The
Ludwig Boltzmann Institute of Endocrinology, Vienna
Paediatric
CONGENITAL ADRENAL HYPERPLASIA: SIMULTANEOUS DETERMINATION OF PLASMA ALDOSTERONE AND 17-HYDROXYPROGESTERONE
By K. Parth1), H.
W. Swoboda, Roswitha Brunel and Edith Bohrn
Zimprich,
ABSTRACT Plasma levels of aldosterne and 17-hydroxyprogesterone were determined in 5 just diagnosed cases of congenital adrenal hyperplasia due to 21-hydroxylase deficiency without salt-loss before onset of therapy, and in 14 children suffering from the same disorder, under glucocorticoid therapy before and after withdrawal of therapy for one week as well as before and after
ACTH-stimulation. Furthermore, urinary pregnanetriol, pregnanetriolone, 17-ketosteroids and 17-ketogenic steroids were determined with and without therapy. Serum concentrations of 17-hydroxyprogesterone in patients before onset of therapy were at least 40 times above the normal range (normal range: 0.39 \m=+-\0.23 ng/ml determined in 19 children of age 1\p=n-\12 aldosterone was also elevated (range 16.5\p=n-\84.4 ng/100 ml, normal aldosterone being 7.3 \m=+-\4.7 ng/ml). In contrast, well controlled patients (judged on urinary pregnanetriol-excretion) had normal aldosterone (one exception) and 17-hydroxyprogesterone levels below 5 ng/ml. Both steroids were well stimulated by ACTH. In 3 poorly controlled cases elevated pregnanetriol and 17-hydroxyprogesterone values up to 130.9 ng/ml were found. Withdrawal of therapy resulted in pronounced rise of aldosterone and 17-hydroxyprogesterone. Exogenous ACTH had no detectable effect in 7 cases leading to further stimulation in the other children. We found an excellent correlation between plasma 17-hydroxyprogesterone and urinary pregnanetriol (r 0.84, P < 0.003, n=14). Fairly good correlation also exists between aldosterone and 17-hydroxyprogesterone values (r= 0.65, P < 0.01, n=14) in patients before the onset and after withdrawal of therapy.
years),
=
l) Present address:
Ludwig
Boltzmann Institute of Paediatric 1090 Vienna, Austria.
Kinderklinik, Währingergürtel 74,
Endocrinology, c/o Univ.
The data confirm the value of 17-hydroxyprogesterone determinations for diagnosis and management of congenital adrenal hyperplasia on the one hand, and the compensatory elevated aldosterone production in the non-salt-losing form of the disorder on the other.
The disorder of congenital adrenal hyperplasia is caused by a hereditary 21hydroxylation defect in a very high percentage of cases. The biosynthesis of cortisol is decreased, resulting in an increased secretion of ACTH via the feed¬ back control. As a consequence, accumulation of cortisol precursors (especially 17-hydroxyprogesterone) and increased production of androgens is observed. In about 30 % of all patients (Degenhart et al. 1965) a salt-losing tendency is associated with congenital adrenal hyperplasia but its pathogenetic mech¬ anism is still a matter of controversy. Eberlein 8c Bongiovanni (1958) have suggested that the difference between the "simple" virilizing form and the sodium-losing form is one of degree of block, the latter being the more severe defect. Bryan et al. (1965) and Degenhart et al. (1965) have shown impaired aldo¬ sterone production and excretion in salt-losing congenital adrenal hyperplasia. Their hypothesis is based on the assumption, that there is a defect in 21hydroxylation of 17-hydroxyprogesterone in all cases and an additional defect in 21-hydroxylation of progesterone in the salt-losing form of the disorder. An intact biosynthetic pathway for aldosterone production in the "simple" virilizing form with elevated and well stimulable aldosterone secretion rates was reported by Bartter et al. (1968). These findings are thought to compen¬ sate for the antagonism of progesterone and 17-hydroxyprogesterone against mineralo-corticoids at the renal tubular level (Landau 8c Lugibihl 1958; Jacobs et al. 1961; George et al. 1965). The simultaneous determination of aldosterone and 17-hydroxyprogesterone values in congenital adrenal hyperplasia should provide some information about the degree of correlation between the two parameters. On the other hand, determination of 17-hydroxyprogesterone levels has become valuable in diag¬ nosis as well as in the therapeutic management of congenital adrenal hyper¬ plasia (Barnes 8c Atherden 1972; Strott et al. 1969; Hughes 8c Winter 1976; v. Schnakenburg et al. 1974). The second purpose of this study was therefore to compare 17-hydroxyprogesterone levels in our congenital adrenal hyperplasia patients with standard techniques for therapeutic monitoring (pregnanetriol,
pregnanetriolone, 17-ketosteroids). PATIENTS AND METHODS Nineteen patients with congenital adrenal aged from 0.5 to 23 years were studied.
