Addison's disease laboratory findings: Difference between revisions
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{{Addison's disease}} | {{Addison's disease}} | ||
{{CMG}} | {{CMG}} ; {{AE}} {{ADG}} | ||
==Overview== | |||
Diagnosis of Addison's disease is made by routine blood tests and specific tests. [[ACTH]] stimulation test is a specific test employed to determine the function of adrenal glands and to diagnose Addison's disease. The prominent finding of a rapid ACTH stimulation test includes failure of [[cortisol]] to rise in response to [[ACTH]] injection. Other routine [[laboratory]] tests employed include plasma [[cortisol]] level, serum [[ACTH]] level, [[plasma renin activity]], [[aldosterone]] levels and serum biochemistry. | |||
==Laboratory Findings== | ==Laboratory Findings== | ||
Diagnosis of Addison's disease is made by routine blood tests and specific tests. The aim of these tests is to determine the levels of [[cortisol]] and then to establish the cause of deficiency.<ref name="pmid20399314">{{cite journal |vauthors=Chakera AJ, Vaidya B |title=Addison disease in adults: diagnosis and management |journal=Am. J. Med. |volume=123 |issue=5 |pages=409–13 |year=2010 |pmid=20399314 |doi=10.1016/j.amjmed.2009.12.017 |url=}}</ref><ref name="pmid24330030">{{cite journal |vauthors=Husebye ES, Allolio B, Arlt W, Badenhoop K, Bensing S, Betterle C, Falorni A, Gan EH, Hulting AL, Kasperlik-Zaluska A, Kämpe O, Løvås K, Meyer G, Pearce SH |title=Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency |journal=J. Intern. Med. |volume=275 |issue=2 |pages=104–15 |year=2014 |pmid=24330030 |doi=10.1111/joim.12162 |url=}}</ref><ref name="pmid23893277">{{cite journal |vauthors=Puttanna A, Cunningham AR, Dainty P |title=Addison's disease and its associations |journal=BMJ Case Rep |volume=2013 |issue= |pages= |year=2013 |pmid=23893277 |pmc=3736622 |doi=10.1136/bcr-2013-010473 |url=}}</ref> | |||
*Specific tests to determine the function of [[adrenal glands]] include: | |||
*Specific tests to determine the function of adrenal glands include: | **[[ACTH]] stimulation test | ||
**ACTH | **[[CRH]] stimulation test | ||
**CRH | |||
*Routine blood tests | *Routine blood tests | ||
**Plasma [[cortisol level]] | |||
**Serum [[ACTH]] level | |||
**Plasma cortisol level | **[[Plasma renin activity]] and [[aldosterone]] levels | ||
**Serum ACTH level | **[[Serum biochemistry]] | ||
**Plasma renin activity and aldosterone levels | |||
**Serum biochemistry | |||
===Diagnostic decision=== | ===Diagnostic decision=== | ||
{| class="wikitable" | {| class="wikitable" | ||
Line 24: | Line 23: | ||
|Non-acute | |Non-acute | ||
| | | | ||
* 8AM cortisol | * 8AM [[cortisol]] | ||
|- | |- | ||
|Acute illness | |Acute illness | ||
| | | | ||
* Random plasma cortisol and ACTH levels | * Random plasma [[cortisol]] and [[ACTH]] levels | ||
* Followed by cortisol levels 30 and 60 minutes after cosyntropin administration. | * Followed by [[cortisol]] levels 30 and 60 minutes after [[cosyntropin]] administration. | ||
|} | |} | ||
==Specific tests to determine adrenal gland function== | ==Specific tests to determine adrenal gland function== | ||
===ACTH Stimulation Test (Rapid ACTH Stimulation Test)=== | ===ACTH Stimulation Test (Rapid ACTH Stimulation Test)=== | ||
*This is the most specific test for diagnosing Addison's disease. | *This is the most specific test for diagnosing Addison's disease. | ||
*In this test, blood cortisol, urine cortisol, or both are measured before and after a synthetic form of ACTH is given by injection. | *In this test, blood [[cortisol]], urine [[cortisol]], or both are measured before and after a synthetic form of [[ACTH]] is given by injection. | ||
*It is called short, or rapid | *It is called short, or rapid [[ACTH]] test because measurement of [[cortisol]] in blood is repeated 30 to 60 minutes after an intravenous [[ACTH]] injection. | ||
