Selective Glucocorticoid Replacement Following Unilateral Adrenalectomy for Hypercortisolism and Primary Aldosteronism

2021 ◽  
Author(s):  
Olivia M DeLozier ◽  
Sophie Y Dream ◽  
James W Findling ◽  
Ty B Carroll ◽  
Douglas B Evans ◽  
...  
Keyword(s):  
At Risk ◽  
Primary Aldosteronism ◽  
Preoperative Evaluation ◽  
Unilateral Adrenalectomy ◽  
Basal Cortisol ◽  
Patients At Risk ◽  
Life Threatening ◽  
Suppression Test ◽  
Dexamethasone Suppression ◽  
Prospective Database

Abstract Background An institutional study previously demonstrated that cosyntropin stimulation testing on postoperative day 1 (POD1-CST) identified patients at risk for adrenal insufficiency (AI) following unilateral adrenalectomy (UA) for adrenal-dependent hypercortisolism (HC) and primary aldosteronism (PA), allowing for selective glucocorticoid replacement (GR). This study reevaluates the need for GR following UA for patients with HC and PA in a larger cohort. Methods A prospective database identified 108 patients who underwent UA for mild autonomous cortisol excess (MACE) (n=47), overt hypercortisolism (OH) (n=27), PA (n=22), and concurrent PA/HC (n=12) from 9/2014-10/2020; all underwent preoperative evaluation for HC. MACE was defined as 1mg dexamethasone suppression test (DST) cortisol >1.8 (μg/dL), with ≥5 defined as OH. GR was initiated for basal cortisol ≤5 or stimulated cortisol ≤14 (≤18 prior to 4/2017) on POD1-CST. Results Fifty-one (47%) patients had an abnormal POD1-CST; 54 (50%) were discharged on GR (27 MACE, 20 OH, 1 PA, 6 PA/HC). Median duration of GR was OH: 6.0 months, MACE: 2.1 months, PA: 1 month, PA/HC: 0.8 months. Overall, 26% (n=7) of OH patients and 43% (n=20) of MACE patients did not require GR. Two (2%) OH patients had normal POD1-CST but developed AI several weeks postoperatively requiring GR. None experienced life-threatening AI. Conclusion POD1-CST identifies HC patients at risk for AI after UA, allowing for selective GR. One-quarter of OH patients and nearly half of MACE patients can forego GR after UA. PA patients do not require evaluation for AI if concurrent HC has been excluded preoperatively.

scholarly journals Confirmation of Feasibility of Selective Glucocorticoid Replacement Following Unilateral Adrenalectomy for Hypercortisolism and Primary Aldosteronism

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A80-A81
Author(s):  
Olivia Mallory DeLozier ◽  
Sophie Y Dream ◽  
James W Findling ◽  
Ty Brian Carroll ◽  
Douglas B Evans ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Primary Aldosteronism ◽  
Preoperative Evaluation ◽  
The Other ◽  
Standard Protocol ◽  
Secondary Adrenal Insufficiency ◽  
Unilateral Adrenalectomy ◽  
Normal Test ◽  
Basal Cortisol ◽  
Cortisol Levels

