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Fang Z, Cai H, Zhang Q, Gong J, Zhou W, Xie L, Peng F. Comparative Analysis of Single-Path and Multipath Adrenal Venous Sampling in Primary Aldosteronism. J Interv Cardiol 2023; 2023:8670365. [PMID: 37601238 PMCID: PMC10439828 DOI: 10.1155/2023/8670365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/23/2023] [Accepted: 05/11/2023] [Indexed: 08/22/2023] Open
Abstract
Objective To evaluate the safety and efficacy of adrenal venous sampling (AVS) via the cubital vein and femoral vein synchronously. Methods A total of 200 patients with primary aldosteronism admitted to the First Hospital of Fujian Medical University were enrolled and randomly divided into a single-path AVS group (SP, N = 108) and a multipath AVS group (MP, N = 92). We analyzed the clinical characteristics, intubation success rate, procedure cost, total fluoroscopy time, complications, contrast dosage, and the number of catheters selected during AVS. A planar quadrant system was established to mark the direction of the adrenal opening, with the intersection of the right renal vein and the inferior vena cava defined as the origin. In digital subtraction angiography images, the RAV opening located in the 0-3 o'clock direction was the first quadrant (I), and the 3-6 o'clock direction was the third quadrant (III). Results There was no statistical difference between the two groups at baseline. Multipath AVS had a significantly higher success rate of right-sided intubation than single-path AVS (success rate of right-sided intubation/%: SP 87.96 vs MP 95.65, P = 0.043). Total fluoroscopy time was significantly reduced (fluoroscopy time/min: SP 9.80 ± 4.07 vs MP 7.42 ± 3.48, P = 0.024) and the cost of the procedure was markedly lower (cost/yuan: SP 3,900.93 ± 1,191.12 vs MP 3,378.26 ± 399.40, P < 0.001). There was no significant difference in postoperative complications between the two groups. In the group I, the procedure was completed mainly with an MPA catheter (catheter selection/%: MPA 98.19 vs TIG 17.65, P < 0.001). In the group III, TIG catheters were used more frequently (catheter selection/%: MPA 1.81 vs TIG 82.35, P < 0.001). Conclusion Multipath AVS via the cubital vein and femoral vein improves the success rate of AVS with comparable safety compared to single-path AVS. When the RAV is opened in the III quadrant, the TIG catheter improves the cannulation success rate. The multipath AVS method provides more catheter options. Patients diagnosed with PA at the First Hospital of Fujian Medical University from December 2019 to December 2021 were included. The collection of medical records of the included population was approved by the ethics committee (approval number: [2021] 311). This was a cross-sectional study in which some patients were treated surgically and some were treated with superselective adrenal artery embolization (SAAE). We conducted a cohort study of patients treated with SAAE. ClinicalTrials.gov Protocol Registration and Results System (PRS) receipt release date: January 11, 2022. This trial is registered with NCT05188872.
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Affiliation(s)
- Zhoufei Fang
- Department of Geriatrics, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Fujian Hypertension Research Institute, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Clinical Research Center for Geriatric Hypertension Disease of Fujian Province, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Branch of National Clinical Research Center for Aging and Medicine, The First Affiliated Hospital of Fujian Medical University, Fujian Province, Fuzhou, China
- Department of Cardiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Han Cai
- Fujian Hypertension Research Institute, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Cardiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
- Department of Cardiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qixiang Zhang
- The First Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Jin Gong
- Department of Geriatrics, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Fujian Hypertension Research Institute, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Clinical Research Center for Geriatric Hypertension Disease of Fujian Province, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Branch of National Clinical Research Center for Aging and Medicine, The First Affiliated Hospital of Fujian Medical University, Fujian Province, Fuzhou, China
| | - Wei Zhou
- Fujian Hypertension Research Institute, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Liangdi Xie
- Department of Geriatrics, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Fujian Hypertension Research Institute, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Clinical Research Center for Geriatric Hypertension Disease of Fujian Province, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Branch of National Clinical Research Center for Aging and Medicine, The First Affiliated Hospital of Fujian Medical University, Fujian Province, Fuzhou, China
- Department of Cardiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Feng Peng
- Fujian Hypertension Research Institute, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Cardiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
- Department of Cardiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
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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.
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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
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Yoneda M, Kometani M, Aiga K, Karashima S, Usukura M, Mori S, Takeda Y, Aono D, Konishi S, Okumura K, Ogi T, Kobayashi S, Takeda Y, Yoneda T. Impact of Conducting Adrenal Venous Sampling in the Morning Versus Afternoon in Primary Aldosteronism. J Endocr Soc 2023; 7:bvad007. [PMID: 36751308 PMCID: PMC9894291 DOI: 10.1210/jendso/bvad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Indexed: 01/15/2023] Open
Abstract
Context Adrenal venous sampling (AVS) is the gold standard technique for subtype differentiation of primary aldosteronism (PA) and to obtain aldosterone and cortisol measurements; however, their secretion patterns show fluctuations during the day. Objective We aimed to examine the effects of AVS timing on AVS results. Methods This multicenter, retrospective, observational study included a total of 753 patients who were diagnosed with PA and underwent AVS in 4 centers in Japan. Among them, 504 and 249 patients underwent AVS in the morning (AM-AVS) and in the afternoon (PM-AVS), respectively. The outcome measures were the impact of AVS timing and hormone fluctuations in a day on AVS results. Results There were no differences in the success rate of AVS, diagnostic rate of disease type, or frequency of discrepancy in PA subtypes between the AM-AVS and PM-AVS groups. Regarding patients with unilateral PA, aldosterone concentrations in adrenal venous blood did not differ between the 2 groups on the dominant or nondominant side. Conversely, regarding patients with bilateral PA, aldosterone concentrations in adrenal venous blood were significantly higher in the AM-AVS than in the PM-AVS group. Conclusions The timing of AVS did not seem to have a significant impact on subtype diagnosis. The aldosterone levels in adrenal venous blood were significantly higher in patients with bilateral PA in the AM-AVS group, but there was no such difference between patients with unilateral PA in the AM-AVS and PM-AVS groups. Each subtype may have a different hormone secretion pattern in a day.
