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*Steroids
Endocrine Reviews 19 (2): 101-143
Copyright © 1998 by The Endocrine Society

Intraadrenal Interactions in the Regulation of Adrenocortical Steroidogenesis

Monika Ehrhart-Bornstein, Joy P. Hinson, Stefan R. Bornstein, Werner A. Scherbaum and Gavin P. Vinson

Department of Internal Medicine III (M.E.-B.), University of Leipzig, 04103 Leipzig, Germany; Department of Biochemistry (J.P.H., G.P.V.), Queen Mary and Westfield College, London E14NS, England; National Institute of Child Health and Human Development (S.R.B.), National Institutes of Health, Bethesda, Maryland 20892; and Diabetes Research Institute at the Heinrich Heine University (W.A.S.), 40225 Düsseldorf, Germany


    Abstract
 Top
 Abstract
 I. Introduction: The Adrenal...
 II. Interaction Between Adrenal...
 III. Innervation of the...
 IV. The Vascular System...
 V. The Intraadrenal CRH/ACTH...
 VI. Immune Cells and...
 VII. Peptide Growth Factors...
 VIII. The Intraadrenal Renin...
 IX. Clinical Implications
 X. Conclusions
 References
 

I. Introduction: The Adrenal Functional Unit
II. Interaction Between Adrenal Medulla and Adrenal Cortex
A. Relationship between medullary and cortical cells
B. Paracrine control of adrenocortical function by the adrenal medulla
C. Gap junctions in the adrenal cortex
D. Summary
III. Innervation of the Adrenal Cortex
A. Evidence for a nerve supply to the adrenal cortex
B. The source of adrenocortical innervation
C. Regulation of adrenocortical innervation
D. Role of the splanchnic nerve in regulating adrenocortical neural function
E. Influence of adrenal innervation on adrenocortical function
F. Effects of neurotransmitter substances on adrenocortical function
G. Summary
IV. The Vascular System of the Adrenal Gland
A. Regulation of blood flow
B. Relationship between blood flow and steroid secretion
C. Effects of vascular endothelial cell products on steroid secretion
D. Summary
V. The Intraadrenal CRH/ACTH System
A. Extrapituitary effect of CRH
B. Intraadrenal ACTH
C. Intraadrenal CRH and CRH receptors
D. Feedback mechanisms
E. Summary
VI. Immune Cells and Cytokines in the Adrenal Gland
A. Source of cytokines within the adrenal
B. Cytokines that influence the adrenal cortex
C. Summary
VII. Peptide Growth Factors and the Adrenal Cortex
A. FGFs
B. IGFs
C. TGFß
D. Summary
VIII. The Intraadrenal Renin-Angiotensin System (RAS)
A. The role of the RAS in adrenocortical function
B. Renin
C. Angiotensinogen
D. Angiotensin-converting enzyme and the production of angiotensin II
E. What is the functional significance of the intraadrenal RAS?
F. How can the angiotensin II produced by the tissue RAS be distinguished from the systemic system?
G. Summary
IX. Clinical Implications
A. Cortisol
B. Aldosterone
C. Adrenal androgens
D. Summary
X. Conclusions


    I. Introduction: The Adrenal Functional Unit
 Top
 Abstract
 I. Introduction: The Adrenal...
 II. Interaction Between Adrenal...
 III. Innervation of the...
 IV. The Vascular System...
 V. The Intraadrenal CRH/ACTH...
 VI. Immune Cells and...
 VII. Peptide Growth Factors...
 VIII. The Intraadrenal Renin...
 IX. Clinical Implications
 X. Conclusions
 References
 
OVER the past few years, considerable evidence has accumulated to challenge the accepted view of the regulation of adrenocortical function. Conventionally, the cortex and medulla have been viewed as distinct functional units, with cortical function regulated primarily by the circulating hormones, ACTH and angiotensin II, acting mainly on the inner adrenocortical zones and the glomerulosa, respectively. However, it has become clear that certain aspects of adrenocortical function cannot be explained in this simplistic manner. Certainly there are discrepancies between the concentrations of these regulatory hormones and the secretion of the corticosteroids, suggesting that other factors may also be involved.

As a result of intensive study in recent years, we now know that the regulatory mechanisms that account for such discrepancies are mainly located within the adrenal itself, and that several different components of the gland contribute to these functions. The adrenal produces a wide variety of hormones, neuropeptides, neurotransmitters, and cytokines, and it is evident that the colocalization of these different systems has a profound functional significance. The cells within the adrenal thus communicate with each other and adapt the function of the gland to different situations. The integrated control of adrenocortical function involves cortico-medullary interactions, the gland’s vascular supply, its neural input, the immune system, growth factors, and the intraglandular renin-angiotensin and CRH-ACTH systems. As well as directly regulating adrenocortical function, these systems influence each other and form complex intraadrenal regulatory circuits.

We here survey the mechanisms involved in the intra-glandular regulation of adrenocortical function and show how they combine to ensure that the gland functions as a unit.


    II. Interaction Between Adrenal Medulla and Adrenal Cortex
 Top
 Abstract
 I. Introduction: The Adrenal...
 II. Interaction Between Adrenal...
 III. Innervation of the...
 IV. The Vascular System...
 V. The Intraadrenal CRH/ACTH...
 VI. Immune Cells and...
 VII. Peptide Growth Factors...
 VIII. The Intraadrenal Renin...
 IX. Clinical Implications
 X. Conclusions
 References
 
The adrenal gland consists of two endocrine tissues of different embryological origin: the primarily steroid-producing adrenocortical tissue and the catecholamine-producing chromaffin cells. During embryogenesis, the adrenal primordium is formed as a condensation of celomic epithelium at the cranial end of the kidney. This adrenal primordium consists of mesodermally derived fetal adrenal cells, which later become steroid-producing cells. In most mammals the adrenal cortex consists of three zones, varying in both their morphological features and the steroid hormones they produce. The zona glomerulosa is the unique source of the mineralocorticoid, aldosterone. The zona fasciculata and the zona reticularis produce the glucocorticoids, cortisol and corticosterone, and the androgens [predominantly dehydroepiandrostenedione (DHEA) and DHEA sulfate in human], which may be relatively more abundant in the zona reticularis.

Adrenomedullary chromaffin cells originate from neural crest precursor cells that migrate into the adrenal "anlagen" and later differentiate into chromaffin cells in the adrenal medulla under the influence of adrenocortical steroids (1, 2). The main secretory products of these differentiated cells are the catecholamines epinephrine and norepinephrine. In addition, chromaffin vesicles contain numerous transmitters, neuropeptides, and proteins, which may be released together with the catecholamines (3).

A. Relationship between medullary and cortical cells
Within the adult tetrapod adrenal, cortical and chromaffin cells are united in one gland. The organization of these two cell types varies among different species. In nonmammalian species chromaffin cells may be distributed in islets, as in amphibia and birds, or concentrated toward one pole of the gland, as in reptiles (4). In mammals, the conventional view holds that the two different endocrine tissues are clearly separated into an outer steroid-producing cortex and a central medulla (4, 5, 6, 7). However, this is an oversimplification, and the distribution of these cells may not be so clearly demarcated, but may instead involve closer contact than previously thought.

The occurrence of medullary cells in the zona glomerulosa of adult rats was first observed nearly 30 yr ago (8, 9). Although slow to receive general acceptance, it is now widely acknowledged that chromaffin cells can be found in all zones of the adult adrenal cortex, either radiating through the cortex from the medulla (8, 9, 10, 11, 12) or distributed as islets or single cells. Medullary cells may also spread into the subcapsular region, where they form larger nests of chromaffin cells (8, 11, 12, 13). Conversely, cortical cells are also located in the medulla, where they may form islets either surrounded by chromaffin tissue or retaining some contact to the rest of the cortex. The adrenal medulla appears, in part, to be peppered with cortical cells (12, 14) (Fig. 1Go). This intimate intermingling of the two cell types allows extensive contact zones for paracrine interaction.



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Figure 1. Cross-section of a human adrenal. Adrenocortical cells are immunostained for 17{alpha}-hydroxylase using diaminobenzidin (COR), and medullary cells are immunostained for chromogranin A using AEC (Dianova, Hamburg, Germany) (MED). Especially in the medulla, medullary and cortical tissues are highly intermingled with islets of cortical tissue (C) surrounded by medullary cells.

 
Ultrastructurally, chromaffin cells are characterized by their dense-cored catecholamine-containing vesicles, while adrenocortical cells can be recognized by their typical mitochondria with tubulovesicular cristae and ample smooth endoplasmic reticulum. Cortical and chromaffin cells contact each other directly without separation by connective tissue or interstitium (12, 14). Figure 2Go illustrates the exocytosis of a chromaffin vesicle from a medullary cell located in the rat zona glomerulosa (15), demonstrating the possible paracrine action of a chromaffin cell on an adrenocortical cell. The close anatomical colocalization forms the basis for possible interactions of the two endocrine systems.



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Figure 2. Electron micrograph of rat adrenal cortex. The exact moment of an exocytosis from a chromaffin cell (arrow) in direct apposition to an adrenocortical cell in the zona glomerulosa is shown. [Reproduced with permission from S. R. Bornstein and M. Ehrhart-Bornstein: Endocrinology 131:3126–3128, 1992 (15). © The Endocrine Society.]

 
B. Paracrine control of adrenocortical function by the adrenal medulla
Is there any physiological relevance to the close anatomical colocalization of the medulla and the cortex? Mounting evidence in recent years suggests an influence of adrenal innervation on adrenocortical functions (see Section III). Here the relevant point is that the integrity of the sympathetic innervation is required to maintain diurnal variation in adrenal steroidogenesis, which persists in CRH knockout mice (16, 17, 18). Neural inputs also seem to mediate compensatory growth in the remaining adrenal after unilateral adrenalectomy (for review see Ref.19). These effects may depend on an increased adrenocortical sensitivity to ACTH, since splanchnic nerve stimulation was found to enhance the secretion of glucocorticoids in response to ACTH (20), and section of both splanchnic nerves in lambs decreased adrenocortical sensitivity to ACTH (21). However, in pigs isolated perfused adrenal glands with intact splanchnic innervation steroidogenesis may be stimulated independently from the hypothalamus-pituitary-adrenal (HPA) axis by electrical activation of the sympathoadrenal system (22, 23, 24, 25), thus indicating an ACTH-independent effect of sympathetic innervation on adrenocortical function. A physiological role for the paracrine regulation of adrenocortical steroidogenesis is also supported by the observation that in nonmammalian vertebrates, hypophysectomy does not abolish corticosteroid secretion (26).

1. Epinephrine, norepinephrine, and serotonin (5-HT). Neuroendocrine regulation of this type may depend on neurotransmitters released from nerve endings in the adrenal cortex (see Section III) or on the chromaffin cell products, epinephrine and norepinephrine. These catecholamines are secreted in response to splanchnic nerve stimulation and may influence adrenocortical function (references in Table 1GoGoGo). For example, the secretion of cortisol, aldosterone, and androstenedione was found to be stimulated by perfusion of the isolated porcine adrenal glands with epinephrine or norepinephrine (22, 24). In addition to this acute effect, catecholamines have a long-term effect on corticosteroid release from isolated adrenocortical cells, involving transcriptional regulation of steroid enzymes (27, 28). Interestingly, epinephrine and norepinephrine had the opposite effect in the frog adrenal, inhibiting steroid secretion (29). These data provide evidence for a direct influence of medullary products on cortical function.


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Table 1. Effects on adrenocortical steroidogenesis at the level of the adrenal of transmitters and neuropeptides released from adrenal nerves and adrenomedullary chromaffin cells

 

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Table 1A. Continued

 

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Table 1B. Continued

 
In addition to the catecholamines, there are other neurotransmitters produced in the adrenal medulla that influence adrenocortical activity. The occurrence of 5-HT in adrenal chromaffin cells has been demonstrated in the mouse (30), the rat (31, 32), and the frog (33). In contrast, human adrenomedullary cells did not contain this amine, and its presence has only been detected in mast cells (34, 35, 36). 5-HT stimulates corticosteroid secretion at the adrenocortical level in various animal models (for review, see Ref.34) including humans (references in Table 1Go).

2. Neuropeptides. However, in addition to catecholamines, adrenomedullary chromaffin cells produce, store, and secrete a whole series of neuropeptides (Table 2GoGo). The first neuropeptides to be discovered in the adrenal medulla were the enkephalins (37), which are by number the most prominent neuropeptides in the chromaffin vesicles (3). In addition, many other neuropeptides are costored with adrenomedullary catecholamines (Table 2Go; for review, see Refs. 3, and 38–40).


