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Mah D, Kneteman M, Przybojewski SJ, Kotha V, Kline GA, Leung AA, So CB. Multiple radiologist review of adrenal CT still frequently misses lateralized surgical primary aldosteronism. J Clin Hypertens (Greenwich) 2024; 26:47-52. [PMID: 38083996 PMCID: PMC10795078 DOI: 10.1111/jch.14747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/23/2023] [Accepted: 10/25/2023] [Indexed: 01/19/2024]
Abstract
Patients with primary aldosteronism (PA) have increased morbidity and mortality compared to those with essential hypertension. Accurate detection of lateralized PA is important so that affected patients can receive potentially curative adrenalectomy. However, around 40% of patients with lateralized PA have "normal" adrenal glands on computed tomography (CT). Additional independent review of imaging has been shown to improve diagnostic accuracy in many areas of imaging. Therefore, the authors sought to establish if multi-reader re-assessment of previously reported normal CT scans would result in increased detection of surgically remediable disease. The authors found that re-assessment of CT imaging by one, two, or three additional radiologists (or a combination thereof) slightly increased the detection of lateralized disease, but these differences were not statistically significant (p > .05). Readers had low inter-observer agreement (kappa = 0.17). If detection of a discrete nodule on CT was made a prerequisite for adrenal vein sampling (AVS), a second read by another reviewer would still result in an excess of missed cases (84.2%, 36.8%, and 65.8%, respectively, for each of the three independent reviewers). Therefore, a "normal" CT does not preclude the possibility of lateralized PA. Adrenal vein sampling should still be strongly considered wherever available and whenever surgery is considered for treatment of PA, irrespective of CT findings.
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Affiliation(s)
- Darren Mah
- Department of RadiologyUniversity of CalgaryCalgaryABCanada
| | - Mark Kneteman
- Department of RadiologyUniversity of CalgaryCalgaryABCanada
| | | | - Vamshi Kotha
- Clinical Assistant ProfessorUniversity of CalgaryCalgaryABCanada
| | - Gregory A. Kline
- Department of MedicineDivision of Endocrinology and MetabolismUniversity of CalgaryCalgaryABCanada
| | - Alexander A. Leung
- Department of MedicineDivision of Endocrinology and MetabolismUniversity of CalgaryCalgaryABCanada
- Department of Community Health SciencesUniversity of CalgaryCalgaryABCanada
| | - C. Benny So
- Department of RadiologyUniversity of CalgaryCalgaryABCanada
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Sukor N, Puar TH, Sunthornyothin S, Kamaruddin NA. Editorial: Expanding spectrum of primary aldosteronism: exploring new grounds. Front Endocrinol (Lausanne) 2023; 14:1171857. [PMID: 37143727 PMCID: PMC10152503 DOI: 10.3389/fendo.2023.1171857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/04/2023] [Indexed: 05/06/2023] Open
Affiliation(s)
- Norlela Sukor
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
- *Correspondence: Norlela Sukor,
| | - Troy H. Puar
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Sarat Sunthornyothin
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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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: 31] [Impact Index Per Article: 15.5] [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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Sam D, Kline GA, So B, Hundemer GL, Pasieka JL, Harvey A, Chin A, Przybojewski SJ, Caughlin CE, Leung AA. External Validation of Clinical Prediction Models in Unilateral Primary Aldosteronism. Am J Hypertens 2022; 35:365-373. [PMID: 34958097 PMCID: PMC8976177 DOI: 10.1093/ajh/hpab195] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/03/2021] [Accepted: 12/22/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Targeted treatment of primary aldosteronism (PA) is informed by adrenal vein sampling (AVS), which remains limited to specialized centers. Clinical prediction models have been developed to help select patients who would most likely benefit from AVS. Our aim was to assess the performance of these models for PA subtyping. METHODS This external validation study evaluated consecutive patients referred for PA who underwent AVS at a tertiary care referral center in Alberta, Canada during 2006–2018. In alignment with the original study designs and intended uses of the clinical prediction models, the primary outcome was the presence of lateralization on AVS. Model discrimination was evaluated using the C-statistic. Model calibration was assessed by comparing the observed vs. predicted probability of lateralization in the external validation cohort. RESULTS The validation cohort included 342 PA patients who underwent AVS (mean age, 52.1 years [SD, 11.5]; 201 [58.8%] male; 186 [54.4%] with lateralization). Six published models were assessed. All models demonstrated low-to-moderate discrimination in the validation set (C-statistics; range, 0.60–0.72), representing a marked decrease compared with the derivation sets (range, 0.80–0.87). Comparison of observed and predicted probabilities of unilateral PA revealed significant miscalibration. Calibration-in-the-large for every model was >0 (range, 0.35–1.67), signifying systematic underprediction of lateralizing disease. Calibration slopes were consistently <1 (range, 0.35–0.87), indicating poor performance at the extremes of risk. CONCLUSIONS Overall, clinical prediction models did not accurately predict AVS lateralization in this large cohort. These models cannot be reliably used to inform the decision to pursue AVS for most patients.
