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Lu YC, Liu KL, Wu VC, Wang SM, Lin YH, Chueh SCJ, Wu KD, Su YR, Huang KH. Unilateral adrenalectomy in bilateral adrenal hyperplasia with primary aldosteronism. J Formos Med Assoc 2023; 122:393-399. [PMID: 36813699 DOI: 10.1016/j.jfma.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 10/08/2022] [Accepted: 12/22/2022] [Indexed: 02/22/2023] Open
Abstract
PURPOSE Mineralocorticoid receptor antagonists are the first-line treatment for bilateral adrenal hyperplasia (BAH) with primary aldosteronism (PA), while unilateral adrenalectomy is the standard treatment for aldosterone-producing adenoma (APA). In this study, we investigated the outcomes of patients with BAH after unilateral adrenalectomy and compared them with those of patients with APA. METHODS From January 2010 to November 2018, 102 patients with a diagnosis of PA confirmed by adrenal vein sampling (AVS) and available NP-59 scans were enrolled. All patients underwent unilateral adrenalectomy based on the lateralization test results. We prospectively collected the clinical parameters over 12 months and compared the outcomes of BAH and APA. RESULTS A total of 102 patients were enrolled in this study: 20 (19.6%) had BAH and 82 (80.4%) had APA. Significant improvements in serum aldosterone-renin ratio (ARR), potassium level, and reduction of antihypertensive drugs were observed in both groups at 12 months after surgery (all p < 0.05). Patients with APA showed a significant decrease in blood pressure after surgery (p < 0.001) than those with BAH. Additionally, multivariate logistic regression analysis indicated that APA was associated with biochemical success (odds ratio: 4.32, p = 0.024) compared to BAH. CONCLUSION Patients with BAH had a higher failure rate in clinical outcomes, and APA was associated with biochemical success after unilateral adrenalectomy. However, significant improvements in ARR, hypokalemia, and a decreased use of antihypertensive drugs were noted in patients with BAH after surgery. Unilateral adrenalectomy is feasible and beneficial in selected patients, and could potentially serve as a treatment option.
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Affiliation(s)
- Yu-Cheng Lu
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kao-Lang Liu
- Department of Medical Imagine, National Taiwan University Hospital, Taipei, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuo-Meng Wang
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yann-Rong Su
- Department of Urology, National Taiwan University BioMedical Park Hospital, Hsin-Chu, Taiwan
| | - Kuo-How Huang
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan; Department of Urology, National Taiwan University BioMedical Park Hospital, Hsin-Chu, Taiwan.
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- TAIPAI, Taiwan Primary Aldosteronism Investigator
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Characteristics and Outcomes in Primary Aldosteronism Patients Harboring Glucocorticoid-Remediable Aldosteronism. Biomedicines 2021; 9:biomedicines9121816. [PMID: 34944634 PMCID: PMC8698750 DOI: 10.3390/biomedicines9121816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 12/23/2022] Open
Abstract
The clinical characteristics and surgical prognosis of glucocorticoid-remediable aldosteronism (GRA, also known as familial hyperaldosteronism type 1, FH-I) have not been widely studied. Using data from the Taiwan Primary Aldosteronism Investigation (TAIPAI) registry retrospectively, we describe the associated clinical factors for GRA and clinical predictors of surgical outcomes among identified GRA patients. We found 79 GRA-positive (51.2 ± 13.8 years; women 39 (49.4%)) and 114 GRA-negative primary aldosteronism (PA) patients matched with age, gender, and body mass index. Lower plasma aldosterone concentrations (PACs) and aldosterone-renin ratios were found among GRA-positive individuals. Multivariable logistic regression demonstrated that a PAC ≤ 40 ng/dL could predict concealed GRA individuals (OR 0.523, p = 0.037). Low serum potassium (OR 0.285, p = 0.008), but not the presence of GRA, was associated with hypertension-remission. Of note, PRA (OR 11.645, p = 0.045) and hypokalemia (OR 0.133, p = 0.048) were associated with hypertension-remission in GRA patients. Unilateral primary aldosteronism patients harboring concomitant GRA were not associated with inferior hypertension-remission after an adrenalectomy. Low serum potassium and high PRA were positively associated with hypertension-remission in GRA patients.
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Yoon JH, Chung HS, Hong AR, Kim HK, Kang HC, Kim MS, Hwang EC, Jung SI, Park K, Kwon D. Is acute kidney injury after laparoscopic adrenalectomy related to the progression of chronic kidney disease in patients with primary aldosteronism? Investig Clin Urol 2021; 62:560-568. [PMID: 34387032 PMCID: PMC8421995 DOI: 10.4111/icu.20200582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/04/2021] [Accepted: 03/24/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose This study was conducted to investigate the predictors of kidney outcome after laparoscopic adrenalectomy in patients with primary aldosteronism (PA). Materials and Methods We retrospectively reviewed the medical records of 74 patients who underwent unilateral adrenalectomy for the treatment of PA from January 2011 to December 2019. Patient characteristics and serial data on postoperative changes in kidney function were analyzed and compared between the two groups according to the presence of acute kidney injury (AKI). Postoperative AKI was defined as a decline in the estimated glomerular filtration rate (eGFR) of >50% or an increase in the serum creatinine level of ≥0.3 mg/dL at 1 week after surgery compared with perioperative levels. Chronic kidney disease (CKD) was defined as an eGFR < 60 mL/min/1.73 m2 present for 3 months. Results Nineteen patients (25.7%) had postoperative AKI. Patients who experienced postoperative AKI had higher aldosterone-to-renin ratios, higher rates of dyslipidemia, and more left ventricular hypertrophy than did patients without postoperative AKI (p=0.015, 0.036, and 0.033, respectively). Twenty-eight patients (37.8%) had CKD at 6 months after surgery, including 15 patients who had newly progressed to CKD postoperatively. In the multivariate regression analysis of patients without preoperative CKD, the only independent predictor of the progression to CKD was preoperative albuminuria (p=0.007). Conclusions In this study, one-quarter of the patients had postoperative AKI after unilateral adrenalectomy for the treatment of PA. However, postoperative AKI was not directly correlated with CKD progression. Preoperative albuminuria was an independent predictor of the progression of CKD.
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Affiliation(s)
- Jee Hee Yoon
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Ho Seok Chung
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea.
| | - A Ram Hong
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Hee Kyung Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Ho Cheol Kang
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Myung Soo Kim
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Eu Chang Hwang
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Seung Il Jung
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Kwangsung Park
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Dongdeuk Kwon
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
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Computed tomography image fusion, Coaxial guidewire technique, Fast intraprocedural cortisol testing technique improves success rate and decreases radiation exposure, procedure time, and contrast use for adrenal vein sampling. J Hypertens 2021; 39:1918-1925. [PMID: 34039913 DOI: 10.1097/hjh.0000000000002852] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Adrenal vein sampling (AVS) is recommended for discriminating patients with unilateral primary aldosteronism from bilateral disease. However, it is a technically demanding procedure that is markedly underused. We developed a computed tomography image fusion, coaxial guidewire technique, fast intraprocedural cortisol testing (CCF) technique to improve AVS success rate, which combines CT image fusion, coaxial guidewire technique, and fast intraprocedural cortisol testing. OBJECTIVE To evaluate the effectiveness and safety of the AVS--CCF technique. METHODS We retrospectively evaluated 105 patients who undervent AVS from June 2016 to October 2020. There were 51 patients in the AVS--CCF group and 54 patients in the AVS group. We compared two groups with technical success rate, procedure time, radiation exposure, volume of contrast medium, and complications (adrenal vein rupture, dissection, infarction, or thrombosis; intraglandular or periadrenal hematoma; and contrast-induced nephropathy). RESULTS The technical success rate was higher for AVS--CCF than for AVS without CCF (98 vs. 83.3% for bilateral adrenal veins, P = 0.016). AVS--CCF was associated with a shorter procedure time (63.6 ± 24.6 vs. 94.8 ± 40.8 min, P < 0.001), shorter fluoroscopy time (15.6 ± 12.6 vs. 20.4 ± 15.0 min, P = 0.043), and lower contrast medium volume (25.10 ± 21.82 vs. 44.1 ± 31.0 ml, P < 0.001). There were no significant differences between groups with respect to the time for cannulating the left or right adrenal vein or the peak skin radiation dose. Adrenal vein rupture occurred in 14 patients and intraglandular hematoma in 1 patient. CONCLUSION The CCF technique during AVS not only contributed to improved technical success rates but also associated with decreased procedure time, radiation exposure, and contrast medium volume.
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Rossi GP. Primary Aldosteronism: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 74:2799-2811. [PMID: 31779795 DOI: 10.1016/j.jacc.2019.09.057] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/13/2019] [Accepted: 09/24/2019] [Indexed: 12/22/2022]
Abstract
Primary aldosteronism (PA) is a common, but frequently overlooked, cause of arterial hypertension and excess cardiovascular events, particularly atrial fibrillation. As timely diagnosis and treatment can provide a cure of hyperaldosteronism and hypertension, even when the latter is resistant to drug treatment, strategies to screen patients for PA early with a simplified diagnostic algorithm are justified. They can be particularly beneficial in some subgroups of hypertensive patients, as those who are at highest cardiovascular risk. However, identification of the surgically curable cases of PA and achievement of optimal results require subtyping with adrenal vein sampling, which, as it is technically challenging and currently performed only in tertiary referral centers, represents the bottleneck in the work-up of PA. Measures aimed at improving the clinical use of adrenal vein sampling and at developing alternative techniques for subtyping, alongside recommendations for drug treatment, including new development in the field, and for follow-up are discussed.
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Affiliation(s)
- Gian Paolo Rossi
- Hypertension Unit, Department of Medicine, DIMED, University of Padova, Padova, Italy.
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6
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Adherence to consensus guidelines for screening of primary aldosteronism in an urban healthcare system. Surgery 2019; 167:211-215. [PMID: 31564486 DOI: 10.1016/j.surg.2019.05.087] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Primary aldosteronism is a common cause of secondary hypertension. Treatment with adrenalectomy or mineralocorticoid receptor-blockers can prevent long-term adverse outcomes. This study aimed to determine primary aldosteronism screening rats in patients with hypertension in an underserved urban healthcare system. METHODS We reviewed records of outpatient adults in an urban healthcare system from 2013 to 2017. Chart review along with International Statistical Classification of Diseases, 9th and 10th editions, diagnosis codes were used to identify patients meeting inclusion criteria for screening according to the 2016 Endocrine Society guidelines. The corresponding aldosterone, plasma renin activity, and 24-hour urine aldosterone values were identified. Multivariate logistic regression was performed to determine positive predictors of screening. RESULTS Of 15,511 hypertensive patients seen, 6,809 (43.8%) met criteria for screening. Blacks were the most common racial group, and Medicare and Medicaid were the most frequent insurers. The aldosterone-to-renin ratio level was checked in 86 (1.3%) patients; 22 (25.6%) had an aldosterone-to-renin ratio >20. Of the 77 patients with hypertension and incidentaloma, 14 (18.2%) had an aldosterone-to-renin ratio checked. Additional positive predictors for being screened were hypertension and hypokalemia and sustained hypertension. CONCLUSION Screening rates for primary aldosteronism in an underserved population are low. Proper identification of primary aldosteronism in those at risk could help ameliorate long-term effects of disease.
