Ágnes Szappanos

Atherosclerotic risk factors and complications in patients with non-functioning adrenal adenomas treated with or without adrenalectomy: a long-term follow-up study

OBJECTIVE Despite the increased prevalences of hypertension, type 2 diabetes mellitus (T2DM), hyperlipidemy, and obesity in patients with non-functioning adrenal adenomas (NFAAs), there is a paucity of data on long-term atherosclerotic morbidity as well as the long-term cardiovascular effects of adrenalectomy in these patients. DESIGN, PATIENTS, AND METHODS This retrospective study includes the results of baseline and follow-up investigations of 125 patients (29 males and 96 females; mean age 60.1 years) with NFAAs referred for endocrine evaluation between 1990 and 2001. Of the 125 patients, 47 underwent unilateral adrenalectomy, while 78 patients were followed conservatively. These patients were reinvestigated after a mean follow-up time of 9.1 (5-16) years in 2006, with special emphasis on laboratory and other atherosclerotic risk factors (ARF), vascular events, and interventions. RESULTS The prevalences of hypertension, impaired glucose tolerance or T2DM, hyperlipidemy, and obesity were 82, 43, 58, and 50%, and 89, 58, 82, and 50% at baseline and follow-up, respectively. None of the investigated ARF prevalences were different between patients treated and not treated with adrenalectomy, and between patients with and without subclinical Cushings syndrome. The prevalences of angina pectoris, acute myocardial infarction, coronary, and peripheral arterial interventions or cerebrovascular stroke did not differ significantly between patients treated and not treated with adrenalectomy. CONCLUSION Our study confirms previous investigations reporting markedly increased prevalences of various ARF in patients with NFAAs. Adrenalectomy performed in these patients failed to decrease the prevalence of ARF and atherosclerotic morbidity.

Skeletal differences in bone mineral area and content before and after cure of endogenous Cushing's syndrome

SummaryWe examined bone densitometric data in a four-year follow-up period before and after the cure of CS. Plasma cortisol concentrations were similar, but the duration of estimated glucocorticoid excess was longer in patients with prevalent bone fractures compared to those without fractures. After therapy of CS, bone area, BMC and BMD increased significantly at the LS and femur during follow-up, but they decreased at the forearm, suggesting redistribution of bone minerals from the peripheral to the axial skeleton.IntroductionOnly a few studies report the changes in bone mineral density (BMD) after the cure of Cushing’s syndrome (CS).MethodsForty-one patients with Cushing’s disease, 21 patients with adrenal CS and 6 patients with ectopic CS were prospectively enrolled. BMD, bone mineral content (BMC) and bone area were measured by DXA.ResultsNo significant correlations were found between serum cortisol concentrations and baseline bone densitometric data. After successful therapy of CS, bone area and BMD increased significantly at the lumbar spine (LS) and femur during follow-up, but they decreased at the forearm. The progressive increase in BMC at the LS had a significant negative correlation with the change of the BMC of radius in the first and second follow-up years. The change in the body mass index was an independent predictor for changes in BMC both at the LS and at the forearm at the second year of remission.ConclusionsThe regional differences and the time-dependent changes of BMC suggest that the source of marked increase in axial BMC after the cure of CS is, at least partly, due to the redistribution of bone minerals from the peripheral to the axial skeleton.

BclI polymorphism of the glucocorticoid receptor gene is associated with decreased bone mineral density in patients with endogenous hypercortisolism.

Objective  The hypothalamic–pituitary–adrenal axis setpoint and the glucocorticoid sensitivity of various tissues are at least partially genetically determined. We investigated the impact of glucocorticoid receptor (GR) gene polymorphisms, including the BclI, N363S, ER22/23EK and A3669G variants on bone turnover and/or mineral density (BMD) in patients with endogenous glucocorticoid excess.

Detection of the Bcl I polymorphism of the glucocorticoid receptor gene by single-tube allele-specific polymerase chain reaction

The Bcl I polymorphism of the glucocorticoid receptor gene, recently identified as an intronic C to G change 646 nucleotides downstream of exon 2, has been associated with increased sensitivity to glucocorticoids and its potential relevance in metabolic disturbances and in various disorders has been extensively investigated. In the present study, we designed a single-tube allele-specific polymerase chain reaction for genotyping this polymorphism in peripheral blood DNA samples. When the Bcl I polymorphism was detected with this novel method in a cohort of 247 healthy subjects, the observed genotype distribution matched the Hardy-Weinberg equilibrium (100 subjects homozygous for the wild-type, 124 heterozygous and 23 homozygous for the mutant allele). In 50 randomly selected subjects the Bcl I polymorphism was also determined using a traditional restriction fragment length polymorphism technique and DNA sequencing, and the results showed 100% coincidence with those obtained by our novel method. The method proved to be more rapid and less labour-intensive compared to currently used techniques, and it avoided the use of extensive instrumentals. We assume that this novel method may have a broad utility in clinical and molecular epidemiological studies aimed to elucidate the impact of the Bcl I polymorphism of the glucocorticoid receptor gene either on metabolic disturbances, or various disorders, including cancer treatment and hormone substitution therapies.

