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Zhang X, Shu X, Wu F, Yang J, Cheng Q, Du Z, Song Y, Yang Y, Hu J, Wang Y, Li Q, Yang S. Treatment decision based on unilateral index from nonadrenocorticotropic hormone-stimulated and adrenocorticotropic hormone-stimulated adrenal vein sampling in primary aldosteronism. J Hypertens 2024; 42:450-459. [PMID: 37937517 DOI: 10.1097/hjh.0000000000003612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
OBJECTIVE Adrenal venous sampling (AVS) is recommended for identifying the subtype of primary aldosteronism before making a surgical treatment decision, but failed cannulation of one adrenal vein is common. To evaluate whether using results of one adrenal vein during AVS could accurately predict unilateral primary aldosteronism. METHODS A retrospective study was conducted in primary aldosteronism patients receiving bilaterally or unilaterally successful AVS. The aldosterone-cortisol ratio from the adrenal vein divided by the aldosterone-cortisol ratio from the inferior vena cava (IVC) was calculated as the AV/IVC index. RESULTS The study examined 455 patients with primary aldosteronism, including 347 patients with unilateral primary aldosteronism. Among them, 250 and 125 patients received non- adrenocorticotropic hormone (ACTH) and ACTH-stimulated AVS, respectively, and 80 patients received both forms of AVS. Under non-ACTH-stimulated AVS, AUC of the AV/IVC index to diagnose ipsilateral and contralateral primary aldosteronism were 0.778 and 0.924, respectively. The specificity was 100% for both, with sensitivities of 5 and 26%, respectively, when using cutoffs of 17.05 to diagnose ipsilateral primary aldosteronism and 0.15 to diagnose contralateral primary aldosteronism. When using cutoffs of 3.60 and 0.70, the specificity decreased, but if combined with CT results (ipsilateral or contralateral adrenal nodules larger than 10 mm), the specificity could be maintained at 99%, with sensitivities of 33 and 45%, respectively. Under ACTH-stimulated AVS, the AV/IVC index showed similar accuracy to diagnose ipsilateral and contralateral primary aldosteronism. CONCLUSION The unilateral AV/IVC index can be used to diagnose unilateral primary aldosteronism during AVS. Combining CT results can increase the accuracy further.
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Affiliation(s)
- Xizi Zhang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Xiaoyu Shu
- Department of Endocrinology, Beijing Chao-yang Hospital, Capital Medical University, Beijing
| | - Feifei Wu
- Department of Endocrinology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, China
| | - Jun Yang
- Department of Medicine, Monash University
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Qingfeng Cheng
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Zhipeng Du
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Ying Song
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Yi Yang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Jinbo Hu
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Yue Wang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Qifu Li
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Shumin Yang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
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O'Malley KJ, Alnablsi MW, Xi Y, Pathak M, Khan F, Pillai AK, Kathuria MK, Vongpatanasin W. Diagnostic performance of the adrenal vein to inferior vena cava aldosterone ratio in classifying the subtype of primary aldosteronism. Hypertens Res 2023; 46:2535-2542. [PMID: 37673958 DOI: 10.1038/s41440-023-01421-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/30/2023] [Accepted: 08/20/2023] [Indexed: 09/08/2023]
Abstract
Adrenal vein sampling (AVS) is the standard procedure for distinguishing unilateral primary aldosteronism (PA) from bilateral PA. In cases where only one adrenal vein is successfully cannulated, it has been suggested that subtype classification can be determined based on the ratio of the concentration of aldosterone between the adrenal vein and the inferior vena cava (AV/IVC index). However, diagnostic performance of the ipsilateral versus contralateral AV/IVC index in predicting lateralization has not been directly compared. In a retrospective cohort of 133 patients with confirmed PA who underwent successful AVS, the performance of the AV/IVC index to predict laterality was evaluated and the area under the receiver operating characteristic (AUROC) curves was calculated. In detecting left unilateral PA (n = 47), the AUROC of the right AV/IVC index (RAV/IVC) was significantly higher than the AUROC of the left AV/IVC (LAV/IVC) index (0.967 vs. 0.871, p = 0.008). In detecting right unilateral PA (n = 30), the AUROC of the LAV/IVC index tended to be higher than that of the RAV/IVC index, but the difference did not reach statistical significance (0.966 vs. 0.906, p = 0.08). In detecting left unilateral PA, the sensitivities of the RAV/IVC and LAV/IVC indices were 83% and 46%, respectively, while the specificities of both were above 90%. In detecting right unilateral PA, the sensitivities of the LAV/IVC and RAV/IVC indices were 80% and 43%, respectively, while the specificities of both were above 90%. The AV/IVC index has superior diagnostic performance in detecting contralateral unilateral PA compared to ipsilateral unilateral PA.
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Affiliation(s)
- Kyle J O'Malley
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mhd W Alnablsi
- Department of Radiology (Division of Vascular Interventional Radiology), University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yin Xi
- Department of Radiology (Division of Vascular Interventional Radiology), University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mona Pathak
- Department of Pharmacotherapy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Fatima Khan
- Department of Radiology (Division of Vascular Interventional Radiology), University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anil K Pillai
- Department of Radiology (Division of Vascular Interventional Radiology), University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Manoj K Kathuria
- Department of Radiology (Division of Vascular Interventional Radiology), University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Wanpen Vongpatanasin
- Department of Internal Medicine (Division of Cardiology, Hypertension Section), University of Texas Southwestern, Dallas, TX, USA.
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3
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Younes N, Larose S, Bourdeau I, Therasse E, Lacroix A. Role of Adrenal Vein Sampling in Guiding Surgical Decision in Primary Aldosteronism. Exp Clin Endocrinol Diabetes 2023; 131:418-434. [PMID: 37567230 DOI: 10.1055/a-2106-4663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
Adrenal vein sampling (AVS) is recommended for subtyping primary aldosteronism (PA) to identify lateralized or bilateral sources of aldosterone excess, allowing for better decision-making in regard to medical or surgical management on a case-by-case basis. To date, no consensus exists on protocols to be used during AVS, especially concerning sampling techniques, the timing of sampling, and whether or not to use adrenocorticotropic hormone (ACTH) stimulation. Interpretation criteria for selectivity, lateralization, and contralateral suppression vary from one expert center to another, with some favoring strict cut-offs to others being more permissive. Clinical and biochemical post-operative outcomes can also be influenced by AVS criteria utilized to indicate surgical therapy.In this review, we reanalyze studies on AVS highlighting the recent pathological findings of frequent micronodular hyperplasia adjacent to a dominant aldosteronoma (APA) overlapping with bilateral idiopathic hyperaldosteronism (IHA) etiologies, as opposed to the less frequent unilateral single aldosteronoma. The variable expression of melanocortin type 2 receptors in the nodules and hyperplasia may explain the frequent discordance in lateralization ratios between unstimulated and ACTH- stimulated samples. We conclude that aldosterone values collected during simultaneous bilateral sampling, both at baseline and post-ACTH stimulation, are required to adequately evaluate selectivity, lateralization, and contralateral suppression during AVS, to better identify all patients with PA that can benefit from a surgical indication. Recommended cut-offs for each ratio are also presented.