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Affiliation(s)
- Davis Sam
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gregory A Kline
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Benny So
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | | | - Janice L Pasieka
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Adrian Harvey
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Alex Chin
- Alberta Precision Laboratories, Alberta Health Services, Calgary, Alberta, Canada
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Cori E Caughlin
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Alexander A Leung
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Correspondence: Alexander A. Leung ()
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Christou F, Pivin E, Denys A, Abid KA, Zingg T, Matter M, Pechère-Bertschi A, Maillard M, Grouzmann E, Wuerzner G. Accurate Location of Catheter Tip With the Free-to-Total Metanephrine Ratio During Adrenal Vein Sampling. Front Endocrinol (Lausanne) 2022; 13:842968. [PMID: 35282466 PMCID: PMC8907625 DOI: 10.3389/fendo.2022.842968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 01/31/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The selectivity index (SI) of cortisol is used to document correct catheter placement during adrenal vein sampling (AVS) in patients with primary aldosteronism (PA). We aimed to determine the cutoff values of the SIs based on cortisol, free metanephrine, and the free-to-total metanephrine ratio (FTMR) using an adapted AVS protocol in combination with CT. METHODS Adults with PA and referred for AVS were recruited in two hypertension centers. The cortisol and free metanephrine-derived SIs were calculated as the concentration of the analyte in adrenal veins divided by the concentration of the analyte in the distal vena cava. The FTMR-derived SI was calculated as the concentration of free metanephrine in the adrenal vein divided by that of total metanephrine in the ipsilateral adrenal vein. The AVS was classified as an unequivocal radiological success (uAVS) if the tip of the catheter was seen in the adrenal vein. The SI cutoffs of each index marker were established using receiver operating characteristic curve analysis. RESULTS Out of 125 enrolled patients, 65 patients had an uAVS. The SI cutoffs were 2.6 for cortisol, 10.0 for free metanephrine, 0.31 for the FTMR on the left side, and 2.5, 9.9, and 0.25 on the right side. Compared to free metanephrine and the FTMR, cortisol misclassified AVS as unsuccessful in 36.6% and 39.0% of the cases, respectively. CONCLUSION This study is the first to calculate the SIs of cortisol, free metanephrine, and the FTMR indices for the AVS procedure. It confirms that free metanephrine-based SIs are better than those based on cortisol.
