1
|
Wernig F, Dunin-Borkowska A, Frisiras A, Khoo B, Todd J, Di Marco A, Palazzo FF, Barnes SC, Tan TM, Meeran K, Alsafi A. Adrenal Vein Sampling: Does the Location of the Non-adrenal Venous Sample Matter? Cardiovasc Intervent Radiol 2024; 47:194-199. [PMID: 38212421 PMCID: PMC10844346 DOI: 10.1007/s00270-023-03647-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/07/2023] [Indexed: 01/13/2024]
Abstract
PURPOSE Adrenal vein sampling (AVS) is used to lateralise and differentiate unilateral from bilateral aldosterone production in primary aldosteronism. The adrenal venous samples are standardised to a peripheral or low inferior vena cava (IVC) sample and compared. It is unknown whether the location of the non-adrenal sample affects the results. This study compares AVS results standardised to the low IVC and right external iliac vein (REIV). METHODS Patients who underwent AVS between March 2021 and May 2023 were included. All procedures were undertaken by a single operator (AA). Demographic data and AVS results were collected from patients' electronic records. Catheterisation success and lateralisation were assessed using both low IVC and REIV samples. Equivalence test was used to compare the cortisol and aldosterone levels. RESULTS Eighty-one patients, (M: F = 38:43), aged between 29 and 74 were included. Bilateral successful adrenal vein cannulation was achieved in 79/81 (97.5%) cases. The mean cortisol levels from the REIV were statistically equivalent although there was a small and not biologically significant difference from the low IVC (respective geometric means 183 nmol/l vs. 185 nmol/l, p = 0.015). This small difference in cortisol may be due to accessory adrenal venous drainage into the IVC. The aldosterone and aldosterone/cortisol ratios were statistically equivalent. There was no discordance in selectivity or lateralisation when the IVC or REIV measurements were used. CONCLUSION The IVC and REIV samples may be used interchangeably during AVS.
Collapse
Affiliation(s)
- Florian Wernig
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Aleksandra Dunin-Borkowska
- Imaging Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS, UK
| | - Angelos Frisiras
- Imaging Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS, UK
| | - Bernard Khoo
- Department of Endocrinology, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Jeannie Todd
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Aimee Di Marco
- Department of Endocrine Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery & Cancer, Imperial College, London, UK
| | - F Fausto Palazzo
- Department of Endocrine Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery & Cancer, Imperial College, London, UK
| | - Sophie C Barnes
- Department of Clinical Biochemistry, North-West London Pathology, London, UK
| | - Tricia M Tan
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Karim Meeran
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Ali Alsafi
- Imaging Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS, UK.
- Department of Surgery & Cancer, Imperial College, London, UK.
| |
Collapse
|
2
|
O'Malley KJ, Alnablsi MW, Xi Y, Pathak M, Khan F, Pillai AK, Kathuria MK, Vongpatanasin W. Diagnostic performance of the adrenal vein to inferior vena cava aldosterone ratio in classifying the subtype of primary aldosteronism. Hypertens Res 2023; 46:2535-2542. [PMID: 37673958 DOI: 10.1038/s41440-023-01421-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/30/2023] [Accepted: 08/20/2023] [Indexed: 09/08/2023]
Abstract
Adrenal vein sampling (AVS) is the standard procedure for distinguishing unilateral primary aldosteronism (PA) from bilateral PA. In cases where only one adrenal vein is successfully cannulated, it has been suggested that subtype classification can be determined based on the ratio of the concentration of aldosterone between the adrenal vein and the inferior vena cava (AV/IVC index). However, diagnostic performance of the ipsilateral versus contralateral AV/IVC index in predicting lateralization has not been directly compared. In a retrospective cohort of 133 patients with confirmed PA who underwent successful AVS, the performance of the AV/IVC index to predict laterality was evaluated and the area under the receiver operating characteristic (AUROC) curves was calculated. In detecting left unilateral PA (n = 47), the AUROC of the right AV/IVC index (RAV/IVC) was significantly higher than the AUROC of the left AV/IVC (LAV/IVC) index (0.967 vs. 0.871, p = 0.008). In detecting right unilateral PA (n = 30), the AUROC of the LAV/IVC index tended to be higher than that of the RAV/IVC index, but the difference did not reach statistical significance (0.966 vs. 0.906, p = 0.08). In detecting left unilateral PA, the sensitivities of the RAV/IVC and LAV/IVC indices were 83% and 46%, respectively, while the specificities of both were above 90%. In detecting right unilateral PA, the sensitivities of the LAV/IVC and RAV/IVC indices were 80% and 43%, respectively, while the specificities of both were above 90%. The AV/IVC index has superior diagnostic performance in detecting contralateral unilateral PA compared to ipsilateral unilateral PA.
Collapse
Affiliation(s)
- Kyle J O'Malley
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mhd W Alnablsi
- Department of Radiology (Division of Vascular Interventional Radiology), University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yin Xi
- Department of Radiology (Division of Vascular Interventional Radiology), University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mona Pathak
- Department of Pharmacotherapy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Fatima Khan
- Department of Radiology (Division of Vascular Interventional Radiology), University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anil K Pillai
- Department of Radiology (Division of Vascular Interventional Radiology), University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Manoj K Kathuria
- Department of Radiology (Division of Vascular Interventional Radiology), University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Wanpen Vongpatanasin
- Department of Internal Medicine (Division of Cardiology, Hypertension Section), University of Texas Southwestern, Dallas, TX, USA.