hyperplasia
due to
21-hydroxylase deficiency
Group
(5 children, age range 7/12-14 years) were newly diagnosed cases. Aldo¬ 17-hydroxyprogesterone were measured before onset of therapy before min after the administration of 0.25 mg synthetic ACTH (iv). No salt-loser I
sterone and
and 20 observed in this group. Group II is represented by 14 patients (2.5-23 years old) had been under therapeutic control since diagnosis, 4 of them being salt-losers. Only one infant (R.B., 2.5 years) showed acute salt-loss and was not yet well controlled. Therefore we were forced to omit withdrawal of therapy in this case. The salt-losing tendency of the other 3 girls (11-12 years old) had improved very much since infancy and now showed no clinical differences compared to the non-salt-losers. Aldosterone and 17-hydroxyprogesterone levels were measured under the following conditions: a) under therapy, before and 20 min after ACTH stimulation (0.25 mg synthetic was
ACTH, iv)
Table 1. Clinical data of
Group
I
F.C. L.M.
7/12 5 14 5 13
»G.R. :;G.F. S.A.
Group R.E. ':V.M. S.M. W.S.
*V.B. F.C. E.E.
patients.
F M M M M
II
prednisolone prednisolone hydrocortisone hydrocortisone prednisolone hydrocortisone
20 mg 20 mg 25 mg 20 mg 20 mg 10 mg
21
M F M F M F F
15 6 10 8/12 2 6/12
F F F F
7,5 mg prednisolone
12 9/12 12 11
F F F
23 16 10 5 2/12 19
13/12
tsalt-losers
20 14 8/12 6 6/12
2 5/12 14 3/12
8/12 until age
15 mg hydrocortisone 20 mg hydrocortisone 10 mg hydrocortisone 0,1 mg 9-fluorohydrocortisone 15 mg prednisolone 30 mg hydrocortisone 25 mg cortoneacetate
19 14 5 3 2
5/12 6/12 11/12 2/12 5/12
12 8/12 8 6/12 9 9/12
without therapy for one week, again before and after ACTH. All plasma samples taken between 9 and 11 a.m. after at least lh with patients in supine position to reduce the influence of circadian variations and posture as far as possible. All children were on unrestricted sodium intake. Parents and (or) patients were told to collect 24 h urines under therapy (day before ACTH stimulation) and on the last day of withdrawal of glucocorticoids for the determination of 17-ketosteroids, 17-ketogenic steroids, pregnanetriol and pregnanetriolone. Unfortunately, this did not work in some cases as a well known complication in the outpatient studies. In Table 1 a summary of clinical data of our patients is given. Our method for the determination of aldosterone (Partit et al. 1976) was modified to achieve simultaneous measurements of 17-hydroxyprogesterone in the same plasma extract, as shown in the following flowsheet:
b)
were
plasma
2 different
10000 7500
cpm
cpm
volumes
0.5 and 1
(usually
ml)
[1,2-3H] aldosterone [1,2-^] 17-hydroxyprogesterone
extract with 6 ml dichloromethane
wash with
take to
1 1 1 1
dryness,
spot separately
develop
17-hydroxyprogesterone elute with 20 °/o ethanol in dichloromethane, count 1/10 for recovery
aliquot for
RIA
to
the start line of
pre-washed TLC-platcs
in benzene-acetone 3:2
detection
suitable
