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Araujo-Castro M, Ruiz-Sánchez JG, Parra Ramírez P, Martín Rojas-Marcos P, Aguilera-Saborido A, Gómez Cerezo JF, López Lazareno N, Torregrosa Quesada ME, Gorrin Ramos J, Oriola J, Poch E, Oliveras A, Méndez Monter JV, Gómez Muriel I, Bella-Cueto MR, Mercader Cidoncha E, Runkle I, Hanzu FA. Screening and diagnosis of primary aldosteronism. Consensus document of all the Spanish Societies involved in the management of primary aldosteronism. Endocrine 2024; 85:99-121. [PMID: 38448679 DOI: 10.1007/s12020-024-03751-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/15/2024] [Indexed: 03/08/2024]
Abstract
Primary aldosteronism (PA) is the most frequent cause of secondary hypertension (HT), and is associated with a higher cardiometabolic risk than essential HT. However, PA remains underdiagnosed, probably due to several difficulties clinicians usually find in performing its diagnosis and subtype classification. The aim of this consensus is to provide practical recommendations focused on the prevalence and the diagnosis of PA and the clinical implications of aldosterone excess, from a multidisciplinary perspective, in a nominal group consensus approach by experts from the Spanish Society of Endocrinology and Nutrition (SEEN), Spanish Society of Cardiology (SEC), Spanish Society of Nephrology (SEN), Spanish Society of Internal Medicine (SEMI), Spanish Radiology Society (SERAM), Spanish Society of Vascular and Interventional Radiology (SERVEI), Spanish Society of Laboratory Medicine (SEQC(ML)), Spanish Society of Anatomic-Pathology, Spanish Association of Surgeons (AEC).
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Affiliation(s)
- Marta Araujo-Castro
- Endocrinology & Nutrition Department, Hospital Universitario Ramón y Cajal. Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS)., Madrid, Spain.
| | - Jorge Gabriel Ruiz-Sánchez
- Endocrinology & Nutrition Department. Hospital Universitario Fundación Jiménez Díaz, Health Research Institute-Fundación Jiménez Díaz University Hospital (IIS-FJD, UAM), Madrid, Spain
| | - Paola Parra Ramírez
- Endocrinology & Nutrition Department, Hospital Universitario La Paz-IdiPAZ, Madrid, Spain
| | | | | | | | - Nieves López Lazareno
- Biochemical Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Jorge Gorrin Ramos
- Biochemical department, Laboratori de Referència de Catalunya, Barcelona, Spain
| | - Josep Oriola
- Biochemistry and Molecular Genetics Department, CDB. Hospital Clínic. University of Barcelona, Barcelona, Spain
| | - Esteban Poch
- Nephrology Department. Hospital Clinic, IDIBAPS. University of Barcelona, Barcelona, Spain
| | - Anna Oliveras
- Nephrology Department. Hospital del Mar, Universitat Pompeu Fabra, Barcelona, ES, Spain
| | | | | | - María Rosa Bella-Cueto
- Pathology Department, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA). Universitat Autònoma de Barcelona. Sabadell, Barcelona, Spain
| | - Enrique Mercader Cidoncha
- General Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Fellow European Board of Surgery -Endocrine Surgery, Madrid, Spain
| | - Isabelle Runkle
- Endocrinology and Nutrition Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Felicia A Hanzu
- Endocrinology & Nutrition Department, Hospital Clinic. IDIBAPS. University of Barcelona, Barcelona, Spain.
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Gunnarsdottir H, Agnarsson BA, Jonasdottir S, Gudmundsson J, Birgisson G, Sigurjonsdottir HA. Immunohistochemical staining seems mandatory for individualizing and shortening follow-up in unilateral primary aldosteronism. Clin Endocrinol (Oxf) 2023; 99:441-448. [PMID: 37525427 DOI: 10.1111/cen.14958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 07/12/2023] [Accepted: 07/24/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE The clinical significance of immunohistochemistry (IHC) for unilateral primary aldosteronism (PA) has been unclear. Individualized follow-up of PA patients could be in sight. Long-term outcomes of patients, classified based on IHC, need further investigation. We aimed to assess long-term clinical outcomes for unilateral PA, classifying patients based on IHC. DESIGN A nationwide observational study, with up to 16 years follow-up, executed in 2007-2016 at Landspitali University Hospital, tertiary referral center. Patients were diagnosed and treated in line with the current guidelines. Haematoxylin and eosin (H&E) tissue slides were stained using CYP11B1 and -B2 antibodies. All cases were re-evaluated and classified according to the HISTALDO consensus. Outcomes were assessed using the PASO criteria. PATIENTS All unilateral PA patients diagnosed in 2007-2016 in Iceland, 26 patients aged 28-73 years, who underwent adrenalectomy, were included. MEASUREMENTS Aldosterone, renin, and cortisol values, use and dosage of antihypertensives, potassium supplementation, blood pressure and serum potassium pre-intervention and throughout follow-up, and histopathology results post-adrenalectomy. RESULTS Following IHC, an aldosterone-producing nodule was seen in 12 adrenals, an aldosterone-producing adenoma in 10 and multiple aldosterone-producing micronodules in four. IHC altered histopathology from previous H&E diagnosis in 23% (6/26) of the patients. In total, 81% (21/26) of the patients had partial clinical success. Eight percent (2/26) of the patients needed potassium supplementation during follow-up. In the classical group, the AVS results were more determinative with significantly higher lateralization index (median 10.1 vs. 5.3, p = .04) and more contralateral suppression (median nondominant ratio 0.4 vs. 1.0, p = .03). One out of five patients with complete clinical success at 12 months post-op had severe relapse later, the other four were normotensive without antihypertensives for up to 10 years. CONCLUSIONS We found IHC mandatory for accurate histopathologic diagnosis of PA. Our results support the importance of contralateral suppression when interpreting AVS results. Also, the study highlights the complicated assessment of clinical outcome and importance of aldosterone and renin measurements during follow-up.
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Affiliation(s)
- Hrafnhildur Gunnarsdottir
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Bjarni A Agnarsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Pathology, Landspitali University Hospital, Reykjavik, Iceland
| | - Sigurros Jonasdottir
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Pathology, Landspitali University Hospital, Reykjavik, Iceland
| | - Jon Gudmundsson
- Department of Radiology, Landspitali University Hospital, Reykjavik, Iceland
| | - Gudjon Birgisson
- Department of Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Helga A Sigurjonsdottir
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
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Rossi GP, Bagordo D, Amar L, Azizi M, Riester A, Reincke M, Degenhart C, Widimský J, Naruse M, Deinum J, Kocjan T, Negro A, Rossi E, Kline G, Tanabe A, Satoh F, Rump LC, Vonend O, Willenberg HS, Fuller PJ, Yang J, Chee NYN, Magill SB, Shafigullina Z, Quinkler M, Oliveras A, Lee BC, Chang CC, Wu VC, Krátká Z, Battistel M, Rossitto G, Seccia TM. Unilaterally Selective Adrenal Vein Sampling for Identification of Surgically Curable Primary Aldosteronism. Hypertension 2023; 80:2003-2013. [PMID: 37317838 DOI: 10.1161/hypertensionaha.123.21247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/23/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Adrenal venous sampling is recommended for the identification of unilateral surgically curable primary aldosteronism but is often clinically useless, owing to failed bilateral adrenal vein cannulation. OBJECTIVES To investigate if only unilaterally selective adrenal vein sampling studies can allow the identification of the responsible adrenal. METHODS Among 1625 patients consecutively submitted to adrenal vein sampling in tertiary referral centers, we selected those with selective adrenal vein sampling results in at least one side; we used surgically cured unilateral primary aldosteronism as gold reference. The accuracy of different values of the relative aldosterone secretion index (RASI), which estimates the amount of aldosterone produced in each adrenal gland corrected for catheterization selectivity, was examined. RESULTS We found prominent differences in RASI values distribution between patients with and without unilateral primary aldosteronism. The diagnostic accuracy of RASI values estimated by the area under receiver operating characteristic curves was 0.714 and 0.855, respectively, in the responsible and the contralateral side; RASI values >2.55 and ≤0.96 on the former and the latter side furnished the highest accuracy for detection of surgically cured unilateral primary aldosteronism. Moreover, in the patients without unilateral primary aldosteronism, only 20% and 16% had RASI values ≤0.96 and >2.55. CONCLUSIONS With the strength of a large real-life data set and use of the gold reference entailing an unambiguous diagnosis of unilateral primary aldosteronism, these results indicate the feasibility of identifying unilateral primary aldosteronism using unilaterally selective adrenal vein sampling results. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01234220.
