Association of hypokalemia with cortisol and ACTH levels in Cushing's disease.

Hypokalemia is a common feature in patients with Cushing's syndrome (CS). Whether the occurrence of hypokalemia is associated with cortisol and adrenocorticotropic hormone (ACTH) levels is still unclear. Approximately 80% of cases of endogenous CS are due to Cushing's disease (CD). The purpose of this study was to determine the association of hypokalemia with cortisol and ACTH levels in patients with CD. The retrospective study included 195 patients with CD referred to our medical center from January 2011 to December 2017. The results show that 25.64% (50/195) of the patients had hypokalemia. The 24-h urinary free cortisol (UFC) and plasma cortisol levels were significantly higher in patients with hypokalemia than those with normokalemia (P < 0.05). Plasma ACTH levels were similar between the patients with hypokalemia and normokalemia (P > 0.05). Cortisol levels were negatively correlated with plasma potassium levels (08:00: r = -0.344 (P < 0.01), 00:00: r = -0.435 (P < 0.01); 24-h UFC: r = -0.281 (P < 0.05)). There was no significant correlation between the plasma ACTH and potassium (08:00: r = -0.093 (P > 0.05), 00:00: r = -0.184 (P > 0.050)). Our current data suggest that cortisol level, instead of ACTH level, is correlated with plasma potassium level. A high cortisol level may be the principal cause of hypokalemia.

Accuracy of adrenal computed tomography in predicting the unilateral subtype in young patients with hypokalaemia and elevation of aldosterone in primary aldosteronism.

CONTEXT: The current Endocrine Society Guideline suggests that patients aged <35 years with marked primary aldosteronism (PA) and unilateral adrenal lesions on adrenal computed tomography (CT) scan may not need adrenal vein sampling (AVS) before proceeding to unilateral adrenalectomy. This suggestion is, however, based on the data from only one report in the literature. OBJECTIVE: We sought to determine the accuracy of CT findings in young PA patients who had unilateral adrenal disease on CT with hypokalaemia and elevation of aldosterone. DESIGN AND PATIENTS: We retrospectively studied 358 PA patients (n = 30, aged <35 years; n = 39, aged 35-40 years; n = 289, aged ≥40 years) with hypokalaemia and elevation of aldosterone and unilateral disease on CT who had successful AVS. MAIN OUTCOME MEASURE: Accuracy of CT findings is determined by AVS findings and/or surgical outcomes in patients aged <35 years. RESULTS: Concordance of the diagnosis between CT and AVS was 90% (27/30) in patients aged <35 years, 79% (31/39) in patients aged 35-40 years and 69% (198/289) in those aged ≥40 years (trend for P < .01). Surgical benefit was confirmed in three patients aged <35 years and in three patients aged 35-40 years with the available surgical data who had discordance between CT and AVS findings. Collectively, the diagnostic accuracy of CT findings was 100% (30/30) if aged <35 years and 87% (34/39) if aged 35-40 years. CONCLUSION: Primary aldosteronism patients aged <35 years with hypokalaemia and elevation of aldosterone and unilateral disease on adrenal CT could be spared AVS.

Dobutamine Stress Echocardiography: Impact of Abnormal Blood Potassium Levels on Cardiac Arrhythmias.

BACKGROUND: Guidelines suggest that an abnormal blood potassium level is a relative contraindication to performing dobutamine stress echocardiography (DSE). However, this has not been previously studied. METHODS: We reviewed a consecutive series of patients who had potassium testing within 48 hours of undergoing DSE for the evaluation of myocardial ischemia over a 10-year period (N = 13,198). Normal potassium range in our laboratory is 3.6-5.2 mmol/L. Hemolyzed samples were not included. The association of potassium levels with the development of supraventricular and ventricular arrhythmias was assessed. RESULTS: The incidence of clinically significant arrhythmias was very low (supraventricular tachycardia/atrial fibrillation, 4.9%; nonsustained ventricular tachycardia, 2.9%; sustained ventricular tachycardia or ventricular fibrillation, 0.1%), confirming the overall safety of DSE. Most arrhythmias (88%) occurred in patients with normal potassium levels, and arrhythmia rates remained low in patients with potassium abnormalities. Patients with hyperkalemia had a lower risk of developing mild (odds ratio [OR], 0.39; 95% CI, 0.22-0.71) and severe (OR, 0.13; 95% CI, 0.01-0.68) supraventricular arrhythmias as well as mild ventricular arrhythmias (OR, 0.58; 95% CI, 0.40-0.83). Even though events were rare, patients with severe hypokalemia (potassium levels ≤ 3.1 mmol/L) had an increased risk of supraventricular arrhythmia and ventricular ectopy. CONCLUSIONS: DSE is safe even in the setting of abnormalities in blood potassium concentrations, and hence cancellation of DSE in patients with potassium abnormalities does not appear warranted. Elevated potassium levels are associated with lower rates of clinically significant supraventricular and ventricular arrhythmias. While remaining at relatively low risk, patients with very low potassium levels (≤3.1 mmol/L) at the time of DSE have a modestly increased risk of arrhythmia. Consideration could be given to correcting severe hypokalemia prior to DSE.