| |
Collapse
|
3
|
Yang S, Du Z, Zhang X, Zhen Q, Shu X, Yang J, Song Y, Yang Y, Li Q, Hu J. Corticotropin Stimulation in Adrenal Venous Sampling for Patients With Primary Aldosteronism: The ADOPA Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2338209. [PMID: 37870836 PMCID: PMC10594148 DOI: 10.1001/jamanetworkopen.2023.38209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/05/2023] [Indexed: 10/24/2023] Open
Abstract
Importance Adrenal venous sampling (AVS) is usually recommended to distinguish between unilateral and bilateral primary aldosteronism (PA) before definitive surgical or medical treatment is offered. Whether a treatment decision based on AVS with or without corticotropin (ACTH) stimulation leads to different biochemical and clinical remission rates in patients with PA remains unclear. Objective To evaluate whether treatment decisions based on AVS with or without ACTH stimulation lead to different biochemical and clinical remission rates in patients with PA. Design, Setting, and Participants This randomized clinical trial (RCT) was conducted at a tertiary hospital in China from July 8, 2020, to February 20, 2023, among patients with PA aged 18 to 70 years. Patients were followed up for 12 months after the initiation of treatment. An intention-to-diagnose analysis was conducted. Interventions Patients were randomly assigned to undergo either ACTH-stimulated or non-ACTH-stimulated AVS. Main Outcomes and Measures The primary end point was the proportion of patients with complete biochemical remission after 12 months of follow-up. Secondary outcomes included the proportion of patients who achieved complete clinical remission after 12 months of follow-up, dosages of antihypertensive agents, rate of successful bilateral AVS, and adverse events. Results Of 228 patients with PA, 115 were randomized to the non-ACTH-stimulated group (median age, 50.0 years [IQR, 41.0-57.0 years]; 70 males [60.9%]) and 113 to the ACTH-stimulated group (median age, 50.0 years [IQR, 43.5-56.5 years]; 63 males [55.8%]). A total of 68 patients (59.1%) underwent adrenalectomy in the non-ACTH group and 65 (57.5%) in the ACTH group. There was no significant difference in the proportion of patients with complete biochemical remission who were managed on the basis of AVS with vs without ACTH stimulation (with: 56 of 113 [49.6%]; without: 59 of 115 [51.3%]; P = .79). There also was no significant difference in the proportion of patients who achieved complete clinical remission between the non-ACTH and ACTH groups (26 of 115 [22.6%] and 31 of 113 [27.4%], respectively; P = .40). The intensity of therapy with antihypertensives, successful catheterization of bilateral adrenal veins, and incidence of adverse events did not significantly differ between the non-ACTH and ACTH groups. Conclusions and Relevance In this RCT, treatment of PA on the basis of non-ACTH-stimulated or ACTH-stimulated AVS did not lead to significant differences in clinical outcomes for the patients. These results suggest that ACTH stimulation during AVS may not have clinical benefit, at least in the Chinese population. Trial Registration ClinicalTrials.gov Identifier: NCT04461535.
Collapse
Affiliation(s)
- Shumin Yang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhipeng Du
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xizi Zhang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qianna Zhen
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoyu Shu
- Department of Endocrinology, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Jun Yang
- Department of Medicine, Monash University, Clayton, Victoria, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Ying Song
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Yang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qifu Li
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinbo Hu
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
4
|
Beninato T, Duh QY, Long KL, Kiernan CM, Miller BS, Patel S, Randle RW, Wachtel H, Zanocco KA, Zern NK, Drake FT. Challenges and controversies in adrenal surgery: A practical approach. Curr Probl Surg 2023; 60:101374. [PMID: 37770163 DOI: 10.1016/j.cpsurg.2023.101374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Affiliation(s)
- Toni Beninato
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Quan-Yang Duh
- Veterans Affairs Medical Center, San Francisco, San Francisco, CA
| | | | - Colleen M Kiernan
- Vanderbilt University Medical Center, Veterans Affairs Medical Center, Tennessee Valley Health System, Nashville, TN
| | - Barbra S Miller
- Division of Surgical Oncology, The Ohio State University, Columbus, OH
| | - Snehal Patel
- Emory University School of Medicine, Atlanta, GA
| | | | | | - Kyle A Zanocco
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
| | | | | |
Collapse
|
5
|
Younes N, Larose S, Bourdeau I, Therasse E, Lacroix A. Role of Adrenal Vein Sampling in Guiding Surgical Decision in Primary Aldosteronism. Exp Clin Endocrinol Diabetes 2023; 131:418-434. [PMID: 37567230 DOI: 10.1055/a-2106-4663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
Adrenal vein sampling (AVS) is recommended for subtyping primary aldosteronism (PA) to identify lateralized or bilateral sources of aldosterone excess, allowing for better decision-making in regard to medical or surgical management on a case-by-case basis. To date, no consensus exists on protocols to be used during AVS, especially concerning sampling techniques, the timing of sampling, and whether or not to use adrenocorticotropic hormone (ACTH) stimulation. Interpretation criteria for selectivity, lateralization, and contralateral suppression vary from one expert center to another, with some favoring strict cut-offs to others being more permissive. Clinical and biochemical post-operative outcomes can also be influenced by AVS criteria utilized to indicate surgical therapy.In this review, we reanalyze studies on AVS highlighting the recent pathological findings of frequent micronodular hyperplasia adjacent to a dominant aldosteronoma (APA) overlapping with bilateral idiopathic hyperaldosteronism (IHA) etiologies, as opposed to the less frequent unilateral single aldosteronoma. The variable expression of melanocortin type 2 receptors in the nodules and hyperplasia may explain the frequent discordance in lateralization ratios between unstimulated and ACTH- stimulated samples. We conclude that aldosterone values collected during simultaneous bilateral sampling, both at baseline and post-ACTH stimulation, are required to adequately evaluate selectivity, lateralization, and contralateral suppression during AVS, to better identify all patients with PA that can benefit from a surgical indication. Recommended cut-offs for each ratio are also presented.