Polymorphisms of the glucocorticoid receptor gene in Graves ophthalmopathy

Background/aims: Glucocorticoids have an important role in the regulation of the immune system, and alterations in glucocorticoid signaling may have an impact on the pathophysiology of autoimmune and inflammatory disorders. Because polymorphisms of the glucocorticoid receptor (GR) gene, including the N363S, ER22/23EK, A3669G and BclI variants were found to influence glucocorticoid signalling, we examined whether these polymorphisms could be associated with the development or clinical manifestations of Graves ophthalmopathy (GO). Methods: The carrier and allelic frequencies of the N363S, ER22/23EK, A3669G, and BclI polymorphisms of the GR were determined in 95 Hungarian outpatients with GO and 160 healthy controls. Results: No significant changes were found in carrier frequencies of the four polymorphisms between GO patients and healthy controls. However, when GO patients were divided into two subgroups (American Thyroid Association Committee, ATA I–II vs ATA III or greater), the frequency of the polymorphic BclI allele was significantly higher in patients with ATA I–II compared with those with ATA III or more (p = 0.009). Conclusion: The significant association between the frequency of the polymorphic BclI allele and ATA stage distribution suggests that this polymorphism of the GR gene may affect clinical manifestations of GO, presumably due to an increased signaling of endogenous glucocorticoids.

The rs4844880 polymorphism in the promoter region of the HSD11B1 gene associates with bone mineral density in healthy and postmenopausal osteoporotic women

INTRODUCTION The 11β-hydroxysteroid dehydrogenase type 1 enzyme (11β-HSD1) plays an important role in the regulation of local glucocorticoid concentration in a tissue specific manner. Previous studies indicated associations between polymorphisms (SNPs) of the HSD11B1 gene and laboratory as well as osteodensitometric parameters of bone metabolism. In our present work we examined whether the tagging HSD11B1 gene polymorphisms could influence bone metabolism in healthy and postmenopausal osteoporotic women. EXPERIMENTAL HapMap database was used for identification and selection of SNPs located in the 38kb range of the HSD11B1 gene. Twelve SNPs were selected and genotyped in 209 healthy control women using Taqman SNP assays on Real-Time PCR and direct DNA sequencing. Of these SNPs, the rs4844880 was genotyped in 154 women with postmenopausal osteoporosis. Functional characterization of the rs4844880 was performed by in vitro luciferase assay. RESULTS One of the 12 HSD11B1 SNPs, the rs4844880 showed a significant association with higher bone mineral density and/or T- and Z-scores at lumbar spine in healthy women. When data from 154 postmenopausal osteoporotic women were compared to those obtained from 101 age-matched postmenopausal healthy women selected from our healthy control group this association was strongly significant at the femoral neck region. In vitro luciferase assay demonstrated that the polymorphic rs4844880 allele inhibited the luciferase activity more significantly than the major allele. CONCLUSIONS The rs4844880 polymorphism in the promoter region of the HSD11B1 gene resulting in a reduced expression of the enzyme may exert a beneficial effect on bone in healthy and postmenopausal osteoporotic women.

The importance of glucocorticoid receptors in systemic lupus erythaematosus. A systematic review

The therapeutic management of systemic lupus erythaematosus (SLE) is still a great debate. Despite the latest innovation agents or developing trials, there is not an integrated and common approach for treating SLE. For decades, natural and synthetic glucocorticoids (GCs) have been the first and most frequently used immune suppressive agents in SLE. Therefore, GCs are the most important therapy in SLE in daily routine, however the response to GCs differs widely and long-term therapy is associated with side-effects. Still now, clinicians and physicians are unable to predict the exact and ideal dose and term of therapy for patients suffering from various symptoms and degree of disease activity of SLE. The biological mechanism of GCs is regulated through activation of glucocorticoid receptors (GRs). There are two major isoforms of GRs: GRα and GRβ; however, the GRα is the predominant one which binds steroids and activates target genes. In the present review, we summarise the anti-inflammatory and immune suppressive effects of GCs via GRs to regulate the target genes.