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Affiliation(s)
- Mau Yoneda
- Department of Health Promotion and Medicine of the Future, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa 920-8641, Japan
| | - Mitsuhiro Kometani
- Correspondence: Mitsuhiro Kometani, MD, Department of Health Promotion and Medicine of the Future, Kanazawa University Graduate School of Medicine, Takara-machi13-1, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Ko Aiga
- Department of Health Promotion and Medicine of the Future, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa 920-8641, Japan
| | - Shigehiro Karashima
- Department of Health Promotion and Medicine of the Future, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa 920-8641, Japan
| | - Mikiya Usukura
- Department of Internal Medicine, Houju Memorial Hospital, Nomi, Ishikawa 923-1226, Japan
| | - Shunsuke Mori
- Department of Internal Medicine, Takaoka City Hospital, Takaoka, Toyama 933-8550, Japan
| | - Yoshimichi Takeda
- Department of Internal Medicine, Saiseikai Kanazawa Hospital, Kanazawa, Ishikawa 920-0353, Japan
| | - Daisuke Aono
- Department of Health Promotion and Medicine of the Future, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa 920-8641, Japan
| | - Seigo Konishi
- Department of Health Promotion and Medicine of the Future, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa 920-8641, Japan
| | - Kenichiro Okumura
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Ishikawa 920-8641, Japan
| | - Takahiro Ogi
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Ishikawa 920-8641, Japan
| | - Satoshi Kobayashi
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Ishikawa 920-8641, Japan
| | - Yoshiyu Takeda
- Department of Health Promotion and Medicine of the Future, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa 920-8641, Japan
| | - Takashi Yoneda
- Department of Health Promotion and Medicine of the Future, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa 920-8641, Japan
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Ng E, Gwini SM, Libianto R, Choy KW, Lu ZX, Shen J, Doery JCG, Fuller PJ, Yang J. Aldosterone, Renin, and Aldosterone-to-Renin Ratio Variability in Screening for Primary Aldosteronism. J Clin Endocrinol Metab 2022; 108:33-41. [PMID: 36179243 DOI: 10.1210/clinem/dgac568] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/23/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT The plasma aldosterone concentration (PAC), renin, and aldosterone-to-renin ratio (ARR) are used to screen for primary aldosteronism (PA). Substantial intra-individual variability of PAC and ARR using plasma renin activity in the context of usual antihypertensive therapy has been described, but there is no data on ARR variability calculated using direct renin concentration (DRC). OBJECTIVE To describe the intra-individual variability of PAC, DRC, and ARR in the absence of interfering medications in patients with and without PA. DESIGN Retrospective cohort study. PATIENTS Hypertensive patients referred for investigation of PA, with at least 2 ARR measurements while off interfering medications. SETTING Endocrine hypertension service of a tertiary center, from May 2017 to July 2021. MAIN OUTCOME MEASURES PAC, DRC, and ARR variability was calculated as coefficient of variation (CV) and percent difference (PD). RESULTS Analysis of 223 patients (55% female, median age 52 years), including 162 with confirmed PA, demonstrated high variability with a sample CV of 22-25% in the PAC and sample CV of 41% to 42% in the DRC and ARR in both the PA and non-PA groups. The degree of variability was substantially higher than the assays' analytical CV. Sixty-two patients (38%) with PA had at least one ARR below 70 pmol/L:mU/L (2.4 ng/dL:mU/L), a cut-off for first-line screening of PA. CONCLUSIONS Significant intra-individual variability in PAC, DRC, and hence ARR occurs in a large proportion of patients being investigated for PA. These findings support the need for at least 2 ARR before PA is excluded or further investigated.
