418
H. Vetter and W. Vetter
References
Carter, J.R., D.8. Martin: The effect of sulfhydryl blockage on insulin action and glucose transport in isolated adipose tissue cells. Biochim.Biophys.Acta 177: 521-526 (1969) Cuatrecasas, P.: Properties of the insulin receptor of isolated fat cell membrane. J.BioI.Chem. 246: 7265-7274 (1971) Dixit, R.K., A. Lazarow: Effects of metal ion and sulfhydryl inhibitors on glucose metabolism by adipose tissue. AmerJ.Physiol. 213: 849-856 (1972) Folch, J., M. Lees, G.H. Stanley: A simple method for the isolation and purification of total lipids from animal tissues. J.BioI.Chem. 226: 497-509 (1957) Lavis, R. V., R.H. Wi/liams: Studies of the insulin like action
of thiols upon isolated fat cells. J.BioI.Chem. 245: 23-41 (1970) Minemura, T., 0.8. Cro[[ord: Insulin-receptor interaction in iso la ted fat cells. I. The insulin-like properties of p-chloromercuribenzene sulfonic acid. J .BioI.Chem. 244: 5181518B (1969) Rodbell, M.: Effects of hormones on glucose metabolism and Iipolysis. J.BioI.Chem. 239: 375-380 (1964) Rodbell, M.: The similar effects of phospholipase C (Clostridium perfringens toxin) and of insulin on glucose and amino acid metabolism. J.BioI.Chem. 241: 130-139 (1966) Simon, 8., G. Zimmerschied, E.M. Kinne-Sa[[ran, R. Kinne: A new synthetic plasma membrane marker: FluorescentMercury-Dextran. J.Membr.Biol. 14: 85-93 (1973)
Horm. Metab. Res. 7 (1975) 418-424
© Georg Thieme Verlag Stuttgart
Regulation of Aldosterone Secretion in Primary Aldosteronism H. Vetter and W. Vetter* Medizinische Poliklinik. University of Bonn. Germany
Summary
Introduction
Plasma aldosterone, plasma renin activity and plasma cortisol were determined in patients with primary aldosteronism in response to posture and at short-time intervals overnight while the patients were supine. In the 5 patients with an aldosterone-producing adenoma postural changes in plasma aldosterone were paralleled by those in cortisol while plasma renin activity was generally undetectable indicating an ACTHdependent secretion of aldosterone. This concept was supported by the observation that in 3 of these patients who were tested overnight 1. episodic secretion of plasma aldosterone was paralleled by those of cortisol and 2. episodic secretion of plasma aldosterone could be blunted by dexamethasone. In the patient with idiopathic adrenal hyperplasia concomittant changes in plasma aldosterone and plasma renin activity occurred. The assumption that in this patient the fluctuations in plasma aldosterone were media ted tbrough changes in renal renin secretion was supported by the finding that episodic secretion of plasma aldosterone persisted under suppression of ACTH-secretion by dexamethasone. Qur results indicate, that the described procedures may all serve as diagnostic criteria to differentiate between aldosterone-producing adenoma and idiopathic adrenal hyperplasia.
The syndrome of primary aldosteronism may be caused generally either by an aldosterone-producing adenoma or by idiopathic adrenal hyperplasia. AIthough this disease has been extensively studied controversial results exist ab out the role of ACTH and renal renin secretion on adrenal aldosterone release (Kaplan and Silah 1964, Newton and Laragh 1968, Horton 1969, Slaton, Schambelan and Big/ieri 1969, George, Wright, Bell and Bartter 1970, Cain, Tuck, Williams, Dluhy and Rosenoff 1972, Ganguly, Melada, Luetscher and Dowdy 1973, Kem, Weinberger, Gomez-Sanchez, Kramer, Lerman, Furuyama and Nugent 1973, Biglieri, Schambelan, Brust, Chang and Hogan 1974, Vetter, Berger, Armbruster, Siegenthaler, Werning and Vetter 1974a).