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Table 2. Location of neuropeptides in the adrenal medulla

 

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Table 2A. Continued

 
Many of these peptides are able to influence adrenocortical steroid production in different species (for review, see Refs. 41–43), mostly by stimulating adrenocortical function (Table 1Go). Some peptides released from the adrenal medulla, however, may exert an inhibitory influence on steroidogenesis. These include atrial natriuretic peptide, which is thought to be involved in the regulation of aldosterone secretion, somatostatin, dynorphin, substance P, neuropeptide Y (NPY), and enkephalins (see Table 1Go for references). However, some of these apparently inhibitory peptides, such as substance P and the enkephalins, are stimulatory under other conditions. The intact architecture of the adrenal is necessary for the action of adrenomedullary peptides that stimulate adrenocortical function via the release of catecholamines from the medulla, i.e., pituitary adenylate-cyclase activating peptide (PACAP) (44), vasoactive intestinal peptide (VIP) (45), substance P (46), adrenomedullin (47), and NPY (48) (Table 1Go). Some neuropeptides synthesized in chromaffin cells, such as atrial natriuretic peptide and somatostatin, influence preferentially the release of mineralocorticoids in the zona glomerulosa. This correlates well with the morphological observations confirming the occurrence of chromaffin cells in the subcapsular area of the zona glomerulosa.

Coculture systems of bovine adrenomedullary chromaffin cells with bovine adrenocortical cells have now supplied evidence for the paracrine influence of chromaffin cells on adrenocortical cells. The secretory products of chromaffin cells stimulate steroidogenesis both when they are in direct contact with adrenocortical cells (Fig. 3Go) and also in a system in which the cell types are separated by a semipermeable membrane (49).



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Figure 3. Primary cultures of bovine adrenocortical cells (A and C) and of bovine adrenocortical cells cultured together with chromaffin cells (B and D). Cells were kept in vitro for 3 days (DMEM/F12 + 10% FCS). Cortical cells were immunostained for 17{alpha}-hydroxylase in panel A, chromaffin cells were immunostained for chromogranin A in panel B (COR, adrenocortical cell; MED, adrenomedullary cell). Isolated cortical cells (2 x 105/well) released 5% of the cortisol released by cortical cells (2 x 105/well) cultured together with chromaffin cells (2 x 105/well); 8.6 ± 2.1 nmol/liter/24 h (C) vs. 186.5 ± 34.9 nmol/liter/24 h (D) (mean ± SEM, n = 4).

 
Within the adrenal medulla, many regulatory peptides that may influence adrenocortical function are stored together with catecholamines in chromaffin granules (for review, see Refs. 3 and 50 and Table 1Go). If different medullary products are able to either stimulate or inhibit adrenocortical function, mechanisms should exist that differentially regulate their synthesis and release. In fact, multiple populations of chromaffin cells exist within the medulla, which vary in their peptide composition (51, 52, 53), depending on the interactions between the calcium, protein kinase A, and protein kinase C-signaling pathways (54, 55) and, presumably, on the concerted action of different neurotransmitters released from splanchnic nerves. These could act via various second messenger pathways as shown for acetylcholine and VIP (55) or humoral or immune factors (56, 57, 58, 59, 60), perhaps of either intraadrenal or extraadrenal origin. Interestingly, interleukin (IL)-1{alpha} and tumor necrosis factor (TNF)-{alpha} differentially regulate Met-enkephalin, VIP, neurotensin, and substance P biosynthesis in chromaffin cells (58). Given the local production of these cytokines by adrenocortical cells (see Section VI), a complete regulatory circuit may exist within the adrenal, with the adrenal cortex releasing cytokines that may influence the peptide composition of chromaffin granules. Adrenomedullary secretory products in turn are able to differentially stimulate or inhibit adrenocortical function.

C. Gap junctions in the adrenal cortex
Although the adrenal cortex and medulla are highly interwoven, only a subpopulation of adrenocortical cells lies in direct contact with adrenomedullary cells and therefore under the influence of adrenomedullary secretory products. A prompt adrenocortical response to stimulation (or inhibition), however, requires an effective cellular communication system. Gap junctions occur within all zones of the mammalian adrenal cortex (61, 65, 671, 672, 673), and active gap junctions have been shown to form between adrenocortical cells in primary culture (65, 66). Furthermore, gap junctions are induced relatively rapidly after ACTH stimulation, suggesting their pivotal role in hormone response. Gap junctions allow small, water-soluble molecules to pass directly from the cytoplasm of one cell to the cytoplasm of the other, and the intracellular signal may thus be propagated from stimulated to unstimulated cells, as observed in dispersed rat adrenocortical cells (67). Thereby, gap junctions could couple the cells both electrically and metabolically and may help to coordinate the function of the gland, especially in response to locally restricted stimulation.

D. Summary
In conclusion, the data presented in this chapter show that the medulla and cortex are interdispersed to various degrees in mammalian adrenals much as in nonmammalian vertebrates. In addition, these two different tissues interact by complex regulatory circuits. Increasing evidence exists that the close colocalization is the prerequisite for paracrine interactions within the adrenal. Various adrenomedullary secretory products, such as catecholamines, 5-HT, and a whole series of neuropeptides, are involved in the regulation of adrenocortical steroidogenesis, by either stimulating or inhibiting adrenocortical function. Under basal conditions, stimulatory influences seem to be dominant. However, the influence of adrenomedullary secretory products on adrenocortical functions is complex and probably varies in different physiological situations. The complexity in the intraadrenal regulation of steroid secretion is increased by the fact that several factors may interact by addition, potentiation, or antagonism of their effects. In turn, adrenocortical secretory products, the steroid hormones and cytokines released by the cortex, influence the neuropeptide, protein, and catecholamine expression in medullary chromaffin cells. It remains to be elucidated how the different adrenomedullary secretory products are involved in the adjustment of adrenocortical functions to the needs of the body and to the maintenance of homeostasis under different conditions.


    III. Innervation of the Adrenal Cortex
 Top
 Abstract
 I. Introduction: The Adrenal...
 II. Interaction Between Adrenal...
 III. Innervation of the...
 IV. The Vascular System...
 V. The Intraadrenal CRH/ACTH...
 VI. Immune Cells and...
 VII. Peptide Growth Factors...
 VIII. The Intraadrenal Renin...
 IX. Clinical Implications
 X. Conclusions
 References
 
A. Evidence for a nerve supply to the adrenal cortex
The classic view of adrenal anatomy is that the nerve supply to the adrenal medulla passes directly through the cortex without branching or synapsing with any adrenocortical cells. The early descriptions of the microanatomy of the adrenal cortex concluded, therefore, that the adrenal cortex is not directly innervated (68, 69, 70, 71, 72). Only one of the early studies differed from this view, and in 1931 Alpert (73) described a "rich, intimate nerve supply to the cortex." It was 40 yr before this observation was confirmed by Unsicker’s report (74) of nerve fibers in the rat and pig adrenal glands, apparently synapsing with adrenocortical cells. This was followed in 1977, by similar observations in sheep adrenals (75). It is now the generally accepted view that the mammalian adrenal cortex receives a rich nerve supply, and there is strong evidence to suggest that nerve terminals may directly contact the steroid-secreting cells of the adrenal cortex (38, 76, 77, 78). Vesicle-containing nerve endings have been observed in direct contact with cortical cells in the frog adrenal (79) and zona glomerulosa cells in the rat adrenal (80), and similar observations have been made in the zona fasciculata of the human adrenal (81).

In addition to the well described afferent innervation of the adrenal cortex, there is also a less well documented efferent innervation. The presence of both chemoreceptors and baroreceptors in the adrenal gland has been reported (82, 83). This efferent innervation has been implicated in the contralateral hypertrophic response to adrenal damage (84).

B. The source of adrenocortical innervation
There is evidence that the afferent innervation of the adrenal cortex derives from two distinct sources (85): one source is the adrenal medulla, and it has been suggested that the adrenal cortex may originally have been a target organ for adrenomedullary postganglionic nerves. During evolution, as the cortex and medulla became more closely associated, the postganglionic fibers terminated entirely within the adrenal gland, forming the chromaffin tissue and innervating the cortical cells (86). The second source of nerves supplying the adrenal cortex is not clear, but these nerves appear to have their cell bodies outside the adrenal gland and enter the gland along blood vessels (85). It has been demonstrated that the adrenal nerves entering the gland contain both pre- and postganglionic fibers (87, 88), and presumably these postganglionic fibers supply the adrenal cortex.

Intraadrenal nerve fibers, originating in the medulla and innervating the outer layers of the cortex, have been described in the rat adrenal gland in particular. The most extensively studied neuropeptide has been VIP. Hökfelt and co-workers (89) described an intrinsic adrenal VIP-ergic neural system with cell bodies in the medulla and varicose fibers in the zona glomerulosa. This finding has been confirmed by others (90) and extended to include reports of other intrinsic adrenal peptidergic nerves, including CGRP-, substance P-, and neuropeptide Y-containing nerves (91, 92, 93). In addition to a wide range of neuropeptides, catecholamines (85, 94) and acetylcholine (95) have been identified as transmitters in nerves supplying the adrenal cortex of different mammalian species (Table 3Go; for reviews see Refs. 38 and 96), although the source of this innervation is often not clear. The term ‘intrinsic’ is frequently used to describe nerve fibers innervating the adrenal gland. This term is most properly used to describe neurons that are wholly contained within the adrenal gland, whose cell bodies can be clearly identified, and should not be extended to include other, less defined, forms of innervation. Unfortunately, it is not always clear in reports of adrenocortical innervation whether the innervation is intrinsic.


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Table 3. Transmitter systems identified in nerves supplying the adrenal cortex

 
C. Regulation of adrenocortical innervation
There have been several studies investigating the mechanisms that regulate adrenocortical innervation, mostly addressing the regulation of neuropeptide content of the adrenal cortex, although their interpretation is frequently difficult. In the mouse it has been shown that neuropeptide Y mRNA levels increase with age in the adrenal and are stimulated by food deprivation for 24 h (97). This study did not distinguish between cortical and medullary peptide. Holzwarth and co-workers (85) have also reported that rat adrenal neuropeptide Y content is ‘sensitive to the stress level of the animal,’ but is not affected by splanchnic nerve section. This group has also found that VIP in the adrenal gland is regulated by the physiological state of the animal and is stimulated by a high potassium diet (85). A more recent study has shown that adrenocortical VIP content is markedly stimulated by a low sodium diet (98). Thus, it is clear that adrenal neuropeptide content is actively regulated in response to the physiological status of the animal, although the mechanism of this effect is far from clear.

D. Role of the splanchnic nerve in regulating adrenocortical neural function
It is not clear to what extent the splanchnic nerve regulates adrenocortical nerve activity. Although it has been found that stimulation of the splanchnic nerve causes the release of several neuropeptides into the adrenal venous effluent, it is not possible to determine what proportion might be contributed by the cortical innervation, compared with the adrenal medulla. As may be seen in Section I, the same neurotransmitters found in nerve fibers innervating the cortex (Table 3Go) are also present in the chromaffin cells of the adrenal medulla (Table 2Go). There have been, however, studies that have directly addressed the question of the role of the splanchnic nerve in regulating cortical innervation, although the results are difficult to interpret.

Hökfelt and colleagues (89) found that the VIP-ergic intraadrenal nerves were independent of splanchnic nerve activity: after extrinsic adrenal denervation (achieved by cutting the splanchnic nerve and periarterial nerves and removing the celiac ganglion) VIP-immunoreactive fibers persisted in the rat adrenal cortex, and indeed no difference was reported in levels of immunoreactive VIP between control and adrenal denervated rats. Holzwarth (90), on the other hand, found that the VIP immunoreactive adrenal nerves with cell bodies in the medulla were regulated by splanchnic nerve activity, with an increase in VIP immunostaining after splanchnic nerve ligation. After adrenal enucleation and cortical regeneration, however, the number of VIP-ergic fibers in the cortex was greatly reduced. A recent study, in which immunoreactive cortical and medullary VIP were measured, reported that, while medullary VIP content was significantly decreased after splanchnic nerve section, there was no effect on cortical VIP (98). The problem with all of these studies is that in each, neuropeptide content is measured at a single point in time since dynamic studies of this type of system are not accessible using current methodology. The question that is posed by these data is: What does a change in neuropeptide content signify? If cytochemical studies can demonstrate a population of neurons that disappears after splanchnic nerve section, then it seems reasonable to conclude that those neurons are regulated by the splanchnic nerve. However, when the amount of a transmitter present increases after nerve ligation, it is questionable whether this reflects increased synthesis or decreased release of the transmitter (85). The converse is also true: if the amount of neuropeptide present decreases, is it because the nerve has degenerated or has its activity increased?

It is difficult to distinguish between intrinsic and extrinsic adrenocortical nerves and equally difficult to determine the influence of the splanchnic nerve on adrenocortical innervation. Most of our understanding of the role of the adrenocortical innervation in regulating adrenocortical function has, therefore, come from functional studies.