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Affiliation(s)
- Foteini Christou
- Service of Internal Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Edward Pivin
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alban Denys
- Department of Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Karim A. Abid
- Laboratoire des Catécholamines et Peptides, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Tobias Zingg
- Department of Visceral Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Maurice Matter
- Hypertension Unit, Service of Nephrology and Hypertension, University Hospital Geneva, Geneva, Switzerland
| | | | - Marc Maillard
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eric Grouzmann
- Laboratoire des Catécholamines et Peptides, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- *Correspondence: Gregoire Wuerzner,
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Dream S, Park S, Yen TW, Rilling W, Rein L, Doffek K, Findling JW, Magill SB, Kidambi S, Evans DB, Wang TS. Utility of Epinephrine Levels in Determining Adrenal Vein Cannulation During Adrenal Venous Sampling for Primary Aldosteronism. Endocr Pract 2021; 28:276-281. [PMID: 34582994 DOI: 10.1016/j.eprac.2021.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE In patients with primary aldosteronism, adrenal venous sampling (AVS) is performed to determine the presence of unilateral or bilateral adrenal disease. During AVS, verification of catheter positioning within the left adrenal vein (AV) and the right AV by comparison of AV and inferior vena cava (IVC) cortisol levels can be variable. The objective of this study was to determine the utility of AV epinephrine levels in assessing successful AV cannulation. METHODS This was a single institution, retrospective review of patients who underwent AVS with cosyntropin stimulation for primary aldosteronism between 2009 and 2018. Successful cannulation of the AV was defined by an AV/IVC cortisol ratio selectivity index (SI) ≥3:1. Epinephrine thresholds to predict catheter placement in the AV were determined using logistic regression. The calculated epinephrine thresholds were compared with previously published thresholds. RESULTS AVS was performed on 101 consecutive patients and, based on the SI, successful cannulation of the left AV and right AV occurred in 98 (97%) and 91(90%) patients, respectively. The calculated optimal epinephrine threshold to predict AV cannulation was 364 pg/mL (sensitivity, 92.1%; specificity, 94.6%) and the calculated optimal AV/IVC epinephrine ratio threshold was 27.4, (sensitivity, 92.1%; specificity, 91.3%). Among the 14 patients with failed AV cannulation, 3 patients would have been considered to have successful AVS using AV epinephrine levels >364 pg/mL and AV/IVC epinephrine ratio >27.4 thresholds. CONCLUSION Obtaining 2 right AV samples routinely as well as AV and IVC epinephrine levels during AVS could prevent unnecessary repeat AVS in patients with failed AV cannulation based on cortisol-based SI <3:1.
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Affiliation(s)
- Sophie Dream
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Sandra Park
- Department of Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Tina W Yen
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - William Rilling
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lisa Rein
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kara Doffek
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - James W Findling
- Endocrine Center and Clinics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Steven B Magill
- Endocrine Center and Clinics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Srividya Kidambi
- Division of Endocrinology, Metabolism and Clinical Nutrition, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Douglas B Evans
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tracy S Wang
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Puar TH, Loh WJ, Lim DS, Loh LM, Zhang M, Foo RS, Lee L, Swee DS, Khoo J, Tay D, Kam JW, Dekkers T, Velema M, Deinum J, Kek PC. Aldosterone-potassium ratio predicts primary aldosteronism subtype. J Hypertens 2021; 38:1375-1383. [PMID: 31851033 DOI: 10.1097/hjh.0000000000002348] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Prediction models have been developed to predict either unilateral or bilateral primary aldosteronism, and these have not been validated externally. We aimed to develop a simplified score to predict both subtypes and validate this externally. METHODS Our development cohort was taken from 165 patients who underwent adrenal vein sampling (AVS) in two Asian tertiary centres. Unilateral disease was determined using both AVS and postoperative outcome. Multivariable analysis was used to construct prediction models. We validated our tool in a European cohort of 97 patients enrolled in the SPARTACUS trial who underwent AVS. Previously published prediction models were also tested in our cohorts. RESULTS Backward stepwise logistic regression analysis yielded a final tool using baseline aldosterone-to-lowest-potassium ratio (APR, ng/dl/mmol/l), with an area under receiver-operating characteristic curve of 0.80 (95% CI 0.70-0.89). In the Asian development cohort, probability of bilateral disease was 90.0% (with APR <5) and probability of unilateral disease was 91.4% (with APR >15). Similar results were seen in the European validation cohort. Combining both cohorts, probability of bilateral disease was 76.7% (with APR <5), and probability for unilateral was 91.7% (with APR >15). Other models had similar predictive ability but required more variables, and were less sensitive for identifying bilateral PA. CONCLUSION The novel aldosterone-to-lowest-potassium ratio is a convenient score to guide clinicians and patients of various ethnicities on the probability of primary aldosteronism subtype. Using APR to identify patients more likely to benefit from AVS may be a cost-effective strategy to manage this common condition.