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Affiliation(s)
- Nada Younes
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Stéphanie Larose
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Eric Therasse
- Department of Radiology, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Québec, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
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4
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Ohara N, Kobayashi M, Yoneoka Y, Hasegawa G, Aoki Y, Nakamura Y, Kazama Y, Nishiyama T. Primary Aldosteronism Presenting with Hypertension Five Days after Delivery: A Case Report and Literature Review. Intern Med 2022; 61:507-512. [PMID: 34393169 PMCID: PMC8907769 DOI: 10.2169/internalmedicine.7778-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
A 35-year-old Japanese woman with no history of hypertension developed hypertension 5 days after normal delivery. Endocrinological and radiological examinations indicated primary aldosteronism (PA) and a 1.4-cm left adrenal tumor. The patient underwent laparoscopic adrenalectomy, and a diagnosis of aldosterone-producing adenoma was confirmed immunohistochemically. Her plasma aldosterone concentration and blood pressure normalized. Cases of PA presenting with hypertension in the postpartum period have been reported. This case suggests that PA should be considered in women with postpartum hypertension, especially in those with blood pressure that suddenly increases shortly after delivery, even if they were normotensive before and throughout pregnancy.
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Affiliation(s)
- Nobumasa Ohara
- Department of Endocrinology and Metabolism, Uonuma Kikan Hospital, Japan
| | - Michi Kobayashi
- Department of Endocrinology and Metabolism, Uonuma Kikan Hospital, Japan
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital of the National Center for Global Health and Medicine, Japan
| | | | - Go Hasegawa
- Department of Pathology, Uonuma Kikan Hospital, Japan
| | - Yayoi Aoki
- Department of Pathology, Tohoku University Hospital, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Japan
| | - Yoshiki Kazama
- Department of Obstetrics and Gynecology, Uonuma Kikan Hospital, Japan
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5
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Parasiliti-Caprino M, Bioletto F, Ceccato F, Lopez C, Bollati M, Di Carlo MC, Voltan G, Rossato D, Giraudo G, Scaroni C, Ghigo E, Maccario M. The Accuracy of Simple and Adjusted Aldosterone Indices for Assessing Selectivity and Lateralization of Adrenal Vein Sampling in the Diagnosis of Primary Aldosteronism Subtypes. Front Endocrinol (Lausanne) 2022; 13:801529. [PMID: 35250861 PMCID: PMC8888437 DOI: 10.3389/fendo.2022.801529] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/19/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the reliability of simple and corrected aldosterone indices for assessing the selectivity and lateralization of adrenal vein sampling (AVS) in patients with primary aldosteronism. METHODS Data of all consecutive patients with primary aldosteronism who underwent AVS for subtype diagnosis, followed at two Italian referral centers, were analyzed retrospectively. RESULTS AVS achieved bilateral selectivity in 112/144 patients. Unilateral disease was diagnosed in 60 cases (53.6%) and idiopathic hyperaldosteronism in 52 individuals (46.4%). The aldosterone index (aldosterone ratio between an adrenal vein and the inferior vena cava) showed a high accuracy in predicting selectivity, compared to a cortisol selectivity index of 1.1, and a moderate accuracy, compared to cortisol cut-offs of 2 and 3. The simple aldosterone index showed a moderate accuracy in predicting ipsi/contralateral aldosterone hypersecretion, while lesion side- and hypokalemia-corrected aldosterone index revealed a significant improvement in predicting ipsi/contralateral disease. Moreover, the comparative aldosterone index (aldosterone ratio in the dominant vs the non-dominant adrenal vein) revealed a high accuracy in predicting unilateral primary aldosteronism. For an immediate clinical application of our results, the adjusted cut-offs were calculated, according to the Youden's criterion and to a pre-established specificity of 90%, for all possible combinations of lesion side at imaging and presence/absence of hypokalemia. CONCLUSIONS This study demonstrated the diagnostic accuracy of simple and clinical-/imaging-corrected aldosterone indices for adrenal vein sampling in subtype diagnosis of primary aldosteronism and suggests the potential application of these tools to select patients for adrenalectomy when standard indices cannot be performed.
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Affiliation(s)
- Mirko Parasiliti-Caprino
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
- *Correspondence: Mirko Parasiliti-Caprino, ; orcid.org/0000-0002-6930-7073
| | - Fabio Bioletto
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, Padua, Italy
| | - Chiara Lopez
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Martina Bollati
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Maria Chiara Di Carlo
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Giacomo Voltan
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, Padua, Italy
| | - Denis Rossato
- Radiology Unit, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Giuseppe Giraudo
- Surgery, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, Padua, Italy
| | - Ezio Ghigo
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Mauro Maccario
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
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6
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So C, Leung A, Chin A, Kline G. Adrenal venous sampling in primary aldosteronism: lessons from over 600 single-operator procedures. Clin Radiol 2021; 77:e170-e179. [DOI: 10.1016/j.crad.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 11/05/2021] [Indexed: 11/25/2022]
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7
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Naruse M, Tanabe A, Yamamoto K, Rakugi H, Kometani M, Yoneda T, Kobayashi H, Abe M, Ohno Y, Inagaki N, Izawa S, Sone M. Adrenal Venous Sampling for Subtype Diagnosis of Primary Hyperaldosteronism. Endocrinol Metab (Seoul) 2021; 36:965-973. [PMID: 34674504 PMCID: PMC8566130 DOI: 10.3803/enm.2021.1192] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/11/2021] [Indexed: 12/01/2022] Open
Abstract
Adrenal venous sampling (AVS) is the key procedure for lateralization of primary hyperaldosteronism (PA) before surgery. Identification of the adrenal veins using computed tomography (CT) and intraoperative cortisol assay facilitates the success of catheterization. Although administration of adrenocorticotropic hormone (ACTH) has benefits such as improving the success rate, some unilateral cases could be falsely diagnosed as bilateral. Selectivity index of 5 with ACTH stimulation to assess the selectivity of catheterization and lateralization index (LI) >4 with ACTH stimulation for unilateral diagnosis is used in many centers. Co-secretion of cortisol from the tumor potentially affects the lateralization by the LI. Patients aged <35 years with hypokalemia, marked aldosterone excess, and unilateral adrenal nodule on CT have a higher probability of unilateral disease. Patients with normokalemia, mild aldosterone excess, and no adrenal tumor on CT have a higher probability of bilateral disease. Although no methods have 100% specificity for subtype diagnosis that would allow bypassing AVS, prediction of the subtype should be considered when recommending AVS to patients. Methodological standardization and strict indication improve diagnostic quality of AVS. Development of non-invasive imaging and biochemical markers will drive a paradigm shift in the clinical practice of PA.