E. Influence of adrenal innervation on adrenocortical function
Several aspects of adrenocortical function have been shown to be influenced by adrenal innervation. Adrenal growth in response to damage of the contralateral adrenal gland (or in response to unilateral adrenalectomy), termed ‘compensatory adrenal hypertrophy,’ has been shown to be mediated by both adrenal afferent and efferent nerves, via the hypothalamus (84). This effect is independent of splanchnic nerve activity (84) and is not associated with an increase in adrenal neuropeptide content (98).

Most functional studies, however, have investigated the effects of splanchnic nerve section on adrenal responses. An account of the role of the splanchnic nerve in the regulation of adrenal blood flow is given in Section IV. Several studies in different species, including dog, calf, and sheep, suggest that splanchnic nerve activity regulates adrenocortical sensitivity to ACTH stimulation: sectioning the splanchnic nerve decreases the adrenal response to ACTH (21, 99), while stimulation enhances it (20, 100). In the pig, isolated perfused adrenal, splanchnic nerve stimulation increases the secretion of aldosterone, cortisol (22), and androstenedione (24). It is likely that the effects of stimulating the nerves supplying the adrenal gland are mediated by the local release of neurotransmitters, either from nerve endings or from medullary cells.

Adrenal innervation has also been implicated in regulating the diurnal variation in cortisol secretion (16, 17).

F. Effects of transmitter substances on adrenocortical function
Many studies have directly addressed the question of the functional role of the different neurotransmitters identified in neurons supplying the adrenal cortex. The results of these studies have implicated the various neurotransmitters in a wide range of effects. Many have been shown to directly stimulate steroidogenesis by dispersed adrenal cells, or by the intact perfused rat adrenal preparation. Others appear to stimulate the growth of the adrenal cortex, or to modulate the adrenocortical response to humoral stimulation. This subject has been recently reviewed by several groups (38, 76, 96, 101, 102, 103, 104). Clearly it is difficult to distinguish between the effects of medullary chromaffin cells and direct adrenal innervation, as the same transmitters may be produced by both. The effects of different transmitters are summarized in Table 1Go.

G. Summary
It is clear that the adrenal cortex receives a direct innervation, at least partly derived from the splanchnic nerve. The neurotransmitters identified in nerves supplying the cortex have a variety of actions, from direct effects on growth and steroidogenesis, to modulation of the actions of humoral stimuli on the adrenal cortex. This innervation also has a role in regulating the vasculature (see Section IV). It would appear that adrenocortical innervation has a role in fine tuning the functions of the adrenal cortex.


    IV. The Vascular System of the Adrenal Gland
 Top
 Abstract
 I. Introduction: The Adrenal...
 II. Interaction Between Adrenal...
 III. Innervation of the...
 IV. The Vascular System...
 V. The Intraadrenal CRH/ACTH...
 VI. Immune Cells and...
 VII. Peptide Growth Factors...
 VIII. The Intraadrenal Renin...
 IX. Clinical Implications
 X. Conclusions
 References
 
The adrenal gland is a highly vascular tissue (Fig. 4Go) and receives a high proportion of the cardiac output relative to its size. The rat adrenal, for example, comprises approximately 0.02% of the total body weight, but receives around 0.14% of the cardiac output (105). The vascular supply to the adrenal gland has been described in several species, and while the general arrangement of blood vessels is similar, it is clear that there are some important variations between species, particularly in relation to the degree of independence of cortical and medullary blood supply (43, 106, 107, 108). In general, the adrenal gland is supplied by small arterioles that arise from the aorta, and from the renal and inferior phrenic arteries. Blood is supplied to a network of arterioles in the connective tissue capsule, referred to as the subcapsular arteriolar plexus, from which it is distributed into two types of vessel: the thin-walled sinusoids that supply the cortex and the medullary arteries that convey blood directly to the adrenal medulla. The numbers of these medullary arteries vary greatly among species (63), with the dog having a relatively large number and the rat very few (109). This is likely to be the reason for differences in the regulation of adrenal cortical and medullary blood flow (43).



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Figure 4. Relationship of the noradrenergic innervation of the rat adrenal gland to the vasculature. Most of the nerve fibers are located in the capsular (c) and subcapsular region where they form arborizations around the vasculature and, to a lesser extent, around the zona glomerulosa cells. In addition, there is a sparse distribution of ganglionic cells and chromaffin cells (tyrosine hydroxylase and dopamine-ß-hydroxylase positive) among the cortical cells. zg, Zona glomerulosa; zf, zona fasciculata; zr, zona reticularis; m, medulla; n, nerve fibers; a, arteriole; ma, medullary artery; s, sinusoids; i, isolated islets of chromaffin cells; gc, ganglionic cells. [Modified and reproduced with permission from G. P. Vinson et al.: J Neuroendocrinol 6:235–246, 1994 (76).]

 
A. Regulation of blood flow
The rate of blood flow through the adrenal gland is highly controlled by a number of different neural and hormonal mechanisms (for review, see Refs. 43 and 63). Stimulation of the splanchnic nerve stimulates adrenal blood flow in both dogs and calves (20, 100, 110). The effects of the splanchnic nerve on adrenal blood flow may be mediated by the release of neuropeptides (111, 112, 113). Several of these neuropeptides have been reported to exert vascular effects on the adrenal gland: VIP, Met-enkephalin, and CGRP cause vasodilation, while NPY causes vasoconstriction (114, 115). Other neuropeptides investigated, including substance P, neurotensin, and Leu-enkephalin, were not found to have significant effects (115).

ACTH is well known to stimulate increases in adrenal blood flow (105, 116, 117, 118). Although it has been suggested that ACTH exerts its effects by constricting medullary arteries and diverting blood into the cortical sinusoids (106), studies in the perfused rat adrenal preparation have suggested that this is not the case: ACTH administration results in an overall increase in the flow of perfusion medium, suggesting a decreased vascular resistance within the gland (62). A mechanism has been proposed to account for the adrenal vascular effects of ACTH: mast cells are known to be present within the adrenal capsule, particularly where it is penetrated by the adrenal arteries. Mast cells contain histamine and 5-HT, both potent vasoactive compounds, which are released by the action of ACTH and cause adrenal vasodilatation. Evidence in support of this hypothesis was obtained by using disodium cromoglycate, an inhibitor of mast cell degranulation. This agent abolishes the vascular effects of ACTH, suggesting that mast cell degranulation is an essential step in the adrenal vascular response to ACTH (119, 120).

The recently identified secretory products of the vascular endothelium—nitric oxide, endothelin-1, and adrenomedullin—have also been implicated in the local regulation of adrenal blood flow. Decreasing endogenous nitric oxide production by administration of an inhibitor of nitric oxide synthase, such as L-NAME causes a decrease in the rate of blood flow through both the adrenal cortex and medulla in the dog (121) and a decrease in perfusion medium flow rate through the perfused rat adrenal gland (122). Perfusing the rat adrenal gland with medium lacking L-arginine, the substrate for nitric oxide synthesis, has a similar vasoconstrictive effect, which is reversed by administration of L-arginine (122), suggesting that nitric oxide exerts a tonic vasodilatory effect in this tissue. The presence or absence of nitric oxide does not significantly affect the vascular action of ACTH (122).

Endothelin also appears to regulate adrenal vascular tone. Administration of an endothelin receptor (ETA) antagonist causes adrenal vasodilation, suggesting that endothelin-1 exerts a tonic vasoconstrictor effect on the adrenal vasculature (122). Adrenomedullin stimulates perfusion medium flow in the intact perfused rat adrenal model (47). The interactions between these agents, which produce an integrated control of adrenal blood flow, remain to be elucidated.

B. Relationship between blood flow and steroid secretion
A relationship between the rate of blood flow through the adrenal gland and the rate of glucocorticoid secretion was proposed in the early 1950s by Hechter and co-workers (123). Further studies in dogs, rats, and calves have shown that, in the presence of submaximal concentrations of ACTH, there is a clear relationship between adrenal blood flow and steroid secretion (123, 124, 125, 126). It has been shown that, under these conditions, increased blood flow causes an increase in the rate of presentation of ACTH to the adrenal gland, and it has been suggested that it is the rate of ACTH presentation, rather than the absolute concentration of ACTH present, that is the major determinant in the adrenocortical response (124). However, a relationship between adrenal blood flow and steroid secretion exists even in the absence of ACTH (62, 127). In the isolated perfused rat adrenal preparation, which has been used to address this question, there is a significant correlation between perfusion medium flow rate and corticosterone secretion that is seen in the absence of ACTH and is found when flow rate is changed either mechanically or by the use of vasodilators. Clearly, increased flow rates in this preparation have implications for the delivery of oxygen and the removal of steroid products, but this is an effect that is unique to the intact adrenal gland: collagenase-dispersed cells superfused on a column simply do not respond in the same way to changes in flow (62). This suggests that the effect of changes in blood (or perfusion medium) flow on steroid secretion are mediated by an element present in the intact gland that is lost when cells are dispersed. This factor is most likely to be one of the secretory products of the cells of the vascular endothelium.

C. Effects of vascular endothelial cell products on steroid secretion
Within the adrenal cortex the arrangement of blood vessels is such that nearly every adrenocortical cell is directly adjacent to a vascular endothelial cell (Fig. 4Go). In addition to their actions on the adrenal vasculature, the secretory products of endothelial cells exert significant effects on adrenal function, which appear to be independent of their vascular effects (Table 4Go). Endothelin-1 has been shown to stimulate aldosterone secretion in several species, including frog (128), cow (129, 130), rabbit (131), rat (132, 133), and human (132). In the calf it appears that endothelin acts through the ETA receptor subtype to stimulate aldosterone secretion (130). In the rat, however, it is not clear which receptor subtype is involved in aldosterone secretion since both subtypes are present in the zona glomerulosa (134, 135, 136, 137); some authors report no effect of ETA antagonists (135), while others have found that both receptor subtypes are involved (137, 138) or that ETA receptors mediate most of the effect of endothelin (137). In the human adrenal cortex, both endothelin receptor subtypes are present in the zona glomerulosa (139, 140) while only ETB receptors are present in the inner zones (139, 140).


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Table 4. Effects of endothelial cell products on adrenal function

 
In addition to its well-established effect on basal aldosterone secretion, endothelin-1 also has been reported to augment angiotensin-II and ACTH-stimulated aldosterone secretion by bovine adrenal cells (141, 142). Endothelin-1 also stimulates proliferation of rat zona glomerulosa cells, acting via the ETA receptor (135). In the human, endothelin-1 infusion appears to enhance the aldosterone, but not cortisol, response to ACTH (143).

Endothelin-1 also stimulates glucocorticoid secretion by inner zone cells from rat and human adrenals (132, 136) by interacting with ETB receptors (134, 136). There is evidence that endothelin-1 is released from vascular endothelial cells in response to shear stress and increased perfusion pressure (144, 145). Since the rat adrenal gland releases endothelin-1 in response to increased perfusion medium flow rates, and also in response to ACTH, which is a vasodilator in this tissue (146), it may be concluded that endothelin-1 mediates at least some of the effects of increased blood flow on steroid secretion (63, 132).

It has been suggested that nitric oxide also has effects on adrenal steroid secretion. The presence or absence of L-arginine, the substrate for nitric oxide synthesis, does not alter rat adrenal glucocorticoid responsiveness to ACTH stimulation, although the basal rate of steroid output is much lower in the absence of endogenous nitric oxide synthesis (122). More recently it has been reported that the nitric oxide synthase inhibitor, L-NMMA (L-NG monomethyl arginine), inhibits the aldosterone response to ACTH stimulation in rat capsular tissue (147), although L-NAME does not have this effect in the perfused rat adrenal (122). In intact rats the administration of inhibitors of nitric oxide synthesis attenuated the adrenal response to angiotensin II in anephric rats but did not affect basal aldosterone secretion (148).

There is some disagreement in the literature as to whether adrenomedullin stimulates (47, 149, 150) or inhibits (151, 152) aldosterone secretion. Nussdorfer and co-workers (47, 151) reported inhibition of stimulated aldosterone secretion using collagenase-dispersed adrenal cells but stimulation of basal aldosterone using an intact adrenal preparation. It has been reported, however, that adrenomedullin stimulates aldosterone and cAMP production by rat adrenal capsular tissue and zona glomerulosa cells (149, 153). The stimulatory effect of adrenomedullin appears to be mediated by specific adrenomedullin receptors (153), while its inhibitory actions appear to be mediated by the CGRP receptor (151). Differential expression of adrenomedullin and CGRP receptor may explain the discrepancies between the findings of different research groups. The related peptide PAMP (proadrenomedullin N-terminal 20 peptide) may have more potent inhibitory effects (154), although stimulatory actions have also been reported (153). It has also been shown that adrenomedullin inhibits angiotensin-stimulated aldosterone secretion in human adrenal cells (155) but stimulates inner zone function in the rat adrenal (47), although this effect may be secondary to vascular actions.

