Adrenal Disorders Flashcards
why does Hyponatremia (low Na), Hyperkalemia (high K), Hypotension (low BP) occur in Primary Adrenal Insufficiency
because of the mineralocorticoid deficiency -> no aldosterone -> affects Na and K channels in priniciple cells of tubule
why does hyperpigmentation occur in Primary Adrenal Insufficiency
Increased ACTH production -> so there is also an increase POMC (a precursor). MSH (Melanocyte stimulating hormone) is also a product POMC
Testing for Primary Adrenal Insufficiency consists of _____
1) morning serum cortisol level (if less than 16 mg/dL) then …
2) 250 mcg IV cosyntropin over 2 mins -> measure cortisol at 30 and 60 min if cortisol less than 20 mg/dl then AI is the diagnosis
whats the difference in Treatment for primary vs secondary Adrenal Insufficiency
In Primary replace both glucocorticoids and mineralocorticoids, whereas secondary is only glucocorticoid replacement
what are the Causes of Hyperaldosteronism
1) Primary aldosteronism (Conn’s)
2) Secondary aldosteronism: Cirrhosis, heart failure
3) Liddle’s Syndrome: mutation in epithelial sodium channel
4) Deoxycorticosterone mediated: Genetic recombination of genes
5) Licorice ingestion: pseudohyperaldosteronism
what are the signs and symptoms of primary Aldosteronism
Resistant hypertension Hypokalemia* Mild hypernatremia Metabolic alkalosis Muscle weakness can occur
Who should be screened for primary hyperaldosteronism
Under 30 with HTN,
Hypokalemia and HTN
Resistant hypertension (on 2 meds)
patients who lack cortisol have _____ that is poorly responsive to _________
low blood pressure,
Pressors (norepinephrine, epinephrine, dopamine).
what are some causes of SECONDARY ADRENAL INSUFFICIENCY
1) Following supraphysiological doses of exogenous glucocorticoids for more than 3 weeks
2) Opioids
3) Following cure of Cushing’s syndrome
4) Hypothalamic/pituitary lesions: tumor, surgery in the area, radiation, infectious, hemorrhagic, infiltrative, metastatic disease to the area
Patients with primary gland (adrenal) failure will have what lab values related to cortisol and aldosterone
whereas
hyponatremia but hyperkalemia,
Patients with secondary disease have preserved aldosterone synthesis from the adrenal gland and are therefore ______, regarding labs.
normokalemic
______ is by far the most common cause of primary adrenal insufficiency in developed countries, whereas _______remains the most common cause in developing countries.
Autoimmune destruction of the adrenal gland (Addison’s disease) ,
tuberculosis
Adrenal insufficiency is associated with other autoimmune disorders, such as _____
Hypothyroidism (25%) Graves’ disease (11%) Primary ovarian (13%) or testicular (2%) failure Type I diabetes mellitus (10%) Autoimmune hypoparathyroidism (4%)
what are the four basic types of primary aldosteronism
1) Aldosterone-producing adenoma (APA) (34%)
2) Idiopathic hyperaldosteronism (IHA); a.k.a. Bilateral Adrenal Hyperplasia (66%)
3) Glucocorticoid-remediable hyperaldosteronism (GRA) (rare)
4) Aldosterone-producing carcinoma (rare
what is the treatment for bilateral adrenal hyperplasia is causing Hyperaldosteronism
mineralocorticoid antagonist (spironolactone 25-100 mg daily or eplerenone
What Can Cause Pseudohyperaldosteronism
Licorice
describe the screening test for hyperaldosteronism
measure baseline aldosterone (PA) and plasma renin activity (PRA) levels. If the PA/PRA ratio is > 20 with a PA > 15 ng/dL, this is highly suggestive of primary aldosteronism.
what can interfere with the screening test for hyperaldosteronism and should be avoided or discontinued before the testing
Spironolactone use
If PA/PRA ratio is elevated, what should you do next?
salt suppression test
Need to demonstrate inappropriate aldosterone secretion after salt loading
Given 2L normal saline over 4 hours and measure aldosterone
Normal: aldosterone suppresses below 5 ng/dL
Hyperaldo: aldosterone above 10 ng/dL
Once a biochemical diagnosis of hyperaldosteronism is certain, what should be done next?
CT or MRI should be performed to look for adenoma or hyperplasia
Then adrenal vein sampling (AVS) should be done for lateralization
In adrenal vein sampling. if there is Unilateral elevation of aldosterone,the a/an _____ is suspected, while bilateral elevation of aldosterone suggests ______
adenoma, idiopathic hyperaldosteronism (IHA)
how is an adrenal adenoma treated?
surgical excision
How is idiopathic hyperaldosteronism (IHA) treated
aldosterone antagonist (spironolactone or eplerenone) and other antihypertensive medications
Tumors that occur in extra-adrenal chromaffin tissue anywhere along the sympathetic chain or parasympathetic chain are referred to as _____
paragangliomas