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Affiliation(s)
- Mitsuhide Naruse
- Endocrine Center and Clinical Research Center, Ijinkai Takeda General Hospital, Kyoto,
Japan
- Clinical Research Institute of Endocrinology and Metabolism, NHO Kyoto Medical Center, Tokyo,
Japan
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Tokyo,
Japan
| | - Koichi Yamamoto
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka,
Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka,
Japan
| | - Mitsuhiro Kometani
- Department of Health Promotion and Medicine of the Future, Graduate School of Medical Sciences, Kanazawa University, Kanazawa,
Japan
| | - Takashi Yoneda
- Department of Health Promotion and Medicine of the Future, Graduate School of Medical Sciences, Kanazawa University, Kanazawa,
Japan
| | - Hiroki Kobayashi
- Division of Nephrology, Hypertension and Endocrinology, Nihon University School of Medicine, Tokyo,
Japan
| | - Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Nihon University School of Medicine, Tokyo,
Japan
| | - Youichi Ohno
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto,
Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto,
Japan
| | - Shoichiro Izawa
- Division of Endocrinology and Metabolism, Tottori University Faculty of Medicine, Yonago,
Japan
| | - Masakatsu Sone
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki,
Japan
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8
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Characteristics of a Novel ATP2B3 K416_F418delinsN Mutation in a Classical Aldosterone-Producing Adenoma. Cancers (Basel) 2021; 13:cancers13184729. [PMID: 34572956 PMCID: PMC8472399 DOI: 10.3390/cancers13184729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary The ATP2B3 channel mutation is a rare cause of primary aldosteronism (PA). ATP2B3 gene mutation leads to the dysfunction of calcium channel that pumps calcium ion out of the cell and accumulates intracellular calcium signal to stimulate aldosterone synthesis. In the present study, we found a novel somatic ATP2B3 K416_F418delinsN mutation in a PA patient, and proved its functionality by demonstrating aldosterone hyper-function in the mutant-transfected adrenal cell-line. The ATP2B3 K416_F418delinsN mutation resulted from the deletion from nucleotides 1248 to 1253. The translated amino acid sequence from 416 to 418 as lysine-phenylalanine-phenylalanine was deleted and an asparagine was inserted due to the merging of residual nucleotide sequences. Abstract In patients with primary aldosteronism (PA), the prevalence of ATP2B3 mutation is rare. The aim of this study is to report a novel ATP2B3 mutation in a PA patient. Based on our tissue bank of aldosterone-producing adenomas (APA), we identified a novel somatic ATP2B3 K416_F418delinsN mutation. The affected individual was a 53 year-old man with a 4 year history of hypertension. Computed tomography (CT) showed bilateral adrenal masses of 1.6 (left) and 0.5 cm (right) in size. An adrenal venous sampling (AVS) showed a lateralization index (LI) of 2.2 and a contralateral suppression index (CLS) of 0.12; indicating left functional predominance. After a left unilateral adrenalectomy, he achieved partial biochemical and hypertension–remission. This classical adenoma harbored a novel ATP2B3 K416_F418delinsN somatic mutation, which is a deletion from nucleotides 1248 to 1253. The translated amino acid sequence from 416 to 418, reading as lysine-phenylalanine-phenylalanine, was deleted; however, an asparagine was inserted due to merging of residual nucleotide sequences. The CYP11B2 immunohistochemistry staining demonstrated strong immunoreactivity in this classical adenoma. The ATP2B3 K416_F418delinsN mutation is a functional mutation in APA, since HAC15 cells, a human adrenal cell line, transfected with the mutant gene showed increased CYP11B2 expression and aldosterone production.
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9
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Tan MO, Puar THK, Swaminathan SK, Tay YKD, Aw TC, Lim DY, Shi H, Dacay LMQ, Zhang M, Khoo JJC, Ng KS. Improved adrenal vein sampling from a dedicated programme: experience of a low-volume single centre in Singapore. Singapore Med J 2020; 63:111-116. [PMID: 33264832 DOI: 10.11622/smedj.2020171] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Min-On Tan
- Department of Radiology, Changi General Hospital, Singapore
| | | | - Saravana Kumar Swaminathan
- Department of Radiology, Changi General Hospital, Singapore.,Department of Neuroradiology, National Neuroscience Institute, Singapore
| | | | - Tar Choon Aw
- Laboratory Medicine, Changi General Hospital, Singapore
| | | | - Haiyuan Shi
- Department of Radiology, Changi General Hospital, Singapore
| | | | - Meifen Zhang
- Department of Endocrinology, Changi General Hospital, Singapore.,William Harvey Research Institute, Queen Mary University of London, London, England, United Kingdom
| | | | - Keng Sin Ng
- Department of Radiology, Changi General Hospital, Singapore.,Mount Alvernia Hospital, Singapore
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Bouchard-Bellavance R, Perrault F, Soulez G, Chagnon M, Kline GA, Bourdeau I, Lacroix A, So B, Therasse E. Adrenal vein sampling: External validation of multinomial regression modelling and left adrenal vein-to-peripheral vein ratio to predict lateralization index without right adrenal vein sampling. Clin Endocrinol (Oxf) 2020; 93:661-671. [PMID: 32687640 DOI: 10.1111/cen.14295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/23/2020] [Accepted: 07/12/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adrenal vein sampling (AVS) failure is mainly due to right adrenal vein unavailability. Multinomial regression modelling (MRM) and left adrenal vein-to-peripheral vein ratio (LAV/PV) were proposed to predict the lateralization index without the right AVS. OBJECTIVE To assess external validity of MRM and LAV/PV to predict lateralization index when right adrenal vein sampling is missing. DESIGN Diagnostic retrospective study. PATIENTS Development and validation cohorts included AVS of 174 and 122 patients, respectively, from 2 different centres. MEASUREMENTS Development and validation cohort data were used, respectively, for calibration and for validation of MRM and LAV/PV to predict the lateralization index without the right adrenal vein sampling. Sensitivity and specificity of MRM and LAV/PV were compared between both centres at different pre-established specificity thresholds based on receiver operating characteristic curves generated from the development cohort data. RESULTS At a specificity threshold of 95% set in the development cohort, specificity values exceeded 90% (range, 90.6%-98.8%) for all verified MRM and LAV/PV models in the validation cohort. Corresponding sensitivities for MRM and LAV/PV, respectively, range from 54.1% to 83.7% and 32.8% to 88.4% for the development cohort compared to 33.3%-87.5% and 2.8%-79.2% for the validation cohort. Overall, diagnostic accuracy of both methods was higher to detect right (82.8%-93.5%) than left (70.2%-80.6%) lateralization index status in both centres. CONCLUSIONS Minimal changes in specificity from development to validation cohorts validate the use of MRM and LAV/PV to predict the lateralization index when the right AVS is missing. Both methods had better accuracy for right than left lateralization detection.