ml 0.1 N NaOH ml 0.2 n acetic acid ml phosphate buffer pH 7 (0.05 m) ml diluted phosphate buffer pH 7 (1:20)
by radioscanning
aldosterone elute in the same way, count 1/10 for recovery
remaining for
RIA
Radioimmunoassay was allowed to proceed overnight at 4°C. Separation of bound and free fractions was achieved by Dextran coated charcoal. Standard curves cover the range of 0-400 pg for both aldosterone and 17-hydroxyprogesterone. Radioactivity in the aldosterone standard curve has to be adapted to the remaining activity in the samples
Equilibration
recovery whereas activity in 17-hydroxyprogesterone aliquots for radio¬ is negligible. Sheep antiserum against aldosterone 18,21 disuccinate coup¬ led to bovine serum albumin (lot 088) was kindly supplied by the National Institute of Health. Rabbit antiserum against 17-hydroxyprogesterone-3-oxime-bovine serum albumin was purchased from Endocrine Sciences and used in a final dilution of 1:4000. 17-hydroxypregnenolone is the only severe cross-reacting steroid (5 %>) and is well separated by thin layer chromatography. Recovery of 17-hydroxyprogesterone is 69.7 ±5.5% (n 40), intra- and interassay variation coefficients are 7.7 °/o (n 12) and 11.8% (n 30), respectively. Method blanks, determined in 1/10 of thin layer chromato¬ graphy eluate, are 4 + 3 pg. Spectrophotometric determination of 17-ketosteroids and
according to immunoassay
=
=
=
17-ketogenic steroids and gas-chromatographic determination of pregnanetriol pregnanetriolone were performed by our standard laboratory methods.
and
RESULTS
Normal values for plasma 17-hydroxyprogesterone levels determined in 19 pre-pubertal children aged from 1-12 years were 0.39 ± 0.23 ng/ml (mean
±
SD, range 0.10-0.88 ng/ml). Data for aldosterone (ng/100ml) and 17-hydroxyprogesterone (ng/ml) be¬ fore and after ACTH and urinary pregnanetriol, pregnanetriolone, 17-keto¬ steroids and 17-ketogenic steroids (mg/24 h) are given in Tables 2, 3 and 4. In our newly diagnosed cases 17-hydroxyprogesterone concentrations are at least 40 times above the normal range. Aldosterone levels are also more or less elevated. The normal range for children older than 2 years is 7.3 ± 4.7 ng/100 ml (mean ± sd, Parth et al. 1975). ACTH-stimulation led to a distinct rise in plasma aldosterone in 4 children, but only two of them were able to increase their 17-hydroxyprogesterone level.
Newly diagnosed
F.C. L.M. *G.R. *G.F. S.A.
' 'siblings
cases
of
congenital
Table 2. adrenal
hyperplasia
before onset of
Aldo
Aldo
17-OHP
(ng/100 ml)
after ACTH
(ng/ml)
17-OHP after ACTH
455.0 378.0 34.1 42.4 347.7
395.7 343.2 327.0 330.8
84.4 32.0 16.5 51.3 49.3
47.5 35.5 98.6 86.3
Aldo-aldosterone 17-OHP-l 7-hydroxyprogesterone 17-KS-17-ketosteroids 17-KGS-17-ketogenic steroids
therapy.
17-KS
17-KGS
(mg/24 h)
(mg/24 h)
2.4
2.6
Table 3. Patients under therapeutic control. Aldo 100
ml)
well controlled 5.8 R.E. 24.0 V.M. 4.1 S.M. W.S. 2.6 10.2 V.B. 16.7 F.C.
»S.M. *G.F. »W.A.
poorly *R.B. GA. G.B. P.R.
