The Journal of Steroid Biochemistry and Molecular Biology
The urinary steroidome of treated children with classic 21-hydroxylase deficiency
Graphical abstract
Introduction
21-Hydroxylase deficiency (21-OHD) is the most common form of congenital adrenal hyperplasia (CAH). 21-OHD is caused by mutations in CYP21A2, the gene encoding the adrenal steroid 21-hydroxylase enzyme (CYP21A2). Inefficient cortisol synthesis in patients with CAH leads to adrenal stimulation, but rather than cortisol, the adrenals produce excess androgen precursors that do not require 21-hydroxylation for their synthesis [1] (Fig. 1).
The aim of treatment of children with classic CAH with glucocorticoids consists in replacing the lack of cortisol and suppressing excess adrenal androgen production. Clinical management of classic CAH is a difficult balance between androgen and cortisol excess [2]. However, monitoring of treatment is difficult in CAH [3]. Laboratory data should indicate the need for dose adjustment. Serum or plasma concentrations of 17α-hydroxyprogesterone (17-OHP), androstenedione and testosterone are currently the most widely used indicators to monitor glucocorticoid treatment [2], [3]; however, biochemical targets of disease control are not well defined and random measurement of plasma concentrations of 17-OHP and androgens on a clinical visit is of only limited value in patients with CAH because it does not reflect a patient’s circadian pattern of adrenal steroid secretion [4], [5].
Analysis of urinary steroid hormone metabolites by gas chromatography–mass spectrometry (GC–MS) (urinary steroidomics) is a non-invasive diagnostic means and provides an overview of the whole spectrum of adrenal steroids in a CAH patient, including glucocorticoid, androgen and 17-OHP metabolites in parallel (Fig. 1). In contrast to the determination of single steroids in a single plasma sample 24-h urinary steroid profile analysis provides an assessment of daily steroid excretion rates [6], [7], [8].
The aim of our study was to analyse retrospectively 24-h urinary steroid metabolite excretion in a large cohort of children with classic CAH due to 21-OHD treated with hydrocortisone and fludrocortisone to characterize their daily excretion pattern of androgen-, 17-OHP-, and cortisol metabolites in the context of their growth and weight gain, and to provide 21-OHD specific reference values. 21-OHD specific reference values could help to classify the individual CAH patient’s urinary steroid metabolome on the basis of a large reference cohort and could be important for research studies in children with CAH.
Section snippets
Patients
Inclusion criteria for our retrospective analysis were: 1.) classic CAH due to 21-OHD. The diagnosis of classic 21-OHD was made on the basis of the characteristic urinary steroid metabolite profile determined by GC–MS analysis with highly elevated concentrations of 17-OHP and 21-deoxycortisol metabolites [8], [9], [10] and of requirement of mineralocorticoid (fludrocortisone) replacement therapy; 2.) oral hydrocortisone given in three divided doses, as the only glucocorticoid replacement
Results
The growth analysis of our CAH cohort demonstrated that the children with 21-OHD started at 3 years of age with a height similar to that of the healthy reference population (Fig. 2A + B; Table 2). Thereafter, children with CAH exhibited an increased height velocity during prepubertal age. This was much more pronounced in boys. Boys reached their maximum height-SDS at about 10 years and girls at about 6 years of age. The period of increased height gain was then followed by a substantial loss of
Discussion
This study characterizes the urinary steroid metabolome of children with classic CAH due to 21-OHD treated with oral hydrocortisone and fludrocortisone, including the daily urinary excretion of cortisol-, 17-OHP- and androgen metabolites in combination with their growth and weight development.
The growth of the children of our cohort indicated that children with CAH exhibit a prepubertal overgrowth, while the pubertal growth spurt is diminished, a finding reported by others as well [26], [27],
Disclosure
The authors have nothing to disclose.
Acknowledgements
We thank Dr. Adrian Sewell for correcting and reading the manuscript. We thank B. Wardega, C. Gregor and L. Hamann for their support in the laboratory. We are indebted to Prof. Dr. T. Remer and Dr. L Shi, Institute of Nutritional and Food Sciences, University of Bonn, for their analysis of the references of daily 11β-hydroxyandrosterone of healthy children.
References (38)
- et al.
Gas chromatography/mass spectrometry (GC/MS) remains a pre-eminent discovery tool in clinical steroid investigations even in the era of fast liquid chromatography tandem mass spectrometry (LC/MS/MS)
J. Steroid Biochem. Mol. Biol.
(2010) Mass spectrometry in the diagnosis of steroid related disorders and in hypertension research
J. Steroid Biochem. Mol. Biol.
(1993)Congenital adrenal hyperplasia caused by defect in steroid 21-hydroxylase. Establishment of definitive urinary steroid excretion pattern during first weeks of life
Clin. Chim. Acta
(1976)- et al.