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Affiliation(s)
| | - Florence Perrault
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Gilles Soulez
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
- Centre de Recherche du CHUM (CRCHUM), Montreal, QC, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, Pavillon André-Aisenstadt, University of Montreal, Montreal, QC, Canada
| | - Gregory A Kline
- Division of Endocrinology, Department of Medicine, Foothills Medical Center (FMC), Calgary, AB, Canada
| | - Isabelle Bourdeau
- Centre de Recherche du CHUM (CRCHUM), Montreal, QC, Canada
- Division of Endocrinology, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - André Lacroix
- Centre de Recherche du CHUM (CRCHUM), Montreal, QC, Canada
- Division of Endocrinology, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Benny So
- Department of Radiology, Foothills Medical Center (FMC), Calgary, AB, Canada
| | - Eric Therasse
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
- Centre de Recherche du CHUM (CRCHUM), Montreal, QC, Canada
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11
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Parasiliti-Caprino M, Bioletto F, Ceccato F, Lopez C, Bollati M, Voltan G, Rossato D, Giraudo G, Scaroni C, Ghigo E, Maccario M. The diagnostic accuracy of adjusted unconventional indices for adrenal vein sampling in the diagnosis of primary aldosteronism subtypes. J Hypertens 2020; 39:1025-1033. [PMID: 33186324 DOI: 10.1097/hjh.0000000000002700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Simple unconventional indices did not demonstrate a satisfactory accuracy for diagnosing unilateral primary aldosteronism when adrenal vein sampling is not bilaterally selective. This study aimed to evaluate the reliability of clinical/imaging-corrected unconventional indices for adrenal vein sampling in predicting unilateral primary aldosteronism. METHODS Data of all consecutive patients with primary aldosteronism subtyped with adrenal vein sampling, referred to two Italian centers, were analyzed retrospectively. All patients with proved unilateral aldosterone hypersecretion underwent adrenalectomy. RESULTS Unilateral disease was diagnosed in 58 cases (54.2%) and idiopathic hyperaldosteronism in 49 individuals (45.8%). The monoadrenal index (aldosterone-to-cortisol ratio in the adrenal vein) showed high accuracy in predicting ipsilateral disease and moderate accuracy in predicting contralateral aldosterone hypersecretion. The monolateral index (aldosterone-to-cortisol ratio in the adrenal vein vs. peripheral blood) revealed moderate accuracy in predicting ipsilateral disease and high accuracy in predicting contralateral aldosterone hypersecretion. Lesion side- and hypokalemia-corrected ROC curves for these unconventional indices revealed a significant improvement in the reliability of predicting ipsilateral/contralateral disease, reaching high accuracy in all models. For an immediate clinical application of our results, the adjusted cut-offs were calculated, according to the Youden's criterion and to a pre-established specificity of 95%, for all possible combinations of lesion side at imaging and presence/absence of hypokalemia. CONCLUSION This study demonstrated the high diagnostic accuracy of clinical-/imaging-corrected unconventional indices for adrenal vein sampling in the diagnosis of primary aldosteronism subtypes and suggests the use of these adjusted indices to select patients for adrenalectomy when adrenal vein sampling is not bilaterally selective.
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Affiliation(s)
- Mirko Parasiliti-Caprino
- Endocrinology, Diabetes and Metabolism, City of Health and Science University Hospital, Department of Medical Sciences, University of Turin, Turin
| | - Fabio Bioletto
- Endocrinology, Diabetes and Metabolism, City of Health and Science University Hospital, Department of Medical Sciences, University of Turin, Turin
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, Padua
| | - Chiara Lopez
- Endocrinology, Diabetes and Metabolism, City of Health and Science University Hospital, Department of Medical Sciences, University of Turin, Turin
| | - Martina Bollati
- Endocrinology, Diabetes and Metabolism, City of Health and Science University Hospital, Department of Medical Sciences, University of Turin, Turin
| | - Giacomo Voltan
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, Padua
| | | | - Giuseppe Giraudo
- Surgery, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, Padua
| | - Ezio Ghigo
- Endocrinology, Diabetes and Metabolism, City of Health and Science University Hospital, Department of Medical Sciences, University of Turin, Turin
| | - Mauro Maccario
- Endocrinology, Diabetes and Metabolism, City of Health and Science University Hospital, Department of Medical Sciences, University of Turin, Turin
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Suntornlohanakul O, Soonthornpun S, Srisintorn W, Murray RD, Kietsiriroje N. Performance of the unilateral AV/IVC index in primary hyperaldosteronism subtype prediction: A validation study in a single tertiary centre. Clin Endocrinol (Oxf) 2020; 93:111-118. [PMID: 32347973 DOI: 10.1111/cen.14210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/12/2020] [Accepted: 04/20/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Failure of cannulation of the right adrenal vein is frequent during AVS for investigation of primary aldosteronism (PA). The aldosterone:cortisol ratio of either adrenal vein compared with the inferior vena cava (AV/IVC index) has been proposed to differentiate between unilateral and bilateral disease, and aid in lateralization of unilateral disease. METHODS Sixty-two patients with unilateral or bilateral PA identified by either successful bilateral (45 patients) or unilateral (17 patients) adrenal vein cannulation, and with biochemical remission following surgery were enrolled into the analysis. The diagnostic performances of the previously identified AV/IVC index cut-offs of ≥5.5 to predict ipsilateral disease and ≤0.5 to predict contralateral disease were validated using data from the entire cohort. RESULTS Fifty-three patients had unilateral PA and 9 patients bilateral PA. The area under ROC curve (AUROC) of the AV/IVC cut-off ≤0.5 for identifying unilateral aldosterone secretion from the contralateral adrenal was 0.95 (95% CI; 0.88-0.99), whereas the AUROC of the AV/IVC cut-off ≥5.5 for identifying unilateral aldosterone secretion from ipsilateral adrenal was 0.96 (95% CI; 0.92-0.99). The AV/IVC index cut-off value of 0.5 had 93% sensitivity and 91% specificity, and the AV/IVC index cut-off value of 5.5 had 21% sensitivity and 100% specificity. The optimal AV/IVC cut-offs to achieve 100% specificity for our cohort were >2.4 and <0.1 to predict ipsilateral and contralateral disease. CONCLUSION Our data confirm that the AV/IVC index is a potential tool for subtype classification and lateralization in patients with PA in the setting of failed bilateral, but successful unilateral, adrenal vein cannulation during AVS.
