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Copeptin Under Glucagon Stimulation

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Copeptin Under Glucagon Stimulation Endocrine (2016) 52:344–351 DOI 10.1007/s12020-015-0783-7 ORIGINAL ARTICLE Copeptin under glucagon stimulation 1 1 1 Krzysztof C. Lewandowski • Andrzej Lewin´ski • Elzbieta_ Skowron´ska-Jo´z´wiak • 2 3 4,5 Magdalena Stasiak • Wojciech Horzelski • Georg Brabant Received: 8 August 2015 / Accepted: 20 October 2015 / Published online: 17 November 2015 Ó The Author(s) 2015. This article is published with open access at Springerlink.com Abstract Stimulation of growth hormone (GH) and patients with intact pituitary function but not in hypopitu- adrenocorticotropic hormone (ACTH) secretion by gluca- itarism. Copeptin concentrations were stimulated over time gon is a standard procedure to assess pituitary dysfunction and the maximal increment correlated with ACTH, while but the pathomechanism of glucagon action remains correlations between copeptin and GH were weaker. unclear. As arginine vasopressin (AVP) may act on the Interestingly, copeptin as well as GH secretion was sig- release of both, GH and ACTH, we tested here the role of nificantly attenuated when comparing subjects within the AVP in GST by measuring a stable precursor fragment, highest to those in the lowest BMI quartile (p \ 0.05). copeptin, which is stoichiometrically secreted with AVP in Copeptin is significantly released following glucagon a 1:1 ratio. ACTH, cortisol, GH, and copeptin were mea- stimulation. As this release is BMI-dependent, the time- sured at 0, 60, 90, 120, 150, and 180 min during GST in 79 dependent relation between copeptin and GH may be subjects: healthy controls (Group 1, n = 32), subjects with obscured, whereas the close relation to ACTH suggests that pituitary disease, but with adequate cortisol and GH AVP/copeptin release might be linked to the activation of responses during GST (Group 2, n = 29), and those with the adrenal axis. overt hypopituitarism (Group 3, n = 18). Copeptin con- centrations significantly increased over baseline 150 and Keywords Copeptin Á Glucagon stimulation test Á 180 min following glucagon stimulation in controls and Hypopituitarism Á GH Á ACTH Á Cortisol Electronic supplementary material The online version of this article (doi:10.1007/s12020-015-0783-7) contains supplementary Introduction material, which is available to authorized users. & Georg Brabant Copeptin is a 39-amino-acids containing glycosylated [email protected] peptide, derived from the C-terminal part of the AVP precursor [1]. In the process of proteolysis, the AVP pre- 1 Department of Endocrinology and Metabolic Diseases, cursor is processed to AVP, neurophysin II, and copeptin in Medical University of Lodz, Lodz, Poland equimolar amounts. Plasma concentrations of arginine 2 Department of Endocrinology and Metabolic Diseases, Polish vasopressin are technically difficult to determine due to the Mother’s Memorial Hospital - Research Institute, Lodz, small molecular size and its binding to platelets. In contrast Poland 3 to AVP, copeptin remains stable for several days at room Faculty of Mathematics and Computer Science, University of temperature in serum or plasma [2]. Copeptin serves as a Lodz, Lodz, Poland bona fide 4 biomarker of AVP release based on large studies Experimental and Clinical Endocrinology Med Clinic I, and is very useful in the diagnosis of diabetes insipidus [3]. University of Luebeck, Ratzeburger Allee 160, 23538 Lu¨beck, Germany In particular, copeptin concentrations 45 min after injec- tion of insulin during an insulin tolerance test (ITT) pro- 5 Department of Endocrinology, The Christie Manchester Academic Health Science Centre, Wilmslow Rd, vide the best sensitivity and specificity for detection of Manchester M20 4BX, UK diabetes insipidus [4]. 123 Endocrine (2016) 52:344–351 345 AVP is involved not only in hemodynamics and insipidus), 1 of lymphocytic hypophysitis, 5 of acromegaly osmoregulation, but also in the endocrine stress response. (1 still active, postsurgery), 1 of isolated childhood-onset Corticotrophin-releasing hormone (CRH) and AVP appear GH deficiency, and 1 of isolated central diabetes insipidus, to have a synergistic effect resulting in ACTH and cortisol while the remaining (n = 16) had non-secreting pituitary release [5, 6]. That is why measurements of copeptin have adenomas. Clinical diagnoses in patients from Group 3 been proposed as a prognostic marker in an emergency included craniopharyngioma (n = 3), dysgerminoma situation, particularly in patients with acute diseases such (n = 2), macroprolactinoma (n = 2), ACTH-secreting as lower respiratory tract infection, heart disease, and pituitary adenoma (cured, n = 1), acromegaly (cured, stroke [7, 8]. Moreover, copeptin measurements seem to n = 1), Prader-Willy syndrome (n = 1), steroid-induced offer many advantages, being not very demanding or time- adrenal suppression (n = 1), and non-functioning pituitary consuming, while at the same time being reliable and adenomas (n = 7). Patients with hypopituitarism (all from reproducible [8]. Hence, there are studies, where the Group 3) received hormone replacement therapy depend- authors suggested that stimulatory effects of AVP (as ing on the magnitude of the defect. This included hydro- assessed by copeptin measurements) might be useful not cortisone (n = 14), L-thyroxine (n = 12), intramuscular only in testing for diabetes insipidus [4]. In addition, it may testosterone (n = 2), or oestrogens ± progestin (n = 3). also be useful in the assessment of anterior pituitary As treatment with GH is not covered by the Polish state function as shown by a significant copeptin stimulation insurance, none of the patients where GH substituted. The following insulin induced hypoglycemia in a standard ITT average time after pituitary surgery ranged between [17]. Alternatively GST is used as a safe, reliable, and 4 months and 10 years. There were no significant age reproducible replacement to ITT to assess GH and differences between groups apart from a slightly increased ACTH/cortisol secretion. Currently, the underlying path- BMI in patients with a history of pituitary disease (age: omechanism for the glucagon-dependent stimulation of Group 1: 34.6 ± 14.4 years, Group 2: 40.7 ± 11.7 years, anterior pituitary hormone release is unknown [9, 10]. As Group 3: 43.5 ± 13.6 years, p = 0.141; BMI: Group 1: glucagon is rapidly increased following insulin-dependent 23.3 ± 4.7 kg/m2, Group 2: 25.9 ± 4.5 kg/m2, Group 3: hypoglycemia, we tested in the current study the hypothesis 26.9 ± 7.0 kg/m2, p = 0.041, difference significant that a glucagon challenge may stimulate copeptin release between Group 1 and 3 only). and explain at least in part the ACTH/cortisol and GH response in GST. Glucagon test protocol All our patients were normotensive and subjected an Patients and methods identical external stress, i.e., glucagon stimulation test was performed in the hospital setting in the morning on the The study involved 79 subjects (16 males), who had a GST second day of admission. All had normal renal function. performed in order to assess ACTH, cortisol, GH and GST was started at 8 am in a fasting state. Glucagon was copeptin secretion. The test involved measurements of administered intramuscularly at a dose of 1.0 mg (and ACTH, cortisol, GH, copeptin, and glucose before and after 1.5 mg for those over 90 kg). Blood samples were taken intramuscular administration of glucagon. The study group before i.m. glucagon (0 min), and subsequently at 60, 90, was further subdivided into healthy controls (Group 1, 120, 150, and 180 min. Exclusion criteria to GST included n = 32) and patients with various forms of pituitary dis- diabetes mellitus and hyponatremia (plasma Sodium below ease. According to their results in the GST, we further 136 mmol/l). The cutoff value for a successful GST was subdivided the patient group into subjects with satisfactory defined as [3 ng GH/ml and [450 nmol cortisol/l cortisol and GH responses (Group 2, n = 29), and those (16.25 lg/dl) [10, 11]. who failed GST with regard either to GH, or cortisol secretion, or to both (Group 3, n = 18). Finally, from Assays patients in Group 3, we selected subjects with diabetes insipidus (Group 3_A, n = 8), i.e., individuals displaying Measurements of cortisol and other hormones including both anterior and posterior pituitary dysfunctions. Diag- free T4, free T3, TSH, LH, FSH, prolactin, testosterone, noses of patients in groups 2 and 3 (n = 47 in total) and oestradiol were performed by immunoassays on Roche included predominantly non-secreting pituitary macroade- Diagnostics COBAS e601 platform, while GH and ACTH nomas after pituitary surgery. In Group 2, two patients were measured by immunoassays on Siemens IMMULITE suffered of an ACTH-secreting pituitary adenoma (cured), 2000 XPi platform. Copeptin was measured with a new 2 of macroprolactinomas (controlled on dopamine ago- sandwich immunoassay, as described before [2, 12]. This nists), 1 of traumatic brain injury (without diabetes assay has a lower detection limit of 0.4 pmol/l; functional 123 346 Endocrine (2016) 52:344–351 assay sensitivity at \20 % interassay CV, \1 pmol/l [2]. Table). In Group 2 and 3, no significant correlation was All samples were assayed as a batch analyzed in one run by found, and in none of these analyses, GH was significantly courtesy of ThermoFisher Scientific, Hennigdorf, altered. Interestingly, when all patients with normal pos- Germany. terior pituitary function were combined (n = 70), the The study was approved by the Ethics Committee of the maximum copeptin response at 150 min significantly cor- Polish Mothers’ Memorial Research Institute, Lodz, related not only to ACTH (r = 0.317, p = 0.016) and Poland. cortisol (r = 0.405, p = 0.0012) but also to GH (r = 0.36, p = 0.006) and remained significant in a multiple regres- Statistical analysis sion model (r = 0.469 ± 0.0457, p \ 0.0001 for ACTH150 min; r = 0.06992 ± 0.2868, p \ 0.0185 for Statistical analysis was performed by means of MedCalc GH150 min). Software 12.6.1 software.
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