Key-Words: Aldosterone - Adrenal Glands - Primary AIdosteronism
·Present address: Department of Internal Medicine, Kantonsspital, University of Zürich, Switzerland. Received: 10 Nov. 1974
Accepted: 18 June 1975
This study was performed to investigate the influence of endogenous ACTH- and renin secretion on adrenal aldosterone release in patients with primary aldosteronism. Materials and Methods Six patients suffering from primary aldosteronism (aldosterone-producing adenoma n z 5, idiopathic adrenal hyperplasia n = I) were examined in this study. In all cases the diagnosis was conflImed by surgery. Blood was taken from the patients at different days under normal sodium intake (120-150 meq sodium/day) at 8 a.m. after the patients were recumbent overnight and two hours
Downloaded by: East Carolina University. Copyrighted material.
Requests for reprints should be addressed to: Dr. H. Kather , Dr. B. Simon, Klinisches Institut zur Erforschung des Herzinfarktes an der Medizinischen Universitätsklinik Heidelberg, D-69 Heidelberg, Bergheimerstr. 58 (Germany)
after change to the upright position. Blood sampies which were drawn at short-time intervals overnight were taken through an indwelling catheter while the patients remained in the supine position. 4 patients (a1dosterone-prod ucing adenoma n = 3, idiopathie adrenal hyperplasia n = 1) were exarnined und er normal sodium intake both under unaffected and suppressed ACTH-secretion. ACTH-secretion was suppressed by oral administration of dexamethasone (2 mg were given at 4 p.m. and 2 mg at 11 p.m., on the day the experiment started). In 3 patients with an aldosterone-produeing adenoma blood was taken at short-time intervals overnight both after 4 days of a high sodium diet (350 meq sodium/ day) and after 10 days of a low sodium intake (10 meq sodium/day). Before and after eaeh test period additional blood specimens were drawn to determine the serum eoncentration of potassium and sodium. Plasma aldosterone (PA) was measured by a radioimmunoassay proeedure without ehromatography (Vetter, Vetter and Siegenthaler 1973) using antisera highly specific to aldosterone (Vetter and Vetter 1974b, Vetter, Freedlender and Haber 1974). Plasma renin activity (PRA) was determined by radioimmunoassay for angiotensin I (Haber, Koerner, Page, KlimJln and Purnode 1979). Plasma eortisol (Pe) was measured by the protein binding method using dextran-coated charcoal to separate bound and free hormone (Murphy, Engelberg and Pattee 1963). The serum eoncentration of potassium and sodium was determined by flame photometry. The specificity of the aldosterone radioimmunoassay was tested by comparing resuIts obtained with radioimmunoassay system employing chromatographie isolation of aldosterone (Poulsen, Sancho and Haber 1974). The high oorrelation coefficient r of 0.90 showed that with both methods comparable values were found. In addition, aldosterone ooncentration was determined in plasma specimens from totally adrenalectomized patients to which 50 J.Ig cortisol/l00 ml, 5 /Jg corticosterone/l00 ml and 0.5 J.Ig deoxycorticosterone/l00 ml bad been added prior to the radioimmunoassay procedure. In these plasma specimens 'aldosterone values' indistinguishable from 0 were found indicating high specificity of the assay system. Under a controlled sodium intake of 120-150 meq sodium/ day our normal supine values for plasma aldosterone are 2().120 pg/ml and 100-450 pg/ml after ehange to the upright position. The respective values for plasma renin activity are 0.3-3.0 ng/ml/3 hr (supine) and 2.0-10.0 ng/ml/3 hr (upright). The lower limit of detectabiIity is 8 pg aldosterone/mi and 0.16 ng generated angiotensin I/ml/ 3 hr.
