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Endocrine > Adrenal Insufficiency > Flashcards

Adrenal Insufficiency Flashcards

1
Q

What is the definition of adrenal insufficiency?

A

Clinical manifestation of deficient cortisol

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2
Q

What is the major difference between primary and secondary adrenal insufficiency it terms of the loss of hormones?

A

Primary loses all three hormones, while secondary does not lose aldosterone

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3
Q

What are the two major etiologies of secondary adrenal insufficiency?

A

Deficiency in CRH or ACTH

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4
Q

What portion of the adrenal gland is the medulla? What does this secrete?

A

20%

Catecholamines

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5
Q

What are the three layers of the adrenal glands, and what does each secrete?

A

GFR, salt, sugar, sex

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6
Q

What causes the release of catecholamines from the adrenal medulla? When does this occur?

A

Sympathetic nerve input

-Fight or flight response

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7
Q

What are the three catecholamines released by the adrenal medulla?

A

Epi
NE
Dopamine

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8
Q

Why is it that there is no clinical syndroem associated with adrenal medulla insufficiency?

A

There are extra-adrenal sites of catecholamine production (paragangliomas along the spinal cord)

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9
Q

What is the tumor that causes an over secretion of catecholamines?

A

Pheochromocytoma

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10
Q

What are the two adrenal androgens? What are these precursors of?

A

DHEA
Androstenedione

Dihydrotesterone and testosterone

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11
Q

True or false: adrenal androgen production is stimulated by ACTH

A

True, but weak

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12
Q

What is the importance of DHEA?

A

Contributes to the development of secondary sexual characteristics in puberty

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13
Q

Why is there no issue with a lack of DHEA secretion from the adrenal medulla?

A

Androgens are made in the tests and the ovaries

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14
Q

What are the three major etiologies of adrenal androgen overproduction?

A

Congenital adrenal hyperplasia

Adrenal tumors

Cushing’s

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15
Q

What is the main mineralocorticoid? What is the action of this?

A

Aldosterone

Causes principal cells of the kidneys to secrete K in exchange for Na and water

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16
Q

Where in the nephron does aldosterone have effect?

A

Distal convoluted tubule

Renal collecting duct

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17
Q

What regulates aldosterone production?

A

Renin-angiotensin system

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18
Q

Where is renin released from? What does this do?

A

Juxtaglomerular cells

Cleaves circulating angiotensinogen into ANG I

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19
Q

What is the enzyme that converts ANG I to ANG II? Where is this found?

A

ACE

Lungs and kidneys

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20
Q

What are the two stimuli for renin release?

A
  • Decreased BP/renal artery hypotension

- Decreased Na delivery to the distal tubules

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21
Q

What is the effect of ANG II on the kidneys?

A

Increases aldosterone release

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22
Q

What is the effect of ANG II on the vasculature?

A

Vasoconstriction

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23
Q

What is the effect of ANG II on the HPA axis?

A

Increases the release of ADH from the posterior pituitary and stimulates thirst

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24
Q

What area of the brain is responsible for thirst and cooling?

A

Anterior hypothalamus

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25
Q

What is the effect of ANG II on NE release?

A

Increases

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26
Q

What is the effect of ANG II on the heart?

A

Stimulates hypertrophy

27
Q

How does cortisol inhibit the immune response?

A

Inhibits the production of Leukotrienes

28
Q

What is the effect of glucocorticoids on metabolism?

A

Increases BG
Increases lipolysis
Increases proteolysis

29
Q

What is the effect of cortisol on fibroblasts?

A

Decreases/inhibits them

30
Q

What are the cells in the anterior pituitary that synthesize and release ACTH? What stimulates them to do this?

A

Corticotroph cells

CRH

31
Q

What are the two acidophils of the anterior pituitary?

A

Lactotrophs
Somatotrophs

(A PiG)

32
Q

What are the four basophils of the anterior pituitary?

A

FSH
LH (gonadotrophs)
ACTH (corticotrophs)
TSH (thyrotrophs)

(B-FLAT)

33
Q

What are the two breakdown products of POMC?

A

MSH

ACTH

34
Q

What happens to renin, aldosterone, and ACTH levels with primary adrenal insufficiency?

A

High renin and ACTH

Low Aldosterone

35
Q

What is the treatment for primary adrenal insufficiency?

