Past attempts to test suppressibility of pituitary-adrenal function by the use of exogenous corticoids have yielded inconsistent findings in patients with Cushing's syndrome. The present study indicates that, with proper selection of suppress]ve agent and adjustment of dosage, valuable diagnostic information can be obtained from such tests. A a -9a!-Fluorocortisol (AFF) and its 16o:-methylated analog (dexamethasone) were employed as suppressive agents. At dosage levels of 0.5 mg. every six hours for 8 doses these agents induced almost complete suppression of 17-hydroxycorticoid excretion in all 54 endocrinologically normal subjects tested. In contrast, all 35 of the patients with true Cushing's syndrome who were studied maintained relatively high urinary 17-hydroxycorticoid levels during such treatment. At these low dosages, therefore, the suppressive agents were useful in separating patients with Cushing's syndrome from those with normal adrenal function. Administration of AFF or dexamethasone in larger dosages of 2.0 mg. every six hours for 8 doses was used to separate patients with ACTH-dependent hyperadrenocorticism from those with autonomously functioning adrenal tissue. In response to large doses of suppressive agents, all patients with bilateral adrenocortical hypersecretion exhibited a definite decrease in 17-hydroxycorticoid excretion, whereas patients with adrenocortical tumors did not. The results support the view that the primary disorder in Cushing's syndrome with bilateral adrenocortical hypersecretion involves alteration of pituitary function in such a way that ACTH secretion is not suppressed by normal levels of cortisol.

Plasma ACTH and 17-hydroxycorticosteroid concentrations were measured at various intervals in patients recovering from prolonged pituitary suppression. Pituitary-adrenal recovery was found to follow a definite pattern requiring several months for completion. Initially, both ACTH and corticosteroid levels were relatively low, a situation similar to that seen in patients with hypopituitarism. Thereafter, plasma ACTH levels gradually increased until they were supernormal, but there was a lag of several

A B S T R A C T The effects of parathyroid hormone (PTH) on plasma and urinary adenosine 3',5'-monophosphate (cyclic AMP) levels were studied in normal subjects. Under basal conditions normal adults have plasma concentrations of cyclic AMP ranging from 10 to 25 nmoles/liter and excrete from 1.5 to 5 imoles of cyclic AMP per g of urinary creatinine. About one-half to two-thirds of the cyclic AMP excreted in the urine is derived from the plasma by glomerular filtration, and the remainder is produced by the kidney. Renal production of cyclic AMP is partly under the control of PTH. It can be suppressed by infusions of calcium and stimulated by infusions of the calcium chelating agent, EDTA. Infusions of PTH in doses up to 10 mU/kg per min were associated with dose-related increases both in urinary cyclic AMP and phosphate. Infusions of PTH in doses ranging from 20 to 80 mU/kg per min did not lead to any further increase in phosphaturia but did lead to further marked increases in urinary cyclic AMP. A modest increase in plasma cyclic AMP was noted when PTH was infused at 40 mU/kg per min. Anephric patients failed to show appreciable increases in plasma cyclic AMP in response to large doses of PTH but did show expected increases in response to glucagon. Surgical removal of parathyroid adenomas from nine patients with primary hyperparathyroidism was invariably followed by a decrease in urinary cyclic This work was presented in part at the 61st Annual

A B S T R A C T Kinetic parameters and the renal clearances of plasma adenosine 3',5'-monophosphate (cyclic AMP) and guanosine 3',5'-monophosphate (cyclic GMP) were evaluated in normal subjects using tritium-labeled cyclic nucleotides. Each tracer was administered both by single, rapid intravenous injection and by constant intravenous infusion, and the specific activities of the cyclic nucleotides in plasma and urine were determined.Both cyclic AMP and cyclic GMP were cleared from plasma by glomerular filtration. The kidney was found to add a variable quantity of endogenous cyclic AMP to the tubular urine, amounting to an average of approximately one-third of the total level of cyclic AMP excreted. Plasma was the source of virtually all of the cyclic GMP excreted.Plasma levels of the cyclic nucleotides appeared to be in dynamic steady state. The apparent volumes of distribution of both nucleotides exceeded extracellular fluid volume, averaging 27 and 38% of body weight for cyclic AMP and cyclic GMP, respectively. Plasma production rates ranged from 9 to 17 nmoles/min for cyclic AMP and from 7 to 13 nnmoles/min for cyclic GMP. Plasma clearance rates averaged 668 mln/in for cyclic AMP and 855 ml/min for cyclic GMP. Approximately 85% of the elimination of the cyclic nucleotides from the circulation was due to extrarenal clearance.These studies were presented in part at the Annual Meeting of the Southern Society for Clinical Investigation, New Orleans, La., January, 1970. Clin. Res. 18: 73. (Abstr.) INTRODUCTION Adenosine 3',5'-monophosphate (cyclic AMP) and guanosine 3',5'-monophosphate (cyclic GMP) were identified in urine several years ago (1-3), but definitive studies concerning the sources of the excreted cyclic nucleotides have not been reported. Cyclic AMP has been found in dog plasma (1), and we have identified both cyclic nucleotides in human plasma, raising the possibility that renal plasma clearance could account for at least a portion of the cyclic nucleotides excreted into the urine. Two hormones known to stimulate renal adenyl cyclase systems (4) have been reported to increase cyclic AMP excretion (5, 6) suggesting the kidney as a source of urinary cyclic AMP. Similarly, the kidney has been suggested as a source of urinary cyclic GMP (7). In the absence of definitive clearance studies, it has not been possible to know whether the cyclic nucleotides in urine are derived solely from the kidney, solely from plasma, or both from plasma and from the kidney.The present studies were designed to evaluate the renal clearances as well as other kinetic parameters of the extracellular cyclic nucleotides. Tracer doses of tritiumlabeled cyclic nucleotides were administered to human subjects by rapid intravenous injection and by constant intravenous infusion. Specific radioactivity determinations of the cyclic nucleotides in plasma and urine provided information regarding the sources of cyclic AMP and cyclic GMP excreted into the urine. The effects of certain hormones on plasma and urinary cyclic nucleotides are repo...

Summary. Several lines of evidence have been developed indicating that the sympathetic nervous system may play a role in mediating the renal and adrenocortical secretary responses to upright posture and sodium deprivation. Despite concurrent increases in arterial blood pressure, the plasma renin activity of normal subjects increased both in response to the infusion of catecholamines (norepinephrine: epinephrine, 10: 1) and in response to stimulation of the sympathetic nervous system by cold. Aldosterone excretion was also increased by catecholamine infusion. In normal subjects the stimuli of upright posture and of sodium depletion both resulted in increases in urinary catecholamines, plasma renin activity, and urinary aldosterone. A patient with severe autonomic insufficiency did not experience normal elevations of urinary catecholamines, plasma renin activity, or urinary aldosterone in response to upright posture or sodium deprivation, despite a substantial fall in arterial blood pressure. When orthostatic hypotension was prevented by infusion of catecholamines, however, increases in plasma renin activity and in aldosterone excretion were observed.We suggest that both upright posture and sodium depletion lead to decreases in effective plasma volume and increases in sympathetic nervous system activity. This increase in sympathetic activity is then responsible for an increase in renal afferent arteriolar constriction, leading to an increase in renin secretion and, ultimately, an increase in aldosterone secretion.

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