Adrenal Disorders 1 Flashcards
Where are the adrenal glands located?
Above kidneys in retroperitoneal space
Outermost zone of adrenal cortex?
Zona Glomerulosa
Middle zone of adrenal cortex?
Zona Fasiculata
largest zone
Inner most zone of adrenal cortex?
Zona reticularis
What class of hormone does the zona glomerulosa produce? And what does it regulate?
Mineralocorticoids
-Aldosterone
Regulates blood pressure & electrolyte homeostasis
What class of hormone does the zona fasciculata Produce? And what does it regulate?
Glucocorticoids
-Cortisol
Regulate stress response, immune system, metabolism
What class of hormone does the Zona reticularis produce? What are they converted to?
Androgens
-DHEA
Converted to sex steroids (estrogen/testosterone)
True or false: The adrenal medulla makes catecholamines including: Epinephrine, norepinephrine, and serotonin?
False:
Epinephrine
Norepinephrine
small amounts of dopamine
________ is synthesized from cholesterol.
Aldosterone
Aldosterone production is stimulated by increased ________ levels and _________
Potassium and angiotensin II
Aldosterone acts on distal convoluted tubules & collecting ducts to….
- Increase reabsorption of Na+
- increase extretion of K+ and H+ ions
Main glucocorticoid in the body? (the stress hormone
Cortisol
Precursor of cortisol
cholesterol
Actions of cortisol
- Increases circulation level of glucose
- stim gluconeogenesis
- smaller role in glycogenolysis
Suppresses immune system, anti-inflammatory
- decrease absorption of Ca++ in GI - decreases osteoblast capacity to produce new bone
At what time of day does cortisol peak?
~8am
At what time of day does cortisol reach its lowest concentrations? Why?
12-4am
Due to circadian rhythm of ACTH
Pathway of the Hypothalamic-pituitary-adrenal axis?
Hypothalamus (corticotropin-releasing hormone) –> Anterior Pit (adrenocorticotropic hormone) –> Adrenal gland (cortisol) –> causes many effects in the body–>negative feedback to hypothalamus/pit
DHEA stands for
Didehydroepiandrosterone
Now say that 5 times fast
DHEA is produced from_______.
Cholesterol
DHEA is a precursor for ___ ______ synthesis
Sex hormone
Estrogen, testosterone and DHT are activated by?
DHEA binding and activating them
This hormone is an agonist of adrenergic receptors?
Epinephrine
Epinephrine causes physiologic effects known as the______ __ _______ response?
Fight or flight
- Increased HR
- Increased RR
- Stim glycogenolysis & lipolysis
- Muscle contraction
- Vasoconstriction & Vasodilation
This hormone / neurotransmitter activates noradrenergic receptors and plays a role in fight or flight…
Norepinephrine
- Increases arousal / alertness in brain
- Help forming / retrieving memories
- Increases restlessness / anxiety
- Increase HR/BP
- triggers glucose store release
- increases blood flow to SM
- decrease motility, urination, blood flow to GI
Overproduction of aldosterone by the adrenal cortex is what condition
Hyperaldosteronism
Classic findings of hyperaldosteronism
- difficult to control HTN (HA, Vision impairment)
- Hypokalemia (muscle weakness, polyruia)
- Hypernatremia
- metabolic alkalosis
Risk factor of hyperaldosteronism
Family Hx
True of False: Secondary hyperaldosteronism is more common than primary
False
Primary is more common
Condition in which one or both adrenal glands are hyperactive
Primary hyperaldosteronism
Causes of primary hyperaldosteronism
- idiopathic
- adrenal adenoma
- adrenal carcinoma
____________ hyperaldosteronism is the overstimulation of adrenal glands to secrete aldosterone
Secondary hyperaldosteronism
Causes of secondary hyperaldosteronism
- hyperkalemia
- hyponatremia
- hypotension
- decreased renal perfusion
Conn’s Syndrome involves which hormone?
Aldosterone
Cushing’s Syndrome involves which hormone?
Cortisol
Hyperandrogenism involves which hormones?
This is a gimme!!
Androgens
True or false: People with sever HTN that is able to be controlled with medications should be tested for hyperaldosteronism.
False
Severe or drug-resistant HTN
True or false: someone with HTN while taking a high dose diuretics-induced hypokalemia should be tested for hyperaldosteronism.
False
HTN + spontaneous or low dose diuretic induced hypokalemia
Patients with HTN +adrenal incidentaloma should / should not get tested for hyperaldosteronism?
Should get tested
A patient with HTN that wife states snores very loudly. Tested or not tested for hyperaldosteronism?
Tested
HTN + sleep apnea
Patients with HTN and FH of early -onset HTN / CVA, age <40 should……
Get tested for hyperaldosteronism
T or F: All hypertensive 2nd degree relatives of someone with primary hyperaldosteronism should get tested?
False
1st degree relative
Step one of diagnosing hyperaldosteronism?
Labs:
-Plasma aldosterone concentration (PAC) - will be high
-Plasma renin activity (PRA)
In a PAC/PRA ratio what findings would you see for primary hyperaldosteronism?
