Le choc septique est défini par une hypotension persistante malgré un remplissage vasculaire adéquat en présence d’une réponse inflammatoire systémique suite à une infection. Il est responsable de 10% des admissions en réanimation et malgré des progrès thérapeutiques constants, la mortalité liée au sepsis varie entre 30% et 60% dans les cas de choc septique. Dans 50% des cas, le choc septique est associé à une insuffisance surrénale relative ce qui diminue la probabilité de survie des patients. Les patients sont alors traités avec de l’hydrocortisone et de la fludrocortisone, mais ce traitement est très controversé. Pour la première fois, nous avons pu mettre au point et valider une technique de quantification de la fludrocortisone plasmatique après une prise de 50 μg. Cette technique a pu ensuite être utilisée pour l’obtention de l’étude pharmacocinétique/pharmacodynamique de la fludrocortisone chez le volontaire sain et le patient septique avec insuffisance surrénale relative. Enfin, nous avons étudié la distribution et l’élimination de cette molécule chez la souris saine et deux modèles de sepsis. Les paramètres pharmacocinétiques montrent que la demi-vie de la fludrocortisone est d’environ 1 h, avec un délai d’absorption d’environ 50 minutes. Nos travaux ont permis de mettre en évidence qu’il existe deux populations de patients : les absorbants et les non-absorbants la fludrocortisone, qui représentent 30 % des patients testés, ce qui pourrait être à l’origine de la controverse sur les effets bénéfiques de cette molécule sur la survie des patients. Cependant nous n’avons pu mettre en évidence aucun effet hémodynamique de cette molécule sur les patients septiques. / The septic shock is defined by persistent hypotension despite fluid resuscitation with systemic inflammation due to infection. This is the cause of 10% of the admission in intensive care unit. Despite steady progress in therapeutics, the mortality of patients with sepsis varies between 30% to 60% for a septic shock. In 50%, the septic shock is associated to relative adrenal insufficiency which decrease survival probability of the patients. The patients receive hydrocortisone and fludrocortisone but this treatment is still controversial. For the first time, we developped and validated a quantification method of low concentration fludrocortisone in plasma. This method were used for the pharmacokinetic/pharmacodynamic study of fludrocortisone in healthy volunteers and patients with septic shock associated with relative adrenal insufficiency. Then we studied the distribution and elimination of this molecule in two mice models of sepsis. The pharmacokinetic parameters show that the half-life of fludrocortisone is about 1h and the delay of absorption is about 50min. Our study shows two groups of patients : absorbent patients and non-absorbent patients which have no detectable fludrocortisone concentrations in plasma. This population represents 30% of the population. This could be the reason of the controversial results. No hemodynamic effetc were found in patients with septic shock due to fludrocortisone after low-dosage administration.

Introduction. Les corticoïdes sont supposés avoir des effets bénéfiques à faibles doses chez les patients en choc septique réfractaire. Ces effets ont été retrouvés dans plusieurs études utilisant l’hydrocortisone. Mais des données similaires n’existent cependant pas pour la fludrocortisone. Pourtant, l’hypothèse est que ces effets seraient liés en partie à l’action minéralocorticoïde. Or, la fludrocortisone est considérée comme un puissant minéralocorticoïde. Avant une éventuelle évaluation de la fludrocortisone chez les patients en choc septique, il est nécessaire dans un premier temps d’étudier sa pharmacocinétique (PK) et sa relation pharmacocinétique-pharmacodynamique (PK-PD) afin de mieux cerner ses effets et de sélectionner sa posologie efficace. Méthodes. Pour répondre aux objectifs, plusieurs travaux ont été réalisés. La modélisation en pharmacométrie par approche de population a été utilisée dans ces travaux pour caractériser la PK et la relation PK-PD de la