Renal Failure Obfuscates the Diagnosis of Cushing's Disease

Sharp, Nina A.; Devlin, John T.; Rimmer, Jeffrey M.

doi:10.1001/jama.1986.03380180126034

Cited by 22 publications

(6 citation statements)

References 8 publications

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“…The diagnostic problem in this patient highlights the increasing appreciation that severe CKD may often be associated with a state of non-neoplastic hypercortisolism accompanied by elevations of plasma ACTH and late-night serum and salivary cortisol as well as abnormal cortisol suppression after dexamethasone suppression (6,7,8,9). The mechanism for the dysregulated cortisol excess in severe CKD is not a decrease in the renal clearance of cortisol, and correspondingly, the urine cortisol measurements are typically normal as in this patient (10). CKD seems to activate the hypothalamic-pituitaryadrenal axis presumably from a hypothalamic origin related to the stress and high inflammatory state resulting from CKD and chronic dialysis (6,9).…”

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confidence: 82%

“…Even in patients with normal renal function, many have questioned the utility of measuring 24-h UFC to diagnose Cushing's disease particularly because of the large number of false negatives (11,12). The measurement of UFC is also questionable considering the likelihood of altered steroid metabolism by severely diseased kidneys (10). It is fortunate in the case of this patient that the clinicians pursued the diagnosis of Cushing's syndrome on clinical grounds despite the normal UFC, and subsequently used the appropriate diagnostic tests.…”

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confidence: 99%

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A commentary on Diagnosing Cushing’s disease in the context of renal failure

Raff

Cohen

Findling

2019

European Journal of Endocrinology

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The diagnosis of endogenous hypercortisolism (Cushing's syndrome) is extremely challenging. Chronic kidney disease (CKD) increases the activity of the hypothalamic-pituitary-adrenal axis making the diagnosis of Cushing's syndrome even more challenging. This is particularly so since urine free cortisol (UFC) testing is not useful in CKD. The case report by Stroud et al. in this issue of the European Journal of Endocrinology highlights this problem by finding normal UFC in a patient with pituitary ACTH-dependent Cushing's syndrome. Elevated late-night salivary cortisol (LNSC) testing was diagnostic and pituitary adenomectomy was curative. LNSC measurement is the diagnostic test of choice in patients with suspected Cushing's syndrome, particularly in the presence of CKD..

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confidence: 82%

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confidence: 99%

A commentary on Diagnosing Cushing’s disease in the context of renal failure

Raff

Cohen

Findling

2019

European Journal of Endocrinology

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“…Advanced kidney disease is associated with elevated levels of cortisol, alterations in cortisol control as well as abnormal response to dexamethasoneinduced cortisol suppression. [41] The mechanism of hypercortisolism in CKD is not secondary to a decrease in renal cortisol clearance as urine free cortisol can be normal in patients with CKD, rather it is thought to be secondary to activation of the hypothalamic-pituitary-adrenal axis at the level of the hypothalamus and may correlate with increased C-reactive protein suggesting that the chronic inflammatory state of CKD is the underlying aetiology [42]. Clinically, serum cortisol, 24 h urine free cortisol and low dose dexamethasone suppression tests should be avoided in patients with CKD due high probability of false positive and false negative results [43].…”

Section: Cushing's Diseasementioning

confidence: 99%

“…Diagnosing Cushing's syndrome in patients with kidney disease can be clinically challenging. Advanced kidney disease is associated with elevated levels of cortisol, alterations in cortisol control as well as abnormal response to dexamethasone-induced cortisol suppression [41]. The mechanism of hypercortisolism in CKD is not secondary to a decrease in renal cortisol clearance as urine free cortisol can be normal in patients with CKD, rather it is thought to be secondary to activation of the hypothalamic-pituitary-adrenal axis at the level of the hypothalamus and may correlate with increased C-reactive protein suggesting that the chronic inflammatory state of CKD is the underlying aetiology [42].…”

Section: Cushing's Diseasementioning

confidence: 99%

Chronic kidney disease in adrenal disorders

Salman

Cohen²

2021

Current Opinion in Endocrinology, Diabetes &Amp; Obesity

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Purpose of review This review will focus on hypertension due to underlying adrenal disorders in chronic kidney disease (CKD). Diagnosis of adrenal hypertension and particularly primary aldosteronism (PA) in CKD is frequently not pursued. We outline limitations that advanced kidney disease poses on the diagnostic work up of these disorders and provide a framework for approaching CKD patients suspected of having an adrenal disorder. Recognition of these disorders is important as they are often underdiagnosed which leads to poorer outcomes. Recent findings Adrenal disease associated with hypertension in CKD is most commonly due to PA whereas pheochromocytoma and Cushing's disease are important but less common. Diagnosis of these diseases is important as their identification leads to better blood pressure control and can possibly mitigate the risk of progression of CKD. Work up and treatment of PA has been shown to be safe and is associated with less antihypertensive medication requirement for the associated hypertension and slower progression of CKD. Summary This chapter summarizes the importance of recognizing adrenal hypertension in CKD and reinforces the need for physicians to pursue these diagnoses in CKD patients as this is safe and improves both BP control and delays progression of CKD.

