Secondary adrenal insufficiency laboratory findings: Difference between revisions

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VisualWikitext

Revision as of 00:41, 10 October 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].

OR

Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

OR

[Test] is usually normal among patients with [disease name].

OR

Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].

OR

There are no diagnostic laboratory findings associated with [disease name].

Laboratory Findings

Source of pathology	CRH	ACTH	DHEA	DHEA-S	cortisol	aldosterone	renin	Na	K	Causes⁵
hypothalamus (tertiary)¹	low	low	low	low	low³	low	low	low	low	tumor of the hypothalamus (adenoma), antibodies, environment (i.e. toxins), head injury
pituitary (secondary)	high²	low	low	low	low³	low	low	low	low	tumor of the pituitary (adenoma), antibodies, environment, head injury, surgical removal⁶, Sheehan's syndrome
adrenal glands (primary)⁷	high	high	high	high	low⁴	low	high	low	high	tumor of the adrenal (adenoma), stress, antibodies, environment, Addison's Disease, trauma, surgical removal (resection), miliary tuberculosis of the adrenal

1	Automatically includes diagnosis of secondary (hypopituitarism)
2	Only if CRH production in the hypothalamus is intact
3	Value doubles or more in stimulation
4	Value less than doubles in stimulation
5	Most common, does not include all possible causes
6	Usually because of very large tumor (macroadenoma)
7	Includes Addison's disease

Routine Investigations

Complete blood count and differential count -
- Eosinophilia
- Lymphocytosis
- Normocytic anemia may be present.
Serum ACTH levels - elevated in primary adrenal insufficiency and decreased in secondary form.
Hypoglycemia^[1]^[2]^[3]
Serum electrolytes:
- Hyponatraemia - (low blood sodium levels)^[4]
- Hyperkalemia- not present
- Mild hypercalcemia - in 20% patients
- Mild non–anion-gap metabolic acidosis
Serum cortisol - decreased (<25mcg/dL)
Urine and sweat sodium - elevated
Azotemia- Elevated BUN and creatinine - when hypovolemia is the cause.
Prolactin - mild elevation may be present.

Hormone	Test	Procedure	Normal response
Growth hormone	Insulin tolerance	Administer insulin, 0.05–0.15 U/kg IV	Glucose should drop <40 mg/dL, (2.2 mmol/L)
		Sample blood at − 30, 0, 30, 60, 120 min for GH and glucose	GH should be >3–5 μg/L Cut-offs for GH response are BMI related
	GHRH + arginine	Administer GHRH, 1 μg/kg (max 100 μg) iv followed by an arginine infusion 0.5 g/kg (max 35 g) over 30 min	Can give false normal GH response if GHD is due to hypothalamic damage (eg, after radiation)
		Sample blood at 0, 30, 45, 60, 75, 90, 105, and 120 min for GH	GH >4 μg/L, but cutoffs for GH response should be correlated to BMI (obesity may blunt GH response to stimulation)
	Glucagon	Administer glucagon, 1 mg (1.5 mg if weight >90 kg) IM Sample blood at 0, 30, 60, 90, 120, 150, 180, 210, and 240 min for GH and glucose	GH >3 μg/L, but cutoffs for GH response should be correlated to BMI (Obesity may blunt GH response to stimulation)
ACTH	Insulin tolerance	Administer insulin, 0.05–0.15 U/kg IV	Glucose should drop <40 mg/dL (2.2 mmol/L)
		Sample blood at −30, 0, 30, 60, and 120 min for cortisol and glucose	Peak cortisol should be >500–550 nmol/L (>18.1–20 μg/dL) depending on assay
	Corticotropin standard dose (250 μg)	Administer ACTH 1–24 (cosyntropin), 250 μg IM or IV Sample blood at 0, 30, and 60 min for cortisol	Cortisol should be at 30 or 60 min >500–550 nmol/L (>18.1–20 μg/dL) depending on assay
	Corticotropin low dose (1 μg)	Administer ACTH 1–24 (cosyntropin), 1 μg IV Sample blood at 0 and 30 min for cortisol	Cortisol should be at 30 min >500 nmol/L (18.1 μg/dL) depending on assay
ADH	Water deprivation test	Initiate fluid deprivation for 8h (starting from 8 AM) Weigh patient at beginning of testing, then measure weight and urine volume hourly during the test Measure plasma and urine osmolality every 2–3 hours At 4 PM administer DDAVP 2 μg im and allow patient to drink freely	Diabetes insipidus (DI): Plasma osmolality >295 mOsm/L with inappropriately hypotonic urine (urine osmolality/plasma osmolality ratio <2) during the fluid deprivation confirms DI (test is discontinued) Central DI: After administering DDAVP, urine osmolality >800 mOsm/kg with central DI Nephrogenic DI: After administering DDAVP, urine osmolality <300 mOsm/kg with nephrogenic DI Partial/primary polydipsia: With partial DI or primary polydipsia, urine concentrates partially during the water deprivation test (300–800 mOsm/kg), and further investigation is required including a prolonged water deprivation test or DDAVP therapeutic trial

