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Medicina & Laboratorio

2009, Número 05-06

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Medicina & Laboratorio 2009; 15 (05-06)


Pruebas dinámicas en endocrinología: insuficiencia adrenal

Clara Arango Toro, Germán Campuzano Maya, Guillermo Latorre Sierra

Idioma: Español
Referencias bibliográficas: 65
Paginas: 211-232
Archivo PDF: 758.83 Kb.


RESUMEN

El diagnóstico de insuficiencia adrenal se sospecha con los hallazgos clínicos en el paciente, pero sólo se confirma con las pruebas de laboratorio. La insuficiencia adrenal primaria es causada por una lesión en la glándula adrenal, en tanto que la insuficiencia adrenal secundaria puede ser causada por enfermedad hipotalámica o hipofisaria, o como resultado de la supresión del eje hipotálamo-hipófisis-adrenal por esteroides. Los hallazgos clínicos de insuficiencia adrenal primaria incluyen fatiga, anorexia, diarrea, dolores osteomusculares e hiperpigmentación, entre otros. Los hallazgos clínicos de la insuficiencia adrenal secundaria son similares; sin embargo, no se presenta hiperpigmentación. Es común que el clínico se enfrente a un paciente con síntomas inespecíficos y no considere la posibilidad de un diagnóstico de insuficiencia adrenal. Una prueba de tamización ideal debe ser de bajo costo, fácil y segura; infortunadamente, hasta el momento, no se dispone de una prueba ideal para la insuficiencia adrenal. La determinación del cortisol basal es una prueba que se utiliza comúnmente para la tamización, que puede incluir (si es ‹ 3 μg/dL o ‹ 5 μg/dL, de acuerdo con diferentes autores) o excluir (si es >18 μg/dL) una insuficiencia adrenal; sin embargo, la mayoría de los pacientes tendrán un valor intermedio y por ello se harán necesarias las pruebas dinámicas. En el presente módulo se revisan las pruebas dinámicas en el estudio de la insuficiencia adrenal, incluyendo la prueba de tolerancia a la insulina, la prueba de estímulo con metirapona y la prueba de estímulo con cosintropina, como agentes inductores de la producción de cortisol. Finalmente, se presenta un algoritmo para el estudio del paciente con sospecha de insuficiencia adrenal.


REFERENCIAS (EN ESTE ARTÍCULO)

  1. Bouillon R. Acute adrenal insufficiency. Endocrinol Metab Clin North Am 2006; 35: 767-775, ix.

  2. Hahner S, Loeffler M, Fassnacht M, Weismann D, Koschker AC, Quinkler M, et al. Impaired subjective health status in 256 patients with adrenal insufficiency on standard therapy based on crosssectional analysis. J Clin Endocrinol Metab 2007; 92: 3912-3922.

  3. Tomlinson JW, Holden N, Hills RK, Wheatley K, Clayton RN, Bates AS, et al. Association between premature mortality and hypopituitarism. West Midlands Prospective Hypopituitary Study Group. Lancet 2001; 357: 425-431.

  4. Bergthorsdottir R, Leonsson-Zachrisson M, Oden A, Johannsson G. Premature mortality in patients with Addison’s disease: a populationbased study. J Clin Endocrinol Metab 2006; 91: 4849-4853.

  5. Wurtman RJ, Pohorecky LA, Baliga BS. Adrenocortical control of the biosynthesis of epinephrine and proteins in the adrenal medulla. Pharmacol Rev 1972; 24: 411-426.

  6. Dorin RI, Qualls CR, Crapo LM. Diagnosis of adrenal insufficiency. Ann Intern Med 2003; 139: 194-204.

  7. Stewart PM. The adrenal cortex. In: Kronenberg HM, Melmed S, Polonsky KS, Larsen PR, eds. Williams textbook of endocrinology (ed 11th edition). Philadephia, USA: Saunders Elsevier; 2008: 445-504.

  8. Carey RM. The changing clinical spectrum of adrenal insufficiency. Ann Intern Med 1997; 127: 1103-1105.

  9. Betterle C, Volpato M, Pedini B, Chen S, Smith BR, Furmaniak J. Adrenal-cortex autoantibodies and steroid-producing cells autoantibodies in patients with Addison’s disease: comparison of immunofluorescence and immunoprecipitation assays. J Clin Endocrinol Metab 1999; 84: 618- 622.