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Affiliation(s)
- Onnicha Suntornlohanakul
- Endocrinology and Metabolism Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Supamai Soonthornpun
- Endocrinology and Metabolism Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Wisarut Srisintorn
- Department of Family and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Robert D Murray
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Noppadol Kietsiriroje
- Endocrinology and Metabolism Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
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Lee J, Kang B, Ha J, Kim MH, Choi B, Hong TH, Kang MI, Lim DJ. Clinical outcomes of primary aldosteronism based on lateralization index and contralateral suppression index after adrenal venous sampling in real-world practice: a retrospective cohort study. BMC Endocr Disord 2020; 20:114. [PMID: 32727424 PMCID: PMC7388450 DOI: 10.1186/s12902-020-00591-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 07/13/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND We investigated whether the contralateral suppression index in aldosterone-producing adrenal adenoma could be used as a diagnostic criterion when catheterization in either right or left adrenal vein fails or when a discrepancy in the adrenal vein sampling (AVS) results and imaging findings occurs in the real-world practice. METHODS We retrospectively reviewed 48 patients who had resistant hypertension (HTN) or hypokalemia with a biochemical diagnosis of primary aldosteronism and who underwent AVS from January 2009 to June 2017 at a tertiary referral hospital. Selection index (SI), lateralization index (LI), and contralateral suppression index (CSI) were calculated based on AVS results and the final clinical outcomes were evaluated. RESULTS The catheterization of both adrenal veins was successful in 43 of 48 (89.6%) patients. The lateralization based only on LI was performed in 23 out of 43 (53.5%) patients. When CSI and LI were combined in decision making, the concordance between adrenal computed tomography scan and AVS for unilateral lesion improved from 59.3% (19/32) to 75.0% (24/32). CSI also correlated well with unilateral adrenal disease in the catheterization failure group. The final outcomes of HTN were better in the contralateral suppression group. CONCLUSION CSI combined with LI could be a supplementary diagnostic tool in patients with non-lateralization or catheterization failure and predict the clinical outcomes of HTN in patients with primary aldosteronism.
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Affiliation(s)
- Jeongmin Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Borami Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeonghoon Ha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min-Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byungil Choi
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae-Ho Hong
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Moo Il Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Jun Lim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Sellgren F, Koman A, Nordenström E, Hellman P, Hennings J, Muth A. Outcomes After Surgery for Unilateral Dominant Primary Aldosteronism in Sweden. World J Surg 2019; 44:561-569. [DOI: 10.1007/s00268-019-05265-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Abstract
Background
Primary aldosteronism (PA) is the most common cause of secondary hypertension. Surgery is the mainstay of treatment for unilateral dominant PA, but reported cure rates varies. The aim of the present study was to investigate contemporary follow-up practices and cure rates after surgery for PA in Sweden.
Methods
Patients operated for PA and registered in the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery (SQRTPA) 2009–2015 were identified. Patient data were extracted, and follow-up data (1–24 months) was recorded. Doses of antihypertensive medication and potassium supplementation were calculated using defined daily doses (DDD), and the Primary Aldosteronism Surgical Outcome (PASO) criteria were used to evaluate outcomes.
Results
Of 190 registered patients, 171 (47% female, mean age 53 years, median follow-up 3.7 months) were available for analysis. In 75 patients (44%), missing data precluded evaluation of biochemical cure according to the PASO criteria. Minimal invasive approach was used in 168/171 patients (98%). Complication rate (Clavien-Dindo >3a) was 3%. No mortality was registered. Pre/postoperatively 98/66% used antihypertensives (mean DDD 3.7/1.5). 89/2% had potassium supplementation (mean DDD 2.0/0) before/after surgery. Complete/partial biochemical and clinical success according to the PASO criteria were achieved in 92/7% and 34/60%, respectively.
Conclusion
In this study, reflecting contemporary clinical practice in Sweden complete/partial biochemical and clinical success after surgery for PA was 92/7% and 34/60%. Evaluation of biochemical cure was hampered by lack of uniform reporting of relevant outcome measures. We suggest mandatory reporting of surgical outcomes using the PASO criteria for all units performing surgery for PA.
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Lin L, Zhou L, Guo Y, Liu Z, Chen T, Liu Z, Wang K, Li J, Zhu Y, Ren Y. Can incomplete adrenal venous sampling data be used in predicting the subtype of primary aldosteronism? ANNALES D'ENDOCRINOLOGIE 2019; 80:301-307. [PMID: 31722788 DOI: 10.1016/j.ando.2019.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/13/2019] [Accepted: 10/03/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Adrenal venous sampling (AVS) is the gold standard for preoperative differentiation between unilateral and bilateral primary aldosteronism (PA). However, results are sometimes vitiated by failing to access the right adrenal vein. MATERIALS AND METHODS The present study assumed that clinical decisions can be made with incomplete AVS data, by comparing aldosterone/cortisol (A/C) ratio in both left and right adrenal veins with that in the inferior vena cava (LAV/IVC and RAV/IVC). Receiver operation characteristic (ROC) curve and scatterplot were used to certify the upper and lower cutoffs and to analyze the significance of discrimination. One hundred and sixty patients diagnosed with PA from April 2017 to June 2018 underwent AVS in the Urology Department of West China Hospital, Chengdu, China. One hundred and eleven with complete AVS data were divided into 3 groups: left-sided (N=40), right-sided (N=29) and bilateral (N=42). We also collected patients from September 2018 to April 2019 in our department as validation cohort to test our hypothesis. RESULTS On the basis of LAV/IVC, RAV/IVC and diagnostic category, upper cutoff was 1.14 (50% sensitivity and 100% specificity) and lower cutoff 0.07 (27.5% sensitivity and 100% specificity) for LAV/IVC, and 1.04 (55% sensitivity and 100% specificity) and 0.08 (40% sensitivity and 100% specificity), respectively, for RAV/IVC. CONCLUSION The diagnostic model in this study contributes to clinical decision-making in patients with only partial PA with incomplete AVS data.
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Affiliation(s)
- Lede Lin
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Liang Zhou
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Yiding Guo
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Zhenghuan Liu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Tao Chen
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Zhihong Liu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Kunjie Wang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Jiaqi Li
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China
| | - Yuchun Zhu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China.
| | - Yan Ren
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital, Sichuan University, Guo xue xiang, 37, Cheng Du, 610000 Sichuan, PR China.
