congenital adrenal hyperplasia due to 21-hydroxylase deficiency ( 21ohd ) is a common autosomal recessive disorder caused by mutations in the cyp21a2 gene , which encodes 21-hydroxylase ( an enzyme involved in aldosterone and cortisol biosynthesis ) . in individuals with the disease , acth levels rise due to impaired cortisol secretion , thereby stimulating the adrenal cortex , accumulating androgen precursors , and resulting in varying degrees of hyperandrogenism [ 13 ] . such impairment ranges from prenatal external genitalia virilization in females and postnatal virilization in both sexes , which may occur with or without salt loss ( classical forms ) , to a milder form with late onset hyperandrogenic signs ( nonclassical ) . the classical forms have a prevalence of approximately one in 10,000 to one in 16,000 live births , while the nonclassical form affects approximately one in 2,500 live births [ 1 , 2 , 4 ] . current cah therapy aims to provide adequate glucocorticoid replacement and , when necessary , mineralocorticoid replacement , to avoid adrenal crisis , to suppress the increased androgen secretion ( to allow the achievement of normal final height ) , and to avoid signs of hypercortisolism . the introduction of glucocorticoid ( gc ) replacement leads to significant improvement in the prognosis of classical forms . during growth periods , preference is given to the use of short half - life glucocorticoids that avoid growth suppression [ 1 , 5 , 6 ] , and after the achievement of final height , the use of long - acting gc is suggested to allow better compliance for long - term therapy . although cah therapy is well established , current limitations make it difficult to replicate the cortisol circadian rhythm , which could result in excessive glucocorticoid and/or androgen exposure . an increased prevalence of obesity has been reported in pediatric cah patients   in addition to increased lipid levels [ 9 , 10 ] and insulin resistance . however , it is difficult to achieve definite conclusions regarding long - term comorbidities , as previous studies included patients with classical and nonclassical forms , as well as both children and adults , all of whom require different approaches to hormonal control during cah management . in the general population , besides lifestyle and environmental factors , genetics variants also predispose to an adverse metabolic profile . glucocorticoid receptor ( nr3c1 ) gene polymorphisms are associated with increased cardiovascular risk , characterized by increased body mass index ( bmi ) , blood pressure , and lipid levels , such as the bcli polymorphism , which is associated with increased gc sensitivity and the a3669 g polymorphism linked to increased inflammatory parameters [ 12 , 13 ] . in addition to the variability in the prevalence of an adverse metabolic profile among cah patients , there are few data in the literature regarding pediatric patients . our aim was to evaluate the influence of nr3c1 polymorphisms on the metabolic profile in a series of pediatric cah patients followed at the same center and undergoing similar approaches to hormone replacement . the study was approved by the ethical committee of hospital das clnicas da faculdade de medicina da universidade de so paulo ( 0231/2010 ) , and written consent was obtained from all patients ' caretakers . the inclusion criteria were pediatric cah patients with classical forms who were under stable glucocorticoid and mineralocorticoid therapy in the last two years , did not use enzyme inductor drugs , demonstrated good compliance , and had received exclusively short - acting glucocorticoids during growth periods . from a cohort of 206 patients , we selected 41 children and adolescents with classical cah , with a mean age of 11.4  3.9 years ( 3.5 to 17.8 years ) . fifteen patients ( 8f ) had the simple virilizing form ( sv ) , which is characterized by ambiguous genitalia at birth in girls and signs of postnatal virilization in both sexes . twenty - six patients ( 16f ) had the salt - wasting form ( sw ) , and they also presented with volume depletion , sodium < 130  mmol / liter , and increased plasma renin activity ( pra ) in the neonatal period . all patients presented with basal 17-hydroxyprogesterone ( 17-ohp ) levels > 150  nmol / l and molecular cah diagnosis through entire cyp21a2 sequence . treatment efficacy was assessed by serum pra and androgen measurements and only patients who had good compliance were selected , this being characterized by normal androgen levels according to chronological age and sex in at least 3 of 4 annual measurements and normal auxological parameters in the last two years . for prepubertal patients , testosterone and androstenedione levels were maintained 14  ng / dl and 2  ng / ml , respectively , and for all older patients androstenedione 3.5  ng / dl and testosterone levels 50  ng / dl for older females . regarding mineralocorticoid replacement , the pra levels of these patients were maintained in the upper normal limit . in this period , mean daily glucocorticoid doses were calculated using body surface area ( mg / m ) and were also evaluated retrospectively in the last 2 years . the glucocorticoid doses were converted