The adrenal-kidney connection

The human body functions as an intricate network, where each component plays its pivotal role. At the heart of this network lie the adrenal glands and the kidneys. This article delves into the ‘adrenal-kidney connection,’ emphasizing the interplay between these vital organs and their overarching importance to our health.

Whether you’re a medical professional, someone eager to gain a deeper understanding of your own body, or searching for insights into health-related queries, this piece will shed light on the essential relationship between the adrenal glands and the kidneys. Join us as we explore their roles, synergies, and their collective influence on our well-being.

 

 

By Majd Isreb, MD, FACP, FASN, IFMCP

The Adrenal Glands: Hormonal Powerhouses

Tucked above each of our kidneys are the adrenal glands, small yet incredibly powerful organs responsible for producing a variety of hormones essential for our body’s function.

Mineralocorticoids:

• Primary hormone: Aldosterone.
• Function: Aldosterone plays a pivotal role in regulating the balance of sodium and potassium in our blood. This balance is essential for controlling blood volume, blood pressure, and the pH balance of our body fluids.

Glucocorticoids:

• Primary hormone: Cortisol.
• Function: Often dubbed the ‘stress hormone,’ cortisol helps our body respond to stress. It also plays a role in regulating metabolism, reducing inflammation, and controlling our sleep-wake cycle. Our body’s glucose levels are also managed by cortisol, as it promotes the production of glucose from proteins in our liver.

Sex Hormones:

• Adrenal Androgens: DHEA (Dehydroepiandrosterone) and Androstenedione.
• Function: Although the adrenal glands produce only a small quantity of male and female sex hormones (with the testes and ovaries being the primary producers), these hormones are essential, especially before puberty. They assist in the development of secondary sexual characteristics like pubic hair. Post-menopause, the adrenal glands become the primary source of estrogen in women.

 

 

Cortisol: The Multifaceted Stress Hormone

Cortisol, the primary glucocorticoid hormone churned out by the adrenal glands, is widely recognized as the “stress hormone.” While its release intensifies during stressful periods, its daily functions go beyond just responding to stress and are vital for overall human health.

1. Glucose production: Cortisol boosts glucose generation from non-carbohydrate sources. This ensures a consistent energy flow, particularly during high-stress moments.
2. Anti-inflammatory actions: Cortisol acts as a brake on inflammation. It achieves this by inhibiting the release of pro-inflammatory agents in the body.
3. Blood pressure regulation: Cortisol indirectly hikes up blood pressure by making blood vessels more receptive to hormones that cause constriction.
4. Water balance: In tandem with aldosterone, cortisol orchestrates the body’s water distribution and balance.
5. Circadian rhythm: The levels of cortisol ebb and flow, peaking just before we wake up in the early hours and dipping to their nadir at night. This rhythm profoundly impacts our sleep-wake cycle.

A testament to cortisol’s widespread influence is the presence of glucocorticoid receptors (GRs) in nearly every cell of our body. Once cortisol binds to these receptors, the resulting complex can move into the cell nucleus and influence gene transcription, leading to various cellular responses.

 

 

Effects of Excess Cortisol

Chronic overproduction of cortisol, or hypercortisolism, can lead to a condition called Cushing’s syndrome. Some potential effects and symptoms include:

• Weight Gain: Particularly around the abdomen and face.
• Muscle Weakness: Due to the catabolic effects of cortisol on muscle tissue.
• Osteoporosis: Increased bone resorption can reduce bone density.
• Hypertension: Elevated cortisol levels can chronically elevate blood pressure.
• Impaired Immune Function: Reduced capability of the body to fight off infections.
• Mood Disorders: Anxiety, depression, and irritability can become more prevalent.
• Hyperglycemia: High blood sugar and potential development of diabetes due to increased glucose production.
• Skin Changes: Thinning skin, easy bruising, and purple stretch marks.
• Cardiovascular disease and death: Even a mild degree of persistent elevated cortisol exposure profoundly impacts cardiovascular disease and mortality.