*250 µg synthetic ACTH (cosyntropin) is administered intravenously or intramuscularly. | *250 µg synthetic [[ACTH]] ([[cosyntropin]]) is administered [[intravenously]] or [[intramuscularly]]. | ||
*The normal response after an injection of ACTH is a rise in blood and urine cortisol levels. | *The normal response after an injection of [[ACTH]] is a rise in blood and urine [[cortisol]] levels. | ||
* Those with primary adrenal insufficiency fail to increase cortisol levels above 18 µg/dL; those with secondary or tertiary adrenal insufficiency also fail to achieve cortisol levels above 18 µg/dL as long as their condition has been present long enough to allow adrenal atrophy (about 2-4 weeks). | * Those with primary adrenal insufficiency fail to increase [[cortisol]] levels above 18 µg/dL; those with secondary or tertiary adrenal insufficiency also fail to achieve [[cortisol]] levels above 18 µg/dL as long as their condition has been present long enough to allow [[adrenal atrophy]] (about 2-4 weeks). | ||
* If a subnormal cortisol response occurs, ACTH measurement and other tests should distinguish between primary and secondary and tertiary causes | * If a subnormal [[cortisol]] response occurs, [[ACTH]] measurement and other tests should distinguish between primary and secondary and tertiary causes | ||
* Patients with either form of adrenal insufficiency respond poorly or do not respond at all. | * Patients with either form of adrenal insufficiency respond poorly or do not respond at all. | ||
Line 69: | Line 69: | ||
===CRH Stimulation Test=== | ===CRH Stimulation Test=== | ||
* When the response to the short ACTH test is abnormal, a "long" CRH stimulation test is required to determine the cause of adrenal insufficiency. | * When the response to the short [[ACTH]] test is abnormal, a "long" [[CRH]] stimulation test is required to determine the cause of adrenal insufficiency. | ||
* In this test, 1 μg synthetic CRH is injected intravenously and blood cortisol is measured before and 30, 60, 90, and 120 minutes after the injection. | * In this test, 1 μg synthetic [[CRH]] is injected intravenously and blood [[cortisol]] is measured before and 30, 60, 90, and 120 minutes after the injection. | ||
* There is some evidence that the low-dose ACTH test is more sensitive than the standard 250 μg test in identifying partial or mild cases of secondary or tertiary adrenal insufficiency | * There is some evidence that the low-dose [[ACTH]] test is more sensitive than the standard 250 μg test in identifying partial or mild cases of secondary or tertiary adrenal insufficiency | ||
* Patients with primary adrenal insufficiency have high ACTHs but do not produce [[cortisol]]. | * Patients with primary adrenal insufficiency have high [[ACTH|ACTHs]] but do not produce [[cortisol]]. | ||
* Patients with secondary adrenal insufficiency have deficient cortisol responses but absent or delayed ACTH responses. | * Patients with secondary adrenal insufficiency have deficient cortisol responses but absent or delayed ACTH responses. | ||
* Absent ACTH response points to the pituitary as the cause; a delayed ACTH response points to the [[hypothalamus]] as the cause. | * Absent [[ACTH]] response points to the [[pituitary]] as the cause; a delayed [[ACTH]] response points to the [[hypothalamus]] as the cause. | ||
== Routine investigations == | |||
Routine investigations include | Routine investigations include | ||
* [[ | *Plasma [[cortisol level]] | ||
* | *Serum [[ACTH]] level | ||
*[[Plasma renin activity]] and [[aldosterone]] levels | |||
*Serum biochemistry | |||
* Serum | |||
{| class="wikitable" | {| class="wikitable" | ||
!Test | !Test | ||
! | !Advantage | ||
!Normal values | !Normal values | ||
!Laboratory Finding | !Laboratory Finding | ||
|- | |- | ||
|Plasma cortisol | |Plasma [[cortisol]] | ||
| | | | ||
* Plasma cortisol: >18 µg/dL at 8<small>AM</small> | * Screening test for adrenal insufficiency | ||
| | |||
* Plasma [[cortisol]]: >18 µg/dL at 8<small>AM</small> | |||
| | | | ||