Collapse
Affiliation(s)
- Nada Younes
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Stéphanie Larose
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Eric Therasse
- Department of Radiology, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Québec, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| |
Collapse
|
6
|
Kline GA, So B, Campbell DJT, Chin A, Harvey A, Venos E, Pasieka J, Leung AA. Apparent failed and discordant adrenal vein sampling: A potential confounding role of cortisol cosecretion? Clin Endocrinol (Oxf) 2022; 96:123-131. [PMID: 34160833 DOI: 10.1111/cen.14546] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/05/2021] [Accepted: 06/07/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Adrenal vein sampling (AVS) and computed tomography (CT) often show confusingly discordant lateralisation results in primary aldosteronism (PA). We tested a biochemical algorithm using AVS data to detect cortisol cosecretion as a potential explanation for discordant cases. DESIGN Retrospective analysis from a large PA + AVS database. PATIENTS All patients with PA and AVS, 2005-2020. MEASUREMENTS An algorithm using biochemical data from paired AVS + CT images was devised from physiological first principles and informed by data from unilateral, AVS-CT concordant patients. The algorithm involved calculations based upon the expectation that low cortisol levels exist in adrenal vein effluent opposite an aldosterone-and-cortisol-producing adrenal mass and may reverse lateralisation due to inflated aldosterone/cortisol ratios. MAIN OUTCOMES The algorithm was applied to cases with discordant CT-AVS lateralisation to determine whether this might be a common or explanatory finding. Clinical and biochemical characteristics of identified cases were collected via chart review and compared to CT-AVS concordant cases to detect evidence of biological plausibility for cortisol cosecretion. RESULTS From a total of 588 AVS cases, 141 AVS + CT pairs were clear unilateral PA cases, used to develop the three-step algorithm for AVS interpretation. Applied to 88 AVS + CT discordant pairs, the algorithm suggested possible cortisol cosecretion in 40%. Case review showed that the proposed cortisol cosecretors, as identified by the algorithm, had low/suppressed adrenocorticotropic hormone levels, larger average nodule size and lower plasma aldosterone. CONCLUSIONS Pending external validation and outcome verification by surgery and tissue immunohistochemistry, cortisol cosecretion from aldosteronomas may be a common explanation for discordant CT-AVS results in PA.
Collapse
Affiliation(s)
- Gregory A Kline
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Benny So
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David J T Campbell
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alex Chin
- Department of Clinical Pathology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Precision Laboratories, Calgary, Alberta, Canada
| | - Adrian Harvey
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erik Venos
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Janice Pasieka
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexander A Leung
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
7
|
So C, Leung A, Chin A, Kline G. Adrenal venous sampling in primary aldosteronism: lessons from over 600 single-operator procedures. Clin Radiol 2021; 77:e170-e179. [DOI: 10.1016/j.crad.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 11/05/2021] [Indexed: 11/25/2022]
|
8
|
Yang J, Yu Y, Zhang Z, Wu Y, He Z. Adrenal venous sampling with adrenocorticotropic hormone stimulation: A meta-analysis. Int J Clin Pract 2021; 75:e14438. [PMID: 34096147 DOI: 10.1111/ijcp.14438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/24/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND This meta-analysis was performed to compare the effect of adrenal venous sampling with adrenocorticotropic hormone with that without adrenocorticotropic hormone in subjects with primary aldosteronism. METHODS A systematic literature search up to May 2020 was performed and 17 studies were detected with 1878 subjects who had adrenal venous sampling operations. They reported relationships between with and without adrenocorticotropic hormone stimulation during adrenal venous sampling in subjects with primary aldosteronism. We calculated the odds ratio (OR) with 95% confidence intervals (CIs), using the dichotomous method with a random- or fixed-effect model. RESULTS Adrenal venous sampling operations with adrenocorticotropic hormone stimulation had statistically significant lower incorrect lateralisation (OR, 0.57; 95% CI, 0.43-0.75, P < .001); lower unsuccessful cannulations in both adrenal veins (OR, 0.35; 95% CI, 0.21-0.58, P < .001); lower unsuccessful cannulations of left adrenal vein (OR, 0.10; 95% CI, 0.06-0.17, P < .001) and lower unsuccessful cannulations of right adrenal vein (OR, 0.25; 95% CI, 0.11-0.54, P < .001) compared with without adrenocorticotropic hormone stimulation in subjects with primary aldosteronism. CONCLUSIONS Adrenal venous sampling operations with adrenocorticotropic hormone stimulation had significantly lower incorrect lateralisation, unsuccessful cannulations in both adrenal veins, unsuccessful cannulations of the left adrenal vein and unsuccessful cannulations of the right adrenal vein compared with adrenal venous sampling operations without adrenocorticotropic hormone stimulation in subjects with primary aldosteronism. Larger prospective studies are recommended to confirm these findings.
Collapse
Affiliation(s)
- Junfeng Yang
- Department of Urology, First People's Hospital of Yunnan Province, Kunming, China
| | - Yanhong Yu
- Department of Urology, First People's Hospital of Yunnan Province, Kunming, China
| | - Zhuorui Zhang
- Department of Urology, First People's Hospital of Yunnan Province, Kunming, China
| | - Yuerong Wu
- Department of Urology, First People's Hospital of Yunnan Province, Kunming, China
| | - Zhengyu He
- Department Of Urology, Yaan People's Hospital, Yaan, China
| |
Collapse
|
9
|
Turcu AF, Auchus R. Approach to the Patient with Primary Aldosteronism: Utility and Limitations of Adrenal Vein Sampling. J Clin Endocrinol Metab 2021; 106:1195-1208. [PMID: 33382421 PMCID: PMC7993592 DOI: 10.1210/clinem/dgaa952] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Indexed: 11/19/2022]
Abstract
Several studies over the past 3 decades document a higher prevalence of primary aldosteronism (PA) among hypertensive patients than generally presumed. PA exists as a spectrum from mild to severe aldosterone excess. Although a variety of PA subtypes exist, the 2 most common are aldosterone-producing adenomas (APAs) and bilateral hyperaldosteronism (BHA). The distinction is important, because APA-and other subtypes, with aldosterone production mostly from 1 adrenal-can be cured surgically, and BHA should be treated medically with mineralocorticoid-receptor antagonists (MRAs). The major shortcomings in the tailored management of patients with possible PA are the low rates of screening for case identification and the expensive and technically challenging imaging and interventional procedures required to distinguish APA from BHA, especially adrenal vein sampling (AVS). When AVS identifies an APA and allows the patient to be cured surgically, the procedure is of great value. In contrast, the patient with BHA is treated with MRA whether AVS is performed or not. Consequently, it is prudent to gauge how likely it is to benefit from imaging and AVS in each case prior to embarking on these studies. The explosion of information about PA in the past decade, including predictors of APA and of surgical benefit, are useful in limiting the evaluation for some patients with a positive PA screening test. This article will review our suggestions for approaching these patients in a pragmatic style, recognizing the limitations to even the best resources and facilities.