Adrenocortical carcinoma initially presenting with hypokalemia and hypertension mimicking hyperaldosteronism: a case report.

BACKGROUND: Adrenocortical carcinoma is a rare malignancy and rare cause of Cushing's syndrome. CASE PRESENTATION: A 65-year-old seemingly well male patient was referred to our clinic under the suspicion of hyperaldosteronism due to hypertension combined with hypokalemia. However, his serum aldosterone and plasma renin activity were within normal limits. Instead, Cushing's syndrome was diagnosed by elevated urine free cortisol and a non-suppressible dexamethasone test. Abdominal computed tomography showed a 7.8 × 4.8 cm mass lesion at the right adrenal gland with liver invasion. Etomidate infusion was performed to reduce his cortisol level before the patient received a right adrenalectomy and liver wedge resection. The pathology report showed adrenocortical carcinoma with liver and lymph node metastasis. According to the European Network for the Study of Adrenal Tumors (ENSAT) staging system, the tumor was classified as T4N1M1, stage IV. Recurrent hypercortisolism was found shortly after surgery. The patient died of Fournier's gangrene with septic shock on the 59th day after diagnosis. CONCLUSIONS: We report a case of rapidly progressive stage IV adrenocortical carcinoma with initial presentations of hypokaelmia and hypertension, mimicking hyperaldosteronism.

The relationship of electrocardiographic left ventricular hypertrophy to decreased serum potassium.

BACKGROUND: Low serum potassium (K) is associated with increased blood pressure, impaired cardiac function and renal dysfunction. Although lower serum K is associated with cardiac hypertrophy in animal models, the relationship of low serum K to the presence and severity of electrocardiographic left ventricular hypertrophy (LVH) is unclear. METHODS: Baseline and yearly Cornell product LVH levels were examined in relation to low serum K (serum K ≤ 3.90 mEq/l, the lowest quartile of baseline K levels) in 8586 patients with baseline K levels. Patients were randomized to losartan-vs atenolol-based treatment and additional hydrochlorothiazide (HCTZ) therapy as needed. RESULTS: After adjusting for age, sex, race, prior antihypertensive treatment, losartan vs atenolol therapy, HCTZ use, baseline diastolic and systolic pressure, body mass index, serum creatinine and urine albumin/creatinine ratio, baseline serum K ≤ 3.90 was associated with significantly higher mean baseline Cornell product LVH (2898 vs 2801 mm•ms, p = 0.001) and a 24% higher risk of Cornell product LVH > 2440 mm•ms at baseline (OR 1.24, 95% CI 1.11-1.38, p < 0.001). After also adjusting for baseline Cornell product and changes in diastolic and systolic pressure between baseline and each year of measurement, in-treatment serum K ≤ 3.90 determined yearly was associated with significantly higher mean Cornell product LVH at years 1-3 and with statistically significant 16-32% increased risks of LVH by Cornell product at years 1-4. CONCLUSIONS: A low serum K is independently associated with a greater likelihood and severity of Cornell product LVH during antihypertensive therapy.

Hypokalemia, diabetes mellitus, and hypercortisolemia are the major contributing factors to cardiac dysfunction in adrenal Cushing's syndrome.

Although cardiovascular complications are the major determinant of the prognosis of Cushing's syndrome (CS), factors contributing to the cardiovascular lesions are still unclear. We investigated clinical factors determining cardiac function in patients with adrenal CS. Fifty patients with adrenal CS were studied. Patients were divided into 3 groups based on their NYHA classification and electrocardiographic (ECG) findings: group A with NYHA grade 0 and normal ECG, group B with NYHA grade I and abnormal ECG, and group C with NYHA grade II or higher. Clinical and echocardiographic findings were compared between the groups. Heart failure of grade I or higher was seen in 40% and grade II or higher was seen in 8% of the patients. Age, HbA1c, and prevalence of diabetes mellitus were positively correlated and serum potassium levels were negatively correlated with the severity of cardiac dysfunction. Decreased ejection fraction (EF) and the ratio of the peak to late transmittal filling velocities (E/A), and increased left ventricular mass index (LVMI) were frequently observed. Multivariate analysis demonstrated that serum potassium and HbA1c levels were independent factors contributing to EF, while serum potassium and cortisol levels were independent factors contributing to LVMI. These results clearly demonstrated that hypokalemia, diabetes mellitus, and hypercortisolemia are the major contributing factors to cardiac dysfunction in adrenal CS. Strict control of these conditions is warranted for the prevention of cardiac dysfunction in adrenal CS.

Abnormal captopril scintigraphy in Bartter syndrome.

A 37-year-old patient with severe hypokalemia (approximately 1.7 mEq/L) and muscular weakness had a very high serum renin level. No renin-producing tumor was found and she was diagnosed with Bartter Syndrome The parathyroid hormone level was high due to concomitant renal calcium loss. Tc-99m-DTPA captopril scintigraphy was performed to confirm the diagnosis.

Primary hyperaldosteronism treated by radiofrequency ablation.

