1
|
Yang J, Bell DA, Carroll R, Chiang C, Cowley D, Croker E, Doery JCG, Elston M, Glendenning P, Hetherington J, Horvath AR, Lu-Shirzad S, Ng E, Mather A, Perera N, Rashid M, Sachithanandan N, Shen J, Stowasser M, Swarbrick MJ, Tan HLE, Thuzar M, Young S, Chong W. Adrenal Vein Sampling for Primary Aldosteronism: Recommendations From the Australian and New Zealand Working Group. Clin Endocrinol (Oxf) 2024. [PMID: 39360599 DOI: 10.1111/cen.15139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 09/05/2024] [Accepted: 09/10/2024] [Indexed: 10/04/2024]
Abstract
Adrenal vein sampling (AVS) is the current recommended procedure for identifying unilateral subtypes of primary aldosteronism (PA), which are amenable to surgery with the potential for cure. AVS is a technically challenging procedure usually undertaken by interventional radiologists at tertiary centres. However, there are numerous variations in AVS protocols relating to patient preparation, sampling techniques and interpretation which may impact the success of AVS and patient care. To reduce practice variations, improve the success rates of AVS and optimise patient outcomes, we established an Australian and New Zealand AVS Working Group and developed evidence-based expert consensus recommendations for the preparation, performance and interpretation of AVS. These recommendations can be used by all healthcare professionals in a multidisciplinary team who look after the diagnosis and management of PA.
Collapse
Affiliation(s)
- Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Damon A Bell
- Department of Clinical Biochemistry, Royal Perth Hospital and Fiona Stanley Hospital Network, Pathwest Laboratory Medicine, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Richard Carroll
- Endocrinology, Diabetes, and Research Centre, Wellington Regional Hospital, Wellington, New Zealand
| | - Cherie Chiang
- Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Diane Cowley
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Emma Croker
- Department of Endocrinology, John Hunter Hospital, Lambton Heights, New South Wales, Australia
| | - James C G Doery
- Department of Medicine, Monash University, Clayton, Victoria, Australia
- Monash Pathology, Monash Medical Centre, Clayton, Victoria, Australia
| | - Marianne Elston
- Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
| | - Paul Glendenning
- Department of Clinical Biochemistry, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Julie Hetherington
- Endocrinology and Metabolism Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Andrea R Horvath
- Department of Chemical Pathology, New South Wales Health Pathology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Shanshan Lu-Shirzad
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Elisabeth Ng
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Amanda Mather
- Department of Renal Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Nimalie Perera
- Department of Endocrinology and Chemical Pathology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Muddassir Rashid
- Department of interventional radiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Bond University Medical School, Gold Coast, Queensland, Australia
| | - Nirupa Sachithanandan
- Department of Endocrinology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Australia
| | - Jimmy Shen
- Monash Medical Centre, Clayton, Victoria, Australia
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland Frazer Institute, Brisbane, Australia
| | | | - Hong Lin Evelyn Tan
- Department of Endocrinology, John Hunter Hospital, Lambton Heights, New South Wales, Australia
| | - Moe Thuzar
- Endocrine Hypertension Research Centre, University of Queensland Frazer Institute, Brisbane, Australia
- Department of Endocrinology, Princess Alexandra Hospital, Wooloongabba, Queensland, Australia
| | - Simon Young
- Department of Endocrinology, North Shore Hospital, North Auckland, New Zealand
| | - Winston Chong
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
2
|