Collapse
Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Ann Arbor, Michigan, USA
| | - Richard Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Ann Arbor, Michigan, USA
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan, USA
- Ann Arbor Veterans Affairs Hospital, Ann Arbor, Michigan, USA
- Correspondence: Richard Auchus, MD, PhD, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, 1150 W Medical Center Dr, MSRB II, 5560A, Ann Arbor, Michigan 48109 USA. E-mail:
| |
Collapse
|
10
|
Miyoshi A, Wada N, Baba S, Obara S, Takahashi B, Usubuchi H, Terae S. Left-right differences in adrenal vein sampling for primary aldosteronism. Endocr J 2020; 67:327-334. [PMID: 31801916 DOI: 10.1507/endocrj.ej19-0372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In adrenal venous sampling (AVS) for patients with primary aldosteronism (PA), adrenocorticotropic hormone (ACTH) stimulation generally increased the success rate. The effect of ACTH stimulation on the left-right differences of laterality diagnosis in AVS remains unclear. A total of 167 patients with PA underwent successful AVS were examined. Patients with autonomous cortisol secretion were excluded. The proportion of dominant side in AVS was compared before and after ACTH stimulation. Unilateral disease on AVS was defined as a lateralization index of more than 4, both before and after ACTH stimulation. Before ACTH stimulation, unilateral disease was more frequently observed on the right side than the left side (right 33.5% vs. left 13.8%, p < 0.01). After ACTH stimulation, unilateral disease was more frequently observed on the left side than the right side, without statistical significance (left 15.6% vs. right 10.8%, p = 0.20). Among the 56 patients who had right unilateral disease before ACTH stimulation, 17 patients (30.0%) also had right unilateral disease after ACTH stimulation. The affected side of AVS was changed from right unilateral to bilateral after ACTH stimulation in 34 (60.7%) out of 56 patients. These patients had milder PA and CT scans showed no nodular lesions on the right side. In AVS, ACTH stimulation not only decreased unilateral results but also shifted to the dominant side. Overestimation should be carefully considered when the surgical indication for the right adrenal gland was decided based on AVS results without ACTH stimulation.
Collapse
Affiliation(s)
- Arina Miyoshi
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Shuhei Baba
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Shinji Obara
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Bunya Takahashi
- Department of Radiology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Hiroaki Usubuchi
- Department of Radiology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Satoshi Terae
- Department of Radiology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| |
Collapse
|
11
|
Nagano H, Kono T, Saiga A, Kubota Y, Fujimoto M, Felizola SJA, Ishiwata K, Tamura A, Higuchi S, Sakuma I, Hashimoto N, Suzuki S, Koide H, Takeshita N, Sakamoto S, Ban T, Yokote K, Nakamura Y, Ichikawa T, Uno T, Tanaka T. Aldosterone Reduction Rate After Saline Infusion Test May Be a Novel Prediction in Patients With Primary Aldosteronism. J Clin Endocrinol Metab 2020; 105:5599822. [PMID: 31628466 DOI: 10.1210/clinem/dgz092] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/17/2019] [Accepted: 10/01/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Accurate assessment and localization of aldosterone-producing adenomas (APAs) are essential for the treatment of primary aldosteronism (PA). Although adrenal venous sampling (AVS) is the standard method of reference for subtype diagnosis in PA, controversy exists concerning the criteria for its interpretation. This study aims to determine better indicators that can reliably predict subtypes of PA. METHOD Retrospective, single-cohort analysis including 209 patients with PA who were subjected to AVS. Eighty-two patients whose plasma aldosterone concentrations (PAC) were normalized after surgery were histopathologically or genetically diagnosed with APA. The accuracy of image findings was compared to AVS results. Receiver operating characteristic (ROC) curve analysis between the operated and the no-apparent laterality groups was performed using AVS parameters and loading test for diagnosis of PA. RESULT Agreement between image findings and AVS results was 56.3%. ROC curve analysis revealed that the lateralization index (LI) after adrenocorticotropin stimulation cutoff was 2.40, with 98.8% sensitivity and 97.1% specificity. The contralateral suppression index (CSI) cutoff value was 1.19, with 98.0% sensitivity and 93.9% specificity. All patients over the LI and CSI cutoff values exhibited unilateral subtypes. Among the loading test, the best classification accuracy was achieved using the PAC reduction rate after a saline infusion test (SIT) >33.8%, which yielded 87.2% sensitivity or a PAC after a SIT <87.9 pg/mL with 86.2% specificity for predicting bilateral PA. CONCLUSION The combined criteria of the PAC reduction rate and PAC after the SIT can determine which subset of patients with APA who should be performed AVS for validation.