* <3 µg/dL: suggests evidence of adrenal insufficiency | * <3 µg/dL: suggests evidence of adrenal insufficiency | ||
Line 106: | Line 99: | ||
|- | |- | ||
|Serum ACTH level | |Serum ACTH level | ||
|Helps to distinguish primary from secondary/tertiary adrenal insufficiency | | | ||
* Helps to distinguish primary from secondary/tertiary adrenal insufficiency | |||
| | | | ||
* ACTH: 5-30 ng/mL | * ACTH: 5-30 ng/mL | ||
| | | | ||
* In Addison disease: ACTH elevated (usually >60 ng/mL) in the face of a low or low-normal cortisol | * In Addison disease: [[ACTH]] elevated (usually >60 ng/mL) in the face of a low or low-normal cortisol | ||
* In secondary/tertiary adrenal insufficiency: ACTH is low (usually <5 ng/mL) in the face of low cortisol | * In secondary/tertiary adrenal insufficiency: [[ACTH]] is low (usually <5 ng/mL) in the face of low cortisol | ||
|- | |- | ||
|Plasma renin activity and aldosterone levels | |[[Plasma renin activity]] and [[aldosterone]] levels | ||
| | | | ||
* A compensatory increase in PRA is the earliest response to mild aldosterone deficiency. | * A compensatory increase in PRA is the earliest response to mild [[aldosterone]] deficiency. | ||
| | | | ||
* Normal PA (ng/dL) to PR (ng/mL/h) is less than 20 with plasma aldosterone levels less than 15 ng/dL. | * Normal PA (ng/dL) to PR (ng/mL/h) is less than 20 with plasma [[aldosterone]] levels less than 15 ng/dL. | ||
| | | | ||
* Patients with Addison disease have increased aldosterone levels | * Patients with Addison disease have increased [[aldosterone]] levels | ||
* Plasma renin activity exhibits a compensatory rise | * [[Plasma renin activity]] exhibits a compensatory rise | ||
|- | |- | ||
|Serum biochemistry | |Serum biochemistry | ||
Line 126: | Line 120: | ||
* Simple, widely available test | * Simple, widely available test | ||
| | | | ||
* Sodium: 135-145 mEq/L | * [[Sodium]]: 135-145 mEq/L | ||
* Potassium: 3.8-5.5 mEq/L | * [[Potassium]]: 3.8-5.5 mEq/L | ||
* Chloride: 95-105 mEq/L | * [[Chloride]]: 95-105 mEq/L | ||
* BUN: 8-18 mg/dL | * [[BUN]]: 8-18 mg/dL | ||
* Creatinine: 0.6-1.2 mg/dL | * [[Creatinine]]: 0.6-1.2 mg/dL | ||
|In Addison disease: | |In Addison disease: | ||
* Sodium and chloride levels may be decreased | * [[Sodium]] and [[chloride]] levels may be decreased | ||
* Potassium levels may be increased | * [[Potassium]] levels may be increased | ||
* BUN-to-creatinine ratio may be increased (prerenal azotemia) | * [[BUN]]-to-[[creatinine]] ratio may be increased (prerenal azotemia) | ||
* Mild non–anion-gap [[metabolic acidosis]] | |||
|} | |} | ||
Latest revision as of 13:14, 12 October 2017
Addison's disease Microchapters |
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Addison's disease laboratory findings On the Web |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
Diagnosis of Addison's disease is made by routine blood tests and specific tests. ACTH stimulation test is a specific test employed to determine the function of adrenal glands and to diagnose Addison's disease. The prominent finding of a rapid ACTH stimulation test includes failure of cortisol to rise in response to ACTH injection. Other routine laboratory tests employed include plasma cortisol level, serum ACTH level, plasma renin activity, aldosterone levels and serum biochemistry.
Laboratory Findings
Diagnosis of Addison's disease is made by routine blood tests and specific tests. The aim of these tests is to determine the levels of cortisol and then to establish the cause of deficiency.[1][2][3]
- Specific tests to determine the function of adrenal glands include:
- Routine blood tests
- Plasma cortisol level
- Serum ACTH level
- Plasma renin activity and aldosterone levels
- Serum biochemistry
Diagnostic decision
Clinical setting | Best initial test |
---|---|
Non-acute |
|
Acute illness |
|
Specific tests to determine adrenal gland function
ACTH Stimulation Test (Rapid ACTH Stimulation Test)
- This is the most specific test for diagnosing Addison's disease.