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Affiliation(s)
- Troy H Puar
- Department of Endocrinology, Changi General Hospital
| | - Wann J Loh
- Department of Endocrinology, Changi General Hospital
| | - Dawn St Lim
- Department of Endocrinology, Singapore General Hospital, SingHealth
| | - Lih M Loh
- Department of Endocrinology, Singapore General Hospital, SingHealth
| | - Meifen Zhang
- Department of Endocrinology, Changi General Hospital
| | - Roger S Foo
- Cardiovascular Research Institute, Centre for Translational Medicine, MD6, National University Health System.,Genome Institute of Singapore
| | - Lynette Lee
- Department of Endocrinology, Changi General Hospital.,Department of Endocrinology, Singapore General Hospital, SingHealth
| | - Du S Swee
- Department of Endocrinology, Singapore General Hospital, SingHealth
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital
| | - Donovan Tay
- Department of Endocrinology, Sengkang General Hospital
| | - Jia W Kam
- Department of Clinical Trial Research Unit, Changi General Hospital, SingHealth, Singapore
| | - Tanja Dekkers
- Department of Internal Medicine, Division of Vascular Medicine
| | - Marieke Velema
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jaap Deinum
- Department of Internal Medicine, Division of Vascular Medicine
| | - Peng C Kek
- Department of Endocrinology, Singapore General Hospital, SingHealth
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Sam D, Kline GA, So B, Pasieka JL, Harvey A, Chin A, Przybojewski SJ, Leung AA. Surgical Outcomes Among Primary Aldosteronism Patients Without Visible Adrenal Lesions. J Clin Endocrinol Metab 2021; 106:e824-e835. [PMID: 33180934 PMCID: PMC7823310 DOI: 10.1210/clinem/dgaa821] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Indexed: 12/13/2022]
Abstract
CONTEXT Many patients with unilateral primary aldosteronism (PA) have normal adrenal imaging, but little is known about their outcome following adrenalectomy. OBJECTIVE To evaluate biochemical and clinical outcomes after adrenalectomy in patients with unilateral PA and normal-appearing adrenal imaging. DESIGN Retrospective cohort study of patients seen between January 2006 and May 2018. SETTING A Canadian tertiary care PA referral center. PATIENTS Consecutive individuals with PA, normal cross-sectional adrenal imaging, and lateralizing adrenal vein sampling (AVS) who underwent adrenalectomy during the study period. PRIMARY OUTCOME Biochemical response to adrenalectomy graded according to the Primary Aldosteronism Surgical Outcome criteria. RESULTS A total of 40 patients were included. Biochemical outcomes were available for 33 people (mean age, 54.7 years; 91% male; median follow-up, 2.7 months), with 28 (85%) showing a complete or partial response and 5 (15%) with no response. Clinical outcomes were available for 36 people (mean age, 54.6 years; 86% male; median follow-up, 9.8 months), with 31 (86%) demonstrating a complete or partial response and 5 (14%) with no response. CONCLUSIONS The prognosis after adrenalectomy is highly favorable for patients with unilateral PA and normal-appearing adrenal imaging. Patients with lateralizing disease should be considered for surgery despite apparently normal adrenal imaging.