fludrocortisone chez des volontaires sains après administration unique et répétée et la PK chez les patients en choc septique. Résultats. Chez les volontaires sains en administration unique seule ou en association avec l’hydrocortisone, la fludrocortisone a montré une demi-vie courte et proche de celle de l’hydrocortisone. Par ailleurs, la fludrocortisone présentait une puissance de l’effet minéralocorticoïde environ 200 fois plus importante que celle de l’hydrocortisone. Les simulations ont montré que la fludrocortisone nécessiterait d’être administrée à raison de quatre fois par jour. Chez les patients en choc septique, l’absorption de la fludrocortisone était très variable (7/21 des patients n’absorbaient pas la molécule) ce qui suggérait la nécessité de mettre au point une forme administrable par voie intraveineuse. A nouveau chez les volontaires sains mais en administration répétée pendant plusieurs jours, la fludrocortisone a montré une demi-vie et des paramètres pharmacocinétiques semblables à ceux retrouvés lors de la première étude et sur le plan pharmacodynamique, des effets hémodynamiques favorables (sur la réactivité vasculaire, la pression artérielle…) montrés pour la première fois avec cette molécule. Conclusion. La fludrocortisone a montré qu’elle pouvait induire les effets biologiques et hémodynamiques recherchés. Les effets hémodynamiques sur la réactivité vasculaire et la pression artérielle ont été observés après une imprégnation de 5 jours d’administration répétée de la fludrocortisone notamment avec la dose de 400 µg/jour. Une évaluation de l’efficacité de la fludrocortisone chez les patients en choc septique et maintenant envisageable et nécessaire pour confirmer les résultats obtenus. / Introduction. Low doses of corticosteroids showed beneficial effects in septic shock patients. These favorable effects may be partly result from the stimulation of the mineralocorticoid receptors. This finding has led us to explore the pharmacokinetic and the effects on hemodynamic and biologic parameters of fludrocortisone which is a potent mineralocorticoid. Methods. In this work, a population approach modeling (nonlinear mixed effects modeling) was used to characterize the pharmacokinetic and the pharmacokinetic-pharmacodynamic relationship of fludrocortisone in healthy volunteers and the pharmacokinetic in septic shock patients. Results. In healthy volunteers after single oral administration alone or in combination with hydrocortisone, fludrocortisone 50 µg showed a short and similar plasma elimination half-life that intravenous hydrocortisone. Fludrocortisone plasma concentrations and effect on urinary sodium/potassium ratio had a higher inter-individual variability as compared to hydrocortisone. Simulations suggested that the administration regimen of fludrocortisone should be reconsidered. In septic shock patient, a single oral dose of fludrocortisone at 50 µg yielded detectable plasma drug concentrations in two-thirds of adults with septic shock. Fludrocortisone pharmacokinetics showed a short plasma elimination half-life and a large inter-individual variability. These results suggested that an intravenous formulation of fludrocortisone would be useful to reduce its pharmacokinetic variability in septic patients. In healthy volunteers again, after 5 days of repeated oral administration, fludrocortisone improved pressor response to phenylephrine. This effect was observed only at the dose of 400 µg/day, suggesting that fludrocortisone at higher doses than previously administered (50 µg/day) may be useful to be effective. Furthermore, we showed that fludrocortisone had a short plasma half-live (1.94 h) which is consistent with our previously published study. After 5 day of repeated administration, fludrocortisone significantly increased blood pressure. This effect was more marked at the dose of 400 µg/day. Conclusion. Our results argue in favor of potential beneficial effects that fludrocortisone could have in septic shock patients. An evaluation of the effectiveness of fludrocortisone in these patients is now possible and necessary to confirm our results.