References

↑ Burke CW (1985). "Adrenocortical insufficiency". Clin Endocrinol Metab. 14 (4): 947–76. PMID 3002680.
↑ Todd GR, Acerini CL, Ross-Russell R, Zahra S, Warner JT, McCance D (2002). "Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdom". Arch. Dis. Child. 87 (6): 457–61. PMC 1755820. PMID 12456538.
↑ Stacpoole PW, Interlandi JW, Nicholson WE, Rabin D (1982). "Isolated ACTH deficiency: a heterogeneous disorder. Critical review and report of four new cases". Medicine (Baltimore). 61 (1): 13–24. PMID 6276646.
↑ Cuesta M, Garrahy A, Slattery D, Gupta S, Hannon AM, Forde H, McGurren K, Sherlock M, Tormey W, Thompson CJ (2016). "The contribution of undiagnosed adrenal insufficiency to euvolaemic hyponatraemia: results of a large prospective single-centre study". Clin. Endocrinol. (Oxf). 85 (6): 836–844. doi:10.1111/cen.13128. PMID 27271953.

Template:WH Template:WS

[pmid3002680-1] Burke CW (1985). "Adrenocortical insufficiency". Clin Endocrinol Metab. 14 (4): 947–76. PMID 3002680.

[pmid12456538-2] Todd GR, Acerini CL, Ross-Russell R, Zahra S, Warner JT, McCance D (2002). "Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdom". Arch. Dis. Child. 87 (6): 457–61. PMC 1755820. PMID 12456538.

[pmid6276646-3] Stacpoole PW, Interlandi JW, Nicholson WE, Rabin D (1982). "Isolated ACTH deficiency: a heterogeneous disorder. Critical review and report of four new cases". Medicine (Baltimore). 61 (1): 13–24. PMID 6276646.

[pmid27271953-4] Cuesta M, Garrahy A, Slattery D, Gupta S, Hannon AM, Forde H, McGurren K, Sherlock M, Tormey W, Thompson CJ (2016). "The contribution of undiagnosed adrenal insufficiency to euvolaemic hyponatraemia: results of a large prospective single-centre study". Clin. Endocrinol. (Oxf). 85 (6): 836–844. doi:10.1111/cen.13128. PMID 27271953.