It has been established that adrenomedullin is produced within the adrenal gland, by both zona glomerulosa and chromaffin cells (153), although it is not yet clear how its secretion is regulated. Like endothelin-1, adrenomedullin may also have a role in mediating the steroid response to vascular events.

D. Summary
The regulation of adrenal blood flow is complex and probably involves a range of humoral and local mediators. There is clearly a close relationship between vascular events and steroid secretion, which may be mediated by the vascular endothelium in a paracrine manner. At present, the most likely agent is endothelin-1, which appears to satisfy the criteria for such a mediator. The evidence regarding adrenomedullin remains unclear at present, although that which is currently available suggests that the effects of this peptide differ according to the receptor subtype it activates.


    V. The Intraadrenal CRH/ACTH System
 Top
 Abstract
 I. Introduction: The Adrenal...
 II. Interaction Between Adrenal...
 III. Innervation of the...
 IV. The Vascular System...
 V. The Intraadrenal CRH/ACTH...
 VI. Immune Cells and...
 VII. Peptide Growth Factors...
 VIII. The Intraadrenal Renin...
 IX. Clinical Implications
 X. Conclusions
 References
 
Cushing’s syndrome may be caused by ectopic ACTH production in a pheochromocytoma (Ref. 156 and literature herein). In addition, CRH-releasing pheochromocytomas causing Cushing’s syndrome have also been described (157, 158). Therefore, local CRH/ACTH production within the adrenal is of relevance in adrenal diseases. However, a local CRH/ACTH system may also be relevant in the regulation of adrenocortical function under physiological conditions.

A. Extrapituitary effect of CRH
The release of glucocorticoids is regulated via the hypothalamo-pituitary-adrenocortical axis, with CRH and ACTH as the respective secretagogues. Ovine CRH was purified and sequenced in 1981 (159, 160), and initial data on a dexamethasone-nonsuppressible, probably extrapituitary effect of CRH on adrenocortical steroidogenesis were published by De Souza and Van Loon in 1984 (161). Data from different experimental models have verified that CRH influences adrenocortical steroidogenesis independently from the HPA-axis. High doses of CRH had a trophic effect on the adrenal cortex of hypophysectomized rats (162), and CRH exerted a substantial steroidogenic effect on the adrenals in functionally hypophysectomized calves (163). In addition, CRH enhances the adrenal response to ACTH. When CRH was combined with a subeffective dose of ACTH, a marked dose-dependent increase in corticosterone release was observed from rat adrenals (164). In healthy humans, cortisol secretion was stimulated either by insulin or CRH. Interestingly, the ratio between the cortisol increment and the ACTH increment was higher after stimulation with CRH than with insulin (165), indicating a direct effect of CRH on the adrenal or via other factors that stimulate cortisol release.

Experiments in which the effect of CRH was neutralized also gave some evidence for the extrapituitary influence of CRH on the adrenal cortex. Immunoneutralization of CRH reduced resting corticosterone levels in rats without inducing concomitant reduction in plasma ACTH (166), and an antibody to CRH reduced the adrenal response to ACTH in dexamethasone-treated rats (164). In hypophysectomized rats, a subcutaneous infusion of {alpha}-helical-CRH or corticotropin-inhibiting peptide, competitive inhibitors of CRH and ACTH, respectively, evoked a further significant lowering of plasma corticosterone concentration and markedly enhanced adrenal atrophy (167).

Is the influence of CRH due to its direct effect of this peptide on the adrenal cortex, or is it mediated by ACTH or another peptide? A direct effect of CRH on adrenocortical steroidogenesis seems unlikely, as CRH had no effect on either isolated, dispersed adrenocortical cells (164) or on adrenocortical autotransplants deprived of chromaffin tissue (168, 169). However, in isolated perfused adrenal glands in situ, the perfusion rate was increased when CRH and a substimulatory dose of ACTH were given together, although neither CRH nor ACTH alone had an effect on the flow rate (164). Thus, the CRH-enhanced adrenal response to ACTH may result from their synergistic action on adrenal blood flow. In another experimental model, CRH enhanced corticosterone secretion in rat adrenal slices containing both cortex and medulla but had no effect on adrenocortical autotransplants that lack chromaffin tissue (168, 169). Although the exact mechanism is not yet clear, the effect is indirect rather than direct, and the intact architecture of the adrenal seems to be mandatory for the stimulatory action of CRH on the adrenal cortex. In this context, two possibilities suggest themselves. First, CRH may act with ACTH directly on intraadrenal blood vessels, and second, the medulla may respond to CRH by releasing a secretagogue that stimulates adrenocortical function.

B. Intraadrenal ACTH
Given that the adrenal medulla is necessary for the action of CRH on the adrenal cortex, which medullary product mediates the effects of CRH? The stimulatory effect of CRH on corticosterone secretion by rat adrenal slices, containing both cortex and medulla, was annulled by corticotropin-inhibiting peptide (168, 169), indicating the involvement of intraadrenal ACTH. Indeed, ACTH immunoreactivity was found in extracts of rat (170) and human (171, 172, 173) adrenal medulla, and in the adrenal venous effluent of hypophysectomized calves in response to splanchnic stimulation (174). In addition, adrenal fragments composed mainly of chromaffin cells released ACTH in response to high concentrations of CRH (168, 169). In patients with proven pituitary ACTH deficiency who received ACTH replacement therapy, subsequent CRH administration induced a significant increase in plasma cortisol that was preceded by a rise in plasma ACTH (175). Taken together, these data suggest that the adrenal medulla is a source of extrapituitary ACTH that can be stimulated by CRH.

C. Intraadrenal CRH and CRH receptors
Plasma levels of CRH are probably too low to stimulate a significant release of ACTH from the adrenal medullary. Within the adrenal itself, CRH-like immunoreactivity with ACTH-releasing activity has been detected in the medulla of cattle (176, 177), dogs (178), humans (171, 172, 173), and rats (170, 179, 180). This adrenal CRH has proved to be identical to the hypothalamic CRH (171, 173) and to be released in response to physiological stimuli, such as hemorrhage (181), splanchnic nerve stimulation (182), K+-induced depolarization, nicotine (180), neurotensin (183), vasopressin (184), neuropeptide K and neurokinin A (185), and IL-1ß (170, 180, 186). The immunohistochemical localization of CRH revealed a distinct CRH-immunoreactive subpopulation of medullary cells in canine, with dense clusters of these cells located at the boundary between the medulla and cortex (178, 181). In sheep, immunostaining revealed a network of CRH-containing cells and varicose fibers in the adrenal cortex. Mono- and bipolar cells were found throughout the cortex, most densely at the corticomedullary junction (187). These nerves were found to be associated with medullary cells at the medullary-cortical interface, islands of medullary cells in the cortex, or with rays of medullary cells extending into the cortex (188). This provides strong morphological evidence for a local intraadrenal CRH/ACTH system that is involved in the regulation of adrenocortical function.

The adrenal CRH/ACTH system is completed by the demonstration of CRH receptors in the monkey adrenal where they were located exclusively in the adrenal medulla with no staining of adrenocortical cells (189, 190). These receptors are coupled to adenylate cyclase and stimulate the secretion of catecholamines and Met-enkephalin (189).

D. Feedback mechanisms
The central CRH/ACTH system is regulated via feedback mechanisms. Similar feedback mechanisms have also been described for the adrenal CRH/ACTH system. In rats, cortisol treatment lowered adrenal ACTH secretion after 2 days of treatment, and adrenal CRH content after 7 days (179). In contrast, the intraadrenal content of CRH and ACTH immunoreactivity increased in hypophysectomized rats in direct relation to the number of days after hypophysectomy. ACTH infusion, at a rate that restored its normal blood concentration, prevented the effect of hypophysectomy on intraadrenal ACTH and CRH concentrations (191), and in hypophysectomized calves, ACTH reduced adrenal CRH output (182). These findings suggest that the elimination of the central CRH/ACTH system induces a marked increase in the activity of the intraadrenal system, and that regulation of adrenal CRH and ACTH is achieved through feedback inhibition through the end products ACTH and glucocorticoids. Evidence exists that some neuropeptides [e.g., PACAP (192, 193) and neuromedin U8 (194)] may stimulate adrenocortical steroid secretion by activating the intraadrenal CRH/ACTH system.

E. Summary
In conclusion, a complete CRH/ACTH system exists within the adrenal, with the adrenal medulla and/or intraadrenal nerves as a source of CRH and adrenal medullary chromaffin cells as the target for this local releasing hormone and the source of ACTH. It is possible that the adrenal CRH/ACTH system is important in the overall function of the gland, and it would seem that as for other products of the medulla (see Section I) the close interrelationship of adrenocortical and chromaffin cells is of great importance.


    VI. Immune Cells and Cytokines in the Adrenal Gland
 Top
 Abstract
 I. Introduction: The Adrenal...
 II. Interaction Between Adrenal...
 III. Innervation of the...
 IV. The Vascular System...
 V. The Intraadrenal CRH/ACTH...
 VI. Immune Cells and...
 VII. Peptide Growth Factors...
 VIII. The Intraadrenal Renin...
 IX. Clinical Implications
 X. Conclusions
 References
 
The interaction between the immune system and the HPA axis has been extensively studied since the pioneering work of Besedovsky and Sorkin (195), and it is now generally accepted that the immune system influences the activity of the HPA axis by stimulating the secretion of CRH and ACTH. These interactions have recently been reviewed in some excellent articles (196, 197, 198, 199, 200, 201, 202, 203, 204). However, increasing evidence exists for a local regulatory effect of the immune system within the adrenal itself.

A. Source of cytokines within the adrenal
It is generally accepted that plasma levels of immune-derived cytokines are too low to account for a direct effect on adrenal function. If secretory products of the immune system influence adrenal function, these factors should therefore be produced within the adrenal itself. The two main sources of cytokines within the adrenal are the local immune cells and the adrenal cells themselves.

1. Immune cells. The adrenal cortex is extensively infiltrated by macrophages under normal conditions (205, 206). Macrophages, shown immunohistochemically to be phagocytic, are found primarily in the zona reticularis close to the medulla (206). In addition to their phagocytotic functions, stimulated macrophages are able to secrete a variety of products, such as cytokines, including IL-1, IL-6, and TNF{alpha} (207), or peptides, such as VIP (208) and transforming growth factor-ß (TGFß) (209, 210), that can influence adrenocortical function. In the adrenal, macrophages have been shown to produce IL-1 (211), IL-6 (212), and TNF{alpha} (213). Since different cytokines may be stimulatory or inhibitory, the regulation of adrenocortical function by monocytes/macrophages may depend on their differential release, although how this is controlled is unclear. Supporting this view, monocytes may stimulate cortisol production by human cells through a non-ACTH factor (214), whereas lipopolysaccharide-stimulated murine macrophages produce a factor(s) that inhibit the action of ACTH on rabbit adrenocortical cells in vitro (215, 216).

The intraadrenal regulatory loop may be completed by the sympathetic regulation of macrophages, through their high numbers of ß-receptors (217) and the inhibition of cytokine secretion by cortisol (218). The macrophage seems to be a key player in the bidirectional immune-adrenocortical communication within the adrenal.

Lymphocytes have also been reported to produce and secrete ACTH-like substances (219), although the levels of extrapituitary, lymphocyte-derived ACTH are probably too low to account for a significant stimulation of adrenal steroidogenesis, even in response to viral infection (220). However, at least one case has been reported in which ectopic ACTH production by a granulomatous mass led to Cushing’s syndrome (221). In adrenals from elderly patients, T lymphocyte infiltration seems to be a regular phenomenon (222), thus making T lymphocyte-derived ACTH more relevant to the regulation of adrenal function. Thus, lymphocytes may also exert a paracrine influence on adrenocortical function during aging or in pathological situations.

2. Cytokines produced by adrenal cells. Adrenal cells themselves are also able to produce cytokines (Table 5Go), and although there is some conflicting evidence, there is agreement that several cytokines are produced, predominantly by adrenocortical cells.