Introdução: A sensibilidade ao sal possui implicações clínicas e prognósticas, porém seu diagnóstico não é habitualmente feito na prática clínica, tendo em vista que o teste de referência é longo e de difícil execução, envolvendo ciclos de dietas hipossódica e hipersódica. O objetivo principal do presente estudo foi avaliar a acurácia do teste da fludrocortisona, quando comparado ao teste de referência. O objetivo secundário foi estudar o teste de referência, avaliando em quanto tempo é possível ser realizado o diagnóstico. Métodos: Foi realizado estudo randomizado e crossover com homens e mulheres hipertensos, sem outras comorbidades, de 40 a 65 anos de idade. Após quatro semanas de washout os pacientes foram randomizados para iniciar pelo teste dos ciclos de dietas ou pelo teste da fludrocortisona. O primeiro consistiu na administração de 7 dias de dieta hipossódica (40 mEq/dia) seguidos por 7 dias de dieta hipersódica (200 mEq/dia), sendo considerados sensíveis os indivíduos com variação da pressão arterial média (PAM) superior a 5 mmHg. O segundo consistiu na administração de 0,4 mg / dia do acetato de fludrocortisona por 7 dias, durante ingestão alimentar habitual, sendo avaliada a variação da PAS ou PAM no quarto e sétimo dias do medicamento. O ponto de corte para esta variação foi estudado pela curva ROC, não sendo assumido arbitrariamente. A acurácia do teste foi medida pela área sob a curva ROC. Em relação ao objetivo secundário, foi estudado o comportamento diário da pressão arterial ao longo dos ciclos de dieta, através da MRPA. Resultados: Foram estudados trinta voluntários hipertensos (53,7 ± 7,6 anos; 72 ± 10,6 Kg; 26% negros, 10% pardos e amarelos), sendo 53% classificados como sensíveis pelo teste de referência. No quarto dia de fludrocortisona, as áreas sob a curva ROC (ASROC) foram de 0,761 ± 0,06 (p < 0,001) para a PAS, de 0,646 ± 0,072 (p < 0,05) para a PAM e de 0,554 ± 0,075 (p=0,469) para a Pressão arterial diastólica (PAD). No sétimo dia de fludrocortisona as ASROC foram 0,849 ± 0,05 (p < 0,001); 0,732 ± 0,06 (p=0,002); e 0,63 ± 0,07 (p=0,079) para respectivamente PAS, PAM e PAD. A maior acurácia foi obtida, portanto, no sétimo dia de fludrocortisona, utilizando a PAS como variável. Neste ponto, com o ponto de corte encontrado de 3 mmHg, o teste tem 83% de sensibilidade e 63% de especificidade. Em relação ao estudo do teste de referência, observou-se que não há diferença significante da variação pressórica obtida entre o quarto e sexto dias de dieta. Conclusões: A administração do acetato de Fludrocortisona na dose 0,4 mg/dia durante 7 dias - Teste da Fludrocortisona - pode ser utilizado para diagnóstico de sensibilidade ao sal em indivíduos hipertensos de 40 a 65 anos, não obesos e sem outras comorbidades. Em relação ao teste de referência para sensibilidade ao sal, é possível fazer o diagnóstico com duração de 8 dias, não sendo necessário prolongá-lo / Introduction: The salt sensitivity has clinical and prognostic implications; however, its diagnosis is not done in clinical practice, having in mind that the reference test is long and difficult to perform, involving cycles of hyposodic and high salt diets. The main objective of this study was to evaluate the accuracy of fludrocortisone test, when compared to the reference test. The secondary objective was to study the reference test, evaluating the necessary time for diagnosis to be carried out. Methods: It was perfomed a randomized and crossover study was conducted, with hypertensives, with no other comorbidities, 40-65 years old. After four weeks of washout patients were randomized to start, the test cycles diets, or the test of fludrocortisone. The first consisted of the administration of 7 days of low sodium diet (40 mEq / day) followed by seven days of high salt diet (200 mEq / day), being considered sensitive individuals when mean arterial pressure variation (MAP) was greater than 5 mmHg. The second consisted in administration of 0.4 mg / day of fludrocortisone acetate for 7 days, during usual dietary intake, being assessed the variation of the systolic (SBP) or MAP in the fourth and seventh days of drug administration. The cutoff point for this variation was studied by the ROC curve, not being taken arbitrarily. The test accuracy was measured by area under the ROC curve. Regarding the secondary objective, the daily blood pressure behavior pattern along the diet cycles was studied, through HBPM. Results: Thirty hypertensives were studied (53.7 ± 7.6 years; 72 ± 10.6 kg; 26% black, 10% brown and 14% asian), with 53% classified as sensitive by the reference test. On the fourth day of fludrocortisone, the areas under the ROC curve (ASROC) were of 0.761 ± 0.06 (p < 0.001) for SBP, of 0.646 ± 0.072 (p < 0.05) for the MAP and of 0.554 ± 0.075 (p = 0.469) for diastolic blood