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Affiliation(s)
- Davis Sam
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregory A Kline
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Benny So
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Janice L Pasieka
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Adrian Harvey
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Alex Chin
- Alberta Precision Laboratories, Alberta Health Services, Calgary, Alberta, Canada
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Alexander A Leung
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Correspondence and Reprint Requests: Alexander A. Leung, MD, MPH, 1820 Richmond Road SW, Calgary, Alberta, T2T 5C7, Canada. E-mail:
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Bouchard-Bellavance R, Perrault F, Soulez G, Chagnon M, Kline GA, Bourdeau I, Lacroix A, So B, Therasse E. Adrenal vein sampling: External validation of multinomial regression modelling and left adrenal vein-to-peripheral vein ratio to predict lateralization index without right adrenal vein sampling. Clin Endocrinol (Oxf) 2020; 93:661-671. [PMID: 32687640 DOI: 10.1111/cen.14295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/23/2020] [Accepted: 07/12/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adrenal vein sampling (AVS) failure is mainly due to right adrenal vein unavailability. Multinomial regression modelling (MRM) and left adrenal vein-to-peripheral vein ratio (LAV/PV) were proposed to predict the lateralization index without the right AVS. OBJECTIVE To assess external validity of MRM and LAV/PV to predict lateralization index when right adrenal vein sampling is missing. DESIGN Diagnostic retrospective study. PATIENTS Development and validation cohorts included AVS of 174 and 122 patients, respectively, from 2 different centres. MEASUREMENTS Development and validation cohort data were used, respectively, for calibration and for validation of MRM and LAV/PV to predict the lateralization index without the right adrenal vein sampling. Sensitivity and specificity of MRM and LAV/PV were compared between both centres at different pre-established specificity thresholds based on receiver operating characteristic curves generated from the development cohort data. RESULTS At a specificity threshold of 95% set in the development cohort, specificity values exceeded 90% (range, 90.6%-98.8%) for all verified MRM and LAV/PV models in the validation cohort. Corresponding sensitivities for MRM and LAV/PV, respectively, range from 54.1% to 83.7% and 32.8% to 88.4% for the development cohort compared to 33.3%-87.5% and 2.8%-79.2% for the validation cohort. Overall, diagnostic accuracy of both methods was higher to detect right (82.8%-93.5%) than left (70.2%-80.6%) lateralization index status in both centres. CONCLUSIONS Minimal changes in specificity from development to validation cohorts validate the use of MRM and LAV/PV to predict the lateralization index when the right AVS is missing. Both methods had better accuracy for right than left lateralization detection.
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Affiliation(s)
| | - Florence Perrault
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Gilles Soulez
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
- Centre de Recherche du CHUM (CRCHUM), Montreal, QC, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, Pavillon André-Aisenstadt, University of Montreal, Montreal, QC, Canada
| | - Gregory A Kline
- Division of Endocrinology, Department of Medicine, Foothills Medical Center (FMC), Calgary, AB, Canada
| | - Isabelle Bourdeau
- Centre de Recherche du CHUM (CRCHUM), Montreal, QC, Canada
- Division of Endocrinology, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - André Lacroix
- Centre de Recherche du CHUM (CRCHUM), Montreal, QC, Canada
- Division of Endocrinology, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Benny So
- Department of Radiology, Foothills Medical Center (FMC), Calgary, AB, Canada
| | - Eric Therasse
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
- Centre de Recherche du CHUM (CRCHUM), Montreal, QC, Canada
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10
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Sam D, Kline GA, So B, Przybojewski SJ, Leung AA. Unilateral Disease Is Common in Patients With Primary Aldosteronism Without Adrenal Nodules. Can J Cardiol 2020; 37:269-275. [PMID: 32428615 DOI: 10.1016/j.cjca.2020.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/21/2020] [Accepted: 05/09/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Patients with primary aldosteronism (PA) without apparent adrenal nodularity have not been well characterised in the literature. The aim of this study was to assess for unilateral aldosterone hypersecretion among patients with primary aldosteronism with normal-appearing adrenals using adrenal vein sampling (AVS). METHODS In this cross-sectional study performed at a Canadian tertiary care centre, we reviewed all consecutive PA patients lacking a definitive adrenal nodule who were referred for AVS in the work-up of PA between January 2006 and May 2018. AVS indications included an elevated aldosterone-to-renin ratio and high-probability features of PA. RESULTS In total, 174 patients were included (mean age, 52.0 years; 62.6% male), and 70 (40.2%) had unilateral aldosterone hypersecretion. There was a positive linear association between higher age categories (by decade) and lateralisation (P = 0.03). For every decade of age, there was a 30% higher odds of lateralisation (odds ratio, 1.03 per year; 95% confidence interval, 1.00-1.05). The frequency of lateralisation was higher in males compared with females (47.7% vs 27.7%), with a 2-fold greater odds of unilateral disease (odds ratio, 2.38; 95% confidence interval, 1.23-4.61). Traditional biomarkers of lateralisation among patients with adrenal nodules (eg, serum potassium and aldosterone-to-renin ratio levels) were not predictive of lateralisation in this population. CONCLUSIONS Many patients with PA who lack definitive adrenal nodules have lateralising disease. Efforts to optimise referrals for AVS may be prioritised by focusing on patients most likely to have unilateral disease, especially males and older adults.