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Affiliation(s)
- Gian Paolo Rossi
- Hypertension Unit, Department of Medicine, DIMED, University Hospital, University of Padova, Italy (G.P.R., D.B., G.R., T.M.S.)
| | - Domenico Bagordo
- Hypertension Unit, Department of Medicine, DIMED, University Hospital, University of Padova, Italy (G.P.R., D.B., G.R., T.M.S.)
| | - Laurence Amar
- Université Paris Cité, INSERM UMRS 970 and CIC1418, F-75015 Paris, France; AP-HP, Hôpital Européen Georges Pompidou, Hypertension Unit, F-75015 Paris, France (L.A., M.A.)
| | - Michel Azizi
- Université Paris Cité, INSERM UMRS 970 and CIC1418, F-75015 Paris, France; AP-HP, Hôpital Européen Georges Pompidou, Hypertension Unit, F-75015 Paris, France (L.A., M.A.)
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Germany (A.R., M.R., C.D.)
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Germany (A.R., M.R., C.D.)
| | - Christoph Degenhart
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Germany (A.R., M.R., C.D.)
| | - Jiří Widimský
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic (J.W., Z.K.)
| | - Mitsuhide Naruse
- Department of Endocrinology Clinical Research Institute, National Hospital Organization Kyoto Medical Center and Endocrine Center, Ijinkai Takeda General Hospital, Kyoto, Japan (M.N.)
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands (J.D.)
| | - Tomaz Kocjan
- University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia (T.K.)
| | - Aurelio Negro
- Internal Medicine and Hypertension Center, Ospedale Sant'Anna di Castelnovo Ne' Monti, Azienda Usl-IRCCS di Reggio Emilia (A.N., E.R.)
| | - Ermanno Rossi
- Internal Medicine and Hypertension Center, Ospedale Sant'Anna di Castelnovo Ne' Monti, Azienda Usl-IRCCS di Reggio Emilia (A.N., E.R.)
| | - Gregory Kline
- Foothills Medical Centre, University of Calgary, Canada (G.K.)
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine (A.T.)
| | - Fumitoshi Satoh
- Department of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai, Japan (F.S.)
| | - Lars Christian Rump
- Department of Nephrology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany (L.C.R., O.V.)
| | - Oliver Vonend
- Department of Nephrology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany (L.C.R., O.V.)
| | - Holger S Willenberg
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Rostock, Germany (H.S.W.)
| | - Peter J Fuller
- Monash Health, Clayton, VIC, Australia (P.J.F., J.Y., N.Y.N.C.)
| | - Jun Yang
- Monash Health, Clayton, VIC, Australia (P.J.F., J.Y., N.Y.N.C.)
| | | | - Steven B Magill
- Endocrinology Center, North Hills Health Center, Medical College of Wisconsin, Menomonee Falls (S.B.M.)
| | | | | | - Anna Oliveras
- Hypertension Unit, Nephrology Department, Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Spain (A.O.)
| | - Bo-Ching Lee
- Department of Medical Imaging, National Taiwan University Hospital (B.-C.L., C.-C.C.), Taipei
| | - Chin-Chen Chang
- Department of Medical Imaging, National Taiwan University Hospital (B.-C.L., C.-C.C.), Taipei
- National Taiwan University College of Medicine (C.-C.C.), Taipei
| | - Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine (V.C.W.), Taipei
| | - Zuzana Krátká
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic (J.W., Z.K.)
| | | | - Giacomo Rossitto
- Hypertension Unit, Department of Medicine, DIMED, University Hospital, University of Padova, Italy (G.P.R., D.B., G.R., T.M.S.)
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (G.R.)
| | - Teresa Maria Seccia
- Hypertension Unit, Department of Medicine, DIMED, University Hospital, University of Padova, Italy (G.P.R., D.B., G.R., T.M.S.)
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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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5
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Voss N, Mørup S, Clausen C, Feltoft CL, Jepsen JV, Hornum M, Andreassen M, Krogh J. Prognostic value of contralateral suppression on kidney function after surgery in patients with primary aldosteronism. Clin Endocrinol (Oxf) 2023; 98:306-314. [PMID: 36263597 DOI: 10.1111/cen.14836] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Adrenalectomy for primary aldosteronism (PA) has been associated with decreased kidney function after surgery. It has been proposed that elimination of excess aldosterone unmasks an underlying failure of the kidney function. Contralateral suppression (CLS) is considered a marker of aldosterone excess and disease severity, and the purpose of this study was to assess the hypothesis that CLS would predict change in kidney function after adrenalectomy in patients with PA. DESIGN AND PATIENTS Patients with PA referred for adrenal venous sampling (AVS) between May 2011 and August 2021 and who were subsequently offered surgical or medical treatment were eligible for the current study. RESULTS A total of 138 patients were included and after AVS 85/138 (61.6%) underwent adrenalectomy while 53/138 (38.4%) were treated with MR-antagonists. In surgically treated patients the estimated glomerular filtration rate (eGFR) was reduced by 11.5 (SD: 18.5) compared to a reduction of 5.9 (SD: 11.5) in medically treated patients (p = .04). Among surgically treated patients, 59/85 (69.4%) were classified as having CLS. After adrenalectomy, patients with CLS had a mean reduction in eGFR of 17.5 (SD: 17.6) compared to an increase of 1.8 (SD: 12.8) in patients without CLS (p < .001). The association between CLS and change in kidney function remained unchanged in multivariate analysis. Post-surgery, 16/59 (27.1%) patients with CLS developed hyperkalemia compared to 2/26 (7.7%) in patients without CLS (p = .04). CONCLUSION This retrospective study found that CLS was a strong and independent predictor of a marked reduction of eGFR and an increased risk of hyperkalemia after adrenalectomy in patients with PA.
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Affiliation(s)
- Nathalie Voss
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sara Mørup
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Caroline Clausen
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Claus Larsen Feltoft
- Department of Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Jan Viberg Jepsen
- Department of Urology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Mads Hornum
- Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Mikkel Andreassen
- Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Jesper Krogh
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark
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Gunnarsdottir H, Jonsdottir G, Birgisson G, Gudmundsson J, Sigurjonsdottir HA. Are We Only Detecting the Tip of the Iceberg? A Nationwide Study on Primary Aldosteronism with up to 8-Year Follow-up. Endocr Res 2022; 47:104-112. [PMID: 35488403 DOI: 10.1080/07435800.2022.2068572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Long-term follow-up studies on primary aldosteronism (PA) are lacking. OBJECTIVE We aim to review results of diagnostic procedures and histopathology for patients diagnosed during 2012-2016 in Iceland, compare unilateral (UD) and bilateral disease (BD) and assess treatment response. METHODS Thirty-two patients aged 28-88 were diagnosed and treated according to guidelines. RESULTS The majority had BD. Everyone needed potassium supplementation at case detection. We saw a reduction in systolic blood pressure (p < .001, both groups), antihypertensive agents (p = .002 UD and p = .04 BD) and potassium supplementation (p < .001, both groups). CONCLUSION Similar treatment response was seen in both subgroups. Ratio of hypokalemia and number of cases indicates severe PA underdiagnosis in Iceland.
