The influence of the peripheral cortisol fluctuation on the success rate of adrenal venous sampling

Strategies for subtyping primary aldosteronism

Adrenal venous sampling (AVS) is a crucial method for the lateralization of primary aldosteronism (PA). It is advised to halt the use of the patient's antihypertensive medications and correct hypokalemia prior to undergoing AVS. Hospitals equipped to conduct AVS should establish their own diagnostic criteria based on current guidelines. If the patient's antihypertensive medications cannot be discontinued, AVS can be performed as long as the serum renin level is suppressed. The Task Force of Taiwan PA recommends using a combination of adrenocorticotropic hormone stimulation, quick cortisol assay, and C-arm cone-beam computed tomography to maximize the success of AVS and minimize errors by using the simultaneous sampling technique. If AVS is not successful, an NP-59 (131 I-6-β-iodomethyl-19-norcholesterol) scan can be used as an alternative method to lateralize PA. We depicted the details of the lateralization procedures (mainly AVS, and alternatively NP-59) and their tips and tricks for confirmed PA patients who would consider to undergo surgical treatment (unilateral adrenalectomy) if the subtyping shows unilateral disease.

Taiwan mini-frontier of primary aldosteronism: Updating detection and diagnosis

BACKGROUND

To update information about the internationally accepted standards and clinical recommendations for the detection and diagnosis of primary aldosteronism (PA).

METHODS

The Taiwan Society of Aldosteronism (TSA) Task Force reviewed the latest literature and reached a consensus after group meetings. The nine critical issues were recognized to provide updated information and internationally acceptable protocols.

RESULTS

When screening for PA by using the plasma aldosterone concentration (PAC) to plasma renin activity (PRA) ratio (ARR), withdrawal or adjustment of antihypertensive medication is not always necessary on the first patient visit. Hypokalemia should be corrected before ARR screening. In spontaneous hypokalemia, plasma renin below detection levels, and PAC higher than 20 ng/dL (550 pmol/L), further confirmatory testing is unnecessary for PA diagnosis. Direct renin concentration (DRC) could be used for PA diagnosis if PRA is unavailable. Although additional confirmatory tests are suggested, the result of a single test is still reliable. For patient safety, discontinuation or adjustment of antihypertensive medications is indicated before adrenal venous sampling (AVS). ACTH could be beneficial for successful adrenal vein cannulation but is not necessary for determining lateralization in AVS. Simultaneous technique is preferred for AVS. Adrenal NP-59 scintigraphy integrated with SPECT/CT could guide PA management.

CONCLUSION

With introduction of these new concepts to the clinicians, we expect better identification, management and treatment of PA patients.

Adrenal venous sampling with or without adrenocorticotropic hormone stimulation: A meta-analysis

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.