pressure (DBP). On the seventh day of fludrocortisone, the ASROC was 0.849 ± 0.05 (p < 0.001); 0.732 ± 0.06 (p = 0.002); and 0.63 ± 0.07 (p = 0.079) respectively for SBP, MBP and DBP. Therefore, the highest accuracy occurred on the seventh day of fludrocortisone, using SBP as a variable. At this point, with the cutoff point of 3 mmHg found, the test showed 83% sensitivity and 63% specificity. Regarding the study of the reference test, it was observed no significant difference of pressure variation obtained between the fourth and sixth days of diet. Conclusions: The administration of fludrocortisone acetate at a dose 0.4 mg / day over 7 days - Fludrocortisone\'s Test - can be used for identification of salt sensitivity in hypertensives 40 65 years old, non-obese and with no other comorbidities. Regarding the reference test for salt sensitivity, it is possible to make the diagnosis with duration of 8 days, not being necessary to extend it

Introdução: A sensibilidade ao sal possui implicações clínicas e prognósticas, porém seu diagnóstico não é habitualmente feito na prática clínica, tendo em vista que o teste de referência é longo e de difícil execução, envolvendo ciclos de dietas hipossódica e hipersódica. O objetivo principal do presente estudo foi avaliar a acurácia do teste da fludrocortisona, quando comparado ao teste de referência. O objetivo secundário foi estudar o teste de referência, avaliando em quanto tempo é possível ser realizado o diagnóstico. Métodos: Foi realizado estudo randomizado e crossover com homens e mulheres hipertensos, sem outras comorbidades, de 40 a 65 anos de idade. Após quatro semanas de washout os pacientes foram randomizados para iniciar pelo teste dos ciclos de dietas ou pelo teste da fludrocortisona. O primeiro consistiu na administração de 7 dias de dieta hipossódica (40 mEq/dia) seguidos por 7 dias de dieta hipersódica (200 mEq/dia), sendo considerados sensíveis os indivíduos com variação da pressão arterial média (PAM) superior a 5 mmHg. O segundo consistiu na administração de 0,4 mg / dia do acetato de fludrocortisona por 7 dias, durante ingestão alimentar habitual, sendo avaliada a variação da PAS ou PAM no quarto e sétimo dias do medicamento. O ponto de corte para esta variação foi estudado pela curva ROC, não sendo assumido arbitrariamente. A acurácia do teste foi medida pela área sob a curva ROC. Em relação ao objetivo secundário, foi estudado o comportamento diário da pressão arterial ao longo dos ciclos de dieta, através da MRPA. Resultados: Foram estudados trinta voluntários hipertensos (53,7 ± 7,6 anos; 72 ± 10,6 Kg; 26% negros, 10% pardos e amarelos), sendo 53% classificados como sensíveis pelo teste de referência. No quarto dia de fludrocortisona, as áreas sob a curva ROC (ASROC) foram de 0,761 ± 0,06 (p < 0,001) para a PAS, de 0,646 ± 0,072 (p < 0,05) para a PAM e de 0,554 ± 0,075 (p=0,469) para a Pressão arterial diastólica (PAD). No sétimo dia de fludrocortisona as ASROC foram 0,849 ± 0,05 (p < 0,001); 0,732 ± 0,06 (p=0,002); e 0,63 ± 0,07 (p=0,079) para respectivamente PAS, PAM e PAD. A maior acurácia foi obtida, portanto, no sétimo dia de fludrocortisona, utilizando a PAS como variável. Neste ponto, com o ponto de corte encontrado de 3 mmHg, o teste tem 83% de sensibilidade e 63% de especificidade. Em relação ao estudo do teste de referência, observou-se que não há diferença significante da variação pressórica obtida entre o quarto e sexto dias de dieta. Conclusões: A administração do acetato de Fludrocortisona na dose 0,4 mg/dia durante 7 dias - Teste da Fludrocortisona - pode ser utilizado para diagnóstico de sensibilidade ao sal em indivíduos hipertensos de 40 a 65 anos, não obesos e sem outras comorbidades. Em relação ao teste de referência para sensibilidade ao sal, é possível fazer o diagnóstico com duração de 8 dias, não sendo necessário prolongá-lo / Introduction: The salt sensitivity has clinical and prognostic implications; however, its diagnosis is not done in clinical practice, having in mind that the reference test is long and difficult to perform, involving cycles of hyposodic and high salt diets. The main objective of this study was to evaluate the accuracy of fludrocortisone test, when compared to the reference test. The secondary objective was to study the reference test, evaluating the necessary time for diagnosis to be carried out. Methods: It was perfomed a randomized and crossover study was conducted, with hypertensives, with no other comorbidities, 40-65 years old. After four weeks of washout patients were randomized to start, the test cycles diets, or the test of fludrocortisone. The first consisted of the administration of 7 days of low sodium diet (40 mEq / day) followed by seven days of high salt diet (200 mEq / day), being considered sensitive individuals when mean