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Affiliation(s)
- Elisabeth Ng
- Department of Endocrinology, Monash Health, Clayton, Victoria, 3168, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Stella May Gwini
- University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Renata Libianto
- Department of Endocrinology, Monash Health, Clayton, Victoria, 3168, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Kay Weng Choy
- Department of Pathology, Northern Health, Epping, Victoria, Australia
| | - Zhong X Lu
- Department of Medicine, Monash University, Clayton, Victoria, Australia
- Monash Health Pathology, Monash Health, Clayton, Victoria, Australia
| | - Jimmy Shen
- Department of Endocrinology, Monash Health, Clayton, Victoria, 3168, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - James C G Doery
- Department of Medicine, Monash University, Clayton, Victoria, Australia
- Monash Health Pathology, Monash Health, Clayton, Victoria, Australia
| | - Peter J Fuller
- Department of Endocrinology, Monash Health, Clayton, Victoria, 3168, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Jun Yang
- Department of Endocrinology, Monash Health, Clayton, Victoria, 3168, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
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Vaidya A, Hundemer GL, Nanba K, Parksook WW, Brown JM. Primary Aldosteronism: State-of-the-Art Review. Am J Hypertens 2022; 35:967-988. [PMID: 35767459 PMCID: PMC9729786 DOI: 10.1093/ajh/hpac079] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022] Open
Abstract
We are witnessing a revolution in our understanding of primary aldosteronism (PA). In the past 2 decades, we have learned that PA is a highly prevalent syndrome that is largely attributable to pathogenic somatic mutations, that contributes to cardiovascular, metabolic, and kidney disease, and that when recognized, can be adequately treated with widely available mineralocorticoid receptor antagonists and/or surgical adrenalectomy. Unfortunately, PA is rarely diagnosed, or adequately treated, mainly because of a lack of awareness and education. Most clinicians still possess an outdated understanding of PA; from primary care physicians to hypertension specialists, there is an urgent need to redefine and reintroduce PA to clinicians with a modern and practical approach. In this state-of-the-art review, we provide readers with the most updated knowledge on the pathogenesis, prevalence, diagnosis, and treatment of PA. In particular, we underscore the public health importance of promptly recognizing and treating PA and provide pragmatic solutions to modify clinical practices to achieve this.
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Affiliation(s)
- Anand Vaidya
- Department of Medicine, Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Kazutaka Nanba
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Wasita W Parksook
- Department of Medicine, Division of Endocrinology and Metabolism, and Division of General Internal Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Maciel AAW, Freitas TC, Fagundes GFC, Petenuci J, Vilela LAP, Brito LP, Goldbaum TS, Zerbini MCN, Ledesma FL, Tanno FY, Srougi V, Chambo JL, Pereira MAA, Coelho FMA, Cavalcante ACBS, Carnevale FC, Pilan B, Pio-Abreu A, Silveira JV, Consolim-Colombo FM, Bortolotto LA, Latronico AC, Fragoso MCBV, Drager LF, Mendonca BB, Almeida MQ. Intraindividual variability of serum aldosterone and its implication for primary aldosteronism screening. J Clin Endocrinol Metab 2022; 108:1143-1153. [PMID: 36413507 DOI: 10.1210/clinem/dgac679] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 11/10/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022]
Abstract
CONTEXT Primary aldosteronism (PA) screening relies on an elevated aldosterone to renin ratio with a minimum aldosterone level, which varies from 10 to 15 ng/dL (277 to 415.5 pmol/L) using immunoassay. AIM To evaluate intraindividual coefficient of variation (CV) of aldosterone and aldosterone to direct renin concentration ratio (A/DRC) and its impact on PA screening. METHODS A total of 671 aldosterone and DRC measurements were performed by the same chemiluminescence assays in a large cohort of 216 patients with confirmed PA and at least two screenings. RESULTS The median intraindividual CV of aldosterone and A/DRC was 26.8% and 26.7%. Almost 40% of the patients had at least one aldosterone level <15 ng/dL, 19.9% had at least two aldosterone levels <15 ng/dL and 16.2% had mean aldosterone levels <15 ng/dL. A lower cut-off of 10 ng/dL was associated with false negative rates for PA screening of 14.3% for a single aldosterone measurement, 4.6% for two aldosterone measurements and only 2.3% for mean aldosterone levels. Considering the minimum aldosterone, true positive rate of aldosterone thresholds was 85.7% for 10 ng/dL and 61.6% for 15 ng/dL. An A/DRC >2 ng/dL/µIU/mL had a true positive rate for PA diagnosis of 94.4% and 98.4% when based on one or two assessments, respectively. CV of aldosterone and A/DRC were not affected by sex, use of interfering anti-hypertensive medications, PA lateralization, hypokalemia, age and number of hormone measurements. CONCLUSION Aldosterone concentrations had a high CV in PA patients, which results in an elevated rate of false negative test in a single screening for PA. Therefore, PA screening should be based in at least two screenings with concomitant aldosterone and renin measurements.
