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Sun F, Hong Y, Zhang H, Liu X, Zhao Z, He H, Yan Z, Zhu Z. Determination of adrenal hypersecretion in primary Aldosteronism without aldosterone-production adenomas. BMC Endocr Disord 2021; 21:114. [PMID: 34059026 PMCID: PMC8167985 DOI: 10.1186/s12902-021-00770-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 05/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Primary aldosteronism (PA) is highly prevalent in hypertensive population. Adrenal vein sampling (AVS) is the only procedure to assess adrenal aldosterone hypersecretion in PA. PA patients without aldosterone-producing adenomas (APA) frequently have unilateral aldosterone hypersecretion (UAH). These patients could bear inappropriate adrenalectomy without AVS. This study aims to identify which clinical characteristics should be recommended to perform AVS in these PA patients. METHODS This study was performed from January 2018 to July 2019 at a center for hypertension and metabolic diseases. Adrenal computed tomography (CT) scan, biochemical evaluation, and AVS were performed. RESULTS Total 141 patients were included in this study. Aldosterone to renin ratio (ARR) after confirmatory test is highly associated with adrenal laterality. The specificity of ARR > 10 (ng/dL)/(mU/L) after confirmatory test is 100%. After confirmatory test, patients with ARR > 10 (ng/dL)/(mU/L) had higher plasma aldosterone concentration and incidences of ischemic heart diseases and renal damage(p < 0.05). CONCLUSIONS After confirmatory tests, ARR > 10 (ng/dL)/(mU/L) indicates adrenal laterality, with increasingly cardiorenal damage in PA patients without APA. Thus, AVS should be recommended in these patients before surgery. TRIAL REGISTRATION NCT03398785 , Date of Registration: December 24, 2017.
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Affiliation(s)
- Fang Sun
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University of PLA, Chongqing, 400042, China
| | - Yangning Hong
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University of PLA, Chongqing, 400042, China
| | - Hexuan Zhang
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University of PLA, Chongqing, 400042, China
| | - Xiaoli Liu
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University of PLA, Chongqing, 400042, China
| | - Zhigang Zhao
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University of PLA, Chongqing, 400042, China
| | - Hongbo He
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University of PLA, Chongqing, 400042, China
| | - Zhencheng Yan
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University of PLA, Chongqing, 400042, China
| | - Zhiming Zhu
- Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Army Medical University of PLA, Chongqing, 400042, China.
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Zhou Y, Wang D, Jiang L, Ran F, Chen S, Zhou P, Wang P. Diagnostic accuracy of adrenal imaging for subtype diagnosis in primary aldosteronism: systematic review and meta-analysis. BMJ Open 2020; 10:e038489. [PMID: 33384386 PMCID: PMC7780716 DOI: 10.1136/bmjopen-2020-038489] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES Accurate subtype classification in primary aldosteronism (PA) is critical in assessing the optimal treatment options. This study aimed to evaluate the diagnostic accuracy of adrenal imaging for unilateral PA classification. METHODS Systematic searches of PubMed, EMBASE and the Cochrane databases were performed from 1 January 2000 to 1 February 2020, for all studies that used CT or MRI in determining unilateral PA and validated the results against invasive adrenal vein sampling (AVS). Summary diagnostic accuracies were assessed using a bivariate random-effects model. Subgroup analyses, meta-regression and sensitivity analysis were performed to explore the possible sources of heterogeneity. RESULT A total of 25 studies, involving a total of 4669 subjects, were identified. The overall analysis revealed a pooled sensitivity of 68% (95% CI: 61% to 74%) and specificity of 57% (95% CI 50% to 65%) for CT/MRI in identifying unilateral PA. Sensitivity was higher in the contrast-enhanced (CT) group versus the traditional CT group (77% (95% CI 66% to 85%) vs 58% (95% CI 50% to 66%). Subgroup analysis stratified by screening test for PA showed that the sensitivity of the aldosterone-to-renin ratio (ARR) group was higher than that of the non-ARR group (78% (95% CI 69% to 84%) vs 66% (95% CI 58% to 72%)). The diagnostic accuracy of PA patients aged ≤40 years was reported in four studies, and the overall sensitivity was 71%, with 79% specificity. Meta-regression revealed a significant impact of sample size on sensitivity and of age and study quality on specificity. CONCLUSION CT/MRI is not a reliable alternative to invasive AVS without excellent sensitivity or specificity for correctly identifying unilateral PA. Even in young patients (≤40 years), 21% of patients would have undergone unnecessary adrenalectomy based on imaging results alone.
