HYPOTHALAMUS HYPOTHALAMICPITUITARY PORTAL SYSTEM CRH (+) ANTERIOR PITUITARY

(-)

(-)

POSTERIOR PITUITARY

ACTH Adrenal Fasiculata CORTISOL

Steroid Hormones
The following are all made from Cholesterol Mineralocorticoids, Glucocorticoids, Androgens, Estrogens, Progestogens In: Zona glomerulosa Zona fasciculata Zona reticularis respectively

Goals of Discussion
Review Adrenal Physiology Identify the clinical features of Adrenal Insufficiency Etiologies of Adrenal Insufficiency Understand testing of adrenal function Examine rationale behind Treatment of Adrenal Insufficiency

Adrenal Development
Cells of origin:
Cortex: Mesenchymal cells Medulla: Neuroectodermal cells

Fetal adrenal is present by 2 months gestation

Mostly cortex Glomerulosa and fasiculata are present at birth Reticularis develops during first year of life

Adrenal Anatomy
Adult adrenal
2-3cm wide 1cm thick 4-6 grams

Located
Upper pole of kidneys

Vascular supply
12 small arteries from aorta

Adrenal Physiology
Glomerulosa
15% of cortex releases Aldosterone
controlled by renin-angiotensin mechanism

Fasciculata
75% of cortex releases Cortisol, Corticosterone
under ACTH control

Reticularis
releases Androgens and Estrogens
under ACTH control

Medulla
releases Catecholamines

Synthesis of steroid hormones

Adrenal Physiology
ACTH and cortisol
Pulsatile secretion Highest in AM at wakening Lowest late afternoon and evening

Increase in response to stress

Hypoglycemia Surgery Illness Hypotension Smoking Cold exposure

DHEA and Androstenedione regulated by ACTH

Blunted response
Chronic illness

Cortisol
Principal glucocorticoid in plasma Circulates bound to Transcortin Plasma concentrations increased by oestrogens, including pregnancy and hormonal contraceptives Marked circadian variation Plasma corticosteroids: Mid night 3-10 g /100ml 0900 h 10-25 g /100ml Plasma aldosterone: Still a research procedure <0.02 g /100 ml urinary excretion <15 g /24 h

Circulation of Cortisol and Adrenal Androgens

Secreted unbound In circulation bind to plasma proteins Unbound is active Cortisol
Free: 10% Bound : 75% (to corticosteroid-binding globulin, CBG)) Albumin: 15%

Androgens
Albumin Sex Hormone binding (SHBG) Testosterone

Cortisol Effects
Connective Tissue
Inhibits fibroblasts Loss of collagen Thinning of skin

Calcium metabolism
Decreases intestinal calcium absorption Stimulates renal 1hydroxylase Increases 1,25 OH vitamin D synthesis Increases calciuria Increases phosphaturia

Bone
Inhibits bone formation Stimulates bone resorption Potentiates actions of PTH
Increased bone resorption

Cortisol Effects
Growth
Accelerates development of fetal tissues Lung maturity Inhibits linear growth Decreased growth hormone

Immunologic
Inhibits prostaglandin synthesis
Phospholipase A2

Erythrocytes
Minimal effect

Decreases IL-1
IL-1 stimulates CRH and ACTH

Leukocytes
Increases PMN by increasing release from bone marrow Decreases lymphocytes, monocytes and eosinophils

Impairs AB production and clearance

Cortisol Effects
Cardiovascular
Increases peripheral vascular tone Hypertension

Nervous system
Enters the brain Euphoria Irritability, depression and emotional lability Hyperkinetic or manic behavior Overt psychosis Increased appetite Impaired memory or concentration Decreased libido Insomnia
Decreased REM and increased Stage II sleep

Renal function
Effects on mineralocorticoid receptors
Na retention Hypokalemia HTN

Effects on Glucocorticoid receptors

Increased GFR

Cortisol Effects Metabolism

Glycogen
Activates glycogen production\ Deactivates glycogen breakdown

Lipids
Activates lipolysis in adipose tissue Redistributes body fat Sparing of the extremities

Glucose
Increases hepatic glucose production Inhibits peripheral tissue utilization of glucose

Adrenocortical Hyperactivity:
Causes Hyperplasia of adrenal cortex Tumour of adrenal cortex Both may be secondary to increased ACTH secretion Cushings syndrome: Increased secretion of cortisol Often associated with abolition of circadian rhythm of and ACTH secretion Overactive anterior pituitary Non-endocrine: Carcinoma of the bronchus with ectopic ACTH Symptoms Insulin resistant diabetes and glycosuria Cessation of growth Muscular wasting Osteoporosis Moon face and buffalo hump

Biochemical effects of adrenal hyperactivity

Moderate alkalosis Sodium and water retention Low plasma potassium Hypertension Lymphopenia Eosinopenia Adrenal androgen secretion little /or not altered .