11.7 6.1 2.4
controlled 7.8 20.4 18.9
t35.4
¡;'salt-losers tdue to a severe enteritis
Aldo after ACTH
17-OHP
(ng/ml)
22.1 6.8 7.5
2.1 0.3 2.2 2.3 2.2 5.2 4.3 4.0
48.6 27.1 67.0
130.9 87.7 48.9 5.5
90.7 13.4
26.3 20.9
17-OHP after ACTH
17-KS
17-KGS
PT
(mg/ 24 h)
(mg/ 24 h)
(mg/ 24 h)
155.0 0.7 92.6
17.3 47.5 35.7
4.5 2.3 5.2 4.5 0.5 6.0 4.7 8.2
8.3 6.0 9.3 8.3 1.2 15.4 9.8 12.7
0.13 2.4 0.15 0.06 0.5 0.7 0.3
0.47 0.07 0.3 0.47 0.12 0.5 1.1 0.7
273.0 126.3 98.6
2.5 11.2 4.5 2.9
10.3 18.1 16.7 13.5
3.7 5.0 7.3 44
0.7 2.1 2.5 0.6
46.0
Aldo-aldosterone 17-KS-17-ketosteroids
PT-pregnanetriol
0.15
PTONE
(mg/ h)
24
17-OHP-l 7-hydroxyprogesterone 17-KGS-17-ketogenic steroids PTONE-pregnanetriolone
Regarding urinary pregnanetriol as control criterion, well substituted pa¬ tients had 17-hydroxyprogesterone values below 5 ng/ml. In 3 cases insuf¬ ficient substitution occurred as indicated by high pregnanetriol and high 17hydroxyprogesterone levels. One child (P.R.) might be regarded as a border¬ line case with moderately elevated pregnanetriol and only slightly increased 17-hydroxyprogesterone. Judgement based on 17-ketosteroids is more difficult because many children are substituted by hydrocortisone and the drug can contribute variable amounts to the fraction of urinary 17-ketosteroids. With a few exceptions, aldosterone under therapy is in the normal range. Both steroids are well stimulated by synthetic ACTH indicating no considerable suppression of the adrenal glands. The lowest aldosterone values after stimu¬ lation are shown by two salt-losers. Withdrawal of substitution for one week leads to an elevation of similar magnitude now caused by endogenous ACTH. Reaction of aldosterone is slightly less pronounced. Extremely high 17-hydroxyprogesterone values have been observed in two salt-losers.
Table 4. Patients without Aldo
Aldo after ACTH
(ng/ 100
R.E. V.M. S.M. W.S. V.B. E.E. G.A. G.B. P.R.
*S.M. »G.F. ?-W.A.
ml)
20.3 31.2 9.6 21.8 29.8 41.7 17.3 16.4 7.8 12.0 30.2 18.8
':'salt-losers
26.3 46.6 16.6 16.8
41.5 43.5 41.8 32.7 26.7 27.0 80.1 15.3
17-OHP
(ng/ml)
therapy 17-OHP after ACTH
144.4 147.0 25.0 145.4
145.0 155.0 37.6 138.0
150.0 67.3 14.8
212.0 249.3 109.3
359.0 261.2
347.0 2S2.0
Aldo-aldosterone 17-KS-17-ketosteroids
PT-pregnanetriol
for
one
week.
17-KS
17-KGS
PT
(mg/ 24 h)
(mg/ 24 h)
(mg/ 24 h)
44.6 20.2
29.7 36.6
10.7
12.2
5.7 40.8 25.3
21.0 60.5 44.3
9.7 31.8
2.1 12.7
10.5
6.7
PTONE
(mg/ h)
24
17-OHP-17-hydroxyprogesterone 17-KGS-17-ketogenic steroids PTONE-pregnanetriolone
Additional exogeneous synthetic ACTH does not alter the 17-hydroxy¬ progesterone levels in 7 cases. Excepting 3 cases, aldosterone rises further. There is an excellent correlation between plasma 17-hydroxyprogesterone and urinary pregnanetriol: r 0.84 (P < 0.003, n 14). As expected, correlation between 17-hydroxyprogesterone and pregnanetriolone is less significant: r =
=
=
(P
Ludwig Boltzmann Institute of Endocrinology, Vienna
Paediatric
CONGENITAL ADRENAL HYPERPLASIA: SIMULTANEOUS DETERMINATION OF PLASMA ALDOSTERONE AND 17-HYDROXYPROGESTERONE
By K. Parth1), H.