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Affiliation(s)
- Yaqiong Zhou
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Dan Wang
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Licheng Jiang
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Fei Ran
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Sichao Chen
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Peng Zhou
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Peijian Wang
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
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Lorenz K, Langer P, Niederle B, Alesina P, Holzer K, Nies C, Musholt T, Goretzki PE, Rayes N, Quinkler M, Waldmann J, Simon D, Trupka A, Ladurner R, Hallfeldt K, Zielke A, Saeger D, Pöppel T, Kukuk G, Hötker A, Schabram P, Schopf S, Dotzenrath C, Riss P, Steinmüller T, Kopp I, Vorländer C, Walz MK, Bartsch DK. Surgical therapy of adrenal tumors: guidelines from the German Association of Endocrine Surgeons (CAEK). Langenbecks Arch Surg 2019; 404:385-401. [PMID: 30937523 DOI: 10.1007/s00423-019-01768-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Previous guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime. METHODS A PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting. RESULTS Overall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided. CONCLUSION Effective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.
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Affiliation(s)
- K Lorenz
- Universitätsklinikum Halle, Halle/Saale, Germany.
| | | | - B Niederle
- Ordination Siebenbrunnenstrasse, Wien, Austria
| | - P Alesina
- Kliniken Essen-Mitte, Essen, Germany
| | - K Holzer
- Universitätsklinikum Marburg, Marburg, Germany
| | - Ch Nies
- Marienhospital Osnabrück, Osnabrück, Germany
| | - Th Musholt
- Universitatsklinikum Mainz, Mainz, Germany
| | - P E Goretzki
- Charité Universitätsmedizin Berlin, Berlin, Germany
| | - N Rayes
- Universitätsklinikum Leipzig, Leipzig, Germany
| | - M Quinkler
- Endokrinologiepraxis Berlin, Berlin, Germany
| | - J Waldmann
- MIVENDO Klinik Hamburg, Hamburg, Germany
| | - D Simon
- Evangelisches Krankenhaus BETHESDA Duisburg, Duisburg, Germany
| | - A Trupka
- Klinikum Starnberg, Klinikum Starnberg, Germany
| | - R Ladurner
- Ludwig-Maximilians-Universität München, München, Germany
| | - K Hallfeldt
- Ludwig-Maximilians-Universität München, München, Germany
| | - A Zielke
- Diakonie-Klinikum Stuttgart, Stuttgart, Germany
| | - D Saeger
- Universitätsklinikum Hamburg, Hamburg, Germany
| | - Th Pöppel
- Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - G Kukuk
- Universitätsklinikum Bonn, Bonn, Germany
| | - A Hötker
- Universitätsklinikum Zürich, Zürich, Switzerland
| | - P Schabram
- RAE Ratacjzak und Partner, Sindelfingen, Germany
| | - S Schopf
- Krankenhaus Agatharied, Hausham, Germany
| | - C Dotzenrath
- HELIOS Universitätsklinikum Wuppertal, Wuppertal, Germany
| | - P Riss
- Medizinische Universität Wien, Wien, Austria
| | - Th Steinmüller
- Deutsches Rotes Kreuz Krankenhaus Berlin, Berlin, Germany
| | - I Kopp
- AWMF, Frankfurt am Main, Germany
| | - C Vorländer
- Bürgerhospital Frankfurt, Frankfurt am Main, Germany
| | - M K Walz
- Kliniken Essen-Mitte, Essen, Germany
| | - D K Bartsch
- Universitätsklinikum Marburg, Marburg, Germany