to hydrocortisone equivalents ( 30  mg hydrocortisone = 37.5 cortisone acetate = 0.75 dexamethasone )   and presented as mg / m . fifteen of 41 patients achieved final height ( mean final height 151.4  7.0 ; mean target height 159.7  9.1 ) , and cortisone acetate was replaced by once - daily dexamethasone ( mean 0.28  0.11  mg ) , which was available in tablet ( 0.5  mg ) and elixir ( 0.1  mg / ml ) formulations . for those with the salt - wasting form , fludrocortisone was maintained at a mean dose of 50  25  mcg / day . the duration of therapy varied from 3.5 to 17.8 years ( mean 11.4  3.9 years ) . children were classified as obese if their bmi was 95th percentile , overweight if their bmi was between the 85th and 95th percentiles , and healthy weight if their bmi was between the 5th and 85th percentiles according to age - sex tables ( centers for disease control and prevention ) . increased systolic or diastolic blood pressure was defined as pressures > 90th percentile for age and sex . increased triglyceride levels were characterized as values 110  mg / dl , since all patients were less than 18 years old . abnormal hdl - c levels were characterized as values 40  mg / dl , and increased impaired glucose levels were characterized as values 100  mg / dl . insulin resistance was assessed by the homeostasis model assessment for insulin resistance ( homa - ir ) . we also assessed homa - b ( % ; h - cell function ) and homa - s ( % ; insulin sensitivity ) . metabolic syndrome was defined according to the national cholesterol education program , adult treatment panel iii criteria ( ncep atpiii ) , adapted to the pediatric group . pcr amplification of the glucocorticoid receptor gene regions was carried out using primer sequences and amplification conditions as previously described [ 18 , 19 ] . pcr products were sequenced using the big dye terminator sequencing kittm ( applied biosystem , inc . , foster city , ca , usa ) and capillary electrophoresis on an abi prism 3100 sequencer ( applied biosystem , inc . ) . the results of the allele - specific pcr were confirmed by direct sequencing in 10 patients . these analyses were performed with adjustments for age , sex , and clinical form by multivariable modeling . pearson 's correlation coefficients were used to calculate correlations between bmi z score ( zbmi ) , gc dose , insulin , homa , and lipid levels after correction for age and sex . statistical analysis was performed using the software sigmastat version 3.5 for windows ( systat software , point richmond , ca ) . the clinical , anthropometric , and biochemical data of the 41 cah patients are presented in table 1 . allelic frequencies of the bcli and a3669 g polymorphisms were in hardy - weinberg equilibrium . the bcli polymorphism was found in 23.1% of the alleles ; one patient was homozygous and 18 patients were heterozygous . the a3669 g polymorphism was found in 9.7% of the alleles ; one patient was homozygous and 6 patients were heterozygous . obesity was observed in 31.7% ( n = 13 ) of patients , which included 10 patients with the salt - wasting form and 6 female patients . overweight was found in 21.9% ( n = 9 ) of patients , including 4 patients with the salt - wasting form and 3 female patients . the mean gc dose in obese and normal weight patients was 14.2  2.8 and 13.7  4.3  mg / m/day ( p > 0.05 ) , respectively , and the mean duration of therapy was 9.6  5.4 and 10.9  4.1 years ( p > 0.05 ) , respectively . there was no significant correlation with increased zbmi , sex , clinical form , or gc dose . zbmi was positively correlated with systolic blood pressure ( r = 0.511 , p < 0.01 ) , homa - ir ( r = 0.474 , p < 0.01 ) , glucose ( r = 0.322 , p < 0.01 ) , total cholesterol ( r = 0.429 , p < 0.01 ) , triglycerides ( r = 0.422 , p < 0.01 ) , and ldl - c levels ( r = 0.430 , p < 0.01 ) . interestingly , sw patients presented a worse lipid profile in comparison with sv patients , as characterized by increased total cholesterol , ldl - c , and tg levels , which were independent of zbmi . blood pressure and homa values did not differ between patients with the sw and sv forms ( table 1 ) . at the time of this analysis , the regression analysis did not show differences in the clinical or metabolic profile between patients receiving cortisone acetate and dexamethasone . a comparison of the metabolic profile between carriers and noncarriers of the a3669 g polymorphism is shown in table 2 . a3669 g carriers had higher ldl - c levels compared to wild - type carriers in the t - test analysis , which maintained significance after adjustment by sex , age , and clinical form ( table 2 ) . there were no significant differences observed in the homa value and blood pressure between carriers and noncarriers of the a3669 g polymorphism . there was no significant difference in the frequency of the a3669 g polymorphism between the obese and nonobese cah patients , 42.8% versus 29.4% , respectively , between the patients with and without metabolic syndrome , 14.3% versus 14.7% , respectively , or between the patients with and without hypertension , 14.3% versus 8.8% , respectively . table 3 shows the metabolic profile of the bcli and wild - type carriers . although bcli