419
In the patient with bilateral adrenal hyperplasia (ease 5) plasma aldosterone inereased in response to posture at two different oeeasions. These inereases were associated with an inerease in plasma renin activity while plasma cortisol inereased in one and showed a deerease in the other test. In patients with an aldosterone-producing adenoma (ease 1-4,6) plasma aldosterone showed a variable response after change to the upright position. In two patients (ease 1 and 4) plasma aldosterone deereased eonstantIy at different oeeasions. In one patient (ease 3) plasma aldosterone inereased, deereased or nearly remained unehanged. In the remaining two patients (ease 2 and 6) either no change or an inerease in plasma aldosterone eoneentration was observed. In patients with an aldosterone-produeing adenoma (ease 1-4,6) ehanges in plasma aldosterone were paralleled by those in plasma eortisol in 15 of 22 different oeeasions. Whenever plasma aldosterone and plasma eortisol were determined at 30 minutes intervals following assumption of upright position almost parallel ehanges in the plasma eoneentrations of both hormones were observed (ease 3f, 4f and 6d; Fig. 1). In only three of all tests (ease I b, 3e and 6e, Fig. 1) marked dissociations were obtained between plasma aldosterone and plasma eortisol. In a11 patients plasma eortisol was within the normal range. The relation of inerease to deerease from 8 to 10 a.m. was 11 to 13. Plasma renin aetivity was normally below the lower limit of deteetability in patients with an aldosterone-producing adenoma « 0.16 ng/ml/3 hr). At times plasma renin aetivity eould be deteeted in 4 of these patients (ease 1, 3, 4, 6), however, in none of the tests where an inerease in plasma renin aetivity oeeurred in response to posture (Fig. 1; ease le, Id, 4e) parallel ehanges in plasma aldosterone and plasma renin aetivity were observed. Statistical analysis of all reeumbent and upright PA, PRA and PC values showed in patients with an aldosterone-producing adenoma a highly signifieant eorrelation between PA and PC (n = 53; r = 0.604; p < 0.001) whereas no eorrelation was seen between PA and PRA.
Statistical analysis were performed by calculation of correlaShort-time fluctuations in plasma aldosterone in supine tion coefficients between PA and Pe and between PA and PRA. The correlation coefficients were tested for significance patients by standard procedures. For all calculations undetectable 1. Patients with an aldosterone-producing adenoma plasma renin levels «0.16 ng/ml/3 hr) were considered to be 0.16 ng/rnl/3 hr. Plasma aldosterone, plasma eortisol and plasma renin
Results Repeated determinations o[ supine and upright aldosterone Plasma aldosterone, plasma eortisol and plasma renin aetivity were determined repeatedly in 6 patients with primary aldosteronism in the supine and 2 hours after change to the upright position (Fig. 1). Supine plasma aldosterone was in a11 patients elevated above the normal range (> 120 pg/ml).
aetivity were determined overnight at short-time intervals in 3 patients with an aldosterone-producing adenoma (ease 3, 4, 6) under different sodium intake and during dexamethasone medieation (Fig. 2). Under normal (120-150 meq sodium/day), high (350 meq sodium/day) and low sodium diet (10 meq sodium/da) aldosterone was seereted episodieally with lower values be fore and at midnight and markedly higher values in the early morning. Under eaeh eon-
Downloaded by: East Carolina University. Copyrighted material.
Regulation of Aldosterone Secretion in Primary Aldosteronism
420
H. Vetter and W. Vetter
pe
• PA pg/ml
Jl9/100 ml
c·",
b·"'"
0
Q/
0 ___
d
°
0"': .-.
0 _0
200
b\.
PRA ng/ml/3h,
,00
~!-
1
300
/
•
0.42
.
d o - -O
C°-"""'o
/
•
0.25
0
100
b!r ./
2a
."",
•
.
~=--=i/
5
o
8\,. ffj~'. ,. 0
0.30
c
21~·~ "-. b
150
50
",.
~r ·bj.
o
_. .,(\/l
:~~
0
.,,/
0.24 0.18
0.38
6a
0.73
c
b
d '\-
X· .--. 0_0
0---:'1
./
L...........I
postur.
_.
er
0.56 0.47 0.25
L...........I
L...........I
L----I
0-
....-".ac . .
pe ••ce. 20 ... / _ ' "
tU 120-'50 ~/da.,
N. 120-150 ",eq/da,
Na 350 meq Id.,
3d.,.