Synthesis of steroid hormones

Congenital Adrenal Hyperplasia

Most adrenal biosynthetic defects result in:
Virilized female Normally virilized male Deficiencies: Mineralocorticoid Glucocorticoid 21-OHase deficiency 11-OHase deficiency

Congenital Adrenal Hyperplasia

Deficiency of CYP 17
17- hydroxylase and 17-20 lyase deficiency Rare cause Diagnosed due to delayed pubertal development Female: 46xx
Hypertensive +/- Hypokalemic Primary amenorrhea Absent secondary sex characteristics

Congenital Adrenal Hyperplasia

Deficiency of CYP 17
Male: 46XY
Complete male pseudohermaphroditism Female external genitalia Blind-ended vagina No mullerian structures Testes intra-abdominal Leydig cell hyperplasia Hypertensive +/- Hypokalemic

Cortisol sufficient
Tolerates general anesthesia and surgery

Treatment
Steroids to suppress excess ACTH Gonadal steroids replacement

Congenital Adrenal Hyperplasia

3 -Hydroxysteroid Dehydrogenase
Presents early infancy Adrenal insufficiency Females can be virilized due to DHEA Males
Normal genital development Hypospadias Pseudohermaphroditism

Females: Can present in puberty with:

Hyperandrogenemia
Hirsuitism Oligomenorrhea

Treatment
Cortisol replacement

Congenital Adrenal Hyperplasia

Steroidogenic Acute Regulatory Protein (StAR)

Congenital Lipoid Adrenal Hyperplasia StAR Deficiency

Transports cholesterol to inner mitochondrial membrane

Rarest form Autosomal recessive All adrenal steroids are deficient Present with adrenal insufficiency Typically fatal infancy Males
Female external genitalia

Renin and Aldosterone

Renin
Enzyme released from the kidneys (macula densa) Activates Angiotensinogen Angiotensin 1 Angiotensin 2 Increased secretion
Low blood pressure Low sodium High potassium Upright posture

Aldosterone
Sodium homeostasis Regulates arterial pressure Regulated
Angiotensin 2

Increases
Renal sodium retention Renal potassium excretion

Low Aldosterone
Adrenal insufficiency
High renin

Hyperkalemia

Renin and Aldosterone

Tumours of the adrenal cortex

Benign tumours produce one hormone Malignant tumours can produce a number of hormones Urinary excretion of corticosteroids and 17oxosteroids are often both increased to more than 50mg /24 h

Primary Aldosteronism (Conns syndrome)

Tumours producing only excess aldosterone Sodium retention Hypokalaemia due to urinary and intestinal potassium loss Muscular weakness, alkalosis, polyuria and hypertension Confirmation: High urinary aldosterone Response to aldosterone antagonist: Spironolactone

Secondary aldosteronism
Found in conditions where there is loss of sodium from extra-cellular fluid such as: Nephrotic syndrome Cirrhosis and ascites Congestive heart failure In all the above, hypokalaemia is rare and plasma renin is increased

Adrenocortical Hypoactivity
May result from hypopituitarism Aldosterone secretion is maintained so that Na+ / K + balance is little altered

Adrenal Hypofunction
Primary lesion of the adrenal glands due to: Destructive or atrophic disease; tuberculous, fungal or auto-immune Deficiency of all adrenocortical hormones Excess urinary Na+ and Cl- loss and K+ retention Low renal plasma flow is the result of Na + deficiency and hypotension leading to prerenal azotaemia (high plasma urea)

Addisons Disease
Other features: Asthenia Loss of weight Hypotension Gastro-intestinal disturbances Skin pigmentation due to excess ACTH secretion (melanophore expansion) Simple screening test: Failure to excrete a water load; contraindicated in low serum sodium Low urinary 17-oxosteroids Increased glucose utilization/ decreased gluconeogenesis hypoglycaemia

Acute Adrenal Insufficiency

Causes : Addisons Long term corticosteroid administration Waterhouse-Friederichsens syndrome in meningococcal septicaemia Results: Severe Sodium and Water depletion Hypotension Hypoglycaemia

Flow of information, Synthetic glucocorticoids, Cortisol Binding Globulin (CBG)

Flow of info: CRFACTH Cortisol Prednisolone and dexamethasone reduce the secretion CRF In circulation glucocorticoids are about 90% bound to proteins; the main protein being CBG Metabolism Glucuronides 17-hydroxy metabolites