The 83,557insA variant of the gene coding 11β-hydroxysteroid dehydrogenase type 1 enzyme associates with serum osteocalcin in patients with endogenous Cushing's syndrome

OBJECTIVE The type 1 and type 2 isoenzymes of the 11β-hydroxysteroid dehydrogenase (HSD11B) play an important role in the prereceptor regulation of glucocorticoid bioavailability and action. The potential importance of gene variants coding HSD11B has not been previously evaluated in patients with endogenous hypercortisolism. The aim of the present study was to explore presumed associations between the 83,557insA variant of the HSD11B1 gene and circulating hormone concentrations, bone turnover and bone mineral density (BMD) in patients with endogenous Cushings syndrome (CS). PATIENTS AND METHODS Forty one patients with ACTH-producing pituitary adenomas (Cushings disease-CD), 32 patients with cortisol-producing adrenal tumors (ACS) and 129 healthy control subjects were genotyped for the 83,557insA variant of the HSD11B1 gene using restriction fragment length analysis. BMD was measured by dual-energy X-ray absorptiometry. Serum cortisol, ACTH, osteocalcin (OC) and C-terminal crosslinks (CTX) of human collagen type I (C-telopeptide) were measured by electrochemiluminescence immunoassay. RESULTS No statistically significant differences were found in the allelic frequencies of the 83,557insA polymorphism among patients with CD, ACS and healthy controls. Among all patients with CS, heterozygous carriers of the 83,557insA had significantly higher serum OC as compared to non-carriers. Patients with ACS carrying the 83,557insA variant had higher plasma ACTH concentrations compared to non-carriers. The 83,557insA variant failed to associate with BMD in patients and controls. CONCLUSIONS Our present findings indicate that the 83,557insA variant of the HSD11B1 gene may influence serum markers of bone turnover, but not BMD in patients with endogenous Cushings syndrome.

Overrepresentation of BclI polymorphism of the glucocorticoid receptor gene in pregnant women with HELLP syndrome.

BACKGROUND Because the pathological background of preeclampsia and its severe variant, HELLP syndrome (hemolysis, elevated liver enzymes and low platelet counts) appears to involve a pathological maternal-fetal immune adaptation, we examined whether any association could exist between these disorders and polymorphisms of the glucocorticoid receptor (GR) gene. METHODS The BclI, N363S, and ER22/23EK polymorphisms of the GR gene were determined in 300 healthy pregnant women, 150 pregnant women with severe preeclampsia including 17 pregnant women with HELLP syndrome. RESULTS There were no significant differences in carrier and allelic frequencies of the N363S and ER22/23EK polymorphisms between healthy pregnant women and those with severe preeclampsia. However, the allelic and carrier frequencies of the BclI polymorphism were significantly higher in women with HELLP syndrome compared to healthy pregnant women (p=0.004; Odds ratio, 2.89) and to those with severe preeclampsia (p=0.013; Odds ratio, 2.56). CONCLUSION Our observations suggest that among pregnant women, the BclI polymorphism is associated with the development of HELLP syndrome, but not that of severe preeclampsia. Since preeclampsia and HELLP syndrome develop exclusively in human, it seems particularly interesting that alignment analysis of DNA sequences obtained from databases indicated the absence of the BclI site in 6 animal vertebral species.

Tissue-specific Glucocorticoid Signaling May Determine the Resistance Against Glucocorticoids in Autoimmune Diseases

Endogenous glucocorticoids exert a diverse array of physiological processes including immune-modulatory or anti-inflammatory responses and play an important role in the pathogenesis of inflammatory and autoimmune diseases. Regulation of inflammatory processes by glucocorticoids is controlled in a cytokine-hypothalamo-pituitary-adrenal axis feedback circuit and on the local, cell-type and context-specific local regulatory system. At the tissue level the sensitivity and response to glucocorticoids are determined by multiple factors: including the local availability to glucocorticoids transported by blood, the locally-formed bioactive glucocorticoids (synthesized and metabolized 11β-hydroxysteroid dehydrogenase enzymes), the number and function of the glucocorticoid receptor (GR) and the GR affinity to its ligands. Numerous molecular factors are known to influence the sensitivity of glucocorticoid response through the GR. Cytokines are one of the major components that can inhibit GR function and can potentiate the resistance against glucocorticoids. GR isoforms, generated by alternative splicing, alternative translation and post-translation modification are further mechanisms which modulate glucocorticoid signaling. Genetic variants within the GR encoding gene are other potential factors that may influence the susceptibility and severity of autoimmune disorders and may play a key role in individual response to medication. In this review our aim was to summarize our knowledge about the connections between the cell type-specific glucocorticoid signaling and the local immune system. Prediction of individual sensitivity to steroids and identification of key players in development of glucocorticoid resistance are essential in individualized therapies. The local, tissue-specific glucocorticoid signaling and its influence by cytokines may be important in determining the magnitude of inflammatory reactions, and may also be related to the success of glucocorticoid-containing therapeutic strategies.