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Table 5. Cytokines produced by adrenal cells

 
The occurrence of IL-1-like immunoreactivity was demonstrated in the noradrenergic chromaffin cells of the mouse and rat adrenal medulla, and adrenal extracts from these animals were shown to have IL-1-like stimulatory activity (223, 224). In contrast, in human adrenals, IL-1 mRNA expression was found predominantly in the steroid-producing cells of the zona reticularis (211), although both human pheochromocytoma (225) and the rat pheochromocytoma cell line PC12 (226) have been shown to produce IL-1. Species differences also exist for the localization of other cytokines such as IL-6 and TNF{alpha}. Within the rat adrenal, both of these cytokines were found in the zona glomerulosa, with only small amounts in the zona reticularis/fasciculata (227, 228). The release of these two cytokines is regulated by secretagogues for corticosteroids such as angiotensin II (229) and ACTH (228, 230), as well as by typical regulators of immune function such as IL-1{alpha}, IL-1ß, lipopolysaccharide (228, 231), or 5-HT (232). As in the rat, IL-6 is produced by human adrenocortical cells, and its mRNA is expressed mainly in the zona reticularis and in steroid-producing cells located within the medulla with little staining in the outer zones of the cortex (212). There is conflicting evidence concerning the production of TNF{alpha} in the human adrenal gland. Using RIA, TNF{alpha} was found in the fetal but not in the adult adrenal (233). In contrast, TNF{alpha} mRNA was localized by in situ hybridization in the steroid-producing cells of the zona reticularis in adult adrenals (213).

Interferon-{gamma}-inducing factor (IGIF, also called IL-1{gamma} or IL-18) is a recently identified cytokine with pleiotropic functions. This cytokine is also produced by rat adrenocortical cells, specifically in the zona reticularis and fasciculata, and its gene expression is induced by cold stress (234). Although no effect of this cytokine on adrenocortical function has yet been shown, it may well turn out to be an additional intra-adrenal cytokine that modulates adrenocortical steroido-genesis.

B. Cytokines that influence the adrenal cortex
There is considerable evidence that cytokines directly influence adrenocortical function (summarized in Table 6Go).


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Table 6. Effects of cytokines on adrenal cells in different experimental systems

 
1. IL-1. Both IL-1{alpha} and -ß directly affect adrenal function, which has been demonstrated in different experimental models. The involvement of an ACTH-independent mechanism in IL-1-induced corticosteroid secretion was recently shown by Kapcala et al. (235), who found that vagotomy attenuated plasma ACTH levels that were stimulated by intraabdominal IL-1ß whereas the corticosterone response was unaltered. This is in accord with a stimulatory effect of IL-1 on the release of glucocorticoids in hypophysectomized rats (186), from in situ perfused rat adrenals (236), rat adrenal slices in vitro (186, 237), and from isolated rat (237, 238, 239), bovine (240), and human (214) adrenal cells. There are conflicting data on the mode of action of IL-1 on adenocortical cells, but three possible mediators have been suggested: 1) prostaglandins, since the addition of indomethacin, a cyclooxygenase inhibitor, completely abolished the stimulatory effect of IL-1 (236, 239, 240); 2) the intraadrenal CRH/ACTH system, since IL-1 has no stimulatory action on adrenocortical preparations lacking chromaffin cells, and its stimulatory effect is annulled by blockade of the intraadrenal CRH/ACTH system (186); and 3) catecholamines released from the medulla (237, 238). However, IL-1 receptors have not so far been demonstrated on adrenomedullary cells (240, 241). In contrast to its stimulatory action on glucocorticoids, IL-1 inhibits angiotensin II-induced aldosterone secretion (242, 243).

2. IL-2. Like IL-1, IL-2 also stimulates the release of corticosterone from isolated rat adrenal cells (239). This effect is accompanied by increased cAMP and prostaglandin E2 accumulation. The occurrence of IL-2 receptors was immunohistochemically demonstrated in rat adrenal cells in culture (244), and in this study the expression of the IL-2 receptor was enhanced by incubation with IL-2, but attenuated by dexamethasone.

3. IL-6. IL-6 alone and in synergism with ACTH stimulates the release of corticosterone from rat adrenocortical cells (245), an effect that may be mediated by prostaglandins (239). In humans, IL-6 activates the HPA axis by stimulating the release of cortisol and ACTH. Interestingly, in these studies plasma levels of ACTH decreased after long-term application of IL-6, whereas cortisol remained elevated, suggesting a direct effect of IL-6 on the adrenal cortex (246, 247). The IL-6 receptor is located on human adrenocortical cells, predominantly in the zona reticularis and inner zona fasciculata, and IL-6 stimulates corticosteroid release from human adrenal cells in primary culture, with a prominent effect on the release of adrenal androgens (248, 249). The effect of IL-6 on adrenal androgen production is of interest for two reasons. First, in view of the discrepancy in plasma ACTH levels and androgen release at adrenarche, and in several other clinical situations (250), IL-6 may be a local factor in the production of C19-steroids. Second, as IL-6 is expressed in the zona reticularis and stimulates DHEA secretion, it may be involved in local immune functions of the adrenal.

4. TNF{alpha}. TNF{alpha} is a 17-kDa polypeptide hormone that is produced by a wide variety of tissues (251). Together with IL-1 and IL-6, TNF{alpha} accounts for most of the HPA-axis-stimulating activity in plasma (203). In the adrenal, however, TNF{alpha} inhibits the angiotensin II- and ACTH-induced release of aldosterone from rat adrenal cells (243) as well as basal and ACTH-stimulated cortisol production. TNF{alpha} also influences P450 enzyme expression in human fetal adrenals (233, 252) with a consequent shift to androgen production (233). In contrast to its inhibitory action on isolated adrenal cells, TNF{alpha} had a direct, ACTH-independent, stimulatory effect on corticosterone secretion in rats with cholestasis due to bile duct resection (253). In cultured human fetal adrenal cells, TNF{alpha} inhibits basal and ACTH-induced insulin-like growth factor (IGF) expression (254, 255), indicating its involvement in growth and differentiation of the fetal adrenal (see Section VII). The direct, intraadrenal inhibitory effect of TNF{alpha} therefore contrasts with its effects in the intact animal, indicating a role of local, intraadrenal produced TNF{alpha}, which is different from the role of circulating inflammatory TNF{alpha}.

5. Interferons. Interferons are a family of polypeptides that disrupt viral replication in infected cells. In addition, they have a wide variety of effects in immunological processes (256). Two members of this family have been shown to influence adrenal steroidogenesis. Interferon-{alpha} stimulates corticosterone secretion from rat adrenal cells in primary culture (257). In contrast, interferon-{gamma} inhibits basal and ACTH-induced IGF-II gene expression in human fetal adrenal cells (254, 255), suggesting its involvement in growth and differentiation of the fetal adrenal.

C. Summary
Cytokines produced either by immune cells that regularly infiltrate the adrenal or by adrenal cells themselves are able to directly influence adrenocortical function. They may, like IL-1, IL-2, and IL-6, stimulate steroidogenesis or, like TNF{alpha} or interferon-{gamma}, exert a regulatory influence on adrenal growth. The immune system and the endocrine system of the HPA axis have a crucial role in the complex adaptive response to the challenge of homeostasis by either stress or disease (for review, see Ref.258). It is therefore not surprising that both systems interact at different levels. In this context, it is of interest that the three cytokines located within the adrenal, namely IL-1, IL-6, and TNF{alpha} (Table 4Go), are responsible for most of the immune-derived HPA axis-stimulating activity in plasma (203). Accordingly, these cytokines seem to play an important role in the regulation of the HPA axis. In this context an acute regulation at the level of the hypothalamus and a long-term regulation at the level of the adrenal have been suggested (203).


    VII. Peptide Growth Factors and the Adrenal Cortex
 Top
 Abstract
 I. Introduction: The Adrenal...
 II. Interaction Between Adrenal...
 III. Innervation of the...
 IV. The Vascular System...
 V. The Intraadrenal CRH/ACTH...
 VI. Immune Cells and...
 VII. Peptide Growth Factors...
 VIII. The Intraadrenal Renin...
 IX. Clinical Implications
 X. Conclusions
 References
 
Although corticotropin and angiotensin II, the classic stimulants of the adrenal cortex, are known to have specific effects on adrenocortical growth and differentiation, their actions may be at least partially mediated via locally produced regulators. Various peptide growth factors may act as paracrine agents in this way and, in particular, basic fibroblast growth factor (bFGF), IGFs, and transforming growth factor-ß1 (TGF-ß1), have emerged in recent years as multifunctional molecules that typically play such regulatory roles and that are widely expressed in many mammalian tissues (259, 260, 261, 262). Characteristically, their actions on mitogenesis and tissue growth are mediated through receptor tyrosine kinases which, on activation, form stable complexes with tissue-signaling molecules, eventually leading to the regulation of protooncogene transcription factors, such as c-fos and c-jun, via the mitogen-activated protein kinase pathway (263, 264, 265, 266, 267). The formation of these and other growth factors has been demonstrated in the adrenal cortex using protein fractionation and immunological and molecular biological methods (268, 269, 270, 271, 272, 273, 274, 275). Clearly, the localized expression, release, and activation of such factors may moderate the actions of the circulating trophic hormones on the growth and differentiation of the zones of the adrenal cortex, and in recent years much evidence has accumulated in support of this hypothesis (259). Receptors for other growth factors, such as epidermal growth factor, may also be present in adrenocortical tissue, but thus far there is little evidence for their local production (274).

A. FGFs
First described in brain and pituitary (276, 277, 278), members of the FGF family have been shown to have a wide distribution (260). Two forms, acidic and basic FGF (aFGF and bFGF) have been studied intensively. These are closely related, with about 55% amino acid sequence identity (260, 279, 280). Both aFGF and bFGF are present in neural tissue, although only bFGF has been isolated from the bovine adrenal (281). Although bFGF cDNA predicts a polypeptide consisting of 155 amino acid residues, there is significant microheterogeneity (260), and various bFGF isoforms may be present in bovine or rat adrenals (282, 283).

bFGF is a multifunctional polypeptide with a wide range of biological activities on various target cells (260, 270). It has mitogenic actions on various mesoderm- and neuroectoderm-derived cells in culture (284, 285). In vivo, it may be associated with wound healing (286), angiogenesis (284), and reproductive function, as well as development and morphogenesis (260). bFGF is also an important neurotrophic factor (283, 285, 287).

Heparan sulfate proteoglycans of the extracellular matrix are important for the biological activity of bFGF by acting as a storage site (288, 289, 290, 291), from which they may be released by heparanase (291) or by plasminogen activator-associated proteolysis (290). Although bFGF is mainly associated with the extracellular matrix and with the basement membranes underlying epithelia, in many tissues, including the adrenal cortex, some may also be intracellular (269).

bFGF is expressed in many rat tissues (292) and has been purified and characterized from extracts of bovine adrenals (281) and cultured adrenocortical cells (286). Immunoblot analysis has shown bFGF-like immunoreactivity in rat adrenal glands (283). Its wide distribution, the low to undetectable mRNA level, and its high affinity for heparin are consistent with the view that bFGF is stored and stabilized in the extracellular matrix (260, 292), and that high levels of bFGF protein found in the adrenal tissues are attributable to storage of the mitogen and not continuous gene expression. Heparan sulfate proteoglycans may be regulated in adrenal tissue by ACTH or TGFß, thus controlling the bioavailability of bFGF (288). Another growth factor-binding protein, {alpha}(2)-macroglobulin, which complexes with TGFß, is itself regulated by bFGF, as well as TGFß (293). Although, in bovine adrenal cells, bFGF release appears to be a prerequisite for its biological action (286), it is also possible that heparan sulfate binding facilitates bFGF interaction with its high-affinity receptor (294).

In studies on the mechanism of the compensatory hypertrophy after unilateral adrenalectomy, it was shown that bFGF receptors are concentrated in the capsule glomerulosa region of the rat adrenal cortex, and that bFGF itself is most abundant in the glomerulosa and in the medulla (289, 295). Compensatory hypertrophy was inhibited by suramin, a growth factor antagonist, and the proliferative actions of bFGF on glomerulosa cells in vitro were blocked by antisense techniques targeted against the bFGF receptor (282). These results are consistent with the concept that the capsule-glomerulosa region is the primary site for cellular proliferation in the adrenal. Although a great deal of evidence supports this view, there is also evidence that in other circumstances proliferation in the rat adrenal may be stimulated in other parts of the gland (296), depending on physiological demand, or during development. Thus, during the first week of postnatal development in rats, immunoreactive bFGF is found in the fasciculata as well as in the glomerulosa, although this declined at later stages: the reticularis expresses little at any stage (296). These changes are paralleled by decreases in the total bFGF mRNA content (297). Consistent with this, in situ hybridization studies showed that very small amounts of bFGF mRNA were detected, predominantly in the zona fasciculata of normal adult female rat adrenal cortex, but this distribution was affected by physiological manipulation. In particular, while a low sodium diet induced more bFGF gene transcription in the glomerulosa, corticotropin treatment resulted in increased message in the outer fasciculata as well as in the subcapsular region (275). In addition, transcription of mRNA coding for bFGF was enhanced by ACTH in human fetal adrenal cells in culture, suggesting that the increased growth induced by corticotropin may be mediated by this growth factor (298). Northern blot analysis also demonstrates the presence of bFGF mRNA in cultured bovine adrenocortical cells (286).

bFGF-binding sites have been detected in bovine adrenocortical cells (294) and in the capsule and zona glomerulosa of rat adrenal cortex (289) and may be directly induced by glucocorticoid in the cortex and medulla (299). bFGF is a potent mitogen in Y1 (300), bovine (286, 301, 302), and human fetal (259, 298) adrenocortical cells. It stimulates protooncogene mRNA expression in bovine adrenocortical cells (303) and increases the expression of 17{alpha}-hydroxylase (303), angiotensin type I receptor, and {alpha}-subunit of Gq and G11 proteins (304).

