- Zentrum für Endokrinologie, Diabetologie, Rheumatologie Dr. Demtröder & Kollegen, Dortmund, Germany
| | - Valdis Pirags
- Paula Stradiņa klīniskā universitātes slimnīca, Riga, Latvia
| | | | - Holger Franz
- Lohmann & Birkner Health Care Consultimg GmbH, Berlin, Germany
| | - Alicia Santos
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Martin Reincke
- Medizinische Klinik UND Poliklinik IV, Campus Innestadt, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
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10
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Balomenaki M, Vassiliadi DA, Tsagarakis S. Cushing's disease: risk of recurrence following trans-sphenoidal surgery, timing and methods for evaluation. Pituitary 2022; 25:718-721. [PMID: 35579775 DOI: 10.1007/s11102-022-01226-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/25/2022]
Abstract
The treatment of choice for Cushing's disease (CD) is trans-sphenoidal surgery (TSS). However, TSS is not always curative and, even when curative it is associated with a substantial rate of recurrence. Published recurrence rates vary between 5 and 20%; half of these recurrences appear within 5-years and the remaining half within or even after 10 years post-surgery. A low or undetectable cortisol in the immediate post-op period is regarded as the best criterion of remission. However, low post-op cortisol levels do not accurately predict long-term remission. Moreover, there are no other robust predictors providing certainty about the long-term outcomes. Interestingly, several studies have shown that the desmopressin test performed in the early post-op period may have some promise in predicting more precisely the risk of recurrence. In view of the lack of robust ways to predict long-term outcomes, current guidelines suggest that every patient in remission should be monitored for the possibility of recurrence. The methods used to detect recurrence are similar to those used to assess the cortisol secretory status and include assessment of: (i) abnormal circadian rhythm by late night salivary cortisol (LNSC) or midnight serum cortisol; (ii) impaired cortisol feedback by the dexamethasone suppression test and; (iii) increased 24-h bioavailable cortisol by urinary free cortisol. The timing of evaluation begins when HPA axis recovers, and then annually or sooner in case of clinical suspicion. Currently LNSC is regarded as the earliest and most sensitive biochemical alteration in detecting recurrence; a major caveat for LNSC, however, is its great variability. In practice, the diagnosis of recurrence is a challenge due to the fact that recurrence is usually a slow process with apparent clinical manifestations that may be delayed and alterations of classical biomarkers that may be delayed as well.
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Affiliation(s)
- Maria Balomenaki
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 45-47 Ipsilantou St., 106 76, Athens, Greece
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 45-47 Ipsilantou St., 106 76, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 45-47 Ipsilantou St., 106 76, Athens, Greece.
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12
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Balomenaki M, Margaritopoulos D, Vassiliadi DA, Tsagarakis S. Diagnostic workup of Cushing's syndrome. J Neuroendocrinol 2022; 34:e13111. [PMID: 35979805 DOI: 10.1111/jne.13111] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 11/29/2022]
Abstract
Cushing's syndrome (CS) is a rare but detrimental endocrine disorder. Early diagnosis and prompt treatment are essential since the duration of hypercortisolism has an adverse impact on the extent of comorbidities and overall survival. The diagnostic approach involves a stepwise process that includes (1) screening and confirming the diagnosis and (2) establishing the aetiology of CS. The tests currently used to confirm the diagnosis of CS include urinary free cortisol measurements, the dexamethasone suppression test and late- night salivary cortisol or midnight serum cortisol measurements. None of these tests are ideal; all have pitfalls and require careful interpretation. Following confirmation of CS, measurement of ACTH discriminates between ACTH-dependent and non-ACTH dependent causes of CS. Adrenal imaging provides clues for the aetiology of non-ACTH dependent forms. Differentiation between the ACTH-dependent forms that involve pituitary corticotroph adenomas and ectopic ACTH sources is more complex and include pituitary MRI imaging, the high dose dexamethasone suppression test, the CRH test, bilateral inferior petrosal sinus sampling and, when required imaging modalities to detect ectopic ACTH secreting lesions. This review, which is part of a special issue on "Update of Cushing's syndrome: 100 years after Minnie G" will provide an update on our current diagnostic workup for the confirmation and differential diagnosis of CS.
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Affiliation(s)
- Maria Balomenaki
- Department of Endocrinology and Diabetes, Evangelismos Hospital, Athens, Greece
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13
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Deutschbein T, Reimondo G, Di Dalmazi G, Bancos I, Patrova J, Vassiliadi DA, Nekić AB, Debono M, Lardo P, Ceccato F, Petramala L, Prete A, Chiodini I, Ivović M, Pazaitou-Panayiotou K, Alexandraki KI, Hanzu FA, Loli P, Yener S, Langton K, Spyroglou A, Kocjan T, Zacharieva S, Valdés N, Ambroziak U, Suzuki M, Detomas M, Puglisi S, Tucci L, Delivanis DA, Margaritopoulos D, Dusek T, Maggio R, Scaroni C, Concistrè A, Ronchi CL, Altieri B, Mosconi C, Diamantopoulos A, Iñiguez-Ariza NM, Vicennati V, Pia A, Kroiss M, Kaltsas G, Chrisoulidou A, Marina LV, Morelli V, Arlt W, Letizia C, Boscaro M, Stigliano A, Kastelan D, Tsagarakis S, Athimulam S, Pagotto U, Maeder U, Falhammar H, Newell-Price J, Terzolo M, Fassnacht M. Age-dependent and sex-dependent disparity in mortality in patients with adrenal incidentalomas and autonomous cortisol secretion: an international, retrospective, cohort study. Lancet Diabetes Endocrinol 2022; 10:499-508. [PMID: 35533704 PMCID: PMC9679334 DOI: 10.1016/s2213-8587(22)00100-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The association between cortisol secretion and mortality in patients with adrenal incidentalomas is controversial. We aimed to assess all-cause mortality, prevalence of comorbidities, and occurrence of cardiovascular events in uniformly stratified patients with adrenal incidentalomas and cortisol autonomy (defined as non-suppressible serum cortisol on dexamethasone suppression testing). METHODS We conducted an international, retrospective, cohort study (NAPACA Outcome) at 30 centres in 16 countries. Eligible patients were aged 18 years or older with an adrenal incidentaloma (diameter ≥1 cm) detected between Jan 1, 1996, and Dec 31, 2015, and availability of a 1 mg dexamethasone suppression test result from the time of the initial diagnosis. Patients with clinically apparent hormone excess, active malignancy, or follow-up of less than 36 months were excluded. Patients were stratified according to the 0800-0900 h serum cortisol values after an overnight 1 mg dexamethasone suppression test; less than 50 nmol/L was classed as non-functioning adenoma, 50-138 nmol/L as possible autonomous cortisol secretion, and greater than 138 nmol/L as autonomous cortisol secretion. The primary endpoint was all-cause mortality. Secondary endpoints were the prevalence of cardiometabolic comorbidities, cardiovascular events, and cause-specific mortality. The primary and secondary endpoints were assessed in all study participants. FINDINGS Of 4374 potentially eligible patients, 3656 (2089 [57·1%] with non-functioning adenoma, 1320 [36·1%] with possible autonomous cortisol secretion, and 247 [6·8%] with autonomous cortisol secretion) were included in the study cohort for mortality analysis (2350 [64·3%] women and 1306 [35·7%] men; median age 61 years [IQR 53-68]; median follow-up 7·0 years [IQR 4·7-10·2]). During follow-up, 352 (9·6%) patients died. All-cause mortality (adjusted for age, sex, comorbidities, and previous cardiovascular events) was significantly increased in patients with possible autonomous cortisol secretion (HR 1·52, 95% CI 1·19-1·94) and autonomous cortisol secretion (1·77, 1·20-2·62) compared with patients with non-functioning adenoma. In women younger than 65 years, autonomous cortisol secretion was associated with higher all-cause mortality than non-functioning adenoma (HR 4·39, 95% CI 1·93-9·96), although this was not observed in men. Cardiometabolic comorbidities were significantly less frequent with non-functioning adenoma than with possible autonomous cortisol secretion and autonomous cortisol secretion (hypertension occurred in 1186 [58·6%] of 2024 patients with non-functioning adenoma, 944 [74·0%] of 1275 with possible autonomous cortisol secretion, and 179 [75·2%] of 238 with autonomous cortisol secretion; dyslipidaemia occurred in 724 [36·2%] of 1999 patients, 547 [43·8%] of 1250, and 123 [51·9%] of 237; and any diabetes occurred in 365 [18·2%] of 2002, 288 [23·0%] of 1250, and 62 [26·7%] of 232; all p values <0·001). INTERPRETATION Cortisol autonomy is associated with increased all-cause mortality, particularly in women younger than 65 years. However, until results from randomised interventional trials are available, a conservative therapeutic approach seems to be justified in most patients with adrenal incidentaloma. FUNDING Deutsche Forschungsgemeinschaft, Associazione Italiana per la Ricerca sul Cancro, Università di Torino.
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Affiliation(s)
- Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany; Medicover Oldenburg MVZ, Oldenburg, Germany
| | - Giuseppe Reimondo
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Turin, Turin, Italy
| | - Guido Di Dalmazi
- Endocrinology and Prevention and Care of Diabetes Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater University of Bologna, Bologna, Italy
| | - Irina Bancos
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Jekaterina Patrova
- Department of Clinical Science and Education, Södersjukhuset AB, Karolinska Institutet, Stockholm, Sweden
| | - Dimitra Argyro Vassiliadi
- Department of Endocrinology, Diabetes, and Metabolism, National Expertise Centre for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece
| | - Anja Barač Nekić
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Miguel Debono
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Pina Lardo
- Endocrinology, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Luigi Petramala
- Second Hypertension Unit, Department of Translational and Precision Medicine, University Sapienza, Rome, Italy
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes, and Metabolism, Birmingham Health Partners, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Iacopo Chiodini
- Istituto Auxologico Italiano, IRCCS, University of Milan, Milan, Italy
| | - Miomira Ivović
- Clinic for Endocrinology, Diabetes, and Metabolic Diseases, University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Krystallenia I Alexandraki
- 1st Department of Propaedeutic and Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Paola Loli
- Department of Endocrinology, Ospedale Niguarda Cà Granda, Milan, Italy
| | - Serkan Yener
- Department of Endocrinology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Katharina Langton
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Dresden, Dresden, Germany
| | - Ariadni Spyroglou
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitäts-Spital Zürich, Zürich, Switzerland; University Hospital Munich, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Tomaz Kocjan
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; Department of Endocrinology, Diabetes, and Metabolic Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Sabina Zacharieva
- Department of Endocrinology, University Hospital of Endocrinology, Medical University, Sofia, Bulgaria
| | - Nuria Valdés
- Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Hospital Universitario de Cabueñes, Gijón, Spain
| | - Urszula Ambroziak
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Mari Suzuki
- Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health, Bethesda, MD, USA
| | - Mario Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Soraya Puglisi
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Turin, Turin, Italy
| | - Lorenzo Tucci
- Endocrinology and Prevention and Care of Diabetes Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater University of Bologna, Bologna, Italy
| | | | - Dimitris Margaritopoulos
- Department of Endocrinology, Diabetes, and Metabolism, National Expertise Centre for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece
| | - Tina Dusek
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Roberta Maggio
- Endocrinology, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Antonio Concistrè
- Second Hypertension Unit, Department of Translational and Precision Medicine, University Sapienza, Rome, Italy
| | - Cristina Lucia Ronchi
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany; Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes, and Metabolism, Birmingham Health Partners, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Barbara Altieri
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Cristina Mosconi
- Endocrinology and Prevention and Care of Diabetes Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Diagnostic and Interventional Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Aristidis Diamantopoulos
- Department of Endocrinology, Diabetes, and Metabolism, National Expertise Centre for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece
| | - Nicole Marie Iñiguez-Ariza
- Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Valentina Vicennati
- Endocrinology and Prevention and Care of Diabetes Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater University of Bologna, Bologna, Italy
| | - Anna Pia
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Turin, Turin, Italy
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany; University Hospital Munich, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Gregory Kaltsas
- 1st Department of Propaedeutic and Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Ljiljana V Marina
- Clinic for Endocrinology, Diabetes, and Metabolic Diseases, University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Valentina Morelli
- Istituto Auxologico Italiano, IRCCS, University of Milan, Milan, Italy
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes, and Metabolism, Birmingham Health Partners, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Claudio Letizia
- Second Hypertension Unit, Department of Translational and Precision Medicine, University Sapienza, Rome, Italy
| | - Marco Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Antonio Stigliano
- Endocrinology, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes, and Metabolism, National Expertise Centre for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece
| | - Shobana Athimulam
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, Diabetes, Bone and Mineral Disorders, Henry Ford Health System, Detroit, MI, USA
| | - Uberto Pagotto
- Endocrinology and Prevention and Care of Diabetes Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater University of Bologna, Bologna, Italy
| | - Uwe Maeder
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - John Newell-Price
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Turin, Turin, Italy
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany; Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany.
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Abstract
PURPOSE OF REVIEW To discuss the most recent findings on the pathophysiology, the genetic and molecular causes of primary bilateral adrenal hyperplasia (PBAH). The diagnostic approach of patients with PBAH will also be presented in detail with an emphasis on the emerging diagnostic tools and finally, the treatment of PBAH will be discussed with an emphasis on the newest surgical and medical treatment approaches. RECENT FINDINGS PBAH is a highly heterogeneous condition mostly detected incidentally on abdominal imaging. Based on the size of the nodules, PBAH is subdivided into primary bilateral macronodular adrenal hyperplasia (PBMAH) and micronodular adrenal hyperplasia. A substantial proportion of patients with PBMAH harbor a germline mutation of the armadillo repeat containing 5 tumor suppression gene and therefore genetic testing is strongly recommended. Measurements of plasma or urinary multisteroid profiles show promising results in that PBMAH has a distinctive plasma steroid fingerprint that can help in diagnosis and subtyping of PBMAH. Finally, although surgery is the mainstay of treatment of patients with PBAH, medical therapy is increasingly emerging as an alternative option. SUMMARY PBAH is a poorly studied and therefore a challenging disease to diagnose and treat. Hopefully with these newest diagnostic and therapeutic tools, a more comprehensive approach will be adopted.
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Affiliation(s)
- Danae A Delivanis
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
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15
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Kardalas E, Stratigou T, Paikopoulou A, Argyro Vassiliadi D, Ioannidis G, Tsagarakis S, Christodoulidou C. MO622: Clinical Value of Kidney Biopsy in Patients with Diabetes Mellitus and Nephrotic -Range Proteinuria: Correlation of Clinical and Laboratory Findings with Histopathological Data. Nephrol Dial Transplant 2022. [DOI: 10.1093/ndt/gfac076.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND AND AIMS
Diabetes mellitus (DM) is tightly associated with the increased prevalence and rapid evolution of diabetic nephropathy (DN). Interestingly, deterioration of kidney function in diabetic patients is often nonetheless caused by other factors besides DM and frequently goes undiagnosed. Nondiabetic renal disease (non-DRD) could be suspected in case of rapid progression of renal function impairment and/or severe, nephrotic-range proteinuria. While biopsy of the kidneys is the ‘gold standard’ of the diagnostic approach in such cases, no real consensus exists regarding the profile of diabetic patients with renal disease and proteinuria, who should be submitted to kidney biopsy. Thus, this study intends to correlate the clinical and biochemical profile of diabetic patients with deteriorated kidney function to the histopathological data of a kidney biopsy and allows early differentiation between DN and non-DRD based on the results of kidney biopsy.