W. Swoboda, Roswitha Brunel and Edith Bohrn
Zimprich,
ABSTRACT Plasma levels of aldosterne and 17-hydroxyprogesterone were determined in 5 just diagnosed cases of congenital adrenal hyperplasia due to 21-hydroxylase deficiency without salt-loss before onset of therapy, and in 14 children suffering from the same disorder, under glucocorticoid therapy before and after withdrawal of therapy for one week as well as before and after
ACTH-stimulation. Furthermore, urinary pregnanetriol, pregnanetriolone, 17-ketosteroids and 17-ketogenic steroids were determined with and without therapy. Serum concentrations of 17-hydroxyprogesterone in patients before onset of therapy were at least 40 times above the normal range (normal range: 0.39 \m=+-\0.23 ng/ml determined in 19 children of age 1\p=n-\12 aldosterone was also elevated (range 16.5\p=n-\84.4 ng/100 ml, normal aldosterone being 7.3 \m=+-\4.7 ng/ml). In contrast, well controlled patients (judged on urinary pregnanetriol-excretion) had normal aldosterone (one exception) and 17-hydroxyprogesterone levels below 5 ng/ml. Both steroids were well stimulated by ACTH. In 3 poorly controlled cases elevated pregnanetriol and 17-hydroxyprogesterone values up to 130.9 ng/ml were found. Withdrawal of therapy resulted in pronounced rise of aldosterone and 17-hydroxyprogesterone. Exogenous ACTH had no detectable effect in 7 cases leading to further stimulation in the other children. We found an excellent correlation between plasma 17-hydroxyprogesterone and urinary pregnanetriol (r 0.84, P < 0.003, n=14). Fairly good correlation also exists between aldosterone and 17-hydroxyprogesterone values (r= 0.65, P < 0.01, n=14) in patients before the onset and after withdrawal of therapy.
years),
=
l) Present address:
Ludwig
Boltzmann Institute of Paediatric 1090 Vienna, Austria.
Kinderklinik, Währingergürtel 74,
Endocrinology, c/o Univ.
The data confirm the value of 17-hydroxyprogesterone determinations for diagnosis and management of congenital adrenal hyperplasia on the one hand, and the compensatory elevated aldosterone production in the non-salt-losing form of the disorder on the other.
The disorder of congenital adrenal hyperplasia is caused by a hereditary 21hydroxylation defect in a very high percentage of cases. The biosynthesis of cortisol is decreased, resulting in an increased secretion of ACTH via the feed¬ back control. As a consequence, accumulation of cortisol precursors (especially 17-hydroxyprogesterone) and increased production of androgens is observed. In about 30 % of all patients (Degenhart et al. 1965) a salt-losing tendency is associated with congenital adrenal hyperplasia but its pathogenetic mech¬ anism is still a matter of controversy. Eberlein 8c Bongiovanni (1958) have suggested that the difference between the "simple" virilizing form and the sodium-losing form is one of degree of block, the latter being the more severe defect. Bryan et al. (1965) and Degenhart et al. (1965) have shown impaired aldo¬ sterone production and excretion in salt-losing congenital adrenal hyperplasia. Their hypothesis is based on the assumption, that there is a defect in 21hydroxylation of 17-hydroxyprogesterone in all cases and an additional defect in 21-hydroxylation of progesterone in the salt-losing form of the disorder. An intact biosynthetic pathway for aldosterone production in the "simple" virilizing form with elevated and well stimulable aldosterone secretion rates was reported by Bartter et al. (1968). These findings are thought to compen¬ sate for the antagonism of progesterone and 17-hydroxyprogesterone against mineralo-corticoids at the renal tubular level (Landau 8c Lugibihl 1958; Jacobs et al. 1961; George et al. 1965). The simultaneous determination of aldosterone and 17-hydroxyprogesterone values in congenital adrenal hyperplasia should provide some information about the degree of correlation between the two parameters. On the other hand, determination of 17-hydroxyprogesterone levels has become valuable in diag¬ nosis as well as in the therapeutic management of congenital adrenal hyper¬ plasia (Barnes 8c Atherden 1972; Strott et al. 1969; Hughes 8c Winter 1976; v. Schnakenburg et al. 1974). The second purpose of this study was therefore to compare 17-hydroxyprogesterone levels in our congenital adrenal hyperplasia patients with standard techniques for therapeutic monitoring (pregnanetriol,
pregnanetriolone, 17-ketosteroids). PATIENTS AND METHODS Nineteen patients with congenital adrenal aged from 0.5 to 23 years were studied.