Collapse
Affiliation(s)
- Hidekazu Nagano
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Takashi Kono
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Atsushi Saiga
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Yoshihiro Kubota
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Masanori Fujimoto
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Saulo J A Felizola
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kazuki Ishiwata
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ai Tamura
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Seiichiro Higuchi
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Internal Medicine, Isumi Medical Center, Chiba, Japan
| | - Ikki Sakuma
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoko Hashimoto
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Sawako Suzuki
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hisashi Koide
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | | | | | - Toshiaki Ban
- Department of Internal Medicine, Isumi Medical Center, Chiba, Japan
| | - Koutaro Yokote
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | | | - Takashi Uno
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Tomoaki Tanaka
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| |
Collapse
|
12
|
Meyrignac O, Arcis É, Delchier MC, Mokrane FZ, Darcourt J, Rousseau H, Bouhanick B. Impact of cone beam - CT on adrenal vein sampling in primary aldosteronism. Eur J Radiol 2020; 124:108792. [DOI: 10.1016/j.ejrad.2019.108792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/20/2019] [Accepted: 12/11/2019] [Indexed: 10/25/2022]
|
13
|
Wannachalee T, Zhao L, Nanba K, Nanba AT, Shields JJ, Rainey WE, Auchus RJ, Turcu AF. Three Discrete Patterns of Primary Aldosteronism Lateralization in Response to Cosyntropin During Adrenal Vein Sampling. J Clin Endocrinol Metab 2019; 104:5867-5876. [PMID: 31408156 PMCID: PMC6800532 DOI: 10.1210/jc.2019-01182] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/07/2019] [Indexed: 01/12/2023]
Abstract
CONTEXT Cosyntropin [ACTH (1-24)] stimulation during adrenal vein (AV) sampling (AVS) enhances the confidence in the success of AV cannulation and circumvents intraprocedure hormonal fluctuations. Cosyntropin's effect on primary aldosteronism (PA) lateralization, however, is controversial. OBJECTIVES To define the major patterns of time-dependent lateralization, and their determinants, after cosyntropin stimulation during AVS. METHODS We retrospectively studied patients with PA who underwent AVS before, 10, and 20 minutes after cosyntropin stimulation between 2009 and 2018. Unilateral (U) or bilateral (B) PA was determined on the basis of a lateralization index (LI) value ≥4 or <4, respectively. Available adrenal tissue underwent aldosterone synthase-guided next-generation sequencing. RESULTS PA lateralization was concordant between basal and cosyntropin-stimulated AVS in 169 of 222 patients (76%; U/U, n = 110; B/B, n = 59) and discordant in 53 patients (24%; U/B, n = 32; B/U, n = 21). Peripheral and dominant AV aldosterone concentrations and LI were highest in U/U patients and progressively lower across intermediate and B/B groups. LI response to cosyntropin increased in 27% of patients, decreased in 33%, and remained stable in 40%. Baseline aldosterone concentrations predicted the LI pattern across time (P < 0.001). Mutation status was defined in 61 patients. Most patients with KCNJ5 mutations had descending LI, whereas those with ATP1A1 and ATP2B3 mutations had ascending LI after cosyntropin stimulation. CONCLUSION Patients with severe PA lateralized robustly regardless of cosyntropin use. Cosyntropin stimulation reveals intermediate PA subtypes; its impact on LI varies with baseline aldosterone concentrations and aldosterone-driver mutations.
Collapse
Affiliation(s)
- Taweesak Wannachalee
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
- Division of Endocrinology and Metabolism, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Lili Zhao
- School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Kazutaka Nanba
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan
| | - Aya T Nanba
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
| | - James J Shields
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - William E Rainey
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
- Correspondence and Reprint Requests: Adina F. Turcu, MD, MS, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, 1150 West Medical Center Drive, MSRB II, 5570B, Ann Arbor, Michigan 48109. E-mail:
| |
Collapse
|
14
|
Lin L, Zhou L, Guo Y, Liu Z, Chen T, Liu Z, Wang K, Li J, Zhu Y, Ren Y. Can incomplete adrenal venous sampling data be used in predicting the subtype of primary aldosteronism? ANNALES D'ENDOCRINOLOGIE 2019; 80:301-307. [PMID: 31722788 DOI: 10.1016/j.ando.2019.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/13/2019] [Accepted: 10/03/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Adrenal venous sampling (AVS) is the gold standard for preoperative differentiation between unilateral and bilateral primary aldosteronism (PA). However, results are sometimes vitiated by failing to access the right adrenal vein. MATERIALS AND METHODS The present study assumed that clinical decisions can be made with incomplete AVS data, by comparing aldosterone/cortisol (A/C) ratio in both left and right adrenal veins with that in the inferior vena cava (LAV/IVC and RAV/IVC). Receiver operation characteristic (ROC) curve and scatterplot were used to certify the upper and lower cutoffs and to analyze the significance of discrimination. One hundred and sixty patients diagnosed with PA from April 2017 to June 2018 underwent AVS in the Urology Department of West China Hospital, Chengdu, China. One hundred and eleven with complete AVS data were divided into 3 groups: left-sided (N=40), right-sided (N=29) and bilateral (N=42). We also collected patients from September 2018 to April 2019 in our department as validation cohort to test our hypothesis. RESULTS On the basis of LAV/IVC, RAV/IVC and diagnostic category, upper cutoff was 1.14 (50% sensitivity and 100% specificity) and lower cutoff 0.07 (27.5% sensitivity and 100% specificity) for LAV/IVC, and 1.04 (55% sensitivity and 100% specificity) and 0.08 (40% sensitivity and 100% specificity), respectively, for RAV/IVC. CONCLUSION The diagnostic model in this study contributes to clinical decision-making in patients with only partial PA with incomplete AVS data.
Collapse
Affiliation(s)
- Lede Lin
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Liang Zhou
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Yiding Guo
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Zhenghuan Liu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Tao Chen
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Zhihong Liu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Kunjie Wang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Jiaqi Li
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Yuchun Zhu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China.
| | - Yan Ren
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China.
| |
Collapse
|
15
|
Surprisingly low aldosterone levels in peripheral veins following intravenous sedation during adrenal vein sampling. J Hypertens 2019; 37:596-602. [DOI: 10.1097/hjh.0000000000001905] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
16
|
Laurent I, Astère M, Zheng F, Chen X, Yang J, Cheng Q, Li Q. Adrenal venous sampling with or without adrenocorticotropic hormone stimulation: A meta-analysis. J Clin Endocrinol Metab 2018; 104:5158213. [PMID: 30403797 DOI: 10.1210/jc.2018-01324] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 11/01/2018] [Indexed: 01/05/2023]
Abstract
CONTEXT Adrenal venous sampling (AVS) with or without adrenocorticotropic hormone (ACTH) stimulation is the test of choice to identify patients with a surgically curable subtype of primary aldosteronism (PA). Whether AVS with ACTH stimulation is more effective than AVS without ACTH stimulation remains controversial. OBJECTIVE To compare the effectiveness of AVS with ACTH stimulation and AVS without ACTH stimulation in patients with PA. METHODS The Cochrane Library, PubMed, Embase, and Web of Science databases were searched to identify relevant articles. All cohort studies comparing the 2 techniques (AVS with ACTH stimulation and AVS without ACTH stimulation in patient with PA) were included in the analysis. RESULTS A total of 14 studies met the inclusion criteria, and they were analyzed. AVS with ACTH stimulation did not significantly reduce the number of incorrect lateralization more than AVS without ACTH stimulation in patients with PA [OR: 0.76, 95% confidence interval (CI): 0.36, 1.59; P=0.47]. AVS with ACTH stimulation significantly reduced the number of unsuccessful cannulations of both adrenal veins more than AVS without ACTH stimulation in patients with PA (OR: 0.26, 95% CI: 0.17, 0.40; P<0.00001). For subgroup analyses, it also significantly reduced the number of unsuccessful cannulations of left adrenal vein and right adrenal vein (OR: 0.14, 95% CI: 0.06, 0.33; P<0.00001 and OR: 0.30, 95% CI: 0.12, 0.71; P=0.007, respectively). CONCLUSION AVS with ACTH stimulation can significantly reduce the number of unsuccessful cannulations, without significantly reducing the number of incorrect lateralization. Further studies are still needed to verify these findings.