METHOD
A total of 32 patients, who were treated in our outpatient's diabetes clinic from a multidisciplinary team of endocrinologists and nephrologists at Evangelismos General Hospital, were retrospectively studied. All patients suffered from DM2 and presented with nephrotic-range levels of proteinuria. Biochemical data of glycemic control and renal function, clinical findings related to DN and histological findings of kidney biopsy were documented. All patients were submitted to kidney biopsy and depending on the histopathologic findings were categorized into three groups: (i) genuine diabetic nephropathy (GDN), (ii) renal disease due to cause other than diabetes mellitus (ODMRD) and (iii) mixed renal disease (MRD).
RESULTS
Among the 32 patients, 15 (46.9%) had findings of a GDN, while 17 patients (53.1%) suffered from ODMRD (13 patients) or MRD (4 patients). All patients were hypertensive. The patients with GDN were younger (54.1 versus 68.2 versus 70.5 years, P = 0.016) and had a higher HbA1C value (7.9 versus 6.5 versus 6.8%, P = 0.069) at the time of the kidney biopsy in comparison to the ODMRD and MRD patients. On the contrary, ODMRD patients had significantly smaller disease duration compared with the GDN and MRD groups (8.4 versus 11.6 versus 13.3 years, P = 0.04). Furthermore, the incidence of diabetic retinopathy was greater among patients with GDN and MRD in comparison to the ODMRD patients (60 versus 75 versus 7.6%, P < 0.01). Additionally, interstitial fibrosis was significantly more prevalent among the patients with GDN in comparison to those with ODMRD and MRD, respectively (73.3 versus 38.4 versus 50%, P = 0.02). Finally, the presence of diabetic retinopathy {OR 4.88, [95% confidence interval (CI) 1.06–22.38], P = 0.04}, higher levels (>25%) of interstitial renal fibrosis [OR 5.71 (95% CI 1.16–28.1), P = 0.032] and longer DM2 duration (>10 years) [OR 5.04, (95% CI 1.1–22.96), P = 0.036] were recognized as factors, which were positively associated with GDN.
CONCLUSIONS
This study highlights emphatically the usefulness of the kidney biopsy and its histopathological findings in case of patients with diabetes mellitus and nephrotic-range levels of proteinuria. The value of a detailed and careful medical history seems to be critical for the early diagnosis of the type of kidney disease in diabetic patients. It is crucial to early differentiate the patients who suffer from nondiabetic nephropathy, from those with diabetic nephropathy and initiate the appropriate therapy, according to the underlying cause. Thus, the detection of nephrotic-range levels of proteinuria in diabetic patients should lead to kidney biopsy especially in case diabetic retinopathy is not present and longer disease duration is observed. Finally, the existing criteria/indications for a kidney biopsy in diabetic patients with nephrotic-range levels of proteinuria should be reconsidered or even revised.
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Affiliation(s)
- Efstratios Kardalas
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, European and National Expertise Centre for Rare Endocrine Diseases, Athens, Greece
| | - Theodora Stratigou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, European and National Expertise Centre for Rare Endocrine Diseases, Athens, Greece
| | | | - Dimitra Argyro Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, European and National Expertise Centre for Rare Endocrine Diseases, Athens, Greece
| | - Georgios Ioannidis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, European and National Expertise Centre for Rare Endocrine Diseases, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, European and National Expertise Centre for Rare Endocrine Diseases, Athens, Greece
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16
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Prete A, Subramanian A, Bancos I, Chortis V, Tsagarakis S, Lang K, Macech M, Delivanis DA, Pupovac ID, Reimondo G, Marina LV, Deutschbein T, Balomenaki M, O'Reilly MW, Gilligan LC, Jenkinson C, Bednarczuk T, Zhang CD, Dusek T, Diamantopoulos A, Asia M, Kondracka A, Li D, Masjkur JR, Quinkler M, Ueland GÅ, Dennedy MC, Beuschlein F, Tabarin A, Fassnacht M, Ivović M, Terzolo M, Kastelan D, Young WF, Manolopoulos KN, Ambroziak U, Vassiliadi DA, Taylor AE, Sitch AJ, Nirantharakumar K, Arlt W. Cardiometabolic Disease Burden and Steroid Excretion in Benign Adrenal Tumors : A Cross-Sectional Multicenter Study. Ann Intern Med 2022; 175:325-334. [PMID: 34978855 DOI: 10.7326/m21-1737] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Benign adrenal tumors are commonly discovered on cross-sectional imaging. Mild autonomous cortisol secretion (MACS) is regularly diagnosed, but its effect on cardiometabolic disease in affected persons is ill defined. OBJECTIVE To determine cardiometabolic disease burden and steroid excretion in persons with benign adrenal tumors with and without MACS. DESIGN Cross-sectional study. SETTING 14 endocrine secondary and tertiary care centers (recruitment from 2011 to 2016). PARTICIPANTS 1305 prospectively recruited persons with benign adrenal tumors. MEASUREMENTS Cortisol excess was defined by clinical assessment and the 1-mg overnight dexamethasone-suppression test (serum cortisol: <50 nmol/L, nonfunctioning adrenal tumor [NFAT]; 50 to 138 nmol/L, possible MACS [MACS-1]; >138 nmol/L and absence of typical clinical Cushing syndrome [CS] features, definitive MACS [MACS-2]). Net steroid production was assessed by multisteroid profiling of 24-hour urine by tandem mass spectrometry. RESULTS Of the 1305 participants, 49.7% had NFAT (n = 649; 64.1% women), 34.6% had MACS-1 (n = 451; 67.2% women), 10.7% had MACS-2 (n = 140; 73.6% women), and 5.0% had CS (n = 65; 86.2% women). Prevalence and severity of hypertension were higher in MACS-2 and CS than NFAT (adjusted prevalence ratios [aPRs] for hypertension: MACS-2, 1.15 [95% CI, 1.04 to 1.27], and CS, 1.37 [CI, 1.16 to 1.62]; aPRs for use of ≥3 antihypertensives: MACS-2, 1.31 [CI, 1.02 to 1.68], and CS, 2.22 [CI, 1.62 to 3.05]). Type 2 diabetes was more prevalent in CS than NFAT (aPR, 1.62 [CI, 1.08 to 2.42]) and more likely to require insulin therapy for MACS-2 (aPR, 1.89 [CI, 1.01 to 3.52]) and CS (aPR, 3.06 [CI, 1.60 to 5.85]). Urinary multisteroid profiling revealed an increase in glucocorticoid excretion from NFAT over MACS-1 and MACS-2 to CS, whereas androgen excretion decreased. LIMITATIONS Cross-sectional design; possible selection bias. CONCLUSION A cardiometabolic risk condition, MACS predominantly affects women and warrants regular assessment for hypertension and type 2 diabetes. PRIMARY FUNDING SOURCE Diabetes UK, the European Commission, U.K. Medical Research Council, the U.K. Academy of Medical Sciences, the Wellcome Trust, the U.K. National Institute for Health Research, the U.S. National Institutes of Health, the Claire Khan Trust Fund at University Hospitals Birmingham Charities, and the Mayo Clinic Foundation for Medical Education and Research.
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Affiliation(s)
- Alessandro Prete
- The Institute of Metabolism and Systems Research, University of Birmingham, Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, and Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom (A.P., V.C., K.L.)
| | - Anuradhaa Subramanian
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom (A.S.)
| | - Irina Bancos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom, and Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota (I.B.)
| | - Vasileios Chortis
- The Institute of Metabolism and Systems Research, University of Birmingham, Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, and Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom (A.P., V.C., K.L.)
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece (S.T., M.B., A.D., D.A.V.)
| | - Katharina Lang
- The Institute of Metabolism and Systems Research, University of Birmingham, Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, and Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom (A.P., V.C., K.L.)
| | - Magdalena Macech
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland (M.M., T.B., A.K., U.A.)
| | - Danae A Delivanis
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota (D.A.D., C.D.Z., D.L., W.F.Y.)
| | - Ivana D Pupovac
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia (I.D.P., T.D., D.K.)
| | - Giuseppe Reimondo
- Division of Internal Medicine, University of Turin, San Luigi Hospital, Turin, Italy (G.R., M.T.)
| | - Ljiljana V Marina
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia (L.V.M., M.I.)
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, and Medicover Oldenburg MVZ, Oldenburg, Germany (T.D.)
| | - Maria Balomenaki
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece (S.T., M.B., A.D., D.A.V.)
| | - Michael W O'Reilly
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom, and Department of Medicine, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Republic of Ireland (M.W.O.)
| | - Lorna C Gilligan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom (L.C.G., C.J., K.N.M., A.E.T.)
| | - Carl Jenkinson
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom (L.C.G., C.J., K.N.M., A.E.T.)
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland (M.M., T.B., A.K., U.A.)
| | - Catherine D Zhang
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota (D.A.D., C.D.Z., D.L., W.F.Y.)
| | - Tina Dusek
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia (I.D.P., T.D., D.K.)
| | - Aristidis Diamantopoulos
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece (S.T., M.B., A.D., D.A.V.)
| | - Miriam Asia
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, and Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom (M.A.)
| | - Agnieszka Kondracka
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland (M.M., T.B., A.K., U.A.)
| | - Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota (D.A.D., C.D.Z., D.L., W.F.Y.)
| | - Jimmy R Masjkur
- Department of Medicine III and Institute of Clinical Chemistry and Laboratory Medicine, Technische Universität Dresden, Dresden, Germany (J.R.M.)
| | | | - Grethe Å Ueland
- Department of Endocrinology, Haukeland University Hospital, Bergen, Norway (G.Å.U.)
| | - M Conall Dennedy
- Department of Endocrinology, University Hospital Galway, Newcastle, Galway, Republic of Ireland (M.C.D.)
| | - Felix Beuschlein
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitäts Spital Zürich (USZ) und Universität Zürich (UZH), Zurich, Switzerland, and Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany (F.B.)
| | - Antoine Tabarin
- Service d'Endocrinologie, Centre Hospitalier Universitaire de Bordeaux, Hôpital du Haut-Lévêque, Pessac, France (A.T.)
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany (M.F.)
| | - Miomira Ivović
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia (L.V.M., M.I.)
| | - Massimo Terzolo
- Division of Internal Medicine, University of Turin, San Luigi Hospital, Turin, Italy (G.R., M.T.)
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia (I.D.P., T.D., D.K.)
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota (D.A.D., C.D.Z., D.L., W.F.Y.)
| | - Konstantinos N Manolopoulos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom (L.C.G., C.J., K.N.M., A.E.T.)
| | - Urszula Ambroziak
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland (M.M., T.B., A.K., U.A.)
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece (S.T., M.B., A.D., D.A.V.)
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom (L.C.G., C.J., K.N.M., A.E.T.)
| | - Alice J Sitch
- Institute of Applied Health Research, University of Birmingham, and NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom (A.J.S.)
| | - Krishnarajah Nirantharakumar
- Institute of Metabolism and Systems Research, University of Birmingham, Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, and Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom (K.N.)
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, and NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom (W.A.)
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Kontogeorgos G, Markussis V, Thodou E, Kyrodimou E, Choreftaki T, Nomikos P, Lampropoulos KI, Tsagarakis S. Association of Pathology Markers with Somatostatin Analogue Responsiveness in Acromegaly. Int J Endocrinol 2022; 2022:8660470. [PMID: 36199813 PMCID: PMC9529452 DOI: 10.1155/2022/8660470] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/25/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Somatotroph adenomas (SAs) exhibit a variable responsiveness to somatostatin analogue (SS-a) treatment, a process that is not well understood. We investigated established and novel histological markers as predictors of SS-a responsiveness. METHODS We retrospectively investigated pathology samples from 36 acromegalic patients that underwent transsphenoidal surgery. Clinical, hormonal, and imaging data were available in 24/36 patients, before and after SS-a treatment. Specimens were semiquantitatively analyzed with immunocytochemistry for Ki-67, KER, SSTR-2, SSTR-5, ZAC-1, E-cadherin, and AIP. RESULTS Collectively, 18 (50%) adenomas were each classified as densely/sparsely granulated somatotroph adenomas (DGSAs/SGSAs), respectively. Patients that received preoperative SS-a had lower expression of SSTR-2 compared to those that did not (2.0 (1.0, 3.0) vs. 3.0 (3.0, 3.0), p = 0.042). Compared with DGSAs, SGSAs had higher Ki-67 labeling index (LI) (1.0 (0.5, 1.0) vs. 2.0 (1.0, 3.5), p = 0.013), and a higher proportion of high MR T2 signal (1 (6%) vs. 6 (33%), p = 0.035), and tended to express less ZAC-1 (p = 0.061) and E-cadherin (p = 0.067). In linear regression corrected for baseline growth hormone (GH), ZAC-1 immunostaining was significantly associated with a decrease in GH levels after SS-a treatment (beta (95% confidence interval): -1.53 (-2.80, -0.26), p = 0.021). No markers were associated with changes in circulating insulin-like growth factor-I (IGF-I) after treatment with SS-a. CONCLUSION The novel marker ZAC-1 was associated with GH response to medical treatment with SS-a. The SGSA cases were characterized by higher Ki-67 values and MR T2 signals indicative of an inferior response to SS-a. These findings improve our understanding of the mechanisms underlying SA response to medical treatment.
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Affiliation(s)
- George Kontogeorgos
- First Propaedeutic Department of Internal Medicine, Division of Endocrinology, Laikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Pathology and Pituitary Tumor Reference Center, “G. Gennimatas” General Hospital of Athens, Athens, Greece
| | | | - Eleni Thodou
- Department of Pathology, University of Thessaly, Larissa, Greece
| | - Efi Kyrodimou
- Department of Pathology and Pituitary Tumor Reference Center, “G. Gennimatas” General Hospital of Athens, Athens, Greece
| | - Theodossia Choreftaki
- Department of Pathology and Pituitary Tumor Reference Center, “G. Gennimatas” General Hospital of Athens, Athens, Greece
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18
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Chasseloup F, Bourdeau I, Tabarin A, Regazzo D, Dumontet C, Ladurelle N, Tosca L, Amazit L, Proust A, Scharfmann R, Mignot T, Fiore F, Tsagarakis S, Vassiliadi D, Maiter D, Young J, Lecoq AL, Deméocq V, Salenave S, Lefebvre H, Cloix L, Emy P, Dessailloud R, Vezzosi D, Scaroni C, Barbot M, de Herder W, Pattou F, Tétreault M, Corbeil G, Dupeux M, Lambert B, Tachdjian G, Guiochon-Mantel A, Beau I, Chanson P, Viengchareun S, Lacroix A, Bouligand J, Kamenický P. Loss of KDM1A in GIP-dependent primary bilateral macronodular adrenal hyperplasia with Cushing's syndrome: a multicentre, retrospective, cohort study. Lancet Diabetes Endocrinol 2021; 9:813-824. [PMID: 34655521 DOI: 10.1016/s2213-8587(21)00236-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/06/2021] [Accepted: 08/06/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND GIP-dependent primary bilateral macronodular adrenal hyperplasia with Cushing's syndrome is caused by aberrant expression of the GIP receptor in adrenal lesions. The bilateral nature of this disease suggests germline genetic predisposition. We aimed to identify the genetic driver event responsible for GIP-dependent primary bilateral macronodular adrenal hyperplasia with Cushing's syndrome. METHODS We conducted a multicentre, retrospective, cohort study at endocrine hospitals and university hospitals in France, Canada, Italy, Greece, Belgium, and the Netherlands. We collected blood and adrenal samples from patients who had undergone unilateral or bilateral adrenalectomy for GIP-dependent primary bilateral macronodular adrenal hyperplasia with Cushing's syndrome. Adrenal samples from patients with primary bilateral macronodular adrenal hyperplasia who had undergone an adrenalectomy for overt or mild Cushing's syndrome without evidence of food-dependent cortisol production and those with GIP-dependent unilateral adrenocortical adenomas were used as control groups. We performed whole genome, whole exome, and targeted next generation sequencing, and copy number analyses of blood and adrenal DNA from patients with familial or sporadic disease. We performed RNA sequencing on adrenal samples and functional analyses of the identified genetic defect in the human adrenocortical cell line H295R. FINDINGS 17 patients with GIP-dependent primary bilateral macronodular adrenal hyperplasia with Cushing's syndrome were studied. The median age of patients was 43·3 (95% CI 38·8-47·8) years and most patients (15 [88%]) were women. We identified germline heterozygous pathogenic or most likely pathogenic variants in the KDM1A gene in all 17 patients. We also identified a recurrent deletion in the short p arm of chromosome 1 harboring the KDM1A locus in adrenal lesions of these patients. None of the 29 patients in the control groups had KDM1A germline or somatic alterations. Concomitant genetic inactivation of both KDM1A alleles resulted in loss of KDM1A expression in adrenal lesions. Global gene expression analysis showed GIP receptor upregulation with a log2 fold change of 7·99 (95% CI 7·34-8·66; p=4·4 × 10-125), and differential regulation of several other G protein-coupled receptors in GIP-dependent primary bilateral macronodular hyperplasia samples compared with control samples. In vitro pharmacological inhibition and inactivation of KDM1A by CRISPR-Cas9 genome editing resulted in an increase of GIP receptor transcripts and protein in human adrenocortical H295R cells. INTERPRETATION We propose that GIP-dependent primary bilateral macronodular adrenal hyperplasia with Cushing's syndrome results from a two-hit inactivation of KDM1A, consistent with the tumour suppressor gene model of tumorigenesis. Genetic testing and counselling should be offered to these patients and their relatives. FUNDING Agence Nationale de la Recherche, Fondation du Grand défi Pierre Lavoie, and the French National Cancer Institute.