hyperplasia
due to
21-hydroxylase deficiency
Group
(5 children, age range 7/12-14 years) were newly diagnosed cases. Aldo¬ 17-hydroxyprogesterone were measured before onset of therapy before min after the administration of 0.25 mg synthetic ACTH (iv). No salt-loser I
sterone and
and 20 observed in this group. Group II is represented by 14 patients (2.5-23 years old) had been under therapeutic control since diagnosis, 4 of them being salt-losers. Only one infant (R.B., 2.5 years) showed acute salt-loss and was not yet well controlled. Therefore we were forced to omit withdrawal of therapy in this case. The salt-losing tendency of the other 3 girls (11-12 years old) had improved very much since infancy and now showed no clinical differences compared to the non-salt-losers. Aldosterone and 17-hydroxyprogesterone levels were measured under the following conditions: a) under therapy, before and 20 min after ACTH stimulation (0.25 mg synthetic was
ACTH, iv)
Table 1. Clinical data of
Group
I
F.C. L.M.
7/12 5 14 5 13
»G.R. :;G.F. S.A.
Group R.E. ':V.M. S.M. W.S.
*V.B. F.C. E.E.
patients.
F M M M M
II
prednisolone prednisolone hydrocortisone hydrocortisone prednisolone hydrocortisone
20 mg 20 mg 25 mg 20 mg 20 mg 10 mg
21
M F M F M F F
15 6 10 8/12 2 6/12
F F F F
7,5 mg prednisolone
12 9/12 12 11
F F F
23 16 10 5 2/12 19
13/12
tsalt-losers
20 14 8/12 6 6/12
2 5/12 14 3/12
8/12 until age
15 mg hydrocortisone 20 mg hydrocortisone 10 mg hydrocortisone 0,1 mg 9-fluorohydrocortisone 15 mg prednisolone 30 mg hydrocortisone 25 mg cortoneacetate
19 14 5 3 2
5/12 6/12 11/12 2/12 5/12
12 8/12 8 6/12 9 9/12
without therapy for one week, again before and after ACTH. All plasma samples taken between 9 and 11 a.m. after at least lh with patients in supine position to reduce the influence of circadian variations and posture as far as possible. All children were on unrestricted sodium intake. Parents and (or) patients were told to collect 24 h urines under therapy (day before ACTH stimulation) and on the last day of withdrawal of glucocorticoids for the determination of 17-ketosteroids, 17-ketogenic steroids, pregnanetriol and pregnanetriolone. Unfortunately, this did not work in some cases as a well known complication in the outpatient studies. In Table 1 a summary of clinical data of our patients is given. Our method for the determination of aldosterone (Partit et al. 1976) was modified to achieve simultaneous measurements of 17-hydroxyprogesterone in the same plasma extract, as shown in the following flowsheet:
b)
were
plasma
2 different
10000 7500
cpm
cpm
volumes
0.5 and 1
(usually
ml)
[1,2-3H] aldosterone [1,2-^] 17-hydroxyprogesterone
extract with 6 ml dichloromethane
wash with
take to
1 1 1 1
dryness,
spot separately
develop
17-hydroxyprogesterone elute with 20 °/o ethanol in dichloromethane, count 1/10 for recovery
aliquot for
RIA
to
the start line of
pre-washed TLC-platcs
in benzene-acetone 3:2
detection
suitable