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Nanba AT, Wannachalee T, Shields JJ, Byrd JB, Rainey WE, Auchus RJ, Turcu AF. Adrenal Vein Sampling Lateralization Despite Mineralocorticoid Receptor Antagonists Exposure in Primary Aldosteronism. J Clin Endocrinol Metab 2019; 104:487-492. [PMID: 30239792 PMCID: PMC6316984 DOI: 10.1210/jc.2018-01299] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 09/10/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Many antihypertensive medications modulate the renin-angiotensin-aldosterone system, possibly skewing the diagnosis and subtyping of primary aldosteronism (PA). Particularly, mineralocorticoid receptor antagonists (MRA) might raise renin and stimulate aldosterone synthesis from nonautonomous areas, potentially obscuring lateralization on adrenal vein sampling (AVS). Withdrawal of MRA in severe PA, however, can precipitate hypokalemia and/or hypertension and therefore is not always practical. OBJECTIVE To assess the effects of MRA on the interpretation of AVS data. DESIGN AND PARTICIPANTS A cohort study of all PA patients who underwent AVS at University of Michigan between January 2009 and January 2018 was conducted. Demographics, diagnostic, AVS, surgical pathology, and follow-up data were collected retrospectively. RESULTS Of 191 patients who underwent AVS, 51 (27%) were exposed to MRA at the time of the procedure. Plasma aldosterone concentration and the daily defined dose of antihypertensives were higher in patients taking vs those not taking MRA. Unilateral PA was more frequent in the MRA group, both precosyntropin and postcosyntropin (P < 0.05). The MRA group included two patients with unsuppressed renin, who demonstrated unequivocal AVS lateralization. To date, 86 patients underwent unilateral adrenalectomy, including 30 patients taking MRA during AVS. The proportion of clinical and biochemical success was not statistically different between patients exposed to and those not exposed to MRA during AVS (P = 0.17 and 0.65, respectively). CONCLUSION Our data suggest that conclusive AVS lateralization is often achieved in patients with severe PA despite MRA use.
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Affiliation(s)
- Aya T Nanba
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
| | - Taweesak Wannachalee
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
- Division of Endocrinology and Metabolism, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - James J Shields
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - James B Byrd
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - William E Rainey
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
- Correspondence and Reprint Requests: Adina F. Turcu, MD, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, 1150 W Medical Center Drive, MSRB II, 5570B, Ann Arbor, Michigan 48109. E-mail:
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Zhang G, Zou X, Liu Q, Xie T, Huang R, Kang H, Lai C, Zhu J. MiR-193a-3p functions as a tumour suppressor in human aldosterone-producing adrenocortical adenoma by down-regulating CYP11B2. Int J Exp Pathol 2018; 99:77-86. [PMID: 29665181 DOI: 10.1111/iep.12267] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 03/01/2018] [Indexed: 12/13/2022] Open
Abstract
The mechanism of aldosterone-producing adrenocortical adenoma (APA) pathogenesis and the role of microRNAs (miRNAs) in APA pathogenesis have not been completely clarified. We examined the expression and function of miR-140-3p, miR-193a-3p and miR-22-3p, which have binding sites in CYP11B2. Expression of miRNAs and CYP11B2 mRNA was measured by quantitative reverse transcription PCR (qRT-PCR). Cell proliferation was monitored by colorimetric analysis, and cell apoptosis and cell cycle progression were analysed by flow cytometry. ELISA was carried out to detect aldosterone levels in cell culture supernatants. Luciferase reporter assays, qRT-PCR and Western blotting were performed to identify CYP11B2 as a target of miR-193a-3p. Of the three miRNAs examined, miR-193a-3p exhibited a significant decrease and CYP11B2 mRNA exhibited a significant increase in expression in APA compared with adjacent normal adrenal gland tissue. Transfection of miR-193a-3p mimic into the human adrenocortical cell line H295R showed that elevated miR-193a-3p expression inhibits proliferation and aldosterone secretion, induces G1-phase arrest and promotes apoptosis in H295R cells. Furthermore, in luciferase reporter assays, overexpression of miR-193a-3p in H295R cells significantly reduced the luciferase activity of the wild-type CYP11B2 3'-UTR construct, which could be reversed by mutation of the miR-193a-3p-binding site. Moreover, miR-193a-3p overexpression downregulated CYP11B2 mRNA and protein expression. Finally, overexpression of CYP11B2 diminished the effects of miR-193a-3p on H295R cells. Taken together, our results suggest that CYP11B2 levels may be modulated by miR-193a-3p in APA, which could explain, at least partially, why downregulation of miR-193a-3p during APA formation may promote cell growth and suppress apoptosis.
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Affiliation(s)
- Guoxi Zhang
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Xiaofeng Zou
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Quanliang Liu
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Tianpeng Xie
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Ruohui Huang
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Huan Kang
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Changfu Lai
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Jiaxing Zhu
- Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
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Wu VC, Hu YH, Er LK, Yen RF, Chang CH, Chang YL, Lu CC, Chang CC, Lin JH, Lin YH, Wang TD, Wang CY, Tu ST, Jeff Chueh SC, Chang CC, Tseng FY, Wu KD. Case detection and diagnosis of primary aldosteronism - The consensus of Taiwan Society of Aldosteronism. J Formos Med Assoc 2017; 116:993-1005. [PMID: 28735660 DOI: 10.1016/j.jfma.2017.06.004] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/17/2017] [Accepted: 06/07/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND/PURPOSE Even though the increasing clinical recognition of primary aldosteronism (PA) as a public health issue, its heightened risk profiles and the availability of targeted surgical/medical treatment being more understood, consensus in its diagnosis and management based on medical evidence, while recognizing the constraints of our real-world clinical practice in Taiwan, has not been reached. METHODS The Taiwan Society of Aldosteronism (TSA) Task Force acknowledges the above-mentioned issues and reached this Taiwan PA consensus at its inaugural meeting, in order to provide updated information of internationally acceptable standards, and also to incorporate our local disease characteristics into the management of PA. RESULTS When there is suspicion of PA, a plasma aldosterone to renin ratio (ARR) should be obtained initially. Patients with abnormal ARR will undergo confirmatory laboratory and image tests. Subtype classification with adrenal venous sampling (AVS) or NP-59 nuclear imaging, if AVS not available, to lateralize PA is recommended when patients are considered for adrenalectomy. The strengths and weaknesses of the currently available identification methods are discussed, focusing especially on result interpretation. CONCLUSION With this consensus we hope to raise more awareness of PA among medical professionals and hypertensive patients in Taiwan, and to facilitate reconciliation of better detection, identification and treatment of patients with PA.
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Affiliation(s)
- Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Hui Hu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Leay Kiaw Er
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Ruoh-Fang Yen
- Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Hui Chang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Ya-Li Chang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Ching-Chu Lu
- Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Chen Chang
- Medical Imagine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jui-Hsiang Lin
- Division of Nephrology, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzung-Dau Wang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Yuan Wang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih Te Tu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Shih-Chieh Jeff Chueh
- Glickman Urological and Kidney Institute, and Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ching-Chung Chang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, 40402, Taiwan
| | - Fen-Yu Tseng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Lee JM, Kim MK, Ko SH, Koh JM, Kim BY, Kim SW, Kim SK, Kim HJ, Ryu OH, Park J, Lim JS, Kim SY, Shong YK, Yoo SJ. Clinical Guidelines for the Management of Adrenal Incidentaloma. Endocrinol Metab (Seoul) 2017; 32:200-218. [PMID: 28685511 PMCID: PMC5503865 DOI: 10.3803/enm.2017.32.2.200] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/09/2017] [Accepted: 06/01/2017] [Indexed: 12/20/2022] Open
Abstract
An adrenal incidentaloma is an adrenal mass found in an imaging study performed for other reasons unrelated to adrenal disease and often accompanied by obesity, diabetes, or hypertension. The prevalence and incidence of adrenal incidentaloma increase with age and are also expected to rise due to the rapid development of imaging technology and frequent imaging studies. The Korean Endocrine Society is promoting an appropriate practice guideline to meet the rising incidence of adrenal incidentaloma, in cooperation with the Korean Adrenal Gland and Endocrine Hypertension Study Group. In this paper, we discuss important core issues in managing the patients with adrenal incidentaloma. After evaluating core proposition, we propose the most critical 20 recommendations from the initially organized 47 recommendations by Delphi technique.
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Affiliation(s)
- Jung Min Lee
- Department of Internal Medicine, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mee Kyoung Kim
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Hyun Ko
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jung Min Koh
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bo Yeon Kim
- Department of Internal Medicine, Soon Chun Hyang University Bucheon Hospital, Soon Chun Hyang University College of Medicine, Bucheon, Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Soo Kyung Kim
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Hae Jin Kim
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Ohk Hyun Ryu
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Juri Park
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jung Soo Lim
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seong Yeon Kim
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Young Kee Shong
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Soon Jib Yoo
- Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea.
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Starker LF, Christakis I, Julien J, Schwarz K, Graham P, Grubbs EG, Lee JE, Perrier ND. Considering Postoperative Functional Hypoaldosteronism after Unilateral Adrenalectomy. Am Surg 2017. [DOI: 10.1177/000313481708300624] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Conn's Syndrome is an uncommon condition. Patients who have undergone adrenalectomy in the early postoperative period can demonstrate biochemical hypoaldosteronism. Given the rare nature of this phenomenon we investigated its incidence and whether it translated to clinical findings. A single-institution retrospective review of all patients with biochemically proven hyperaldosteronism from 2005 to 2014 that underwent unilateral adrenalectomy. A total of 29 patients fit the inclusion criteria. Functional hypoaldosteronism had appreciated in 18/29 (62%) patients, whereas 11 patients (38%) had normal postoperative aldosterone. No significant differences between diagnostic groups were found in terms of clinical outcomes (length of stay, postoperative symptomatology, and readmissions P = 0.669, 0.154, and 0.268, respectively). Two (7%) patients required medical therapy. Biochemical evidence of functional hypoaldosteronism was identified in two-thirds of patients undergoing unilateral adrenalectomy. Although contralateral aldosterone suppression can be anticipated, the phenotypic response varied and the outcomes were similar to patients with normal aldosterone levels. Current guidelines make no formal recommendations for assessment of hypoaldosteronism after adrenalectomy, resulting in varying practice paradigms. Surgeons should consider the risk of postoperative hypoaldosteronism in these patients and counsel patients accordingly. Prospective investigations should be performed to assist in development of an outcomes-based care delivery model for these patients.