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Affiliation(s)
- Fanny Chasseloup
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes, and Nutrition, Hôpital Haut Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France
| | - Daniela Regazzo
- Endocrinology Unit, Department of Medicine, Hospital-University of Padua, Padua, Italy
| | - Charles Dumontet
- Université Claude Bernard Lyon 1, UMR INSERM 1052, CNRS 5286, Centre de Recherche de Cancérologie de Lyon, Lyon, France
| | - Nataly Ladurelle
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - Lucie Tosca
- Service d'Histologie, Embryologie et Cytogénétique, Assistance Publique-Hôpitaux de Paris, Hôpital Antoine Béclère, Clamart, France
| | - Larbi Amazit
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France; UMS 44, Institut Biomédical du Val de Bièvre, Le Kremlin-Bicêtre, France
| | - Alexis Proust
- Service de Génétique Moléculaire et d'Hormonologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Tiphaine Mignot
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - Frédéric Fiore
- US12 Centre d'immunophénomique, Parc Scientifique et Technologique de Luminy, Marseille, France
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes, and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Dimitra Vassiliadi
- Department of Endocrinology, Diabetes, and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Dominique Maiter
- Department of Endocrinology and Nutrition, Université catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jacques Young
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France; Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anne-Lise Lecoq
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France; Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Vianney Deméocq
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - Sylvie Salenave
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France; Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Hervé Lefebvre
- Department of Endocrinology, Diabetes and Metabolic Diseases, Normandie Univ, Rouen University Hospital, Rouen, France
| | - Lucie Cloix
- CHR Orleans, Service d'Endocrinologie, Diabète et Nutrition, Orleans, France
| | - Philippe Emy
- CHR Orleans, Service d'Endocrinologie, Diabète et Nutrition, Orleans, France
| | - Rachel Dessailloud
- Department of Endocrinology, Diabetes, and Nutrition, and PériTox, UMR-I 01 INERIS, Université de Picardie Jules Verne, Amiens, France
| | | | - Carla Scaroni
- Endocrinology Unit, Department of Medicine, Hospital-University of Padua, Padua, Italy
| | - Mattia Barbot
- Department of Neuroscience, Hospital-University of Padua, Padua, Italy
| | - Wouter de Herder
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - François Pattou
- Service de Chirurgie Générale et Endocrinienne, Univ Lille, Institut Pasteur de Lille, INSERM U1190, Translational Research Laboratory for Diabetes, CHU Lille, Lille, France
| | - Martine Tétreault
- Department of Neurosciences, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Gilles Corbeil
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Margot Dupeux
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Benoit Lambert
- Service de Chirurgie Digestive et Endocrinienne, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Gérard Tachdjian
- Service d'Histologie, Embryologie et Cytogénétique, Assistance Publique-Hôpitaux de Paris, Hôpital Antoine Béclère, Clamart, France
| | - Anne Guiochon-Mantel
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France; Service de Génétique Moléculaire et d'Hormonologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Isabelle Beau
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - Philippe Chanson
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France; Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Say Viengchareun
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Jérôme Bouligand
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France; Service de Génétique Moléculaire et d'Hormonologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Peter Kamenický
- Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France; Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.
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19
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Fleseriu M, Auchus R, Bancos I, Ben-Shlomo A, Bertherat J, Biermasz NR, Boguszewski CL, Bronstein MD, Buchfelder M, Carmichael JD, Casanueva FF, Castinetti F, Chanson P, Findling J, Gadelha M, Geer EB, Giustina A, Grossman A, Gurnell M, Ho K, Ioachimescu AG, Kaiser UB, Karavitaki N, Katznelson L, Kelly DF, Lacroix A, McCormack A, Melmed S, Molitch M, Mortini P, Newell-Price J, Nieman L, Pereira AM, Petersenn S, Pivonello R, Raff H, Reincke M, Salvatori R, Scaroni C, Shimon I, Stratakis CA, Swearingen B, Tabarin A, Takahashi Y, Theodoropoulou M, Tsagarakis S, Valassi E, Varlamov EV, Vila G, Wass J, Webb SM, Zatelli MC, Biller BMK. Consensus on diagnosis and management of Cushing's disease: a guideline update. Lancet Diabetes Endocrinol 2021; 9:847-875. [PMID: 34687601 PMCID: PMC8743006 DOI: 10.1016/s2213-8587(21)00235-7] [Citation(s) in RCA: 265] [Impact Index Per Article: 88.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/22/2021] [Accepted: 08/04/2021] [Indexed: 12/19/2022]
Abstract
Cushing's disease requires accurate diagnosis, careful treatment selection, and long-term management to optimise patient outcomes. The Pituitary Society convened a consensus workshop comprising more than 50 academic researchers and clinical experts to discuss the application of recent evidence to clinical practice. In advance of the virtual meeting, data from 2015 to present about screening and diagnosis; surgery, medical, and radiation therapy; and disease-related and treatment-related complications of Cushing's disease summarised in recorded lectures were reviewed by all participants. During the meeting, concise summaries of the recorded lectures were presented, followed by small group breakout discussions. Consensus opinions from each group were collated into a draft document, which was reviewed and approved by all participants. Recommendations regarding use of laboratory tests, imaging, and treatment options are presented, along with algorithms for diagnosis of Cushing's syndrome and management of Cushing's disease. Topics considered most important to address in future research are also identified.
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Affiliation(s)
| | | | | | | | - Jerome Bertherat
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares de la Surrénale, Service d'Endocrinologie, Hôpital Cochin, Paris, France
| | - Nienke R Biermasz
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | | | | | | | - John D Carmichael
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Felipe F Casanueva
- Santiago de Compostela University and Ciber OBN, Santiago de Compostela, Spain
| | - Frederic Castinetti
- Aix Marseille Université, Marseille Medical Genetics, INSERM, Marseille, France; Assistance Publique Hopitaux de Marseille, Marseille, France; Department of Endocrinology, La Conception Hospital, Marseille, France
| | - Philippe Chanson
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Mônica Gadelha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eliza B Geer
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | - Ashley Grossman
- University of London, London, UK; University of Oxford, Oxford, UK
| | - Mark Gurnell
- University of Cambridge, Cambridge, UK; NIHR Cambridge Biomedical Research Center, Cambridge, UK; Addenbrooke's Hospital, Cambridge, UK
| | - Ken Ho
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Ursula B Kaiser
- Brigham & Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - André Lacroix
- Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Ann McCormack
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Mark Molitch
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Alberto M Pereira
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany and University of Duisburg-Essen, Essen, Germany
| | | | - Hershel Raff
- Medical College of Wisconsin, Milwaukee, WI, USA; Advocate Aurora Research Institute, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Martin Reincke
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | | | - Ilan Shimon
- Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | | | | | - Antoine Tabarin
- CHU de Bordeaux, Hôpital Haut Lévêque, University of Bordeaux, Bordeaux, France
| | | | - Marily Theodoropoulou
- Department of Medicine IV, University Hospital of LMU, Ludwig-Maximilians-Universität, Munich, Germany
| | | | - Elena Valassi
- Endocrinology Unit, Hospital General de Catalunya, Barcelona, Spain; Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain
| | | | - Greisa Vila
- Medical University of Vienna, Vienna, Austria
| | - John Wass
- Churchill Hospital, Oxford, United Kingdom
| | - Susan M Webb
- Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
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Vassiliadi DA, Vassiliou AG, Ilias I, Tsagarakis S, Kotanidou A, Dimopoulou I. Pituitary-Adrenal Responses and Glucocorticoid Receptor Expression in Critically Ill Patients with COVID-19. Int J Mol Sci 2021; 22:11473. [PMID: 34768903 PMCID: PMC8584241 DOI: 10.3390/ijms222111473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/18/2021] [Accepted: 10/21/2021] [Indexed: 12/15/2022] Open
Abstract
The hypothalamus-pituitary-adrenal (HPA) axis was described as the principal component of the stress response 85 years ago, along with the acute-phase reaction, and the defense response at the tissue level. The orchestration of these processes is essential since systemic inflammation is a double-edged sword; whereas inflammation that is timely and of appropriate magnitude is beneficial, exuberant systemic inflammation incites tissue damage with potentially devastating consequences. Apart from its beneficial cardiovascular and metabolic effects, cortisol exerts a significant immunoregulatory role, a major attribute being that it restrains the excessive inflammatory reaction, thereby preventing unwanted tissue damage. In this review, we will discuss the role of the HPA axis in the normal stress response and in critical illness, especially in critically ill patients with coronavirus disease 2019 (COVID-19). Finally, a chapter will be dedicated to the findings from clinical studies in critical illness and COVID-19 on the expression of the mediator of glucocorticoid actions, the glucocorticoid receptor (GCR).
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Affiliation(s)
- Dimitra A. Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, National Expertise Centre for Rare Endocrine Diseases, Evangelismos Hospital, 106 76 Athens, Greece; (D.A.V.); (S.T.)
| | - Alice G. Vassiliou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National & Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.)
| | - Ioannis Ilias
- Department of Endocrinology, Helena Venizelos Hospital, 115 21 Athens, Greece;
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, National Expertise Centre for Rare Endocrine Diseases, Evangelismos Hospital, 106 76 Athens, Greece; (D.A.V.); (S.T.)
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National & Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.)
| | - Ioanna Dimopoulou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National & Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.)
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21
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Ilias I, Pratikaki M, Diamantopoulos A, Jahaj E, Mourelatos P, Athanasiou N, Tsipilis S, Zacharis A, Vassiliou AG, Vassiliadi DA, Tsagarakis S, Kotanidou A, Dimopoulou I. Testosterone, free, bioavailable and total, in patients with COVID-19. Minerva Endocrinol (Torino) 2021; 47:111-116. [PMID: 34546019 DOI: 10.23736/s2724-6507.21.03610-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Low Testosterone (mainly total testosterone; TTe) has been noted in patients with COVID-19. Calculated free testosterone (FTe) and bioavailable testosterone (BavTe) may reflect more accurately this hormone's levels. In this study, we sought to assess TTe, FTe as well as BavTe in male patients with COVID-19. SUBJECTS/METHODS Sera were collected upon admission from 65 men (10 in the intensive care units [ICU] and 55 in the wards) with polymerase chain reaction - proven COVID-19. A group of age-matched COVID-19-negative men (n=29) hospitalized in general medical wards served as controls. Age, body mass index (BMI) and 28-day mortality were noted. Measurements included TTe, sex-hormone binding globulin, albumin (the latter two for calculating FTe and BavTe) and laboratory markers of inflammation (white blood cell count [WBC], D-Dimers [D-D], lactate dehydrogenease [LDH], ferritin [Fer] and C-reactive protein [CRP]). RESULTS Profoundly low TTe, FTe and BavTe were noted in most patients, and were associated with disease severity/outcome (being the lowest in COVID-19 patients in the ICU and overall being lower in non-survivors; analysis of covariance p<0.05). Pearson's correlations for logTe, logFTe or logBavTe versus WBC, D-D, LDH, Ferr or CRP were negative, ranging from -0.403 to -0.293 (p=0.009 to 0.014). CONCLUSIONS TTe, FTe and BavTe are prone to be low in patients with COVID-19, are negatively associated with disease severity and may be considered to have prognostic value.
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Affiliation(s)
- Ioannis Ilias
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens, Greece -
| | - Maria Pratikaki
- Department of Microbiology, Evangelismos Hospital, Athens, Greece
| | | | - Edison Jahaj
- First Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Medical School of National & Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Mourelatos
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Nikolaos Athanasiou
- First Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Medical School of National & Kapodistrian University of Athens, Athens, Greece
| | | | - Alexandros Zacharis
- First Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Medical School of National & Kapodistrian University of Athens, Athens, Greece
| | - Alice G Vassiliou
- First Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Medical School of National & Kapodistrian University of Athens, Athens, Greece
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Medical School of National & Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Dimopoulou
- First Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Medical School of National & Kapodistrian University of Athens, Athens, Greece
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22
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Vassiliadi DA, Mourelatos P, Kratimenos T, Tsagarakis S. Inferior petrosal sinus sampling in Cushing's syndrome: usefulness and pitfalls. Endocrine 2021; 73:530-539. [PMID: 34080096 DOI: 10.1007/s12020-021-02764-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 05/10/2021] [Indexed: 12/24/2022]
Abstract
In patients with ACTH-dependent Cushing's syndrome (CS), the differentiation between Cushing's disease (CD) and ectopic ACTH secretion (EAS) can often be challenging. The traditionally used biochemical tests have limited diagnostic accuracy and imaging modalities may fail to detect the culprit lesion. Inferior petrosal sinus sampling (IPSS) was introduced more than 3 decades ago as a test with optimal diagnostic accuracy and has since become the gold standard in the differential diagnosis between CD and EAS. However, several, albeit rare, pitfalls may limit its diagnostic accuracy and awareness is needed to avoid incorrect interventions. Moreover, it is an invasive and demanding procedure, available in a limited number of centers worldwide. This review aims to critically present the usefulness and pitfalls of IPSS and define strategies for its optimal place in the contemporary management of CS.
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Affiliation(s)
- D A Vassiliadi
- Department of Endocrinology and Diabetes, Evangelismos Hospital, Athens, Greece
| | - P Mourelatos
- Department of Endocrinology and Diabetes, Evangelismos Hospital, Athens, Greece
| | - T Kratimenos
- Department of Interventional Radiology, Evangelismos Hospital, Athens, Greece
| | - S Tsagarakis
- Department of Endocrinology and Diabetes, Evangelismos Hospital, Athens, Greece.