ml 0.1 N NaOH ml 0.2 n acetic acid ml phosphate buffer pH 7 (0.05 m) ml diluted phosphate buffer pH 7 (1:20)
by radioscanning
aldosterone elute in the same way, count 1/10 for recovery
remaining for
RIA
Radioimmunoassay was allowed to proceed overnight at 4°C. Separation of bound and free fractions was achieved by Dextran coated charcoal. Standard curves cover the range of 0-400 pg for both aldosterone and 17-hydroxyprogesterone. Radioactivity in the aldosterone standard curve has to be adapted to the remaining activity in the samples
Equilibration
recovery whereas activity in 17-hydroxyprogesterone aliquots for radio¬ is negligible. Sheep antiserum against aldosterone 18,21 disuccinate coup¬ led to bovine serum albumin (lot 088) was kindly supplied by the National Institute of Health. Rabbit antiserum against 17-hydroxyprogesterone-3-oxime-bovine serum albumin was purchased from Endocrine Sciences and used in a final dilution of 1:4000. 17-hydroxypregnenolone is the only severe cross-reacting steroid (5 %>) and is well separated by thin layer chromatography. Recovery of 17-hydroxyprogesterone is 69.7 ±5.5% (n 40), intra- and interassay variation coefficients are 7.7 °/o (n 12) and 11.8% (n 30), respectively. Method blanks, determined in 1/10 of thin layer chromato¬ graphy eluate, are 4 + 3 pg. Spectrophotometric determination of 17-ketosteroids and
according to immunoassay
=
=
=
17-ketogenic steroids and gas-chromatographic determination of pregnanetriol pregnanetriolone were performed by our standard laboratory methods.
and
RESULTS
Normal values for plasma 17-hydroxyprogesterone levels determined in 19 pre-pubertal children aged from 1-12 years were 0.39 ± 0.23 ng/ml (mean
±
SD, range 0.10-0.88 ng/ml). Data for aldosterone (ng/100ml) and 17-hydroxyprogesterone (ng/ml) be¬ fore and after ACTH and urinary pregnanetriol, pregnanetriolone, 17-keto¬ steroids and 17-ketogenic steroids (mg/24 h) are given in Tables 2, 3 and 4. In our newly diagnosed cases 17-hydroxyprogesterone concentrations are at least 40 times above the normal range. Aldosterone levels are also more or less elevated. The normal range for children older than 2 years is 7.3 ± 4.7 ng/100 ml (mean ± sd, Parth et al. 1975). ACTH-stimulation led to a distinct rise in plasma aldosterone in 4 children, but only two of them were able to increase their 17-hydroxyprogesterone level.
Newly diagnosed
F.C. L.M. *G.R. *G.F. S.A.
' 'siblings
cases
of
congenital
Table 2. adrenal
hyperplasia
before onset of
Aldo
Aldo
17-OHP
(ng/100 ml)
after ACTH
(ng/ml)
17-OHP after ACTH
455.0 378.0 34.1 42.4 347.7
395.7 343.2 327.0 330.8
84.4 32.0 16.5 51.3 49.3
47.5 35.5 98.6 86.3
Aldo-aldosterone 17-OHP-l 7-hydroxyprogesterone 17-KS-17-ketosteroids 17-KGS-17-ketogenic steroids
therapy.
17-KS
17-KGS
(mg/24 h)
(mg/24 h)
2.4
2.6
Table 3. Patients under therapeutic control. Aldo 100
ml)
well controlled 5.8 R.E. 24.0 V.M. 4.1 S.M. W.S. 2.6 10.2 V.B. 16.7 F.C.
»S.M. *G.F. »W.A.
poorly *R.B. GA. G.B. P.R.