 

 

The HPA Axis: Understanding the dynamics of cortisol function

The Hypothalamic-Pituitary-Adrenal (HPA) axis constitutes a sophisticated interplay between three principal glands: the hypothalamus, the pituitary gland, and the adrenal glands. This system plays a critical role in controlling reactions to stress, digestion, the immune system, mood and emotions, sexuality, and energy storage.

Here’s a brief walkthrough of the process:

1. Stress Perception: Upon detecting stress or other stimuli, the hypothalamus secretes corticotropin-releasing hormone (CRH).
2. Pituitary Activation: CRH then galvanizes the pituitary gland to release adrenocorticotropic hormone (ACTH).
3. Adrenal Response: ACTH interacts with the adrenal cortex, spurring it to synthesize and release cortisol. Notably, cortisol also serves as a regulatory checkpoint: once released, it suppresses the production of both CRH and ACTH, establishing a feedback loop that prevents excessive cortisol release.

The secretion of cortisol isn’t arbitrary; our circadian rhythm finely tunes it. Cortisol levels peak in the early morning hours (around 8 a.m.) and drop to their lowest at midnight. This rhythm ensures our body is alert, ready for the day’s challenges, and winds down as nighttime approaches.

About 90% of cortisol in the blood is bound to a protein called corticosteroid-binding globulin (CBG), with the remaining 10% being free or unbound. Only the unbound cortisol is biologically active.

Cortisol has a relatively short half-life of approximately 60-90 minutes. The liver metabolizes cortisol, converting it into inactive metabolites, including cortisone. These metabolites are then excreted in the urine via the kidneys.

To strike a balance between cortisol and cortisone in the body, two pivotal enzymes come into play:

• 11β-Hydroxysteroid Dehydrogenase Type 1 (11β-HSD1): Converts cortisone into the active cortisol. This enzyme utilizes a cofactor called NADPH (nicotinamide adenine dinucleotide phosphate) and is mainly present in metabolically active tissues such as the liver, fat, and skeletal muscles.
• 11β-Hydroxysteroid Dehydrogenase Type 2 (11β-HSD2): Converts cortisol back into the inactive cortisone. The cofactor for this enzyme is NAD+ (nicotinamide adenine dinucleotide). It is highly expressed in the kidneys. This is particularly important in mineralocorticoid target tissues, ensuring the prevention of excessive activation of the mineralocorticoid receptors by cortisol.

Finally, while the amount of circulating cortisol is 10 times that of cortisone, cortisol has a higher affinity to bind to CBG. Therefore, the amount of free cortisol in the blood is comparable to that of free cortisone.

 

Join us to end the kidney disease epidemic

 

The adrenal kidney-connection

Cortisol levels in CKD

Chronic Kidney Disease (CKD) has a complex interplay with cortisol. Researchers have delved into how CKD affects cortisol levels, yielding the following insights:

1. Early morning cortisol levels: Studies measuring early morning blood cortisol in CKD patients have shown mixed results.
2. Cortisol circadian rhythm: A consistent finding in medical research has been the presence of elevated evening cortisol levels, especially in stage 3 CKD and beyond.
3. Saliva Cortisol Levels: This test, indicative of serum-free active cortisol, echoes the finding of high evening cortisol levels in CKD.
4. 24-hour urine collection: This method measures the total cortisol and its metabolites in the urine. Intriguingly, it shows that the daily cortisol output from the adrenal glands remains relatively unchanged in mild to moderate CKD. This phenomenon might stem from CKD’s reduced clearance of free cortisol, rendering the 24-hour urine free cortisol measurement unreliable for detecting cortisol excess in CKD patients.
5. Protein binding and cortisol: Data suggests that cortisol’s protein binding to CBG remains stable in CKD.
6. Changes in the HPA axis feedback: While the adrenal glands’ response to ACTH remains intact in CKD, cortisol levels display a partial resistance to suppression by dexamethasone – a compound typically used to probe the HPA axis’s negative feedback mechanism. This resistance can be overcome with higher dexamethasone doses or longer exposure, pointing to a diminished negative feedback mechanism in CKD, essential for modulating adrenal cortisol output.
7. Prolonged cortisol half-life in CKD: The half-life of circulating cortisol is extended in CKD for various reasons, such as the buildup of cortisol metabolites due to hampered renal function, reduced cortisol breakdown in the liver, and diminished activity of the enzyme 11β-HSD2, attributed to loss of kidney tissue.