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Success rate of adrenal venous sampling and predictors for success: a retrospective study. Pol J Radiol 2019; 84:e136-e141. [PMID: 31019607 PMCID: PMC6479143 DOI: 10.5114/pjr.2019.84178] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 01/24/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose To report the success rate of adrenal venous sampling (AVS) and identify the predictors for procedural success. Material and methods Sixty-four patients (18 men and 46 women) with a mean ± SD age of 50 ± 11.8 years (range 28-69 years) diagnosed as primary hyperaldosteronism, and who underwent AVS from January 2009 to December 2016, were retrospectively reviewed. In our institution, the initial period to perform the AVS was set from 2009 to 2013, and the post-initial period was defined as procedures performed after 2013. Successful sampling was determined when the ratio of cortisol from the adrenal vein to the level of cortisol in the inferior vena cava ≥ 5. The procedural success and subject factors between success and failure were analysed. A p value < 0.05 was considered statistically significant. Results The success rate of bilateral AVS was 71.9%. The success rates of right and left AVS were 76.6% and 90.6%, respectively. Male patients were more likely to succeed than female patients (adjusted odds ratio [aOR], 9.83; 95% confidence interval [CI], 1.14-85.14; p = 0.009). In our institution, the procedure performed in the post-initial period also succeeded more often compared to the initial period (aOR, 5.05; 95% CI, 1.2-21.16; p = 0.017). No other factors were associated with the success rate in this study. Conclusions The success rate of bilateral AVS in our institution was rather high. Male gender and procedure performed in the post-initial period were significant predictive factors for a successful procedure.
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Loh WJ, Lim DST, Loh LM, Kek PC. Factors Associated with Resolution of Hypertension after Adrenalectomy in Patients with Primary Aldosteronism. Endocrinol Metab (Seoul) 2018; 33:355-363. [PMID: 30112867 PMCID: PMC6145965 DOI: 10.3803/enm.2018.33.3.355] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/22/2018] [Accepted: 06/03/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the factors associated with resolution of hypertension after adrenalectomy in patients with primary aldosteronism. A secondary aim was to describe our use of the contralateral ratio in adrenal venous sampling (AVS) in the setting of suboptimal successful cannulation rates. METHODS A retrospective review of patients who underwent AVS followed by unilateral adrenalectomy for primary aldosteronism was performed. RESULTS Complete resolution of hypertension and hypokalemia was seen in 17 of 40 patients (42.5%), while a clinical improvement in hypertension was seen in 38 of 40 (95%). Shorter duration of hypertension, mean aldosteronoma resolution score (ARS), and a high ARS of 3 to 5 were associated with resolution of hypertension after adrenalectomy (P=0.02, P=0.02, and P=0.004, respectively). Of the individual components of ARS, only a duration of hypertension of ≤6 years was associated with resolution of hypertension after adrenalectomy (P=0.03). CONCLUSION A shorter duration of hypertension was significantly associated with resolution of hypertension after adrenalectomy in patients with primary aldosteronism.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore.