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Affiliation(s)
- Ana Alice W Maciel
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Thais C Freitas
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Gustavo F C Fagundes
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Janaina Petenuci
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Leticia A P Vilela
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
- Disciplina de Endocrinologia, Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, 38400-902, Brasil
| | - Luciana P Brito
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Tatiana S Goldbaum
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Maria Claudia N Zerbini
- Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Felipe L Ledesma
- Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Fabio Y Tanno
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Victor Srougi
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Jose L Chambo
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Maria Adelaide A Pereira
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Fernando M A Coelho
- Instituto de Radiologia InRad, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Aline C B S Cavalcante
- Instituto de Radiologia InRad, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Francisco C Carnevale
- Instituto de Radiologia InRad, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Bruna Pilan
- Instituto de Radiologia InRad, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Andrea Pio-Abreu
- Unidade de Hipertensão, Instituto do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-900, Brasil
| | | | - Fernanda M Consolim-Colombo
- Universidade Nove de Julho, São Paulo, 03155-000, Brasil
- Unidade de Hipertensão, Disciplina de Nefrologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | | | - Ana Claudia Latronico
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Maria Candida B V Fragoso
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
- Divisão de Oncologia Endócrina, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brasil
| | - Luciano F Drager
- Unidade de Hipertensão, Instituto do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-900, Brasil
- Universidade Nove de Julho, São Paulo, 03155-000, Brasil
| | - Berenice B Mendonca
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Madson Q Almeida
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
- Divisão de Oncologia Endócrina, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brasil
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7
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Carsote M. The Entity of Connshing Syndrome: Primary Aldosteronism with Autonomous Cortisol Secretion. Diagnostics (Basel) 2022; 12:diagnostics12112772. [PMID: 36428832 PMCID: PMC9689802 DOI: 10.3390/diagnostics12112772] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/22/2022] [Accepted: 11/08/2022] [Indexed: 11/15/2022] Open
Abstract
Connshing syndrome (CoSh) (adrenal-related synchronous aldosterone (A) and cortisol (C) excess) represents a distinct entity among PA (primary hyperaldosteronisms) named by W. Arlt et al. in 2017, but the condition has been studied for more than 4 decades. Within the last few years, this is one of the most dynamic topics in hormonally active adrenal lesions due to massive advances in steroids metabolomics, molecular genetics from CYP11B1/B2 immunostaining to genes constellations, as well as newly designated pathological categories according to the 2022 WHO classification. In gross, PA causes 4-10% of all high blood pressure (HBP) cases, and 20% of resistant HBP; subclinical Cushing syndrome (SCS) is identified in one-third of adrenal incidentalomas (AI), while CoSh accounts for 20-30% to 77% of PA subjects, depending on the tests used to confirm autonomous C secretion (ACS). The clinical picture overlaps with PA, hypercortisolemia being mild. ACS is suspected in PA if a more severe glucose and cardiovascular profile is identified, or there are larger tumours, ACS being an independent factor risk for kidney damage, and probably also for depression/anxiety and osteoporotic fractures. It seems that one-third of the PA-ACS group harbours mutations of C-related lines like PRKACA and GNAS. A novel approach means we should perform CYP11B2/CYP11B1 immunostaining; sometimes negative aldosteronoma for CYP11B1 is surrounded by micronodules or cell clusters with positive CYP11B1 to sustain the C excess. Pitfalls of hormonal assessments in CoSh include the index of suspicion (check for ACS in PA patients) and the interpretation of A/C ratio during adrenal venous sample. Laparoscopic adrenalectomy is the treatment of choice. Post-operative clinical remission rate is lower in CoSh than PA. The risk of clinically manifested adrenal insufficiency is low, but a synthetic ACTH stimulating testing might help to avoid unnecessary exposure to glucocorticoids therapy. Finally, postponing the choice of surgery may impair the outcome, having noted that long-term therapy with mineralocorticoids receptors antagonists might not act against excessive amounts of C. Awareness of CoSh improves management and overall prognosis.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy & C.I. Parhon National Institute of Endocrinology, 011683 Bucharest, Romania
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Leung AA, Symonds CJ, Hundemer GL, Ronksley PE, Lorenzetti DL, Pasieka JL, Harvey A, Kline GA. Performance of Confirmatory Tests for Diagnosing Primary Aldosteronism: a Systematic Review and Meta-Analysis. Hypertension 2022; 79:1835-1844. [PMID: 35652330 PMCID: PMC9278709 DOI: 10.1161/hypertensionaha.122.19377] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Confirmatory tests are recommended for diagnosing primary aldosteronism, but the supporting evidence is unclear. Methods: We searched Medline, EMBASE, and the Cochrane Central Register of Controlled Trials. Studies evaluating any guideline-recommended confirmatory test (ie, saline infusion test, salt loading test, fludrocortisone suppression test, and captopril challenge test), compared with a reference standard were included. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to assess the risk of bias. Meta-analyses were conducted using hierarchical summary receiver operating characteristic models. Results: Fifty-five studies were included, comprising 26 studies (3654 participants) for the recumbent saline infusion test, 4 studies (633 participants) for the seated saline infusion test, 2 studies (99 participants) for the salt loading test, 7 studies (386 participants) for the fludrocortisone suppression test, and 25 studies (2585 participants) for the captopril challenge test. Risk of bias was high, affecting more than half of studies, and across all domains. Studies with case-control sampling overestimated accuracy by 7-fold (relative diagnostic odds ratio, 7.26 [95% CI, 2.46–21.43]) and partial verification or use of inconsistent reference standards overestimated accuracy by 5-fold (5.12 [95% CI, 1.48–17.77]). There were large variations in how confirmatory tests were conducted, interpreted, and verified. Under most scenarios, confirmatory testing resulted in an excess of missed cases. The certainty of evidence underlying each test (Grading of Recommendations, Assessment, Development, and Evaluations) was very low. Conclusions: Recommendations for confirmatory testing in patients with abnormal screening tests and high probability features of primary aldosteronism are based on very low-quality evidence and their routine use should be reconsidered.