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23
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Karapanou O, Saltiki K, Simeakis G, Botoula E, Tsagarakis S, Alevizaki M, Vlassopoulou B. Histology is more ιmportant than persistent anti-Tg antibodies for progression of differentiated thyroid cancer. Clin Endocrinol (Oxf) 2021; 95:217-223. [PMID: 33682167 DOI: 10.1111/cen.14456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/28/2021] [Accepted: 03/03/2021] [Indexed: 11/27/2022]
Abstract
CONTEXT Anti-thyroglobulin antibodies (anti-Tg), present in 20%-25% of differentiated thyroid cancer (DTC) patients, interfere with thyroglobulin measurements posing a challenge in the follow-up. OBJECTIVES The aim of this study was to identify clinical-histological factors that may affect anti-Tg persistence and disease outcome in DTC with positive anti-Tg. METHODS We retrospectively studied 234 DTC patients, with positive anti-Tg at diagnosis (females: 82.1%, age at diagnosis: 46.0 ± 14.4 yrs, median follow-up: 5 yrs (1.5-32 yrs). 221/234 (94.4%) received radioiodine (RAI) ablation. Patients were divided into two subgroups: those whose anti-Tg became undetectable (anti-Tg-NEG) and those whose anti-Tg remained positive (anti-Tg-POS) at the end of the follow-up period. RESULTS Anti-Tg-POS patients (n = 80, 34.2%) compared to anti-Tg-NEG (n = 154, 65.8%) had more frequently lymph node infiltration (36.3% vs 20.1%, P = .01), extrathyroidal extension (ETE, 35.0% vs 22.1%, P = .04), poorly differentiated DTC and increased tumour size (P ≤ .004). They received higher total RAI dose (P < .001). In most cases, additional RAI administration and/or additional surgeries did not lead to anti-Tg elimination. These had more frequently structural disease persistence/progression compared to anti-Tg-NEG (remission: 78.8% vs 95.5%, persistence: 13.8% vs 3.9%, progression: 7.5% vs 0.6%, P < .001). In Kaplan-Meier analysis, the probability of disease progression was higher in anti-Tg-POS. In Cox proportional hazard analysis, the predictors of disease progression were size (P = .002) and ETE (P = .006). CONCLUSIONS Worse histological features are more frequent in patients with anti-Tg persistence during follow-up. Further additional RAI administration and/or surgeries do not affect anti-Tg elimination in most cases. Anti-Tg persistence correlates with structural persistence although tumour size and extrathyroidal extension are the main predictors of disease progression.
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Affiliation(s)
- Olga Karapanou
- Department of Endocrinology Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Katerina Saltiki
- Endocrine Unit, Dept Clinical Therapeutics, Medical School National Kapodistrian University, Athens, Greece
| | - George Simeakis
- Endocrine Unit, Dept Clinical Therapeutics, Medical School National Kapodistrian University, Athens, Greece
| | - Efi Botoula
- Department of Endocrinology Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Maria Alevizaki
- Endocrine Unit, Dept Clinical Therapeutics, Medical School National Kapodistrian University, Athens, Greece
| | - Barbara Vlassopoulou
- Department of Endocrinology Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
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Vassiliadi DA, Ilias I, Pratikaki M, Jahaj E, Vassiliou AG, Detsika M, Ampelakiotou K, Koulenti M, Manolopoulos KN, Tsipilis S, Gavrielatou E, Diamantopoulos A, Zacharis A, Athanasiou N, Orfanos S, Kotanidou A, Tsagarakis S, Dimopoulou I. Thyroid hormone alterations in critically and non-critically ill patients with SARS-CoV-2 infection. Endocr Connect 2021; 10:646-655. [PMID: 34010152 PMCID: PMC8240704 DOI: 10.1530/ec-21-0029] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/19/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Following the evolution of COVID-19 pandemic, reports pointed on a high prevalence of thyroiditis-related thyrotoxicosis. Interpretation of thyroid tests during illness, however, is hampered by changes occurring in the context of non-thyroidal illness syndrome (NTIS). In order to elucidate these findings, we studied thyroid function in carefully selected cohorts of COVID-19 positive and negative patients. DESIGN Cohort observational study. METHODS We measured TSH, FT4, T3 within 24 h of admission in 196 patients without thyroid disease and/or confounding medications. In this study, 102 patients were SARS-CoV-2 positive; 41 admitted in the ICU, 46 in the ward and 15 outpatients. Controls consisted of 94 SARS-CoV-2 negative patients; 39 in the ICU and 55 in the ward. We designated the thyroid hormone patterns as consistent with NTIS, thyrotoxicosis and hypothyroidism. RESULTS A NTIS pattern was encountered in 60% of ICU and 36% of ward patients, with similar frequencies between SARS-CoV-2 positive and negative patients (46.0% vs 46.8%, P = NS). A thyrotoxicosis pattern was observed in 14.6% SARS-CoV-2 ICU patients vs 7.7% in ICU negative (P = NS) and, overall in 8.8% of SARS-CoV-2 positive vs 7.4% of negative patients. In these patients, thyroglobulin levels were similar to those with normal thyroid function or NTIS. The hypothyroidism pattern was rare. CONCLUSIONS NTIS pattern is common and relates to the severity of disease rather than SARS-CoV-2 infection. A thyrotoxicosis pattern is less frequently observed with similar frequency between patients with and without COVID-19. It is suggested that thyroid hormone monitoring in COVID-19 should not differ from other critically ill patients.
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Affiliation(s)
- Dimitra Argyro Vassiliadi
- Department of Endocrinology Diabetes and Metabolism, National Expertise Center for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece
- Correspondence should be addressed to D A Vassiliadi:
| | - Ioannis Ilias
- Department of Endocrinology Diabetes and Metabolism, Elena Venizelou Hospital, Elena Venizelou Square, Athens, Greece
| | - Maria Pratikaki
- 1st Department of Critical Care & Pulmonary Services, Medical School National & Kapodistrian, Evangelismos Hospital, University of Athens, Athens, Greece
| | - Edison Jahaj
- 1st Department of Critical Care & Pulmonary Services, Medical School National & Kapodistrian, Evangelismos Hospital, University of Athens, Athens, Greece
| | - Alice G Vassiliou
- 1st Department of Critical Care, GP Livanos & M Simou Laboratories, Medical School National & Kapodistrian, Evangelismos Hospital, University of Athens, Athens, Greece
| | - Maria Detsika
- 1st Department of Critical Care, GP Livanos & M Simou Laboratories, Medical School National & Kapodistrian, Evangelismos Hospital, University of Athens, Athens, Greece
| | - Kleio Ampelakiotou
- Department of Immunology and Histocompatibility Evangelismos Hospital, Athens, Greece
| | - Marina Koulenti
- Department of Endocrinology Diabetes and Metabolism, National Expertise Center for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece
| | - Konstantinos N Manolopoulos
- Department of Endocrinology Diabetes and Metabolism, National Expertise Center for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece
| | - Stamatis Tsipilis
- 1st Department of Critical Care & Pulmonary Services, Medical School National & Kapodistrian, Evangelismos Hospital, University of Athens, Athens, Greece
| | - Evdokia Gavrielatou
- 1st Department of Critical Care & Pulmonary Services, Medical School National & Kapodistrian, Evangelismos Hospital, University of Athens, Athens, Greece
| | - Aristidis Diamantopoulos
- Department of Endocrinology Diabetes and Metabolism, National Expertise Center for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece
| | - Alexandros Zacharis
- 1st Department of Critical Care & Pulmonary Services, Medical School National & Kapodistrian, Evangelismos Hospital, University of Athens, Athens, Greece
| | - Nicolaos Athanasiou
- 1st Department of Critical Care & Pulmonary Services, Medical School National & Kapodistrian, Evangelismos Hospital, University of Athens, Athens, Greece
| | - Stylianos Orfanos
- 2nd Department of Critical Care Medical School National & Kapodistrian University of Athens Attikon University Hospital, Athens-Haidari, Greece
| | - Anastasia Kotanidou
- 1st Department of Critical Care & Pulmonary Services, Medical School National & Kapodistrian, Evangelismos Hospital, University of Athens, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology Diabetes and Metabolism, National Expertise Center for Rare Endocrine Diseases, Evangelismos Hospital, Athens, Greece
| | - Ioanna Dimopoulou
- 1st Department of Critical Care & Pulmonary Services, Medical School National & Kapodistrian, Evangelismos Hospital, University of Athens, Athens, Greece
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Zacharieva S, Pivonello R, Elenkova A, Toth M, Shimon I, Stigliano A, Badiu CP, Brue TC, Georgescu CE, Tsagarakis S, Cohen FJ, Fleseriu M. Safety and Efficacy of Levoketoconazole in the Treatment of Endogenous Cushing’s Syndrome (LOGICS): Results From a Double-Blind, Placebo-Controlled, Randomized Withdrawal Study. J Endocr Soc 2021. [PMCID: PMC8090707 DOI: 10.1210/jendso/bvab048.1072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Endogenous Cushing’s syndrome (CS) is a rare, serious disorder caused by chronic cortisol excess. A phase 3, open-label study (SONICS) demonstrated efficacy and safety of levoketoconazole in adults with CS. LOGICS is a phase 3, double-blind (DB), placebo-controlled, randomized-withdrawal (R-W) study that investigated levoketoconazole in adults with CS via an open-label titration-maintenance (T-M) phase (14-19 weeks) followed by a DB R-W phase (~8 weeks) and a restoration phase (~8 weeks). The primary endpoint is the proportion of patients with loss of mean urinary free cortisol (mUFC) response during R-W (ie, mUFC ≥1.5x ULN or mUFC >40% above baseline if baseline was >1.0x ULN, or other rescue criterion met). Key secondary endpoints include mUFC normalization and changes in comorbidity biomarkers at the end of R-W. Of 84 patients dosed in LOGICS (12 SONICS-completers and 72 de novo), 79 were titrated (72 de novo) and 44 patients (39 from T-M and 5 direct roll-overs from SONICS) were randomized 1:1 to receive levoketoconazole (n=22) at an individualized therapeutic dose or a matching placebo regimen (n=22). The R-W population mean age was 44.3 years, 77% were female, 91% were white, mean weight was 83.2 kg, and 86% had Cushing’s disease. Selected results from an interim analysis at the end of R-W are presented. At the end of R-W, significantly more patients on placebo (95.5%) achieved primary endpoint of loss of mUFC response than those who continued on levoketoconazole (40.9%) (treatment difference [TD], -54.5%; 95% CI: -75.7, -27.4; P=0.0002). Similarly, the mUFC normalization rate at the end of R-W was significantly higher for levoketoconazole (50.0%) versus placebo (4.5%; TD, 45.5%; 95% CI: 19.2, 67.9; P=0.0015). Mean change from R-W baseline to end of R-W in total cholesterol was -1.4 mg/dL for levoketoconazole and +35.6 mg/dL for placebo (P=0.0004); mean change in LDL cholesterol was -0.2 mg/dL and +25.0 mg/dL, respectively (P=0.0056). Mean change in glycemia markers and high sensitivity C-reactive protein were not significantly different between treatment groups. 90% of levoketoconazole-treated patients across the T-M and R-W phases (n=80) had ≥1 treatment-emergent adverse event (AE); AEs led to treatment discontinuation in 19% (15/80) of patients, 11% (9/80) of which were considered treatment-related. The most common AEs were nausea (29%), hypokalemia (28%), and headache (21%); serious AEs drug related were reported in 4 patients (3 liver-related, 1 gastroenteritis, 1 hypokalemia); AEs of special interest included liver-related (11%), QT prolongation (10%), and adrenal insufficiency (10%). These LOGICS interim results confirm the safety and efficacy findings from SONICS, establishing treatment benefit as levoketoconazole specific. This evidence further supports the use of levoketoconazole as an important treatment option for endogenous CS. Support: Strongbridge Biopharma.
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Affiliation(s)
| | | | | | | | - Ilan Shimon
- Rabin Medical Center and Tel Aviv University, Tel Aviv, Israel
| | | | - Corin P Badiu
- National Institute of Endocrinology CI Parhon, Bucharest, Romania
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Ilias I, Diamantopoulos A, Botoula E, Athanasiou N, Zacharis A, Tsipilis S, Jahaj E, Vassiliou AG, Vassiliadi DA, Kotanidou A, Tsagarakis S, Dimopoulou I. Covid-19 and Growth Hormone/Insulin-Like Growth Factor 1: Study in Critically and Non-Critically Ill Patients. Front Endocrinol (Lausanne) 2021; 12:644055. [PMID: 34220703 PMCID: PMC8242942 DOI: 10.3389/fendo.2021.644055] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 05/28/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE We aimed to measure insulin-like growth factor 1 (IGF1) and growth hormone (GH) in critically and non-critically ill patients with Covid-19 and assess them vis-a-vis clinical and laboratory parameters and prognostic tools. SUBJECTS AND METHODS We included patients who were admitted to the wards or the ICU of the largest Covid-19 referral hospital in Greece; patients with non-Covid-19 pneumonia served as controls. Apart from the routine laboratory work-up for Covid-19 we measured GH and IGF1 (and calculated normalized IGF-1 values as standard deviation scores; SDS), after blood sampling upon admission to the wards or the ICU. RESULTS We studied 209 critically and non-critically ill patients with Covid-19 and 39 control patients. Patients with Covid-19 who were ICU non-survivors were older and presented with a worse hematological/biochemical profile (including white blood cell count, troponin, glucose, aminotransferases and lactate dehydrogenase) compared to ICU survivors or Covid-19 survivors in the wards. Overall, IGF-1 SDS was higher in Covid-19 survivors compared to non-survivors (-0.96 ± 1.89 vs -2.05 ± 2.48, respectively, p=0.030). No significant differences were noted in GH between the groups. Nevertheless, in critically ill patients with Covid-19, the prognostic value of IGF-1 (raw data), IGF-1 (SDS) and GH for survival/non-survival was on a par with that of APACHE II and SOFA (with a marginal difference between GH and SOFA). CONCLUSION In conclusion, our findings suggest that there might be an association between low IGF1 (and possibly GH) and poor outcome in patients with Covid-19.