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Treistman N, Moraes AB, Cozzolino S, Teixeira PDFDS, Vieira Neto L. Adrenal Venous Sampling in Primary Aldosteronism: The Usefulness of Contralateral Suppression Index. Case Rep Med 2019; 2019:1604367. [PMID: 31565059 PMCID: PMC6745108 DOI: 10.1155/2019/1604367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 11/29/2022] Open
Abstract
Adrenal venous sampling (AVS) is the gold standard test to differentiate the unilateral from the bilateral form in patients with primary aldosteronism (PA) although it may be a difficult procedure, especially the successful cannulation of the right adrenal vein. In this report, we describe a 49-year-old female patient diagnosed with PA, after investigating resistant hypertension and refractory hypokalemia. Abdominal computed tomography scan revealed a 2.5 cm adenoma on the right adrenal vein. AVS was performed under cosyntropin infusion. Aldosterone and cortisol concentrations were obtained from the right and left adrenal veins and inferior vena cava (IVC). Cortisol on each adrenal vein divided by cortisol on IVC confirmed successful cannulation of the left side only, which makes it impossible to calculate the lateralization index (LI). From the data on the left adrenal vein and IVC, the aldosterone-to-cortisol ratio divided by the IVC aldosterone-to-cortisol ratio was less than 1.0, suggesting that the left adrenal vein was suppressed with the excess aldosterone originating from the contralateral side (contralateral suppression index (CSI)). Right adrenalectomy was performed; postoperative hypoaldosteronism was confirmed. This report highlights the importance of CSI obtained in AVS when technical difficulties occur making it impossible to obtain LI, which is most commonly used to decide between surgical and clinical management of PA.
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Affiliation(s)
- Natalia Treistman
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital—Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Aline Barbosa Moraes
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital—Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Stéphanie Cozzolino
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital—Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patrícia de Fatima dos Santos Teixeira
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital—Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonardo Vieira Neto
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital—Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Sam D, Kline GA, So B, Leung AA. Discordance Between Imaging and Adrenal Vein Sampling in Primary Aldosteronism Irrespective of Interpretation Criteria. J Clin Endocrinol Metab 2019; 104:1900-1906. [PMID: 30590677 DOI: 10.1210/jc.2018-02089] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/19/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Subtyping of primary aldosteronism (PA) using imaging and adrenal vein sampling (AVS) may yield discordant results, causing confusion in management. Interpretation criteria for AVS lateralization may affect discordance rates. METHODS We identified consecutive patients with PA who underwent AVS at a quaternary care center between January 2006 and May 2018. Patient demographics, laboratory results, diagnostic imaging, and AVS results were retrieved. Adrenal cross-sectional imaging was compared with AVS findings. The presence of lateralization was defined using varying thresholds for the lateralization index (LI) from >2:1 to >5:1. Discordance was defined by a unilateral lesion on imaging with contralateral or nonlateralization on AVS. RESULTS A total of 342 patients were included; 68.7% had hypokalemia. With cross-sectional imaging, 191 (55.6%) patients had unilateral lesions, 47 (13.7%) had bilateral lesions, and 104 (30.4%) had normal imaging. Overall discordance rates were high, ranging from 22% to 28% for LI thresholds of >2:1 and >5:1, respectively. Discordance between imaging and AVS was positively correlated with LI threshold stringency (P < 0.001). Patients with normal or bilateral lesions on imaging frequently lateralized on AVS. Lateralization, when present, was approximately equal between left and right sides, irrespective of the LI threshold. CONCLUSIONS Discrepancies between imaging and AVS were common, even among patients with nonspecific imaging. Discordance was greatest with the strictest AVS interpretation criteria. Even under the most lenient thresholds, apparent discordance between imaging and AVS exceeded 20% and may limit the ability to make surgical decisions. Reliance on imaging alone for detecting lateralization may be misleading.
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Affiliation(s)
- Davis Sam
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregory A Kline
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Benny So
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Alexander A Leung
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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18
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Surprisingly low aldosterone levels in peripheral veins following intravenous sedation during adrenal vein sampling. J Hypertens 2019; 37:596-602. [DOI: 10.1097/hjh.0000000000001905] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Loh WJ, Lim DST, Loh LM, Kek PC. Factors Associated with Resolution of Hypertension after Adrenalectomy in Patients with Primary Aldosteronism. Endocrinol Metab (Seoul) 2018; 33:355-363. [PMID: 30112867 PMCID: PMC6145965 DOI: 10.3803/enm.2018.33.3.355] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/22/2018] [Accepted: 06/03/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the factors associated with resolution of hypertension after adrenalectomy in patients with primary aldosteronism. A secondary aim was to describe our use of the contralateral ratio in adrenal venous sampling (AVS) in the setting of suboptimal successful cannulation rates. METHODS A retrospective review of patients who underwent AVS followed by unilateral adrenalectomy for primary aldosteronism was performed. RESULTS Complete resolution of hypertension and hypokalemia was seen in 17 of 40 patients (42.5%), while a clinical improvement in hypertension was seen in 38 of 40 (95%). Shorter duration of hypertension, mean aldosteronoma resolution score (ARS), and a high ARS of 3 to 5 were associated with resolution of hypertension after adrenalectomy (P=0.02, P=0.02, and P=0.004, respectively). Of the individual components of ARS, only a duration of hypertension of ≤6 years was associated with resolution of hypertension after adrenalectomy (P=0.03). CONCLUSION A shorter duration of hypertension was significantly associated with resolution of hypertension after adrenalectomy in patients with primary aldosteronism.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore.
| | - Dawn Shao Ting Lim
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Lih Ming Loh
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Peng Chin Kek
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
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Strajina V, Al-Hilli Z, Andrews JC, Bancos I, Thompson GB, Farley DR, Lyden ML, Dy BM, Young WF, McKenzie TJ. Primary aldosteronism: making sense of partial data sets from failed adrenal venous sampling-suppression of adrenal aldosterone production can be used in clinical decision making. Surgery 2018; 163:801-806. [DOI: 10.1016/j.surg.2017.10.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 09/25/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
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Nanba AT, Nanba K, Byrd JB, Shields JJ, Giordano TJ, Miller BS, Rainey WE, Auchus RJ, Turcu AF. Discordance between imaging and immunohistochemistry in unilateral primary aldosteronism. Clin Endocrinol (Oxf) 2017; 87:665-672. [PMID: 28787766 PMCID: PMC5698145 DOI: 10.1111/cen.13442] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 07/26/2017] [Accepted: 08/02/2017] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Correct subtyping of primary aldosteronism (PA) is essential for good surgical outcomes. Adrenal vein sampling (AVS) and/or computed tomography (CT) are used for PA subclassification. Clinical and/or biochemical improvement after surgery, however, is not always achieved in patients with presumed unilateral PA. We aimed to identify the pitfalls in PA subclassification leading to surgical treatment failures. PATIENTS AND DESIGN We retrospectively studied 208 patients who underwent adrenal vein sampling (AVS) for PA subclassification in a tertiary referral centre, between January 2009 and August 2016. Simultaneous bilateral AVS was performed before and after cosyntropin administration. We implemented immunohistochemistry for aldosterone synthase (CYP11B2) and 17α-hydroxylase/17,20 lyase (CYP17A1) in adrenal glands resected from patients without improvement of PA after surgical treatment and from those with limitations in AVS interpretation. RESULTS Of 55 patients who underwent adrenalectomy, three (5.5%) had no improvement of PA. All three patients underwent partial adrenalectomy to remove a CT-detected nodule present on the same side with AVS lateralization. Immunohistochemistry revealed a CYP11B2-negative nodule in both cases available. All patients who underwent total adrenalectomy based on AVS lateralization benefitted from surgery, including three patients with unilateral unsuccessful AVS and aldosterone suppression in the catheterized side vs inferior vena cava. CONCLUSIONS Radiographically identified adrenal nodules are not always a source of PA, even when ipsilateral with AVS lateralization. These data caution against reliance on imaging findings, either alone or in conjunction with AVS, to guide surgery for PA.