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Affiliation(s)
- Alexander A Leung
- Division of Endocrinology and Metabolism, Department of Medicine (A.A.L., C.J.S., G.A.K.), University of Calgary, AB.,Department of Community Health Sciences (A.A.L., P.E.R., D.L.L.), University of Calgary, AB
| | - Christopher J Symonds
- Division of Endocrinology and Metabolism, Department of Medicine (A.A.L., C.J.S., G.A.K.), University of Calgary, AB
| | - Gregory L Hundemer
- Division of Nephrology, Department of Medicine and the Ottawa Hospital Research Institute, University of Ottawa, ON (G.L.H.)
| | - Paul E Ronksley
- Department of Community Health Sciences (A.A.L., P.E.R., D.L.L.), University of Calgary, AB
| | - Diane L Lorenzetti
- Department of Community Health Sciences (A.A.L., P.E.R., D.L.L.), University of Calgary, AB
| | - Janice L Pasieka
- Department of Surgery (J.L.P., A.H.), University of Calgary, AB.,Department of Oncology (J.L.P., A.H.), University of Calgary, AB
| | - Adrian Harvey
- Department of Surgery (J.L.P., A.H.), University of Calgary, AB.,Department of Oncology (J.L.P., A.H.), University of Calgary, AB
| | - Gregory A Kline
- Division of Endocrinology and Metabolism, Department of Medicine (A.A.L., C.J.S., G.A.K.), University of Calgary, AB
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Affiliation(s)
- John W Funder
- Hudson Institute (Steroid Biology) and Monash University, Clayton, Victoria, Australia
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10
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Younes N, Therasse E, Bourdeau I, Lacroix A. Successful Adrenal Vein Sampling Using Dexamethasone Premedication in Patients With Iodine Contrast Media Allergy. J Endocr Soc 2022; 6:bvac093. [PMID: 35795806 PMCID: PMC9249974 DOI: 10.1210/jendso/bvac093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Indexed: 01/30/2023] Open
Abstract
Abstract
Context
Preparation of patients with iodine contrast media (ICM) allergy who require adrenal vein sampling (AVS) to establish source of aldosterone excess of their confirmed primary aldosteronism (PA) is controversial. Usual premedication with high-dose prednisone can interfere with cortisol determinations, possibly altering the aldosterone to cortisol ratios for the identification of lateralized aldosterone excess.
Objective
We aimed to evaluate the efficacy and safety of premedication with high-dose dexamethasone to perform AVS in patients with ICM.
Methods
One hundred and seventy-seven consecutive patients with confirmed PA who underwent bilateral simultaneous basal and post-ACTH bolus AVS at our center between January 2010 and December 2020 were retrospectively analyzed for history of ICM allergy. A total of 7 patients (4%) with previous allergic reactions to ICM were prepared with 3 doses of 7.5 mg dexamethasone premedication rather than the usual 50 mg of prednisone.
Results
No breakthrough allergic reactions were reported in the 7 patients. Despite adequate serum cortisol suppression following dexamethasone, the basal and post-ACTH selectivity index were respectively > 2 and > 5 bilaterally in all patients, confirming adequate cannulation of both adrenal veins. Four patients had lateralized ratios (A/C ratio > 2 basally and > 4 post-ACTH), while 3 had bilateral source during AVS study. In the 3 patients undergoing unilateral adrenalectomy for lateralized source and contralateral suppression and adequate follow-up data, cure of PA was achieved at mean 58 months postoperatively.
Conclusion
AVS using dexamethasone premedication is safe and accurate for diagnosing the source of aldosterone excess in patients with PA and ICM allergy.
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Affiliation(s)
- Nada Younes
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l’Université de Montréal (CHUM) , Montréal, Québec H2X 0A9 , Canada
| | - Eric Therasse
- Department of Radiology, Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Université de Montréal , Québec H2X 0A9 , Canada
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l’Université de Montréal (CHUM) , Montréal, Québec H2X 0A9 , Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l’Université de Montréal (CHUM) , Montréal, Québec H2X 0A9 , Canada
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11
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Brown JM, Auchus RJ, Honzel B, Luther JM, Yozamp N, Vaidya A. Re-Calibrating Interpretations of Aldosterone Assays Across the Physiologic Range: Immunoassay and Liquid Chromatography-Tandem Mass Spectrometry Measurements Under Multiple Controlled Conditions. J Endocr Soc 2022; 6:bvac049. [PMID: 35475027 PMCID: PMC9032635 DOI: 10.1210/jendso/bvac049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Indexed: 11/19/2022] Open
Abstract
Context Clinicians frequently rely on aldosterone thresholds derived from older immunoassays to diagnose primary aldosteronism. Liquid chromatography–tandem mass spectrometry (LC-MS/MS) is increasingly widespread and reported to yield lower aldosterone concentrations. Objective Given the health impact of incorrect interpretations of aldosterone levels, we compared measurements using LC-MS/MS and immunoassay across the full range of aldosterone physiology by evaluating distinct regulation by angiotensin II and adrenocorticotropin (ACTH). Methods Normotensive volunteers underwent prospective characterization of aldosterone production by immunoassay and LC-MS/MS during 4 conditions (n = 188): oral sodium suppression and restriction (to assess angiotensin II–mediated aldosterone production) and dexamethasone suppression and cosyntropin stimulation (to assess ACTH-mediated aldosterone production). Results Serum aldosterone concentrations by LC-MS/MS and immunoassay had a correlation of 0.69 (P < .001), with good agreement (intraclass correlation 0.76; 95% CI 0.52-0.87). Aldosterone was lower by LC-MS/MS than immunoassay (median 10.5 [3.8, 21.9] vs 19.6 [9.5, 28.0] ng/dL; P < .001), with an average difference of 37.2%. The most notable discrepancy was in the clinically discriminatory range <20 ng/dL: 9.9 (7.1, 13.8) ng/dL using immunoassay corresponded to 5.5 (1.4, 8.9) ng/dL by LC-MS/MS (P < .001). Following oral sodium suppression, the aldosterone-to-renin ratio was 4-fold higher using immunoassay (27.2 [19.7, 62.4] vs 6.4 [3.5, 19.1] ng/dL per ng/mL/hour; P < .001). Conclusion Aldosterone measurements are substantially lower by LC-MS/MS than immunoassay across the full physiologic range, especially when aldosterone levels were less than 20 ng/dL. These findings highlight the need to recalibrate diagnostic interpretations when measuring aldosterone via LC-MS/MS and provide insights into potential biologic causes of assay differences.
