V. Bähr

Endocrine activity of the "silent" adrenocortical adenoma is uncovered by response to corticotropin-releasing hormone.

SummaryThe purpose of this study was to ascertain whether the pituitary-adrenal responses to human corticotropin-releasing hormone (hCRH) in “non-functioning” adrenocortical adenoma would uncover a functional activity in these adrenal nodules. Eleven patients with incidentally discovered “silent” adrenocortical adenoma and eleven controls were studied. The initial clinical and laboratory examination, including an overnight 1 mg dexamethasone suppression test, revealed no abnormalities in any of the subjects. IR-ACTH and serum steroids (F, S, P, 17OHP, 18OHB, and aldosterone) were normal in both controls and patients. After pulse IV injection of 100 νg hCRH, the cortisol response was significantly exaggerated (P=0.01). Stimulated plasma ACTH levels were, however, significantly lower in patients than in controls (P=0.01), indicating counter-feedback regulation of cortisol. The peak cortisol/peak ACTH ratio (Fmax/ACTHmax) in the patients was significantly elevated (26.8±4.37 nmol/ng vs. 14.6±2.16 nmol/ ng,P=0.02). Two further patients with incidentally discovered “pre-Cushings” adrenocortical adenoma displayed an even higher ratio (43.5 and 45.5 nmol/ng). In established Cushings syndrome due to an autonomous adrenocortical adenoma, suppression of ACTH and of the ACTH response to hCRH occurs with a very high basal cortisol/ basal ACTH ratio. Our findings suggest some functional activity even in clinically “silent” adrenocortical adenoma. Response to hCRH uncovers a continuous spectrum between adrenocortical adenoma, “pre-Cushings”, and Cushings syndrome.

Metabolism of Synthetic Corticosteroids by 11β-hydroxysteroid-Dehydrogenases in Man

The presence of an 11 beta-hydroxyl group is essential for the anti-inflammatory and immunosuppressive effects of glucocorticoids. Interconversion of the 11 beta-hydroxyl into the corresponding 11 beta-keto group and vice versa by 11 beta-hydroxysteroid-dehydrogenase (11 beta-HSD) may thus play a pivotal role in the efficacy of these steroids. Therefore, we have compared the metabolism of the endogenous glucocorticoid cortisol (F) with that of synthetic 9 alpha-fluorinated steroids by 11 beta-HSDs in humans in vivo and in vitro. Whereas 30% of the free steroids in urine after oral administration of 5 mg of F is F itself and 70% the inactive keto-product cortisone (E), the urinary excretion of an identical dose of oral 9 alpha-fluorocortisol (9 alpha FF) is 90% 9 alpha FF and 10% inactive 9 alpha-fluorocortisone (9 alpha FE). Kidney slices similarly convert F much faster to E than 9 alpha FF to 9 alpha FE; conversely, renal 11 beta-reduction of 9 alpha FE to 9 alpha FF is much more effective than that of E to F. Kinetic analyses in human kidney cortex microsomes prove that the preference of fluorinated steroids for reduction in human kidney slices is catalyzed by 11 beta-HSD type II: the NADH-dependent conversion of 11-dehydro-dexamethasone (DH-D), another fluorinated steroid, to dexamethasone (D) is very effective (high affinity, high Vmax), whereas reduction of E to F is very slow. In human liver microsomes (11 beta-HSD type I), nonfluorinated (E) and fluorinated 11-dehydrosteroids (DH-D) are both reduced to their corresponding active 11-hydroxyderivatives but with a Michaelis-Menten constant about 20-fold higher than for kidney microsomes (11 beta-HSD-II). Our results suggest that the decreased renal 11 beta-oxidation of 9 alpha-fluorinated steroids may offer pharmacokinetic advantages for renal immunosuppression. Furthermore, administration of fluorinated 11-dehydrosteroids is a new and exciting idea in glucocorticoid therapy in that small amounts of oral DH-D may pass the liver largely unmetabolized (11 beta-HSD-I has low affinity for such steroids) and may then be activated to D by high-affinity 11 beta-HSD-II, thus allowing selective immunosuppression in organs expressing 11 beta-HSD-II (kidney and colon).

Torsemide inhibits aldosterone secretion in vitro

Torsemide inhibited aldosterone secretion by adrenal cells from rats, cows, and guinea pigs stimulated in vitro by potassium, angiotensin, dibutyryl cyclic AMP, ACTH, or corticosterone. Inhibitory concentrations for adrenal cells (micromolar) were comparable with those reported to inhibit ion transport in isolated renal tubules. Inhibition of aldosterone secretion could reduce kaliuresis, and that may explain why torsemide causes less kaliuresis than other diuretics.