arterial pressure variation (MAP) was greater than 5 mmHg. The second consisted in administration of 0.4 mg / day of fludrocortisone acetate for 7 days, during usual dietary intake, being assessed the variation of the systolic (SBP) or MAP in the fourth and seventh days of drug administration. The cutoff point for this variation was studied by the ROC curve, not being taken arbitrarily. The test accuracy was measured by area under the ROC curve. Regarding the secondary objective, the daily blood pressure behavior pattern along the diet cycles was studied, through HBPM. Results: Thirty hypertensives were studied (53.7 ± 7.6 years; 72 ± 10.6 kg; 26% black, 10% brown and 14% asian), with 53% classified as sensitive by the reference test. On the fourth day of fludrocortisone, the areas under the ROC curve (ASROC) were of 0.761 ± 0.06 (p < 0.001) for SBP, of 0.646 ± 0.072 (p < 0.05) for the MAP and of 0.554 ± 0.075 (p = 0.469) for diastolic blood pressure (DBP). On the seventh day of fludrocortisone, the ASROC was 0.849 ± 0.05 (p < 0.001); 0.732 ± 0.06 (p = 0.002); and 0.63 ± 0.07 (p = 0.079) respectively for SBP, MBP and DBP. Therefore, the highest accuracy occurred on the seventh day of fludrocortisone, using SBP as a variable. At this point, with the cutoff point of 3 mmHg found, the test showed 83% sensitivity and 63% specificity. Regarding the study of the reference test, it was observed no significant difference of pressure variation obtained between the fourth and sixth days of diet. Conclusions: The administration of fludrocortisone acetate at a dose 0.4 mg / day over 7 days - Fludrocortisone\'s Test - can be used for identification of salt sensitivity in hypertensives 40 65 years old, non-obese and with no other comorbidities. Regarding the reference test for salt sensitivity, it is possible to make the diagnosis with duration of 8 days, not being necessary to extend it

Background: Primary aldosteronism (PAL) has emerged as the commonest specifically treatable and potentially curable form of secondary hypertension. With its propensity towards cardiovascular complications above that expected from hypertension alone, PAL is a potentially highly detrimental state which should be detected as early as possible in the course of the disease and treated appropriately. The detection of earlier, milder, normokalaemic forms of PAL using the aldosterone/renin ratio (ARR) as a screening test has significantly enlarged the clinical spectrum of PAL and facilitated identification of a new familial variety (familial hyperaldosteronism type II, FH-II). Unlike familial hyperaldosteronism type I (FH-I), FH-II is not glucocorticoid remediable and is not caused by the CYP11B1/CYP11B2 “hybrid” gene mutation. The genetic defects underlying FH-II have not yet been elucidated and hence, detection of FH-II still involves complicated and time-consuming biochemical screening by ARR testing and confirmation by carefully performed suppression testing such as fludrocortisone suppression testing. Diagnosing PAL by currently available biochemical methods is tedious. Finding a simple and reliable genetic test for FH-II which could be applied to all members of a family with known FH-II and also to apparently sporadic PAL would simplify patient management. A genome-wide search has already demonstrated linkage of FH-II to chromosome 7p22, consistent with this locus harbouring the causative gene/s for FH-II. Three candidate genes [retinoblastoma-associated Kruppel-associated box gene (RBaK, involved in tumorigenesis and cell cycle control), postmeiotic segregation increased 2 (PMS2, involved in DNA mismatch repair and tumour predisposition) and guanine nucleotide-binding protein alpha-12 (GNA12, a transforming oncogene)] within this linked locus have been examined in an attempt to find the causative mutations for FH-II, but no clear causative mutations have so far been found. PAL continues to be a challenging yet rewarding disease to manage. Although much has been learnt about PAL, there are still many areas which have not been explored. PAL considered due to bilateral autonomous production of aldosterone is usually treated medically because unilateral adrenalectomy has been considered ineffective. Since medical treatment may cause adverse effects or fail to control hypertension, defining the role of unilateral adrenalectomy in bilateral PAL is an important clinical issue, but quality outcome data are lacking. The candidate therefore peformed a retrospective study of the efficacy of unilateral adrenalectomy in patients with bilateral PAL. In patients with unilateral PAL, unilateral laparoscopic adrenalectomy has been shown to correct hypokalaemia and lead to cure or improvement in hypertension control. While most studies have focused on clinical and biochemical outcomes, to the