Collapse
Affiliation(s)
- Irakoze Laurent
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University
- Kamenge military hospital, Ministry of Public Health and Fighting AIDS, Bujumbura, Burundi
| | - Manirakiza Astère
- Department of Oncology, First Affiliated Hospital of Chongqing Medical University
| | - Fengfan Zheng
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University
| | - Xiangjun Chen
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University
| | - Jun Yang
- Cardiovascular Endocrinology Laboratory, Hudson Institute of Medical Research, Australia
| | - Qingfeng Cheng
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University
| | - Qifu Li
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University
| |
Collapse
|
17
|
|
18
|
Subtyping of primary aldosteronism with adrenal vein sampling: Hormone- and side-specific effects of cosyntropin and metoclopramide. Surgery 2017; 163:789-795. [PMID: 29198769 DOI: 10.1016/j.surg.2017.09.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/31/2017] [Accepted: 09/13/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cosyntropin and metoclopramide can affect the subtyping of primary aldosteronism when used with adrenal vein sampling by exerting hormone- and side-specific effects on cortisol and aldosterone secretion. We investigated how these stimuli affect the selectivity index, the relative aldosterone secretion index, and the lateralization index in consecutive primary aldosteronism patients submitted to adrenal vein sampling. METHODS We recruited 171 patients; of these, 149 underwent adrenal vein sampling before and after stimulation with cosyntropin (250 µg intravenous bolus, n= 53, 73% with an aldosterone-producing adenoma) or with metoclopramide (10 mg intravenous bolus, n= 96, 65% aldosterone-producing adenoma), and 32 with an aldosterone-producing adenoma were investigated for the relative gene expression of dopamine, melanocortin 2, and 5-hydroxytryptamine (serotonin) 4 receptor with microarrays. Cosyntropin increased the selectivity index similarly on both sides; metoclopramide did not. Cosyntropin decreased relative aldosterone secretion index on the aldosterone-producing adenoma side but not contralaterally. Metoclopramide did not affect the selectivity index, but increased the relative aldosterone secretion index similarly on both sides. Because of these changes, cosyntropin decreased the lateralization index, while metoclopramide did not affect it. The relative gene expression of melanocortin 2, albeit heterogeneous across tumors, was 35% less (P<.0001) in aldosterone-producing adenoma than in the normal adrenal cortex, while dopamine receptor D2 and 5-hydroxytryptamine (serotonin) 4 receptors did not differ between tissues. CONCLUSION Cosyntropin, while facilitating ascertainment of selectivity, lessens the lateralization, likely because of a blunted melanocortin 2 expression in aldosterone-producing adenoma. The similar expression of dopamine and 5-hydroxytryptamine (serotonin) 4 receptors in aldosterone-producing adenoma and the normal adrenal cortex can explain why metoclopramide increased the relative aldosterone secretion index on both sides and, therefore, failed to increase the lateralization index.
Collapse
|
19
|
Kline G, Holmes DT. Adrenal venous sampling for primary aldosteronism: laboratory medicine best practice. J Clin Pathol 2017; 70:911-916. [PMID: 28893861 DOI: 10.1136/jclinpath-2017-204423] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 07/06/2017] [Accepted: 07/23/2017] [Indexed: 01/13/2023]
Abstract
Primary aldosteronism (PA) is the most common form of secondary hypertension and is critical to identify because when caused by an aldosterone-producing adenoma (APA) or another unilateral form, it is potentially curable, and even when caused by bilateral disease, antihypertensives more specific to PA treatment can be employed (ie, aldosterone antagonists). Identification of unilateral forms is not generally accomplished with imaging because APAs may be small and elude detection, and coincidental identification of a non-functioning incidentaloma contralateral to an APA may lead to removal of an incorrect gland. For this reason, the method of choice for identifying unilateral forms of PA is selective adrenal venous sampling (AVS) followed by aldosterone and cortisol analysis on collected samples. This procedure is technically difficult from a radiological standpoint and, from the laboratory perspective, is fraught with opportunities for preanalytical, analytical and postanalytical error. We review the process of AVS collection, analysis and reporting. Suggestions are made for patient preparation, specimen labelling practices and nomenclature, analytical dilution protocols, which numerical results to report, and the necessary subsequent calculations. We also identify and explain frequent sources of confusion in the aldosterone and cortisol results and provide an example of tabular reporting to facilitate interpretation and communication between laboratorian, radiologist and clinician.