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Affiliation(s)
- Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard J Auchus
- Department of Pharmacology and Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
- Endocrinology and Metabolism Section, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan
| | - Brooke Honzel
- Center for Adrenal Disorders, Division of Diabetes, Endocrinology, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - James M Luther
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nicholas Yozamp
- Washington University School of Medicine, St. Louis, Missouri
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Diabetes, Endocrinology, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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12
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Parksook WW, Yozamp N, Hundemer GL, Moussa M, Underhill J, Fudim T, Sacks B, Vaidya A. Morphologically Normal-Appearing Adrenal Glands as a Prevalent Source of Aldosterone Production in Primary Aldosteronism. Am J Hypertens 2021; 35:561-571. [PMID: 34883509 PMCID: PMC9890245 DOI: 10.1093/ajh/hpab189] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/19/2021] [Accepted: 12/06/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Normal-appearing adrenal glands on cross-sectional imaging may still be the source of aldosterone production in primary aldosteronism (PA). METHODS We evaluated the prevalence of aldosterone production among morphologically normal-appearing adrenal glands and the impact of this phenomenon on interpretations of localization studies and treatment decisions. We performed a retrospective cohort study of PA patients with at least 1 normal adrenal gland and reanalyzed contemporary studies to assess interpretations of imaging and adrenal venous sampling (AVS) at the individual patient and adrenal levels. RESULTS Among 243 patients, 43 (18%) had bilateral normal-appearing adrenals and 200 (82%) had a unilateral normal-appearing adrenal, for a total of 286 normal-appearing adrenal glands. 38% of these normal-appearing adrenal glands were a source of aldosteronism on AVS, resulting in discordance between imaging and AVS findings in 31% of patients. Most patients with lateralizing PA underwent curative unilateral treatment (80%); however, curative treatment was pursued in 92% of patients who had concordant imaging-AVS results but in only 38% who had discordant results (P < 0.05). In young patients, imaging-AVS discordance was detected in 32% of those under 45 years and 21% of those under 35 years. Among 20 contemporary studies (including 4,904 patients and 6,934 normal-appearing adrenal glands), up to 64% of normal-appearing adrenals were a source of aldosteronism resulting in 31% of patients having discordant results. CONCLUSIONS Morphologically normal-appearing adrenal glands are commonly the source of aldosterone production in PA, even among young patients. The lack of awareness of this issue may result in inappropriate treatment recommendations.
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Affiliation(s)
- Wasita W Parksook
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA,Department of Medicine (Division of Endocrinology and Metabolism, and Division of General Internal Medicine), Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Nicholas Yozamp
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Marwan Moussa
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Underhill
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Tali Fudim
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Barry Sacks
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Sato Y, Shirota G, Makita K, Itoh D, Hayashi TY, Akamatsu N, Matsui S, Saito J, Omura M, Nishikawa T, Abe O. Anatomical Variations of the Left Adrenal Vein Encountered During Venous Sampling. J Vasc Interv Radiol 2021; 33:71-77.e3. [PMID: 34555539 DOI: 10.1016/j.jvir.2021.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 08/25/2021] [Accepted: 09/09/2021] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To identify anatomical variations in the left adrenal vein (LAV) and to evaluate the role of preprocedural contrast-enhanced computed tomography (CT) planning. METHODS The length of the left adrenal central vein (LACV), the vessel that receives blood from all tributaries of the left adrenal gland, was measured using venograms of patients who had undergone adrenal venous sampling (AVS) for the diagnosis of primary aldosteronism between October 2017 and December 2019. The anatomical variants of the LAV were described and classified. Contrast-enhanced CT was used to evaluate the detection rate of the following: (a) confluence of the left inferior phrenic vein and the LAV and (b) the last tributary flowing into the LAV. RESULTS In total, 311 patients (143 men, 168 women; mean age: 49.3 years ± 11.0) were enrolled. Of them, 9 (2.9%) patients had anatomical variants lacking a LACV. In patients with a LACV (n = 302), the venographic LACV length was 9.0 mm ± 3.9 (<1 mm in 9 patients). The detection rate of the confluence of the left inferior phrenic vein and LAV, as determined using contrast-enhanced CT, was high (96.2%), whereas that of the last tributary flowing into the LAV was low (0.8%). In 4 of 18 patients with short or absent LACV, the variant was visualized using contrast-enhanced CT. CONCLUSIONS In some patients, the LACV is absent or short, which is an anatomical variation. Understanding venographic anatomical variations can help avoid misleading results resulting from a suboptimal sampling site in AVS. For some subtypes, contrast-enhanced CT may also help in planning the AVS procedure.