| | - Dawn Shao Ting Lim
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Lih Ming Loh
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Peng Chin Kek
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
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Worth PJ, Kunio NR, Siegfried I, Sheppard BC, Gilbert EW. Characteristics predicting clinical improvement and cure following laparoscopic adrenalectomy for primary aldosteronism in a large cohort. Am J Surg 2015; 210:702-9. [DOI: 10.1016/j.amjsurg.2015.05.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/02/2015] [Accepted: 05/29/2015] [Indexed: 01/05/2023]
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Utsumi T, Kamiya N, Endo T, Yano M, Kamijima S, Kawamura K, Imamoto T, Naya Y, Ichikawa T, Suzuki H. Development of a novel nomogram to predict hypertension cure after laparoscopic adrenalectomy in patients with primary aldosteronism. World J Surg 2015; 38:2640-4. [PMID: 24831672 DOI: 10.1007/s00268-014-2612-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Primary aldosteronism is the most common curable cause of secondary hypertension. Despite resection, however, many patients with primary aldosteronism continue to require antihypertensive drugs to control their blood pressure. Although many patients with primary aldosteronism want to know the postoperative probability of hypertension cure before surgery, there are no predictive models calculating its probability. We therefore developed a nomogram to predict hypertension cure in patients with primary aldosteronism after laparoscopic adrenalectomy. METHODS We retrospectively surveyed 132 Japanese patients with primary aldosteronism who were treated by unilateral laparoscopic adrenalectomy. Hypertension cure was defined as normal blood pressure (<140/90 mmHg) without antihypertensive drugs 6 months postoperatively. We developed a novel nomogram that postoperatively predicted cured hypertension in 105 (80 %) randomly selected patients and validated it with the remaining 27 (20 %). RESULTS At 6 months, blood pressure had normalized in 42 % of patients without antihypertensive drugs. Duration of hypertension, preoperative number of antihypertensive drug classes, age, and sex were incorporated into a novel nomogram as independent predictors of hypertension cure. The value of the area under the receiver operating characteristics curve for this nomogram was 0.83-which was significantly higher than that of the Aldosteronoma Resolution Score-on internal validation. CONCLUSIONS We developed the first nomogram that can accurately predict postoperative hypertension cure in patients with primary aldosteronism. This nomogram can help clinicians calculate the probability of postoperative hypertension cure in patients with primary aldosteronism and objectively inform them of their hypertension outcome before laparoscopic adrenalectomy.
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Affiliation(s)
- Takanobu Utsumi
- Department of Urology, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura-shi, Chiba, 285-8741, Japan,
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Diagnostic performance of multidetector computed tomography in distinguishing unilateral from bilateral abnormalities in primary hyperaldosteronism: comparison of multidetector computed tomography with adrenal vein sampling. J Comput Assist Tomogr 2015; 39:414-8. [PMID: 25594382 DOI: 10.1097/rct.0000000000000208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The management of patients with primary hyperaldosteronism (PH) varies depending on whether the unregulated aldosterone secretion localizes to a single unilateral adrenal gland, traditionally determined using adrenal vein sampling (AVS). This study seeks to determine if the performance of multidetector computed tomography (MDCT) examinations performed using the latest scanner technology can reasonably match the results of AVS, and potentially avoid AVS in some patients. MATERIALS AND METHODS Computed tomographic scans in 56 patients with PH were independently reviewed by 2 radiologists for the presence of adrenal nodules and qualitative adrenal thickening. Results were correlated with AVS results. RESULTS Of 35 patients with MDCT evidence of unilateral nodules, the imaging findings correctly predicted AVS localization in only 23 (65.7%) cases. When stratified by size, MDCT was accurate in only 71.4% of cases for nodules measuring 10 mm or less, and only 55.0% of cases for nodules measuring 11 to 20 mm. Of the 12 cases where MDCT did not correctly localize, AVS localized to the contralateral adrenal gland in 4 cases, whereas AVS suggested no lateralization in 8 cases. In patients with normal bilateral adrenal glands on MDCT, 2/7 (28.6%) of cases demonstrated unilateral localization on AVS, and in patients with bilateral adrenal nodules, only 3/14 (21.4%) did not demonstrate lateralization on AVS. CONCLUSIONS Multidetector computed tomography, even when performed with the latest generation of MDCT scanners, does not offer sufficient diagnostic accuracy to replace AVS in patients with PH.