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A Multi-institutional Comparison of Adrenal Venous Sampling in Patients with Primary Aldosteronism: Caution Advised if Successful Bilateral Adrenal Vein Sampling is Not Achieved. World J Surg 2017; 42:466-472. [DOI: 10.1007/s00268-017-4327-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Shariq OA, Bancos I, Cronin PA, Farley DR, Richards ML, Thompson GB, Young WF, McKenzie TJ. Contralateral suppression of aldosterone at adrenal venous sampling predicts hyperkalemia following adrenalectomy for primary aldosteronism. Surgery 2017; 163:183-190. [PMID: 29129366 DOI: 10.1016/j.surg.2017.07.034] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/30/2017] [Accepted: 07/27/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND We aimed to determine whether a greater degree of contralateral suppression of aldosterone secretion at adrenal venous sampling predicted the development of postoperative hyperkalemia after unilateral adrenalectomy for primary aldosteronism. METHODS A retrospective analysis of patients undergoing unilateral adrenalectomy for primary aldosteronism between 2004-2015 was performed. Clinical and biochemical parameters of patients who developed hyperkalemia (≥5.2 mmol/L) after unilateral adreanlectomy were compared with those who remained normokalemic. The contralateral suppression index was defined as the aldosterone-to-cortisol ratio from the nondominant adrenal vein divided by the aldosterone-to-cortisol ratio from the external iliac vein. RESULTS Of 192 patients who met criteria for inclusion, 12 (6.3%) developed hyperkalemia (median serum potassium 5.5 mmol/L, range 5.2-6.2 mmol/L), with a median time to onset of 13.5 days (range 7-55 days). Five patients had transiently increased serum potassium concentrations that normalized spontaneously. Four patients received mineralocorticoid replacement therapy with fludrocortisone. On univariate analysis, hyperkalemic patients had slightly greater preoperative serum creatinine levels (1.2 vs 1.0 mg/dL, P = .01), higher postoperative creatinine (1.3 vs 1.0 mg/dL, P = .02), lesser median contralateral suppression index (0.14 vs 0.27, P = .03), and larger adenomas (1.9 vs 1.4 cm, P = .02). On multivariable logistic regression, the contralateral suppression index remained the only significant predictor of postoperative hyperkalemia (P = .04) with an optimal cut-off of <0.47. CONCLUSION Hyperkalemia after unilateral adrenalectomy for primary aldosteronism is uncommon and usually transient, but may require mineralocorticoid supplementation. Patients with a contralateral suppression index of <0.47 require meticulous follow-up and monitoring of serum potassium concentrations after unilateral adrenalectomy.
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Affiliation(s)
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Patricia A Cronin
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | | | | | | | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
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Kline G, Holmes DT. Adrenal venous sampling for primary aldosteronism: laboratory medicine best practice. J Clin Pathol 2017; 70:911-916. [PMID: 28893861 DOI: 10.1136/jclinpath-2017-204423] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 07/06/2017] [Accepted: 07/23/2017] [Indexed: 01/13/2023]
Abstract
Primary aldosteronism (PA) is the most common form of secondary hypertension and is critical to identify because when caused by an aldosterone-producing adenoma (APA) or another unilateral form, it is potentially curable, and even when caused by bilateral disease, antihypertensives more specific to PA treatment can be employed (ie, aldosterone antagonists). Identification of unilateral forms is not generally accomplished with imaging because APAs may be small and elude detection, and coincidental identification of a non-functioning incidentaloma contralateral to an APA may lead to removal of an incorrect gland. For this reason, the method of choice for identifying unilateral forms of PA is selective adrenal venous sampling (AVS) followed by aldosterone and cortisol analysis on collected samples. This procedure is technically difficult from a radiological standpoint and, from the laboratory perspective, is fraught with opportunities for preanalytical, analytical and postanalytical error. We review the process of AVS collection, analysis and reporting. Suggestions are made for patient preparation, specimen labelling practices and nomenclature, analytical dilution protocols, which numerical results to report, and the necessary subsequent calculations. We also identify and explain frequent sources of confusion in the aldosterone and cortisol results and provide an example of tabular reporting to facilitate interpretation and communication between laboratorian, radiologist and clinician.
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Affiliation(s)
- Gregory Kline
- Division of Endocrinology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Daniel T Holmes
- Department of Pathology and Laboratory Medicine, St. Paul's Hospital, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
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Wolley MJ, Ahmed AH, Gordon RD, Stowasser M. Does ACTH improve the diagnostic performance of adrenal vein sampling for subtyping primary aldosteronism? Clin Endocrinol (Oxf) 2016; 85:703-709. [PMID: 27213822 DOI: 10.1111/cen.13110] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 05/04/2016] [Accepted: 05/18/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Adrenal vein sampling (AVS) is used for determining treatment options for primary aldosteronism (PA), but is a difficult procedure. Adrenocorticotropic hormone (ACTH) infusion or bolus has been reported to improve AVS success rates by increasing cortisol secretion, but effects on lateralization are controversial. We therefore assessed the effects of ACTH in regard to AVS success and lateralization in our unit, after a change in protocol to ACTH-stimulated AVS. SETTING AVS was performed after overnight recumbency in patients with PA confirmed by fludrocortisone suppression testing. Bilateral sequential sampling was performed before and after an intravenous bolus of 250 mcg of ACTH. Lateralization was defined as an aldosterone/cortisol ratio in one adrenal vein at least twice peripheral, combined with a contralateral adrenal ratio no higher than peripheral (contralateral suppression). RESULTS In 47 AVS procedures, the median adrenal/peripheral cortisol gradient increased on the left (11·6 vs 18·2 μg/100 ml, P < 0·001) and right (15·6 vs 31·5 μg/100 ml, P < 0·001) after ACTH. A total of 34 of 47 studies were diagnostic pre-ACTH (six failing because of low aldosterone levels bilaterally and seven failing to cannulate one or both sides) vs 44 of 47 (P = 0·011) studies diagnostic post-ACTH (failure to cannulate one or both sides in 3). Concordance between diagnostic studies pre- and post-ACTH was 91%, but two bilateral cases became unilateral after ACTH and one unilateral case before ACTH was bilateral afterwards. CONCLUSIONS ACTH improved cortisol gradients and aldosterone secretion, resulting in a reduction in the proportion of nondiagnostic studies. There was a low proportion of discordance between pre- and post-ACTH diagnoses, the significance of which is unclear.