  10. Salvatori R. Adrenal insufficiency. JAMA 2005; 294: 2481-2488.

  11. Arlt W, Allolio B. Adrenal insufficiency. Lancet 2003; 361: 1881-1893.

  12. Betterle C, Lazzarotto F, Presotto F. Autoimmune polyglandular syndrome Type 2: the tip of an iceberg? Clin Exp Immunol 2004; 137: 225-233.

  13. Arlt W. The approach to the adult with newly diagnosed adrenal insufficiency. J Clin Endocrinol Metab 2009; 94: 1059-1067.

  14. Obermayer-Straub P, Strassburg CP, Manns MP. Autoimmune polyglandular syndrome type 1. Clin Rev Allergy Immunol 2000; 18: 167-183.

  15. Schatz DA, Winter WE. Autoimmune polyglandular syndrome. II: Clinical syndrome and treatment. Endocrinol Metab Clin North Am 2002; 31: 339- 352.

  16. Majeroni BA, Patel P. Autoimmune polyglandular syndrome, type II. Am Fam Physician 2007; 75: 667-670.

  17. Xarli VP, Steele AA, Davis PJ, Buescher ES, Rios CN, Garcia-Bunuel R. Adrenal hemorrhage in the adult. Medicine (Baltimore) 1978; 57: 211-221. 18. Krasner AS. Glucocorticoid-induced adrenal insufficiency. JAMA 1999; 282: 671-676.

  18. Aimaretti G, Ambrosio MR, Di Somma C, FuscoA, Cannavo S, Gasperi M, et al. Traumatic brain injury and subarachnoid haemorrhage are conditions at high risk for hypopituitarism: screening study at 3 months after the brain injury. Clin Endocrinol (Oxf) 2004; 61: 320-326.

  19. Schlaghecke R, Kornely E, Santen RT, Ridderskamp P. The effect of long-term glucocorticoid therapy on pituitary-adrenal responses to exogenous corticotropin-releasing hormone. N Engl J Med 1992; 326: 226-230.

  20. Betterle C, Greggio NA, Volpato M. Clinical review 93: Autoimmune polyglandular syndrome type 1. J Clin Endocrinol Metab 1998; 83: 1049- 1055.

  21. Pal SK, Ghosh KK, Panja RK, Banerjee PK. Adrenocortical function in vitiligo. Clin Chim Acta1981; 113: 325-327.

  22. Graner JL. Addison, pernicious anemia and adrenal insufficiency. CMAJ 1985; 133: 855-857, 880.

  23. Bagchi N, Komanicky P. Loss of pubic and axillary hair following treatment with glucocorticoids. Am J Med Sci 1989; 297: 263-264.

  24. Snow K, Jiang NS, Kao PC, Scheithauer BW. Biochemical evaluation of adrenal dysfunction: the laboratory perspective. Mayo Clin Proc 1992; 67: 1055-1065.

  25. Oelkers W, Diederich S, Bahr V. Diagnosis and therapy surveillance in Addison’s disease: rapid adrenocorticotropin (ACTH) test and measurement of plasma ACTH, renin activity, and aldosterone. J Clin Endocrinol Metab 1992; 75: 259-264.

  26. Jacobs DS, Garg U, Oxley DK, Shideler C, H.J. G, DeMott WR, et al. Chemistry. In: Jacobs D, De- Mott W, Oxley D, eds. Laboratory test handbook (ed 5th ed). Hudson (Cleveland), OH: Lexi-Comp, Inc; 2001: 75-302.

  27. Hagg E, Asplund K, Lithner F. Value of basal plasma cortisol assays in the assessment of pituitaryadrenal insufficiency. Clin Endocrinol (Oxf) 1987; 26: 221-226.

  28. Plumpton FS, Besser GM. The adrenocortical response to surgery and insulin-induced hypoglycaemia in corticosteroid-treated and normal subjects. Br J Surg 1969; 56: 216-219.

  29. Grinspoon SK, Biller BM. Clinical review 62: Laboratory assessment of adrenal insufficiency. J Clin Endocrinol Metab 1994; 79: 923-931.

  30. Finucane FM, Liew A, Thornton E, Rogers B, Tormey W, Agha A. Clinical insights into the safety and utility of the insulin tolerance test (ITT) in the assessment of the hypothalamo-pituitary-adrenal axis. Clin Endocrinol (Oxf) 2008; 69: 603-607.