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Affiliation(s)
- Davis Sam
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregory A Kline
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Benny So
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | | | - Alexander A Leung
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
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11
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Shidlovskyi VO, Shidlovskyi OV, Tovkai OA, Sheremet MI, Maksymyuk VV, Tarabanchuk VV, Ivanovych SM, Heryak MS, Andreychyn MS, Hanberher II, Piddubna AA. Topical Diagnosis and Determination of the Primary Hyperaldosteronism Variant. J Med Life 2020; 12:322-328. [PMID: 32025248 PMCID: PMC6993286 DOI: 10.25122/jml-2019-0072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Laboratory diagnosis of primary hyperaldosteronism is based on determining blood levels of aldosterone, renin on request, potassium, and sodium. The results of these studies are significantly influenced by drugs, preparation for the study and blood collection methods, age, gender, and concomitant diseases. The work analyzes the factors influencing the results of the study of aldosterone and identifies the main ways of their exclusion at each stage of the diagnosis. Their neglecting is the determining factor in obtaining false results, diagnostic errors, the selection of ill-treatment tactics, and inadequate treatment. All these diagnostic problems are covered in a variety of ways in the review, which is based on the analysis of results of individual authors' research and practical and clinical recommendations from leading world endocrinological associations. Results of laboratory diagnostics of PHA depend on the influence of many factors. Among them, it is essential to use different medication drugs, the rules for preparing for the study, and the method of conducting it. In assessing the results of research, it is necessary to take into account not only the indicators of the level of aldosterone in the blood but also the features of the clinical course of the disease, its compliance to the drug therapy, age, and gender of the patients.
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Affiliation(s)
- Viktor O Shidlovskyi
- Surgery Department, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Olexandr V Shidlovskyi
- Surgery Department, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Oleksandr A Tovkai
- Ukrainian Scientific and Practical Center of Endocrine Surgery, Endocrine and Tissue Transplantation of the Ministry of Health of Ukraine, Kyiv, Ukraine
| | - Michael I Sheremet
- First Surgery Department, Bukovinian State Medical University, Chernivtsi, Ukraine
| | - Vitaliy V Maksymyuk
- First Surgery Department, Bukovinian State Medical University, Chernivtsi, Ukraine
| | | | - Shved M Ivanovych
- Department of First Emergency Medical Aid and Emergency Medical Treatment, Ternopil, Ukraine
| | - Mykolaivna S Heryak
- Second Department of Obstetrics and Gynecology, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Mykhailovych S Andreychyn
- Department of Propaedeutic of Internal Medicine and Phthisiology, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Igorivna I Hanberher
- Department of Propaedeutic of Internal Medicine and Phthisiology, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Antonina A Piddubna
- Department of Clinical Immunology, Allergology and Endocrinology, Bukovinian State Medical University, Chernivtsi, Ukraine
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Left-versus-right-adrenal-volume ratio as a screening index before adrenal venous sampling to identify unilateral primary aldosteronism patients. J Hypertens 2020; 38:347-353. [DOI: 10.1097/hjh.0000000000002271] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Hundemer GL, Vaidya A. Primary Aldosteronism Diagnosis and Management: A Clinical Approach. Endocrinol Metab Clin North Am 2019; 48:681-700. [PMID: 31655770 PMCID: PMC6824480 DOI: 10.1016/j.ecl.2019.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Primary aldosteronism used to be considered a rare cause of secondary hypertension. However, accruing evidence indicates that primary aldosteronism is more common than previously recognized. The implications of this increased prevalence are important to public health because autonomous aldosterone production contributes to cardiovascular disease and can be treated in a targeted manner. This article focuses on clinical approaches for diagnosing primary aldosteronism more frequently and earlier in its course, as well as practical treatment objectives to reduce the risk for incident cardiovascular disease.
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Affiliation(s)
- Gregory L Hundemer
- Division of Nephrology, Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Box 511, Ottawa, ON K1H 8L6, Canada
| | - Anand Vaidya
- Center for Adrenal Disorders, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA.
