ABSTRACT
Monitoring treatment of children with classic congenital adrenal hyperplasia (CAH) is difficult and biochemical targets are not well defined. We retrospectively analysed 576 daily urinary steroid hormone metabolite profiles determined by gas chromatography-mass spectrometry of 150 children aged 3.0-17.9 years with classic 21-hydroxylase deficiency (21-OHD) on hydrocortisone and fludrocortisone treatment. Daily urinary excretion of glucocorticoid-, 17α-hydroxyprogesterone (17-OHP)-, and androgen metabolites as well as growth and weight gain are presented. Children with classic CAH exhibited increased height velocity during prepubertal age, which was then followed by diminished growth velocity during pubertal age until final height was reached. Final height was clearly below the population mean. 11ß-Hydroxyandrosterone was the dominant urinary adrenal-derived androgen metabolite in CAH children. Adrenarche is blunted in children with CAH under hydrocortisone treatment and androgen metabolites except 11ß-hydroxyandrosterone were suppressed. Cortisol metabolite excretion reflected supraphysiological hydrocortisone treatment dosage, which resulted in higher body-mass-indices in children with CAH. Reference values of daily urinary steroid metabolite excretions of treated children with CAH allow the clinician to adequately classify the individual patient regarding the androgen-, 17-OHP-, and glucocorticoid status in the context of the underlying disorder. Additionally, urinary 21-OHD-specific reference ranges will be important for research studies in children with CAH.
Subject(s)
Adrenal Hyperplasia, Congenital/urine , Steroids/urine , Urinalysis/methods , Adolescent , Adrenarche/metabolism , Adrenarche/urine , Androgens/metabolism , Androgens/urine , Androsterone/analogs & derivatives , Androsterone/metabolism , Androsterone/urine , Body Height , Body Weight , Child , Child, Preschool , Cohort Studies , Female , Fludrocortisone/metabolism , Fludrocortisone/therapeutic use , Gas Chromatography-Mass Spectrometry , Glucocorticoids/metabolism , Glucocorticoids/urine , Humans , Hydrocortisone/metabolism , Hydrocortisone/therapeutic use , Hydrocortisone/urine , Male , Reference Values , Retrospective Studies , Steroid 21-Hydroxylase/urineABSTRACT
BACKGROUND: Up to now, the regulation of adrenarche remains a myth although ACTH may possibly play an important role. METHODS: Urinary steroid profiling by gas chromatography-mass spectrometry was used to study non-invasively the adrenarchal steroid metabolome in 13 children aged 6-16 years with partial or complete hypopituitarism (HP) whose ACTH/cortisol axis was affected and compared it with 24 healthy age-matched controls. The sum of DHEA, 16α-hydroxy-DHEA and 3ß,16α,17ß-androstenetriol served as markers for adrenarche parameters (AP). The excretion rates of major urinary cortisol metabolites were also determined. RESULTS: The excretion rates for AP were significantly lower for the HP subjects than for the controls (p < 0.001). After dividing the HP group into a subgroup treated with hydrocortisone (HC) and an HC-untreated subgroup, a significant difference for AP remained for each subgroup when compared to the control group (p < 0.001 and p = 0.045, respectively). Treatment with HC had no influence on AP. CONCLUSION: The data imply indirectly a significant contribution of ACTH to the regulation of adrenarche. Our results also signify important diagnostic information: absent adrenarche can be indicative of ACTH deficiency.
Subject(s)
Adrenarche/physiology , Dehydroepiandrosterone/urine , Hypopituitarism/physiopathology , Adolescent , Adrenarche/urine , Adrenocorticotropic Hormone/physiology , Child , Female , Gas Chromatography-Mass Spectrometry , Humans , Hydrocortisone/metabolism , Hydrocortisone/therapeutic use , Hydrocortisone/urine , Hypopituitarism/urine , Male , MetabolomicsABSTRACT
CONTEXT: Inactivating mutations in the enzyme hexose-6-phosphate dehydrogenase (H6PDH, encoded by H6PD) cause apparent cortisone reductase deficiency (ACRD). H6PDH generates cofactor NADPH for 11ß-hydroxysteroid dehydrogenase type 1 (11ß-HSD1, encoded by HSD11B1) oxo-reductase activity, converting cortisone to cortisol. Inactivating mutations in HSD11B1 cause true cortisone reductase deficiency (CRD). Both ACRD and CRD present with hypothalamic-pituitary-adrenal (HPA) axis activation and adrenal hyperandrogenism. OBJECTIVE: To describe the clinical, biochemical and molecular characteristics of two additional female children with ACRD and to illustrate the diagnostic value of urinary steroid profiling in identifying and differentiating a total of six ACRD and four CRD cases. DESIGN: Clinical, biochemical and genetic assessment of two female patients presenting during childhood. In addition, results of urinary steroid profiling in a total of ten ACRD/CRD patients were compared to identify distinguishing characteristics. RESULTS: Case 1 was compound heterozygous for R109AfsX3 and a novel P146L missense mutation in H6PD. Case 2 was compound heterozygous for novel nonsense mutations Q325X and Y446X in H6PD. Mutant expression studies confirmed loss of H6PDH activity in both cases. Urinary steroid metabolite profiling by gas chromatography/mass spectrometry suggested ACRD in both cases. In addition, we were able to establish a steroid metabolite signature differentiating ACRD and CRD, providing a basis for genetic diagnosis and future individualised management. CONCLUSIONS: Steroid profile analysis of a 24-h urine collection provides a diagnostic method for discriminating between ACRD and CRD. This will provide a useful tool in stratifying unresolved adrenal hyperandrogenism in children with premature adrenarche and adult females with polycystic ovary syndrome (PCOS).