11β-Hydroxyandrostenedione: downstream metabolism by 11βHSD, 17βHSD and SRD5A produces novel substrates in familiar pathways
Mol. Cell. Endocrinol.
(2015) - et al.
11β-Hydroxydihydrotestosterone and 11-ketodihydrotestosterone, novel C19 steroids with androgenic activity: a putative role in castration resistant prostate cancer
Mol. Cell. Endocrinol.
(2013) - et al.
Cortisol production rate in childhood and adolescence
J. Pediatr.
(1990) - et al.
Urinary free cortisol values in normal children and adolescents
J. Pediatr.
(1991) - et al.
Height outcome in congenital adrenal hyperplasia caused by 21-hydroxylase deficiency: a meta-analysis
J. Pediatr.
(2001) - et al.
Canadian Pediatric Endocrine Group: indicators of adult height outcome in classical 21-hydroxylase deficiency congenital adrenal hyperplasia
J. Pediatr.
(2002) - et al.
Congenital adrenal hyperplasia due to 21-hydroxylase deficiency
Endocr. Rev.
(2000)
Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: an Endocrine Society Clinical Practice Guideline
J. Clin. Endocrinol. Metab.
Monitoring of therapy in congenital adrenal hyperplasia
Clin. Chem.
Circadian patterns of plasma cortisol, 17-hydroxyprogesterone, and testosterone in congenital adrenal hyperplasia
Arch. Dis. Child.
Circadian variation in plasma 17-hydroxyprogesterone in patients with congenital adrenal hyperplasia
Arch. Dis. Child.
Gas chromatography-mass spectrometry profiling of steroids in times of molecular biology
Horm. Metab. Res.
Hormonal diagnosis of 21-hydroxylase deficiency in plasma and urine of neonates using bench top gas chromatography-mass spectrometry
J. Endocrinol.
Referenzperzentile für anthropometrische Maßzahlen und Blutdruck aus der Studie zur Gesundheit von Kindern und Jugendlichen in Deutschland (KiGGS)
Smoothing reference centile curves: the LMS method and penalized likelihood
Stat. Med.
Sexual dimorphism in cortisol secretion starts after age 10 in healthy children: urinary cortisol metabolite excretion rates during growth
Am. J. Physiol. Endocrinol. Metab.
Cited by (25)
Metabotypes of congenital adrenal hyperplasia in infants determined by gas chromatography-mass spectrometry in spot urine
2023, Journal of Steroid Biochemistry and Molecular BiologyInvestigating the biosynthesis and metabolism of 11β-hydroxyandrostenedione
2023, Methods in EnzymologyBack where it belongs: 11β-hydroxyandrostenedione compels the re-assessment of C11-oxy androgens in steroidogenesis
2021, Molecular and Cellular EndocrinologyCitation Excerpt :Of note is that hydrocortisone treatment resulted in adrenarche being impaired. In addition, data showed that besides A4, 21dF also contributed to 11OHAn levels (Kamrath et al., 2017, 2018) which our in vitro studies have confirmed with 21dF as well as 11OHP4, 11KP4 and 21dE, showing conversion to C11-oxy C19 steroids by steroidogenic enzymes in the backdoor pathway (Barnard et al., 2017; van Rooyen et al., 2018, 2020; Gent et al., 2019a). Key earlier investigations undertaken into steroid metabolism in 21OHD neonates had already identified intermediate metabolites evident of inactivation by liver P450 enzymes.
Targeted LC–MS/MS analysis of steroid glucuronides in human urine
2021, Journal of Steroid Biochemistry and Molecular BiologyUrinary GC–MS steroid metabotyping in treated children with congenital adrenal hyperplasia.
2020, Metabolism: Clinical and ExperimentalCitation Excerpt :The simultaneous quantification of daily cortisol-, 17OHP-and androgen metabolite excretion thus enables to find the right hydrocortisone dose for the patient and to reduce both over and under treatment. This is of eminent importance for the patient, since both overdosing and underdosing of hydrocortisone could lead to long-term negative consequences for the patient [1–4]. Additionally, we could identify a fourth metabotype.
Urinary steroidomic profiles by LC-MS/MS to monitor classic 21-Hydroxylase deficiency
2020, Journal of Steroid Biochemistry and Molecular Biology
- 1
Both authors contributed equally to this work.