Abstract Background: Secondary adrenal insufficiency (AI) can develop following unilateral adrenalectomy (UA) foradrenal-dependent hypercortisolism (HC) and has been reported after UA for primaryaldosteronism (PA). An institutional study previously demonstrated that cosyntropin stimulationtesting on postoperative day 1 (POD1-CST) successfully identified patients who requiredglucocorticoid replacement (GR) following UA; 50% of HC patients required GR and no PApatients required GR. The aim of this study was to reevaluate the need for GR following UA forpatients with HC and PA in a larger cohort of patients. Methods We reviewed 108 patients from a prospectively maintained adrenal database who underwent UAfor HC (n=74), PA (n=22), and concurrent HC/PA (n=12) from 9/2014-10/2020. PA patientswithout preoperative evaluation for HC were excluded. Patients with 1mg dexamethasonesuppression test (DST) cortisol >1.8 (µg/dL) were defined as having mild HC, with ³5 defined asovert Cushing’s Syndrome (CS). All patients underwent our institutional POD1-CST protocoland GR was initiated for patients with basal cortisol £5 or stimulated cortisol £14 (<18 prior to4/2017). Results: Overall, 51 (47%) patients had an abnormal POD1-CST and were discharged on GR (44 HC, 1PA, and 6 HC/PA). Two (2%) patients with CS had a normal POD1-CST but developed AIrequiring GR at 8 and 12 weeks post UA. Of the 74 patients with HC, 44 (59%) had an abnormalPOD1-CST and were discharged on GR, including 19/28 (68%) with CS and 25/46 (54%) withmild HC. Preoperative DST cortisol was higher in HC patients who required GR compared topatients with a normal POD1-CST (4.1 vs 3.6; p=0.007). Median cortisol levels for HC patientswith an abnormal POD1-CST vs those with a normal test were: basal: 3.8 vs 15.6 (p=0.027); 30-minute: 10.1 vs 20.1 (p=0.403); and 60-minute 11.4 vs 22.2 (p=0.260). Of the 22 PA patients, 19(86%) had a normal POD1-CST. Median cortisol levels for PA patients with an abnormal POD1-CST vs those with a normal test were: basal: 0.4 vs 12.1; 30-minute: 8.8 vs 24.6; and 60-minute:12.2 vs 28.9. Of the 3 (14%) PA patients with an abnormal POD1-CST, 1 was dischargedwith GR and began tapering after 2 weeks; the other 2 did not require GR and did not developAI. Of the 12 patients with combined PA/HC, 6 (50%) were discharged on GR based on POD1-CST. GR was required by 30 (59%) patients for <3 months and 82% for <12 months; 7/9 whorequired GR >12 months had CS. Conclusions: Using a standard protocol for POD1-CST in patients who underwent unilateral adrenalectomyfor HC, PA, or combined PA/HC, this study demonstrated that routine GR is not required in 32%of patients with CS and 46% of patients with mild HC. POD1-CST safely identifies patients whowill require GR with no immediate concern for adrenal insufficiency. These data also suggestthat routine evaluation for AI in postoperative PA patients is not needed if cortisol excess hasbeen excluded preoperatively.

scholarly journals Hypothalamic-pituitary-adrenal axis function in patients with bipolar disorder

2004 ◽  
Vol 184 (6) ◽  
pp. 496-502 ◽  
Author(s):  
Stuart Watson ◽  
Peter Gallagher ◽  
James C. Ritchie ◽  
I. Nicol Ferrier ◽  
Allan H. Young
Keyword(s):  
Bipolar Disorder ◽  
Hpa Axis ◽  
Cortisol Response ◽  
Hypothalamic Pituitary Adrenal ◽  
The Core ◽  
Basal Cortisol ◽  
Suppression Test ◽  
Cortisol Levels ◽  
Dexamethasone Suppression ◽  
Pituitary Adrenal Axis

BackgroundHypothalamic-pituitary-adrenal (HPA) axis function, as variously measured by the responses to the combined dexamethasone/ corticotrophin-releasing hormone (dex/ CRH) test, the dexamethasone suppression test (DST) and basal cortisol levels, has been reported to be abnormal in bipolar disorder.AimsTo test the hypothesis that HPA axis dysfunction persists in patients in remission from bipolar disorder.MethodSalivary cortisol levels and the plasma cortisol response to the DST and dex/CRH test were examined in 53 patients with bipolar disorder, 27 of whom fulfilled stringent criteria for remission, and in 28 healthy controls. Serum dexamethasone levels were measured.ResultsPatients with bipolar disorder demonstrated an enhanced cortisol response to the dex/CRH test compared with controls (P=0.001). This response did not differ significantly between remitted and non-remitted patients. These findings were present after the potentially confounding effects of dexamethasone levels were accounted for.ConclusionsThe dex/CRH test is abnormal in both remitted and non-remitted patients with bipolar disorder. Thismeasure of HP Aaxis dysfunction is a potential trait marker in bipolar disorder and thus possibly indicative of the core pathophysiological process in this illness.

scholarly journals The liver as an organ at risk for Toxoplasma transmission during transplantation: myth or reality?