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Affiliation(s)
- Yuko Sato
- Department of Radiology, Nerima Hikarigaoka Hospital, Tokyo, Japan; Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama City, Kanagawa, Japan
| | - Go Shirota
- Department of Radiology, Nerima Hikarigaoka Hospital, Tokyo, Japan.
| | - Kohzoh Makita
- Department of Radiology, Nerima Hikarigaoka Hospital, Tokyo, Japan; Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama City, Kanagawa, Japan
| | - Daisuke Itoh
- Department of Radiology, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | | | - Nobuhiko Akamatsu
- Department of Radiology, Nerima Hikarigaoka Hospital, Tokyo, Japan; Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Seishi Matsui
- Department of Interventional Radiology, Yokohama Rosai Hospital, Yokohama City, Kanagawa, Japan
| | - Jun Saito
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama City, Kanagawa, Japan
| | - Masao Omura
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama City, Kanagawa, Japan
| | - Tetsuo Nishikawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama City, Kanagawa, Japan
| | - Osamu Abe
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Yozamp N, Hundemer GL, Moussa M, Underhill J, Fudim T, Sacks B, Vaidya A. Adrenocorticotropic Hormone-Stimulated Adrenal Venous Sampling Underestimates Surgically Curable Primary Aldosteronism: A Retrospective Cohort Study and Review of Contemporary Studies. Hypertension 2021; 78:94-103. [PMID: 33993726 DOI: 10.1161/hypertensionaha.121.17248] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Nicholas Yozamp
- From the Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (N.Y., A.V.)
| | - Gregory L Hundemer
- Division of Nephrology, Department of Medicine and the Ottawa Hospital Research Institute, University of Ottawa, Canada (G.L.H.)
| | - Marwan Moussa
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.M., J.U., T.F., B.S.)
| | - Jonathan Underhill
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.M., J.U., T.F., B.S.)
| | - Tali Fudim
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.M., J.U., T.F., B.S.)
| | | | - Anand Vaidya
- From the Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (N.Y., A.V.)
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Ruilope LM, Ruiz-Hurtado G, Tamargo J. Adequate blood pressure control unattainable without adequate recognition and treatment of primary aldosteronism. Trends Cardiovasc Med 2021; 32:234-236. [PMID: 33872758 DOI: 10.1016/j.tcm.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Luis M Ruilope
- Cardiorenal Translational Laboratory, Institute of Research i+12 and Hypertension Unit, Hospital Universitario 12 de Octubre, Madrid, Spain; CIBER in Cardiovascular (CIBERCV), Hospital Universitario 12 de Octubre, Madrid, Spain; School of Doctoral Studies and Research, Universidad Europea, Madrid, Spain.
| | - Gema Ruiz-Hurtado
- Cardiorenal Translational Laboratory, Institute of Research i+12 and Hypertension Unit, Hospital Universitario 12 de Octubre, Madrid, Spain; CIBER in Cardiovascular (CIBERCV), Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Instituto De Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Primary aldosteronism. Trends Cardiovasc Med 2021; 32:228-233. [PMID: 33775861 DOI: 10.1016/j.tcm.2021.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/20/2021] [Accepted: 03/20/2021] [Indexed: 12/15/2022]
Abstract
In 1955 Dr Jerome Conn first documented primary aldosteronism (PA). Since then, screening, diagnosis and treatment have developed, in the process both refining and complicating management. Currently, screening requires 4-6 weeks of lead-up, including major changes in antihypertensive therapy, followed by a blood draw for plasma aldosterone concentration (PAC) and plasma renin activity (PRA) or concentration (PRC). Screening is considered indicative of PA on the basis of the PAC and the aldosterone to renin ratio (ARR). This is then followed by one or more of 6 confirmatory/exclusion tests. Three things have changed. First is now incontrovertible evidence that a single spot PAC is a deeply flawed index of true aldosterone status, so that many referred patients with PA fall at the first hurdle. A valid index of aldosterone status is an integrated value, measured as urinary aldosterone excretion (UEA) over 24 h. On the basis of the UEA, the prevalence of PA appears to be 3-5 times higher than the currently accepted figure of 5-10% of hypertensives. The second is the recognition that inadequately treated PA has a cardiovascular risk profile ~threefold that of matched essential hypertensives. Third is the realization that <1% of hypertensives are ever screened for PA, who are thus in double jeopardy for the risks of untreated PA on top of those for hypertension per se. Taken together, this a major if occult public health issue; if it is to be addressed, radical changes in management are needed. Some are in screening, which needs to be simply done on all newly-presenting hypertensives; others are major simplifications of screening in established hypertension. The front-line actors need to be Internists/Primary Care Providers; the costs will be significant, but much less than those of increased morbidity/premature mortality in unrecognized PA. Possible suggestions as to how best to address this constitute the final chapter of this article.