A

Fludrocortisone + hydrocortisone

36
Q

What is synthetic aldosterone?

A

Fludrocortisone

37
Q

What are the major etiologies of primary adrenal insufficiency? (2 one most common in developed countries, and undeveloped)

A

Autoimmune destruction

TB granuloma

38
Q

What are the antibodies that are found with primary adrenal insufficiency?

A

21-hydroxylase antibodies

39
Q

What are the gross findings associated with autoimmune destruction of the adrenal glands vs TB infiltration?

A

Autoimmune = small, fibrotic

TB = Caseating granuloma

40
Q

What is the common fungal causes of primary adrenal insufficiency?

A

Histoplasmosis

41
Q

What is the major cause of hemorrhage into the adrenal glands? What is the name of this syndrome?

A

Warfarin

Waterhouse-friderichsen syndrome

42
Q

For metastatic causes of adrenal insufficiency, what percent of the gland must be affected before seeing ssx?

A

90%

43
Q

What are the three major medications that can cause primary adrenal insufficiency?

A

Ketoconazole
Aminoglutethimide
Rifampin

44
Q

What are the following lab findings like with primary adrenal insufficiency:

  • cortisol
  • aldosterone
  • DHEA
  • ACTH
  • Renin
A
  • cortisol = low
  • aldosterone = low
  • DHEA = low
  • ACTH = high
  • Renin = high
45
Q

What are the two symptoms that are specific to primary adrenal insufficiency, as opposed to other forms of adrenal insufficiency?

A

Hyperpigmentation from POMC production

Hyperkalemia from lack of aldosterone

46
Q

What is the value of cortisol that is diagnostic of primary adrenal insufficiency (morning random)?

A

Morning cortisol less than 3 mcg

Random less than 5 mcg

47
Q

What is the name of synthetic ACTH?

A

Cortrosyn stimulation test

48
Q

What is the reasoning behind the cortrosyn stimulation test? What are the results of this?

A

Injecting ACTH, wait 30 mins, and measure cortisol levels.

–Should have a more than 18 mcg/dL increase. If not, Addison’s disease

49
Q

What are the common acute symptoms of Addison’s disease?

A

Postural hypotension
Arthralgias/myalgias
Abdo pain

50
Q

What are the common chronic ssx of AI?

A

Weakness
Anorexia
Nausea

51
Q

How do you monitor exogenous cortisol administration?

A

Weight/BP
Lytes
Well being

52
Q

True or false: the smallest dose of exogenous cortisol should be used in pts with primary AI

A

True

53
Q

What should patients with Addison’s disease do when sick? After major surgery?

A

Double when sick

200-300 mg/day post op

54
Q

What are the 5 “S’s” of treating an adrenal crisis?

A
  • Salt (NS)
  • Sugar (5% dextrose)
  • Steroids
  • Support
  • Search for precipitating cause
55
Q

How do you taper off steroids for a AI pt following surgery?

A

Taper for a few days as tolerated until physiological levels achieved

56
Q

What is the minimal amount of steroids that can cause transient adrenal insufficiency?

A

15 mg for x14 days

57
Q

How do you differentiate secondary AI from primary AI in the clinic?

A

Measure ACTH levels–will be decreased with secondary causes

58
Q

Why is it that secondary AI can show a lack of response with a cortrosyn stimulation test?

A

Adrenal gland atrophy

59
Q

What is the basis of rh metyrapone test, and what are the results that can be expected?

A

Metyrapone blocks 11-deoxycortisol/compensatory, causing an increase in ACTH under normal conditions. If there is not, then secondary AI

60
Q

What is the insulin induced hypoglycemia test done for?

A

Hypoglycemia should cause ACTH secretion, thus by measure ACTH following insulin.

61
Q

What is the treatment for secondary AI?

A
  • Hydrocortisone 16 mg daily

- Prednisone once daily

62
Q

What is the lab test that can be done to confirm that the HPA axis has recovered after long term administration of corticosteroids?

A

Measure morning cortisol levels–needs to be more than 10 mcg/dL

63
Q

Which should always be corrected first: cortisol levels, or thyroid levels? Why?

A

Cortisol, since thyroid may increase renal clearance, and cause an adrenal crisis

Endocrine (32 decks)

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