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Adrenal Insufficiency Flashcards

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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
What is the effect of ANG II on NE release?
Increases
26
What is the effect of ANG II on the heart?
Stimulates hypertrophy
27
How does cortisol inhibit the immune response?
Inhibits the production of Leukotrienes
28
What is the effect of glucocorticoids on metabolism?
Increases BG Increases lipolysis Increases proteolysis
29
What is the effect of cortisol on fibroblasts?
Decreases/inhibits them
30
What are the cells in the anterior pituitary that synthesize and release ACTH? What stimulates them to do this?
Corticotroph cells | CRH
31
What are the two acidophils of the anterior pituitary?
Lactotrophs Somatotrophs (A PiG)
32
What are the four basophils of the anterior pituitary?
FSH LH (gonadotrophs) ACTH (corticotrophs) TSH (thyrotrophs) (B-FLAT)
33
What are the two breakdown products of POMC?
MSH | ACTH
34
What happens to renin, aldosterone, and ACTH levels with primary adrenal insufficiency?
High renin and ACTH | Low Aldosterone
35
What is the treatment for primary adrenal insufficiency?
Fludrocortisone + hydrocortisone
36
What is synthetic aldosterone?
Fludrocortisone
37
What are the major etiologies of primary adrenal insufficiency? (2 one most common in developed countries, and undeveloped)
Autoimmune destruction | TB granuloma
38
What are the antibodies that are found with primary adrenal insufficiency?
21-hydroxylase antibodies
39
What are the gross findings associated with autoimmune destruction of the adrenal glands vs TB infiltration?
Autoimmune = small, fibrotic TB = Caseating granuloma
40
What is the common fungal causes of primary adrenal insufficiency?
Histoplasmosis
41
What is the major cause of hemorrhage into the adrenal glands? What is the name of this syndrome?
Warfarin Waterhouse-friderichsen syndrome
42
For metastatic causes of adrenal insufficiency, what percent of the gland must be affected before seeing ssx?
90%
43
What are the three major medications that can cause primary adrenal insufficiency?
Ketoconazole Aminoglutethimide Rifampin
44
What are the following lab findings like with primary adrenal insufficiency: - cortisol - aldosterone - DHEA - ACTH - Renin
- cortisol = low - aldosterone = low - DHEA = low - ACTH = high - Renin = high
45
What are the two symptoms that are specific to primary adrenal insufficiency, as opposed to other forms of adrenal insufficiency?
Hyperpigmentation from POMC production Hyperkalemia from lack of aldosterone
46
What is the value of cortisol that is diagnostic of primary adrenal insufficiency (morning random)?
Morning cortisol less than 3 mcg Random less than 5 mcg
47
What is the name of synthetic ACTH?
Cortrosyn stimulation test
48
What is the reasoning behind the cortrosyn stimulation test? What are the results of this?
Injecting ACTH, wait 30 mins, and measure cortisol levels. | --Should have a more than 18 mcg/dL increase. If not, Addison's disease
49
What are the common acute symptoms of Addison's disease?
Postural hypotension Arthralgias/myalgias Abdo pain
50
What are the common chronic ssx of AI?
Weakness Anorexia Nausea
51
How do you monitor exogenous cortisol administration?
Weight/BP Lytes Well being
52
True or false: the smallest dose of exogenous cortisol should be used in pts with primary AI
True
53
What should patients with Addison's disease do when sick? After major surgery?
Double when sick 200-300 mg/day post op
54
What are the 5 "S's" of treating an adrenal crisis?
- Salt (NS) - Sugar (5% dextrose) - Steroids - Support - Search for precipitating cause
55
How do you taper off steroids for a AI pt following surgery?
Taper for a few days as tolerated until physiological levels achieved
56
What is the minimal amount of steroids that can cause transient adrenal insufficiency?
15 mg for x14 days
57
How do you differentiate secondary AI from primary AI in the clinic?
Measure ACTH levels--will be decreased with secondary causes
58
Why is it that secondary AI can show a lack of response with a cortrosyn stimulation test?
Adrenal gland atrophy
59
What is the basis of rh metyrapone test, and what are the results that can be expected?
Metyrapone blocks 11-deoxycortisol/compensatory, causing an increase in ACTH under normal conditions. If there is not, then secondary AI
60
What is the insulin induced hypoglycemia test done for?
Hypoglycemia should cause ACTH secretion, thus by measure ACTH following insulin.
61
What is the treatment for secondary AI?
- Hydrocortisone 16 mg daily | - Prednisone once daily
62
What is the lab test that can be done to confirm that the HPA axis has recovered after long term administration of corticosteroids?
Measure morning cortisol levels--needs to be more than 10 mcg/dL
63
Which should always be corrected first: cortisol levels, or thyroid levels? Why?
Cortisol, since thyroid may increase renal clearance, and cause an adrenal crisis

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