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Affiliation(s)
- Ioannis Ilias
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens, Greece
- *Correspondence: Ioannis Ilias,
| | | | - Efthymia Botoula
- Department of Endocrinology, Diabetes and Metabolism, Evagelismos Hospital, Athens, Greece
| | - Nikolaos Athanasiou
- First Department of Critical Care Medicine & Pulmonary Services, Medical School of National & Kapodistrian University of Athens, Evagelismos Hospital, Athens, Greece
| | - Alexandros Zacharis
- First Department of Critical Care Medicine & Pulmonary Services, Medical School of National & Kapodistrian University of Athens, Evagelismos Hospital, Athens, Greece
| | | | - Edison Jahaj
- First Department of Critical Care Medicine & Pulmonary Services, Medical School of National & Kapodistrian University of Athens, Evagelismos Hospital, Athens, Greece
| | - Alice G. Vassiliou
- First Department of Critical Care Medicine & Pulmonary Services, Medical School of National & Kapodistrian University of Athens, Evagelismos Hospital, Athens, Greece
| | - Dimitra A. Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evagelismos Hospital, Athens, Greece
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine & Pulmonary Services, Medical School of National & Kapodistrian University of Athens, Evagelismos Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evagelismos Hospital, Athens, Greece
| | - Ioanna Dimopoulou
- First Department of Critical Care Medicine & Pulmonary Services, Medical School of National & Kapodistrian University of Athens, Evagelismos Hospital, Athens, Greece
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Karapanou O, Tzanela M, Rondogianni P, Dacou-Voutetakis C, Chiotis D, Vlassopoulou B, Vassiliadi D, Kanaka-Gantenbein C, Tsagarakis S. Long-term outcome of differentiated thyroid cancer in children and young adults: risk stratification by ATA criteria and assessment of pre-ablation stimulated thyroglobulin as predictors of disease persistence. Endocrine 2020; 70:566-574. [PMID: 32533509 DOI: 10.1007/s12020-020-02378-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/01/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Differentiated thyroid cancer (DTC) has an increasing incidence in childhood and adolescence but long-term outcome data are limited. We aimed to identify possible risk factors associated with disease persistence, with special focus on the usefulness of ATA risk stratification system and pre-ablation stimulated thyroglobulin (Tg) levels. METHODS We retrospectively studied 103 patients, 79 females (76.7%), aged 15.6 ± 3.2 years (range 5-21 years) who underwent total thyroidectomy for DTC. Patients were classified by ATA risk stratification criteria as low, intermediate, and high risk for recurrence. All, except five with papillary microcarcinoma, received radioactive iodine (RAI) treatment. RESULTS At diagnosis, 44.7% of patients had cervical lymph node and 7.8% pulmonary metastases. Amongst the 72 patients with long-term follow-up data, 31.9% had persistent disease. Lymph node as well as pulmonary metastases and increased pre-ablation stimulated thyroglobulin (Tg) levels were associated with persistent disease. The risk of persistent disease was significantly higher in both the intermediate- (OR 17.95; 95% CI 2.66-120.94, p < 0.01) and high-risk (OR 17.65; 95% CI 4.47-69.74, p < 0.001) groups. ROC curve analysis showed that a pre-ablation Tg level higher than 14 ng/ml had a sensitivity of 94.7% to predict persistence, corresponding to a positive (PPV) and negative predictive values (NPV) of 66.7% and 93.8%, respectively. CONCLUSIONS ATA risk stratification was validated in our population of children and young adults with DTC. Moreover, pre-ablation stimulated Tg levels of <14 ng/ml were associated with a low risk of long-term persistence and may therefore serve as a marker to identify patients who may need less intensive surveillance.
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Affiliation(s)
- Olga Karapanou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece.
| | - Marinella Tzanela
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece
| | - Phoebe Rondogianni
- Department of Nuclear Medicine, Evangelismos Hospital, 10676, Athens, Greece
| | - Catherine Dacou-Voutetakis
- Division of Endocrinology, Diabetes and Metabolism, First Department of Pediatrics, Faculty of Medicine, National and Kapodistrian University of Athens, Medical School, "Aghia Sofia" Children's Hospital, 11527, Athens, Greece
| | - Dimitrios Chiotis
- Division of Endocrinology, Diabetes and Metabolism, First Department of Pediatrics, Faculty of Medicine, National and Kapodistrian University of Athens, Medical School, "Aghia Sofia" Children's Hospital, 11527, Athens, Greece
| | - Barbara Vlassopoulou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece
| | - Dimitra Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece
| | - Christina Kanaka-Gantenbein
- Division of Endocrinology, Diabetes and Metabolism, First Department of Pediatrics, Faculty of Medicine, National and Kapodistrian University of Athens, Medical School, "Aghia Sofia" Children's Hospital, 11527, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece
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Martel-Duguech LM, Jorgensen JOL, Korbonits M, Johannsson G, Webb SM, Amadidou F, Mintziori G, Arosio M, Giavoli C, Badiu C, Boschetti M, Ferone D, Ricci Bitti S, Brue T, Albarel F, Cannavò S, Cotta OR, Carvalho D, Salazar D, Christ E, Debono M, Dusek T, Garcia-Centeno R, Ghigo E, Gasco V, Góth MI, Oláh D, Kovacs L, Höybye C, Kocjan T, Mlekuš Kozamernik K, Kužma M, Payer J, Medic-Stojanoska M, Novak A, Miličević T, Pekic S, Miljic D, Perez Luis J, Pico AM, Preda V, Raverot G, Borson-Chazot F, Rochira V, Monzani ML, Sandahl K, Tsagarakis S, Mitravela V, Zacharieva S, Zilaitiene B, Verkauskiene R. ESE audit on management of Adult Growth Hormone Deficiency in clinical practice. Eur J Endocrinol 2020; 184:EJE-20-1180.R1. [PMID: 33320830 DOI: 10.1530/eje-20-1180] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/14/2020] [Indexed: 11/08/2022]
Abstract
Guidelines recommend adults with pituitary disease in whom GH therapy is contemplated, to be tested for GH deficiency (AGHD); however, clinical practice is not uniform. AIMS 1) To record current practice of AGHD management throughout Europe and benchmark it against guidelines; 2) To evaluate educational status of healthcare professionals about AGHD. DESIGN On-line survey in endocrine centres throughout Europe. PATIENTS AND METHODS Endocrinologists voluntarily completed an electronic questionnaire regarding AGHD patients diagnosed or treated in 2017-2018. RESULTS Twenty-eight centres from 17 European countries participated, including 2139 AGHD patients, 28% of childhood-onset GHD. Aetiology was most frequently non-functioning pituitary adenoma (26%), craniopharyngioma (13%) and genetic/congenital mid-line malformations (13%). Diagnosis of GHD was confirmed by a stimulation test in 52% (GHRH+arginine, 45%; insulin-tolerance, 42%, glucagon, 6%; GHRH alone and clonidine tests, 7%); in the remaining, ≥3 pituitary deficiencies and low serum IGF-I were diagnostic. Initial GH dose was lower in older patients, but only women <26 years were prescribed a higher dose than men; dose titration was based on normal serum IGF-I, tolerance and side-effects. In one country, AGHD treatment was not approved. Full public reimbursement was not available in four countries and only in childhood-onset GHD in another. AGHD awareness was low among non-endocrine professionals and healthcare administrators. Postgraduate AGHD curriculum training deserves being improved. CONCLUSION Despite guideline recommendations, GH replacement in AGHD is still not available or reimbursed in all European countries. Knowledge among professionals and health administrators needs improvement to optimize care of adults with GHD.
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Affiliation(s)
| | - Jens Otto L Jorgensen
- J Jorgensen, Department of Clinical Medicine - The Department of Endocrinology and Diabetes, University hospital Arhus, Arhus, Denmark
| | - Marta Korbonits
- M Korbonits, Endocrinology, William Harvey Reserch Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Gudmundur Johannsson
- G Johannsson, Institute of Medicine, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden
| | - Susan M Webb
- S Webb, Medicine/Endocrinology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Fotini Amadidou
- F Amadidou, Endocrinology Department, Hippokration General Hospital, Thessaloniki, Greece
| | - G Mintziori
- G Mintziori, Department of Endocrinology and Metabolism, Hippokration General Hospital, Thessaloniki, Greece
| | - Maura Arosio
- M Arosio, Department of Clinical Sciences and Community Health, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudia Giavoli
- C Giavoli, Endocrinology, La Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico, Milano, Italy
| | - Corin Badiu
- C Badiu, Endocrinology, National Institute of Endocrinology, Bucharest, Romania
| | - Mara Boschetti
- M Boschetti, Centre of Excellence for Biomedical Research (CEBR), University of Genova, Genova, Italy
| | - Diego Ferone
- D Ferone, Centre of Excellence for Biomedical Research (CEBR), , University of Genova, Genova, Italy
| | - Silvia Ricci Bitti
- S Ricci Bitti, Department of Internal Medicine and Medical Specialties, University of Genoa, Genova, 16126, Italy
| | - Thierry Brue
- T Brue, Endocrinology, Assistance publique-Hôpitaux de Marseille , Hôpital de la Conception , Marseille, France
| | - F Albarel
- F Albarel, Institut national de la santé et de la recherche médicale (INSERM) U1251, Aix-Marseille Université, Marseille, 13005, France
| | | | - Oana Ruxandra Cotta
- O Cotta, Department of Human Pathology, University of Messina, Messina, Italy
| | - Davide Carvalho
- D Carvalho, Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal
| | - Daniela Salazar
- D Salazar, Endocrinology, Diabetes and Metabolism, Centro Hospitalar de São João EPE, Porto, Portugal
| | - Emanuel Christ
- E Christ, Interdisciplinary Endocrinology, ENETS Center of Excellence, Basel, Switzerland
| | - Miguel Debono
- M Debono, Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom of Great Britain and Northern Ireland
| | - Tina Dusek
- T Dusek, Division of Endocrinology, Dept of Internal Medicine-Rebro, University Hospital Center - Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Rogelio Garcia-Centeno
- R Garcia - Centeno, Endocrinology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ezio Ghigo
- E Ghigo, Division of Endocrinology, Diabetes and Metabolism, University of Turin, Torino, Italy
| | - Valentina Gasco
- V Gasco, Endocrinology, University of Turin, Turin, 10126, Italy
| | - Miklós I Góth
- M Góth, Division of Endocrinology, 2nd Dept. of Medicine, Health Center, Hungarian Defense Forces, Budapest, Hungary
| | - Dóra Oláh
- D Oláh, 2nd Dept. of Medicine, Health Center, Hungarian Defense Forces, Budapest, Hungary
| | - Laszlo Kovacs
- L Kovacs , Division of Endocrinology, 2nd Dept. of Medicine, Hungarian Defence Forces Medical Centre, Budapest, Hungary
| | - Charlotte Höybye
- C Höybye, Department of Molecular Medicine and Surgery, Endocrinology, Karolinska Institute, Stockholm, Sweden
| | - Tomaz Kocjan
- T Kocjan, Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre, Ljubljana, Slovenia
| | - Katarina Mlekuš Kozamernik
- K Mlekuš Kozamernik, Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Martin Kužma
- M Kužma, 5th Department of Internal Medicine, Comenius University Faculty of Medicine and University Hospital Bratislava, Bratislava, Slovakia
| | - Juraj Payer
- J Payer, 5th Department of Internal Medicine, Medical Faculty of Comenius University, University Hospital, Bratislava, Slovakia
| | - Milica Medic-Stojanoska
- M Medic-Stojanoska, Clinic of endocrinology, diabetes and metabolic disorders, Clinical Centre of Vojvodina, Novi Sad, Serbia
| | - Anela Novak
- A Novak, Endocrinology and Diabetes, University Hospital Center Split Križine, Split, Croatia
| | - Tanja Miličević
- T Miličević, Endocrinology Department, University Hospital Center Split Križine, Split, Croatia
| | - Sandra Pekic
- S Pekic, University of Belgrade, School of Medicine, Belgrade, 11000, Serbia
| | - Dragana Miljic
- D Miljic, Clinic for Endocrinology, Diabetes and Diseases of Metabolism, Clinical Center of Serbia, Beograd, Serbia
| | - Jesus Perez Luis
- J Perez Luis, Endocrinology, University Hospital of the Canary Islands, La Laguna, Spain
| | - Antonio M Pico
- A Pico, MEDICINA CLINICA, UNIVERSITY MIGUEL HERNANDEZ, ALICANTE, 03003, Spain
| | - Veronica Preda
- V Preda, Department of Endocrinology, Macquarie University, Sydney, 2109, Australia
| | - Gerald Raverot
- G Raverot, Federation d'endocrinologie, Hospices civils de Lyon, bron, 69677, France
| | - Francoise Borson-Chazot
- F Borson-Chazot, Faculte RTH Laennec, Universite Claude Bernard Lyon1, Lyon, F-69008, France
| | - Vincenzo Rochira
- V Rochira, Department of Biomedical, Metabolic and Neural Sciences, Unit of Endocrinology, Modena, 41126, Italy
| | - María Laura Monzani
- M Monzani, Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Kristian Sandahl
- K Sandahl, Department of Endocrinology/Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Stylianos Tsagarakis
- S Tsagarakis, Endocrinology, Evangelismos Athens General Hospital, Athens, Greece
| | - Vana Mitravela
- V Mitravela, Endocrinology Department, Evangelismos Athens General Hospital, Athens, Greece
| | - Sabina Zacharieva
- S Zacharieva, Clinical Center of Endocrinology and Gerontology, Medical University - Sofia, Sofia, Bulgaria
| | - Birute Zilaitiene
- B Zilaitiene, Department of endocrinology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rasa Verkauskiene
- R Verkauskiene, Institute of Endocrinology, Medical Academy, Lithuanian University of Health Sciencies, Kaunas, Lithuania
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Abstract
INTRODUCTION Pituitary gland is vulnerable to traumatic brain injury (TBI). As a result a series of neuroendocrine changes appear after head injury; in many occasions they reverse with time, while occasionally new late onset changes may develop. AREAS COVERED In this review, we focus on the prevalence of anterior and posterior pituitary hormonal changes in the acute and chronic post-TBI period in both children and adults. Moreover, we present evidence supporting the need for evaluating pituitary function along with the current suggestions for the most appropriate screening strategies. We attempted to identify all published literature and we conducted an online search of PubMed, from January 1970 to June 2020. EXPERT OPINION Adrenal insufficiency and water metabolism disorders are medical emergencies and should be promptly recognized. Awareness for long-term hormonal derangements is necessary, as they may lead to a series of chronic health issues and compromise quality of life. There is a need for well-designed prospective long-term studies that will estimate pituitary function during the acute and chronic phase after head injury.
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Affiliation(s)
- Georgia Ntali
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital , Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital , Athens, Greece
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Bancos I, Taylor AE, Chortis V, Sitch AJ, Jenkinson C, Davidge-Pitts CJ, Lang K, Tsagarakis S, Macech M, Riester A, Deutschbein T, Pupovac ID, Kienitz T, Prete A, Papathomas TG, Gilligan LC, Bancos C, Reimondo G, Haissaguerre M, Marina L, Grytaas MA, Sajwani A, Langton K, Ivison HE, Shackleton CHL, Erickson D, Asia M, Palimeri S, Kondracka A, Spyroglou A, Ronchi CL, Simunov B, Delivanis DA, Sutcliffe RP, Tsirou I, Bednarczuk T, Reincke M, Burger-Stritt S, Feelders RA, Canu L, Haak HR, Eisenhofer G, Dennedy MC, Ueland GA, Ivovic M, Tabarin A, Terzolo M, Quinkler M, Kastelan D, Fassnacht M, Beuschlein F, Ambroziak U, Vassiliadi DA, O'Reilly MW, Young WF, Biehl M, Deeks JJ, Arlt W. Urine steroid metabolomics for the differential diagnosis of adrenal incidentalomas in the EURINE-ACT study: a prospective test validation study. Lancet Diabetes Endocrinol 2020; 8:773-781. [PMID: 32711725 PMCID: PMC7447976 DOI: 10.1016/s2213-8587(20)30218-7] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Cross-sectional imaging regularly results in incidental discovery of adrenal tumours, requiring exclusion of adrenocortical carcinoma (ACC). However, differentiation is hampered by poor specificity of imaging characteristics. We aimed to validate a urine steroid metabolomics approach, using steroid profiling as the diagnostic basis for ACC. METHODS We did a prospective multicentre study in adult participants (age ≥18 years) with newly diagnosed adrenal masses. We assessed the accuracy of diagnostic imaging strategies based on maximum tumour diameter (≥4 cm vs <4 cm), imaging characteristics (positive vs negative), and urine steroid metabolomics (low, medium, or high risk of ACC), separately and in combination, using a reference standard of histopathology and follow-up investigations. With respect to imaging characteristics, we also assessed the diagnostic utility of increasing the unenhanced CT tumour attenuation threshold from the recommended 10 Hounsfield units (HU) to 20 HU. FINDINGS Of 2169 participants recruited between Jan 17, 2011, and July 15, 2016, we included 2017 from 14 specialist centres in 11 countries in the final analysis. 98 (4·9%) had histopathologically or clinically and biochemically confirmed ACC. Tumours with diameters of 4 cm or larger were identified in 488 participants (24·2%), including 96 of the 98 with ACC (positive predictive value [PPV] 19·7%, 95% CI 16·2-23·5). For imaging characteristics, increasing the unenhanced CT tumour attenuation threshold to 20 HU from the recommended 10 HU increased specificity for ACC (80·0% [95% CI 77·9-82·0] vs 64·0% [61·4-66.4]) while maintaining sensitivity (99·0% [94·4-100·0] vs 100·0% [96·3-100·0]; PPV 19·7%, 16·3-23·5). A urine steroid metabolomics result indicating high risk of ACC had a PPV of 34·6% (95% CI 28·6-41·0). When the three tests were combined, in the order of tumour diameter, positive imaging characteristics, and urine steroid metabolomics, 106 (5·3%) participants had the result maximum tumour diameter of 4 cm or larger, positive imaging characteristics (with the 20 HU cutoff), and urine steroid metabolomics indicating high risk of ACC, for which the PPV was 76·4% (95% CI 67·2-84·1). 70 (3·5%) were classified as being at moderate risk of ACC and 1841 (91·3%) at low risk (negative predictive value 99·7%, 99·4-100·0). INTERPRETATION An unenhanced CT tumour attenuation cutoff of 20 HU should replace that of 10 HU for exclusion of ACC. A triple test strategy of tumour diameter, imaging characteristics, and urine steroid metabolomics improves detection of ACC, which could shorten time to surgery for patients with ACC and help to avoid unnecessary surgery in patients with benign tumours. FUNDING European Commission, UK Medical Research Council, Wellcome Trust, and UK National Institute for Health Research, US National Institutes of Health, the Claire Khan Trust Fund at University Hospitals Birmingham Charities, and the Mayo Clinic Foundation for Medical Education and Research.