The response to stress

Mediated by CRF and ACTH Stimuli include surgical operations Emotional stress Insulin hypoglycaemia

Circadian Rhythm
The circadian rhythm of plasma cortisol is related to the rhythm of an individuals sleeping-waking cycle. The pathway for its control also depends on the CRF and ACTH. Stimulation of the adrenals by ACTH leads to the increased release of stored cortisol, androgens and oestrogens There is also increased new synthesis of cortisol Long term response is an increase in the sensitivity of the gland and hypertrophy of the adrenal cortex

Plasma cortisol
Specimens must be collected at standard times (0800 h and 2200 h) because of the nychthemeral rhythm) The most reliable reference ranges have been defined for these times (160-565 nmol/L) at 800 h and less than 205 nmol/L at 2200 h

 Early in the overproduction of cortisol, the 0800 h plasma level still remains within the reference range but the 2200 h value increases much above 205 nmol/L

Tests of glucocorticoid metabolism

KINDS OF TESTS: PLASMA/URINE TESTS: Used in the first place to support a clinical diagnosis of hypofunction or hyperfunction of the adrenal cortex STIMULATION/SUPPRESSION: Further tests which may provide information about the nature of the disease process

Important points to observe when collecting specimens for measuring plasma cortisol

Anxiety: large increases in plasma cortisol may be observed in response to emotional stress Venous stasis: must be avoided because cortisol is bound to protein (CBG) Storage: Blood: 4C, do not freeze for short periods. If analysis is to be delayed more than 12h plasma should be separated immediately and then frozen

Cortisol-binding globulin
Increased in : Pregnancy Patients taking oestrogens and oestrogen containing oral contraceptives Decreased in: Hypoproteinaemic states e.g. nephrotic syndrome Salivary cortisol represents plasma unbound cortisol

Plasma ACTH
Only a few specialized laboratories do plasma ACTH (Follow detailed instructions for collecting, preserving and transporting the specimens) Specimens to be collected at 0800 h and 2200 h Stress should be avoided

Lipotrophin (LPH)
Secreted by the anterior pituitary in response to the same stimuli as cause release of ACTH There are therefore parallel changes in plasma concentrations of these two compounds LPH is more stable than ACTH and its plasma measurement offers some advantages over that of ACTH

Urinary glucocorticoids and metabolites

Urinary free cortisol (measures plasma free unbound cortisol-the level of active hormone to which the tissues are exposed) Urinary 17-hydroxycorticosteroids (17-OHCS)(almost the same group of compounds as urinary 17-oxogenic steroids -17OGS, metabolites of cortisol, 11deoxycortisol, 17-hydroxyprogesterone). Urinary 17OHCS and 17-OGS now virtually obsolete (Many drugs-metabolites of anti-hypertensive agents, cardiac glycosides and tranquilizers interfere with the determinations)

Urinary 17-OS
This comprises a group of metabolites formed mainly from androgens- adrenal or testicular or ovarian in origin about 5%-10% of cortisol is metabolized to 17-OS Since immunological tests are now available for individual androgens this test is also virtually obsolete

Investigation of disorders of Glucocorticoid Production

Screening tests. Is a disorder of adrenocortical function (hypofunction or hyperfunction a possibility?) Confirmatory tests. How can the provisional diagnosis be confirmed or excluded Determining the cause. If adrenal cortical dysfunction is confirmed; (a) what is the site of the pathological lesion? Adrenal cortex, pituitary or elsewhere? (b) what is the nature of the pathological lesion?

Screening tests
Dexamethazone or Bethamethazone Urinary free cortisol: creatinine ratio All performed on out-patient basis

Overproduction of cortisol suspected

Overproduction of cortisol suspected Screening tests on outpatients Tests to confirm there is overproduction of cortisol (inpatient procedures) Tests to identify the cause of Cushings Syndrome Dexamethasone screening test or Urinary free cortisol: creatinine ratio Loss of nychthemeral rhythm of plasma cortisol 24 h excretion of cortisol in the urine Insulin hypoglycaemia test Low dose dexamethasone test Plasma ACTH High dose dexamethasone test Metyrapone test

Dexamethazone screening test excluding the diagnosis of Cushings syndrome

Patient takes a 2 mg tablet of dexamethazone (or betamethazone) at 2200 h the night before the test Blood sample for plasma cortisol is collected the following morning at 0900 h (ref range 160-565 nmol/L Normal response: suppression of plasma cortisol to 150 nmol/L or less

Dexamethazone suppression test

Patients with simple obesity respond to the 2 mg dexamethazone or betamethazone but in patients with Cushings syndrome plasma cortisol may be 300 nmol/L If the dexamethazone suppression test is normal there is no need for further tests If it is abnormal, the patient will need further tests to 1. confirm the diagnosis 2. To determine the site of the lesion