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Affiliation(s)
- Lee F. Starker
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Ioannis Christakis
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Jamii Julien
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Kelly Schwarz
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Paul Graham
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, Texas
| | | | - Jeffrey E. Lee
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Nancy D. Perrier
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, Texas
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12
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Christakis I, Livesey JA, Sadler GP, Mihai R. Laparoscopic Adrenalectomy for Conn's Syndrome is Beneficial to Patients and is Cost Effective in England. J INVEST SURG 2017; 31:300-306. [DOI: 10.1080/08941939.2017.1323055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ioannis Christakis
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - John A. Livesey
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Gregory P. Sadler
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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13
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Rossi GP, Ceolotto G, Rossitto G, Seccia TM, Maiolino G, Berton C, Basso D, Plebani M. Prospective validation of an automated chemiluminescence-based assay of renin and aldosterone for the work-up of arterial hypertension. Clin Chem Lab Med 2017; 54:1441-50. [PMID: 26824982 DOI: 10.1515/cclm-2015-1094] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 12/14/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND The availability of simple and accurate assays of plasma active renin (DRC) and aldosterone concentration (PAC) can improve the detection of secondary forms of arterial hypertension. Thus, we investigated the performance of an automated chemiluminescent assay for DRC and PAC in referred hypertensive patients. METHODS We prospectively recruited 260 consecutive hypertensive patients referred to an ESH Center for Hypertension. After exclusion of six protocol violations, 254 patients were analyzed: 67.3% had primary hypertension, 17.3% an aldosterone producing adenoma (APA), 11.4% idiopathic hyperaldosteronism (IHA), 2.4% renovascular hypertension (RVH), 0.8% familial hyperaldosteronism type 1 (FH-1), 0.4% apparent mineralocorticoid excess (AME), 0.4% a renin-producing tumor, and 3.9% were adrenalectomized APA patients. Bland-Altman plots and Deming regression were used to analyze results. The diagnostic accuracy (area under the curve, AUC of the ROC) of the DRC-based aldosterone-renin ratio (ARRCL) was compared with that of the PRA-based ARR (ARRRIA) using as reference the conclusive diagnosis of APA. RESULTS At Bland-Altman plot, the DRC and PAC assay showed no bias as compared to the PRA and PAC assay. A tight relation was found between the DRC and the PRA values (concordance correlation coefficient=0.92, p<0.0001) and the PAC values measured with radioimmunoassay and chemiluminescence (concordance correlation coefficient=0.93, p<0.001). For APA identification the AUC of the ARRCL was higher than that of the ARRRIA [0.974 (95% CI 0.940-0.991) vs. 0.894 (95% CI 0.841-0.933), p=0.02]. CONCLUSIONS This rapid automated chemiluminescent DRC/PAC assay performed better than validated PRA/PAC radioimmunoassays for the identification of APA in referred hypertensive patients.
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14
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Sertedaki A, Markou A, Vlachakis D, Kossida S, Campanac E, Hoffman DA, De La Luz Sierra M, Xekouki P, Stratakis CA, Kaltsas G, Piaditis GP, Chrousos GP, Charmandari E. Functional characterization of two novel germline mutations of the KCNJ5 gene in hypertensive patients without primary aldosteronism but with ACTH-dependent aldosterone hypersecretion. Clin Endocrinol (Oxf) 2016; 85:845-851. [PMID: 27293068 PMCID: PMC5118167 DOI: 10.1111/cen.13132] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 05/03/2016] [Accepted: 06/10/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Germline mutations of the KCNJ5 gene encoding Kir3·4, a member of the inwardly rectifying K+ channel, have been identified in 'normal' adrenal glands, patients with familial hyperaldosteronism (FH) type III, aldosterone-producing adenomas (APAs) and sporadic cases of primary aldosteronism (PA). OBJECTIVE To present two novel KCNJ5 gene mutations in hypertensive patients without PA, but with Adrenocorticotropic hormone (ACTH)-dependent aldosterone hypersecretion. DESIGN AND PATIENTS Two hypertensive patients without PA, who exhibited enhanced ACTH-dependent response of aldosterone secretion, underwent genetic testing for the presence of the CYP11B1/CYP11B2 chimeric gene and KCNJ5 gene mutations. Genomic DNA was isolated from peripheral white blood cells, and the exons of the entire coding regions of the above genes were amplified and sequenced. Electrophysiological studies were performed to determine the effect of identified mutation(s) on the membrane reversal potentials. Structural biology studies were also carried out. RESULTS Two novel germline heterozygous KCNJ5 mutations, p.V259M and p.Y348N, were detected in the two subjects. Electrophysiological studies showed that the Y348N mutation resulted in significantly less negative reversal potentials, suggesting loss of ion selectivity, while the V259M mutation did not affect the Kir3.4 current. In the mutated structural biology model, the N348 mutant resulted in significant loss of the ability for hydrogen bonding, while the M259 mutant was capable of establishing weaker interactions. The CYP11B1/CYP11B2 chimeric gene was not detected. CONCLUSIONS These findings expand on the clinical spectrum of phenotypes associated with KCNJ5 mutations and implicate these mutations in the pathogenesis of hypertension associated with increased aldosterone response to ACTH stimulation.
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Affiliation(s)
- Amalia Sertedaki
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| | - Athina Markou
- Department of Endocrinology and Diabetes Center, “G. Gennimatas” General Hospital, Athens, Greece
| | - Dimitrios Vlachakis
- Bioinformatics & Medical Informatics Team Biomedical Research Foundation of the Academy of Athens, 4 Soranou Efesiou Street, 11527 Athens, Greece
| | - Sophia Kossida
- Bioinformatics & Medical Informatics Team Biomedical Research Foundation of the Academy of Athens, 4 Soranou Efesiou Street, 11527 Athens, Greece
| | - Emilie Campanac
- Molecular Neurophysiology and Biophysics Section, Program in Developmental Neuroscience, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Dax A. Hoffman
- Molecular Neurophysiology and Biophysics Section, Program in Developmental Neuroscience, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Maria De La Luz Sierra
- Program in Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892 USA
| | - Paraskevi Xekouki
- Program in Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892 USA
| | - Constantine A. Stratakis
- Program in Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892 USA
| | - Gregory Kaltsas
- Department of Pathophysiology, National and Kapodistrian University of Athens Medical School, ‘Laikon’ Hospital, Athens, Greece
| | - George P. Piaditis
- Department of Endocrinology and Diabetes Center, “G. Gennimatas” General Hospital, Athens, Greece
| | - George P. Chrousos
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| | - Evangelia Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
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Significance of adrenal computed tomography in predicting laterality and indicating adrenal vein sampling in primary aldosteronism. J Hum Hypertens 2016; 31:195-199. [PMID: 27582025 DOI: 10.1038/jhh.2016.61] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 07/20/2016] [Indexed: 11/08/2022]
Abstract
Although laterality assessed by computed tomography (CT) in primary aldosteronism (PA) is not always concordant with that assessed by adrenal vein sampling (AVS), it is unclear whether all patients diagnosed with PA should undergo AVS for subtype classification. The aim of the current study was to investigate the accuracy of CT in subtype classification and to develop a prediction score for bilateral subtype in patients without adrenal tumour. As part of the WAVES-J study, 393 patients with PA were analysed. Subtyping using CT was concordant with that using AVS in 68% (269/393) of patients in the total sample, and in 38% (68/156) of patients with unilateral tumours, 56% (5/9) of patients with bilateral tumours and 89% (204/228) of patients without tumour. In patients without tumour, female gender, plasma aldosterone concentration (pg ml-1) to plasma renin activity ratio ⩽550 and serum potassium ⩾3.8 mEq l-1 were shown to be independent predictors for bilateral subtype. A prediction score based on these three variables was constructed with one point attributed to each variable. A score of three points had 29% sensitivity and 96% specificity in a receiver operating characteristic curve analysis. The results suggest that although CT is not sufficiently accurate for subtype classification in patients with adrenal tumours, it is sufficient to determine bilateral subtype in patients without tumour. Moreover, using our clinical prediction score in patients without tumour could be useful in determining the necessity of AVS for subtype classification.
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Reznik Y, Amar L, Tabarin A. SFE/SFHTA/AFCE consensus on primary aldosteronism, part 3: Confirmatory testing. ANNALES D'ENDOCRINOLOGIE 2016; 77:202-7. [PMID: 27318644 DOI: 10.1016/j.ando.2016.01.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 01/25/2016] [Indexed: 11/28/2022]
Abstract
Aldosterone/renin ratio (ARR) identifies patients at high or low risk of primary aldosteronism (PA), but sensitivity and especially specificity are suboptimal and confirmatory testing may therefore be necessary, in some but not all patients. In patients with elevated ARR and plasma aldosterone concentration above 550pmol/L (20ng/dL) on two assessments, PA can be diagnosed without confirmatory testing. Conversely, PA can be ruled out without confirmatory testing in patients with normal ARR and plasma aldosterone concentration below 240pmol/L (9ng/dL) on two assessments. In patients not corresponding to either of the previous conditions, dynamic confirmatory testing is mandatory. Several tests are available, based on aldosterone suppression by saline loading, fludrocortisone administration or converting enzyme inhibition by captopril. One test is based on renin stimulation by furosemide administration. Each of these tests has its limitations, and validation is incomplete. We recommend aldosterone suppression by saline infusion test. Renin stimulation by captopril may be used if sodium loading is contraindicated by impaired cardiac function.
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Affiliation(s)
- Yves Reznik
- Service d'endocrinologie et maladies métaboliques, CHU Côte-de-Nacre, 14033 Caen cedex, France.
| | - Laurence Amar
- Unité d'hypertension artérielle, université Paris Descartes, Sorbonne Paris Cité, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, 75098 Paris cedex 15, France
| | - Antoine Tabarin
- Service d'endocrinologie, hôpital Haut-Lévêque, CHU de Bordeaux, avenue de Magellan, 33600 Pessac, France
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17
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Expression and functional role of the prorenin receptor in the human adrenocortical zona glomerulosa and in primary aldosteronism. J Hypertens 2016; 33:1014-22. [PMID: 25668351 DOI: 10.1097/hjh.0000000000000504] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Prorenin can be detected in plasma of hypertensive patients. If detected in patients with primary aldosteronism could implicate prorenin in the development of primary aldosteronism. To address this issue, we measured the plasma prorenin levels in primary aldosteronism patients, the expression of the prorenin receptor (PRR) in the normal human adrenocortical zona glomerulosa and aldosterone-producing adenoma (APA), and we investigated the functional effects of PRR activation in human adrenocortical cells. METHOD Plasma renin activity, aldosterone, and active and total trypsin-activated renin were measured in primary aldosteronism patients, essential hypertensive patients, and healthy individuals, and then prorenin levels were calculated. Localization and functional role of PRR were investigated in human and rat tissues, and aldosterone-producing cells. RESULTS Primary aldosteronism patients had detectable plasma levels of prorenin. Using digital-droplet real-time PCR, we found a high PRR-to-porphobilinogen deaminase ratio in both the normal adrenal cortex and APAs. Marked expression of the PRR gene and protein was also found in HAC15 cells. Immunoblotting, confocal, and immunogold electron microscopy demonstrated PRR at the cell membrane and intracellularly. Renin and prorenin significantly triggered both CYP11B2 expression (aldosterone synthase) and ERK1/2 phosphorylation, but only CYP11B2 transcription was prevented by aliskiren. CONCLUSION The presence of detectable plasma prorenin in primary aldosteronism patients, and the high expression of PRR in the normal human adrenal cortex, APA tissue, CD56+ aldosterone-producing cells, along with activation of CYP11B2 synthesis and ERK1/2 phosphorylation, suggest that the circulating and locally produced prorenin may contribute to the development or maintenance of human primary aldosteronism.