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Affiliation(s)
- Irina Bancos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Vasileios Chortis
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alice J Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Carl Jenkinson
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | | | - Katharina Lang
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Magdalena Macech
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Anna Riester
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Ivana D Pupovac
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Thomas G Papathomas
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Lorna C Gilligan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Cristian Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe Reimondo
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Turin, Turin, Italy
| | - Magalie Haissaguerre
- Department of Endocrinology, Hôpital Haut Lévêque, CHU de Bordeaux, Pessac, France
| | - Ljiljana Marina
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marianne A Grytaas
- Department of Clinical Science, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ahmed Sajwani
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Katharina Langton
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technical University, Dresden, Germany
| | - Hannah E Ivison
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Cedric H L Shackleton
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; UCSF Benioff Children's Hospital Oakland Research Institute, Oakland, CA, USA
| | - Dana Erickson
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Miriam Asia
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sotiria Palimeri
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Agnieszka Kondracka
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Ariadni Spyroglou
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Cristina L Ronchi
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Bojana Simunov
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Danae A Delivanis
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Robert P Sutcliffe
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ioanna Tsirou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Martin Reincke
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Stephanie Burger-Stritt
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Richard A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Letizia Canu
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Harm R Haak
- Department of Internal Medicine, Maxima Medisch Centrum, Eindhoven, Netherlands; Department of Health Services Research and CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technical University, Dresden, Germany
| | - M Conall Dennedy
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Grethe A Ueland
- Department of Clinical Science, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Miomira Ivovic
- Department for Obesity, Reproductive and Metabolic Disorders, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Antoine Tabarin
- Department of Endocrinology, Hôpital Haut Lévêque, CHU de Bordeaux, Pessac, France
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Turin, Turin, Italy
| | | | - Darko Kastelan
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, University of Würzburg, Würzburg, Germany; Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, University of Würzburg, Würzburg, Germany; Central Laboratory, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Felix Beuschlein
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany; Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zurich, Switzerland
| | - Urszula Ambroziak
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Michael W O'Reilly
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Michael Biehl
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, Netherlands
| | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK.
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Margaritopoulos D, Vassiliadi DA, Markou M, Evangelatou E, Tzanela M, Tsagarakis S. Suprasellar extension independently predicts preoperative pituitary hormone deficiencies in patients with nonfunctioning pituitary macroadenomas: a single-center experience. Hormones (Athens) 2020; 19:245-251. [PMID: 32124257 DOI: 10.1007/s42000-020-00183-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 02/13/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Nonfunctioning pituitary adenomas (NFPAs) are among the commonest benign tumors of the pituitary. Hypopituitarism is frequently present at the time of diagnosis, and this has been attributed to stalk portal vessel compression and/or destruction of normal anterior pituitary cells. The aim of our study was to examine possible factors at diagnosis associated with the presence of hypopituitarism. METHODS We retrospectively evaluated the records of patients with nonfunctioning pituitary macroadenomas from the database of our department. The inclusion criterion was the availability of imaging data regarding the extension of the lesion. RESULTS A total of 148 patients (89 men, 60.1%) with nonfunctioning macroadenomas and available imaging data were identified. Mean age at diagnosis was 56.0 ± 14.5 years, and hypopituitarism was found in 66.2%. The maximum diameter of the adenoma, the patient's age at diagnosis, and compression of the optic chiasm were significant factors predicting the presence of hypopituitarism (OR 1.077, p = 0.006; OR 1.025, p = 0.045; and OR 2.893, p = 0.042, respectively). Suprasellar adenomas with extension to adjacent sinuses, although larger than those with only suprasellar extension, did not differ as to the degree of hypopituitarism. Moreover, in suprasellar adenomas, prolactin levels, albeit not independently, were also related to hypopituitarism (OR 1.035, p = 0.045). CONCLUSIONS In patients with NFPAs, prognostic factors related to increased risk of hypopituitarism are age at diagnosis, size of the adenoma, and most importantly the presence of suprasellar extension. These data accentuate the necessity for surgical decompression in case of suprasellar extension, in order, apart from saving visual acuity, to possibly avoid or reverse hypopituitarism.
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Affiliation(s)
- Dimitris Margaritopoulos
- Department of Endocrinology Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece.
| | | | - Maria Markou
- Department of Endocrinology Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece
| | - Eirini Evangelatou
- Department of Endocrinology Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece
| | - Marinella Tzanela
- Department of Endocrinology Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece
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Abstract
PURPOSE OF REVIEW The current review provides a summary on the most recent developments regarding the cause, work-up and management of bilateral adrenal incidentalomas (BAI). RECENT FINDINGS The recent ENS@T/ESE guidelines provide comprehensive directions on the evaluation and management of patients with adrenal incidentalomas with special focus on those with bilateral tumours. Intraadrenal ACTH synthesis that may locally stimulate cortisol secretion challenging the traditionally used term 'ACTH-independent'. Inactivating mutations of a new tumour suppressor gene, armadillo repeat containing 5 (ARMC5), are implicated in a number of patients, especially those with multiple macronodules (bilateral macronodular hyperplasia) and evidence of hypercortisolism. Loss-of-function mutations of the glucocorticoid receptor gene (NR3C1) consist a new possible genetic cause of BAIs. Regarding management an increasing number of studies provide data on the benefits and safety of unilateral rather than bilateral adrenalectomy. There is also emerging data on the beneficial use of steroidogenesis inhibitors in a dosing schedule that aims to mimic the normal cortisol rhythm with promising short-term results, but the long-term clinical benefits of this approach remain to be demonstrated. SUMMARY The diagnostic approach consists of imaging and hormonal evaluation. Imaging characterization should be done separately for each lesion. Hormonal evaluation includes testing for primary aldosteronism, pheochromocytoma and evaluation for autonomous cortisol secretion, using the 1-mg overnight dexamethasone suppression test. Midnight cortisol or 24-h urinary-free cortisol may aid in establishing the degree of cortisol excess. In patients with hypercortisolism ACTH levels should be measured to establish ACTH-independency. The appropriate management of BAI associated with cortisol excess remains controversial. Bilateral adrenalectomy results in lifetime steroid dependency and is better reserved only for patients with overt and severe hypercortisolism. Unilateral adrenalectomy might be considered in selected patients. Medical therapy is not an established approach yet but it may be considered when control of hypercortisolism is desired, but surgery is not an option.
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Affiliation(s)
- Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes, and Metabolism, National Expertise Center for Rare Endocrine Disorders, Evangelismos Hospital, Athens, Greece
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Vassiliadi DA, Tsagarakis S. Cushing's disease: the desmopressin test as a compelling predictive marker of long-term remission after transsphenoidal surgery. Eur J Endocrinol 2020; 182:C17-C19. [PMID: 32234974 DOI: 10.1530/eje-20-0261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/01/2020] [Indexed: 11/08/2022]
Abstract
Transsphenoidal surgery (TSS) is the treatment of choice in Cushing's disease. However, recurrence rates are substantial and currently there are no robust predictors of late prognosis. As accumulating evidence challenge the accuracy of the traditionally used early postoperative cortisol values, alternative tests are required. The study of Cambos et al., published in a recent issue of the European Journal of Endocrinology, adds to the existing data that support a role of the desmopressin test as an early and reliable predictive marker in successfully TSS-treated patients. However, despite these promising data, the use of this test is hampered by the fact that it can be applied only in patients with a documented preoperative positive test. Moreover, the lack of robust criteria to define positive postoperative responses represents another major limitation.
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Affiliation(s)
- D A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - S Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
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Deutschbein T, Reimondo G, Dalmazi GD, Bancos I, Falhammar H, Tsagarakis S, Newell-Price J, Kastelan D, Stigliano A, Scaroni CM, Letizia C, Prete A, Morelli V, Ivocic M, Kaltsas G, Pazaitou-Panayiotou K, Hanzu FA, Loli P, Yener AS, Shafigullina Z, Langton K, Zacharieva S, Kocjan T, Terzolo M, Fassnacht M. OR25-05 Increased Overall Mortality and Cardiovascular Morbidity in Patients with Adrenal Incidentalomas and Autonomous Cortisol Secretion: Results of the ENS@T NAPACA-Outcome Study. J Endocr Soc 2020. [PMCID: PMC7207858 DOI: 10.1210/jendso/bvaa046.1640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective. Several smaller studies on adrenal incidentalomas (AI) suggested an association between autonomous cortisol secretion (ACS) and mortality (Di Dalmazi Lancet Diabetes Endocrinol 2014, Debono J Clin Endocrinol Metab 2014, Patrova Endocrine 2017). However, a recent meta-analysis (9 studies, 1356 patients) could not confirm these findings (Elhassan Ann Intern Med 2019). Aim. To investigate the effects of ACS on mortality, prevalence of cardiovascular (CV) risk factors, and (CV) morbidity, in a representative cohort of AI. Design. Retrospective observational study conducted at 27 ENS@T centers from 15 countries. Methods. Inclusion criteria: AI diagnosed 1996-2015, 1 mg dexamethasone suppression test, follow-up (FU) of ≥36 months, known survival status. Exclusion criteria: clinically relevant adrenal hormone excess (i.e. Cushing’s syndrome, pheochromocytoma, primary hyperaldosteronism), known malignancy. Patient stratification: serum cortisol after dexamethasone (>5 µg/dl, ACS; 1.9-5 µg/dl, possible ACS (PACS); ≤1.8 µg/dl, non-functioning adenoma (NFA)). Definition of CV events (CVE): hospitalization due to myocardial infarction and related interventions (PTCA, surgical bypass), stroke, deep vein thrombosis, pulmonary embolism. Results. 3640 patients (57% NFA, 36% PACS, 7% ACS) were considered eligible: 64% females; median age 61 years (range 18-91); median FU 84 months (36-277) (distribution between subgroups n.s.). 352 patients died during FU. Age- and sex adjusted overall survival was significantly reduced in patients with PACS (HR 1.55; 95%CI 1.24-1.94) and ACS (1.84; 1.29-2.61). Prevalence of CV risk factors were significantly higher in PACS and ACS than in NFA (hypertension: 72, 73, 57%, p<0.0001; dyslipidemia: 42, 49, 35%, p<0.0001; diabetes: 22, 25, 17%, p<0.0001) When adjusted to relevant confounders (i.e. age, sex, CV risk factors), time to first CVE was shorter in PACS (HR 1.36; 1.07-1.73) and ACS (HR 1.62; 1.10-2.40) compared to NFA. Conclusion. PACS and ACS are associated with increased overall mortality and CV morbidity. However, to prove causality a large randomized intervention trial is required.
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Giustina A, Barkan A, Beckers A, Biermasz N, Biller BMK, Boguszewski C, Bolanowski M, Bonert V, Bronstein MD, Casanueva FF, Clemmons D, Colao A, Ferone D, Fleseriu M, Frara S, Gadelha MR, Ghigo E, Gurnell M, Heaney AP, Ho K, Ioachimescu A, Katznelson L, Kelestimur F, Kopchick J, Krsek M, Lamberts S, Losa M, Luger A, Maffei P, Marazuela M, Mazziotti G, Mercado M, Mortini P, Neggers S, Pereira AM, Petersenn S, Puig-Domingo M, Salvatori R, Shimon I, Strasburger C, Tsagarakis S, van der Lely AJ, Wass J, Zatelli MC, Melmed S. A Consensus on the Diagnosis and Treatment of Acromegaly Comorbidities: An Update. J Clin Endocrinol Metab 2020; 105:5586717. [PMID: 31606735 DOI: 10.1210/clinem/dgz096] [Citation(s) in RCA: 166] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/04/2019] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Andrea Giustina
- Division of Endocrinology and Metabolism, San Raffaele University Hospital, Milan, Italy
| | - Ariel Barkan
- Division of Endocrinology, University of Michigan Health System, Ann Arbor, Michigan
| | - Albert Beckers
- Department of Endocrinology, University of Liège, Liège, Belgium
| | - Nienke Biermasz
- Division of Endocrinology and Center for Endocrine Tumors, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Beverly M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cesar Boguszewski
- SEMPR, Endocrine Division, Department of Internal Medicine, Federal University of Parana, Curitiba, Brazil
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Vivien Bonert
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Marcello D Bronstein
- Division of Endocrinology and Metabolism, Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil
| | - Felipe F Casanueva
- Division of Endocrinology, Santiago de Compostela University and Ciber OBN, Santiago de Compostela, Spain
| | - David Clemmons
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Annamaria Colao
- Division of Endocrinologia, Universita' Federico II di Napoli, Naples, Italy
| | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Maria Fleseriu
- Departments of Medicine and Neurological Surgery, Pituitary Center, Oregon Health & Science University, Portland, Oregon
| | - Stefano Frara
- Division of Endocrinology and Metabolism, San Raffaele University Hospital, Milan, Italy
| | - Monica R Gadelha
- Neuroendocrinology Research Center/Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ezio Ghigo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Turin, Turin, Italy
| | - Mark Gurnell
- University of Cambridge & Addenbrooke's Hospital, Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, United Kingdom
| | - Anthony P Heaney
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Ken Ho
- The Garvan Institute of Medical Research and St. Vincent's Hospital, Sydney, Australia
| | - Adriana Ioachimescu
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, and Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Laurence Katznelson
- Departments of Medicine and Neurosurgery, Stanford University School of Medicine, Stanford, California
| | | | - John Kopchick
- Edison Biotechnology Institute and Department of Biomedical Sciences, Ohio University, Athens, Ohio
| | - Michal Krsek
- 2nd Department of Medicine, 3rd Faculty of Medicine of the Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | | | - Marco Losa
- Department of Neurosurgery, San Raffaele University Health Institute Milan, Milan, Italy
| | - Anton Luger
- Division of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
| | - Pietro Maffei
- Department of Medicine, Padua University Hospital, Padua, Italy
| | - Monica Marazuela
- Department of Medicine, CIBERER, Universidad Autónoma de Madrid, Madrid, Spain
| | - Gherardo Mazziotti
- Endocrinology Unit, Humanitas University and Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Moises Mercado
- Division of Medicine, National Autonomous University of Mexico, Experimental Endocrinology Unit, Centro Médico Nacional, Siglo XXI, IMSS, Mexico City, Mexico
| | - Pietro Mortini
- Department of Neurosurgery, San Raffaele University Health Institute Milan, Milan, Italy
| | - Sebastian Neggers
- Pituitary Center Rotterdam, Endocrinology Section, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alberto M Pereira
- Division of Endocrinology and Center for Endocrine Tumors, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Manel Puig-Domingo
- Endocrinology Service, CIBER and CIBERES Germans Trias i Pujol Research Institute and Hospital, Autonomous University of Barcelona, Badalona, Spain
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes, and Metabolism and Pituitary Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ilan Shimon
- Endocrine Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Christian Strasburger
- Department of Medicine for Endocrinology, Diabetes and Nutritional Medicine, Charité Universitätsmedizin, Berlin, Germany
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - A J van der Lely
- Pituitary Center Rotterdam, Endocrinology Section, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - John Wass
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, United Kingdom
| | - Maria Chiara Zatelli
- Section of Endocrinology & Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Shlomo Melmed
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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Vassiliou AG, Stamogiannos G, Jahaj E, Botoula E, Floros G, Vassiliadi DA, Ilias I, Tsagarakis S, Tzanela M, Orfanos SE, Kotanidou A, Dimopoulou I. Longitudinal evaluation of glucocorticoid receptor alpha/beta expression and signalling, adrenocortical function and cytokines in critically ill steroid-free patients. Mol Cell Endocrinol 2020; 501:110656. [PMID: 31756425 DOI: 10.1016/j.mce.2019.110656] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/10/2019] [Accepted: 11/16/2019] [Indexed: 01/23/2023]
Abstract
PURPOSE Glucocorticoid actions are mediated by the glucocorticoid receptor (GCR) whose dysfunction leads to glucocorticoid tissue resistance. Our objective was to evaluate GCR-α and GCR-β expression and key steps in the GCR signalling cascade in critical illness. METHODS Expression of GCR and major GCR-target genes, cortisol, adrenocorticotropin (ACTH) and cytokines was measured in 42 patients on ICU admission and on days 4, 8, and 13. Twenty-five age- and sex-matched subjects were used as controls. RESULTS Acutely, mRNA expression of GCR-α was 10-fold and of GCR-β 3-fold the expression of controls, while during the sub-acute phase expression of both isoforms was lower compared to controls. Expression of FKBP5 and GILZ decreased significantly. Cortisol levels remained elevated and ACTH increased during the 13-day period. CONCLUSIONS GCR expression and hypothalamic-pituitary-adrenal axis function undergo a biphasic response during critical illness. The dissociation between low GCR expression and high cortisol implies an abnormal stress response.