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@@ Line 69: / Line 69: @@
 * Azotemia- Elevated [[BUN]] and [[creatinine]] - when [[hypovolemia]] is the cause.
 * [[Prolactin]] - mild elevation may be present.
+{| class="wikitable"
+! align="center" style="background:#4479BA; color: #FFFFFF;" + |Hormone
+! align="center" style="background:#4479BA; color: #FFFFFF;" + |Test
+! align="center" style="background:#4479BA; color: #FFFFFF;" + |Procedure
+! align="center" style="background:#4479BA; color: #FFFFFF;" + |Normal response
+|-
+|'''[[Growth hormone]]'''
+|'''[[Insulin]] tolerance'''
+|
+* Administer [[insulin]], 0.05–0.15 U/kg [[Intravenous|IV]]
+|
+* [[Glucose]] should drop <40 mg/dL, (2.2 mmol/L)
+|-
+|
+|
+|
+* Sample [[blood]] at − 30, 0, 30, 60, 120 min for [[Growth hormone|GH]] and [[glucose]]
+|
+* [[Growth hormone|GH]] should be >3–5 μg/L
+* Cut-offs for [[Growth hormone|GH]] response are [[BMI]] related
+|-
+|
+|'''[[GHRH]] + [[arginine]]'''
+|
+* Administer [[Growth hormone-releasing hormone|GHRH]], 1 μg/kg (max 100 μg) iv followed by an [[arginine]] [[infusion]] 0.5 g/kg (max 35 g) over 30 min
+|
+* Can give false normal [[Growth hormone|GH]] response if GHD is due to [[hypothalamic]] damage (eg, after [[radiation]])
+|-
+|
+|
+|
+* Sample [[blood]] at 0, 30, 45, 60, 75, 90, 105, and 120 min for [[GH]]
+|
+* [[Growth hormone|GH]] >4 μg/L, but cutoffs for [[Growth hormone|GH]] response should be correlated to [[Body mass index|BMI]] ([[obesity]] may blunt [[Growth hormone|GH]] response to stimulation)
+|-
+|
+|'''[[Glucagon]]'''
+|
+* Administer [[glucagon]], 1 mg (1.5 mg if weight >90 kg) [[Intramuscular|IM]]
+* Sample [[blood]] at 0, 30, 60, 90, 120, 150, 180, 210, and 240 min for [[Growth hormone|GH]] and [[glucose]]
+|
+* GH >3 μg/L, but cutoffs for [[Growth hormone|GH]] response should be correlated to [[Body mass index|BMI]] ([[Obesity]] may blunt [[GH]] response to stimulation)
+|-
+|'''ACTH'''
+|'''[[Insulin]] tolerance'''
+|
+* Administer [[insulin]], 0.05–0.15 U/kg [[Intravenous|IV]]
+|
+* [[Glucose]] should drop <40 mg/dL (2.2 mmol/L)
+|-
+|
+|
+|
+* Sample [[blood]] at −30, 0, 30, 60, and 120 min for [[cortisol]] and [[glucose]]
+|
+* Peak [[cortisol]] should be >500–550 nmol/L (>18.1–20 μg/dL) depending on [[assay]]
+|-
+|
+|'''[[Corticotropin]] standard dose (250 μg)'''
+|
+* Administer [[Adrenocorticotropic hormone|ACTH]] 1–24 ([[cosyntropin]]), 250 μg [[Intramuscular|IM]] or [[Intravenous|IV]]
+* Sample blood at 0, 30, and 60 min for [[cortisol]]
+|
+* [[Cortisol]] should be at 30 or 60 min >500–550 nmol/L (>18.1–20 μg/dL) depending on [[assay]]
+|-
+|
+|'''[[Corticotropin]] low dose (1 μg)'''
+|
+* Administer [[Adrenocorticotropic hormone|ACTH]] 1–24 ([[cosyntropin]]), 1 μg [[Intravenous|IV]]
+* Sample [[blood]] at 0 and 30 min for [[cortisol]]
+|
+* [[Cortisol]] should be at 30 min >500 nmol/L (18.1 μg/dL) depending on [[assay]]
+|-
+|'''[[Antidiuretic hormone|ADH]]'''
+|'''Water deprivation test'''
+|
+* Initiate [[fluid]] deprivation for 8h (starting from 8 AM)
+* Weigh patient at beginning of testing, then measure weight and [[urine]] volume hourly during the test
+* Measure [[plasma]] and urine [[osmolality]] every 2–3 hours
+* At 4 PM administer [[Desmopressin (patient information)|DDAVP]] 2 μg im and allow patient to drink freely
+|[[Diabetes insipidus|'''Diabetes insipidus (DI)''']]: [[Plasma]] [[osmolality]] >295 mOsm/L with inappropriately [[hypotonic]] [[urine]] ([[urine]] [[osmolality]]/[[plasma]] [[osmolality]] ratio <2) during the [[fluid]] deprivation confirms [[Diabetes insipidus|DI]] (test is discontinued)
+* '''[[Central DI]]:''' After administering [[Desmopressin (patient information)|DDAVP]], [[urine]] [[osmolality]] >800 mOsm/kg with [[central DI]]
+* '''[[Nephrogenic DI]]:''' After administering [[DDAVP]], [[urine]] [[osmolality]] <300 mOsm/kg with [[nephrogenic DI]]
+'''[[Polydipsia|Partial/primary polydipsia]]:''' With partial [[Diabetes insipidus|DI]] or primary [[polydipsia]], [[urine]] concentrates partially during the water deprivation test (300–800 mOsm/kg), and further investigation is required including a prolonged water deprivation test or [[DDAVP]] therapeutic trial
+|}
 ==References==