  31. Nelson JC, Tindall DJ, Jr. A comparison of the adrenal responses to hypoglycemia, metyrapone and ACTH. Am J Med Sci 1978; 275: 165-172.

  32. Ceroni L, Cota D, Pasquali R. [Pseudo-Cushing syndrome. Physiopathologic aspects and differential diagnosis]. Minerva Endocrinol 2000; 25: 47- 54.

  33. Arlt W. Adrenal insufficiency. Clin Med 2008; 8: 211-215.

  34. Nye EJ, Grice JE, Hockings GI, Strakosch CR, Crosbie GV, Walters MM, et al. The insulin hypoglycemia test: hypoglycemic criteria and reproducibility. J Neuroendocrinol 2001; 13: 524-530.

  35. Liddle GW, Estep HL, Kendall JW, Jr., Williams WC, Jr., Townes AW. Clinical application of a new test of pituitary reserve. J Clin Endocrinol Metab 1959; 19: 875-894.

  36. Fiad TM, Kirby JM, Cunningham SK, McKenna TJ. The overnight single-dose metyrapone test is a simple and reliable index of the hypothalamicpituitary- adrenal axis. Clin Endocrinol (Oxf) 1994; 40: 603-609.

  37. Nieman LK. Dynamic evaluation of adrenal hypofunction. J Endocrinol Invest 2003; 26: 74-82.

  38. Dolman LI, Nolan G, Jubiz W. Metyrapone test with adrenocorticotrophic levels. Separating primary from secondary adrenal insufficiency. JAMA 1979; 241: 1251-1253.

  39. Thornton PS, Alter CA, Katz LE, Gruccio DA, Winyard PJ, Moshang T, Jr. The new highly sensitive adrenocorticotropin assay improves detection of patients with partial adrenocorticotropin deficiency in a short-term metyrapone test. J Pediatr Endocrinol 1994; 7: 317-324.

  40. Inagaki M, Akizuki N, Kugaya A, Fujii H, Akechi T, Uchitomi Y. Metyrapone for Cushing’s syndrome. Am J Psychiatry 2002; 159: 1246.

  41. Spiger M, Jubiz W, Meikle AW, West CD, Tylor FH. Single-dose metyrapone test: review of a fouryear experience. Arch Intern Med 1975; 135: 698-700.

  42. Berneis K, Staub JJ, Gessler A, Meier C, Girard J, Muller B. Combined stimulation of adrenocorticotropin and compound-S by single dose metyrapone test as an outpatient procedure to assess hypothalamic-pituitary-adrenal function. J Clin Endocrinol Metab 2002; 87: 5470-5475.

  43. Sparks LL, Smilo RP, Pavlatos FC, Forsham PH. Experience with a rapid oral metyrapone test and the plasma ACTH content in determining the cause of Cushing’s syndrome. Metabolism 1969; 18: 175-192.

  44. Addison GM. Biochemical basis of pediatric disease. In: Soldin SJ, Rifai N, Hicks JMB, eds. Biochemical basis of pediatric disease. Washington, D.C.: AACC Press, American Association of Clinical Chemistry; 1992: 228-229.

  45. Hartzband PI, Van Herle AJ, Sorger L, Cope D. Assessment of hypothalamic-pituitary-adrenal (HPA) axis dysfunction: comparison of ACTH stimulation, insulin-hypoglycemia and metyrapone. J Endocrinol Invest 1988; 11: 769-776.

  46. Meikle AW, Jubiz W, Matsukura S, West CD, Tyler FH. Effect of diphenylhydantoin on the metabolism of metyrapone and release of ACTH in man. J Clin Endocrinol Metab 1969; 29: 1553-1558.

  47. Endert E, Ouwehand A, Fliers E, Prummel MF, Wiersinga WM. Establishment of reference values for endocrine tests. Part IV: Adrenal insufficiency. Neth J Med 2005; 63: 435-443.

  48. Watts NB, Tindall GT. Rapid assessment of corticotropin reserve after pituitary surgery. JAMA 1988; 259: 708-711.

  49. Dickstein G, Shechner C, Nicholson WE, Rosner I, Shen-Orr Z, Adawi F, et al. Adrenocorticotropin stimulation test: effects of basal cortisol level, time of day, and suggested new sensitive low dose test. J Clin Endocrinol Metab 1991; 72: 773-778.