Confirmation of cortisol overproduction

Loss of nychthemeral rhythm Increased 24 h excretion of urinary free cortisol Insulin-hypoglycaemia low dose dexamethasone

Stress tests for the HPA axis

Insulin-hypoglycaemia test: Fast overnight, sol insulin 0.15 u/kg bdy wt i.v., sampling for cortisol at 30, 45, 60, and 90 min The most widely used stress test of HPA integrity Plasma glucose is reduced The adrenals respond by increasing production of cortisol which is measured The test is contra-indicated in patients with epilepsy or heart disease The test is ended by giving the patient a glucose containing meal and a drink

Method: A mid-night sample is collected for diurnal rhythm studies. 0900h: Collect 10ml heparinized blood for corticosteroid (cortisol baseline) assay Inject I.M. 250 g Tetracosactrin in 0.5 ml water 0930h: Collect blood for corticosteroid (cortisol) assay.

Tetracosactrin (Syncotropin, Synacthen) Test

Tetracosactrin test
Interpretation: (values may be given in nmol/L) In a normal subject the baseline value is more than 7 g /100ml and there is an increase of at least 10 g / 100ml over the baseline at 30min In Addisons disease there is a low baseline and less than 5g / 100ml response to tetracosactrin In hypopituitarism there may be a subnormal rise at 30min In Cushings syndrome (hyperplasia) there may be an exaggerated response. This does not occur when there is a tumour

Depot or Prolonged ACTH stimulation..1

This gives a greater stimulus than the Tetracosactrin test Method. Control period: Collect a 24h specimen of urine for corticosteroid analysis (0800h -0800h) First test day: At 0800h and 2000h inject S.C. 50u of ACTH gel Second and third days: Repeat the injections and urine collection as on the first day

Prolonged ACTH stimulation..2

Interpretation In a normal adult there is a rise in corticosteroid excretion over the control value of at least about 30 mg /24h by the second or third test days In Cushings syndrome due to hyperplasia, there is often an exaggerated response over 60 mg /24h. This does not occur if there is a tumour

Prolonged ACTH stimulation..3

Interpretation In Addisons disease, there is usually a low value for the control excretion followed by an absent or very low rise In hypopituitarism there is usually a delayed rise

Dexamethasone suppression test..1

Dexamethasone is a synthetic steroid which inhibits ACTH secretion and suppresses the plasma and urinary corticosteroids in normal subjects The test is used to differentiate adrenal hyperplasia from tumour Method Collect 24h urine samples for baseline corticosteroid estimation for 2 days (days 1 & 2) Collect blood samples for baseline corticosteroid estimation at 0900h for 2 days (days 1 & 2)

Dexamethasone suppression test..2

Dexamethasone is given 6 hourly in 0.5 mg oral doses for 8 doses (days 3 & 4) followed by 2 mg oral doses 6 hourly for 8 doses (days 5 & 6) 24 h urine samples are collected for corticosteroid estimations while on dexamethasone (days 3, 4, 5, & 6) Blood samples are collected for corticosteroid assays preceding the dexamethasone doses on days 4,5,6 and 7

Dexamethasone suppression test..3

Interpretation In a normal subject, the urine and plasma corticosteroids are suppressed on the lower dosage below 50% of the baseline values. On the lower dose of dexamethasone, patients with Cushings syndrome will show no suppression irrespective of the cause On the higher dose, those with hyperplasia, have a 50% or more suppression, while those with adenoma or carcinoma are unaffected

Metyrapone Test..1
Metyrapone (Metapirone) blocks the actions of the enzyme 11 hydroxylase in the adrenal cortex, thus inhibiting cortisol synthesis. This triggers the feed-back mechanism, causing excess ACTH secretion. The result is excess adrenocortical secretion of 11-deoxycortisol, which is measured as a urinary corticosteroid. The test is used for investigating hypothalamic or anterior pituitary deficiency

Metyrapone Test..2
Method: Collect 24-h urine samples for baseline corticosteroid estimation for two days (days 1 & 2) Metyrapone is given 4 hourly in 750mg oral doses for 6 doses (day 3) Collect 24-h urine samples for corticosteroid estimation on day of and after Metyrapone administration (days 3 & 4)

Metyrapone Test..3
Interpretation A normal subject shows an increase in urine corticosteroid values of at least 10 mg /24 h or a two-fold increase above the resting level. A subnormal response in the presence of normal adrenocortical function shows deficiency at the level of hypothalamus or anterior pituitary Patients with autonomous tumours of the adrenal cortex fail to show a response