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14
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Shidlovskyi VO, Shidlovskyi OV, Sheremet M, Zhulkevych IV, Andreychyn SM, Hanberher II, Smachylo II, Dobrorodny VB, Futuima YM. Laboratory Diagnostics of Primary Hyperaldosteronism and its Peculiarities (Literature Review). J Med Life 2019; 12:215-220. [PMID: 31666819 PMCID: PMC6814876 DOI: 10.25122/jml-2019-0073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The final stage of the diagnostic of primary hyperaldosteronism is to identify the causes of excessive secretion of aldosterone and determination of its variants. Based on the analysis of literature data, the diagnostic value, sensitivity and specificity of the methods of radiation diagnostics for primary hyperaldosteronism were assessed: ultrasound, computed tomography, magnetic resonance imaging, photon emission tomography, magnetic resonance spectroscopy, scintigraphy with iodine radiopharmaceuticals. The causes of false-positive and false-negative evaluations of changes in adrenal glands in the application of these diagnostics have been analyzed. There are many genetic and morphological studies when searching the literature data on the principles and methods of distinguishing the nosological forms of primary hyperaldosteronism based on the results of the aldosterone level estimation in the separated blood from the central veins of both adrenal glands or segmental veins of one gland with subsequent determination of the concentration gradient. It was noted that topical diagnostics and, especially, the determination of nosological forms of primary hyperaldosteronism are complex and expensive, but their results allow choosing an appropriate treatment approach for each particular case.
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Affiliation(s)
- Viktor O Shidlovskyi
- 1st Surgery Department of I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Oleander V Shidlovskyi
- 1st Surgery Department of I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Mikhail Sheremet
- 1st Surgery Department of Bukovinian State Medical University, Chernivtsi, Ukraine
| | - Igor V Zhulkevych
- 1st Surgery Department of I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Sergyi M Andreychyn
- 1st Surgery Department of I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Inna I Hanberher
- 1st Surgery Department of I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Ivan I Smachylo
- 1st Surgery Department of I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Volodimir B Dobrorodny
- 1st Surgery Department of I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Yuryi M Futuima
- 1st Surgery Department of I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
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15
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Sam D, Kline GA, So B, Leung AA. Discordance Between Imaging and Adrenal Vein Sampling in Primary Aldosteronism Irrespective of Interpretation Criteria. J Clin Endocrinol Metab 2019; 104:1900-1906. [PMID: 30590677 DOI: 10.1210/jc.2018-02089] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/19/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Subtyping of primary aldosteronism (PA) using imaging and adrenal vein sampling (AVS) may yield discordant results, causing confusion in management. Interpretation criteria for AVS lateralization may affect discordance rates. METHODS We identified consecutive patients with PA who underwent AVS at a quaternary care center between January 2006 and May 2018. Patient demographics, laboratory results, diagnostic imaging, and AVS results were retrieved. Adrenal cross-sectional imaging was compared with AVS findings. The presence of lateralization was defined using varying thresholds for the lateralization index (LI) from >2:1 to >5:1. Discordance was defined by a unilateral lesion on imaging with contralateral or nonlateralization on AVS. RESULTS A total of 342 patients were included; 68.7% had hypokalemia. With cross-sectional imaging, 191 (55.6%) patients had unilateral lesions, 47 (13.7%) had bilateral lesions, and 104 (30.4%) had normal imaging. Overall discordance rates were high, ranging from 22% to 28% for LI thresholds of >2:1 and >5:1, respectively. Discordance between imaging and AVS was positively correlated with LI threshold stringency (P < 0.001). Patients with normal or bilateral lesions on imaging frequently lateralized on AVS. Lateralization, when present, was approximately equal between left and right sides, irrespective of the LI threshold. CONCLUSIONS Discrepancies between imaging and AVS were common, even among patients with nonspecific imaging. Discordance was greatest with the strictest AVS interpretation criteria. Even under the most lenient thresholds, apparent discordance between imaging and AVS exceeded 20% and may limit the ability to make surgical decisions. Reliance on imaging alone for detecting lateralization may be misleading.
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Affiliation(s)
- Davis Sam
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregory A Kline
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Benny So
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Alexander A Leung
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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