This is a report of a 57-year-old Jordanian man who had uncontrolled hypertension and hypokalemia. He was diagnosed to have primary hyperaldosteronism with left adrenal adenoma. Traditionally, surgical resection of the adrenal gland whether by laparotomy or laparoscopic procedures would have been considered at this point. However, the treating team elected radiofrequency ablation of the left adrenal in view of the fact that this facility and the expertise was available in the hospital; in addition, this procedure required a shorter duration of hospitalization, was less expensive, and was less invasive. Subsequently, the patients blood pressure improved to 120/75 mm Hg and his anti-hypertensive medications were reduced. Serum aldosterone and computed tomography scan of adrenals improved. We are reporting this case as it is the first time such modalities in the treatment of adrenal adenoma was used.

[Hyperaldosteronism persisting after subtotal adrenalectomy]. / Persistenz eines primären Hyperaldosteronismus nach subtotaler Adrenalektomie.

BACKGROUND: Primary aldosteronism is known to be caused by aldosterone-producing adenoma (APA). Total adrenalectomy is the standard procedure. In contrast to bilateral adrenal diseases (e.g., MEN II pheochromocytomas), there is no consensus about the effect of subtotal adrenalectomy. CASE REPORT: A 44-year-old patient with primary aldosteronism caused by APA underwent subtotal adrenalectomy including removal of one adenoma. Because hypertension and hypokalemia did not disappear and hyperaldosteronism persisted, the patient had to undergo reoperation in which the adrenalectomy was completed. DISCUSSION: Subtotal adrenalectomy in patients with Conn's syndrome is an interesting therapeutic option,whereas its effect is much higher in hereditary diseases of the adrenal gland. The benefit of preserved adrenal tissue has to be weighed against a possible persistence of hyperaldosteronism, especially in cases with normal opposite adrenal glands.

[Renovascular hypertension due to unilateral renal artery stenosis with hypokalemic alkalosis, the salt-losing syndrome and reversible hyperechogenicity of the contralateral kidney. A study of 2 infants]. / Hipertensión renovascular por estenosis unilateral de la arteria renal con alcalosis hipocaliémica, síndrome de pérdida salina e hiperecogenicidad reversible del riñón contralateral. Estudio de dos lactantes.

This report describes two infants with severe arterial hypertension secondary to unilateral renal artery stenosis which was manifested by polyuria, polydipsia, hypokalemic alkalosis, hyponatremia, increased natriuresis and increased plasma values of rennin and aldosterone. On sonographic examination, the contralateral non-stenotic kidney of both patients appeared enlarged and hyperechogenic mimicking parenchymal lesion. When the patients became normotensive, their sodium and potassium balance became normal and their contralateral non-stenotic kidney also became normal in size and echogenicity. The increase of the filtration and the natriuresis observed in the contralateral non-stenotic kidney of the patients with renovascular hypertension due to renal artery stenosis might be responsible for the hyperechogenicity. When the patients became normotensive, the filtration and excretion of sodium of the contralateral kidney also became normal and the increase of echogenicity also disappeared. The reversibility of the sonographic findings suggest a functional origin.

Symptoms and course of chronic hypokalemic nephropathy in man.

The symptoms and clinical course of chronic hypokalemic nephropathy are described in 21 patients with longstanding potassium deficiency. In 14 patients (group A) the potassium depletion was caused by malnutrition and/or abuse of laxatives and/or diuretics. 7 patients (group B) suffered from primary (6 cases) or secondary (1 case) aldosteronism. The average duration of potassium depletion was 8.8 years in group A and 3.4 years in group B. Depending on the duration of potassium depletion, chronic renal disease develops which may end in terminal renal failure. Urinalysis is non-specific or negative. The clearance of creatinine slowly decreases. Metabolic alkalosis is a constant finding and in group A occurs with a tendency to hyponatremia and hypochloremia, with the development of metabolic acidosis only in advanced renal insufficiency. In contrast to patients of group B, patients of group A have normal or low blood pressures converting to hypertension, if at all only in the late phase. The cases of group A had secondary aldosteronism (and, correspondingly, a hyperplastic juxtaglomerular apparatus). Although urinary tract infection is a regular finding in advanced stages, the clinical, radiological and histological evidence suggests that bacterial pyelonephritis, if occurring at all, is rather a complication than the cause of the disease. In 5 patients 7 instances of acute renal failure of unknown origin were observed which was lethal in one case. Another patient died from terminal renal failure, a third from an intercurrent pneumonia. Renal histology obtained from 13 patients showed the picture of diffuse chronic abacterial interstitial nephritis.

Radiologic and pathologic characteristics of the WDHA syndrome.

A case of a non-beta islet cell tumor of the pancreas that produced the WDHA (watery diarrhea, hypokalemia, and achlorhydria) syndrome is presented. An enlarged body-tail region of the pancreas is demonstrated on transaxial views; multiple fluid-filled loops of small and large bowel are also noted. The angiography of the tumor is similar to other non-beta islet cell lesions consisting of a large hypervascular mass with hypertrophied feeding vessels and a persistent, dense capillary stain. The demonstration of elevated levels of vasoactive intestinal polypeptide in both tumor and plasma and the ultrastructural description of endocrine granules may help to explain the pathophysiology in this case.