Dose–response relationship between plasma ACTH and serum cortisol in the insulin–hypoglycaemia test in 25 healthy subjects and 109 patients with pituitary disease

OBJECTIVE The insulin hypoglycaemia test (IHT) is believed to be the most reliable test for evaluating the entire hypothalamo-pituitary-adrenal (HPA) axis. The lower limit for the normal peak serum cortisol response has been reported to be between 500 and 580 nmol/l. Reference levels for a normal plasma ACTH response have not been reported recently. DESIGN AND PATIENTS We performed the IHT in 25 healthy subjects and in 109 patients with proven or suspected pituitary disorders with serial measurements of serum or plasma cortisol and of plasma ACTH, in order to establish reference levels and to study the dose-response relationship between ACTH and cortisol in this test. In most patients, other pituitary hormonal axes were evaluated in addition. RESULTS With the cortisol kit from Diagnostic Products Corporation (DPC), serum cortisol was about 13% lower than plasma (EDTA) levels with an excellent correlation between serum and plasma (r = 0.976; P<0.001). In the normals, the lower limit of the cortisol response (mean cortisol peak level minus 2 SD.) was 570 nmol/l for plasma and 500 nmol/l (calculated) for serum, while the lower limit of the ACTH response was 17.6 pmol/l (80 ng/l). In normals, the cortisol response was independent of the magnitude of the ACTH response. Seventeen out of 30 patients with ACTH responses to levels < 8.8 pmol/l (< 40 ng/l) had subnormal cortisol responses. However, 38 of the patients with pituitary disease had normal cortisol responses in spite of subnormal ACTH responses (group 2), while 47 patients had completely normal IHT results (group 1). Patients in group 2 had more often additional pituitary hormone deficiencies than those of group 1. The dose-response relationship between ACTH and cortisol in the patients resembled a dose-response curve that had been set up previously in normal subjects who received incremental doses of subcutaneous human ACTH (1-39). CONCLUSIONS The normal increment of plasma ACTH in the IHT is greater than necessary for stimulating serum cortisol to levels > 500 nmol/l. Patients with a subnormal ACTH but normal cortisol response in the IHT have a decreased ACTH secretory reserve. It is unlikely that they are at increased risk of developing an adrenal crisis perioperatively or in other stressful situations unless pituitary function deteriorates. The ACTH-cortisol relationship in the IHT performed in patients with pituitary disease shows no sharp dividing line between normality and disease, and whether a patient needs permanent glucocorticoid substitution is a discretionary decision.

Zone-specific localization of cytochrome P45011B1 in human adrenal tissue by PCR-derived riboprobes.

Cytochrome P45011B1 (11β-hydroxylase) was detected in the human adrenal cortex and in human adenomas by in situ hybridization methods. Specific riboprobes were generated by in vitro transcription of 11β-hydroxylase-specific synthetic oligonucleotides with attached T7 and SP6 polymerase promotors. [35S]- and digoxigenin-labeled riboprobes were hybridized to sections of an aldosterone-producing adenoma (APA), the non-tumour portion of the corresponding adrenal gland, and two adenomas not related to hyperaldosteronism using standard protocols and varying washing conditions. After exposure of the radiolabeled sections to X-ray film, the signals were quantified and compared by statistical tests. Following autoradiography or immunohistochemical detection of the digoxigenin cytochrome P45011B1 mRNA was clearly localized in the zona fasciculata/reticularis of non-tumour portion of an human adrenal with an APA. Zona glomerulosa, medulla and connective tissue were free of label. As revealed by the semi-quantitative analysis, 11β-hydroxylase mRNA signals in the APA were significantly lower than those in the attached non-tumour portion and the other two adenomas. The results confirm known observations on the occurrence of cytochrome P45011B1 in the adrenal cortex of other species, but show, contrary to several immunohistochemical studies, that the enzyme is obviously not expressed in the zona glomerulosa.

Differential diagnosis of polyuric/polydipsic syndromes with the aid of urinary vasopressin measurement in adults

OBJECTIVE A water deprivation test or a hypertonic saline infusion test with the measurement of plasma osmolality and plasma vasopressin are the gold standard tests in the differential diagnosis of polyuric syndromes. Because commercially available vasopressin kits are too insensitive for this approach, and the concentration of vasopressin in urine is much higher than in plasma, urinary vasopressin measurements may be an alternative to the more difficult plasma vasopressin measurement.

Enzyme-mediated protection of the mineralocorticoid receptor against progesterone in the human kidney.

