Division of Clinical and Molecular Endocrinology, Louis Stokes Cleveland Veterans Medical Center, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.
Endocr Pract. 2011 Mar-Apr;17(2):261-70. doi: 10.4158/EP10262.RA.
To review biochemical tests used in establishing the challenging diagnosis of adrenal insufficiency.
We reviewed the relevant literature, including our own data, on various biochemical tests used to determine adrenal function. The advantages and limitations of each approach are discussed.
Baseline measurements of serum cortisol are helpful only when they are very low (≤ 5 μg/dL) or clearly elevated, whereas baseline plasma adrenocorticotropic hormone levels are helpful only when primary adrenal insufficiency is suspected. Measurements of baseline serum dehydroepiandrosterone sulfate (DHEA-S) levels are valuable in patients suspected of having adrenal insufficiency. Although serum DHEA-S levels are low in patients with primary or central adrenal insufficiency, a low level of this steroid is not sufficient by itself for establishing the diagnosis. A normal age- and sex-adjusted serum DHEA-S level, however, practically rules out the diagnosis of adrenal insufficiency. Many patients require dynamic biochemical studies, such as the 1-μg cosyntropin test, to assess adrenal function.
In establishing the diagnosis of central adrenal insufficiency, we recommend measurements of baseline serum cortisol and DHEA-S levels. In addition to these, determination of plasma levels of aldosterone, adrenocorticotropic hormone, and renin activity is necessary when primary adrenal insufficiency is suspected. With a random serum cortisol level of ≥ 12 μg/dL in the ambulatory setting or a normal age- and sex-adjusted DHEA-S level (or both), the diagnosis of adrenal insufficiency is extremely unlikely. When serum DHEA-S levels are low or equivocal, however, dynamic testing will be necessary to determine hypothalamic-pituitary-adrenal axis function.
回顾用于确立肾上腺功能不全挑战性诊断的生化检测方法。
我们回顾了各种用于确定肾上腺功能的生化检测的相关文献，包括我们自己的数据。讨论了每种方法的优缺点。
血清皮质醇的基础测量值只有在非常低（≤5μg/dL）或明显升高时才有帮助，而基础血浆促肾上腺皮质激素水平只有在怀疑原发性肾上腺功能不全时才有帮助。怀疑患有肾上腺功能不全的患者，基础血清脱氢表雄酮硫酸酯（DHEA-S）水平的测量值很有价值。尽管原发性或中枢性肾上腺功能不全患者的血清 DHEA-S 水平较低，但这种类固醇水平本身不足以确立诊断。然而，正常的年龄和性别调整后的血清 DHEA-S 水平实际上可以排除肾上腺功能不全的诊断。许多患者需要进行动态生化研究，如 1μg 促皮质素测试，以评估肾上腺功能。
在确立中枢性肾上腺功能不全的诊断时，我们建议测量基础血清皮质醇和 DHEA-S 水平。此外，当怀疑原发性肾上腺功能不全时，还需要测定血浆醛固酮、促肾上腺皮质激素和肾素活性水平。在门诊环境中，随机血清皮质醇水平≥12μg/dL 或正常的年龄和性别调整后的 DHEA-S 水平（或两者），肾上腺功能不全的诊断极不可能。然而，当血清 DHEA-S 水平较低或不确定时，需要进行动态检测以确定下丘脑-垂体-肾上腺轴功能。