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Affiliation(s)
- Hrafnhildur Gunnarsdottir
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | | | - Gudjon Birgisson
- Department of Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Jon Gudmundsson
- Department of Radiology, Landspitali University Hospital, Reykjavik, Iceland
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7
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Mørup S, Voss N, Clausen C, Feltoft CL, Andreassen M, Krogh J. Prognostic value of contralateral suppression for remission after surgery in patients with primary aldosteronism. Clin Endocrinol (Oxf) 2022; 96:793-802. [PMID: 35060161 DOI: 10.1111/cen.14678] [Citation(s) in RCA: 1] [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: 10/07/2021] [Revised: 01/04/2022] [Accepted: 01/04/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Primary aldosteronism (PA) is the most common cause of endocrine hypertension and adrenalectomy is the firstline treatment for unilateral PA. Suppression of aldosterone secretion of the nondominant adrenal gland at adrenal venous sampling (AVS), that is, contralateral suppression (CLS) has been suggested as a marker of disease severity. However, whether factors such as CLS, age, gender or comorbidities are associated with remission after surgery is controversial. The objective of this study is to investigate the prognostic value of CLS, age, gender, aldosterone-to-renin ratio, antihypertensives and comorbidities for clinical and biochemical remission following unilateral adrenalectomy in patients with PA. DESIGN AND PATIENTS A retrospective study of patients with PA referred for AVS at Rigshospitalet from May 2011 to September 2020, who subsequently underwent adrenalectomy. Clinical remission was defined according to the PA surgical outcome criteria, whereas complete biochemical remission was defined as normalization of hypokalaemia without potassium substitution. RESULTS Eighty-four patients were available for analysis of primary outcome. Among patients with CLS, 28/58 (48.3%) obtained complete clinical remission after surgery compared with 10/26 (38.5%) without CLS (p = .40). Complete biochemical remission was obtained in 55/58 (94.8%) of patients with CLS compared with 25/28 (89.3%) without CLS (p = .44). Female gender and lower number of antihypertensives at baseline were associated with higher odds for complete clinical remission, whereas none of the investigated variables were associated with biochemical remission. CONCLUSION CLS was not significantly associated with complete clinical or biochemical remission in this cohort. Our results confirmed that female gender and lower number of antihypertensives were predictors of clinical remission.
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Affiliation(s)
- Sara Mørup
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nathalie Voss
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Caroline Clausen
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Claus Larsen Feltoft
- Department of Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Mikkel Andreassen
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health and Clinical Sciences, Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Jesper Krogh
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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8
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Lee SH, Kim JW, Yoon HK, Kim SW, Kim SJ, Lee KE, Lee YM, Sung TY, Hong SJ, Shin CS, Koh JM, Kim JH. Indices of ACTH-stimulated adrenal venous sampling as predictors of postsurgical outcomes in primary aldosteronism. Clin Endocrinol (Oxf) 2022; 96:521-530. [PMID: 34647340 DOI: 10.1111/cen.14610] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/30/2021] [Accepted: 09/26/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to investigate the impact of indices of adrenal venous sampling (AVS) on postsurgical outcomes in patients with primary aldosteronism (PA). DESIGN AND PATIENTS This retrospective study determined biochemical and clinical outcomes based on ACTH-stimulated AVS parameters (lateralisation index [LI], contralateral ratio [CLR], and ipsilateral ratio [ILR]) in 251 patients with PA at 3 months after surgery. RESULTS Modified complete biochemical success was achieved in 8 of 12 (66.7%) patients with LI = 3-4, 39 of 47 (83.0%) with LI = 4-10, and 155 of 169 (91.7%) with LI ≥ 10 (p = .004 for trend). Modified complete biochemical success was achieved in 29 of 38 (76.3%) patients with CLR ≥ 1 and ILR ≤ 2, 73 of 86 (84.9%) with CLR = 0.25-1 and ILR > 2, and 100 of 104 (96.2%) with CLR < 0.25 and ILR > 2 (p = .001 for trend). After adjusting for confounders, modified complete biochemical success was associated with an LI ≥ 10 (odds ratio [OR] = 6.32; 95% confidence interval [CI] = 1.33-29.93) using LI = 3-4 as a reference and combined CLR < 0.25 and ILR > 2 (OR = 11.49; 95% confidence interval [CI] = 2.49-53.01) using combined CLR ≥ 1 and ILR ≤ 2 as a reference. Using combined CLR ≥ 1 and ILR ≤ 2 as a reference, complete clinical success was associated with combined CLR < 0.25 and ILR > 2 (OR = 3.10; 95% CI = 1.03-9.28) and combined CLR = 0.25-1 and ILR > 2 (OR = 4.92; 95% CI = 1.64-14.76). CONCLUSION LI ≥ 10 may be appropriate for achieving biochemical success. With ILR > 2, CLR < 0.25, and CLR < 1 may be appropriate for achieving biochemical and clinical success, respectively.
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Affiliation(s)
- Seung Hun Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyun-Ki Yoon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea
| | - Su Jin Kim
- Department of Surgery, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
| | - Kyu Eun Lee
- Department of Surgery, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
| | - Yu-Mi Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae-Yon Sung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Suck Joon Hong
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chan Soo Shin
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-Min Koh
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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9
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Dominguez DA, Chatani P, Murphy R, Copeland AR, Chang R, Sadowski SM, Hannah-Shmouni F, Stratakis CA, Nilubol N. Contralateral Suppression Index Does Not Predict Clinical Cure in Patients Undergoing Surgery for Primary Aldosteronism. Ann Surg Oncol 2021; 28:7487-7495. [PMID: 33939050 PMCID: PMC8530859 DOI: 10.1245/s10434-021-09692-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/17/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Adrenal venous sampling (AVS) is recommended before adrenalectomy for patients with primary aldosteronism (PA) over 35 years old. The literature examining contralateral suppression (CoS) on AVS in predicting surgical outcomes is conflicting. We examined the presence of CoS in patients who underwent adrenalectomy while adjusting for clinical and biochemical factors associated with a clinical cure of hypertension (ccHTN). METHODS We performed a retrospective review of patients with successful AVS who underwent unilateral adrenalectomy for PA at a quaternary referral center. Patients were excluded if they had overt cortisol co-secretion, or inadequate follow-up. We first evaluated the aldosterone resolution score (ARS) in predicting ccHTN in our cohort. Next, the receiver-operator characteristic analysis (ROC) was used to determine the optimal contralateral suppression index (CSI) cutoff to define CoS. We performed univariable and multivariable analyses of factors associated with ccHTN. The primary outcome was ccHTN defined as blood pressure less than 140/90 mmHg, and off blood pressure medications. RESULTS Of the 102 patients on bivariable analysis, age, sex, duration of HTN, number of medications, preoperative systolic blood pressure, and creatinine level were associated with ccHTN. ROC analysis of ARS had an AUC of 0.850 (p < 0.001). On multivariable analysis, only ARS remained associated with ccHTN (OR 3.40, 95% CI 1.20-9.61, p = 0.021). CSI was not significantly associated with ccHTN on ROC, bivariable, or multivariable analyses. CONCLUSION The presence of CoS was not useful in predicting ccHTN following unilateral adrenalectomy for PA in our cohort. After adjusting for clinical and biochemical factors, ARS remains a useful predictor for ccHTN.
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Affiliation(s)
- Dana A Dominguez
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Praveen Chatani
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ryan Murphy
- Endocrine Surgery Section, National Institutes of Health, Bethesda, MD, USA
| | - Amy R Copeland
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Richard Chang
- Interventional Radiology Section, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Samira M Sadowski
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
- Endocrine Surgery Section, National Institutes of Health, Bethesda, MD, USA
| | - Fady Hannah-Shmouni
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Naris Nilubol
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
- Endocrine Surgery Section, National Institutes of Health, Bethesda, MD, USA.