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18
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Rodríguez Maya B, Rodríguez Goncer I, Diego Hernández C. [Hypokalemia, a key clinical data for diagnosing primary hyperaldosteronism]. HIPERTENSION Y RIESGO VASCULAR 2016; 33:69-73. [PMID: 26869044 DOI: 10.1016/j.hipert.2015.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 12/29/2015] [Indexed: 10/22/2022]
Abstract
We report a case of a 37 year-old man with a long history of hypertension under treatment, who was admitted at our institution with intense fatigue and weakness of lower limbs. The laboratory results at Emergency Department showed severe hypokalemia. A study of secondary hypertension was carried out. With the initial suspicion of primary hyperaldosteronism, complete blood test was done including plasma renine activity, which was completely suppressed, and plasma aldosterone concentration, which resulted normal. Likewise, an abdomen CT was performed and revealed a left adrenal mass consistent of suprarrenal adenoma. Therefore, a salt loading suppression test was done with subsequent measure of plasmatic renine activity, which was still suppressed, plasma aldosterone concentration, that persisted normal, and a 24-h urinary aldosterone excretion rate, which was clearly high, supporting the suspected diagnosis. After the adrenalectomy, the patient remained asymptomatic with normal blood pressure without treatment and with normal serum potassium levels.
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Affiliation(s)
- B Rodríguez Maya
- Servicio de Medicina Interna, Hospital Universitario de Móstoles, Móstoles, Madrid, España.
| | - I Rodríguez Goncer
- Servicio de Medicina Interna, Hospital Universitario de Móstoles, Móstoles, Madrid, España
| | - C Diego Hernández
- Servicio de Anatomía Patológica, Hospital Universitario de Móstoles, Móstoles, Madrid, España
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19
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Sechi LA, Colussi GL, Novello M, Uzzau A, Catena C. Mineralocorticoid Receptor Antagonists and Clinical Outcomes in Primary Aldosteronism: As Good as Surgery? Horm Metab Res 2015; 47:1000-6. [PMID: 26667803 DOI: 10.1055/s-0035-1565128] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Primary aldosteronism (PA) is detected with increasing frequency in hypertensive patients and is associated with excess cardiovascular, renal, and metabolic complications. For these reasons, appropriate choices for treatment of this endocrine condition are mandatory. Adrenalectomy is safely performed in PA patients when adrenal venous sampling (AVS) demonstrates lateralized aldosterone secretion. AVS, however, is a complex procedure and even among worldwide referral centers there are substantial discrepancies for interpretation of results. Also, in the majority of PA patients with lateralized aldosterone secretion, hypertension may persist after adrenalectomy requiring use of additional antihypertensive agents. Treatment with mineralocorticoid receptor antagonists (MRAs) is currently recommended for PA patients with bilateral adrenal disease, but these agents effectively decrease blood pressure also in patients with unilateral disease, although concern remains for possible sex-related side effects. Prospective studies indicate that MRAs have therapeutic values comparable to surgery in the long-term, inasmuch as they effectively correct metabolic abnormalities and subclinical organ damage and reduce the risk of cardiovascular events and renal disease progression. This article overviews the clinical outcomes obtained in patients with PA with use of MRAs.
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Affiliation(s)
- L A Sechi
- Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - G L Colussi
- Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - M Novello
- Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - A Uzzau
- General Surgery, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - C Catena
- Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
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20
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Nanba K, Chen A, Nishimoto K, Rainey WE. Role of Ca(2+)/calmodulin-dependent protein kinase kinase in adrenal aldosterone production. Endocrinology 2015; 156:1750-6. [PMID: 25679868 PMCID: PMC4398758 DOI: 10.1210/en.2014-1782] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
There is considerable evidence supporting the role of calcium signaling in adrenal regulation of both aldosterone synthase (CYP11B2) and aldosterone production. However, there have been no studies that investigated the role played by the Ca(2+)/calmodulin-dependent protein kinase kinase (CaMKK) in adrenal cells. In this study we investigated the role of CaMKK in adrenal cell aldosterone production. To determine the role of CaMKK, we used a selective CaMKK inhibitor (STO-609) in the HAC15 human adrenal cell line. Cells were treated with angiotensin II (Ang II) or K+ and evaluated for the expression of steroidogenic acute regulatory protein and CYP11B2 (mRNA/protein) as well as aldosterone production. We also transduced HAC15 cells with lentiviral short hairpin RNAs of CaMKK1 and CaMKK2 to determine which CaMKK plays a more important role in adrenal cell regulation of the calcium signaling cascade. The CaMKK inhibitor, STO-609, decreased aldosterone production in cells treated with Ang II or K+ in a dose-dependent manner. STO-609 (20 μM) also inhibited steroidogenic acute regulatory protein and CYP11B2 mRNA/protein induction. CaMKK2 knockdown cells showed significant reduction of CYP11B2 mRNA induction and aldosterone production in cells treated with Ang II, although there was no obvious effect in CaMKK1 knockdown cells. In immunohistochemical analysis, CaMKK2 protein was highly expressed in human adrenal zona glomerulosa with lower expression in the zona fasciculata. In conclusion, the present study suggests that CaMKK2 plays a pivotal role in the calcium signaling cascade regulating adrenal aldosterone production.
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Affiliation(s)
- Kazutaka Nanba
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, Michigan 48109
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21
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Iacobone M, Citton M, Viel G, Rossi GP, Nitti D. Approach to the surgical management of primary aldosteronism. Gland Surg 2015; 4:69-81. [PMID: 25713782 DOI: 10.3978/j.issn.2227-684x.2015.01.05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 01/15/2015] [Indexed: 11/14/2022]
Abstract
Primary aldosteronism (PA) is the most common cause of endocrine hypertension; it has been reported in more than 11% of referred hypertensive patients. PA may be caused by unilateral adrenal involvement [aldosterone producing adenoma (APA) or unilateral adrenal hyperplasia (UAH)], and bilateral disease (idiopathic adrenal hyperplasia). Only patients with unilateral adrenal hypersecretion may be cured by unilateral adrenalectomy, while patients with bilateral and non-surgically correctable PA are usually treated by mineralocorticoid receptor antagonists; thus the distinction between unilateral and bilateral aldosterone hypersecretion is crucial. Most experts agree that the referral diagnostic test for lateralization of aldosterone hypersecretion should be adrenal venous sampling (AVS) because the interpretation of other imaging techniques [computed tomography (CT), magnetic resonance imaging (MRI) and scintigraphy] may lead to inappropriate treatment. Adrenalectomy represents the elective treatment in unilateral PA variants. Laparoscopic surgery, using transperitoneal or retroperitoneal approaches, is the preferred strategy. Otherwise, the indications to laparoscopic unilateral total or partial adrenalectomy in patients with unilateral PA remain controversial. Adrenalectomy is highly successful in curing the PA, with correction of hypokalemia in virtually all patients, cure of hypertension in about 30-60% of cases, and a marked improvement of blood pressure values in the remaining patients. Interestingly, in several papers the outcomes of surgery focus only on blood pressure changes and the normalization of serum potassium levels is often used as a surrogate of PA recovery. However, the goal of surgery is the normalization of aldosterone, because chronically elevated levels of this hormone can lead to cardiovascular complications, independently from blood pressure levels. Thus, we strongly advocate the need of considering the postoperative normalization of aldosterone-renin ratio (ARR) as the main endpoint for determining outcomes of PA.
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Affiliation(s)
- Maurizio Iacobone
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Marilisa Citton
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Giovanni Viel
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Gian Paolo Rossi
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Donato Nitti
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
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22
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Magill SB. Pathophysiology, diagnosis, and treatment of mineralocorticoid disorders. Compr Physiol 2015; 4:1083-119. [PMID: 24944031 DOI: 10.1002/cphy.c130042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The renin-angiotensin-aldosterone system (RAAS) is a major regulator of blood pressure control, fluid, and electrolyte balance in humans. Chronic activation of mineralocorticoid production leads to dysregulation of the cardiovascular system and to hypertension. The key mineralocorticoid is aldosterone. Hyperaldosteronism causes sodium and fluid retention in the kidney. Combined with the actions of angiotensin II, chronic elevation in aldosterone leads to detrimental effects in the vasculature, heart, and brain. The adverse effects of excess aldosterone are heavily dependent on increased dietary salt intake as has been demonstrated in animal models and in humans. Hypertension develops due to complex genetic influences combined with environmental factors. In the last two decades, primary aldosteronism has been found to occur in 5% to 13% of subjects with hypertension. In addition, patients with hyperaldosteronism have more end organ manifestations such as left ventricular hypertrophy and have significant cardiovascular complications including higher rates of heart failure and atrial fibrillation compared to similarly matched patients with essential hypertension. The pathophysiology, diagnosis, and treatment of primary aldosteronism will be extensively reviewed. There are many pitfalls in the diagnosis and confirmation of the disorder that will be discussed. Other rare forms of hyper- and hypo-aldosteronism and unusual disorders of hypertension will also be reviewed in this article.
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Affiliation(s)
- Steven B Magill
- Division of Endocrinology, Metabolism, and Clinical Nutrition, Department of Medicine, Medical College of Wisconsin, Menomonee Falls, Wisconsin
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23
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Outcome of surgical treatment of primary aldosteronism. Langenbecks Arch Surg 2015; 400:325-31. [DOI: 10.1007/s00423-014-1269-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 12/22/2014] [Indexed: 10/24/2022]
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24
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Catena C, Colussi G, Sechi LA. Treatment of Primary Aldosteronism and Organ Protection. Int J Endocrinol 2015; 2015:597247. [PMID: 26074961 PMCID: PMC4449945 DOI: 10.1155/2015/597247] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/31/2015] [Indexed: 12/25/2022] Open
Abstract
Primary aldosteronism is a frequent form of secondary hypertension that had long been considered relatively benign. Experimental and clinical evidence collected in the last two decades, however, has clearly demonstrated that this endocrine disorder is associated with excess cardiovascular and renal complications as compared to essential hypertension. These complications reflect the ability of inappropriate elevation of plasma aldosterone to cause tissue damage beyond that induced by high blood pressure itself, thereby setting the stage for major cardiovascular and renal disease. Because of the impact of elevated aldosterone on organ damage, goals of treatment in patients with primary aldosteronism should not be limited to normalization of blood pressure, and prevention or correction of organ complications is mandatory. Treatment with mineralocorticoid receptor antagonists or unilateral adrenalectomy is the respective options for treatment of idiopathic adrenal hyperplasia or aldosterone-producing adenoma. Last years have witnessed a rapid growth in knowledge concerning the effects of these treatments on cardiovascular and renal protection. This paper is an overview of the cardiovascular and renal complications that occur in patients with primary aldosteronism and a summary of the results that have been obtained in the long term on cardiovascular and renal outcomes with either medical or surgical treatment.