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“…말기 신부전 환자에서 쿠싱증후군이 동반될 경우 진단이 어려운데, 이는 만성 신부전 환자에서는 혈청 코르티솔 치가 정상이거나 증가되어 있으며, 코르티솔의 신장 청소율이 저 하되어 있어서 뇌하수체-부신축의 상태를 평가하는데 어려 움이 있기 때문이다 [4]. 또한 덱사메타손의 위장관 흡수율이 저하되며 시상하부-뇌하수체-부신축의 이상으로 진단적인 호르몬 검사의 정확도가 낮다 [5].…”

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A Case of Cushing's Disease with Renal Cell Carcinoma and End-stage Renal Disease

Eun

Choi

Park

et al. 2007

J Korean Endocr Soc

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62 -서 론 1) 쿠싱병은 뇌하수체에서 과다 분비된 부실피질자극 호르 몬에 의해 체내 부신피질호르몬이 증가되어 나타나는 질환 으로, 대부분이 뇌하수체의 원발 종양에 의하며, 부신피질 자극 세포의 과다증식에 의한 것은 10% 이하로 알려져 있다[1]. 대 부분은 직경이 10 mm 미만인 미세선종이며 거대선종은 접수일자: 2006년 8월 24일 통과일자: 2006년 10월 7일 책임저자: 안유배, 가톨릭대학교 의과대학 내과학교실 10% 미만으로 보고되고, 미세선종의 경우 내시경 경접형동 접근법을 통한 절제술로 80%이상의 완치율을 보이는 것으 로 알려져 있다[2]. 쿠싱병의 진단은 임상적 양상과 내분비학적 검사, 방사선 학 검사를 통해 이루어지며 내분비학적 검사에서는 쿠싱 증 후군에 대한 선별검사로 기저 코르티솔 치, 호르몬의 일중변 동 변화, 17-hydroxycorticosteroid (17-OHCS), 24시간 소변 내 유리 코르티솔 측정 및 1 mg 덱사메타손 억제 검사를 시 행할 수 있으며 쿠싱증후군의 원인 감별을 위한 검사로 기 저 혈장 adrenocorticotropic hormone (ACTH)검사, 8 mg 말기 신부전 환자에서 신세포암과 쿠싱병이 동시에 발병한 1예 가톨릭대학교 의과대학 내과학교실ABSTRACT Cushing's disease is the most common cause of endogenous Cushing's syndrome caused by the excessive secretion of adrenocorticotropic hormone (ACTH) by pituitary ACTH-secreting tumors. The tumors are usually microadenomas (< 10 mm in diameter). Macroadenomas are rare, and corticotroph hyperplasia and carcinomas are extremely rare. Patients with these tumors exhibit an increase in plasma ACTH and cortisol levels, elevated urinary excretion of cortisol and adrenocortical steroid metabolites, evidence of altered negative feedback of cortisol and disturbances in neuroendocrine regulation. The diagnosis of Cushing's disease can be challenging in patients with renal failure the presence of abnormal plasma cortisol, poor gastrointestinal tract absorption of dexamethasone and altered functioning of the hypophyseal-pituitary-adrenal axis have been reported in end-stage renal disease, and the urinary cortisol increment method is not reliable in these patients. The prevalence of renal cell carcinoma in patients on dialysis is higher than in the general population. We recently treated a patient with Cushing's disease and end-stage renal disease as a result of renal cell carcinoma. The diagnosis was made by laboratory evaluation of plasma and radiological examination. Here we report a case of Cushing's disease with a review of the medical literature. (J Kor Endocrinol Soc 22:62~67, 2007) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ

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Renal Failure Obfuscates the Diagnosis of Cushing's Disease

Cited by 22 publications

References 8 publications

A commentary on Diagnosing Cushing’s disease in the context of renal failure

A commentary on Diagnosing Cushing’s disease in the context of renal failure

Chronic kidney disease in adrenal disorders

A Case of Cushing's Disease with Renal Cell Carcinoma and End-stage Renal Disease

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