candidate’s knowledge, there are no data on the effects of adrenalectomy on quality of life (QOL). Assessing the QOL in patients with unilateral PAL before and after unilateral laparoscopic adrenalectomy (which cured hypokalaemia in all and hypertension in the majority) provided an insight into the degree to which the disease process and/or its treatment affects the life of an individual with PAL. Aims: The overall aims of this thesis were to further explore the genetic basis of FH-II, to examine the role of adrenalectomy in patients with bilateral PAL and the effects of unilateral adrenalectomy on QOL in unilateral PAL as a first step in dissecting out the effects of medical and surgical treatment on QOL in the more common bilateral PAL. In order to address the overall aims, the specific aims of the thesis were (1) to narrow the linked region at 7p22 by phenotyping and genotyping additional FH-II families from Italy, using more closely spaced microsatellite markers at 7p22, and then assess the combined multipoint logarithm of odds (LOD) score for these Italian as well as two Australian and one South American families; (2) to sequence candidate genes in the narrowed linked region for FH-II associated mutations; (3) to assess the role of unilateral adrenalectomy in bilateral PAL and identify predictive parameters; and (4) to assess the quality of life following unilateral adrenalectomy in patients with unilateral PAL. Methods and Results: Two Italian families with FH-II were genotyped using seven closely spaced microsatellite markers at 7p22. All known affected individuals from each of the two Italian families were found to share identical haplotypes for the seven markers, consistent with linkage of the disease locus with the 7p22 region. The multipoint LOD score of the now five known families with FH-II which demonstrate linkage at 7p22, calculated using MERLIN linkage analysis was highly significant at 5.22. Three candidate genes in this linked region were then examined for mutations causing FH-II; the replication protein A 3 (RPA3), zinc finger protein 12 (ZNF12) and glucocorticoid induced transcripts 1 (GLCCI1) genes were selected as they are involved in cell cycle control, and adrenal hyperplasia and adenomas are common in FH-II. Using the method of polymerase chain reaction-sequencing, coding regions, splice sites, proximal promoter, 5’ and 3’ untranslated regions (UTR) were sequenced in affected and unaffected subjects from the 7p22-linked FH-II families. Identified single nucleotide polymorphisms (SNPs) were genotyped to assess significance. For RPA3, four different SNPs were initially found to segregate with the affectation status, that is, they were present in the two affected and not the two unaffected subjects from the largest Australian family (family 1, eight affecteds) with FH-II. However, only two SNPs (rs2024374 G/C and rs17169194 T/G) were further genotyped as that they were in functionally important positions of the gene (that is, in regulatory regions within the promoter and 5’ UTR) and because of the relatively low allele frequency reported in the literature for these two SNPs in controls. Further genotyping of these SNPs was carried out in another six affecteds and four unaffecteds from the same family and a complete segregation of these two SNPs with affectation status was seen in family 1. The G/C mutation rs2024374 in the RPA3 promoter results in the loss of three transcription factor binding sites and creation of one new site. The factors for which the binding sites in the RPA3 promoter and 5’UTR were altered by these two SNPs were involved in regulation of cell differentiation, proliferation and apoptosis. Hence, it is possible that altered activity of the RPA3 promoter and 5’UTR in family 1 could result in predisposition to adrenal hyperplasia or neoplasia, altered ARR and/or hypertension. Genotyping of these SNPs was then carried out in another two pedigrees (families 2 and 3) that showed linkage to 7p22, and in 75 normotensive, non-PAL control subjects. However, neither of these two SNPs segregated with the affectation status in family 2 and 3, and they were present in 30% and 20% of controls, respectively. For ZNF12 and GLCCI1, no evidence of causative mutations was found in the coding regions, splice sites, proximal promoter region and proximal 5’ and 3’ UTR. Between 1984 and 2004, 51 of 684 patients diagnosed with bilateral PAL underwent unilateral adrenalectomy. Forty patients fulfilled the inclusion criteria and were followed for at least 12 (median 56.4) months. Hypertension was cured in 15% and improved in 20%, usually within one year of unilateral adrenalectomy. The proportion with controlled hypertension was significantly (p<0.001) higher after adrenalectomy (65%) than before (25%). Mean systolic (p<0.001) and