Progesterone (P) is a mineralocorticoid (MC)-antagonist in vitro. During pregnancy, plasma P concentrations exceed aldosterone concentrations at least 50-fold, but plasma aldosterone increases only 4-8-fold in a compensatory manner. Since the in vivo anti-MC activity of P seems to be only moderate, we hypothesized that P is metabolized by enzymes of MC target tissue similar to the way cortisol is metabolized by 11beta-hydroxysteroid dehydrogenase (11beta-HSD) type 2 in order to protect the MC receptor. We, therefore, examined P metabolism using 4-(14)C-P in subcellular fractions of human postmenopausal and male kidneys, and in homogenates of one premenopausal kidney. We found that P is converted effectively, even at high P concentrations (10(-6) mol/l), to various metabolites: 20alpha-dihydro(DH)-P; 17alpha-OH-P; 17alpha-OH,20alpha-DH-P; 5alpha-DH-P; 3beta,5alpha-tetrahydro(TH)-P; and 20alpha-DH,5alpha-DH-P. Homogenates of premenopausal kidney also showed conversion to 3alpha- and 5beta-reduced P metabolites. These results confirm the existence of an efficient renal enzyme system as a possible mechanism of an enzyme-mediated MC receptor selectivity.

11β‐Hydroxysteroid‐dehydrogenase isoforms: tissue distribution and implications for clinical medicine

11β‐hydroxylation is essential for glucocorticoid and mineralocorticoid activity of a steroid. The enzyme catalyzing this reaction is termed 11β‐hydroxysteroid‐dehydrogenase (11β‐HSD). Two isoenzymes of 11β‐HSD have been characterized in human tissues. Whereas 11β‐HSD‐I works mainly as a reductase, 11β‐HSD‐II only functions as an oxidizing (inactivating) enzyme for physiological glucocorticoids. Thus, the tissue distribution of both enzymes plays a crucial role for the specific glucocorticoid status of an organ. This review summarizes our knowledge of tissue distribution of both 11β‐HSD isoenzymes, their physiological function and pathophysiological role in certain clinical abnormalities, and their relevance to the metabolism of synthetic glucocorticoid and mineralocorticoid compounds.

The role of vasopressin in the nicotine-induced stimulation of ACTH and cortisol in men

SummaryExperimental evidence indicates that arginine vasopressin (AVP) contributes to the release of ACTH under certain conditions. The present study investigates the role of vasopressin as a secretagogue of ACTH during cigarette smoking or nicotine infusion with additional injection of corticotropin releasing hormone (CRH) and using the specific AVP antagonist d(CH2)5Tyr(Me)-AVP. We first tested the effect of the AVP antagonist (10 μg/kg body weight i.v.) on ACTH and cortisol release following cigarette smoking in 15 healthy young male smokers. Smoking led to marked increments in plasma nicotine and to a small rise in plasma ACTH and cortisol. Mean plasma ACTH and cortisol levels were at no time significantly altered by the antagonist. This might be due to a slight agonistic effect of the AVP antagonist, to high interindividual variability of the ACTH and cortisol responses after smoking or to a neglegible role of AVP in smoking-induced ACTH release. In a second study we performed the following tests in six healthy male non-smokers: (1) nicotine infusion (1.0 μg/kg body weight per min); (2) CRH i.v. (100 μg); (3) AVP antagonist i.v. (5 μg/ kg); (4) nicotine infusion plus CRH i.v.; (5) nicotine infusion plus AVP antagonist i.v. ; (6) nicotine infusion plus CRH and AVP antagonist i.v.; and (7) sham infusion. Nicotine infusion led to greater increments of AVP, ACTH and cortisol than smoking without causing nausea. Peak nicotine levels after nicotine infusion were lower than after smoking. The AVP antagonist in the reduced dosage given alone had no effect on hormone levels. However, it slightly attenuated the effect of nico tite on ACTH and cortisol (P<0.05, ANOVA). Nicotine and CRH given together stimulated AACH and cortisol in a less than additive manner. The combined effect of nicotine and CRH was not inhibited by the antagonist. Our results indicate that the effect of nicotine on ACTH and cortisol may be partly mediated by hypothalamic AVP. Nicotine may also enhance CRH release by stimulating acetylcholine receptors of hypothalamic CRH neurons.

The metabolism of 9α-fluorinated steroids in the human kidney

We compared the renal metabolism of 9α-fluorinated steroids with that of the unfluorinated, endogenous steroid cortisol (F) By defining kinetic variables, we characterized isoenzyme activities of 11s-hydroxysteroid-dehydrogenase (11s-HSD). Methods: I) In human kidney slices, we studied the conversion of 9α-fluoro-cortisol (FF) and F to their oxo-products (and vice versa). II) In human kidney microsomes, we performed the kinetic analysis of 11s-HSD activity for the steroid pairs F/cortisone (E) and dexamethasone (D)/11-dehydro-dexamethasone (DH-D). Results: I) In kidney slices, FF is very weakly oxidized to 9α-fluorocortisone (FE), while the reduction of FE to FF is very effective. In contrast, E is hardly reduced to F, but F is strongly inactivated to E. II) Enzyme kinetics in kidney microsomes: 1a) Oxidation of F to E: exclusively NAD-dependent; Km = 25.5 nmol/L. b) Reduction of E to F: clearly NADH-preferring; Km = 81 nmol/L; Vmaxoxidation/Vmaxreduction (F/E) = 26. 2a) Oxidation of D to DH-D: exclusivel...