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10
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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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11
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Yang YS, Lee SH, Kim JH, Yoo JH, Lee JH, Lee SY, Hong AR, Lee DH, Koh JM, Kim JH, Kim SW. Contralateral Suppression at Adrenal Venous Sampling Is Associated with Renal Impairment Following Adrenalectomy for Unilateral Primary Aldosteronism. Endocrinol Metab (Seoul) 2021; 36:875-884. [PMID: 34376041 PMCID: PMC8419620 DOI: 10.3803/enm.2021.1047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/12/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Adrenal venous sampling (AVS) is performed to distinguish the subtype of primary aldosteronism (PA). The clinical implication of contralateral suppression (CS; aldosterone/cortisolnondominant<aldosterone/cortisolperipheral) at AVS remains unclear. We aimed to investigate the clinical significance of CS and its impact on postoperative outcomes after unilateral adrenalectomy. METHODS In this retrospective observational multi-center study, we analyzed PA patients who underwent both successful adrenocorticotropin hormone-stimulated AVS and unilateral adrenalectomy. Successful cannulation was defined as the selectivity index (cortisoladrenal/cortisolperipheral) ≥3. Clinical and biochemical outcomes after unilateral adrenalectomy were evaluated based on the international Primary Aldosteronism Surgical Outcome consensus. RESULTS Among 263 patients analyzed, 247 had CS (93.9%). Patients with CS had lower serum potassium levels, higher plasma aldosterone concentration, higher aldosterone-to-renin ratio (ARR), and larger adenoma size than those without CS. Those with CS showed significantly higher lateralization index than those without CS (P<0.001). Although postoperative blood pressure and ARR significantly decreased in those with CS, clinical and biochemical outcomes were comparable in both groups. When the cut-off value of age was determined using receiver operating characteristic (ROC) analysis, patients aged ≥50 years old with contralateral suppression index (CSI; the ratio between aldosterone/cortisolnondominant and aldosterone/cortisolperipheral) ≤0.26 had greater odds ratio (6.43; 95% confidence interval, 1.30 to 31.69) of incident chronic kidney disease than those aged <50 years with CSI >0.26 after adjusting for other factors. CONCLUSION CS may not predict postoperative clinical and biochemical outcomes in subjects with unilateral aldosterone excess, but it is associated with postsurgical deterioration of renal function in subjects over 50 years with CSI ≤0.26.
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Affiliation(s)
- Ye Seul Yang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
- Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Seoul,
Korea
| | - Seung Hun Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
| | - Jee Hee Yoo
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Jung Hyun Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
| | - Seo Young Lee
- Department of Internal Medicine, Mediplex Sejong Hospital, Incheon,
Korea
| | - A Ram Hong
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju,
Korea
| | - Dong-Hwa Lee
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju,
Korea
| | - Jung-Min Koh
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
- Division of Endocrinology and Metabolism, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul,
Korea
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12
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Nakamaru R, Yamamoto K, Akasaka H, Rakugi H, Kurihara I, Yoneda T, Ichijo T, Katabami T, Tsuiki M, Wada N, Yamada T, Kobayashi H, Tamura K, Ogawa Y, Kawashima J, Inagaki N, Fujita M, Watanabe M, Kamemura K, Okamura S, Tanabe A, Naruse M. Age-stratified comparison of clinical outcomes between medical and surgical treatments in patients with unilateral primary aldosteronism. Sci Rep 2021; 11:6925. [PMID: 33767283 PMCID: PMC7994572 DOI: 10.1038/s41598-021-86290-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/10/2021] [Indexed: 12/24/2022] Open
Abstract
Although adrenalectomy (ADX) is an established treatment for unilateral primary aldosteronism (uPA), the influence of age on the surgical outcomes is poorly understood. Therefore, we aimed to elucidate how age affects the clinical outcomes after treatments. We analyzed 153 older (≥ 65 years) and 702 younger patients (< 65 years) with uPA, treated either with ADX or mineralocorticoid receptor antagonist (MRA) in the Japan PA Study, and compared the estimated glomerular filtration rate (eGFR) or blood pressure over a 36-month period after treatments. ADX-treated patients showed severer biochemical indicators than MRA-treated patients. During 6 and 36 months, the eGFR decreased more prominently in older but not in younger patients with ADX than in those with MRA, which remained significant after adjustment with the inverse probability of treatment weighting (IPTW). There was a significant interaction between the age-groups and the treatment choices in the change of the eGFR with IPTW-adjusted analysis. The post-treatment dose of antihypertensive medication was lower in younger and higher in older patients with ADX than those with MRA. The clinical benefit of ADX differed between younger and older patients with uPA. These findings indicate the need for further validation on whether ADX can benefit older patients with uPA.
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Affiliation(s)
- Ryo Nakamaru
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, 5650871, Japan
| | - Koichi Yamamoto
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, 5650871, Japan.
| | - Hiroshi Akasaka
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, 5650871, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, 5650871, Japan
| | - Isao Kurihara
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine, Keio University, Tokyo, Japan
| | - Takashi Yoneda
- Department of Health Promotion and Medicine of the Future, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takamasa Ichijo
- Department of Diabetes and Endocrinology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Mika Tsuiki
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Tetsuya Yamada
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroki Kobayashi
- Division of Nephrology, Hypertension and Endocrinology, Nihon University School of Medicine, Tokyo, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Junji Kawashima
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Megumi Fujita
- Division of Nephrology and Endocrinology, University of Tokyo, Tokyo, Japan
| | - Minemori Watanabe
- Department of Endocrinology and Diabetes, Okazaki City Hospital, Okazaki, Japan
| | | | | | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mitsuhide Naruse
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.,Endocrine Center, Ijinkai Takeda General Hospital, Kyoto, Japan
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13
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Lee SE, Park SW, Choi MS, Kim G, Yoo JH, Ahn J, Jun JE, Park HS, Hyun D, Cho SK, Ko SE, Kim BJ, Kim JW, Yoon HK, Koh JM, Lee SH, Kim JH. Primary aldosteronism subtyping in the setting of partially successful adrenal vein sampling. Ther Adv Endocrinol Metab 2021; 12:2042018821989239. [PMID: 33633828 PMCID: PMC7887669 DOI: 10.1177/2042018821989239] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 01/03/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND AIMS Frequent failure of adrenal vein (AV) cannulation is a major obstacle to the universal use of adrenal vein sampling (AVS) for subtyping primary aldosteronism (PA). This study aimed to confirm and modify the value of a previously reported AVS parameter for PA subtyping in the case of cannulation failure on one side. METHODS Successfully catheterized AVS studies in 157 patients (121 patients as a derivation cohort and 36 patients as a validation cohort) from two tertiary hospitals were retrospectively reviewed. The AV/inferior vena cava (IVC) index was defined by dividing the aldosterone/cortisol ratio (ACR) of AV by the ACR of the IVC. Cutoff values for lateralized PA were obtained from two methods: scatterplots and the values corresponding to Youden's index in receiver operating characteristic (ROC) curves, on the assumption of catheterization failure on one side. RESULTS Due to multiple samplings in a single AVS procedure, 252 left AV/IVC ratios (LIRs) and 272 right AV/IVC ratios (RIRs) were calculated. Scatterplot cutoffs of LIR >5.4 or <0.5 predicted unilateral PA with a sensitivity of 42.1% and a specificity of 98.6%. Scatterplot cutoffs of RIR <0.5 or >7.0 showed a sensitivity of 55.1% and a specificity of 98.6%. ROC curve cutoffs of LIR ⩽0.8 or >3.1 predicted unilateral PA with a sensitivity of 82.5% and a specificity of 69.6%. ROC curve cutoffs of RIR ⩽0.8 or >3.9 resulted in 87.4% sensitivity and 80.7% specificity. CONCLUSION In the case of unilateral AVS failure, the AV/IVC index may help in diagnosing PA subtype.