.dayl
/\-/
r/I'j
10/
/
11--
eo.te 4
-v~. 7.2 ........ /
\,
cO. HI- O.S"
./
c
,...,....---_..... /
5.0/\-'
PIIA cO.•
0200
/-
H. Vetter and W. Vetter
References
Carter, J.R., D.8. Martin: The effect of sulfhydryl blockage on insulin action and glucose transport in isolated adipose tissue cells. Biochim.Biophys.Acta 177: 521-526 (1969) Cuatrecasas, P.: Properties of the insulin receptor of isolated fat cell membrane. J.BioI.Chem. 246: 7265-7274 (1971) Dixit, R.K., A. Lazarow: Effects of metal ion and sulfhydryl inhibitors on glucose metabolism by adipose tissue. AmerJ.Physiol. 213: 849-856 (1972) Folch, J., M. Lees, G.H. Stanley: A simple method for the isolation and purification of total lipids from animal tissues. J.BioI.Chem. 226: 497-509 (1957) Lavis, R. V., R.H. Wi/liams: Studies of the insulin like action
of thiols upon isolated fat cells. J.BioI.Chem. 245: 23-41 (1970) Minemura, T., 0.8. Cro[[ord: Insulin-receptor interaction in iso la ted fat cells. I. The insulin-like properties of p-chloromercuribenzene sulfonic acid. J .BioI.Chem. 244: 5181518B (1969) Rodbell, M.: Effects of hormones on glucose metabolism and Iipolysis. J.BioI.Chem. 239: 375-380 (1964) Rodbell, M.: The similar effects of phospholipase C (Clostridium perfringens toxin) and of insulin on glucose and amino acid metabolism. J.BioI.Chem. 241: 130-139 (1966) Simon, 8., G. Zimmerschied, E.M. Kinne-Sa[[ran, R. Kinne: A new synthetic plasma membrane marker: FluorescentMercury-Dextran. J.Membr.Biol. 14: 85-93 (1973)
Horm. Metab. Res. 7 (1975) 418-424
© Georg Thieme Verlag Stuttgart
Regulation of Aldosterone Secretion in Primary Aldosteronism H. Vetter and W. Vetter* Medizinische Poliklinik. University of Bonn. Germany
Summary
Introduction
Plasma aldosterone, plasma renin activity and plasma cortisol were determined in patients with primary aldosteronism in response to posture and at short-time intervals overnight while the patients were supine. In the 5 patients with an aldosterone-producing adenoma postural changes in plasma aldosterone were paralleled by those in cortisol while plasma renin activity was generally undetectable indicating an ACTHdependent secretion of aldosterone. This concept was supported by the observation that in 3 of these patients who were tested overnight 1. episodic secretion of plasma aldosterone was paralleled by those of cortisol and 2. episodic secretion of plasma aldosterone could be blunted by dexamethasone. In the patient with idiopathic adrenal hyperplasia concomittant changes in plasma aldosterone and plasma renin activity occurred. The assumption that in this patient the fluctuations in plasma aldosterone were media ted tbrough changes in renal renin secretion was supported by the finding that episodic secretion of plasma aldosterone persisted under suppression of ACTH-secretion by dexamethasone. Qur results indicate, that the described procedures may all serve as diagnostic criteria to differentiate between aldosterone-producing adenoma and idiopathic adrenal hyperplasia.
The syndrome of primary aldosteronism may be caused generally either by an aldosterone-producing adenoma or by idiopathic adrenal hyperplasia. AIthough this disease has been extensively studied controversial results exist ab out the role of ACTH and renal renin secretion on adrenal aldosterone release (Kaplan and Silah 1964, Newton and Laragh 1968, Horton 1969, Slaton, Schambelan and Big/ieri 1969, George, Wright, Bell and Bartter 1970, Cain, Tuck, Williams, Dluhy and Rosenoff 1972, Ganguly, Melada, Luetscher and Dowdy 1973, Kem, Weinberger, Gomez-Sanchez, Kramer, Lerman, Furuyama and Nugent 1973, Biglieri, Schambelan, Brust, Chang and Hogan 1974, Vetter, Berger, Armbruster, Siegenthaler, Werning and Vetter 1974a).