- In this test, blood cortisol, urine cortisol, or both are measured before and after a synthetic form of ACTH is given by injection.
- It is called short, or rapid ACTH test because measurement of cortisol in blood is repeated 30 to 60 minutes after an intravenous ACTH injection.
- 250 µg synthetic ACTH (cosyntropin) is administered intravenously or intramuscularly.
- The normal response after an injection of ACTH is a rise in blood and urine cortisol levels.
- Those with primary adrenal insufficiency fail to increase cortisol levels above 18 µg/dL; those with secondary or tertiary adrenal insufficiency also fail to achieve cortisol levels above 18 µg/dL as long as their condition has been present long enough to allow adrenal atrophy (about 2-4 weeks).
- If a subnormal cortisol response occurs, ACTH measurement and other tests should distinguish between primary and secondary and tertiary causes
- Patients with either form of adrenal insufficiency respond poorly or do not respond at all.
8 am cortisol | |||||||||||||||||||||||||||||||||||||||||||
>15Ug/dL | 3-15Ug/dL | <3Ug/dL | |||||||||||||||||||||||||||||||||||||||||
Adrenal insufficiency is ruled out | Measure ACTH | ||||||||||||||||||||||||||||||||||||||||||
30 min cortisol during cosyntropin stimulation test | |||||||||||||||||||||||||||||||||||||||||||
>18Ug/dL | <18Ug/dL | ||||||||||||||||||||||||||||||||||||||||||
Adrenal insufficiency is ruled out | |||||||||||||||||||||||||||||||||||||||||||
Adrenal insufficiency confirmed | |||||||||||||||||||||||||||||||||||||||||||
Measure ACTH | |||||||||||||||||||||||||||||||||||||||||||
Low/normal | Elevated | ||||||||||||||||||||||||||||||||||||||||||
Secondary Adrenal insufficiency | Primary Adrenal insufficiency | ||||||||||||||||||||||||||||||||||||||||||
CRH Stimulation Test
- When the response to the short ACTH test is abnormal, a "long" CRH stimulation test is required to determine the cause of adrenal insufficiency.
- In this test, 1 μg synthetic CRH is injected intravenously and blood cortisol is measured before and 30, 60, 90, and 120 minutes after the injection.
- There is some evidence that the low-dose ACTH test is more sensitive than the standard 250 μg test in identifying partial or mild cases of secondary or tertiary adrenal insufficiency
- Patients with primary adrenal insufficiency have high ACTHs but do not produce cortisol.
- Patients with secondary adrenal insufficiency have deficient cortisol responses but absent or delayed ACTH responses.
- Absent ACTH response points to the pituitary as the cause; a delayed ACTH response points to the hypothalamus as the cause.
Routine investigations
Routine investigations include
- Plasma cortisol level
- Serum ACTH level
- Plasma renin activity and aldosterone levels
- Serum biochemistry
Test | Advantage | Normal values | Laboratory Finding |
---|---|---|---|
Plasma cortisol |
|
|
|
Serum ACTH level |
|
|
|
Plasma renin activity and aldosterone levels |
|
|
|
Serum biochemistry |
|
|
In Addison disease:
|
References
- ↑ Chakera AJ, Vaidya B (2010). "Addison disease in adults: diagnosis and management". Am. J. Med. 123 (5): 409–13. doi:10.1016/j.amjmed.2009.12.017. PMID 20399314.
- ↑ Husebye ES, Allolio B, Arlt W, Badenhoop K, Bensing S, Betterle C, Falorni A, Gan EH, Hulting AL, Kasperlik-Zaluska A, Kämpe O, Løvås K, Meyer G, Pearce SH (2014). "Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency". J. Intern. Med. 275 (2): 104–15. doi:10.1111/joim.12162. PMID 24330030.
- ↑ Puttanna A, Cunningham AR, Dainty P (2013). "Addison's disease and its associations". BMJ Case Rep. 2013. doi:10.1136/bcr-2013-010473. PMC 3736622. PMID 23893277.