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Affiliation(s)
- Cristiana Catena
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, 33100 Udine, Italy
- *Cristiana Catena:
| | - GianLuca Colussi
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, 33100 Udine, Italy
| | - Leonardo A. Sechi
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, 33100 Udine, Italy
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Measurement of plasma renin concentration instead of plasma renin activity decreases the positive aldosterone-to-renin ratio tests in treated patients with essential hypertension. J Hypertens 2014; 32:627-34. [DOI: 10.1097/hjh.0000000000000076] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Chen YC, Chiu JS, Wang YF. NP-59 SPECT/CT imaging in stage 1 hypertensive and atypical primary aldosteronism: a 5-year retrospective analysis of clinicolaboratory and imaging features. ScientificWorldJournal 2013; 2013:317934. [PMID: 24235884 PMCID: PMC3818974 DOI: 10.1155/2013/317934] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 09/18/2013] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE We retrospectively analyzed all primary aldosteronism (PA) patients undergoing NP-59 SPECT/CT imaging with regard to their clinicolaboratory and imaging features, investigation, and outcomes. MATERIAL AND METHODS 11 PA patients who presented to our hospital for NP-59 SPECT/CT imaging between April 2007 and March 2012 and managed here were analyzed. RESULTS Among 11 PA patients, eight (73%) had stage 1 hypertension, three (27%) stage 2 hypertension, four (36%) normal plasma aldosterone concentration, nine (82%) nonsuppressed plasma renin activity (PRA), six (55%) normal aldosterone-renin-ratio (ARR), eight (73%) serum potassium ≧3 mEq/L, seven (64%) subclinical presentation, seven (64%) negative confirmatory testing, and four (36%) inconclusive results on CT scan and seven (64%) on planar NP-59 scan. All 11 (100%) patients had positive results on NP-59 SPECT/CT scan. Two (18%) met typical triad and nine (82%) atypical triad. Among nine atypical PA patients, three (33%) had clinical presentation, six (67%) subclinical presentation, six (67%) negative confirmatory testing, and four (44%) inconclusive results on CT scan and six (67%) on planar NP-59 scan. All patients had improved outcomes. Significant differences between typical and atypical PA existed in PRA and ARR. CONCLUSIONS NP-59 SPECT/CT may provide diagnostic potential in stage 1 hypertensive and atypical PA.
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Affiliation(s)
- Yi-Chun Chen
- Division of Nephrology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2 Minsheng Road, Dalin Township, Chiayi County 622, Taiwan
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
| | - Jainn-Shiun Chiu
- Department of Nuclear Medicine, Saint Paul's Hospital, Taoyuan City 330, Taiwan
| | - Yuh-Feng Wang
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
- Department of Nuclear Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 622, Taiwan
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Kim JY, Kim SH, Lee HJ, Kim YH, Kim MJ, Cho SH. Adrenal venous sampling for stratifying patients for surgery of adrenal nodules detected using dynamic contrast enhanced CT. Diagn Interv Radiol 2013; 20:65-71. [PMID: 24047720 DOI: 10.5152/dir.2013.13144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to assess the value of adrenal venous sampling (AVS) for diagnosing primary aldosteronism (PA) subtypes in patients with a unilateral nodule detected on adrenal computed tomography (CT) and scheduled for adrenalectomy. MATERIALS AND METHODS This retrospective study included 80 consecutive patients with PA undergoing CT and AVS. Different lateralization indices were assessed, and a cutoff established using receiver operating characteristic curve analysis. The value of CT alone versus CT with AVS for differentiating PA subtypes was compared. The adrenalectomy outcome was assessed, and predictors of cure were determined using univariate analysis. RESULTS AVS was successful in 68 patients. A cortisol-corrected aldosterone affected-to-unaffected ratio cutoff of 2.0 and affected-to-inferior vena cava ratio cutoff of 1.4 were the best lateralization indices, with accuracies of 82.5% and 80.4%, respectively. CT and AVS diagnosed 38 patients with aldosterone-producing adenomas, five patients with unilateral adrenal hyperplasia, and 25 patients with bilateral adrenal hyperplasia. Of the 52 patients with a nodule detected on CT, subsequent AVS diagnosed bilateral adrenal hyperplasia in 14 patients (27%). Compared to the results of combining CT with AVS, the accuracy of CT alone for diagnosing aldosterone-producing adenomas was 71.1% (P < 0.001). The cure rate for hypertension after adrenalectomy was 39.2%, with improvement in 53.5% of patients. On univariate analysis, predictors of persistent hypertension were male gender and preoperative systolic blood pressure. CONCLUSION To avoid inappropriate surgery, AVS is necessary for diagnosing unilateral nodules with aldosterone hypersecretion detected by CT.
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Affiliation(s)
- Jin Young Kim
- From the Department of Radiology (J.Y.K. e-mail: , S.H.K., H.J.L., Y.H.K., M.J.K.), Dongsan Hospital, Keimyung University College of Medicine, Daegu, Republic of Korea; the Department of Radiology (S.H.C.), Kyungpook National University School of Medicine, Daegu, Republic of Korea
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Chiang WF, Cheng CJ, Wu ST, Sun GH, Lin MY, Sung CC, Lin SH. Incidence and factors of post-adrenalectomy hyperkalemia in patients with aldosterone producing adenoma. Clin Chim Acta 2013; 424:114-8. [DOI: 10.1016/j.cca.2013.05.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 04/23/2013] [Accepted: 05/15/2013] [Indexed: 10/26/2022]
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Baba Y, Hayashi S, Nakajo M. Are catecholamine-derived indexes in adrenal venous sampling useful for judging selectivity and laterality in patients with primary aldosteronism? Endocrine 2013; 43:611-7. [PMID: 22990404 DOI: 10.1007/s12020-012-9793-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 09/04/2012] [Indexed: 12/17/2022]
Abstract
In order to investigate retrospectively whether catecholamine concentrations obtained by adrenal venous sampling (AVS) are useful for lateralization of the aldosteronoma-bearing adrenal gland. The study population comprised 35 patients (10 men, 25 women; mean age, 49.8 years) with aldosteronoma and 18 patients (9 men, 9 women; mean age, 51.8 years) with non-functioning adenoma who underwent AVS between 1994 and 2010. In all cases, AVS was performed without administering adrenocorticotrophic hormone. Successful or unsuccessful adrenal vein blood sampling (selectivity) was judged by the ratio of plasma cortisol (C) level in each adrenal vein to that in the infra-renal inferior vena cava [C(side)/C(IVC)] as a gold standard, with successful selectivity defined using four different cut-off values [C(side)/C(IVC) ≥ 3.0, 2.0, 1.36 or 1.1]. Receiver operating characteristics (ROC) analyses were conducted to determine: (1) degree of selectivity; and (2) the best catecholamine (epinephrine, norepinephrine, and dopamine)-derived index for lateralization of the aldosteronoma-bearing adrenal gland. Among the catecholamine-derived indexes, the epinephrine concentration ratio of adrenal vein to IVC was the most reliable for all four different cut-off values in the evaluation of adrenal vein selectivity. Meanwhile, the ratio of aldosterone to norepinephrine between dominant and non-dominant sides was the most reliable index (right: area under the curve (AUC), 0.965 ± 0.024; 95 % confidence interval (CI), 0.874-0.996; left: AUC, 0.937 ± 0.033; 95 % CI, 0.834-0.985) for lateralization of the aldosteronoma-bearing gland. Catecholamine concentrations obtained by AVS are useful for not only judging selectivity, but also lateralization of the aldosteronoma-bearing gland.
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Affiliation(s)
- Yasutaka Baba
- Department of Radiology, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan.
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Impact of aldosterone-producing adenoma on cardiac structures in echocardiography. J Echocardiogr 2013; 11:123-9. [PMID: 24319340 PMCID: PMC3851697 DOI: 10.1007/s12574-013-0168-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 01/21/2013] [Accepted: 01/23/2013] [Indexed: 01/20/2023]
Abstract
Background Primary aldosteronism (PA) is a most common cause of secondary hypertension. In PA, left ventricular hypertrophy (LVH) is more progressive than in any other cause of hypertension. Aldosterone-producing adenoma (APA) and idiopathic hyperaldosteronism (IHA) are major subtypes of PA. However there is little information concerned with differences of cardiac structures between these two subtypes. Methods We reviewed echocardiographic findings in 46 patients with PA. All patients had a positive screen test and subtypes of PA were confirmed by adrenal vein sampling. Subjects consisted of 20 patients with APA (APA group, 52.4 ± 10.8 years) and 26 patients with IHA (IHA group, 56.2 ± 9.5 years). We investigated differences of cardiac structures and functions in the left atrium and ventricle between the APA group and IHA group. Results In terms of clinical characteristics, the height and duration of hypertension were greater and serum potassium concentration and BMI were lower in the APA group than in the IHA group. Plasma aldosterone concentration (PAC) and PAC to plasma renin activity ratio were higher in the APA group than in the IHA group. In echocardiographic assessment, the left atrial volume, left ventricular end-diastolic and end-systolic diameters, left ventricular mass (LVM), and prevalence of LVH were greater in the APA group than in the IHA group. Multiple linear regression analysis revealed that the diagnosis of APA independently correlated with left atrial volume, left ventricular end-diastolic diameter, and LVM. Conclusions We demonstrated that differences of cardiac structures between the APA group and IHA group existed. In APA, left atrial enlargement and LVH were more prominent than in IHA.
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Rossitto G, Regolisti G, Rossi E, Negro A, Nicoli D, Casali B, Toniato A, Caroccia B, Seccia TM, Walther T, Rossi GP. Elevation of Angiotensin-II Type-1-Receptor Autoantibodies Titer in Primary Aldosteronism as a Result of Aldosterone-Producing Adenoma. Hypertension 2013; 61:526-33. [DOI: 10.1161/hypertensionaha.112.202945] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Giacomo Rossitto
- From the Department of Medicine—DIMED, Internal Medicine 4, Padua University—School of Medicine, Padova, Italy (G.Ro., B.C., T.M.S., G.P.R.); Department of Internal Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy (G.Re., E.R., A.N., D.N., B.C.); Surgical Pathology Unit, Department of Medical and Surgical Sciences, Padua University, Padua, Italy (A.T.); Hull York Medical School, Hull University, Cottingham, UK (T.W.)
| | - Giuseppe Regolisti
- From the Department of Medicine—DIMED, Internal Medicine 4, Padua University—School of Medicine, Padova, Italy (G.Ro., B.C., T.M.S., G.P.R.); Department of Internal Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy (G.Re., E.R., A.N., D.N., B.C.); Surgical Pathology Unit, Department of Medical and Surgical Sciences, Padua University, Padua, Italy (A.T.); Hull York Medical School, Hull University, Cottingham, UK (T.W.)
| | - Ermanno Rossi
- From the Department of Medicine—DIMED, Internal Medicine 4, Padua University—School of Medicine, Padova, Italy (G.Ro., B.C., T.M.S., G.P.R.); Department of Internal Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy (G.Re., E.R., A.N., D.N., B.C.); Surgical Pathology Unit, Department of Medical and Surgical Sciences, Padua University, Padua, Italy (A.T.); Hull York Medical School, Hull University, Cottingham, UK (T.W.)
| | - Aurelio Negro
- From the Department of Medicine—DIMED, Internal Medicine 4, Padua University—School of Medicine, Padova, Italy (G.Ro., B.C., T.M.S., G.P.R.); Department of Internal Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy (G.Re., E.R., A.N., D.N., B.C.); Surgical Pathology Unit, Department of Medical and Surgical Sciences, Padua University, Padua, Italy (A.T.); Hull York Medical School, Hull University, Cottingham, UK (T.W.)
