RESUMO
Acromegaly is a chronic and slowly progressive disease that results from the hypersecretion of growth hormone (GH) and consequently insulin-like growth factor type 1 (IGF-1), due to a GH-secreting pituitary adenoma in 95-98% of cases. There are several complications or co-morbidities associated with acromegaly, the most frequent being cardiovascular, metabolic and neoplastic. The cardiovascular complications of acromegaly go from arterial hypertension to a peculiar form of cardiomyopathy and are the result of the long-standing exposure to high GH and IGF-1 levels. The pathophysiology of these complications is complex and includes an increased tubular reabsorption of sodium and the direct effects of GH and IGF-1 on the endothelium and the cardiac tissue itself. Frequently, the cardiovascular comorbidities of acromegaly occur concomitantly with metabolic complications such as diabetes and respiratory abnormalities such as the sleep apnea syndrome. In this brief review we analyze the pathophysiology, the clinical manifestations and the management of the cardiovascular complications of acromegaly.
La acromegalia es una enfermedad crónica lentamente progresiva causada por la hipersecreción de hormona de crecimiento (GH) y consecuentemente de factor de crecimiento insulinoide tipo 1 (IGF-1), originada en el 95-98% de las ocasiones por un adenoma hipofisario secretor de GH. Existen diversas complicaciones o comorbilidad asociadas a la acromegalia, de las cuales destacan las enfermedades cardiovasculares, metabólicas y neoplásicas. Las complicaciones cardiovasculares van desde la hipertensión arterial hasta la cardiomiopatía acromegálica, y resultan de la exposición crónica a valores elevados de GH y de IGF-1. La fisiopatología de estas complicaciones es compleja e incluye tanto un aumento en la reabsorción tubular de sodio como efectos directos de la GH y del IGF-1 sobre el endotelio vascular y las células cardiacas. Con frecuencia estas alteraciones cardiovasculares ocurren simultáneamente con trastornos metabólicos como la diabetes y trastornos respiratorios como la apnea del sueño, y son agravadas por ellos. En esta breve revisión se analizan la fisiopatología, las manifestaciones clínicas y el manejo de las complicaciones cardiovasculares de la acromegalia.
Assuntos
Acromegalia , Adenoma , Adenoma Hipofisário Secretor de Hormônio do Crescimento , Hormônio do Crescimento Humano/metabolismo , Fator de Crescimento Insulin-Like I/metabolismo , Acromegalia/complicações , Acromegalia/diagnóstico , HumanosRESUMO
CONTEXT: Acromegaly registries constitute a valuable source of therapeutic outcome information in real-life. OBJECTIVE: The objective of this work is to analyze surgical and pharmacological outcomes in the Mexican Acromegaly Registry (MAR). DESIGN AND METHODS: Data were extracted from the MAR informatic platform. Surgical remission was defined by a postoperative postglucose (GH) of less than 1 ng/mL and an insulin-like growth factor 1 (IGF-1) of less than 1.2â ×â upper limit of normal (ULN). Pharmacological remission was defined by a basal GH of less than 1 ng/mL and an IGF-1 of less than 1.2â ×â ULN. RESULTS: A total of 650 surgical outcomes were analyzed (94.6% transsphenoidal). Surgical remission was achieved in 40.15%, whereas 44.15% remained biochemically active. Persistently active disease after surgery was significantly associated with harboring an invasive macroadenoma, a basal GH of greater than 10 ng/mL, and/or an IGF-1 of greater than 2â ×â ULN at diagnosis on bivariate and multivariate analysis. The outcome of monotherapy with first-generation somatostatin analogs (SSAs) was evaluated in 267 patients (adjunctive in 65%), of whom 28.4% achieved remission. Persistently active disease was significantly associated with harboring an invasive macroadenoma as well as with pretreatment basal GH and IGF-1 levels of greater than 10 ng/mL and greater than 2â ×â ULN, respectively, on bivariate and multivariate analysis. Combined therapy with SSA and cabergoline was analyzed in 100 patients, of whom 19% achieved remission and 44% remained active; in this subset of patients, only a pretreatment IGF-1 of greater than 2â ×â ULN was significantly associated with persistent disease activity. CONCLUSION: Surgical and pharmacological outcomes in acromegaly are highly dependent on tumor size/invasiveness as well as on the degree of hypersomatotropinemia.
