title: New diagnostic criteria for subclinical hypercortisolism using postsurgical hypocortisolism: the Co-work of Adrenal Research study.
abstract: OBJECTIVE
  There is no consensus on the biochemical diagnostic criteria for subclinical hypercortisolism (SH). Using parameters related to the hypothalamic-pituitary-adrenal axis, we aimed to develop a diagnostic model of SH for predicting postsurgical hypocortisolism and metabolic complications.
  
  
  METHODS
  Prospective and cross-sectional, observational, multicentre study in Korea.
  
  
  METHODS
  After exclusion of overt Cushing's syndrome, adrenal incidentaloma (AI) patients who underwent unilateral adrenalectomy (n = 99) and AI patients (n = 843) were included. Primary outcome was defined as the presence of postsurgical hypocortisolism; secondary outcome was the presence of ≥4 complications (components of the metabolic syndrome and low bone mass). Postsurgical hypocortisolism was determined on the fifth postsurgery day using the ACTH stimulation test.
  
  
  RESULTS
  Thirty-three of the 99 patients developed postsurgical hypocortisolism. Analysis of the presurgery overnight 1-mg dexamethasone suppression test (1-mg DST) showed that all patients with cortisol levels of >138 nmol/l experienced postsurgical hypocortisolism, whereas those with levels of ≤61 nmol/l did not. The models of (i) 1-mg DST >138 nmol/l or (ii) >61 nmol/l with the presence of one among low levels of ACTH and dehydroepiandrosterone-sulphate had the highest accuracy (89·9%, P < 0·001) and odds ratio [OR 111·62, 95% confidence interval (CI) 21·98-566·74, P < 0·001] for predicting postsurgical hypocortisolism. Finally, patients with the same criteria in the 843 AI patients showed the highest risk for having ≥4 complications (OR 3·51, 95% CI 1·84-6·69, P < 0·001), regardless of gender, age, body mass index and bilaterality.
  
  
  CONCLUSIONS
  Our proposed model is able to accurately predict subtle cortisol excess and its chronic manifestations in AI patients.
authors.affiliation: Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors.forename: Seung Hun
authors.initials: SH
authors.lastname: Lee
authors.affiliation: Division of Endocrinology and Metabolism, Department of Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea.
authors.forename: Kee-Ho
authors.initials: KH
authors.lastname: Song
authors.affiliation: Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors.forename: Jinju
authors.initials: J
authors.lastname: Kim
authors.affiliation: Division of Endocrinology and Metabolism, Department of Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea.
authors.forename: Sooyoun
authors.initials: S
authors.lastname: Park
authors.affiliation: Department of Endocrinology, Inha University School of Medicine, Incheon, Korea.
authors.forename: Seong Hee
authors.initials: SH
authors.lastname: Ahn
authors.affiliation: Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors.forename: Hyeonmok
authors.initials: H
authors.lastname: Kim
authors.affiliation: Division of Endocrinology and Metabolism, Department of Medicine, Gyeongsang National University School of Medicine, Jinju, Korea.
authors.forename: Yoon Young
authors.initials: YY
authors.lastname: Cho
authors.affiliation: Division of Endocrinology and Metabolism, Department of Medicine, Dong-A University Medical Center, Dong-A University School of Medicine, Busan, Korea.
authors.forename: Sunghwan
authors.initials: S
authors.lastname: Suh
authors.affiliation: Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors.forename: Beom-Jun
authors.initials: BJ
authors.lastname: Kim
authors.affiliation: Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
authors.forename: Jae Hyeon
authors.initials: JH
authors.lastname: Kim
authors.affiliation: Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors.forename: Jung-Min
authors.initials: JM
authors.lastname: Koh
mesh_terms: D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D003480:Cushing Syndrome / Q000097:blood / Q000150:complications / Q000175:diagnosis*; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000097:blood* / Q000209:etiology; D011446:Prospective Studies
chemical_list: D006854:Hydrocortisone