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Asmar M, Wachtel H, Yan Y, Fraker DL, Cohen D, Trerotola SO. Reversing the established order: Should adrenal venous sampling precede cross-sectional imaging in the evaluation of primary aldosteronism? J Surg Oncol 2015; 112:144-8. [DOI: 10.1002/jso.23963] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 06/13/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Melissa Asmar
- Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Heather Wachtel
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Yan Yan
- Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Douglas L. Fraker
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Debbie Cohen
- Department of Medicine, Renal, Electrolyte and Hypertension Division; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Scott O. Trerotola
- Department of Radiology, Division of Vascular and Interventional Radiology; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
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Kohi MP, Agarwal VK, Naeger DM, Taylor AG, Kolli KP, Fidelman N, LaBerge JM, Kerlan RK. The inferior emissary vein: a reliable landmark for right adrenal vein sampling. Acta Radiol 2015; 56:454-7. [PMID: 24682403 DOI: 10.1177/0284185114529107] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Right adrenal vein (RAV) catheterization can be a very challenging step in adrenal venous sampling (AVS). Visualization of the inferior emissary vein (IEV) may be an indication of successful RAV catheterization. PURPOSE To compare the rate of successful RAV sampling in the presence of the IEV. MATERIAL AND METHODS Retrospective review of all consecutive patients with PA who underwent AVS between April 2009 and April 2012 was performed. A total of 30 patients were identified. Procedural images, cortisol, and aldosterone values obtained from sampling of the RAV and inferior vena cava (IVC) were reviewed. Cortisol measurements obtained from RAV samples were divided by measurements from the infra-renal IVC blood samples in order to calculate the selectivity index (SI). An SI >3 was considered indicative of technically successful RAV sampling. RESULTS RAV sampling was considered technically successful in 29 out of 30 cases (97%). In cases of successful RAV sampling (29 patients), the IEV was identified in 25 patients (86%). The IEV was visualized in isolation in 16 patients (64%), and in conjunction with visualization of the RAV or right adrenal gland stain in nine patients (36%). The IEV was not visualized in the one case of unsuccessful RAV sampling. Visualizing the IEV had a sensitivity of 86.2% for successful RAV sampling. CONCLUSION The IEV may serve as a reliable landmark for the RAV during RAV sampling.
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Affiliation(s)
- Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Vishal K Agarwal
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - David M Naeger
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Andrew G Taylor
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - K Pallav Kolli
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Nicholas Fidelman
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Jeanne M LaBerge
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Robert K Kerlan
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
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Sze WCC, Soh LM, Lau JH, Reznek R, Sahdev A, Matson M, Riddoch F, Carpenter R, Berney D, Grossman AB, Chew SL, Akker SA, Druce MR, Waterhouse M, Monson JP, Drake WM. Diagnosing unilateral primary aldosteronism - comparison of a clinical prediction score, computed tomography and adrenal venous sampling. Clin Endocrinol (Oxf) 2014; 81:25-30. [PMID: 24274335 DOI: 10.1111/cen.12374] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 10/21/2013] [Accepted: 11/21/2013] [Indexed: 11/27/2022]
Abstract
CONTEXT In patients with primary aldosteronism (PA), adrenalectomy is potentially curative for those correctly identified as having unilateral excessive aldosterone production. It has been suggested that a recently developed and published clinical prediction score (CPS) may correctly identify some patients as having unilateral disease, without recourse to adrenal venous sampling. OBJECTIVE We have applied the CPS to a large cohort of PA patients with defined and documented outcomes. We also incorporated a minor modification to the CPS and a radiological grading score (RGS) into our analysis to assess whether its performance could be augmented. RESULTS A total of 75 patients with a robust diagnosis following bilateral adrenal venous cannulation and/or strictly defined surgical outcome were analysed. Applying the CPS to this group of patients produced a sensitivity of 38·8% and a specificity of 88·5% of correctly identifying unilateral aldosterone production. Using a suggested modification to the CPS, in which different levels of hypokalaemia were given different weightings, the sensitivity rose to 40·8%, with an identical specificity. Using the RGS alone improved sensitivity to 91·7%, but specificity was reduced to 62·5%. CONCLUSION Applying the recently developed CPS to this cohort of patients, it was not possible to reproduce the 100% specificity reported in the original publication. Using the modified score or incorporating the RGS did not improve its performance. In this cohort, we were unable to show superiority of the CPS over an imaging-based strategy. CPS may have a role in guiding clinical decision-making, especially in those whose adrenal venous sampling (AVS) has been unsuccessful.