| | - Davide Nicoli
- From the Department of Medicine—DIMED, Internal Medicine 4, Padua University—School of Medicine, Padova, Italy (G.Ro., B.C., T.M.S., G.P.R.); Department of Internal Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy (G.Re., E.R., A.N., D.N., B.C.); Surgical Pathology Unit, Department of Medical and Surgical Sciences, Padua University, Padua, Italy (A.T.); Hull York Medical School, Hull University, Cottingham, UK (T.W.)
| | - Bruno Casali
- From the Department of Medicine—DIMED, Internal Medicine 4, Padua University—School of Medicine, Padova, Italy (G.Ro., B.C., T.M.S., G.P.R.); Department of Internal Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy (G.Re., E.R., A.N., D.N., B.C.); Surgical Pathology Unit, Department of Medical and Surgical Sciences, Padua University, Padua, Italy (A.T.); Hull York Medical School, Hull University, Cottingham, UK (T.W.)
| | - Antonio Toniato
- From the Department of Medicine—DIMED, Internal Medicine 4, Padua University—School of Medicine, Padova, Italy (G.Ro., B.C., T.M.S., G.P.R.); Department of Internal Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy (G.Re., E.R., A.N., D.N., B.C.); Surgical Pathology Unit, Department of Medical and Surgical Sciences, Padua University, Padua, Italy (A.T.); Hull York Medical School, Hull University, Cottingham, UK (T.W.)
| | - Brasilina Caroccia
- From the Department of Medicine—DIMED, Internal Medicine 4, Padua University—School of Medicine, Padova, Italy (G.Ro., B.C., T.M.S., G.P.R.); Department of Internal Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy (G.Re., E.R., A.N., D.N., B.C.); Surgical Pathology Unit, Department of Medical and Surgical Sciences, Padua University, Padua, Italy (A.T.); Hull York Medical School, Hull University, Cottingham, UK (T.W.)
| | - Teresa Maria Seccia
- From the Department of Medicine—DIMED, Internal Medicine 4, Padua University—School of Medicine, Padova, Italy (G.Ro., B.C., T.M.S., G.P.R.); Department of Internal Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy (G.Re., E.R., A.N., D.N., B.C.); Surgical Pathology Unit, Department of Medical and Surgical Sciences, Padua University, Padua, Italy (A.T.); Hull York Medical School, Hull University, Cottingham, UK (T.W.)
| | - Thomas Walther
- From the Department of Medicine—DIMED, Internal Medicine 4, Padua University—School of Medicine, Padova, Italy (G.Ro., B.C., T.M.S., G.P.R.); Department of Internal Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy (G.Re., E.R., A.N., D.N., B.C.); Surgical Pathology Unit, Department of Medical and Surgical Sciences, Padua University, Padua, Italy (A.T.); Hull York Medical School, Hull University, Cottingham, UK (T.W.)
| | - Gian Paolo Rossi
- From the Department of Medicine—DIMED, Internal Medicine 4, Padua University—School of Medicine, Padova, Italy (G.Ro., B.C., T.M.S., G.P.R.); Department of Internal Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy (G.Re., E.R., A.N., D.N., B.C.); Surgical Pathology Unit, Department of Medical and Surgical Sciences, Padua University, Padua, Italy (A.T.); Hull York Medical School, Hull University, Cottingham, UK (T.W.)
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Catena C, Colussi G, Sechi LA. Mineralocorticoid receptor antagonists and renal involvement in primary aldosteronism: opening of a new era. Eur J Endocrinol 2013; 168:C1-5. [PMID: 23082005 DOI: 10.1530/eje-12-0899] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Primary aldosteronism (PA) is one of the commonest forms of curable hypertension, and use of the plasma aldosterone-to-renin ratio as a screening test has led to a more efficient identification of this condition. Both animal and human studies have indicated that PA is associated with a variety of cardiovascular and renal complications that reflect the capability of elevated aldosterone to induce tissue damage exceeding that induced by hypertension itself. Involvement of the kidney in PA is highly relevant because structural renal damage is associated with less favorable outcome, both in terms of blood pressure response to treatment and possibility to develop progressive renal failure. However, early involvement of the kidney in PA is characterized by functional changes that are largely reversible with treatment. Unilateral adrenalectomy or administration of mineralocorticoid receptor antagonists are the current options for treating an aldosterone-producing adenoma or idiopathic adrenal hyperplasia. Both treatments are effective in correcting hypertension and hypokalemia, and currently available information on their capability to prevent deterioration of renal function indicates that both surgery and medical treatment are of considerable value.
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Affiliation(s)
- Cristiana Catena
- Department of Experimental and Clinical Medical Science, University of Udine, Udine, Italy
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Hypertension caused by primary hyperaldosteronism: increased heart damage and cardiovascular risk. Rev Esp Cardiol 2012; 66:47-52. [PMID: 23153688 DOI: 10.1016/j.recesp.2012.07.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 07/15/2012] [Indexed: 01/07/2023]
Abstract
INTRODUCTION AND OBJECTIVES Primary hyperaldosteronism is the most common cause of secondary hypertension. Elevated aldosterone levels cause heart damage and increase cardiovascular morbidity and mortality. Early diagnosis could change the course of this entity. The objective of this report was to study the clinical characteristics, cardiac damage and cardiovascular risk associated with primary hyperaldosteronism. METHODS We studied 157 patients with this diagnosis. We analyzed the reason for etiological investigation, and the routinely performed tests, including echocardiography. We used a cohort of 720 essential hypertensive patients followed in our unit for comparison. RESULTS Compared with essential hypertensive patients, those with hyperaldosteronism were younger (56.9 [11.7] years vs 60 [14.4] years; P<.001), had higher blood pressure prior to the etiological diagnosis (136 [20.6] mmHg vs 156 [23.2] mmHg), more frequently had a family history of early cardiovascular disease (25.5% vs 2.2%; P<.001), and had a higher prevalence of concentric left ventricular hypertrophy (69% vs 25.7%) and higher cardiovascular risk. Specific treatment resulted in optimal control of systolic and diastolic blood pressures (from 150.7 [23.0] mmHg and 86.15 [14.07] mmHg to 12.69 [15.3] mmHg and 76.34 [9.7] mmHg, respectively). We suspected the presence of hyperaldosteronism because of resistant hypertension (33.1%), hypokalemia (38.2%), and hypertensive crises (12.7%). Only 4.6% of these patients had been referred from primary care with a suspected diagnosis of hyperaldosteronism. CONCLUSIONS Hyperaldosteronism should be suspected in cases of resistant hypertension, hypokalemia and hypertensive crises. The diagnosis of hyperaldosteronism allows better blood pressure control. The most prevalent target organ damage is left ventricular hypertrophy.
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Volpe C, Wahrenberg H, Hamberger B, Thorén M. Screening for primary aldosteronism in a primary care unit. J Renin Angiotensin Aldosterone Syst 2012; 14:212-9. [DOI: 10.1177/1470320312463833] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Cristina Volpe
- Department of Internal Medicine, Division of Endocrinology, Södersjukhuset, Stockholm, Sweden
- Departments of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Hans Wahrenberg
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Bertil Hamberger
- Departments of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Marja Thorén
- Departments of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
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Jaïdane A, Ouertani H, Dorai A, Zouaoui C, Ibrahim H, Zidi B. [Association of renovascular hypertension and primary aldosteronism]. Rev Med Interne 2012; 33:700-2. [PMID: 23102642 DOI: 10.1016/j.revmed.2012.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 09/11/2012] [Accepted: 09/17/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Renal artery stenosis is rarely associated with Conn adenoma. CASE REPORT We report a 27-year-old male patient who presented in 2001 with a severe high blood pressure associated with hypokaliemia. Radiologic investigations showed a left renal artery stenosis with agenesis of left kidney. A left nephrectomy was performed and blood pressure returned to normal with a single antihypertensive drug. Five years later, the patient again presented with severe high blood pressure. Laboratory studies revealed a low serum potassium level at 2.8 mmol/L associated with high urinary potassium excretion (84 mmol/24h) and a very high aldosterone/renin ratio (>462). Abdominal CT scan demonstrated a right adrenal mass. The patient underwent a right adrenalectomy (adenoma). Blood pressure returned to normal with a single antihypertensive. Serum potassium levels as well as aldosterone/renin ratio normalized. CONCLUSION We discussed whether the association between these two entities is merely fortuitous or conversely based on a causal relationship.
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Affiliation(s)
- A Jaïdane
- Service d'endocrinologie, hôpital militaire de Tunis, 1008 Montfleury, Tunis, Tunisie.
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Charmandari E, Sertedaki A, Kino T, Merakou C, Hoffman DA, Hatch MM, Hurt DE, Lin L, Xekouki P, Stratakis CA, Chrousos GP. A novel point mutation in the KCNJ5 gene causing primary hyperaldosteronism and early-onset autosomal dominant hypertension. J Clin Endocrinol Metab 2012; 97:E1532-9. [PMID: 22628607 PMCID: PMC3410272 DOI: 10.1210/jc.2012-1334] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Aldosterone production in the adrenal zona glomerulosa is mainly regulated by angiotensin II, [K(+)], and ACTH. Genetic deletion of subunits of K(+)-selective leak (KCNK) channels TWIK-related acid sensitive K(+)-1 and/or TWIK-related acid sensitive K(+)-3 in mice results in primary hyperaldosteronism, whereas mutations in the KCNJ5 (potassium inwardly rectifying channel, subfamily J, member 5) gene are implicated in primary hyperaldosteronism and, in certain cases, in autonomous glomerulosa cell proliferation in humans. OBJECTIVE The objective of the study was to investigate the role of KCNK3, KCNK5, KCNK9, and KCNJ5 genes in a family with primary hyperaldosteronism and early-onset hypertension. PATIENTS AND METHODS Two patients, a mother and a daughter, presented with severe primary hyperaldosteronism, bilateral massive adrenal hyperplasia, and early-onset hypertension refractory to medical treatment. Genomic DNA was isolated and the exons of the entire coding regions of the above genes were amplified and sequenced. Electrophysiological studies were performed to determine the effect of identified mutation(s) on the membrane reversal potentials. RESULTS Sequencing of the KCNJ5 gene revealed a single, heterozygous guanine to thymine (G → T) substitution at nucleotide position 470 (n.G470T), resulting in isoleucine (I) to serine (S) substitution at amino acid 157 (p.I157S). This mutation results in loss of ion selectivity, cell membrane depolarization, increased Ca(2+) entry in adrenal glomerulosa cells, and increased aldosterone synthesis. Sequencing of the KCNK3, KCNK5, and KCNK9 genes revealed no mutations in our patients. CONCLUSIONS These findings explain the pathogenesis in a subset of patients with severe hypertension and implicate loss of K(+) channel selectivity in constitutive aldosterone production.
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Affiliation(s)
- Evangelia Charmandari
- Division of Endocrinology, First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens 11527, Greece.