2018 ◽  
Vol 71 (9) ◽  
pp. 763-766 ◽  
Author(s):  
Brice Autier ◽  
Sarah Dion ◽  
Florence Robert-Gangneux
Keyword(s):  
At Risk ◽  
Parasite Load ◽  
Liver Weight ◽  
Parasite Strain ◽  
Serological Screening ◽  
Patients At Risk ◽  
Life Threatening ◽  
Frequent Site ◽  
Organ At Risk ◽  
The Brain

AimToxoplasmosis following liver transplant with donor–recipient mismatch is rare, but is often life-threatening. However, there are no data on the frequency of cyst carriage in the liver, nor consensual chemoprophylaxis guidelines. This study aimed at describing frequency and localisation of Toxoplasma cysts in the liver in a mouse model of chronic infection to predict the risk in liver transplantation.MethodsHeart, brain and liver lobes of 21 mice chronically infected with Toxoplasma were collected for DNA extraction and amplification of Toxoplasma gondii rep529 sequence by real-time PCR.ResultsParasite DNA was detected in the liver of 19/21 mice (90.5%), with no preferential anatomical localisation, but with higher parasite loads in the papillary process. Parasite loads in the liver were far lower than in brain and heart. The number of infected lobes was inversely correlated to the total liver weight, but was independent of the brain parasite load and of the parasite strain.ConclusionsThe liver is a frequent site of cyst carriage, confirming that transplantation of an organ from a seropositive donor to seronegative recipient is at high risk for acquired toxoplasmosis. Systematic serological screening prior to transplantation and chemoprophylaxis in patients at risk are fully justified.

Mutation Analysis in Hereditary Angioedema Identifies Patients at Risk for Developing Acute and Life Threatening Edema

2006 ◽  
pp. 120-122
Author(s):  
T. Förster ◽  
A. Kocot ◽  
J. Schröder ◽  
W. Kreuz ◽  
E. Aygören-Pürsün ◽  
...  
Keyword(s):  
At Risk ◽  
Mutation Analysis ◽  
Hereditary Angioedema ◽  
Patients At Risk ◽  
Life Threatening

Relationship between Adrenal Cortex Pathology in Cushing's Syndrome and its Response to the Dexamethasone Suppression Test

1996 ◽  
Vol 24 (3) ◽  
pp. 278-283
Author(s):  
G Akçay ◽  
Y Orhan ◽  
F Aral ◽  
N Özbey ◽  
A Azezli ◽  
...  
Keyword(s):  
Adrenal Cortex ◽  
Cushing’S Syndrome ◽  
Plasma Levels ◽  
Cushing's Syndrome ◽  
High Dose ◽  
Cell Adenoma ◽  
Unilateral Adrenalectomy ◽  
High Dose Dexamethasone ◽  
Suppression Test ◽  
Dexamethasone Suppression

Cushing's syndrome is a severely disabling condition which can cause death if left untreated. Endogenous Cushing's syndrome can be ACTH-dependent or ACTH-independent. The ACTH-dependent type is more common and is usually caused by diffuse hyperplasia on the adrenal cortex. This study investigated the response to low- and high-dose dexamethasone suppression testing of 30 adrenalectomized patients with Cushing's syndrome, average age 37.3 ± 9.7 years. Twenty-four (79.3%) patients were female, and six (20.7%) were male. Bilateral adrenalectomy was performed in 14 (48.2%) patients and unilateral adrenalectomy (nine and seven right adrenalectomy) in 16 (51.8%). Two of the bilateral adrenalectomies were applied via endoscopic surgical approach. In the histopathological evaluation, diffuse hyperplasia was diagnosed in 13 (44.8%) patients and nodular hyperplasia in eight (26.6%), three macronodular and five micronodular hyperplasia. Adrenal cell adenoma was diagnosed in nine (28.6%) patients. Classic dexamethasone suppression testing was performed on all patients. Plasma levels of cortisol were not significantly decreased after low-dose testing, but plasma levels of cortisol were significantly decreased after high-dose testing in the diffuse hyperplasia group. In summary, due to the pathological changes of the adrenal cortex, dexamethasone suppression testing can differentiate between the two types of Cushing's syndrome.

scholarly journals Dexamethasone suppression test predicts later development of an impaired adrenal function after a 14-day course of prednisone in healthy volunteers

2010 ◽  
Vol 162 (5) ◽  
pp. 943-949 ◽  
Author(s):  
Stefanie Neidert ◽  
Philipp Schuetz ◽  
Beat Mueller ◽  
Mirjam Christ-Crain
Keyword(s):  
Clinical Score ◽  
Dexamethasone Suppression Test ◽  
Adrenal Function ◽  
Receiver Operating Curve ◽  
Acth Test ◽  
Glucocorticoid Treatment ◽  
Basal Cortisol ◽  
Suppression Test ◽  
Cortisol Levels ◽  
Dexamethasone Suppression