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Affiliation(s)
- Seung-Eun Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Sung Woon Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, CHA Gangnam Medical Center, CHA University, Gangnam-gu, Seoul, Republic of Korea
| | - Min Sun Choi
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Gyuri Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Jee Hee Yoo
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju-si, Gangwon-do, Republic of Korea
| | - Jiyeon Ahn
- Division of Endocrinology and Metabolism, Department of Medicine, Myongji Hospital, Deogyang-gu, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Ji Eun Jun
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Gangdong-gu, Seoul, Republic of Korea
| | - Hong Suk Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Dongho Hyun
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Sung Ki Cho
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Seong Eun Ko
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Beom-Jun Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Songpa-gu, Seoul, Republic of Korea
| | - Hyun-Ki Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Songpa-gu, Seoul, Republic of Korea
| | - Jung-Min Koh
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Seung Hun Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, Republic of Korea
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14
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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: 2] [Impact Index Per Article: 0.5] [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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15
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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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16
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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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17
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Influence of antihypertensive drugs in the subtype diagnosis of primary aldosteronism by adrenal venous sampling. J Hypertens 2020; 37:1493-1499. [PMID: 31033727 DOI: 10.1097/hjh.0000000000002047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Because of the influence on the renin-angiotensin-aldosterone system, it is recommended to avoid, if possible, the use of angiotensin-converting-enzyme inhibitors, angiotensin II type 1 receptor blockers, diuretics, β-blockers, and mineralocorticoid receptor antagonists during the diagnostic period of primary aldosteronism. A laterality index more than 4 in adrenocorticotropic hormone (ACTH)-stimulated adrenal venous sampling (ACTH-AVS) is a widely used classification of the unilateral subtype that can benefit from adrenalectomy. Here, we revealed clinical features of patients taking drugs that could affect the primary aldosteronism diagnosis (DAPD) and investigated whether the classification with laterality index more than 4 in ACTH-AVS is applicable to these patients. PATIENTS AND METHODS Using a large database of primary aldosteronism patients in Japan, we analyzed 2122 patients with successful ACTH-AVS. RESULTS Patients who received any DAPD (n = 209) showed higher prevalence of comorbidity burdens and took more antihypertensive drugs compared with patients without DAPD. In patients taking DAPD, those with laterality index more than 4 had a higher prevalence of hypokalemia, a higher aldosterone-to-renin ratio and a higher prevalence of adrenal mass than those with laterality index of 4 or less. Adrenalectomy was performed in 76% patients with laterality index more than 4 and 20% with laterality index of 4 or less. Patients who underwent adrenalectomy showed biochemical cure in 89% with laterality index more than 4 and 50% with laterality index of 4 or less (P = 0.001). Multivariate regression analysis showed that laterality index more than 4 was an independent predictor of a biochemical cure. Biochemical cure rate in patients with laterality index more than 4 was consistently high, irrespective of the potential effect of individual DAPD on laterality index. CONCLUSION Our findings suggest that in primary aldosteronism patients to whom DAPD were administrated due to severe clinical features, laterality index more than 4 in ACTH-AVS could accurately predict a biochemical cure after adrenalectomy.
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Huang CW, Lee BC, Liu KL, Chang YC, Wu VC, Lee PT, Chang CC. Preoperative non-stimulated adrenal venous sampling index for predicting outcomes of adrenalectomy for unilateral primary aldosteronism. J Formos Med Assoc 2020; 119:1185-1192. [DOI: 10.1016/j.jfma.2020.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 10/24/2022] Open
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Cosyntropin stimulation in adrenal vein sampling improves the judgment of successful adrenal vein catheterization and outcome prediction for primary aldosteronism. Hypertens Res 2020; 43:1105-1112. [PMID: 32355223 DOI: 10.1038/s41440-020-0445-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 03/09/2020] [Accepted: 03/31/2020] [Indexed: 01/16/2023]
Abstract
The importance of cosyntropin stimulation during adrenal vein sampling (AVS) is not fully established, partly due to insufficient AVS data relating the presence and absence of cosyntropin stimulation with postoperative outcome. Therefore, we investigated differences in AVS indices before and after cosyntropin stimulation, and determined whether unstimulated or stimulated AVS indices better correlated with treatment outcome. A retrospective study was conducted in two parts: one with 185 patients who underwent AVS and the other with 81 patients who underwent unilateral adrenalectomy for unilateral aldosterone oversecretion. The selectivity index (SI), lateralized ratio (LR), and contralateral ratio (CR) before and after cosyntropin stimulations were determined, along with blood pressure outcome 1 year after surgery. Primary aldosteronism was diagnosed according to the Japanese Endocrine Society 2009 guidelines. The percentage of AVS patients with successful catheterization, defined as unstimulated SI > 2 before and stimulated SI > 5, increased after cosyntropin stimulation from 52% to 93% and from 74% to 98% for the right and left adrenal veins, respectively. LR decreased after cosyntropin stimulation (P < 0.001). In the postoperative patients, complete and partial clinical success was achieved in 49 and 27%, respectively. Low CR (<1) and high LR (≥2.6) after cosyntropin stimulation better correlated with postoperative blood pressure outcome than those before stimulation (CR < 1 and LR ≥ 2). These data suggest that cosyntropin stimulation facilitated the judgment of catheter insertion and postcosyntropin AVS indices may be more useful for predicting treatment outcome after unilateral adrenalectomy. Further study should examine the usefulness of cosyntropin stimulation in AVS performed in other settings.
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20
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Nagano H, Kono T, Saiga A, Kubota Y, Fujimoto M, Felizola SJA, Ishiwata K, Tamura A, Higuchi S, Sakuma I, Hashimoto N, Suzuki S, Koide H, Takeshita N, Sakamoto S, Ban T, Yokote K, Nakamura Y, Ichikawa T, Uno T, Tanaka T. Aldosterone Reduction Rate After Saline Infusion Test May Be a Novel Prediction in Patients With Primary Aldosteronism. J Clin Endocrinol Metab 2020; 105:5599822. [PMID: 31628466 DOI: 10.1210/clinem/dgz092] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/17/2019] [Accepted: 10/01/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Accurate assessment and localization of aldosterone-producing adenomas (APAs) are essential for the treatment of primary aldosteronism (PA). Although adrenal venous sampling (AVS) is the standard method of reference for subtype diagnosis in PA, controversy exists concerning the criteria for its interpretation. This study aims to determine better indicators that can reliably predict subtypes of PA. METHOD Retrospective, single-cohort analysis including 209 patients with PA who were subjected to AVS. Eighty-two patients whose plasma aldosterone concentrations (PAC) were normalized after surgery were histopathologically or genetically diagnosed with APA. The accuracy of image findings was compared to AVS results. Receiver operating characteristic (ROC) curve analysis between the operated and the no-apparent laterality groups was performed using AVS parameters and loading test for diagnosis of PA. RESULT Agreement between image findings and AVS results was 56.3%. ROC curve analysis revealed that the lateralization index (LI) after adrenocorticotropin stimulation cutoff was 2.40, with 98.8% sensitivity and 97.1% specificity. The contralateral suppression index (CSI) cutoff value was 1.19, with 98.0% sensitivity and 93.9% specificity. All patients over the LI and CSI cutoff values exhibited unilateral subtypes. Among the loading test, the best classification accuracy was achieved using the PAC reduction rate after a saline infusion test (SIT) >33.8%, which yielded 87.2% sensitivity or a PAC after a SIT <87.9 pg/mL with 86.2% specificity for predicting bilateral PA. CONCLUSION The combined criteria of the PAC reduction rate and PAC after the SIT can determine which subset of patients with APA who should be performed AVS for validation.