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Affiliation(s)
- Alice G Vassiliou
- 1st Department of Critical Care Medicine & Pulmonary Services, GP Livanos and M Simou Laboratories, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Georgios Stamogiannos
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Edison Jahaj
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Efi Botoula
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Georgios Floros
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Ioannis Ilias
- Endocrine Unit, Elena Venizelou Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Marinella Tzanela
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stylianos E Orfanos
- 1st Department of Critical Care Medicine & Pulmonary Services, GP Livanos and M Simou Laboratories, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece; 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Kotanidou
- 1st Department of Critical Care Medicine & Pulmonary Services, GP Livanos and M Simou Laboratories, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece; 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Dimopoulou
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece.
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Abstract
Hypertension is one of the commonest chronic diseases contributing to cardiovascular disease. Idiopathic (primary) hypertension accounts for approximately 85% of the diagnosed cases, and 15% of hypertensive patients have other contributing conditions leading to elevated blood pressure (secondary hypertension). Endocrine hypertension is a common secondary cause of hypertension. The most common causes of endocrine hypertension are excess production of mineralocorticoids (ie, primary hyperaldosteronism), glucocorticoids (Cushing syndrome), and catecholamines (pheochromocytoma). After biochemical confirmation of hormonal excess, appropriate use of imaging modalities, both functional and anatomic, should occur for the diagnostic workup of these patients and for location of the source of hormonal excess.
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Affiliation(s)
- Danae A Delivanis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 45 Ipsilantou Street, Athens 106 76, Greece; Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Dimitra-Argyro Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 45 Ipsilantou Street, Athens 106 76, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 45 Ipsilantou Street, Athens 106 76, Greece.
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Valassi E, Tabarin A, Brue T, Feelders RA, Reincke M, Netea-Maier R, Tóth M, Zacharieva S, Webb SM, Tsagarakis S, Chanson P, Pfeiffer M, Droste M, Komerdus I, Kastelan D, Maiter D, Chabre O, Franz H, Santos A, Strasburger CJ, Trainer PJ, Newell-Price J, Ragnarsson O. High mortality within 90 days of diagnosis in patients with Cushing's syndrome: results from the ERCUSYN registry. Eur J Endocrinol 2019; 181:461-472. [PMID: 31480014 DOI: 10.1530/eje-19-0464] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/02/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Patients with Cushing's syndrome (CS) have increased mortality. The aim of this study was to evaluate the causes and time of death in a large cohort of patients with CS and to establish factors associated with increased mortality. METHODS In this cohort study, we analyzed 1564 patients included in the European Registry on CS (ERCUSYN); 1045 (67%) had pituitary-dependent CS, 385 (25%) adrenal-dependent CS, 89 (5%) had an ectopic source and 45 (3%) other causes. The median (IQR) overall follow-up time in ERCUSYN was 2.7 (1.2-5.5) years. RESULTS Forty-nine patients had died at the time of the analysis; 23 (47%) with pituitary-dependent CS, 6 (12%) with adrenal-dependent CS, 18 (37%) with ectopic CS and two (4%) with CS due to other causes. Of 42 patients whose cause of death was known, 15 (36%) died due to progression of the underlying disease, 13 (31%) due to infections, 7 (17%) due to cardiovascular or cerebrovascular disease and 2 due to pulmonary embolism. The commonest cause of death in patients with pituitary-dependent CS and adrenal-dependent CS were infectious diseases (n = 8) and progression of the underlying tumor (n = 10) in patients with ectopic CS. Patients who had died were older and more often males, and had more frequently muscle weakness, diabetes mellitus and ectopic CS, compared to survivors. Of 49 deceased patients, 22 (45%) died within 90 days from start of treatment and 5 (10%) before any treatment was given. The commonest cause of deaths in these 27 patients were infections (n = 10; 37%). In a regression analysis, age, ectopic CS and active disease were independently associated with overall death before and within 90 days from the start of treatment. CONCLUSION Mortality rate was highest in patients with ectopic CS. Infectious diseases were the commonest cause of death soon after diagnosis, emphasizing the need for careful clinical vigilance at that time, especially in patients presenting with concomitant diabetes mellitus.
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Affiliation(s)
- Elena Valassi
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University of Bordeaux, Bordeaux, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale INSERM U1251, Marseille Medical Genetics, Marseille, France and Assistance Publique Hôpitaux de Marseille (APHM), Hôpital de la Conception, Marseille, France
| | | | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Campus Innestadt, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Miklós Tóth
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
| | | | - Susan M Webb
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | | | - Philippe Chanson
- Univ Paris-Sud, Université Paris-Saclay UMR-S1185, Le Kremlin Bicêtre, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service de Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, Paris, France
- Institut National de la Santé et de la Recherche Médicale U1185, Le Kremlin Bicêtre, Paris, France
| | | | | | - Irina Komerdus
- Moscow Regional Research Clinical Institute n.a. Vladimirsky, Moscow, Russia
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Zagreb, Zagreb, Croatia
| | | | | | - Holger Franz
- Lohmann & Birkner Health Care Consulting GmbH, Berlin, Germany
| | - Alicia Santos
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - Christian J Strasburger
- Division of Clinical Endocrinology, Department of Medicine CCM, Charité-Universitätsmedizin, Berlin, Germany
| | - Peter J Trainer
- Department of Endocrinology, Christie Hospital, Manchester, UK
| | - John Newell-Price
- Academic Unit of Diabetes, Endocrinology and Reproduction, Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
| | - Oskar Ragnarsson
- Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and the Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Abstract
Primary bilateral macronodular adrenal hyperplasia (PBMAH) is a highly heterogeneous entity. The incidental identification of an increasing number of cases has shifted its clinical expression from the rarely encountered severe forms, regarding both cortisol excess and adrenal enlargement, to mild forms of asymptomatic or oligosymptomatic cases with less impressive imaging phenotypes. Activation of cAMP/PKA pathway, either due to alterations of the different downstream signaling pathways or through aberrantly expressed G-protein-coupled receptors, relates to both cortisol secretion and adrenal growth. Germline ARMC5 mutations are a frequent genetic defect. The diagnostic approach consists of both imaging and hormonal characterization. Imaging characterization should be done separately for each lesion. Endocrine evaluation in cases with clinically overt Cushing’s syndrome (CS) is similar to that applied for all forms of CS. In incidentally detected PBMAH, hormonal evaluation includes testing for primary aldosteronism, pheochromocytoma and evaluation for autonomous cortisol secretion, using the 1 mg overnight dexamethasone suppression test. Midnight cortisol or 24-h urinary free cortisol may aid in establishing the degree of cortisol excess. In patients with hypercortisolism, ACTH levels should be measured in order to establish ACTH independency. At variance with other forms of CS, PBMAH may be characterized by a distinct pattern of inefficient steroidogenesis. The appropriate management of PBMAH remains controversial. Bilateral adrenalectomy results in lifetime steroid dependency and is better reserved only for patients with severe CS. Unilateral adrenalectomy might be considered in selected patients. In cases where the regulation of cortisol secretion is mediated by aberrant receptors there is some potential for medical therapy.
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Affiliation(s)
- Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes, and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes, and Metabolism, Evangelismos Hospital, Athens, Greece
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Abstract
The ratio of human to bacterial cells in the human body (microbiota) is around 1:1. As a result of co-evolution of the host mucosal immune system and the microbiota, both have developed multiple mechanisms to maintain homeostasis. However, dissociations between the composition of the gut microbiota and the human host may play a crucial role in the development of type 2 diabetes. Metformin, the most frequently administered medication to treat patients with type 2 diabetes, has only recently been suggested to alter gut microbiota composition through the increase in mucin-degrading Akkermansia muciniphila, as well as several SCFA-producing (short-chain fatty acid) microbiota. The gut microbiota of participants on metformin has exerted alterations in gut metabolomics with increased ability to produce butyrate and propionate, substances involved in glucose homeostasis. Thus, metformin appears to affect the microbiome, and an individual's metformin tolerance or intolerance may be influenced by their microbiome. In this review, we will focus on the effects of metformin in gut microbiota among patients with T2DM.
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Affiliation(s)
- Natalia G Vallianou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos General Hospital, 45-47 Ipsilantou str, Athens, Greece.
| | - Theodora Stratigou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos General Hospital, 45-47 Ipsilantou str, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos General Hospital, 45-47 Ipsilantou str, Athens, Greece
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Abstract
PURPOSE It is estimated that approximately 69 million individuals worldwide will sustain a TBI each year, which accounts for substantial morbidity and mortality in both children and adults. TBI may lead to significant neuroendocrine changes, if the delicate pituitary is ruptured. In this review, we focus on the anterior pituitary hormonal changes in the acute post-TBI period and we present the evidence supporting the need for screening of anterior pituitary function in the early post-TBI time along with current suggestions regarding the endocrine assessment and management of these patients. METHODS Original systematic articles with prospective and/or retrospective design studies of acute TBI were included, as were review articles and case series. RESULTS Although TBI may motivate an acute increase of stress hormones, it may also generate a wide spectrum of anterior pituitary hormonal deficiencies. The frequency of post-traumatic anterior hypopituitarism (PTHP) varies according to the severity, the type of trauma, the time elapsed since injury, the study population, and the methodology used to diagnose pituitary hormone deficiency. Early neuroendocrine abnormalities may be transient, but additional late ones may also appear during the course of rehabilitation. CONCLUSIONS Acute hypocortisolism should be diagnosed and managed promptly, as it can be life-threatening, but currently there is no evidence to support treatment of acute GH, thyroid hormones or gonadotropins deficiencies. However, a more comprehensive assessment of anterior pituitary function should be undertaken both in the early and in the post-acute phase, since ongoing hormone deficiencies may adversely affect the recovery and quality of life of these patients.
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Affiliation(s)
- Georgia Ntali
- Department of Endocrinology and Diabetes, Evangelismos Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology and Diabetes, Evangelismos Hospital, Athens, Greece.
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Tampourlou M, Karapanou O, Vassiliadi DA, Tsagarakis S. Medical therapy for non-functioning pituitary tumors-a critical approach. Hormones (Athens) 2019; 18:117-126. [PMID: 30368687 DOI: 10.1007/s42000-018-0070-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 10/01/2018] [Indexed: 01/12/2023]
Abstract
Non-functioning pituitary adenomas (NFPAs) are the second most common variant of pituitary tumors. When symptomatic, primary therapy is surgery. Recurrence rates are high. Since many NFPAs express dopamine and somatostatin receptors, medical therapy has been used after surgery in order to prevent recurrence. So far, dopamine agonists have been more widely tested with some promise when introduced immediately after surgery but with less efficacy when introduced later upon tumor regrowth. Currently, the role of medical therapy to prevent tumor regrowth in NFPAs is limited by imprecisions as to final outcome and uncertainties concerning on patient selection, dosing, duration, and side effects.