BackgroundSuppression of the adrenal function after glucocorticoid treatment is common, potentially dangerous, and unpredictable. Identification of patients at risk is of clinical importance. We hypothesized that the dexamethasone suppression test predicts the development of corticosteroid-induced impaired adrenal function.MethodsWe included 39 healthy male volunteers. After a 1-μg ACTH test, all participants underwent an overnight 0.5-mg dexamethasone suppression test. Participants then took prednisone, 0.5 mg/kg body weight, for 14-day. After the withdrawal of prednisone, a 1-μg ACTH test was performed and a clinical score was assessed on days 1, 3, 7, and 21.ResultsOn days 1, 3, 7, and 21, 100, 50, 26.5 and 32.4% of the participants had a suppressed adrenal function. The risk of developing suppressed adrenal function decreased from 44 to 0% in patients with cortisol levels after the administration of dexamethasone in the lowest and highest quartiles respectively. Receiver operating curve (ROC) analysis performed to predict a suppressed adrenal function on day 7 after the withdrawal of prednisone showed an area under the curve (AUC) of 0.76 (95% confidence interval (CI) 0.58–0.89) for cortisol after the administration of dexamethasone, which was in the range of the AUC of 0.78 (95% CI 0.6–0.9) for pre-intervention cortisol after the administration of ACTH. Basal cortisol before intake of prednisone (AUC 0.62 (95% CI 0.44–0.78)) and the clinical score (AUC 0.64 (95% CI 0.45–0.79)) had significantly lower AUCs.ConclusionCirculating cortisol levels after a dexamethasone suppression test and a pre-intervention-stimulated cortisol level are predictive of later development of a suppressed adrenal function after a 14-day course of prednisone, and are superior to a clinical score or basal cortisol levels. This may allow a more targeted concept for the need of stress prophylaxis after cessation of steroid therapy.

scholarly journals Defining Nonfunctioning Adrenal Adenomas on the Basis of the Occurrence of Hypocortisolism after Adrenalectomy

2020 ◽  
Vol 4 (8) ◽  
Author(s):  
Cristina Eller-Vainicher ◽  
Valentina Morelli ◽  
Carmen Aresta ◽  
Antonio Stefano Salcuni ◽  
Alberto Falchetti ◽  
...  
Keyword(s):  
Serum Cortisol ◽  
Urinary Free Cortisol ◽  
Tolerance Test ◽  
Cortisol Secretion ◽  
Unilateral Adrenalectomy ◽  
Insulin Tolerance ◽  
Free Cortisol ◽  
Suppression Test ◽  
Dexamethasone Suppression ◽  
Rule Out

Abstract Background In patients with adrenal incidentalomas (AIs), there is uncertainty on how to rule out hypercortisolism. The occurrence of postsurgical (unilateral adrenalectomy) hypocortisolism (PSH) has been proposed as a proof of the presence of presurgical hypercortisolism in AI patients. The aim of this study was to define the thresholds of cortisol level after the 1 mg overnight dexamethasone suppression test (F-1mgDST), urinary free cortisol (UFC), midnight serum cortisol (MSC), and adrenocorticotropin (ACTH) to predict the absence of PSH in AI patients undergoing surgery. Methods In 60 patients who underwent AI excision, cortisol secretion was assessed by a low-dose corticotropin stimulation test or insulin tolerance test when needed. We searched for the lowest presurgical value of F-1mgDST, UFC, and MSC and the highest value for ACTH in AI patients with PSH as indexes of normal cortisol secretion. Results The lowest values of F-1mgDST, UFC, and MSC and the highest value for ACTH in PSH patients were 1.2 µg/dL (33 nmol/L), 10.4 µg/24 hours (29 nmol/24 hours), 1.2 µg/dL (33 nmol/L), and 26.9 pg/mL (6 pmol/L), respectively, but only F-1mgDST <1.2 µg/dL (33 nmol/L) was able to predict the absence of PSH. Among AI patients with F-1mgDST <1.2 µg/dL (33 nmol/L) no subjects had diabetes mellitus and/or metabolic syndrome, and these subjects tended to have a better metabolic profile than those with F-1mgDST ≥1.2 µg/dL (33 nmol/L) Conclusion In AI patients a F-1mgDST <1.2 µg/dL (33 nmol/L) rules out PSH and could be used to exclude hypercortisolism in AI patients.

Sign in / Sign up

Export Citation Format

Share Document