11.7 6.1 2.4
controlled 7.8 20.4 18.9
t35.4
¡;'salt-losers tdue to a severe enteritis
Aldo after ACTH
17-OHP
(ng/ml)
22.1 6.8 7.5
2.1 0.3 2.2 2.3 2.2 5.2 4.3 4.0
48.6 27.1 67.0
130.9 87.7 48.9 5.5
90.7 13.4
26.3 20.9
17-OHP after ACTH
17-KS
17-KGS
PT
(mg/ 24 h)
(mg/ 24 h)
(mg/ 24 h)
155.0 0.7 92.6
17.3 47.5 35.7
4.5 2.3 5.2 4.5 0.5 6.0 4.7 8.2
8.3 6.0 9.3 8.3 1.2 15.4 9.8 12.7
0.13 2.4 0.15 0.06 0.5 0.7 0.3
0.47 0.07 0.3 0.47 0.12 0.5 1.1 0.7
273.0 126.3 98.6
2.5 11.2 4.5 2.9
10.3 18.1 16.7 13.5
3.7 5.0 7.3 44
0.7 2.1 2.5 0.6
46.0
Aldo-aldosterone 17-KS-17-ketosteroids
PT-pregnanetriol
0.15
PTONE
(mg/ h)
24
17-OHP-l 7-hydroxyprogesterone 17-KGS-17-ketogenic steroids PTONE-pregnanetriolone
Regarding urinary pregnanetriol as control criterion, well substituted pa¬ tients had 17-hydroxyprogesterone values below 5 ng/ml. In 3 cases insuf¬ ficient substitution occurred as indicated by high pregnanetriol and high 17hydroxyprogesterone levels. One child (P.R.) might be regarded as a border¬ line case with moderately elevated pregnanetriol and only slightly increased 17-hydroxyprogesterone. Judgement based on 17-ketosteroids is more difficult because many children are substituted by hydrocortisone and the drug can contribute variable amounts to the fraction of urinary 17-ketosteroids. With a few exceptions, aldosterone under therapy is in the normal range. Both steroids are well stimulated by synthetic ACTH indicating no considerable suppression of the adrenal glands. The lowest aldosterone values after stimu¬ lation are shown by two salt-losers. Withdrawal of substitution for one week leads to an elevation of similar magnitude now caused by endogenous ACTH. Reaction of aldosterone is slightly less pronounced. Extremely high 17-hydroxyprogesterone values have been observed in two salt-losers.
Table 4. Patients without Aldo
Aldo after ACTH
(ng/ 100
R.E. V.M. S.M. W.S. V.B. E.E. G.A. G.B. P.R.
*S.M. »G.F. ?-W.A.
ml)
20.3 31.2 9.6 21.8 29.8 41.7 17.3 16.4 7.8 12.0 30.2 18.8
':'salt-losers
26.3 46.6 16.6 16.8
41.5 43.5 41.8 32.7 26.7 27.0 80.1 15.3
17-OHP
(ng/ml)
therapy 17-OHP after ACTH
144.4 147.0 25.0 145.4
145.0 155.0 37.6 138.0
150.0 67.3 14.8
212.0 249.3 109.3
359.0 261.2
347.0 2S2.0
Aldo-aldosterone 17-KS-17-ketosteroids
PT-pregnanetriol
for
one
week.
17-KS
17-KGS
PT
(mg/ 24 h)
(mg/ 24 h)
(mg/ 24 h)
44.6 20.2
29.7 36.6
10.7
12.2
5.7 40.8 25.3
21.0 60.5 44.3
9.7 31.8
2.1 12.7
10.5
6.7
PTONE
(mg/ h)
24
17-OHP-17-hydroxyprogesterone 17-KGS-17-ketogenic steroids PTONE-pregnanetriolone
Additional exogeneous synthetic ACTH does not alter the 17-hydroxy¬ progesterone levels in 7 cases. Excepting 3 cases, aldosterone rises further. There is an excellent correlation between plasma 17-hydroxyprogesterone and urinary pregnanetriol: r 0.84 (P < 0.003, n 14). As expected, correlation between 17-hydroxyprogesterone and pregnanetriolone is less significant: r =
=
=
(P