Key-Words: Aldosterone - Adrenal Glands - Primary AIdosteronism
·Present address: Department of Internal Medicine, Kantonsspital, University of Zürich, Switzerland. Received: 10 Nov. 1974
Accepted: 18 June 1975
This study was performed to investigate the influence of endogenous ACTH- and renin secretion on adrenal aldosterone release in patients with primary aldosteronism. Materials and Methods Six patients suffering from primary aldosteronism (aldosterone-producing adenoma n z 5, idiopathic adrenal hyperplasia n = I) were examined in this study. In all cases the diagnosis was conflImed by surgery. Blood was taken from the patients at different days under normal sodium intake (120-150 meq sodium/day) at 8 a.m. after the patients were recumbent overnight and two hours
Downloaded by: East Carolina University. Copyrighted material.
Requests for reprints should be addressed to: Dr. H. Kather , Dr. B. Simon, Klinisches Institut zur Erforschung des Herzinfarktes an der Medizinischen Universitätsklinik Heidelberg, D-69 Heidelberg, Bergheimerstr. 58 (Germany)
after change to the upright position. Blood sampies which were drawn at short-time intervals overnight were taken through an indwelling catheter while the patients remained in the supine position. 4 patients (a1dosterone-prod ucing adenoma n = 3, idiopathie adrenal hyperplasia n = 1) were exarnined und er normal sodium intake both under unaffected and suppressed ACTH-secretion. ACTH-secretion was suppressed by oral administration of dexamethasone (2 mg were given at 4 p.m. and 2 mg at 11 p.m., on the day the experiment started). In 3 patients with an aldosterone-produeing adenoma blood was taken at short-time intervals overnight both after 4 days of a high sodium diet (350 meq sodium/ day) and after 10 days of a low sodium intake (10 meq sodium/day). Before and after eaeh test period additional blood specimens were drawn to determine the serum eoncentration of potassium and sodium. Plasma aldosterone (PA) was measured by a radioimmunoassay proeedure without ehromatography (Vetter, Vetter and Siegenthaler 1973) using antisera highly specific to aldosterone (Vetter and Vetter 1974b, Vetter, Freedlender and Haber 1974). Plasma renin activity (PRA) was determined by radioimmunoassay for angiotensin I (Haber, Koerner, Page, KlimJln and Purnode 1979). Plasma eortisol (Pe) was measured by the protein binding method using dextran-coated charcoal to separate bound and free hormone (Murphy, Engelberg and Pattee 1963). The serum eoncentration of potassium and sodium was determined by flame photometry. The specificity of the aldosterone radioimmunoassay was tested by comparing resuIts obtained with radioimmunoassay system employing chromatographie isolation of aldosterone (Poulsen, Sancho and Haber 1974). The high oorrelation coefficient r of 0.90 showed that with both methods comparable values were found. In addition, aldosterone ooncentration was determined in plasma specimens from totally adrenalectomized patients to which 50 J.Ig cortisol/l00 ml, 5 /Jg corticosterone/l00 ml and 0.5 J.Ig deoxycorticosterone/l00 ml bad been added prior to the radioimmunoassay procedure. In these plasma specimens 'aldosterone values' indistinguishable from 0 were found indicating high specificity of the assay system. Under a controlled sodium intake of 120-150 meq sodium/ day our normal supine values for plasma aldosterone are 2().120 pg/ml and 100-450 pg/ml after ehange to the upright position. The respective values for plasma renin activity are 0.3-3.0 ng/ml/3 hr (supine) and 2.0-10.0 ng/ml/3 hr (upright). The lower limit of detectabiIity is 8 pg aldosterone/mi and 0.16 ng generated angiotensin I/ml/ 3 hr.
