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commit 5b4d4872efaa7d941ee9af6e2dd623808d972608
parent 75cb65f38a386cbecee2ce195e92bf0e71e46956
Author: Beau <cbeauhilton@gmail.com>
Date:   Thu, 28 Oct 2021 10:56:36 -0500

aldo lecture

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learn/2021-10-28-adrenal-disorders.md
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+# Adrenal disorders
+
+Dr Mona Mashayekhi MD, PhD
+
+---
+
+## Overview of adrenal insufficiency
+
+|          | ACTH | Cortisol | Aldosterone | Renin | DHEA       |   Na   |  K  |  ACTH stim  |
+|----------|------|----------|-------------|-------|------------|--------|-----|-------------|
+| Primary  | high |   low    | low         | high  | low        | low    |high | nonreactive |
+| Central  | low  |   low    | wnl         | wnl   | low-normal*| low**  | wnl | reactive $  |
+
+
+\* DHEA has some response to ACTH
+\*\* via DDAVP, less extreme hypoNa compared to primary
+$ if longstanding central process, ACTH stim will *not* be normal d/t atrophy
+
+Sheehan - ACTH zero, cortisol zero, ACTH stim will be normal (no time yet for atrophy)
+
+
+## Primary adrenal insufficiency
+
+post-op, infx, hemorrhage, mets, autoimmune
+
+## Secondary adrenal insufficiency (central)
+
+
+E.g. chronic steroids (causes 1, 2, 3 of AI are iatrogenic d/t steroid use), Sheehans
+
+
+### Sx
+
+ACTH cleaved to POMC, melanocortin -> hyperpigmentation (palms more specific)
+
+Electrolyte abnormalities - aldosterone problems (ENAC -> K up, Na down, also some vessel tonicity -> HoTN)
+
+
+### Primary AI tx
+
+Prefer hydrocortisone, 
+as has short half-life and allows closer mimicry of physiologic levels. 
+Higher AM dose, lower PM dose.
+
+Relative half-lives and physiologic doses of steroids:
+
+|       | dose        | t 1/2 |
+|-------|-------------|-------|
+| dex   | 0.25mg      | +++   |
+| pred  | 4mg         | ++    |
+| hydro | ?           | +     |
+
+
+---
+
+
+## Primary hyperaldosteronism
+
+Common, should suspect if low K and resistant HTN.
+
+Many BP meds modulate HPA axis in some way or another, 
+practically only MRAs are considered sufficiently problematic to interfere with standard testing.
+
+Start with aldo/renin ratio.
+
+### Primary hyperaldosteronism tx
+
+Primary therapy is surgical.
+
+MRA therapy can be helpful, 
+but does not prevent other effect of unopposed aldosterone (e.g. cardiac),
+so preferred when pts are not surgical candidates.
+
+For maximum effectiveness, titrate MRA dose to level of renin.
+
+Adrenal venous sampling (AVS) - done by interventional radiology, highly specialized even within IR.
+
+So some places, if <40yo, will just use CT evidence of nodule to justify removal. 
+(if >40yo, high  likelihood of benign adenoma)