Assuntos
Acromegalia/tratamento farmacológico , Acromegalia/cirurgia , Acromegalia/diagnóstico , Acromegalia/epidemiologia , Adenoma/diagnóstico , Adenoma/tratamento farmacológico , Adenoma/epidemiologia , Adenoma/cirurgia , Adulto , Cabergolina/uso terapêutico , Terapia Combinada , Feminino , Adenoma Hipofisário Secretor de Hormônio do Crescimento/diagnóstico , Adenoma Hipofisário Secretor de Hormônio do Crescimento/tratamento farmacológico , Adenoma Hipofisário Secretor de Hormônio do Crescimento/epidemiologia , Adenoma Hipofisário Secretor de Hormônio do Crescimento/cirurgia , Hormônio do Crescimento Humano/sangue , Humanos , Fator de Crescimento Insulin-Like I/metabolismo , Masculino , México/epidemiologia , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Período Pós-Operatório , Prognóstico , Sistema de Registros , Estudos Retrospectivos , Somatostatina/análogos & derivados , Resultado do TratamentoRESUMO
BACKGROUND: Currently, bariatric surgery is the most effective treatment for severe obesity and its metabolic complications; however, 15-35% of the patients that undergo bariatric surgery do not reach their goal for weight loss. The aim of this study was to determine the proportion of patients that didn't reach the goal of an excess weight loss of 50% or more during the first 12 months and determine the factors associated to this failure. METHODS: We obtained the demographic, anthropometric and biochemical information from 130 patients with severe obesity who underwent bariatric surgery in our institution between 2012 and 2017. We used self-reports of physical activity, caloric intake and diet composition. An unsuccessful weight loss was considered when the patient lost < 50% or more of the excess weight 12 months after surgery. We compared the characteristics between the successful and unsuccessful groups in order to find the factors associated with success. RESULTS: We included 130 patients (mean age 48 ± 9 years, 81.5% were women). One year after surgery, 26 (20%) had loss < 50% EBW. Unsuccessful surgery was associated with an older age, previous history of hypertension, abdominal surgery or depression/anxiety, also the number of comorbidities and unemployment affected the results. These patients loss enough weight to improve some of their comorbidities, but they are more prone to regain weight 2 years after surgery. CONCLUSIONS: A fifth of the patients undergoing bariatric surgery may not lose enough weight to be considered successful by current standards. Some patients may benefit from the surgery in the short term, but they are more likely to regain weight after 2 years. The factors influencing this result are still controversial but may be population-specific. Early detection of the patients that are more likely to fail is imperative to establish additional therapeutic strategies, without denying them the opportunity of surgery or waiting for weight re-gain to occur.
Assuntos
Cirurgia Bariátrica/métodos , Índice de Massa Corporal , Obesidade/cirurgia , Aumento de Peso , Redução de Peso , Dieta , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/patologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Prader-Willi syndrome (PWS) is a major cause of syndromic obesity, caused by deletions on chromosome 15q11-q13. It is characterized by neonatal hypotonia, difficulty in feeding with low birth-weight and subsequent development of hyperphagia, behavioral disorders and obesity. Treatment options for weight control in those patients is limited and there are controversies for a surgical approach. CASE REPORT: we present the case of a patient with PWS who achieved weight loss and control through the use of liraglutide, nutritional therapy and physical activity. DISCUSSION: the treatment of obesity in patients with PWS is challenging and requires an adequate nutritional approach combined with psychological therapy. In those patients that persist with uncontrolled appetite, medications such as metformin or GLP-1 analogs can be used.