Thus the sites of bFGF gene transcription in the adrenal cortex, its regulation by ACTH, and its actions on mitosis and tissue growth are all consistent with its role in mediating the tropic actions of ACTH, and other tropic agents, since bFGF may also be involved in the proliferation of adrenocortical cells during the compensatory adrenal growth response (Ref. 295 and see below).

bFGF is also highly expressed in the medulla (283, 285, 297) and, like nerve growth factor it stimulates cell division and, perhaps more weakly, neurite outgrowth from cultured neonatal rat chromaffin cells (287). It also stimulates catecholamine storage (287). Neuronal differentiation, but not cell division, induced by bFGF is inhibited by glucocorticoids (285, 305), which increase FGF receptor mRNA transcription in the medulla as well as the cortex (299). Since the innervation of the cortex is partly derived from the medulla, bFGF may in this way also be involved in the development of adrenocortical innervation. In addition, since bFGF is a potent angiogenic factor (260, 281, 284, 291), it may also be involved in the organization of the adrenal vasculature.

B. IGFs
The IGF family consists of two closely related peptides, designated IGF-I and IGF-II. Both circulate in the plasma as hormones, and IGF-I is probably the principal blood-borne mediator of the actions of GH on bone elongation. These hormones are also widespread in tissues, with multiple actions as paracrine/autocrine agents (262). Of the two IGF receptor subtypes, the tetrameric type-1 IGF receptor structurally resembles the insulin receptor and has a higher affinity for IGF-I. The type-2 IGF receptor, which also binds mannose-6-phosphate, has no intrinsic tyrosine kinase activity, and in fact has an entirely different structure, with a short cytoplasmic domain and 15 cysteine-rich extracellar domains (262, 265). The IGF type-1 receptor mediates most of the effects of IGF-I and II (262).

A family of specific IGF-binding proteins (IGFBPs), with affinities for IGF-I equal to or higher than the high-affinity type-1 receptor, regulates its bioavailability (265).

Despite their similar chemical structures and in vitro activities, IGFs-I and II exhibit significant differences in their pattern of expression and activities in vivo. IGF-II is expressed predominantly in the embryonic stages of mammalian development in a wide variety of different tissues. Relatively higher amounts of IGF-II mRNA than IGF-I mRNA are present in multiple human fetal tissues (306, 307, 308). Both IGF-II mRNA and peptide are present in human (255, 306, 307, 308, 309, 310) and ovine (311) fetal adrenocortical cells, and transcription is induced by ACTH and cAMP as two components of complex multifactorial regulation (255, 309). In man, IGF-II expression is tightly linked to the H19 gene, which has an important role in embryogenesis and fetal development (255, 312). IGF-II may also be present in tumors (313). In contrast, IGF-I mRNA content of human fetal adrenocortical cells is low (310), although it is present in the capsule (309). On the other hand, IGF-I has been shown to maintain the differentiated function of fetal adrenal as well as bovine fasciculata cells in vitro (314, 315, 316), and IGF-I and II are equipotently mitogenic in cultured fetal adrenal cells, probably reflecting their common action through the IGF type-1 receptor (309). In contrast, IGF-I mRNA is present in cultured human adult adrenals (309). Thus, it is suggested that IGF-II is an important fetal growth factor, whereas IGF-I is more important postnatally (309, 311).

Both IGF-I mRNA and peptide are also detected in adult rat adrenal glands (310, 317), and using in situ hybridization, IGF-I mRNA was localized mainly in the zona fasciculata in normal adult female rat adrenal cortex. However, its expression in the glomerulosa was increased by ACTH pretreatment and by a low sodium diet (275).

Since the IGF peptides and their receptors have been detected in the adrenal cortex of various species, IGF-I appears to have an important regulatory role in adrenocortical growth and in the induction and maintenance of steroidogenic function (259, 316, 318, 319, 320, 321, 322, 323). Generally, IGF type-1 receptors have been studied, although in bovine adrenocortical cells, IGF type-2 receptors are in fact the more abundant (324). IGF-I stimulates DNA synthesis in primary cultures of bovine adrenal glomerulosa cells (319) and also acts as a mitogen for fetal rat (325) and ovine (314) adrenocortical cells in vitro, although apparently only weakly so in bovine adrenocortical cells (316). It also induces steroidogenesis in adrenocortical cells (316, 326). IGF formation and secretion is induced by FGF, ACTH, and by angiotensin II in bovine adrenocortical cells in vitro (315, 327). In contrast, both IGF-I and IGF-II mRNAs were reduced by ACTH in rat adrenals, despite significant growth and increased side chain cleavage P-450, while they were unchanged by compensatory hypertrophy (328).

The effect of IGF-I on ACTH-induced steroidogenesis in adrenocortical cells remains unresolved (316, 329, 330). Long-term treatment of bovine adrenocortical cells with IGF-I increases both angiotensin II and ACTH receptors and enhances the steroidogenic response to these hormones by increasing the activity of several steroid hydroxylases (316). In these cells, IGF-I potentiates the effect of ACTH on the expression of ACTH receptors and on the secretion of cortisol (331). The stimulatory effect of IGF-I on corticosteroidogenesis may also be ascribed to an increased expression of stimulatory G proteins (332). In contrast, the acute effect of IGF-I in ACTH-stimulated rat adrenocortical cells is inhibitory. IGF-I, acting through its specific receptor, reduces both cAMP production and corticosterone secretion (330). Neither insulin nor IGF-I was found to have any effect on steroidogenesis by guinea pig adrenocortical cells in vitro (329).

It has also been shown that IGFBPs are synthesized locally in the rat, as well as bovine adrenals (315, 333, 334, 335). It is probable that the IGFBPs play an important role in regulating IGF-I bioavailability. In one study, ACTH and angiotensin II were found to specifically induce a 38- to 42-kDa IGFBP, although other IGFBPs were inhibited or unaffected (315). In contrast, another study identified four IGFBPs in culture media from bovine adrenocortical cells, and all were increased by ACTH. Furthermore, IGF-II and a truncated form of IGF-I that does not bind to IGFBPs were both more potent than IGF-I in stimulating steroidogenesis (335).

C. TGFß
TGFß belongs to a large TGF superfamily that represents a family of low molecular mass (5–28 kDa) peptides with the ability to influence the phenotype and the growth characteristics of nontransformed cells (261). TGFß is a homodimeric, disulfide-bonded protein made up from two 12-kDa polypeptide chains: five different TGFß isoforms (TGFß 1–5) are found in vertebrates, and TGFß 1–3 are found during mammalian development (336).

TGFß protein has been detected in the bovine adrenal cortex by immunostaining, mainly in the zona fasciculata, with less staining in the glomerulosa, but with none in the adrenal medulla (337). TGFß mRNA was also found in adult mouse adrenal tissue, and the TGFß protein has been detected in the adult mouse adrenal inner cortex (338). Very small amounts of TGFß mRNA were detected in the zona fasciculata of the rat adrenal cortex and in the medulla, and these were not markedly affected by ACTH or a low-sodium diet (275). Bovine adrenocortical cells also secrete TGFß1, although in latent (activatable) forms, one of which is complexed with {alpha}2-macroglobulin (339). Latent TGFß can be activated by an ACTH-induced secreted protein (CISP), a member of the thrombospondin family (340).

In bovine adrenocortical cells, TGFß1 receptors have been characterized by RRAs and cross-linking techniques (341). Only type I and III receptors appear to be expressed in adrenocortical cells and are increased in number by ACTH stimulation (336, 341).

TGFß1 alone exhibits no detectable effect on DNA synthesis and has no effect on bovine adrenocortical cell proliferation (336, 342). In contrast, it is antimitogenic for cultured human fetal adrenocortical cells (343, 344), an action that is opposed by ACTH in the neocortex (344), although apparently not in the fetal zone (343).

TGFß is a potent modulator of differentiated adrenocortical cell functions, and it has recently been demonstrated that TGFß1 exerts an autocrine inhibitory effect on bovine adrenocortical cells (345). In this study, basal steroidogenic activity was increased through the suppression of TGFß1 expression by antisense nucleotides. TGFß exerts its inhibitory effect on different cellular levels. It has a significant inhibitory effect on the steroidogenic activities of bovine and ovine adrenocortical cells in culture in both basal and ACTH- or angiotensin II-stimulated conditions, though it has no effect on ACTH-stimulated adenylyl cyclase activity (342, 346). Cytochrome P-45017{alpha} (CYP17, 17{alpha}-hydroxylase) is a major target for this action, and its formation is inhibited at the mRNA transcriptional level (336, 347, 348).

TGFß also regulates receptor expression. Angiotensin II receptor expression is decreased in bovine adrenocortical cells (336, 349), as is the expression of low-density lipoprotein receptors (349). ACTH receptors are decreased in ovine adrenocortical cells (350). TGFß also stimulates the production of fibronectin (351, 352), heparan sulfate proteoglycans (288), and {alpha}2-macroglobulin in bovine adrenocortical cells (336, 353), thus contributing to an increased accumulation of growth factor-binding extracellular matrix. In fact, TGFß1 acts as an activator of {alpha}2-macroglobulin gene expression at the transcriptional level. TGFß2 and angiotensin II also appear able to stimulate {alpha}2-macroglobulin secretion in bovine cells, whereas ACTH is strongly inhibitory. Since {alpha}2-macroglobulin is a TGFß-binding protein, these observations suggest that it may play an important role in conjunction with hormones and growth factors in the homeostatic regulation of adrenocortical functions (336, 339, 353, 354).

The observed effects are different for the human adrenal and sometimes even in contrast to data from ovine and bovine adrenals. The most striking effect of TGFß on steroidogenesis in fetal (355, 356) as well as in adult (357) human adrenals seems to be the reduction of dehydroepiandrosterone sulfate. It had no effect on ACTH receptor mRNA levels and enhanced angiotensin-II type 1 receptor mRNA and binding sites (356, 357). TGFß had a differential effect on the expression of steroidogenic enzymes. It had no effect on cholesterol side-chain cleavage cytochrome P-450 mRNA, increased mRNA accumulation of 3ß-hydroxysteroid dehydrogenase mRNA (356, 357), and reduced those of cytochrome P-450 17{alpha}-hydroxylase mRNA (355, 356, 357).

There is agreement that the inhibitory effect of TGFß action occurs distal to the formation of cAMP. TGFß did not influence cAMP levels in bovine adrenocortical cells (342) nor could the effect be overcome by the addition of (Bu)2-cAMP (348, 358). In human fetal adrenals, TGFß inhibits (Bu)2-cAMP-stimulated steroid secretion (342). However, in bovine adrenocortical cells, the effect could be completely reversed by the addition of 25-hydroxycholesterol, pregnenolone, or progesterone (342). These data suggest that TGFß induced inhibition of steroidogenesis at a site before the formation of cholesterol.

In a single report, TGF{alpha} has also been identified in human adrenocortical tissue and tumors (274).

D. Summary
In summary, the development and maintenance of the adrenal cortex, like those of other tissues, appear, at least in part, to be mediated by the local production of growth factors. These include IGFs, TGFß, and ßFGF, which exert a variety of both stimulatory and inhibitory actions on the growth, differentiation, and differentiated functions of the gland. In these roles the growth factors may well mediate the growth-regulating effects of systemic factors, such as ACTH, and perhaps also contribute to their acute effects on steroid hormone secretion.