Increased Aldosterone
&
Decreased Renin
When a PAC/PRA ratio shows an increase in aldosterone AND Renin is this primary or secondary hyperaldosteronism?
Secondary hyperaldosteronism
What is the treatment for hyperaldosteronism if a single adrenal gland is the cause?
Unilateral Laparoscopic adrenalectomy
What is the treatment for hyperaldosteronism if there is bilateral adrenal gland involvement?
spironolactone (Aldactone)
side effects: hyperkalemia, gynecomastia, etc
What is 2nd line treatment for hyperaldosteronism?
Eplerenone
Has fewer side effects but not as effective for HTN
Side effects: Hyperkalemia , Hypertriglyceridemia
True or false: patients receiving treatment for hyperaldosteronism do not need close monitoring.
False
They need close monitoring of BP and BMP
Mineralocorticoid excess can occur with the use of ________ in hyperaldosteronism so patients should avoid its use.
Tobacco
What are some lifestyle changes patient with hyperaldosteronism can make?
- regular exercise
- low Na+ diets
- maintain ideal body weight
Condition caused by aldosterone deficiency or impairment of aldosterone function.
Hypoaldosteronism
Risk factors for hypoaldosteronism
- DM
- Nephropathy
- meds (NSAIDS, aldactone, haparin, B-blockers)
- FH
Most common cause of aldosterone deficiency / reduced production?
Renal disease
- diabetic nephropathy - NSAIDS use
T of F: Spironolactone can cause a decreased response to aldosterone?
True:
as well as certain antibiotics (i.e. bactrim)
Cause of pseudohypoaldosteronism?
Renal aldosterone receptors aren’t responsive to aldosterone
What are the clinical features of hypoaldosteronism?
- Often asymptomatic
- Hyperkalemia
- Mild hyperchloremic metabolic acidosis
Diagnosis of hypoaldosteronism?
BMP
-Hyperkalemia
- may see hyponatremia
-Hyperchloremic metabolic acidosis
- may have increased BUN/CR2/2
Plasma renin activity, serum aldosteroneIn hypoaldosteronism low renin & low aldosterone indicates?
hyporeninemic hypoaldosteronism
In hypoaldosteronism High renin & high aldosterone indicates?
End-organ is refractory to aldosterone
in hypoaldosteronism High renin & low aldosterone indicates?
Adrenal gland abnormality
Treatment for primary adrenal insufficiency?
Mineralocorticoid replacement therapy
- Fludrocortisone (Florinef)
Treatment for Hyporeninemic Hypoaldosteronism?
- Fludrocortisone (Florinef)
- Low K+ diet and/or loop or thiazide diuretics
Adrenal Insufficiency is …
When the adrenal glands don’t produce enough cortisol and/or aldosterone
T or F: Adrenal insufficiency is not life threatening?
False
It can be life-threatening
Addison’s Disease is a_______ adrenal insufficiency.
Primary adrenal insufficiency
Causes of Addison’s Disease
- Autoimmune adrenalitis
- genetic
- infectious - TB, HIV, fungal
- meds
- Adrenal hemorrhage
- Mets to adrenal gland
Secondary adrenal insufficiency is caused by….
Lack of ACTH stimulation from pituitary
Tertiary adrenal insufficiency is caused by…
Lack of CRH from hypothalamus
T or F: Adrenal insufficiencies can be caused by abrupt WD of steroid treatments>
True
Common clinical features of adrenal insufficiency
- Weakness
- Fatigue
- GI symptoms
- anorexia / weight loss
- Hypotension
- hypoglycemia
Hyperpigmentation of the skin and mucous membranes due to increased ACTH can be seen in which type of adrenal insufficiency?
Primary (Addison's disease) also see -hyponatremia -->hypotension -hyperkalemia -salt cravings
T or F: hyperpigmentation is seen in secondary adrenal insufficiency but not Tertiary.
False:
Only seen in primary
T or F: Hypoglycemia is more common in secondary and tertiary adrenal insufficiency than in Addison’s ?
True
clinical features of Adrenal crisis (Addisonian crisis)
- Hypotension –>hypovolemic shock
- may mimic acute abdomen
- May have decreased LOC, stupor, coma
- can be triggered by PA SCHOOL, or other stress, surgery, acute illness
Dx for Adrenal insufficiency
- BMP
- -Hyperkalemia (primary)
- -Hyponatremia
- -hypoglycemia
- Simplified cosyntropin test (ACTH stim test) is diagnostic
Treatment for Acute Adrenal Insufficiency (Addisonian crisis)
- aggressive IV fluids
- Glucocorticoid replacement
- -hydrocortisone or dexamethasoe
T or F: you should wait for plasma cortisol levels before providing treatment.
False
don’t delay treatment while waiting for the plasma cortisol results
T or F: People with adrenal insufficiency should avoid Sodium intake?
False
They can have liberal sodium intake
Treatment for Primary Adrenal insufficiency
- Mineralocorticoid replacement
- -Fludrocortisone + Hydrocortisone OR Prednisone
T or F: A patient is never allowed to increase their glucocorticoid dose because this could be fatal!
False:
During illness or prior to surgery they should increase the dose