Collapse
Affiliation(s)
- Gregory Kline
- Division of Endocrinology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Daniel T Holmes
- Department of Pathology and Laboratory Medicine, St. Paul's Hospital, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| |
Collapse
|
20
|
Abstract
PURPOSE OF REVIEW Primary aldosteronism accounts for 3 to 5% of all hypertension cases. Unilateral aldosterone hypersecretion can be treated with adrenalectomy. Guidelines for primary aldosteronism management recommend adrenal vein sampling (AVS) to ascertain unilateral primary aldosteronism before surgery. Many different protocols are used to perform AVS and for the interpretation of its results, but without hard evidence of why one should be given preference. Experts have proposed recommendations to guide clinical practice and the grounds for future research to address this situation. RECENT FINDINGS Proper patient preparation is a prerequisite for interpretable results. New trends are emerging to improve adequate cannulation of adrenal veins including: training of a limited number of dedicated radiologists, contrast computed tomography of adrenal veins before or during AVS, and rapid assays to measure cortisol concentrations during AVS. Cosyntropin stimulation is performed in several centers to avoid the variability of cortisol secretion during AVS, but whether this improves diagnostic performance is unknown. SUMMARY Better markers of adequate catheter placement are currently under investigation, including other adrenal steroids and metanephrines. Innovative strategies for interpreting partially failed AVS are also being developed. Other approaches to ascertain primary aldosteronism subtype will be necessary because of limited patient access to AVS.
Collapse
Affiliation(s)
- Olivier Steichen
- aInternal Medicine Department, AP-HP, Tenon HospitalbFaculty of Medicine, Sorbonne Universités, UPMC University Paris 06cINSERM, Sorbonne Universités, UPMC Univ Paris 06, UMR_S1142dFaculty of Medicine, Université Paris-DescarteseHypertension Unit, AP-HP, Georges Pompidou European HospitalfINSERM, UMR_S970, équipe 14, Paris, France
| | | |
Collapse
|
21
|
Funder JW, Carey RM, Mantero F, Murad MH, Reincke M, Shibata H, Stowasser M, Young WF. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101:1889-916. [PMID: 26934393 DOI: 10.1210/jc.2015-4061] [Citation(s) in RCA: 1610] [Impact Index Per Article: 201.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop clinical practice guidelines for the management of patients with primary aldosteronism. PARTICIPANTS The Task Force included a chair, selected by the Clinical Guidelines Subcommittee of the Endocrine Society, six additional experts, a methodologist, and a medical writer. The guideline was cosponsored by American Heart Association, American Association of Endocrine Surgeons, European Society of Endocrinology, European Society of Hypertension, International Association of Endocrine Surgeons, International Society of Endocrinology, International Society of Hypertension, Japan Endocrine Society, and The Japanese Society of Hypertension. The Task Force received no corporate funding or remuneration. EVIDENCE We searched for systematic reviews and primary studies to formulate the key treatment and prevention recommendations. We used the Grading of Recommendations, Assessment, Development, and Evaluation group criteria to describe both the quality of evidence and the strength of recommendations. We used "recommend" for strong recommendations and "suggest" for weak recommendations. CONSENSUS PROCESS We achieved consensus by collecting the best available evidence and conducting one group meeting, several conference calls, and multiple e-mail communications. With the help of a medical writer, the Endocrine Society's Clinical Guidelines Subcommittee, Clinical Affairs Core Committee, and Council successfully reviewed the drafts prepared by the Task Force. We placed the version approved by the Clinical Guidelines Subcommittee and Clinical Affairs Core Committee on the Endocrine Society's website for comments by members. At each stage of review, the Task Force received written comments and incorporated necessary changes. CONCLUSIONS For high-risk groups of hypertensive patients and those with hypokalemia, we recommend case detection of primary aldosteronism by determining the aldosterone-renin ratio under standard conditions and recommend that a commonly used confirmatory test should confirm/exclude the condition. We recommend that all patients with primary aldosteronism undergo adrenal computed tomography as the initial study in subtype testing and to exclude adrenocortical carcinoma. We recommend that an experienced radiologist should establish/exclude unilateral primary aldosteronism using bilateral adrenal venous sampling, and if confirmed, this should optimally be treated by laparoscopic adrenalectomy. We recommend that patients with bilateral adrenal hyperplasia or those unsuitable for surgery should be treated primarily with a mineralocorticoid receptor antagonist.
Collapse
Affiliation(s)
- John W Funder
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Robert M Carey
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Franco Mantero
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - M Hassan Murad
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Martin Reincke
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Hirotaka Shibata
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Michael Stowasser
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - William F Young
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| |
Collapse
|
22
|
Doumas M, Douma S. Primary Aldosteronism: A Field on the Move. UPDATES IN HYPERTENSION AND CARDIOVASCULAR PROTECTION 2016. [DOI: 10.1007/978-3-319-34141-5_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|
23
|
Pasternak JD, Epelboym I, Seiser N, Wingo M, Herman M, Cowan V, Gosnell JE, Shen WT, Kerlan RK, Lee JA, Duh QY, Suh I. Diagnostic utility of data from adrenal venous sampling for primary aldosteronism despite failed cannulation of the right adrenal vein. Surgery 2016; 159:267-73. [DOI: 10.1016/j.surg.2015.06.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 06/03/2015] [Accepted: 06/24/2015] [Indexed: 10/23/2022]
|
24
|
Laboratory challenges in primary aldosteronism screening and diagnosis. Clin Biochem 2015; 48:377-87. [DOI: 10.1016/j.clinbiochem.2015.01.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 01/08/2015] [Accepted: 01/12/2015] [Indexed: 01/07/2023]
|
25
|
Peitzsch M, Dekkers T, Haase M, Sweep FCGJ, Quack I, Antoch G, Siegert G, Lenders JWM, Deinum J, Willenberg HS, Eisenhofer G. An LC-MS/MS method for steroid profiling during adrenal venous sampling for investigation of primary aldosteronism. J Steroid Biochem Mol Biol 2015; 145:75-84. [PMID: 25312486 DOI: 10.1016/j.jsbmb.2014.10.006] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 08/28/2014] [Accepted: 10/08/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Steroid profiling for diagnosis of endocrine disorders featuring disordered production of steroid hormones is now possible from advances in liquid chromatography with tandem mass spectrometry (LC-MS/MS). Adrenal venous (AV) measurements of aldosterone and cortisol are a standard practice in the clinical work-up of primary aldosteronism, but do not yet take advantage of steroid profiling. METHODS A novel LC-MS/MS based method was developed for simultaneous measurement of 15 adrenal steroids: aldosterone, corticosterone, 11-deoxycorticosterone, progesterone, pregnenolone, cortisone, cortisol, 11-deoxycortisol, 17-hydroxyprogesterone, androstenedione, dehydroepiandrosterone, dehydroepiandrosterone-sulfate, 21-deoxycortisol, 18-oxocortisol and 18-hydroxycortisol. These were compared in peripheral venous (pV) and AV plasma from 70 patients undergoing AV sampling with and without cosyntropin stimulation. Aldosterone and cortisol levels measured by LC-MS/MS were compared with those measured by immunoassay. RESULTS Reproducibility of measurements with coefficients of variation ≤10% as well as analytical sensitivity sufficient to measure low pV levels particularly of aldosterone demonstrate the utility of the assay for profiling adrenal steroids in primary aldosteronism. Method comparisons indicated assay and concentration dependent differences of cortisol and aldosterone concentrations measured by immunoassay and LC-MS/MS. Median AV/pV ratios of 11-deoxycortisol (53.0), 17-hydroxyprogesterone (33.4), pregnenolone (62.4), androstenedione (40.6) and dehydroepiandrosterone (33.3) were 2.9- to, 5.4-fold larger than those for cortisol (11.6), with additionally generally larger increases than for cortisol with than without cosyntropin stimulation. CONCLUSION Our LC-MS/MS assay, in addition to improvements over existing immunoassay measurements of aldosterone and cortisol, offers profiling of 13 other adrenal steroids, providing a potentially useful method for the clinical work-up of patients with primary aldosteronism. In particular, the larger AV/pV ratios of several steroids compared to cortisol suggest more sensitive alternatives to the latter for assessing positioning of AV sampling catheters.