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Affiliation(s)
- Hidekazu Nagano
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Takashi Kono
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Atsushi Saiga
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Yoshihiro Kubota
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Masanori Fujimoto
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Saulo J A Felizola
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kazuki Ishiwata
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ai Tamura
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Seiichiro Higuchi
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Internal Medicine, Isumi Medical Center, Chiba, Japan
| | - Ikki Sakuma
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoko Hashimoto
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Sawako Suzuki
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hisashi Koide
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | | | | | - Toshiaki Ban
- Department of Internal Medicine, Isumi Medical Center, Chiba, Japan
| | - Koutaro Yokote
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | | | - Takashi Uno
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Tomoaki Tanaka
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
- Division of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
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21
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Historical changes and between-facility differences in adrenal venous sampling for primary aldosteronism in Japan. J Hum Hypertens 2019; 34:34-42. [PMID: 31462725 DOI: 10.1038/s41371-019-0229-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 06/16/2019] [Accepted: 06/28/2019] [Indexed: 01/14/2023]
Abstract
Primary aldosteronism (PA) is a common curable cause of hypertension. Adrenal venous sampling (AVS) is recommended for subtype diagnosis but is a difficult procedure. Recently, an increased prevalence of PA was reported, creating a greater demand for treatment of the condition in clinical facilities. The aim of the present study was to identify the historical changes over time and the differences between facilities in the success rate and subtype diagnosis of PA. The database of the PA registry developed by the Japan PA Study (JPAS) was used. A total of 2599 patients with PA who underwent AVS were evaluated. The overall success rate of AVS was 88%. The bilateral subtype was the dominant subtype, comprising 69% of cases. During the period 2004-2011 to 2011-2017, there were significant changes in the total number of AVS procedures (from 562 to 1732), ratio of ACTH administration with AVS (75 to 97%), success rate (79 to 90%), and proportion with bilateral subtype diagnosis (53 to 72%). There were also significant inter-facility differences in the number of AVS procedures (6 to 322), success rate (59 to 97%), and proportion with the bilateral subtype (44 to 86%). The principal enrolled department was Endocrinology (86%), and the ratio of unilateral PA was significantly higher in this department than in others (32% vs. 25%). In conclusion, the number of AVS procedures performed, the success rate, and the proportion with the bilateral subtype increased over time after normalizing the centre difference. Significant differences were observed between the centres.
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22
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Abstract
Primary aldosteronism (PA), the most common form of secondary hypertension, can be either surgically cured or treated with targeted pharmacotherapy. PA is frequently undiagnosed and untreated, leading to aldosterone-specific cardiovascular morbidity and nephrotoxicity. Thus, clinicians should perform case detection testing for PA at least once in all patients with hypertension. Confirmatory testing is indicated in most patients with positive case detection testing results. The next step is to determine whether patients with confirmed PA have a disease that can be cured with surgery or whether it should be treated medically; this step is guided by computed tomography scan of the adrenal glands and adrenal venous sampling. With appropriate surgical expertise, laparoscopic unilateral adrenalectomy is safe, efficient and curative in patients with unilateral adrenal disease. In patients who have bilateral aldosterone hypersecretion, the optimal management is a low-sodium diet and lifelong treatment with a mineralocorticoid receptor antagonist administered at a dosage to maintain a high-normal serum potassium concentration without the aid of oral potassium supplements.
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Affiliation(s)
- W F Young
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
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23
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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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Umakoshi H, Ogasawara T, Takeda Y, Kurihara I, Itoh H, Katabami T, Ichijo T, Wada N, Shibayama Y, Yoshimoto T, Ogawa Y, Kawashima J, Sone M, Inagaki N, Takahashi K, Watanabe M, Matsuda Y, Kobayashi H, Shibata H, Kamemura K, Otsuki M, Fujii Y, Yamamto K, Ogo A, Yanase T, Okamura S, Miyauchi S, Suzuki T, Tsuiki M, Naruse M. Accuracy of adrenal computed tomography in predicting the unilateral subtype in young patients with hypokalaemia and elevation of aldosterone in primary aldosteronism. Clin Endocrinol (Oxf) 2018; 88:645-651. [PMID: 29464741 DOI: 10.1111/cen.13582] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 02/06/2018] [Accepted: 02/07/2018] [Indexed: 11/29/2022]
Abstract
CONTEXT The current Endocrine Society Guideline suggests that patients aged <35 years with marked primary aldosteronism (PA) and unilateral adrenal lesions on adrenal computed tomography (CT) scan may not need adrenal vein sampling (AVS) before proceeding to unilateral adrenalectomy. This suggestion is, however, based on the data from only one report in the literature. OBJECTIVE We sought to determine the accuracy of CT findings in young PA patients who had unilateral adrenal disease on CT with hypokalaemia and elevation of aldosterone. DESIGN AND PATIENTS We retrospectively studied 358 PA patients (n = 30, aged <35 years; n = 39, aged 35-40 years; n = 289, aged ≥40 years) with hypokalaemia and elevation of aldosterone and unilateral disease on CT who had successful AVS. MAIN OUTCOME MEASURE Accuracy of CT findings is determined by AVS findings and/or surgical outcomes in patients aged <35 years. RESULTS Concordance of the diagnosis between CT and AVS was 90% (27/30) in patients aged <35 years, 79% (31/39) in patients aged 35-40 years and 69% (198/289) in those aged ≥40 years (trend for P < .01). Surgical benefit was confirmed in three patients aged <35 years and in three patients aged 35-40 years with the available surgical data who had discordance between CT and AVS findings. Collectively, the diagnostic accuracy of CT findings was 100% (30/30) if aged <35 years and 87% (34/39) if aged 35-40 years. CONCLUSION Primary aldosteronism patients aged <35 years with hypokalaemia and elevation of aldosterone and unilateral disease on adrenal CT could be spared AVS.
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Affiliation(s)
- Hironobu Umakoshi
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Tatsuki Ogasawara
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yoshiyu Takeda
- Department of Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Isao Kurihara
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine, Keio University, Tokyo, Japan
| | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine, Keio University, Tokyo, Japan
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Takamasa Ichijo
- Department of Endocrinology and Metabolism, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Yui Shibayama
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Takanobu Yoshimoto
- Department of Molecular Endocrinology and Metabolism, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshihiro Ogawa
- Department of Molecular Endocrinology and Metabolism, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junji Kawashima
- Faculty of Life Science, Department of Metabolic Medicine, Kumamoto University, Kumamoto, Japan
| | - Masakatsu Sone
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University, Kyoto, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University, Kyoto, Japan
| | - Katsutoshi Takahashi
- Division of Nephrology and Endocrinology, University of Tokyo School of Medicine, Tokyo, Japan
| | - Minemori Watanabe
- Department of Endocrinology and Diabetes, Okazaki City Hospital, Okazaki, Japan
| | - Yuichi Matsuda
- Department of Cardiology, Sanda City Hospital, Sanda, Japan
| | - Hiroki Kobayashi
- Division of Nephrology, Hypertension and Endocrinology, Nihon University School of Medicine, Tokyo, Japan
| | - Hirotaka Shibata
- Faculty of Medicine, Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Oita University, Yufu, Japan
| | - Kohei Kamemura
- Department of Cardiology, Akashi Medical Center, Akashi, Japan
| | - Michio Otsuki
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuichi Fujii
- Department of Cardiology, JR Hiroshima Hospital, Hiroshima, Japan
| | - Koichi Yamamto
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Ogo
- Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Toshihiko Yanase
- Faculty of Medicine, Department of Endocrinology and Diabetes Mellitus, Fukuoka University, Fukuoka, Japan
| | - Shintaro Okamura
- Department of Endocrinology and Metabolism, Tenriyorozu Hospital, Tenri, Nara, Japan
| | - Shozo Miyauchi
- Department of Internal Medicine, Uwajima City Hospital, Uwajima, Japan
| | - Tomoko Suzuki
- Department of Public Health, School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Mika Tsuiki
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Mitsuhide Naruse
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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25
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Umakoshi H, Tsuiki M, Takeda Y, Kurihara I, Itoh H, Katabami T, Ichijo T, Wada N, Yoshimoto T, Ogawa Y, Kawashima J, Sone M, Inagaki N, Takahashi K, Watanabe M, Matsuda Y, Kobayashi H, Shibata H, Kamemura K, Otsuki M, Fujii Y, Yamamto K, Ogo A, Yanase T, Suzuki T, Naruse M. Significance of Computed Tomography and Serum Potassium in Predicting Subtype Diagnosis of Primary Aldosteronism. J Clin Endocrinol Metab 2018; 103:900-908. [PMID: 29092077 DOI: 10.1210/jc.2017-01774] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 10/03/2017] [Indexed: 02/04/2023]
Abstract
CONTEXT The number of centers with established adrenal venous sampling (AVS) programs for the subtype diagnosis of primary aldosteronism (PA) is limited. OBJECTIVE Aim was to develop an algorithm for AVS based on subtype prediction by computed tomography (CT) and serum potassium. DESIGN A multi-institutional retrospective cohort study in Japan. PATIENTS A total of 1591 patients with PA were classified into four groups according to CT findings and potassium status. Subtype diagnosis of PA was determined by AVS. MAIN OUTCOME MEASURE Prediction value of the combination of CT findings and potassium status for subtype diagnosis. RESULTS The percentages of unilateral hyperaldosteronism on AVS were higher in patients with unilateral disease on CT than those with bilateral normal results on CT (50.8% vs 14.6%, P < 0.01), and these percentages were higher in those with hypokalemia than those with normokalemia (58.4% vs 11.5%, P < 0.01). The prevalence and odds ratio for unilateral hyperaldosteronism on AVS were as follows: bilateral normal on CT with normokalemia, 6.2% (reference); unilateral disease on CT with normokalemia, 23.8% and 4.8 [95% confidence interval (CI), 3.1 to 7.2]; bilateral normal on CT with hypokalemia, 38.1% and 9.4 (95% CI, 6.2 to 14.1), and unilateral disease on CT with hypokalemia, 70.6% and 36.4 (95% CI, 24.7 to 53.5). CONCLUSIONS Patients with PA with bilateral normal results on CT and normokalemia likely have a low prior probability of a lateralized form of AVS and could be treated medically, whereas those with unilateral disease on CT and hypokalemia have a high probability of a lateralized form of AVS.