419
In the patient with bilateral adrenal hyperplasia (ease 5) plasma aldosterone inereased in response to posture at two different oeeasions. These inereases were associated with an inerease in plasma renin activity while plasma cortisol inereased in one and showed a deerease in the other test. In patients with an aldosterone-producing adenoma (ease 1-4,6) plasma aldosterone showed a variable response after change to the upright position. In two patients (ease 1 and 4) plasma aldosterone deereased eonstantIy at different oeeasions. In one patient (ease 3) plasma aldosterone inereased, deereased or nearly remained unehanged. In the remaining two patients (ease 2 and 6) either no change or an inerease in plasma aldosterone eoneentration was observed. In patients with an aldosterone-produeing adenoma (ease 1-4,6) ehanges in plasma aldosterone were paralleled by those in plasma eortisol in 15 of 22 different oeeasions. Whenever plasma aldosterone and plasma eortisol were determined at 30 minutes intervals following assumption of upright position almost parallel ehanges in the plasma eoneentrations of both hormones were observed (ease 3f, 4f and 6d; Fig. 1). In only three of all tests (ease I b, 3e and 6e, Fig. 1) marked dissociations were obtained between plasma aldosterone and plasma eortisol. In a11 patients plasma eortisol was within the normal range. The relation of inerease to deerease from 8 to 10 a.m. was 11 to 13. Plasma renin aetivity was normally below the lower limit of deteetability in patients with an aldosterone-producing adenoma « 0.16 ng/ml/3 hr). At times plasma renin aetivity eould be deteeted in 4 of these patients (ease 1, 3, 4, 6), however, in none of the tests where an inerease in plasma renin aetivity oeeurred in response to posture (Fig. 1; ease le, Id, 4e) parallel ehanges in plasma aldosterone and plasma renin aetivity were observed. Statistical analysis of all reeumbent and upright PA, PRA and PC values showed in patients with an aldosterone-producing adenoma a highly signifieant eorrelation between PA and PC (n = 53; r = 0.604; p < 0.001) whereas no eorrelation was seen between PA and PRA.
Statistical analysis were performed by calculation of correlaShort-time fluctuations in plasma aldosterone in supine tion coefficients between PA and Pe and between PA and PRA. The correlation coefficients were tested for significance patients by standard procedures. For all calculations undetectable 1. Patients with an aldosterone-producing adenoma plasma renin levels «0.16 ng/ml/3 hr) were considered to be 0.16 ng/rnl/3 hr. Plasma aldosterone, plasma eortisol and plasma renin
Results Repeated determinations o[ supine and upright aldosterone Plasma aldosterone, plasma eortisol and plasma renin aetivity were determined repeatedly in 6 patients with primary aldosteronism in the supine and 2 hours after change to the upright position (Fig. 1). Supine plasma aldosterone was in a11 patients elevated above the normal range (> 120 pg/ml).
aetivity were determined overnight at short-time intervals in 3 patients with an aldosterone-producing adenoma (ease 3, 4, 6) under different sodium intake and during dexamethasone medieation (Fig. 2). Under normal (120-150 meq sodium/day), high (350 meq sodium/day) and low sodium diet (10 meq sodium/da) aldosterone was seereted episodieally with lower values be fore and at midnight and markedly higher values in the early morning. Under eaeh eon-
Downloaded by: East Carolina University. Copyrighted material.
Regulation of Aldosterone Secretion in Primary Aldosteronism
420
H. Vetter and W. Vetter
pe
• PA pg/ml
Jl9/100 ml
c·",
b·"'"
0
Q/
0 ___
d
°
0"': .-.
0 _0
200
b\.
PRA ng/ml/3h,
,00
~!-
1
300
/
•
0.42
.
d o - -O
C°-"""'o
/
•
0.25
0
100
b!r ./
2a
."",
•
.
~=--=i/
5
o
8\,. ffj~'. ,. 0
0.30
c
21~·~ "-. b
150
50
",.
~r ·bj.
o
_. .,(\/l
:~~
0
.,,/
0.24 0.18
0.38
6a
0.73
c
b
d '\-
X· .--. 0_0
0---:'1
./
L...........I
postur.
_.
er
0.56 0.47 0.25
L...........I
L...........I
L----I
0-
....-".ac . .
pe ••ce. 20 ... / _ ' "
tU 120-'50 ~/da.,
N. 120-150 ",eq/da,
Na 350 meq Id.,
3d.,.
.dayl
/\-/
r/I'j
10/
/
11--
eo.te 4
-v~. 7.2 ........ /
\,
cO. HI- O.S"
./
c
,...,....---_..... /
5.0/\-'
PIIA cO.•
0200
/-
