PrimaryAdrenalInsufficiency(2013)

1、Primary Adrenal Insufficiency（Addisons disease)The Department of EndocrinologyThe First Affiliated HospitalRong Li (李蓉）DefinitionAddisons disease (chronic adrenal insufficiency) is a rare, chronic endocrine disorder wherein the adrenal glands(肾上腺）, produce insufficient steroid hormones (glucocortico

2、ids and often mineralocorticoids). steroid hormones类固醇激素glucocorticoids糖皮质激素mineralocorticoids盐皮质激素BackgroundPrimary adrenal insufficiency(原发性原发性) Due to disease of adrenal glands. e.g. Addisons disease Secondary adrenal insufficiency(继发性继发性) Due to hypothalamic-pituitary disease. e.g. Sheehans synd

3、romeOutlineUnderstanding the Adrenal GlandsCausesSymptoms Laboratory StudiesTreatmentUnderstanding the Adrenal GlandsThe Adrenal Gland releasesAndrogens (雄激素雄激素)Mineralocorticoids 盐皮质激素盐皮质激素Glucocorticoids 糖皮质激素糖皮质激素Glucocortoicoids(most potent is cortisol)Action: anti-inflammatory, regulation of th

4、e metabolism of glucose，growth suppressing,affects sleep patterns & awareness, stress responseMineralcorticoids(Aldosterone)Action: Managessodium/potassium balance皮质 髓质Physiologic action of adrenal steroids Steroid Effect Cortisol (皮质醇皮质醇) - Increasing blood sugar Stimulation of gluconeogenesis (糖异生

5、） Inhibits the peripheral（外周） utilization of glucose - aiding in fat, protein metabolism - Stress response - Anti-inflammatory up-regulate the expression of anti-inflammatory proteins down-regulate the expression of pro-inflammatory proteins Aldosterone (醛固酮醛固酮) - Salt retention（保钠）（保钠） - K excretio

6、n（排钾）（排钾） - Acid secretionDHEA/(去氢表雄酮去氢表雄酮) - Muscle maintenance Androstenedione - Bone anabolism (雄烯二酮雄烯二酮) - Mental drive - Sexual functionDecreased adrenal steroidsDecreased Mineralcorticoids blood Na, H2O blood volume(血容量血容量) hypotension blood K metabolic acidosis(代谢性酸中毒代谢性酸中毒)No symptoms if ing

7、esting enough salt.Decreased GlucocorticoidsFatigue （疲劳） Muscle weakness Loss of appetite Low blood pressureHypoglycaemia（低血糖） Causes Autoimmune destruction of the adrenal cortex (Most common 80% ) in isolation （单独发生） part of autoimmune polyglandular disease(自身免疫多内分泌腺病） Causes (cont.)Type 1 autoimmu

8、ne polyglandular disease More common in children An autosomal recessive disorder（常染色体隐性遗传） （AIRE gene on chromosome 21 ） Chronic mucocutaneous candidiasis(慢性皮肤粘膜念珠菌病) Hypoparathyroidism(甲状旁腺功能减退） Addisons disease Type 2 autoimmune polyglandular disease More common in younger adults Type 1 diabetes m

9、ellitus（1型糖尿病）, Autoimmune thyroid disease （自身免疫性甲状腺病）, Addisons diseaseOther causes Tuberculosis （结核）（in China, is common cause)Chronic infection (HIV infection ,fungal infections (真菌感染 )Cancer cells spreading from other parts of the body to the adrenal glands (especially breast cancer)Surgical rem

10、oval of the adrenal glands. Metabolic disorders (eg. adrenoleukodystrophy 肾上腺脑白质营养不良)Sarcoidosis(类肉瘤病 ) , amyloidosis(淀粉样变）, hemochromatosis（血色病）Symptoms Chronic fatigue that progressively worsens Skin hyperpigmentation（皮肤色素沉着） Muscle weakness Loss of appetite Weight loss Nausea（恶心） ,vomiting （呕吐）Di

11、arrhea （腹泻）Low blood pressure (esp. when standing, causing dizziness or fainting )Hypoglycaemia（低血糖） HyperpigmentationExposed（暴露） and non-exposed parts of the bodymost visible on scars，skin folds, pressure points (such as the elbows, knees, knuckles, and toes), lips, and mucous membranes. Hypothalam

12、us: CRHAdrenal cortex: CortisolPituitary: ACTHMechanism of hyperpigmentationNegativefeedback Mechanism of hyperpigmentation (cont.)MSH(黑色素细胞刺激素)POMC pro-opiomelanocortin 阿黑皮素原MelanocyteMelanin（黑色素）（黑色素）黑色素细胞黑色素细胞Mechanism of hyperpigmentation (cont.)CortisolACTHThe similar action of MSH(黑色素细胞刺激素)Mel

13、anin pigment deposition (黑色素沉积) HyperpigmentationLaboratory StudiesGeneral considerations and tests Electrolyte levels (Na+ K+ or normal)Fasting blood sugar （ or normal)Serum adrenocorticotropic hormone (ACTH) （ ）Serum cortisol , preferably obtained at 8:00 am （ or normal) Adrenal insufficiency is u

14、nlikely if a serum cortisol 400nmol/L Adrenal insufficiency is unlikely if a serum cortisol 900nmol/L in a sick and stressed patient. Serum cortisol 3 mcg/dL(83nmol/L) is suggestive of adrenal insufficiency Laboratory Studies(Cont.)ACTH stimulation test （ Golden standard test） One hour ACTH stimulat

15、ion test Administration of 250 mcg of ACTH at morning, cortisol is tested at 0min, 30min and 60 min. Adrenal insufficiency is likely if the serum cortisol concentration is less than 500nmol/L 30-60 minutes after ACTH Antiadrenal antibodies Ultrasounds or CT scan for adrenal areaTreatmentNo cure for

16、primary adrenal insufficiency Life-long glucocorticoid replacement Glucocorticoid replacement Hydrocortisone(8am:20mg 2pm:10mg) 氢化可的松Prednisone (8am: 5mg, 2pm:2.5mg) 强的松Increase the dose during times of stress or illness Mineralocorticoids replacement Ingest enough saltsome patients require fludroco

17、rtisone（氟氢可的松）Adrenal Crisis (Addisonian crisis) Underlying adrenal insufficiency Acute StressAdrenalCrisisnInfectionnSurgerynTrauma(创伤）nDelivery（分娩）Adrenal CrisisSudden penetrating pain in the lower back, abdomen, or legs Severe vomiting and diarrhea Dehydration Low blood pressure Hypoglycaemia Los

18、s of consciousness. If left untreated, an Addisonian crisis can be fatal(致命的）Treatment (cont.)Acute adrenal insufficiencyIntravenously administered saline （生理盐水）Intravenously administered Dextrose （葡萄糖水）Potassium is generally not needed in acute situationsAdminister stress doses of glucocorticoid. an initial dose of Hydrocortisone（氢化可的松）50-100 mg, q6h, given intravenously. Thank you for your Attention!Treatment (cont.)Surgical CareBefore surgery：Hydrocortisone 50-75 m