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Affiliation(s)
- Hironobu Umakoshi
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Mika Tsuiki
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yoshiyu Takeda
- Department of Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Isao Kurihara
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine, Keio University, Tokyo, Japan
| | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine, Keio University, Tokyo, Japan
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Takamasa Ichijo
- Department of Endocrinology and Metabolism, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Takanobu Yoshimoto
- Department of Molecular Endocrinology and Metabolism, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshihiro Ogawa
- Department of Molecular Endocrinology and Metabolism, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junji Kawashima
- Department of Metabolic Medicine, Faculty of Life Science, Kumamoto University, Kumamoto University, Kumamoto, Japan
| | - Masakatsu Sone
- Department of Diabetes, Endocrinology and Nutrition Kyoto University, Kyoto, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition Kyoto University, Kyoto, Japan
| | - Katsutoshi Takahashi
- Division of Nephrology and Endocrinology, University of Tokyo School of Medicine, Tokyo, Japan
- Division of Metabolism, Showa General Hospital, Tokyo, Japan
| | - Minemori Watanabe
- Department of Endocrinology and Diabetes, Okazaki City Hospital, Okazaki, Japan
| | - Yuichi Matsuda
- Department of Cardiology, Sanda City Hospital, Sanda, Japan
| | - Hiroki Kobayashi
- Division of Nephrology, Hypertension and Endocrinology, Nihon University School of Medicine, Tokyo, Japan
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Yufu, Japan
| | - Kohei Kamemura
- Department of Cardiology, Akashi Medical Center, Akashi, Japan
| | - Michio Otsuki
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuichi Fujii
- Department of Cardiology, JR Hiroshima Hospital, Hiroshima, Japan
| | - Koichi Yamamto
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Ogo
- Clinical Research Institute, National Hospital Organization Kyusyu Medical Center, Fukuoka, Japan
| | - Toshihiko Yanase
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Tomoko Suzuki
- Department of Public Health, School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Mitsuhide Naruse
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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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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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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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: 79] [Impact Index Per Article: 11.3] [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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Subtype Diagnosis of Primary Aldosteronism: Is Adrenal Vein Sampling Always Necessary? Int J Mol Sci 2017; 18:ijms18040848. [PMID: 28420172 PMCID: PMC5412432 DOI: 10.3390/ijms18040848] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 04/11/2017] [Accepted: 04/12/2017] [Indexed: 12/21/2022] Open
Abstract
Aldosterone producing adenoma and bilateral adrenal hyperplasia are the two most common subtypes of primary aldosteronism (PA) that require targeted and distinct therapeutic approaches: unilateral adrenalectomy or lifelong medical therapy with mineralocorticoid receptor antagonists. According to the 2016 Endocrine Society Guideline, adrenal venous sampling (AVS) is the gold standard test to distinguish between unilateral and bilateral aldosterone overproduction and therefore, to safely refer patients with PA to surgery. Despite significant advances in the optimization of the AVS procedure and the interpretation of hormonal data, a standardized protocol across centers is still lacking. Alternative methods are sought to either localize an aldosterone producing adenoma or to predict the presence of unilateral disease and thereby substantially reduce the number of patients with PA who proceed to AVS. In this review, we summarize the recent advances in subtyping PA for the diagnosis of unilateral and bilateral disease. We focus on the developments in the AVS procedure, the interpretation criteria, and comparisons of the performance of AVS with the alternative methods that are currently available.
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Wolley MJ, Stowasser M. New Advances in the Diagnostic Workup of Primary Aldosteronism. J Endocr Soc 2017; 1:149-161. [PMID: 29264474 PMCID: PMC5686599 DOI: 10.1210/js.2016-1107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 01/24/2017] [Indexed: 11/19/2022] Open
Abstract
Primary aldosteronism is an important and common cause of hypertension that carries a high burden of morbidity. Outcomes, however, are excellent if diagnosed and treated appropriately. The diagnostic workup for primary aldosteronism is complex and comprises three steps: (1) screening, (2) confirmatory testing, and (3) subtype differentiation. In this review, we discuss recent advances in the diagnostic workup for primary aldosteronism. The development of accurate mass spectroscopy-based assays for measuring aldosterone will lead to improved confidence in all diagnostic aspects involving measurement of aldosterone, and accurate measurement of angiotensin II may soon advance us beyond the measurement of renin. We now have a greater understanding of hormonal influences on the aldosterone/renin ratio, which are particularly important when screening premenopausal women or those taking estrogen-containing preparations. Confirmatory testing is important, but there are limitations to the commonly used methods that have recently become more apparent, with new approaches offering a way forward. Adrenal venous sampling (AVS) is a challenging procedure but is important for deciding on treatment options. Success rates may be improved by the use of Synacthen stimulation and of rapid intraprocedural measurement of cortisol. Better understanding of AVS interpretation criteria allows improved prognostication and aids treatment decisions. The use of labeled metomidate positron emission tomography computed tomography scanning may also offer an alternative to AVS in some units. Although the diagnostic approach to patients with primary aldosteronism remains a complex multistep process in which attention to detail is important, recent advances will improve patient care and outcomes.
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Affiliation(s)
- Martin J Wolley
- Endocrine Hypertension Research Centre, University of Queensland School of Medicine, Greenslopes Hospital, Greenslopes and Princess Alexandra Hospitals, Brisbane, Queensland, Australia 4102
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland School of Medicine, Greenslopes Hospital, Greenslopes and Princess Alexandra Hospitals, Brisbane, Queensland, Australia 4102
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Umakoshi H, Xiaomei Y, Ichijo T, Kamemura K, Matsuda Y, Fujii Y, Kai T, Fukuoka T, Sakamoto R, Ogo A, Suzuki T, Ogasawara T, Tsuiki M, Naruse M. Reassessment of the cosyntropin stimulation test in the confirmatory diagnosis and subtype classification of primary aldosteronism. Clin Endocrinol (Oxf) 2017; 86:170-176. [PMID: 27474252 DOI: 10.1111/cen.13167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 04/21/2016] [Accepted: 07/27/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Although corticotropin is a representative secretagogue of aldosterone, the utility of the cosyntropin stimulation test (C-ST) in diagnosing primary aldosteronism (PA) has not been elucidated. Aim of the study was to evaluate the clinical utility of C-ST for confirmatory testing and subtype classification of PA. DESIGN, SETTING AND PATIENTS In this retrospective study, we identified patients with hypertension and positive case-detection results for PA who underwent C-ST and saline infusion testing (SIT) between 2006 and 2013 at eight referral centres in Japan. PA and essential hypertension (EH) were distinguished based on SIT results. PA subtype classification was determined by adrenal venous sampling (AVS). Plasma aldosterone concentration (PAC) was measured before and 30 and 60 min after intravenous cosyntropin administration. The ability of C-ST to distinguish PA from EH and to distinguish unilateral from bilateral disease was assessed by the area under the receiver operating characteristic curve. RESULTS Of 205 patients with hypertension and positive case-detection results, 139 (68%) had PA based on SIT results. Eighteen patients in whom AVS was unsuccessful were excluded from analysis. The baseline PAC before C-ST was significantly higher (P < 0·01) in patients with PA than in those with EH. However, the degree of difference in PAC between patients with PA and EH was not enhanced by the administration of cosyntropin. In addition, the administration of cosyntropin did not improve the distinction between bilateral and unilateral PA subtypes. CONCLUSIONS C-ST has no utility as a confirmatory and subtype testing of PA when the diagnosis of PA is based on the positive results in SIT.