Cohen DL, Wachtel H, Vaidya A, Hundemer GL, Tezuka Y, Davio A, Turcu AF, Cohen JB. Primary Aldosteronism in Chronic Kidney Disease: Blood Pressure Control and Kidney and Cardiovascular Outcomes After Surgical Versus Medical Management. Hypertension 2023; 80:2187-2195. [PMID: 37593884 DOI: 10.1161/hypertensionaha.123.21474] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/07/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Diagnosis and treatment of primary aldosteronism (PA) in chronic kidney disease (CKD) may be deferred due to limited evidence supporting safety and efficacy of treatment. Our goal was to assess clinical outcomes in patients with PA and CKD who received surgical or medical management. METHODS We conducted a multicenter, retrospective cohort study of patients with PA and CKD who underwent adrenal vein sampling from 2009-2019. We characterized clinical outcomes and evaluated differences by surgical versus medical management. Primary outcomes were systolic blood pressure and number of antihypertensive medications. Secondary outcomes were diastolic blood pressure, serum potassium, estimated glomerular filtration rate (eGFR), and kidney and cardiovascular events. Analyses were adjusted for age, sex, race, cardiovascular disease, diabetes, and eGFR. RESULTS Of 239 participants with PA and CKD, 158 (66%) underwent adrenalectomy, and 81 (34%) were treated medically. Mean age was 57±10 years, 67% were female, mean eGFR was 45±12 mL/min per 1.73 m2, and 49% were on potassium supplementation. At 5 years, mean blood pressure decreased from 149±22/85±14 to 131±28/78±16 mm Hg and mean number of antihypertensive medications decreased from 4.0±1.5 to 2.4±1.4. Adrenalectomy, compared to medical management, was associated with similar systolic blood pressure (-0.90 mm Hg [95% CI, -6.99 to 5.07]) but fewer medications (1.7 [95% CI, -2.24 to -1.10]), and no difference in potassium levels or kidney or cardiovascular outcomes. CONCLUSIONS Patients with PA and CKD are likely to benefit from either surgical adrenalectomy or medical management. Detection and treatment of PA may help to reduce blood pressure and medication burden in patients with CKD.
Collapse
Affiliation(s)
- Debbie L Cohen
- Renal-Electrolyte and Hypertension Division (D.L.C., J.B.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Heather Wachtel
- Department of Surgery (H.W.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Anand Vaidya
- Division of Endocrinology, Diabetes, and Hypertension, Center for Adrenal Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.V.)
| | - Gregory L Hundemer
- Division of Nephrology, Department of Medicine, Ottawa Hospital, University of Ottawa, ON, Canada (G.L.H.)
| | - Yuta Tezuka
- Division of Clinical Hypertension, Endocrinology and Metabolism (Y.T.), Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
- Division of Nephrology, Endocrinology and Vascular Medicine (Y.T.), Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Angela Davio
- Department of Medicine, University of Michigan, Ann Arbor (A.D., A.F.T.)
| | - Adina F Turcu
- Department of Medicine, University of Michigan, Ann Arbor (A.D., A.F.T.)
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division (D.L.C., J.B.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics (J.B.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| |
Collapse
|
5
|
Steichen O, Lorthioir A, Zinzindohoue F, Plouin PF, Amar L. Outcomes of drug-based and surgical treatments for primary aldosteronism. Adv Chronic Kidney Dis 2015; 22:196-203. [PMID: 25908468 DOI: 10.1053/j.ackd.2014.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 10/08/2014] [Accepted: 10/08/2014] [Indexed: 12/16/2022]
Abstract
Treatments for primary aldosteronism (PA) aim to correct or prevent the deleterious consequences of hyperaldosteronism: hypertension, hypokalemia, and direct target organ damage. Patients with unilateral PA considered fit for surgery can undergo laparoscopic adrenalectomy, which significantly decreases blood pressure (BP) and medications in most cases and cures hypertension in about 40%. Mineralocorticoid receptor antagonists (MRA) are used to treat patients with bilateral PA and those with unilateral PA if surgery is not possible or not desired. Spironolactone is more potent than eplerenone, but high doses are poorly tolerated in men. MRA can be replaced or complemented with epithelial sodium channel blockers, such as amiloride. Thiazide diuretics and calcium channel blockers are used when the first-line drugs are insufficient to control BP. Dietary sodium restriction should be implemented in all cases because the deleterious consequences of hyperaldosteronism are dependent on salt loading. Several studies comparing the results of surgery and MRA have reported no differences in terms of BP, serum potassium concentration, or cardiovascular and kidney outcomes, although the benefits of treatment tend to be observed sooner with surgery. Patients with PA display relative glomerular hyperfiltration, which is reversed by specific treatment, revealing CKD in 30% of patients. However, further kidney damage is lessened by the treatment of PA.
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|