  50. Daidoh H, Morita H, Mune T, Murayama M, Hanafusa J, Ni H, et al. Responses of plasma adrenocortical steroids to low dose ACTH in normal subjects. Clin Endocrinol (Oxf) 1995; 43: 311-315.

  51. Villabona CV, Koh C, Panergo J, Reddy A, Fogelfeld L. Adrenocorticotropic hormone stimulation test during high-dose glucocorticoid therapy. Endocr Pract 2009; 15: 122-127.

  52. Tordjman K, Jaffe A, Grazas N, Apter C, Stern N. The role of the low dose (1 microgram) adrenocorticotropin test in the evaluation of patients with pituitary diseases. J Clin Endocrinol Metab 1995; 80: 1301-1305.

  53. Thaler LM, Blevins LS, Jr. The low dose (1-microg) adrenocorticotropin stimulation test in the evaluation of patients with suspected central adrenal insufficiency. J Clin Endocrinol Metab 1998; 83: 2726-2729.

  54. Henzen C, Suter A, Lerch E, Urbinelli R, Schorno XH, Briner VA. Suppression and recovery of adrenal response after short-term, high-dose glucocorticoid treatment. Lancet 2000; 355: 542-545.

  55. Mayenknecht J, Diederich S, Bahr V, Plockinger U, Oelkers W. Comparison of low and high dose corticotropin stimulation tests in patients with pituitary disease. J Clin Endocrinol Metab 1998; 83: 1558-1562.

  56. Kazlauskaite R, Evans AT, Villabona CV, Abdu TA, Ambrosi B, Atkinson AB, et al. Corticotropin tests for hypothalamic-pituitary- adrenal insufficiency: a metaanalysis. J Clin Endocrinol Metab 2008; 93: 4245-4253.

  57. Reimondo G, Bovio S, Allasino B, Terzolo M, Angeli A. Secondary hypoadrenalism. Pituitary 2008; 11: 147-154.

  58. Soule S, Van Zyl Smit C, Parolis G, Attenborough S, Peter D, Kinvig S, et al. The low dose ACTHstimulation test is less sensitive than the overnight metyrapone test for the diagnosis of secondary hypoadrenalism. Clin Endocrinol (Oxf) 2000; 53: 221-227.

  59. Courtney CH, McAllister AS, McCance DR, Bell PM, Hadden DR, Leslie H, et al. Comparison of one week 0900 h serum cortisol, low and standard dose synacthen tests with a 4 to 6 week insulin hypoglycaemia test after pituitary surgery in assessing HPA axis. Clin Endocrinol (Oxf) 2000; 53: 431- 436.

  60. Reimondo G, Pia A, Bovio S, Allasino B, Daffara F, Paccotti P, et al. Laboratory differentiation of Cushing’s syndrome. Clin Chim Acta 2008; 388: 5-14.

  61. Auchus RJ, Shewbridge RK, Shepherd MD. Which patients benefit from provocative adrenal testing after transsphenoidal pituitary surgery? Clin Endocrinol (Oxf) 1997; 46: 21-27.

  62. Tordjman K, Jaffe A, Trostanetsky Y, Greenman Y, Limor R, Stern N. Low-dose (1 microgram) adrenocorticotrophin (ACTH) stimulation as a adrenal axis function: sensitivity, specificity and accuracy in comparison with the high-dose (250 microgram) test. Clin Endocrinol (Oxf) 2000; 52: 633-640.

  63. Dickstein G, Arad E, Shechner C. Low-dose ACTH stimulation test. Endocrinologist 1997; 285-293.

  64. Schulte HM, Chrousos GP, Avgerinos P, Oldfield EH, Gold PW, Cutler GB Jr, et al. The corticotropin-releasing hormone stimulation test: A possible aid in the evaluation of patients with adrenal insufficiency. J Clin Endocrinol Metab 1984; 58: 1064.

  65. Gold PW, Kling MA, Khan I, Calabrese JR, Kalogeras K, Post RM, et al. Corticotropin releasinghormone: relevance to normal physiology and to the pathophysiology and differential diagnosis of hypercortisolism and adrenal insufficiency. Adv Biochem Psychopharmacol 1987; 43: 183-200.




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