Collapse
Affiliation(s)
- Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany.
| | - Tanja Dekkers
- Department of General Internal Medicine, Radboud University Medical Center, Geert Grooteplein 8, 6525 Nijmegen, The Netherlands
| | - Matthias Haase
- Heinrich-Heine-University of Dusseldorf, Medical Faculty, Division for Specific Endocrinology, Moorenstrasse 5, 40225 Dusseldorf, Germany; Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud University Medical Center, Geert Grooteplein 10, 6525 Nijmegen, The Netherlands
| | - Ivo Quack
- Heinrich-Heine-University of Dusseldorf, Medical Faculty, Department of Nephrology, Moorenstrasse 5, 40225 Dusseldorf, Germany
| | - Gerald Antoch
- Heinrich-Heine-University of Dusseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, Moorenstrasse 5, 40225 Dusseldorf, Germany
| | - Gabriele Siegert
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Jacques W M Lenders
- Department of General Internal Medicine, Radboud University Medical Center, Geert Grooteplein 8, 6525 Nijmegen, The Netherlands; Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Jaap Deinum
- Department of General Internal Medicine, Radboud University Medical Center, Geert Grooteplein 8, 6525 Nijmegen, The Netherlands
| | - Holger S Willenberg
- Heinrich-Heine-University of Dusseldorf, Medical Faculty, Division for Specific Endocrinology, Moorenstrasse 5, 40225 Dusseldorf, Germany; Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| |
Collapse
|
26
|
Venos ES, So B, Dias VC, Harvey A, Pasieka JL, Kline GA. A clinical prediction score for diagnosing unilateral primary aldosteronism may not be generalizable. BMC Endocr Disord 2014; 14:94. [PMID: 25495254 PMCID: PMC4320464 DOI: 10.1186/1472-6823-14-94] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 12/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A published clinical prediction score indicated that a unilateral adrenal adenoma and either hypokalemia or an estimated glomerular filtration rate of 100 ml/min/1.73 m2 was 100% specific for unilateral primary aldosteronism. This study aimed to validate this score in a separate cohort of patients with primary aldosteronism. METHODS A review of patients with primary aldosteronism from June 2005 to July 2013 at a single center's hypertension clinic. One hundred twelve patients with primary aldosteronism underwent successful adrenal vein sampling and the 110 patients with full data available were included in the final analysis. Adrenal vein sampling was performed all patients desiring surgery by the simultaneous collection of sample prior to and 15 minutes after a cosyntropin infusion with a 3:1 aldosterone/cortisol ratio diagnosing unilateral primary aldosteronism. The derived score was applied to the cohort. Sensitivity and specificity were calculated for clinical prediction score of ≥5 points. RESULTS There were 64 patients found to have unilateral primary aldosteronism and 48 had bilateral disease. A score ≥5 points had 64% sensitivity (95% confidence interval, 51-76) and 85% specificity (95% confidence interval, 71-94) for unilateral disease. Four patients had lateralization of primary aldosteronism to the side contralateral to the adenoma. CONCLUSIONS The 100% specificity of the score for the unilateral origin of primary aldosteronism was not validated in this cohort with a score of ≥5 points. At best, a high score in this prediction rule may be an additional tool for helping to confirm a decision to offer patients adrenal vein sampling.
Collapse
Affiliation(s)
- Erik S Venos
- />Division of Endocrinology, Faculty of Medicine, University of Calgary, 1820 Richmond Road SW, Calgary, AB T2T 5C7 Canada
| | - Benny So
- />Department of Radiology, University of Calgary, Calgary, AB Canada
| | - Valerian C Dias
- />Division of Clinical Pathology, University of Calgary, Calgary, AB Canada
| | - Adrian Harvey
- />Department of Surgery, University of Calgary, Calgary, AB Canada
| | - Janice L Pasieka
- />Department of Surgery, University of Calgary, Calgary, AB Canada
| | - Gregory A Kline
- />Division of Endocrinology, Faculty of Medicine, University of Calgary, 1820 Richmond Road SW, Calgary, AB T2T 5C7 Canada
| |
Collapse
|
27
|
Visualization of the right adrenal vein using CT during right inferior phrenic arteriography in hepatocellular carcinoma patients. Jpn J Radiol 2014; 32:630-6. [DOI: 10.1007/s11604-014-0356-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 08/21/2014] [Indexed: 12/21/2022]
|
28
|
Despite Limited Specificity, Computed Tomography Predicts Lateralization and Clinical Outcome in Primary Aldosteronism. World J Surg 2014; 38:2855-62. [DOI: 10.1007/s00268-014-2694-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
29
|
|