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Kline GA, Leung AAC, Sam D, Chin A, So B. Repeat Adrenal Vein Sampling in Aldosteronism: Reproducibility and Interpretation of Persistently Discordant Results. J Clin Endocrinol Metab 2021; 106:e1170-e1178. [PMID: 33320942 PMCID: PMC7947749 DOI: 10.1210/clinem/dgaa930] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT The reproducibility of adrenal vein sampling (AVS) is unknown. OBJECTIVE This work aimed to determine reproducibility of biochemical results and diagnostic lateralization in patients undergoing repeat AVS. METHODS A retrospective chart review was conducted of single-center, single-operator AVS procedures at a tertiary care center. Included were patients with confirmed primary aldosteronism (PA) undergoing repeat AVS because of concerns about technical success or discordant diagnostic results. Simultaneous AVS was performed by an experienced operator using a consistent protocol of precosyntropin and postcosyntropin infusion. Among successfully catheterized adrenal veins (selectivity index ≥ 2), the correlation of the adrenalaldosterone/cortisol (A/C) ratio was measured between the first and second AVS. The secondary outcome measure was diagnostic agreement on repeat AVS lateralization (lateralization index ≥ 3). RESULTS There were 46 sets of AVS from 23 patients at a median of 3 months apart. There was moderate correlation in A/C ratios in the adrenal veins and inferior vena cava (Spearman r = 0.49-0.59, P < .05) pre cosyntropin. Post cosyntropin, the correlation was better (Spearman r = 0.67-0.76, P < .05). In technically successful AVS, there was moderate correlation between the repeated lateralization indices (Spearman r = 0.53, P < .05). In 15 patients in whom repeat AVS was performed because of apparent lateralization discordance with computed tomography imaging, the final diagnosis was the same in the second AVS procedure. Initial failed AVS was successful 75% of the time on repeat attempt. CONCLUSION Repeat AVS was feasible and usually successful when an initial attempt failed. There was modest correlation between individual repeat adrenal A/C ratios and lateralization indices when AVS was performed twice. The final lateralization diagnosis was identical in all cases. This demonstrates that AVS is a reliable and reproducible localizing test in PA.
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Affiliation(s)
- Gregory A Kline
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Correspondence: Gregory A. Kline, MD, Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, 1820 Richmond Rd SW, Calgary, AB, T2T 5C7 Canada.
| | - Alexander Ah-Chi Leung
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Davis Sam
- Division of Endocrinology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alex Chin
- Department of Clinical Pathology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Precision Laboratories, AB, Canada
| | - Benny So
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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18
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Funder JW. Primary Aldosteronism: Strike Two. Am J Hypertens 2021; 34:28-29. [PMID: 33534897 DOI: 10.1093/ajh/hpaa171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 10/15/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- John W Funder
- Steroid Biology, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Chancellery, Monash University, Clayton, Victoria, Australia
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Schiffrin EL. From the Editor-in-Chief: Issue at a glance. Am J Hypertens 2021; 34:1-2. [PMID: 33599749 DOI: 10.1093/ajh/hpaa214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ernesto L Schiffrin
- The American Journal of Hypertension, Lady Davis Institute for Medical Research, and Department of Medicine, Sir Mortimer B. Davis, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Yozamp N, Hundemer GL, Moussa M, Underhill J, Fudim T, Sacks B, Vaidya A. Intraindividual Variability of Aldosterone Concentrations in Primary Aldosteronism: Implications for Case Detection. Hypertension 2020; 77:891-899. [PMID: 33280409 DOI: 10.1161/hypertensionaha.120.16429] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Primary aldosteronism is an underdiagnosed cause of hypertension. Although inadequate screening is one reason for underdiagnosis, another important contributor is that clinicians may inappropriately exclude the diagnosis when screening aldosterone concentrations fall below traditionally established thresholds. We evaluated the intraindividual variability in screening aldosterone concentrations and aldosterone-to-renin ratios, and how this variability could impact case detection, among 51 patients with confirmed primary aldosteronism who had 2 or more screening measurements of renin and aldosterone on different days. There were a total of 137 screening measurements with a mean of 3 (range 2-6) per patient. The mean intraindividual variability, expressed as coefficients of variation, was 31% for aldosterone and 45% for the aldosterone-to-renin ratio. Aldosterone concentrations ranged from 4.9 to 51 ng/dL; 49% of patients had at least one aldosterone measurement below 15 ng/dL, 29% had at least 2 aldosterone measurements below 15 ng/dL, and 29% had at least one measurement below 10 ng/dL. Individual aldosterone-to-renin ratios ranged from 8.2 to 427 ng/dL per ng/mL·hour; 57% had at least one ratio below 30 ng/dL per ng/mL·hour, 27% had at least 2 ratios below 30 ng/dL per ng/mL·hour, and 24% had at least one ratio below 20 ng/dL per ng/mL·hour. Aldosterone concentrations and aldosterone-to-renin ratios are highly variable in patients with primary aldosteronism, with many screening values falling below conventionally accepted diagnostic thresholds. The diagnostic yield for primary aldosteronism may be substantially increased by recalibrating the definition of a positive screen to include more liberal thresholds for aldosterone and the aldosterone-to-renin ratio.
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Affiliation(s)
- Nicholas Yozamp
- From the Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital (N.Y., A.V.), Harvard Medical School, Boston, MA
| | - Gregory L Hundemer
- Division of Nephrology, The Ottawa Hospital, University of Ottawa, Canada (G.L.H.)
| | - Marwan Moussa
- Department of Radiology, Beth Israel Deaconess Medical Center (M.M., J.U., T.F., B.S.), Harvard Medical School, Boston, MA
| | - Jonathan Underhill
- Department of Radiology, Beth Israel Deaconess Medical Center (M.M., J.U., T.F., B.S.), Harvard Medical School, Boston, MA
| | - Tali Fudim
- Department of Radiology, Beth Israel Deaconess Medical Center (M.M., J.U., T.F., B.S.), Harvard Medical School, Boston, MA
| | - Barry Sacks
- Department of Radiology, Beth Israel Deaconess Medical Center (M.M., J.U., T.F., B.S.), Harvard Medical School, Boston, MA
| | - Anand Vaidya
- From the Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital (N.Y., A.V.), Harvard Medical School, Boston, MA
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