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Affiliation(s)
- W C Candy Sze
- Department of Endocrinology, St. Bartholomew's Hospital, London, UK
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Park SI, Rhee Y, Lim JS, Park S, Kang SW, Lee MS, Lee M, Lee SJ, Kim IJ, Lee DY, Cho JS. Right adrenal venography findings correlated with C-arm CT for selection during C-arm CT-assisted adrenal vein sampling in primary aldosteronism. Cardiovasc Intervent Radiol 2013; 37:1469-75. [PMID: 24352864 DOI: 10.1007/s00270-013-0820-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 11/26/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE This study was designed to evaluate retrospectively the efficacy of C-arm CT to confirm right adrenal vein catheterization during adrenal vein sampling (AVS) and to correlate adrenal venography findings with C-arm CT and/or biochemical results for right adrenal vein selection. METHODS Forty-two consecutive primary aldosteronism patients (M:F = 21:21; age: 29-70 years) underwent C-arm CT assisted sequential AVS. After catheterization of right adrenal vein, C-arm CT was performed to confirm catheter position. Catheter was repositioned when right adrenal gland was not opacified. Radiological images, medical records, and biochemical results were reviewed for technical/biochemical success rates and complications. Right adrenal venography findings of pinnate pattern, visualization of renal capsular vein, and retroperitoneal vein other than renal capsular vein were correlated with C-arm CT and/or biochemical results for right adrenal vein selection. RESULTS Both the technical and biochemical success of AVS was achieved in 40 patients (95.2%). C-arm CT failed due to catheter instability in one, and adrenal/vena cava cortisol gradient was <3 in one patient. Catheter was repositioned in four patients (9.5%) according to C-arm CT findings. Right adrenal venography finding of renal capsular vein significantly correlated with C-arm CT and/or biochemical results (100%) for right adrenal vein selection (p = 0.011, χ(2) test), whereas pinnate pattern (p = 0.099) and other retroperitoneal veins (p = 0.347) did not. There was no procedure-related complication. CONCLUSIONS C-arm CT increases confidence of right adrenal vein catheterization during AVS. Visualization of renal capsular vein on adrenal venography suggests right adrenal vein catheterization and C-arm CT may not be required.
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Affiliation(s)
- Sung Il Park
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea,
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Siracuse JJ, Gill HL, Epelboym I, Clarke NC, Kabutey NK, Kim IK, Lee JA, Morrissey NJ. The vascular surgeon's experience with adrenal venous sampling for the diagnosis of primary hyperaldosteronism. Ann Vasc Surg 2013; 28:1266-70. [PMID: 24355161 DOI: 10.1016/j.avsg.2013.10.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 10/03/2013] [Accepted: 10/09/2013] [Indexed: 01/11/2023]
Abstract
BACKGROUND Adrenal venous sampling (AVS) is used to distinguish between bilateral idiopathic hyperplasia and a functional adrenal tumor in patients with hyperaldosteronism. Successful sampling from both adrenal veins is necessary for lateralization and may require more than 1 procedure. AVS has traditionally been performed by interventional radiologists; however, our goal was to examine the outcomes when performed by a vascular surgeon. METHODS All patients with a diagnosis of hyperaldosteronism were referred for AVS regardless of imaging findings. Cortisol and aldosterone levels were measured in blood samples from both adrenal veins. Postoperative analysis of intraoperative laboratory values before and after cosyntropin administration determined successful cannulation and sampling of each vein. RESULTS Between 2007 and 2012, 53 patients underwent AVS by one vascular surgeon. The average age was 54 and 63% were men. Our success rate increased with experience, because during the earlier years (2007-2010) primary and secondary success rates were 58% and 68%, respectively compared with later years (2011-2012) when primary and secondary success rates were 82% and 95%, respectively (P<0.05). Results of AVS altered localization of disease compared with what had been anticipated based on preoperative imaging and thus influenced surgical decision making in 47% of cases. CONCLUSIONS AVS is an important procedure in the work up of hyperaldosteronism to help identify and localize metabolically active tumors. It is an additional area in medicine where a vascular surgeon can lend expertise. Success with the procedure improves with experience and should be performed by high volume surgeons.