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Iwasaki T, Kurisu S, Mitsuba N, Ishibashi K, Dohi Y, Nishioka K, Kihara Y. Effect of body mass index on the location of the right adrenal vein in patients with primary aldosteronism. J Renin Angiotensin Aldosterone Syst 2012; 14:156-60. [DOI: 10.1177/1470320312454765] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Toshitaka Iwasaki
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Japan
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Japan
| | - Naoya Mitsuba
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Japan
| | - Ken Ishibashi
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Japan
| | - Yoshihiro Dohi
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Japan
| | - Kenji Nishioka
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Japan
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Åkerström T, Crona J, Delgado Verdugo A, Starker LF, Cupisti K, Willenberg HS, Knoefel WT, Saeger W, Feller A, Ip J, Soon P, Anlauf M, Alesina PF, Schmid KW, Decaussin M, Levillain P, Wängberg B, Peix JL, Robinson B, Zedenius J, Bäckdahl M, Caramuta S, Iwen KA, Botling J, Stålberg P, Kraimps JL, Dralle H, Hellman P, Sidhu S, Westin G, Lehnert H, Walz MK, Åkerström G, Carling T, Choi M, Lifton RP, Björklund P. Comprehensive re-sequencing of adrenal aldosterone producing lesions reveal three somatic mutations near the KCNJ5 potassium channel selectivity filter. PLoS One 2012; 7:e41926. [PMID: 22848660 PMCID: PMC3407065 DOI: 10.1371/journal.pone.0041926] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 06/29/2012] [Indexed: 11/19/2022] Open
Abstract
Background Aldosterone producing lesions are a common cause of hypertension, but genetic alterations for tumorigenesis have been unclear. Recently, either of two recurrent somatic missense mutations (G151R or L168R) was found in the potassium channel KCNJ5 gene in aldosterone producing adenomas. These mutations alter the channel selectivity filter and result in Na+ conductance and cell depolarization, stimulating aldosterone production and cell proliferation. Because a similar mutation occurs in a Mendelian form of primary aldosteronism, these mutations appear to be sufficient for cell proliferation and aldosterone production. The prevalence and spectrum of KCNJ5 mutations in different entities of adrenocortical lesions remain to be defined. Materials and Methods The coding region and flanking intronic segments of KCNJ5 were subjected to Sanger DNA sequencing in 351 aldosterone producing lesions, from patients with primary aldosteronism and 130 other adrenocortical lesions. The specimens had been collected from 10 different worldwide referral centers. Results G151R or L168R somatic mutations were identified in 47% of aldosterone producing adenomas, each with similar frequency. A previously unreported somatic mutation near the selectivity filter, E145Q, was observed twice. Somatic G151R or L168R mutations were also found in 40% of aldosterone producing adenomas associated with marked hyperplasia, but not in specimens with merely unilateral hyperplasia. Mutations were absent in 130 non-aldosterone secreting lesions. KCNJ5 mutations were overrepresented in aldosterone producing adenomas from female compared to male patients (63 vs. 24%). Males with KCNJ5 mutations were significantly younger than those without (45 vs. 54, respectively; p<0.005) and their APAs with KCNJ5 mutations were larger than those without (27.1 mm vs. 17.1 mm; p<0.005). Discussion Either of two somatic KCNJ5 mutations are highly prevalent and specific for aldosterone producing lesions. These findings provide new insight into the pathogenesis of primary aldosteronism.
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Affiliation(s)
- Tobias Åkerström
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Joakim Crona
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Alberto Delgado Verdugo
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Lee F. Starker
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Kenko Cupisti
- Department of General, Visceral and Pediatric Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Holger S. Willenberg
- Department of Endocrinology, Diabetes and Rheumatology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Wolfram T. Knoefel
- Department of General, Visceral and Pediatric Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Alfred Feller
- Department of Pathology, University Hospital Lübeck, Lübeck, Germany
| | - Julian Ip
- University of Sydney, Endocrine Surgical Unit and Cancer Genetics, Hormones and Cancer Group , Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Patsy Soon
- University of Sydney, Endocrine Surgical Unit and Cancer Genetics, Hormones and Cancer Group , Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
- Department of Surgery, Bankstown Hospital, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Martin Anlauf
- Institute of Pathology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Pier F. Alesina
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Universität Duisburg-Essen, Essen, Germany
| | - Kurt W. Schmid
- Institut für Pathologie und Neuropathologie Universitätsklinikum, Universität Duisburg-Essen, Essen, Germany
| | - Myriam Decaussin
- Department of Pathology, Centre Hospitalier Lyon Sud, Lyon, France
| | - Pierre Levillain
- Pathology Department, Centre Hospitalier Poitiers, Poitiers, France
| | - Bo Wängberg
- Sahlgrenska akademin, Göteborg University, Göteborg, Sweden
| | - Jean-Louis Peix
- Department of Endocrine Surgery, Centre Hospitalier Lyon Sud, Lyon, France
| | - Bruce Robinson
- University of Sydney, Endocrine Surgical Unit and Cancer Genetics, Hormones and Cancer Group , Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Jan Zedenius
- Department of Molecular Medicine and Surgery, Endocrine Surgery Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Bäckdahl
- Department of Molecular Medicine and Surgery, Endocrine Surgery Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Stefano Caramuta
- Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - K. Alexander Iwen
- Medizinischen Klinik Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Johan Botling
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Henning Dralle
- Department of General, Visceral and Vascular Surgery, University Hospital, University of Halle-Wittenberg, Halle/Saale, Germany
| | - Per Hellman
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Stan Sidhu
- University of Sydney, Endocrine Surgical Unit and Cancer Genetics, Hormones and Cancer Group , Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Gunnar Westin
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Hendrik Lehnert
- Medizinischen Klinik Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Martin K. Walz
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Universität Duisburg-Essen, Essen, Germany
| | - Göran Åkerström
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Tobias Carling
- Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Murim Choi
- Department of Genetics, School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Richard P. Lifton
- Department of Genetics, School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Peyman Björklund
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- * E-mail:
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Hannemann A, Bidlingmaier M, Friedrich N, Manolopoulou J, Spyroglou A, Völzke H, Beuschlein F, Seissler J, Rettig R, Felix SB, Biffar R, Döring A, Meisinger C, Peters A, Wichmann HE, Nauck M, Wallaschofski H, Reincke M. Screening for primary aldosteronism in hypertensive subjects: results from two German epidemiological studies. Eur J Endocrinol 2012; 167:7-15. [PMID: 22495491 DOI: 10.1530/eje-11-1013] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The prevalence of primary aldosteronism in unselected hypertensive patients is currently unknown. We investigated the frequency of positive screening results for primary aldosteronism based on the aldosterone-to-renin ratio (ARR) in hypertensive subjects aged 30-79 years from two German epidemiological studies. We further examined the frequency of positive screening results in subjects with resistant hypertension or stage III hypertension and assessed possible disparities between untreated and treated hypertensive subjects. METHODS Data were obtained from the first follow-ups of the population-based study of health in Pomerania (SHIP; n=1392) and the cooperative health research in the region of Augsburg (KORA; n=1052). Study-specific reference ranges for plasma aldosterone concentration (PAC), plasma renin concentration (PRC) and the ARR were applied. Confirmation tests for primary aldosteronism were not performed in these epidemiological studies.Three definitions for a positive screening for primary aldosteronism were applied: A) increased ARR; B) increased ARR and decreased PRC; and C) increased ARR and increased PAC and decreased PRC. RESULTS The frequency of positive screening results was 7.0, 3.8 and 0.2% according to definitions A-C respectively. In the subgroups of subjects with resistant hypertension (11.9, 5.5 and 0.9%) or stage III hypertension (18.3, 14.0 and 1.1%), these frequencies were markedly higher than those in the general hypertensive population. There was no difference in the frequency of positive screening results between the treated and untreated hypertensive subjects. CONCLUSIONS A maximum of 7.0% of the hypertensive population in Germany shows a positive screening result for primary aldosteronism. Thus, primary aldosteronism may be less frequent than previously expected based on data from referred hypertensive patients.
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Affiliation(s)
- A Hannemann
- Institute of Clinical Chemistry and Laboratory Medicine, Ernst-Moritz-Arndt-University Greifswald, Ferdinand-Sauerbruch-Strasse, D-17475 Greifswald, Germany.
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Prospective appraisal of the prevalence of primary aldosteronism in hypertensive patients presenting with atrial flutter or fibrillation (PAPPHY Study): rationale and study design. J Hum Hypertens 2012; 27:158-63. [DOI: 10.1038/jhh.2012.21] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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41
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Seccia TM, Miotto D, Battistel M, Motta R, Barisa M, Maniero C, Pessina AC, Rossi GP. A stress reaction affects assessment of selectivity of adrenal venous sampling and of lateralization of aldosterone excess in primary aldosteronism. Eur J Endocrinol 2012; 166:869-75. [PMID: 22330150 DOI: 10.1530/eje-11-0972] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND A stress reaction involving increased cortisol release, which has not been documented thus far, might affect the assessment of selectivity of catheterization during adrenal venous sampling (AVS). OBJECTIVE To investigate whether an ACTH-driven cortisol release occurs during AVS and whether it influences the assessment of selectivity by the step-up of cortisol (plasma cortisol concentrations, PCC) between the adrenal vein blood (PCC(SIDE)) and the inferior vena cava (PCC(IVC)), e.g. the selectivity index (SI). DESIGN AND METHODS We determined the SI in samples obtained simultaneously at starting AVS (t-15) and again after 15 min (t0) in 34 consecutive patients with proven aldosterone-producing adenoma. We then calculated the SI with PCC(SIDE) obtained at t-15 and at t0, and the PCC(IVC) values obtained at the different time point, thus simulating sequential AVS. RESULTS The PCC(SIDE) and the SI fell significantly from t-15 to t0 on both the sides. When PCC(SIDE) obtained at t-15 was combined with PCC(IVC) at t0, the SI values were higher than those obtained with simultaneously drawn samples. This led to label as selective more AVS studies than with bilaterally simultaneous data, especially when using higher cutoffs for the SI. CONCLUSIONS A transient increase in cortisol release from both adrenal glands occurs in the majority of the patients who undergo AVS. This stress reaction can influence the assessment of both the selectivity of the catheterization during the sequential AVS technique and the lateralization of aldosterone excess.