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Affiliation(s)
- Martin J Wolley
- Endocrine Hypertension Research Centre, Greenslopes and Princess Alexandra Hospitals, University of Queensland School of Medicine, Brisbane, Qld, Australia
| | - Ashraf H Ahmed
- Endocrine Hypertension Research Centre, Greenslopes and Princess Alexandra Hospitals, University of Queensland School of Medicine, Brisbane, Qld, Australia
| | - Richard D Gordon
- Endocrine Hypertension Research Centre, Greenslopes and Princess Alexandra Hospitals, University of Queensland School of Medicine, Brisbane, Qld, Australia
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, Greenslopes and Princess Alexandra Hospitals, University of Queensland School of Medicine, Brisbane, Qld, Australia.
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Abstract
PURPOSE OF REVIEW Primary aldosteronism accounts for 3 to 5% of all hypertension cases. Unilateral aldosterone hypersecretion can be treated with adrenalectomy. Guidelines for primary aldosteronism management recommend adrenal vein sampling (AVS) to ascertain unilateral primary aldosteronism before surgery. Many different protocols are used to perform AVS and for the interpretation of its results, but without hard evidence of why one should be given preference. Experts have proposed recommendations to guide clinical practice and the grounds for future research to address this situation. RECENT FINDINGS Proper patient preparation is a prerequisite for interpretable results. New trends are emerging to improve adequate cannulation of adrenal veins including: training of a limited number of dedicated radiologists, contrast computed tomography of adrenal veins before or during AVS, and rapid assays to measure cortisol concentrations during AVS. Cosyntropin stimulation is performed in several centers to avoid the variability of cortisol secretion during AVS, but whether this improves diagnostic performance is unknown. SUMMARY Better markers of adequate catheter placement are currently under investigation, including other adrenal steroids and metanephrines. Innovative strategies for interpreting partially failed AVS are also being developed. Other approaches to ascertain primary aldosteronism subtype will be necessary because of limited patient access to AVS.
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Affiliation(s)
- Olivier Steichen
- aInternal Medicine Department, AP-HP, Tenon HospitalbFaculty of Medicine, Sorbonne Universités, UPMC University Paris 06cINSERM, Sorbonne Universités, UPMC Univ Paris 06, UMR_S1142dFaculty of Medicine, Université Paris-DescarteseHypertension Unit, AP-HP, Georges Pompidou European HospitalfINSERM, UMR_S970, équipe 14, Paris, France
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El Ghorayeb N, Mazzuco TL, Bourdeau I, Mailhot JP, Zhu PS, Thérasse E, Lacroix A. Basal and Post-ACTH Aldosterone and Its Ratios Are Useful During Adrenal Vein Sampling in Primary Aldosteronism. J Clin Endocrinol Metab 2016; 101:1826-35. [PMID: 26918291 DOI: 10.1210/jc.2015-3915] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Adrenal vein sampling (AVS) is required to identify a lateralized or bilateral aldosterone source in primary aldosteronism. OBJECTIVES Our objectives were to compare basal and post-ACTH selectivity ratio (SR) and lateralization ratio (LR) and to determine the prevalence of basal contralateral suppression and its effect on surgical outcome. PATIENTS AND INTERVENTION Bilateral simultaneous adrenal vein samples were obtained before and after a 250-μg bolus of ACTH. Analyses were conducted on 171 technically successful AVS and on the subgroup of 66 operated patients with evaluable outcome data. RESULTS ACTH increased selectivity on both sides from 66.7% in basal samples (SR ≥ 2) to 91.8% poststimulation (SR ≥ 5). A discordance of lateralization between basal (LR ≥ 2) and post-ACTH (LR ≥ 4) values was observed in 28% of cases, which were mostly lateralized cases basally that became bilateral post-ACTH. Basal CL suppression is present in only 30% using absolute ratio of aldosterone between the opposite (nondominant) adrenal vein and the peripheral vein AOPP/AP below 1.5 vs in 77% using aldosterone/cortisol ratio (A/C)OPP/(A/C)P below 1.5. The absence of CL suppression was associated with a lower rate of response to adrenalectomy in terms of clinical and biochemical parameters with difference in clinical cure (55% vs 13% P = .0003) and overall cure (35% vs 9%, P = .0084) using AOPP/AP, but not when using (A/C)OPP/(A/C)P. CONCLUSIONS Stimulation with ACTH is useful to improve selectivity of AVS but can frequently modify interpretation of lateralization. Basal ratios are as important as post-ACTH ratios to set an indication of adrenalectomy. AOPP/AP is superior to (A/C)OPP/(A/C)P to assess contralateral suppression. Infrequent CL suppression reveals frequent occurrence of contralateral hyperplasia in lateralized cases and helps predict postoperative outcomes.
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Affiliation(s)
- Nada El Ghorayeb
- Department of Medicine (N.E.G., T.L.M., I.B., P.S.Z., A.L.) and Department of Radiology (J.-P.M., E.T.), Division of Endocrinology, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Québec, H2W 1T8, Canada
| | - Tânia L Mazzuco
- Department of Medicine (N.E.G., T.L.M., I.B., P.S.Z., A.L.) and Department of Radiology (J.-P.M., E.T.), Division of Endocrinology, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Québec, H2W 1T8, Canada
| | - Isabelle Bourdeau
- Department of Medicine (N.E.G., T.L.M., I.B., P.S.Z., A.L.) and Department of Radiology (J.-P.M., E.T.), Division of Endocrinology, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Québec, H2W 1T8, Canada
| | - Jean-Philippe Mailhot
- Department of Medicine (N.E.G., T.L.M., I.B., P.S.Z., A.L.) and Department of Radiology (J.-P.M., E.T.), Division of Endocrinology, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Québec, H2W 1T8, Canada
| | - Ping Shi Zhu
- Department of Medicine (N.E.G., T.L.M., I.B., P.S.Z., A.L.) and Department of Radiology (J.-P.M., E.T.), Division of Endocrinology, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Québec, H2W 1T8, Canada
| | - Eric Thérasse
- Department of Medicine (N.E.G., T.L.M., I.B., P.S.Z., A.L.) and Department of Radiology (J.-P.M., E.T.), Division of Endocrinology, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Québec, H2W 1T8, Canada
| | - André Lacroix
- Department of Medicine (N.E.G., T.L.M., I.B., P.S.Z., A.L.) and Department of Radiology (J.-P.M., E.T.), Division of Endocrinology, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Québec, H2W 1T8, Canada
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