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Affiliation(s)
- Metaxia Tampourlou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece.
| | - Olga Karapanou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
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Prete A, Taylor A, Alice S, Gilligan L, Vassiliadi D, Ambroziak U, Lang K, Kastelan D, Tabarin A, Dennedy M, Ueland G, Quinkler M, Masjkur J, Fassnacht M, Ivovic M, Terzolo M, Beuschlein F, Manolopoulos K, O'Reilly M, Tsagarakis S, Shackleton C, Deeks J, Bancos I, Arlt W. OR29-2 Mild Autonomous Cortisol Excess (MACE) in Adrenal Incidentalomas - Metabolic Risk Profile and Urinary Steroid Metabolome Analysis in 1208 Prospectively Recruited Patients. J Endocr Soc 2019. [PMCID: PMC6554888 DOI: 10.1210/js.2019-or29-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND: Adrenal incidentalomas (AI) are frequently associated with mild autonomous cortisol excess (MACE). The 1mg-dexamethasone suppression test (1mg-DST) differentiates MACE into MACE-1 (possible MACE; post-Dex cortisol 50-138 nmol/L) and MACE-2 (definitive MACE; post-Dex cortisol >138 nmol/L). MACE patients do not show clinically overt signs of hypercortisolism but are thought to carry a higher metabolic risk than nonfunctioning (NF) AIs. However, large-scale data about the metabolic impact of MACE are lacking. METHODS: We included 1208 patients with benign AIs and 1mg-DST results prospectively recruited as part of the ENSAT EURINE-ACT study. Clinical information and 24-h urines were available for all patients. Results of mass spectrometry-based urinary steroid profiling were compared to 162 healthy controls and 56 patients with overt adrenal Cushing’s syndrome (CUSH), using a sex- and age-adjusted linear regression model. RESULTS: MACE was found in 48% of adrenal incidentaloma patients (MACE-1 37%, MACE-2 11%), predominantly affecting women (NF 64%, MACE-1 67%, MACE-2 77%). MACE patients were significantly older than those with NF (p<0.001). MACE AIs were larger (median 32mm vs. 22mm in NF) and more often bilateral (31% vs. 17% in NF). The presence and grade of MACE were significantly linked to metabolic risk as assessed by prevalence of hypertension (NF 64%, MACE-1 75%, MACE-2 78%), type 2 diabetes (NF 20%, MACE-1 27%, MACE-2 30%), use of lipid-lowering medications (NF 40%, MACE-1 54%, MACE-2 52%), and osteopenia/osteoporosis (NF 37%, MACE-1 50%, MACE-2 56%) (all p<0.01 by Fisher’s exact test). Patients with MACE and type 2 diabetes more frequently required insulin treatment (31% vs. 15% in NF; p<0.01), and those with hypertension more often needed ≥3 medications (42% vs. 35% in NF; p<0.01). Urinary steroid metabolome analysis of MACE urines revealed a profile characterized by decreased androgen metabolites and increased glucocorticoid metabolites, resembling the profile of CUSH patients, with the latter also showing significantly increased mineralocorticoid precursor excretion (corticosterone and 11- deoxycorticosterone metabolites) (all p<0.001 vs. controls). CONCLUSIONS: MACE is highly prevalent in AIs and associated with an increased burden of metabolic co-morbidities. In addition, the similarities between the MACE and CUSH steroid metabolomes suggests that MACE is both a highly relevant clinical and biochemical entity.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, , United Kingdom
| | - Angela Taylor
- Clinical and Experimental Medicine, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, , United Kingdom
| | - Sitch Alice
- Institute of Applied Health Research, University of Birmingham, Birmingham, , United Kingdom
| | - Lorna Gilligan
- Floor 2, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, , United Kingdom
| | - Dimitra Vassiliadi
- Dept of Endo Metab Diab, Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, , Greece
| | - Urszula Ambroziak
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, , Poland
| | - Katharina Lang
- Centre for Endocrinology, Diabetes and Metabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, , United Kingdom
| | - Darko Kastelan
- Department of Endocrinology, Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, , Croatia
| | - Antoine Tabarin
- USN du Haut-Leveque, Serv Endo, Service d'Endocrinologie, Centre Hospitalier Universitaire, Hopital du Haut Leveque, Pessac, , France
| | - Michael Dennedy
- Pharmacology and Therpeutics, Department of Endocrinology, University Hospital Galway, Galway, , Ireland
| | - Grethe Ueland
- Department of Endocrinology, Haukeland University Hospital, Bergen, , Norway
| | | | - Jimmy Masjkur
- Department of Medicine III and Institute of Clinical Chemistry and Laboratory Medicine, Technische Universitat Dresden, Dresden, , Germany
| | - Martin Fassnacht
- Dept of Med I-Endo/Diab Unit, Department of Internal Medicine I, Endocrine and Diabetes Unit, University Hospital, University of Wuerzburg, Wuerzburg, , Germany
| | - Miomira Ivovic
- obesity,metabolic and reproductive disease, Department for Obesity, Reproductive and Metabolic Disorders, University of Belgrade, Belgrade, , Serbia
| | - Massimo Terzolo
- Dept of Clin and Biol Sci, Division of Internal Medicine I, University of Turin, San Luigi Hospital, Turin, , Italy
| | | | - Konstantinos Manolopoulos
- Institute of Metabolism and Systens Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, , United Kingdom
| | - Michael O'Reilly
- Centre for Endocrinology, Diabetes and Metabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, , United Kingdom
| | - Stylianos Tsagarakis
- Department of Endocrinology, Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, , Greece
| | - Cedric Shackleton
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, , United Kingdom
| | - Jonathan Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, , United Kingdom
| | - Irina Bancos
- Endocrinology, Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, , United Kingdom
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Vassiliou AG, Floros G, Jahaj E, Stamogiannos G, Gennimata S, Vassiliadi DA, Tsagarakis S, Tzanela M, Ilias I, Orfanos SE, Kotanidou A, Dimopoulou I. Decreased glucocorticoid receptor expression during critical illness. Eur J Clin Invest 2019; 49:e13073. [PMID: 30703253 DOI: 10.1111/eci.13073] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 09/27/2018] [Accepted: 01/01/2019] [Indexed: 01/07/2023]
Abstract
INTRODUCTION In critically ill patients, the hypothalamic-pituitary-adrenal axis is activated, resulting in increased serum cortisol concentrations. However, in some patients, especially those with sepsis, cortisol levels are relatively low for the degree of illness severity. Therefore, in the present project, we aim to characterize the time course of glucocorticoid receptor (GCR) alpha and beta expression in peripheral polymorphonuclear cells of critically ill septic or nonseptic patients using real-time PCR. DESIGN A prospective observational study conducted on 32 critically ill adults not receiving steroids, in a university-affiliated, multidisciplinary intensive care unit (ICU). Blood samples were collected for measurement of glucocorticoid receptor expression within 24-48 hours of admission to the ICU and at days 4, 8 and 13 after admission, reflecting the acute and chronic phase of the illness. RESULTS During ICU stay, patients expressed over time reduced levels of both GCR-α and GCR-β mRNA. More specifically, GCR-α mRNA expression was decreased fourfold 4 days after admission (P < 0.0001) and remained low up to 2 weeks after admission (P < 0.001). On the other hand, GCR-β mRNA levels remained stable shortly after admission, but approx. one week after admission, its levels decreased threefold (P < 0.01) and remained reduced up to 2 weeks after admission (P < 0.001). DISCUSSION Our results suggest that critically ill patients have highly variable expression of alpha and beta GCR, and moreover, the levels of both receptors decrease during ICU stay. Taken together, these might explain the differential responsiveness of patients to exogenous steroid administration or to endogenous cortisol secretion.
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Affiliation(s)
- Alice G Vassiliou
- 1st Department of Critical Care Medicine & Pulmonary Services, GP Livanos and M Simou Laboratories, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Georgios Floros
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Edison Jahaj
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Georgios Stamogiannos
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Sofianna Gennimata
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Marinella Tzanela
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Ioannis Ilias
- Endocrine Unit, Elena Venizelou Hospital, Athens, Greece
| | - Stylianos E Orfanos
- 1st Department of Critical Care Medicine & Pulmonary Services, GP Livanos and M Simou Laboratories, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece.,1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Kotanidou
- 1st Department of Critical Care Medicine & Pulmonary Services, GP Livanos and M Simou Laboratories, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece.,1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Dimopoulou
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
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Stratigou T, Vallianou N, Vlassopoulou B, Tzanela M, Vassiliadi D, Ioannidis G, Tsagarakis S. DKA cases over the last three years: has anything changed? Diabetes Metab Syndr 2019; 13:1639-1641. [PMID: 31336534 DOI: 10.1016/j.dsx.2019.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 03/13/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) has been related mainly to type 1 diabetes mellitus (T1DM). However, it is not solely related to T1DM. The purpose of this study was to assess the prevalence of DKA among type 1 and type 2 patients with diabetes mellitus, who were hospitalized in our Clinic due to DKA, as well as to determine the etiology beyond DKA. PATIENTS AND METHODS A cohort of 109 patients with DKA, 17-86 years of age, who were hospitalized in the Department of Endocrinology, Diabetes and Metabolism of our hospital between 2015 and 2017, were included in the study. RESULTS Among the 109 patients, 50 (45.9%) had mild DKA, 48 (44.1%) had moderate DKA, whereas 11 patients (10%) had severe DKA. Sixty-five patients (60%) developed DKA as the first manifestation of T1DM, 30 patients (27%) developed DKA in the context of type 2 diabetes (T2DM), mainly due to the co-existence of serious infections, 11 patients (10%) had T1DM, but had omitted their insulin dosages, and 3 patients (3%) developed DKA due to unknown reasons. CONCLUSIONS Most patients with DKA presented with mild and moderate DKA and only a minority presented with the severe form of the disease. The etiology of DKA was mainly T1DM and less frequent uncontrolled T2DM, usually due to the co-existence of severe infections, while only in a tiny minority, the causes remained unidentifiable.
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Affiliation(s)
- T Stratigou
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
| | - N Vallianou
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece.
| | - B Vlassopoulou
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
| | - M Tzanela
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
| | - D Vassiliadi
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
| | - G Ioannidis
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
| | - S Tsagarakis
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
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Stratigou T, Vallianou N, Koutroumpi S, Vlassopoulou B, Apostolou T, Tsagarakis S, Ioannidis G. Progression of Albuminuria Among Patients with Type 1 Diabetes Mellitus: A Long Term Observational Follow-up Study. Exp Clin Endocrinol Diabetes 2019; 129:276-282. [PMID: 30802917 DOI: 10.1055/a-0848-8076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The purpose of the present study was to determine whether patients with DM1 have shown improvement, stabilization or deterioration of their urine albumin excretion levels during a close follow-up. PATIENTS AND METHODS A cohort of 84 patients, 18-76 years of age, a median duration of diabetes of 24 years (1-50 years) and a median follow-up duration of 12 years (1-37 years) were included in the study. RESULTS Among the 84 patients for whom we had UAE levels at the beginning and by the end of the study, mean glycosylated hemoglobin was statistically significantly decreased during the follow-up period, from 8.02±2.04-7.06±1.05% (p=0.036). Normoalbuminuria was present in 66 patients and remained so in 56 patients while 9 patients progressed to microalbuminuria and one patient to macroalbuminuria by the end of the study. Microalbuminuria was present in 15 patients: regression was observed in 8 patients, and progression in one patient. Regression of macroalbuminuria to microalbuminuria was noted in one patient and to normoalbuminuria was noted in one participant, too. CONCLUSIONS Improvement of glycemic control with close monitoring of DM1 patients together with the appropriate use ACE or AT2 inhibitors and statins, seems to exert nephron-protective potential and to delay or even reverse the presence of micro/macroalbuminuria. This long term follow-up study has demonstrated a statistically significant increase in serum HDLcholesterol levels. The study also revealed that intensively treated diabetes patients may show reductions in serum ALP levels. Whether this finding is related to diabetic nephropathy, NAFLD, or diabetic hepatosclerosis remains to be assessed in future trials.
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Affiliation(s)
- Theodora Stratigou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Natalia Vallianou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stavroula Koutroumpi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Barbara Vlassopoulou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Theofanis Apostolou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - George Ioannidis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
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Vallianou N, Stratigou T, Koutroumpi S, Vlassopoulou B, Tsagarakis S, Ioannidis G. Autoimmune thyroiditis in patients with type 1 diabetes mellitus: A long-term follow-up study. Diabetes Metab Syndr 2019; 13:608-611. [PMID: 30641774 DOI: 10.1016/j.dsx.2018.11.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 11/13/2018] [Indexed: 02/07/2023]
Abstract
AIMS In type 1 diabetes mellitus and autoimmune thyroiditis, there seems to be common genetic loci. The purpose of the present study was to determine whether patients with type 1 diabetes had increased prevalence of autoimmune thyroiditis, and which factors were influencing the co-existence of these two clinical entities. PATIENTS AND METHODS A cohort of 256 patients, 18-79 years of age, a median duration of diabetes of 20 years and a mean follow-up duration of 13 years were included in the study. RESULTS Of the 256 patients with type 1 diabetes, 150 participants (58.6%) were women and 106 (41.4%) were men. One hundred and fifty-nine patients (64.6%) did not have autoimmune thyroiditis, whereas 97 (35.4%) had autoimmune thyroiditis, as was documented by the presence of anti-thyroid antibodies (anti-TPO and/or anti-TG). Of the 97 patients with both diabetes type 1 and autoimmune thyroiditis, 64 (66%) were women and 33 (34%) were men. Among the 97 patients who had both diabetes type 1 and autoimmune thyroiditis, 87 had abnormal levels of both anti-TPO and anti-TG, while 7 patients had subnormal levels of solely anti-TPO and only 3 patients had abnormal levels of only anti-TG. CONCLUSIONS There was a slightly higher prevalence of autoimmune thyroiditis among our patients with type 1 diabetes mellitus. Also, female sex was predominant, when compared to male sex, among the adult participants of this study. Therefore, regular screening of thyroid function and thyroid autoantibodies may be suggested for all patients with type 1 diabetes.
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Affiliation(s)
- Natalia Vallianou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece.
| | - Theodora Stratigou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stavroula Koutroumpi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Barbara Vlassopoulou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - George Ioannidis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
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Abstract
Alterations in the diversity or structure of gut microbiota known as dysbiosis, may affect metabolic activities, resulting in metabolic disorders, such as obesity and diabetes. The development of more sophisticated methods, such as metagenomics sequencing, PCR-denaturing gradient gel electrophoresis, microarrays and fluorescence in situ hybridization, has expanded our knowledge on gut microbiome. Dysbiosis has been related to increased plasma concentrations of gut microbiota-derived lipopolysaccharide (LPS), which triggers the production of a variety of cytokines and the recruitment of inflammatory cells. Metabolomics have demonstrated that butyrate and propionate suppress weight gain in mice with high fat diet-induced obesity, and acetate has been proven to reduce food intake in healthy mice. The role of prebiotics, probiotics, genetically modified bacteria and fecal microbiota transplantation, as potential therapeutic challenges for type 2 diabetes will be discussed in this review.
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Affiliation(s)
- Natalia G Vallianou
- Evangelismos General Hospital, Department of Endocrinology, Diabetes and Metabolism, Athens, Greece.
| | - Theodora Stratigou
- Evangelismos General Hospital, Department of Endocrinology, Diabetes and Metabolism, Athens, Greece
| | - Stylianos Tsagarakis
- Evangelismos General Hospital, Department of Endocrinology, Diabetes and Metabolism, Athens, Greece
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Vallianou N, Stratigou T, Paikopoulou A, Apostolou T, Vlassopoulou B, Tsagarakis S, Ioannidis G. Monitoring of patients with type 2 diabetes and nephropathy in a specialized diabetic nephropathy clinic seems to be beneficial. Diabetes Metab Syndr 2018; 12:689-692. [PMID: 29685824 DOI: 10.1016/j.dsx.2018.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 04/09/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the outcome of DM2 patients with nephropathy when they are under surveillance of a joined clinic run by endocrinologists & nephrologists. PATIENTS AND METHODS A cohort of 106 patients with DM2, 42-83 years of age, and eGFR < 60 ml/min/m2 were included. Age, sex, duration of diabetes, duration of attending our clinic, smoking habits, BMI, data regarding ischemic heart disease and induction of hemodialysis, urine albumin excretion (UAE) levels, eGFR (MDRD equation) and values of various biochemical parameters were recorded too. Follow-up period ranged from one to 25 years. Paired samples t-test and non-parametrical Kruskal-Wallis test were used for the analyses of the data. RESULTS Fifty percent of patients had no further progression, 25.9% improvement, while 24.1% had worsening of the UAE levels. During the follow-up in the joined clinic, there was a smaller than the expected from the medical literature decrease in median eGFR, i.e. 2,3 ml/min/m2 and a statistically significant improvement in glycosylated hemoglobin levels from 8.0% to 7.4% (p = 0.016). Time in years of follow-up in the joined clinic of our hospital appeared to be the most significant factor in the improvement or stabilization against deterioration of the UAE levels (p = 0.018). CONCLUSIONS Close follow-up of DM2 patients with eGFR < 60 ml/min/m2 has resulted in a minor annual eGFR decrease. Monitoring of these patients in a specialized diabetic nephropathy clinic is beneficial for this group of patients for delaying the occurrence of end-stage renal disease.
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Affiliation(s)
- N Vallianou
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece.
| | - T Stratigou
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
| | - A Paikopoulou
- Department of Nephrology, Evangelismos Hospital, Athens, Greece
| | - T Apostolou
- Department of Nephrology, Evangelismos Hospital, Athens, Greece
| | - B Vlassopoulou
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
| | - S Tsagarakis
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
| | - G Ioannidis
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
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Affiliation(s)
- D A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - S Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece.
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