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Affiliation(s)
- Jeffrey J Siracuse
- Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY.
| | - Heather L Gill
- Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Irene Epelboym
- Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Noelle C Clarke
- Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Nii-Kabu Kabutey
- Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - In-Kyong Kim
- Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - James A Lee
- Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Nicholas J Morrissey
- Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
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15
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Galati SJ, Hopkins SM, Cheesman KC, Zhuk RA, Levine AC. Primary aldosteronism: emerging trends. Trends Endocrinol Metab 2013; 24:421-30. [PMID: 23796656 DOI: 10.1016/j.tem.2013.05.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 05/15/2013] [Accepted: 05/16/2013] [Indexed: 01/07/2023]
Abstract
Primary aldosteronism (PA) is the most common etiology of endocrine hypertension (HTN), and recent prevalence studies suggest that it may be under-diagnosed. Indications for screening have been expanded with recognition that many patients with PA do not have hypokalemia and that the disease may be familial. The aldosterone:renin ratio (ARR) is the preferred screening test for PA. The ARR can be interpreted in patients on most anti-hypertensive agents, and can be used to guide medical therapy of HTN even in patients without PA. Once PA is confirmed, adrenal venous sampling (AVS) should be performed to determine if PA is due to bilateral disease or a unilateral adenoma, if surgery is being considered. Targeted medical or surgical therapy improves patient outcomes.
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Affiliation(s)
- Sandi-Jo Galati
- Division of Endocrinology, Metabolism and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, Adrenal Center at Mount Sinai Hospital, 1 Gustave L. Levy Place, #1055, New York, NY 10029, USA
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Higashide T, Funabashi N, Tanaka T, Inoue K, Kazama T, Motoori K, Nagano H, Nakatani Y, Ichikawa T, Takaoka H, Uehara M, Yokote K, Kobayashi Y, Uno T. Detection of adrenal veins on selective retrograde CT adrenal venography in comparison with digital subtraction angiography in subjects with established diagnosis of one-sided adrenal aldosterone-producing tumor confirmed by adrenal vein sampling, histopathology and clinical course. Int J Cardiol 2013; 168:3254-8. [PMID: 23647597 DOI: 10.1016/j.ijcard.2013.04.140] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 04/06/2013] [Indexed: 12/09/2022]
Abstract
PURPOSE Adrenal vein (AV) sampling (AVS) is the diagnostic gold standard for primary aldosteronism (PA), but right-sided AVS is difficult. We compared detection of AVs by selective retrograde CT adrenal venography (SRCTAV) with digital subtraction angiography (DSA). MATERIALS AND METHODS Data on 29 subjects (11 males, mean age 55 y) with increased serum aldosterone concentrations (SAC) and a diagnosed right or left aldosterone-producing tumor (APT) by AVS who underwent laparoscopic adrenalectomy were retrospectively analyzed. Before AVS, visualizing AVs was attempted by DSA and SRCTAV (Aquilion). If after the adrenocorticotropic hormone loading test serum cortisol concentration (SCC) from either AV was >200 μg/dl, AVS was considered successful. If the SAC/SCC ratio for one side was ≥4 times higher than the other side, we diagnosed a one-sided APT. RESULTS Left and right AV, respectively, were visualized in 29 (100%) and 22 subjects (76%) by DSA and 29 (100%) and 28 subjects (97%) by SRCTAV, with right-AV detection significantly higher by SRCTAV (p<0.05). Cannulations were regarded successful in 28 subjects having both AVs observed on SRCTAV but not in the remaining subject whose adrenocortical scintigram was positive, however. Adrenalectomy was performed with a diagnosis of adenoma. Among 28 subjects with successful AVS, histopathological diagnoses included adenoma (25), nodular hyperplasia (2) and normal (1). After adrenalectomy, antihypertensive drug usage in 28 patients was reduced or stopped with decreases in SAC (97%). CONCLUSIONS Detection of AV was significantly higher by SRCTAV than DSA, especially on the right side, in 29 subjects diagnosed with one-sided APT.
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Affiliation(s)
- Takashi Higashide
- Department of Radiology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba 260-8670, Japan
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