    VIII. The Intraadrenal Renin-Angiotensin System (RAS)
 Top
 Abstract
 I. Introduction: The Adrenal...
 II. Interaction Between Adrenal...
 III. Innervation of the...
 IV. The Vascular System...
 V. The Intraadrenal CRH/ACTH...
 VI. Immune Cells and...
 VII. Peptide Growth Factors...
 VIII. The Intraadrenal Renin...
 IX. Clinical Implications
 X. Conclusions
 References
 
A. The role of the RAS in adrenocortical function
In 1958, Gross (359) first drew attention to the primary importance of the RAS in the regulation of aldosterone secretion. Since that time it has been demonstrated unequivocally that reduced sodium balance brings about rises in PRA, angiotensin II, and aldosterone concentrations, and that the increase in aldosterone can be blocked by use of a converting enzyme inhibitor, such as captopril (360, 361, 362). The ability of angiotensin II to stimulate aldosterone secretion has been shown directly in numerous species, including humans, rat, sheep, dog, and rabbit (363, 364, 365, 366, 367, 368), and, in general, this is unaccompanied by increases in glucocorticoid secretion by the inner adrenocortical zones (fasciculata and reticularis), although there is species variation in this respect (e.g., Refs. 369 and 370). The cells of the zona glomerulosa contain specific angiotensin receptors, mostly of the AT1 subtype (371, 372, 373, 374), and linkage to the synthesis and secretion of aldosterone is via the phosphatidyl inositol/ITP/intracellular calcium pathway (375, 376, 377, 378, 379, 380, 381). If anything, the action of angiotensin II on cAMP generation is inhibitory (377, 379, 382). In most species, concentrations of angiotensin II receptors are considerably lower in the inner adrenocortical zones than in the glomerulosa, and high concentrations of angiotensin II are required to stimulate steroid output in bovine fasciculata cells (370, 383, 384). Receptor subtypes in the adrenocortical inner zones have not been unequivocally identified but, since the signaling pathways in bovine cells are apparently the same as in the glomerulosa (385, 386), the AT1 subtype seems to be implicated here as well. The medulla also contains angiotensin receptors, though mostly of the AT2 subtype (372). In addition to its acute actions on aldosterone secretion, longer term treatment with angiotensin II also has a proliferative effect on the glomerulosa and on the maintenance of aldosterone synthase, and in this way it reproduces the chronic effects of a low-sodium diet (361, 387, 388, 389, 390, 391). In ovine adrenal cells, angiotensin II has also been shown to suppress 17{alpha}-hydroxylase expression and to inhibit the response of cortisol to ACTH stimulation, in other words suppressing fasciculata-type function (392).

Most interpretations have been based on the premise that it is systemically generated angiotensin II that regulates aldosterone formation and secretion by the zona glomerulosa. However, the evidence has accumulated in recent years to suggest that, like other tissues, the adrenal gland contains its own tissue-localized RAS, and that angiotensin II is generated within the tissue, thus exercising paracrine regulation. This evidence consists of the identification of gene transcripts for prorenin, angiotensinogen, and angiotensin-converting enzyme in adrenal tissue, and of the proteins for which they code, both in the active (renin, angiotensin II) and inactive precursor forms. The evidence also suggests that these products are released in response to physiological demand. The specific role for the tissue system, as opposed to the systemic RAS, remains uncertain.

B. Renin
The presence of renin-like activity in the adrenal was shown by Ryan (393) and by Granzer (394), and subsequently by others in a variety of species, including rabbit, dog, rats, human, and mouse (395, 396, 397, 398). Its molecular mass, isoelectric point, and pH activation profile, as well as immunological similarity and the presence of the inactive prorenin form, proved the identity of the adrenal enzyme with that produced by the kidney in human and rat glands (397, 399). That the enzyme was locally formed within the adrenal was shown by its increased concentration in nephrectomized animals (in spontaneously hypertensive rats as well as in normal strains) and by the fact that in humans it has little correlation with PRA (397, 400, 401, 402, 403, 404).

The zona glomerulosa is the primary site of renin formation in the rat and human gland (403, 405, 406, 407, 408, 409, 410, 411, 412), where it is localized in particulate subcellular components, identified as the mitochondrial fraction in human and rat adrenals (397, 413), as lysosome-like dense bodies (401, 414, 415) or intramitochondrial dense bodies (416) in rats, or as lysosomal granules in fetal mice (417, 418, 419). There may be both glomerulosa and inner zone sources of renin in the mouse adrenal (398, 403), while transgenic rats bearing the mouse Ren-2 gene also express renin in inner zones (420). Medullary cells are also a source of renin (421).

Prorenin is also present in human and rat adrenals (400, 410, 421, 422) and is activated in the glomerulosa (400, 423); there are lower amounts of prorenin than renin in human normal tissue and adenomas (422). Transcription of prorenin mRNA has been shown in adrenal tissue and cells using Northern blot, PCR, and in situ hybridization techniques in rat glands and in normal human glands and adenomas (408, 411, 422, 424, 425, 426, 427).

Adrenal renin expression is regulated in accordance with apparent physiological requirement; thus prorenin mRNA transcription activity is increased in rats by a low-sodium diet or by potassium loading (428, 429, 430), and a high-sodium diet decreases it (430). Similarly, potassium, ACTH, or angiotensin II stimulation of cultured rat glomerulosa cells increased renin mRNA in vitro and also the formation both of active renin (which remained largely cellular) and prorenin, the predominant secreted form (408, 409, 431). In bovine glomerulosa cells, potassium, ACTH, and cAMP stimulated the secretion of active renin, whereas prorenin secretion was stimulated by catecholamines (432).

C. Angiotensinogen
The presence of angiotensinogen mRNA has been demonstrated in the adrenals of mouse, rat (424, 433, 434), and human (422), in capsular fibroblast-like cells rather than in adrenocortical cells in rats (433), and in normal and abnormal glomerulosa, fasciculata, and medullary cells in the human gland (422). While angiotensinogen was synthesized, it was apparently not stored, and there was no correlation between immunoassayable angiotensinogen and its mRNA (422, 426).

D. Angiotensin-converting enzyme and the production of angiotensin II
Direct evidence for angiotensin formation in the adrenal comes from several studies. Assay of HPLC-fractionated angiotensins I, II, and III and des-Asp angiotensin II shows that the rat adrenal zona glomerulosa contains higher concentrations of these than the inner zones. Tissue angiotensin content is unaffected by nephrectomy (402), is enhanced (particularly angiotensin II) by a low-sodium diet (402) or potassium loading (428), but is reduced in sodium-replete animals, as are renin- and angiotensin II-binding activities (407). Angiotensin II is secreted by superfused rat adrenal capsules and superfused human adrenal glands (426, 435), and secretion of both angiotensin I and II by rat tissue was stimulated by increased potassium ion concentrations (435). Superfused rat adrenal zona glomerulosa cells similarly respond to high potassium ion concentrations with increased angiotensin II secretion, although the source is only a subpopulation of cells. In chronic stimulation, by low dietary sodium, both output per cell and the number of cells involved in angiotensin II secretion are increased (436). Previous evidence suggested that formation of angiotensin II in the rat adrenal glomerulosa is extracellular (437), although there appears to be no direct evidence of the precise location of angiotensin-converting enzyme. Nevertheless, angiotensin II secretion by rat adrenal capsule/glomerulosa explants was attenuated by the addition of a converting enzyme inhibitor under control (unstimulated) conditions and also when stimulated by increased potassium ion concentration, as was aldosterone (410). Angiotensin I-stimulated aldosterone secretion was also inhibited by converting enzyme inhibition in superfused rat adrenal capsules, whereas angiotensin II-stimulated aldosterone secretion was not (438). In other experiments with human tissue, the addition of a converting enzyme inhibitor caused a concomitant decrease in angiotensin II/III and aldosterone in three normal samples, although it was without effect in two aldosteronomas (439).

Quite remarkably, in addition to the effect of converting enzyme inhibition on potassium-stimulated aldosterone synthesis, noted above, ACTH-stimulated aldosterone output is also attenuated (431), conveying the possibility that at least a part of the stimulatory action of ACTH on aldosterone may be modulated by the tissue RAS. This is difficult to reconcile with the literature, which shows that the action of exogeneously added angiotensin II and ACTH may be antagonistic.

E. What is the functional significance of the intraadrenal RAS?
To interpret this function correctly, two fundamental questions require resolution, viz 1) what specific roles of the tissue RAS are not or cannot be fulfilled by the systemic RAS? and 2) how are the systemic and tissue RAS separately maintained and independently distinguished by target organ receptors?

There are very few clues to suggest a specific role for the adrenal RAS, because it and the systemic RAS appear to respond broadly to the same stimuli. It is certainly possible that tissue-generated angiotensin II may be more effective than plasma angiotensin in mediating increases in aldosterone secretion, e.g., to a low-sodium diet, and this is suggested by the parallel kinetics of tissue angiotensin II and plasma aldosterone in rats, which may require 1–2 days to reach a plateau, in contrast to the relatively rapid peak in PRA, reached 8 h after onset of sodium restriction (440). In superfused rat glomerulosa tissue and in dispersed cells, the secretion of aldosterone and angiotensin II were highly significantly correlated, and secretion of both was oscillatory (435).

Nevertheless, it has also become apparent that the response of aldosterone secretion to stimulation by other factors may, in fact, depend on the adrenal RAS. Thus, both the effects of ACTH and of potassium ions are attenuated by converting enzyme inhibition in rat adrenal glomerulosa cells in monolayer culture (410, 431) and by the specific type 1 angiotensin II (AT1) receptor antagonist, losartan (441), In bovine adrenocortical cells, the aldosterone-secretory response to ouabain was inhibited by losartan (442). It may be, therefore, that the activity of the tissue RAS is required to maintain adrenocortical cells in an appropriate functional state to be able to respond to acute or chronic stimulation by other factors. One can only speculate what such effects of the RAS may be, and it might be worth studying, for example, its actions on the replenishment of steroid precursor pools, such as cellular cholesterol, or of calcium pools in the endoplasmic reticulum (cf. Ref.442).

The view that the local tissue RAS may be more concerned with the longer term purely tropic actions of angiotensin II, rather than with the acute response of aldosterone secretion, has been suggested by studies with rats transfected with the Ren-2 mouse renin gene, the hypertensive transgenic [TGR (mRen-2)27] animal (443). In these, there are high concentrations of adrenal renin, not only in the glomerulosa, but also in inner adrenocortical zones, whereas kidney renin content and renin gene expression are low (444). Aldosterone production was also found in the inner adrenocortical zones, prompting the view that one role of the adrenal RAS is to support aldosterone synthase expression (419, 420). The concept that chronic tropic actions, rather than the acute effects, are the characteristic response to the tissue rather than the systemic RAS accords with similar interpretations of the cardiac RAS (445). Certainly, angiotensin II infusions, like a low-sodium diet, promote cell division both in the glomerulosa and reticularis (446). The capacity of angiotensin II to model the tissue becomes more complex with the finding that, whereas the AT1 receptor modulates the mitotic response, the AT2 receptor may be specifically concerned with apoptosis (447). The precise action of angiotensin II on tissue structure may therefore depend in part on the relative abundance of the two receptor subtypes.

The possibility also exists that adrenal-generated angiotensin II may have systemic effects, at least in a spontaneously stroke-prone rat strain (402, 448), and the transgenic [TGR (mRen-2)27] rat (449, 450), through the secretion of prorenin, which may in this case have an intrinsic activity without the requirement for conversion to renin (451). The adrenal RAS may also have a role in the hypotensive response to angiotensin-converting enzyme (ACE) inhibition in normal rats (452). In both the transgenic rats and in normal animals, basal adrenal renin content is stimulated by angiotensin II, suggesting a remarkable positive feedback loop (409, 453), but in normal rats the ACTH-stimulated increase in renin is blocked by angiotensin II (409). Nevertheless, nephrectomy enhances adrenal renin content (450), as in nontransgenic animals (see above); thus, the regulation of adrenal renin production is complex.

Another possibility is that the adrenal tissue RAS is associated with regulation of the vasculature. It is clear that the function of the inner adrenocortical zones and the secretion of glucocorticoids are greatly influenced by vascular events. In particular, increased blood flow through the gland is associated with, and indeed stimulates, glucocorticoid secretion, presumably through changes in the secretion of factors originating in the vessels themselves, such as nitric oxide and the endothelins (Section IV). It is possible that tissue angiotensin II also has a role here, in view of its vasoactive properties and its known vasoconstrictive action in the rat adrenal (454). Together with other possible functions, a role in regulating regional blood flow has also been suggested for the local RAS in the heart (455). Further studies are required to establish the validity of any of these hypotheses (see also Refs. 412 and 456).

F. How can the angiotensin II produced by the tissue RAS be distinguished from the systemic system?
Precise data on the cellular localizations of the sites of production of the RAS components, their regulation, and their spatial relationship to the sites of angiotensin II receptors are an absolute requirement for the interpretation of these systems. In general, this has not been achieved because of a lack of monoclonal antibodies to the receptors (412, 434). Gross measurement of angiotensin II-binding activity and adrenal renin and angiotensin II concentrations in rat adrenals has suggested little overall relationship between these parameters (407), although, in view of the intimacy of sites of angiotensin production and action, resolution at the light microscope, if not the ultrastructural, level is required.

However, if both angiotensin II formation and angiotensin II receptors occur in the same cell type, what implications does this hold for receptor occupancy and the gland’s capacity to respond to physiological demand? One possibility is that angiotensin receptors are in some way sequestrated intracellularly so that their availability to locally generated angiotensin II can be regulated.