diastolic (p<0.001) blood pressure, left ventricular mass index (p<0.05) and aldosterone/renin ratio (p<0.001) fell. Serum creatinine independently predicted hypertension cure. From 2007 through 2008, QOL was evaluated prospectively using the internationally validated SF-36 questionnaire before and 3 and 6 months post-operatively in 22 patients [14 males, 8 females; mean age 50.0 ± 2.0 (range 27-69) years] with unilateral PAL who underwent adrenalectomy within the Endocrine Hypertension Centre, Greenslopes and Princess Alexandra Hospitals. Pre-operatively, the SF36 score for each QOL domain was lower for PAL patients than reported for the Australian general population, significantly so for physical functioning (p<0.05), role physical (p<0.001), vitality (p<0.001) and general health (p<0.05). Compared with pre-adrenalectomy, there were significant increments in mean scores at 3 months for physical functioning (p<0.05), role physical (p<0.05), general health (p<0.001), role emotional (p<0.05), social functioning (p<0.05), mental health (p<0.001) and vitality (p<0.001); and at 6 months for physical functioning (p<0.05), role physical (p<0.05), general health (p<0.05), role emotional (p<0.05), mental health (p<0.05) and vitality (p<0.001). Mean SBP and DBP improved significantly (p<0.001), with 86% of these patients cured (BP≤140/90, no drugs) and the remaining 14 % improved. Mean plasma potassium (p<0.001) and renin concentration rose (p<0.01), whereas mean upright plasma aldosterone (p<0.001), aldosterone/renin ratio (p<0.001) and number of antihypertensive agents fell (p<0.001). Conclusion: In the Italian families with FH-II available for study, work by the candidate included in this thesis confirmed linkage of FH-II to chromosome 7p22. The combined multipoint LOD score of 5.22 for the five families showing linkage at 7p22 was highly significant. Linkage to 7p22 in Italian families with FH-II extends the previous positive findings to a third geographical area, bringing greater certainty regarding the importance of this locus in identifying causative mutations. Although no clear causative mutations were found in the three 7p22 candidate genes examined, it is conceivable that the rs2024374 G/C and/or rs17169194 T/G SNPs in RPA3 could act in conjunction with another 7p22 mutation in family 1, resulting in the FH-II phenotype. Examination of the outcome of unilateral adrenalectomy in patients with bilateral PAL suggests that this surgical approach can be beneficial in certain carefully selected patients and should not be automatically excluded as a treatment option. Unilateral adrenalectomy in patients with unilateral PAL has positive impacts not only on clinical and biochemical parameters but also on QOL. The findings of this thesis provide new insights into the genetic basis and therapeutic options and treatment outcomes of PAL and further highlight its importance as a common, genetically based, specifically treatable and potentially curable cause of hypertension and cardiovascular disease. It also points the way to potentially very useful studies in future by exploring longer term effects of unilateral laparoscopic adrenalectomy as treatment for PAL on QOL, to compare unilateral adrenalectomy in those with unilateral versus bilateral PAL, and to compare surgery with specific medical treatment.

Introduction: Sodium chloride supplementation in saltwasting congenital adrenal hyperplasia (CAH) is generally recommended in infants, but its implementation in routine care is very heterogeneous. Objective: To evaluate oral sodium chloride supplementation, growth, and hydrocortisone and fludrocortisone dose in infants with salt-wasting CAH due to 21-hydroxylase in 311 infants from the AQUAPE CAH database. Results: Of 358 patients with classic CAH born between 1999 and 2015, 311 patients had salt-wasting CAH (133 females, 178 males). Of these, 86 patients (27.7%) received oral sodium chloride supplementation in a mean dose of 0.9 ± 1.4 mmol/kg/day (excluding nutritional sodium content) during the first year of life. 225 patients (72.3%) were not treated with sodium chloride. The percentage of sodium chloride-supplemented patients rose from 15.2% in children born 1999–2004 to 37.5% in children born 2011–2015. Sodium chloride-supplemented and -unsupplemented infants did not significantly differ in hydrocortisone and fludrocortisone dose, target height-corrected height-SDS, and BMI-SDS during the first 2 years of life. Conclusion: In the AQUAPE CAH database, approximately one-third of infants with salt-wasting CAH receive sodium chloride supplementation. Sodium chloride supplementation is performed more frequently in recent years. However, salt supplementation had no influence on growth, daily fludrocortisone and hydrocortisone dose, and frequency of adrenal crisis.