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Affiliation(s)
- Teresa M Seccia
- Department of Medicine, DIMED - Internal Medicine 4, University of Padua, via Giustiniani, 2, 35126 Padua, Italy
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Graham UM, Ellis PK, Hunter SJ, Leslie H, Mullan KR, Atkinson AB. 100 cases of primary aldosteronism: careful choice of patients for surgery using adrenal venous sampling and CT imaging results in excellent blood pressure and potassium outcomes. Clin Endocrinol (Oxf) 2012; 76:26-32. [PMID: 21767289 DOI: 10.1111/j.1365-2265.2011.04177.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Patients with primary aldosteronism (PA) who are suitable for surgery should undergo adrenal computerised tomography (CT) and adrenal venous sampling (AVS). A retrospective study was performed of 100 patients with PA. We determined the optimal AVS lateralisation ratio for unilateral disease and reviewed adrenalectomy outcomes evaluating which characteristics predicted hypertension cure. METHODS AVS was performed in 93 patients. Lateralisation criteria were assessed using ROC curve analysis. The outcome of adrenalectomy was reviewed in 39 patients and predictive factors for cure determined using univariate and multivariate analysis. RESULTS Of previously published criteria, ROC curve analysis found a cortisol corrected aldosterone affected to unaffected (Aldo/Cort A:U) cut-off of 2·0 was the best predictor of adenoma identifying 80·4% of patients. A novel ratio calculated by dividing the affected to unaffected ratio by the unaffected to peripheral ratio [(Aldo/Cort A:U)/(Aldo/Cort U:IVC)] was successful in identifying 87·0% of patients. Cure rate for blood pressure after adrenalectomy was 38·5% with improvement in 59·0%. On univariate analysis, predictors of post-operative hypertension were increased weight, raised creatinine, left ventricular hypertrophy (LVH) and male sex. On multivariate analysis, male sex and higher pre-operative systolic blood pressure were predictive. CONCLUSIONS Patients with PA should have CT scanning and AVS. Aldo/Cort A:U >2·0 is the most accurate of previously published ratios in predicting unilateral disease. When patients were carefully selected for surgery, 97% had cure or improvement in blood pressure control. Further confirmatory work is required on a novel ratio which was even more predictive in our series.
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Affiliation(s)
- U M Graham
- Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, UK.
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Segura J, Cerezo C, Garcia-Donaire JA, Schmieder RE, Praga M, de la Sierra A, Ruilope LM. Validation of a therapeutic scheme for the treatment of resistant hypertension. ACTA ACUST UNITED AC 2011; 5:498-504. [DOI: 10.1016/j.jash.2011.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 08/01/2011] [Accepted: 08/03/2011] [Indexed: 11/24/2022]
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Abstract
A few simple rules can allow physicians to successfully identify many patients with arterial hypertension caused by PA among the so-called essential hypertensive patients. The hyperaldosteronism and the hypokalemia can be cured with adrenalectomy in practically all of these patients. Moreover, in a substantial proportion of them, the blood pressure can be normalized or markedly lowered if a unilateral cause of PA is discovered. Hence, the screening for PA can be rewarding both for the patient and for the clinician, particularly in those cases where hypertension is severe and/or resistant to treatment, in which the removal of an APA can allow blood pressure to be brought under control despite withdrawal of, or a prominent reduction in, the number and doses of antihypertensive medications.
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Affiliation(s)
- Gian Paolo Rossi
- Molecular Hypertension Laboratory, Dipartimento di Medicina Clinica e Sperimentale G. Patrassi - Internal Medicine 4, University of Padua, University Hospital Padua, Via Giustiniani, 2, 35126 Padua, Italy.
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Abstract
Primary aldosteronism is much more common than previously thought. The high prevalence of primary aldosteronism, the damage this condition does to the heart, blood vessels and kidneys (which causes a high rate of cardiovascular events), along with the notion that a timely diagnosis followed by an appropriate therapy can correct the arterial hypertension and hypokalemia, justify efforts to search for primary aldosteronism in many patients with hypertension. Most centers can use a cost-effective strategy to screen for patients with primary aldosteronism. By contrast, the identification of primary aldosteronism subtypes, which involves adrenal-vein sampling, should only be undertaken at tertiary referral centers that have experience in performing and interpreting this test. The identification of a curable form of primary aldosteronism can be beneficial for the patient. In some subgroups of patients with hypertension who are at high risk of primary aldosteronism or can benefit most from an accurate diagnosis, an aggressive diagnostic approach is necessary.
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Affiliation(s)
- Gian Paolo Rossi
- Department of Clinical and Experimental Medicine (DMCS) 'Gino Patrassi', Internal Medicine 4, Policlinico Universitario, Via Giustiniani 2, 35126 Padova, Italy.
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Vonend O, Ockenfels N, Gao X, Allolio B, Lang K, Mai K, Quack I, Saleh A, Degenhart C, Seufert J, Seiler L, Beuschlein F, Quinkler M, Podrabsky P, Bidlingmaier M, Lorenz R, Reincke M, Rump LC. Adrenal Venous Sampling. Hypertension 2011; 57:990-5. [DOI: 10.1161/hypertensionaha.110.168484] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In patients with primary aldosteronism, adrenal venous sampling is helpful to distinguish between unilateral and bilateral adrenal diseases. However, the procedure is technically challenging, and selective bilateral catheterization often fails. The aim of this analysis was to evaluate success rate in a retrospective analysis and compare data with procedures done prospectively after introduction of measures designed to improve rates of successful cannulation. Patients were derived from a cross-sectional study involving 5 German centers (German Conn's registry). In the retrospective phase, 569 patients with primary aldosteronism were registered between 1990 and 2007, of whom 230 received adrenal venous sampling. In 200 patients there were sufficient data to evaluate the procedure. In 2008 and 2009, primary aldosteronism was diagnosed in 156 patients, and adrenal venous sampling was done in 106 and evaluated prospectively. Retrospective evaluation revealed that 31% were bilaterally selective when a selectivity index (cortisol adrenal vein/cortisol inferior vena cava) of ≥2.0 was applied. Centers completing <20 procedures had success rates between 8% and 10%. Overall success rate increased in the prospective phase from 31% to 61%. Retrospective data demonstrated the pitfalls of performing adrenal venous sampling. Even in specialized centers, success rates were poor. Marked improvements could be observed in the prospective phase. Selected centers that implemented specific measures to increase accuracy, such as rapid-cortisol-assay and introduction of standard operating procedures, reached success rates of >70%. These data demonstrate the importance of throughput, expertise, and various potentially beneficial measures to improve adrenal vein sampling.
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Affiliation(s)
- Oliver Vonend
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Nora Ockenfels
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Xing Gao
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Bruno Allolio
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Katharina Lang
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Knut Mai
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Ivo Quack
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Andreas Saleh
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Christoph Degenhart
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Jochen Seufert
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Lysann Seiler
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Felix Beuschlein
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Marcus Quinkler
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Petr Podrabsky
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Martin Bidlingmaier
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Reinhard Lorenz
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Martin Reincke
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
| | - Lars Christian Rump
- From the Department of Nephrology (O.V., N.O., X.G., I.Q., L.C.R.), Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany; Institute of Radiology (A.S.), University Hospital Düsseldorf, Düsseldorf, Germany; Clinical Endocrinology (M.Q.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Department of Radiology (P.P.), Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany; Medizinische Klinik Innenstadt (M.R., R.L., C.D., F.B., M.B.),
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Diagnostic value of I-131 NP-59 SPECT/CT scintigraphy in patients with subclinical or atypical features of primary aldosteronism. J Biomed Biotechnol 2011; 2011:209787. [PMID: 21541242 PMCID: PMC3085291 DOI: 10.1155/2011/209787] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 02/15/2011] [Indexed: 11/17/2022] Open
Abstract
Accumulating evidence has shown the adverse effect of long-term hyperaldosteronism on cardiovascular morbidity that is independent of blood pressure. However, the diagnosis of primary aldosteronism (PA) remains a challenge for patients who present with subtle or atypical features or have chronic kidney disease (CKD). SPECT/CT has proven valuable in the diagnosis of a number of conditions. The aim of this study was to determine the usefulness of I-131 NP-59 SPECT/CT in patients with atypical presentations of PA and in those with CKD. The records of 15 patients with PA were retrospectively analyzed. NP-59 SPECT/CT was able to identify adrenal lesion(s) in CKD patients with suspected PA. Patients using NP-59 SPECT/CT imaging, compared with those not performing this procedure, significantly featured nearly normal serum potassium levels, normal aldosterone-renin ratio, and smaller adrenal size on CT and pathological examination and tended to feature stage 1 hypertension and non-suppressed plasma renin activity. These findings show that noninvasive NP-59 SPECT/CT is a useful tool for diagnosis in patients with subclinical or atypical features of PA and those with CKD.
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Abstract
Primary aldosteronism involves more than 11% of hypertensive patients who are referred to specialized centers for the diagnosis and treatment of hypertension. If not diagnosed early it causes an excess damage to the heart, vessels and kidney, which translates into an cardiovascular events. Since these ominous consequences can be corrected with a timely diagnosis and an appropriate therapy, physicians should exercise a high degree of alert concerning the possibility that primary aldosteronism is present in hypertensive patients. The purpose of this review is to provide up-dated information on the strategy for case detection, the subtype differentiation and the management of primary aldosteronism.
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Westerdahl C, Bergenfelz A, Isaksson A, Nerbrand C, Valdemarsson S. Primary aldosteronism among newly diagnosed and untreated hypertensive patients in a Swedish primary care area. Scand J Prim Health Care 2011; 29:57-62. [PMID: 21323498 PMCID: PMC3347934 DOI: 10.3109/02813432.2011.554015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate the prevalence of primary aldosteronism (PA) in newly diagnosed and untreated hypertensive patients in primary care using the aldosterone/renin ratio (ARR), and to assess clinical and biochemical characteristics in patients with high and normal ARR. DESIGN Patient survey study. SETTING AND SUBJECTS A total of 200 consecutive patients with newly diagnosed and untreated hypertension from six primary health care centres in Sweden were included. MAIN OUTCOME MEASURES ARR was calculated from serum aldosterone and plasma renin concentrations. The cut-off level for ARR was 65. Patients with an increased ARR were considered for confirmatory testing with the fludrocortisone suppression test (FST), followed by adrenal computed tomographic radiology (CT) and adrenal venous sampling (AVS). RESULTS Of 200 patients, 36 patients had an ARR > 65. Of these 36 patients, 11 patients had an incomplete aldosterone inhibition during FST. Three patients were diagnosed with an aldosterone producing adenoma (APA) and eight with bilateral adrenal hyperplasia (BHA). Except for moderately lower level of P-K in patients with an ARR > 65 and in patients with PA, there were no biochemical or clinical differences found among hypertensive patients with PA compared with patients without PA. CONCLUSION Eleven of 200 evaluated patients (5.5%) were considered to have PA. The diagnosis of PA should therefore be considered in newly diagnosed hypertensive subjects and screening for the diagnosis is warranted.
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Cardiovascular and renal damage in primary aldosteronism: outcomes after treatment. Am J Hypertens 2010; 23:1253-60. [PMID: 20706195 DOI: 10.1038/ajh.2010.169] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Primary aldosteronism (PA) is one of the common forms of curable hypertension. Recent views have suggested that PA is far from being relatively benign, as it was previously thought, but it is associated with a variety of cardiovascular and renal sequelae that reflect the capability of inappropriately elevated aldosterone to induce tissue damage over that induced by hypertension itself. The evidence supporting these views has been obtained from experiments conducted in hypertensive animal models and studies involving patients with PA. Preclinical studies have also indicated that aldosterone causes cardiovascular and renal tissue damage only in the context of inappropriate salt status. It has been suggested that untoward effects of high-salt intake are dependent on activation of mineralocorticoid receptors (MRs) that might result from increased oxidative stress and changes in the intracellular redox potential. Unilateral adrenalectomy or treatment with MR antagonists are the current options for treating an aldosterone-producing adenoma (APA) or idiopathic adrenal hyperplasia (IHA). Treatments are effective in correcting hypertension and hypokalemia, and currently available information on their capability to prevent cardiovascular events and deterioration of renal function indicates that surgery and medical treatment are equally beneficial in the long term.
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