carriers showed a tendency to adverse metabolic profile , these differences were not statistically significant ( table 3 ) . there was no significant difference in the frequency of the bcli polymorphism between the obese and nonobese cah patients , 33.3% versus 30.4% , respectively , between the patients with and without metabolic syndrome , 22.2% versus 8.7% , respectively , or between the patients with and without hypertension , 16.7% versus 4.3% , respectively . the increased prevalences of obesity and adverse metabolic profiles are important factors in the development of cardiovascular disease . some studies have described abnormal body compositions and unfavorable trends in metabolic risk in cah adults [ 9 , 2023 ] ; however , data regarding the metabolic profile of the pediatric cah are limited . similar to what was observed in the general population , in our series of pediatric cah patients , the zbmi and waist - hip ratio were positively correlated with blood pressure , an adverse lipid profile , and insulin resistance . we did not observe differences in the metabolic profile of cah patients receiving dexamethasone compared to those receiving cortisone acetate . surprisingly , we observed that sw patients presented worse clinical and metabolic profiles compared to sv patients , independent of age and sex . in addition , a tendency to overtreat sw patients in the first year of life can not be ruled out . the main cause of increased obesity in cah patients is related to chronic glucocorticoid exposure . however , as occurs in the general population , environmental factors and genetic predisposition may contribute to increased obesity frequency in this population [ 24 , 25 ] , and these factors have not been evaluated among patients with cah . recently , we described the influence of the nr3c1-bcli polymorphism on the prevalence of obesity in adult cah patients . however , in this pediatric cah cohort , despite zbmi and waist circumferences being higher in bcli carriers than wild type carriers , these differences were not statistically significant and we can not rule out a sample size effect . therefore , we tested the influence of nr3c1 polymorphisms on the metabolic profiles of pediatric cah patients and found a positive association between the presence of the a3669 g allele and higher ldl - c levels . our results are in line with previous data from the general population , as our patients carrying the a3669 g allele presented with a poor metabolic profile , independent of sex , age , and clinical form ( table 2 ) . this polymorphism is associated with increased expression and stabilization of the 9 gr - isoform and a recent study suggested that it is associated with increased cardiovascular risk in comparison to noncarriers , which was supported by the findings of elevated levels of inflammatory parameters in a large cohort of elderly subjects . however , the main limitation of this study is the sample size , which was restricted by our attempt to select a homogenous cah cohort . in conclusion , our findings suggest that the a3669 g polymorphism is involved with a susceptibility to an adverse lipid profile in pediatric cah patients . therefore , this study provides new insight into the gr screening during cah treatment , which could help to identify the subgroup of at - risk patients who would most benefit from preventive therapeutic action . however , despite our cohort having a good sample size considering the disease frequency , these data should be reevaluated in future multicentric studies , focusing on these polymorphisms and their possible influence on clinical phenotypes of cah patients under gc replacement .
background . pediatric cah patients have an increased risk of cardiovascular disease , and it remains unknown if genetic predisposition is a contributing factor . 
 glucocorticoid receptor gene ( nr3c1 ) polymorphisms are associated with an adverse metabolic profile . 
 our aim was to analyze the association between the nr3c1 polymorphisms and the metabolic profile of pediatric cah patients . 
 methods . 
 forty - one patients ( 26sw/15sv ) received glucocorticoid ( gc ) replacement therapy to achieve normal androgen levels . 
 obesity was defined by bmi  95th percentile . 
 nr3c1 alleles were genotyped , and association analyses with phenotype were done with chi - square , t - test , and multivariate and regression analysis . 
 results . 
 obesity was observed in 31.7% of patients and was not correlated with gc doses and treatment duration . 
 z - score bmi was positively correlated with blood pressure , triglycerides , ldl - c levels , and homa - ir . 
 nr3c1 polymorphisms , bcli and a3669 g , were found in 23.1% and 9.7% of alleles , respectively . 
 a3669 g carriers presented higher ldl - c levels compared to wild - type subjects . 
 bcli - carriers and noncarriers did not differ . 
 conclusion . 
 our results suggest that a3669g - polymorphism could be involved with a susceptibility to adverse lipid profile in pediatric cah patients . 
 this study provides new insight into the gr screening during cah treatment , which could help to identify the subgroup of at - risk patients who would most benefit from preventive therapeutic action .