 

 

Effects of elevated cortisol levels in CKD

Cortisol plays a complex role in the setting of CKD. Elevated cortisol levels bring forth a range of effects:

1. Mortality risks: Multiple studies spotlight the association of raised cortisol levels with an uptick in all-cause and cardiovascular mortality. Even slight elevations in cortisol can be linked to such adverse outcomes.
2. Changes in kidney function:
   1. Short-Term Effects: Administering ACTH or cortisol in the short term has been seen to increase glomerular filtration rates (GFR) in humans. Conversely, diminished cortisol levels correlate with a drop in kidney blood flow and GFR.
   2. Long-Term Impacts: On the other hand, chronic exposure to high cortisol concentrations can lead to a decline in kidney functionality. Alarmingly, individuals with Cushing’s disease (characterized by cortisol excess) exhibited compromised kidney function, a condition persisting even post-treatment. The disease’s duration has been pinpointed as a key factor affecting kidney health.
3. Metabolic changes: High cortisol levels can incite insulin resistance and alterations in blood lipid profiles. Such shifts enhance susceptibility to diabetes and metabolic syndrome. These two factors can further worsen kidney function.
4. Other consequences in CKD: Elevated cortisol levels in CKD patients manifest in various other ways:

• • Muscle Mass: A discernible loss of muscle mass.
  • Nutrition: Deteriorated nutritional status.
  • Immune System: A compromised immune function.
  • Mental Health: Increased likelihood of depression.
  • Sleep Patterns: Disrupted and poor-quality sleep.

Strategies to Lower Cortisol Levels in CKD

Ensuring a balance in stress and hormones is pivotal for overall health, especially in individuals with CKD. Here are several natural strategies to mitigate elevated cortisol levels, particularly in the evenings:

• Relaxation techniques: Incorporating consistent relaxation practices, such as deep breathing exercises, meditation, and gentle yoga, can substantially curtail stress-driven spikes in cortisol.
• Sleep hygiene:
  • Consistency: Stick to a regular sleep schedule.
  • Environment: Prepare for sleep in a dimly lit, calm setting.
  • Tech Break: Avoid electronic screens at least an hour before bedtime. This practice aids in realigning the body’s circadian rhythm, potentially tempering evening cortisol surges.
• Dietary adjustments:
  • Nutrient-rich foods: Prioritize a diet abundant in anti-inflammatory ingredients and omega-3 fatty acids. Inflammation, which can be controlled through diet, is a significant catalyst for elevated cortisol in CKD.
  • Caffeine Caution: Limit caffeine consumption, especially during the latter part of the day.
  • Supplements: supplements such as fish oil and Ashwagandha have been found to decrease cortisol levels.
• Light therapy: An often-underestimated tool, light therapy can be transformative in regulating cortisol levels. Light exposure deeply influences our circadian rhythm (10,000 lux; equivalent to ambient light intensity just after sunrise). Utilizing morning light therapy devices, which emulate natural sunlight, can recalibrate this internal clock. As a result, cortisol levels witness a steadier, more organic drop come evening.
• Addressing metabolic acidosis: In CKD, metabolic acidosis and an increased dietary acid load have been linked to elevated cortisol levels. Rectifying this by embracing an alkaline diet and curtailing animal protein consumption can be beneficial in moderating cortisol levels.
• Finally, moderate exercise, healthy relationships, laughing, and taking care of pets can also relieve stress and decrease cortisol levels.

 

 

The Bottom line

The intricate relationship between the adrenal glands and the kidneys plays a critical role in our overall health, with cortisol acting as a central figure in this dance. Elevated cortisol levels, especially in the context of CKD, have multifaceted implications, from metabolic changes to compromised kidney function. Addressing these elevated levels is vital, and methods such as stress management, dietary adjustments, light therapy, and improved sleep hygiene offer promising avenues. As research continues to delve deeper into this adrenal-kidney connection, it becomes increasingly evident that a comprehensive, holistic approach to managing cortisol is paramount for the well-being of CKD patients and everyone alike.