G. Summary
In summary, the evidence is very powerful that, as in certain other tissues, a complete RAS is present in the adrenal cortex, primarily in the glomerulosa. This system generates angiotensin II to act in a paracrine/autocrine fashion on the cells of the glomerulosa and responds to physiological demand as does the circulating system, e.g., its activity is enhanced in conditions of dietary sodium restriction. It can be conjectured that this system is concerned with various aspects of glomerulosa function, including the mediation of the effects of other stimulants, such as ACTH or potassium ions, and tissue differentiation and modeling.


    IX. Clinical Implications
 Top
 Abstract
 I. Introduction: The Adrenal...
 II. Interaction Between Adrenal...
 III. Innervation of the...
 IV. The Vascular System...
 V. The Intraadrenal CRH/ACTH...
 VI. Immune Cells and...
 VII. Peptide Growth Factors...
 VIII. The Intraadrenal Renin...
 IX. Clinical Implications
 X. Conclusions
 References
 
A. Cortisol
Why should a neuro-adrenocortical axis or other intraadrenal mechanism be relevant to clinical medicine? Is there evidence for extrapituitary, intraadrenal regulation of cortisol secretion? It is well established that glucocorticoids are mainly regulated by pituitary ACTH and that hypophysectomy leads to atrophy of the adrenal cortex. However, it has been known for many years that in individuals given dexamethasone in doses large enough to suppress pituitary function, plasma corticosteroids nevertheless increase in response to surgical stress (457, 458), although ACTH and CRH levels may fall below presurgical values (458). The rise in cortisol can, however, be abolished by interrupting the neural connection at the operative site (6). This elevation of cortisol levels after surgery is not attributable to changes in cortisol metabolism (459), and it therefore presumably arises through direct stimulation of the adrenal cortex. TNF and IL-6 concentrations are elevated during major surgery and may remain elevated for an additional 48–72 h, corresponding to the period of increased levels of cortisol (460).

There is further evidence of the dissociation between plasma ACTH concentrations and cortisol secretion. In patients with bacterial sepsis (461, 462) and in the chronic severe illness of late-stage human immunodeficiency virus disease, persistently elevated cortisol levels are accompanied by suppressed ACTH values (463). In this context, cytokines such as IL-6 may be relevant, since this cytokine is a potent activator of the HPA axis (246, 247) and may exceed in potency the action of CRH (464). While the effect of IL-6 on the pituitary appears to be acute, IL-6 has a long-term direct action on the adrenal cortex at concentrations that may occur in critical illness (246, 249). Ten to 20% of patients with critical illness, however, develop adrenocortical insufficiency (465). In these cases cytokines such as TGFß, which are elevated in sepsis, may directly block adrenal function.

Corticosteroids are essential for survival during periods of critical illness. It is obvious that during severe stress, the neuroendocrine systems and the immune system need to interact at multiple levels in an attempt to provide a coordinated response that meets the challenge to homeostasis with minimal damage to the organism as a whole (464, 466).

The disturbance of the peripheral immune-adrenal axis may lead to adrenal disease. For example, a case of Cushing’s syndrome that disappeared after removal of inflammatory tissue has been described (221). We treated a patient with Cushing’s syndrome due to an adrenal adenoma with aberrant expression of IL-1 receptor. Adrenocortical cells from this patient demonstrated a marked release of cortisol after incubation with IL-1 with no response to ACTH (H. Willenberg, C. A. Stratakis, C. Marx, M. Ehrhart-Bornstein, G. P. Chrousos, and S. R. Bornstein, unpublished observation).

Extrapituitary mechanisms may also be relevant in clinical situations other than severe illness. In patients with proven pituitary ACTH deficiency, CRH induced a significant increase in plasma cortisol, preceded by a rise in plasma ACTH (175), indicating the involvement of an extrapituitary, perhaps intraadrenal, CRH/ACTH-system. It is also of interest that the mechanism of adrenal stimulation in diabetic patients is apparently not solely mediated through the pituitary since there is a diminished pituitary response to metyrapone (467).

Depressed patients may have enlarged adrenals and cortisol hypersecretion (468), although the ACTH response to CRH may be blunted (469). It is possible that stressors acting directly on the adrenal cortex may contribute to the stimulation of the adrenals in these patients. Indeed, a number of neurotransmitters and neuropeptides secreted from the adrenal medulla that are able to stimulate the adrenal cortex in a paracrine manner have been postulated to play a role in the development of psychiatric and other idiopathic syndromes (470).

In human adrenals, adrenomedullary and adrenocortical tissue are particularly extensively intermingled within the normal adrenal medulla (14). Interestingly, cells of all three zones of the cortex occur in the human adrenal medulla (471). This provides the basis for a close cellular interaction, allowing a fine tuning of the two stress systems. The occurrence of adrenocortical cells within the medulla has direct consequences during isolation of adrenomedullary tissue for autologous transplantation to the caudate nucleus as a treatment in patients suffering from Parkinson’s disease. As pointed out by Carmichael et al. (472), it is especially important to minimize the percentage of cortical cells and to remove these islets in these preparations since cortical steroids would stimulate the conversion of dopamine to epinephrine.

Another important observation is that adrenal nodules and adenomata frequently appear to originate from cortical islets in the medulla (471). It seems that these islets, which are under direct stimulatory influence of the surrounding adrenomedullary tissue, bear a higher risk for a pathological development compared with cortical cells located within the adrenal cortex.

There are case descriptions in the literature reporting patients with the clinical signs of pheochromocytoma with elevated catecholamine levels and the histological features of adrenocortical adenoma or carcinoma (473, 474, 475, 476, 477). In many of these patients, steroid levels were found to be elevated. Therefore, it was suggested that adrenal cortical neoplasm may be added to the list of pathological entities (pseudopheochromocytoma) that may occasionally be associated with the clinical picture of pheochromocytoma.

On the other hand, patients have been described with the clinical signs of Cushing’s syndrome and the pathological finding of a pheochromocytoma (478, 479, 480, 481, 482, 483, 484). This may be due to production of CRH or ectopic ACTH production in the pheochromocytoma, although the diagnosis of ectopic ACTH production was made preoperatively in only three of the 46 cases reported in the literature (for review, see Ref.482). A wide variety of both eutopic and ectopic neurotransmitters and neuropeptides expressed in pheochromocytoma are able to stimulate cortisol secretion and may be involved in causing Cushing’s syndrome (485).

There has been some speculation that adrenocortical tumor cells may produce catecholamines or that chromaffin-derived tumor cells produce steroids, but this may be less likely than the possibility that interactions between the two distinct cell types that are adjacent to each other in these conditions give rise to correlated medullary and cortical hyperactivity.

It is possible that corticotropin-independent Cushing’s syndrome could arise from the aberrant expression in the cortex of receptors, such as ß-receptors (486) or vasopressin receptors (487, 488), for secretagogues released from the adrenal medulla. In addition, patients have been described in whom Cushing’s syndrome was caused by a member of the glucagon/VIP peptide family, gastric inhibitory polypeptide (489, 490).

B. Aldosterone
Are there any clinical implications for intraadrenal aldosterone regulation?

In acute stress, activation of the RAS may depend, not on volume and blood pressure changes alone, but also on stimulation of renin and aldosterone release via neural pathways (491). Interestingly, the adrenal RAS can be activated via the sympathoadrenal system (432). Evidently, the neural and intraadrenal regulation of adrenal aldosterone production and the adrenal RAS has important clinical implications. It has been suggested that the differences in adrenal responses to angiotensin II with high, normal, and low sodium balance may be at least partially if not completely accounted for by a decreased dopaminergic inhibition of aldosterone secretion (for review see Ref.492). In addition, in idiopathic hyperaldosteronism and low renin essential hypertension, there is increased adrenocortical sensitivity to angiotensin (493, 494) with low circulating levels of angiotensin. The pathogenesis of these disorders could be related to a primary reduction of dopaminergic activity, which would result in an increased secretion of aldosterone in response to low levels of angiotensin. In idiopathic cyclic edema, orthostatic weight gain is associated with an increased secretion of aldosterone and antinatriuresis in the upright position (495). In these patients, the increase in PRA does not sufficiently explain the marked increase of aldosterone secretion with erect posture, and evidence suggests that reduced dopaminergic or increased adrenergic activity may be responsible for the increased aldosterone secretion in some of these cases (495).

Since arginine vasopressin is a potent stimulator of aldosterone production in human glomerulosa cells (496) and since it is also formed in the adrenal medulla, it is clear that, together with the products of the adrenal RAS and other factors from the endothelium and chromaffin tissue, including ANF (497), there are numerous possibilities for intra-adrenal regulation of aldosterone production in humans. This local regulation may provide an explanation for the continued normal secretion of aldosterone under conditions where peripheral angiotensin II is altered and for the increases observed in aldosterone secretion when the circulating angiotensin II concentration remains unchanged.

Another intriguing finding is that in patients with primary hyperaldosteronism (Conn’s syndrome) due to an adrenal adenoma, the remaining cortex may demonstrate morphological features of stimulation (498). This suggests that there is a paracrine interaction between the adenoma and the remnant cortex.

The fact that adrenocortical cells express a large array of receptors for various neurotransmitters also has pharmacological implications: drugs administered for the treatment of various disorders may exert unwanted effects on the adrenal cortex. For instance, 5-HT4 receptor agonists that are used as antiemetic agents will also stimulate aldosterone secretion (499). Similarly, the neuroleptic drug metoclopramide exhibits 5-HT4 agonistic activity and can thus stimulate aldosterone secretion (500, 501).

C. Adrenal androgens
Finally, intraadrenal regulation of adrenal androgen secretion may have several clinical implications. First, considering the fact that there is a discrepancy in ACTH levels in plasma and androgen release in the time of adrenarche and in several other clinical situations (250), the regulation of adrenal androgen production by the sympatho-adrenal system may be particularily important during that time. Also, IL-6 appears to be a local factor in the production of C19-steroids. Interestingly, IL-6 receptor is expressed with high density in the zona reticularis, and IL-6 stimulates DHEA secretion (249). DHEA influences the immune system at various levels, and the interaction with cytokines may be of relevance for the process of adrenal senescence and autoimmunity. Cytokines produced by the inner zones of the human adrenal cortex, such as TNF{alpha} (213), may participate in the constitutive expression of MHC class II molecules in the inner cortical zone, which is related to differentiation and programmed cell death in the adrenal cortex (502, 503). On the basis of these findings, MHC class II was found to be a reliable tumor marker for adrenocortical carcinoma, with its presence excluding malignancy (504).

D. Summary
In conclusion, cellular proximity and functional coordination between the different cellular systems may explain several of the discrepancies between cortisol secretion and its main regulatory hormones, ACTH and angiotensin II, in many physiological and pathophysiological states, including adrenarche, severe stress, depression, and others. The notion of a potent endocrine and paracrine interaction between the immune and endocrine systems at the level of the adrenal gland is supported by the number of reports showing strong interdependence of cytokine and adrenal hormone levels in clinical states, such as sepsis, exercise, and inflammation.


    X. Conclusions
 Top
 Abstract
 I. Introduction: The Adrenal...
 II. Interaction Between Adrenal...
 III. Innervation of the...
 IV. The Vascular System...
 V. The Intraadrenal CRH/ACTH...
 VI. Immune Cells and...
 VII. Peptide Growth Factors...
 VIII. The Intraadrenal Renin...
 IX. Clinical Implications
 X. Conclusions
 References
 
The complexity of adrenocortical function is only now becoming apparent (Fig. 5Go). Clearly, the gland is capable of responding to physiological demand with infinite flexibility and subtlety in a manner that depends on the interactions of numerous cell types, each contributing its own signals to the system and each responding in varied ways to the signals from the cells around it. In addition to the regulation of adrenal steroidogenesis through the pituitary, intraadrenal mechanisms play a role during development, differentiation, physiological, and pathophysiological processes of the adrenal gland. The concept that adrenocortical function can be adequately interpreted by studying the functions of individual cells in isolation, if it was ever seriously believed, is certainly unreliable. The clear requirement for future research is to establish new methods in which integrated functions of the adrenal gland can be successfully studied in physiological settings. This constitutes a major challenge.



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Figure 5. Numerous cell types and numerous systems with their specific signals interact in the intraadrenal regulation of adrenocortical steroidogenesis.

 


    Footnotes
 
Address reprint requests to: Monika Ehrhart-Bornstein, Ph.D., NIH, NIMH, Building 10, Room 2D46, 10 Center Drive, MSC 1284, Bethesda, Maryland 20892.


    References
 Top
 Abstract
 I. Introduction: The Adrenal...
 II. Interaction Between Adrenal...
 III. Innervation of the...
 IV. The Vascular System...
 V. The Intraadrenal CRH/ACTH...
 VI. Immune Cells and...
 VII. Peptide Growth Factors...
 VIII. The Intraadrenal Renin...
 IX. Clinical Implications
 X. Conclusions
 References
 

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