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Affiliation(s)
- Hironobu Umakoshi
- Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yang Xiaomei
- Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Takamasa Ichijo
- Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama, Japan
| | - Kohei Kamemura
- Department of Cardiology, Akashi Medical Center, Akashi, Japan
| | - Yuichi Matsuda
- Department of Cardiology, Sanda City Hospital, Sanda, Japan
| | - Yuichi Fujii
- Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan
| | - Tatsuya Kai
- Department of Cardiology, Saiseikai Tondabayashi Hospital, Tondabayashi, Japan
| | - Tomikazu Fukuoka
- Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Ryuichi Sakamoto
- Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Atsushi Ogo
- Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Tomoko Suzuki
- Department of Public Health, Kitasato University School of Medicine, Tokyo, Japan
| | - Tatsuki Ogasawara
- Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Mika Tsuiki
- Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Mitsuhide Naruse
- Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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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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Funder JW, Carey RM, Mantero F, Murad MH, Reincke M, Shibata H, Stowasser M, Young WF. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101:1889-916. [PMID: 26934393 DOI: 10.1210/jc.2015-4061] [Citation(s) in RCA: 1610] [Impact Index Per Article: 201.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop clinical practice guidelines for the management of patients with primary aldosteronism. PARTICIPANTS The Task Force included a chair, selected by the Clinical Guidelines Subcommittee of the Endocrine Society, six additional experts, a methodologist, and a medical writer. The guideline was cosponsored by American Heart Association, American Association of Endocrine Surgeons, European Society of Endocrinology, European Society of Hypertension, International Association of Endocrine Surgeons, International Society of Endocrinology, International Society of Hypertension, Japan Endocrine Society, and The Japanese Society of Hypertension. The Task Force received no corporate funding or remuneration. EVIDENCE We searched for systematic reviews and primary studies to formulate the key treatment and prevention recommendations. We used the Grading of Recommendations, Assessment, Development, and Evaluation group criteria to describe both the quality of evidence and the strength of recommendations. We used "recommend" for strong recommendations and "suggest" for weak recommendations. CONSENSUS PROCESS We achieved consensus by collecting the best available evidence and conducting one group meeting, several conference calls, and multiple e-mail communications. With the help of a medical writer, the Endocrine Society's Clinical Guidelines Subcommittee, Clinical Affairs Core Committee, and Council successfully reviewed the drafts prepared by the Task Force. We placed the version approved by the Clinical Guidelines Subcommittee and Clinical Affairs Core Committee on the Endocrine Society's website for comments by members. At each stage of review, the Task Force received written comments and incorporated necessary changes. CONCLUSIONS For high-risk groups of hypertensive patients and those with hypokalemia, we recommend case detection of primary aldosteronism by determining the aldosterone-renin ratio under standard conditions and recommend that a commonly used confirmatory test should confirm/exclude the condition. We recommend that all patients with primary aldosteronism undergo adrenal computed tomography as the initial study in subtype testing and to exclude adrenocortical carcinoma. We recommend that an experienced radiologist should establish/exclude unilateral primary aldosteronism using bilateral adrenal venous sampling, and if confirmed, this should optimally be treated by laparoscopic adrenalectomy. We recommend that patients with bilateral adrenal hyperplasia or those unsuitable for surgery should be treated primarily with a mineralocorticoid receptor antagonist.
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Affiliation(s)
- John W Funder
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Robert M Carey
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Franco Mantero
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - M Hassan Murad
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Martin Reincke
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Hirotaka Shibata
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Michael Stowasser
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - William F Young
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
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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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Umakoshi H, Naruse M, Wada N, Ichijo T, Kamemura K, Matsuda Y, Fujii Y, Kai T, Fukuoka T, Sakamoto R, Ogo A, Suzuki T, Nanba K, Tsuiki M. Adrenal Venous Sampling in Patients With Positive Screening but Negative Confirmatory Testing for Primary Aldosteronism. Hypertension 2016; 67:1014-9. [PMID: 26975712 DOI: 10.1161/hypertensionaha.115.06607] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/18/2016] [Indexed: 11/16/2022]
Abstract
Adrenal venous sampling is considered to be the most reliable diagnostic procedure to lateralize aldosterone excess in primary aldosteronism (PA). However, normative criteria have not been established partially because of a lack of data in non-PA hypertensive patients. The aim of the study was to investigate aldosterone concentration and its gradient in the adrenal vein of non-PA hypertensive patients. We retrospectively studied the results of cosyntropin-stimulated adrenal venous sampling in 40 hypertensive patients who showed positive screening testing but negative results in 2 confirmatory tests/captopril challenge test and saline infusion test. Plasma aldosterone concentration, aldosterone/cortisol ratio, its higher/lower ratio (lateralization index) in the adrenal vein with cosyntropin stimulation were measured. Median plasma aldosterone concentration in the adrenal vein was 25 819 pg/mL (range, 5154-69 920) in the higher side and 12 953 (range, 1866-36 190) pg/mL in the lower side (P<0.001). There was a significant gradient in aldosterone/cortisol ratio between the higher and the lower sides (27.2 [5.4-66.0] versus 17.3 [4.0-59.0] pg/mL per μg/dL;P<0.001) with lateralization index ranging from 1.01 to 3.87. The aldosterone lateralization gradient was between 1 to 2 in 32 patients and 2 to 4 in 8 patients. None of the patients showed lateralization index ≥4. The present study demonstrated that plasma aldosterone concentration in the adrenal veins showed significant variation and lateralization gradient even in non-PA hypertensive patients. Adrenal venous sampling aldosterone lateralization gradients between 2 and 4 should be interpreted with caution in patients with PA because these gradients can be found even in patients with negative confirmatory testing for PA.
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Affiliation(s)
- Hironobu Umakoshi
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.)
| | - Mitsuhide Naruse
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.).
| | - Norio Wada
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.)
| | - Takamasa Ichijo
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.)
| | - Kohei Kamemura
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.)
| | - Yuichi Matsuda
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.)
| | - Yuichi Fujii
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.)
| | - Tatsuya Kai
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.)
| | - Tomikazu Fukuoka
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.)
| | - Ryuichi Sakamoto
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.)
| | - Atsushi Ogo
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.)
| | - Tomoko Suzuki
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.)
| | - Kazutaka Nanba
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.)
| | - Mika Tsuiki
- From the Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (H.U., M.N., K.N., M.T.); Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan (N.W.); Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama City, Japan (T.I.); Department of Cardiology, Akashi Medical Center, Akashi, Japan (K.K.); Department of Cardiology, Sanda City Hospital, Sanda, Japan (Y.M.); Department of Cardiology, Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan (Y.F.); Department of Cardiology, Saiseikai Tondabayashi Hospital, Osaka, Japan (T.K.); Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan (T.F.); Department of Metabolism and Endocrinology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (R.S., A.O.); and Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan (T.S.)
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Adrenal Vein Sampling for Conn's Syndrome: Diagnosis and Clinical Outcomes. Diagnostics (Basel) 2015; 5:254-71. [PMID: 26854152 PMCID: PMC4665593 DOI: 10.3390/diagnostics5020254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 05/06/2015] [Accepted: 06/03/2015] [Indexed: 11/30/2022] Open
Abstract
Adrenal vein sampling (AVS) is the gold standard test to determine unilateral causes of primary aldosteronism (PA). We have retrospectively characterized our experience with AVS including concordance of AVS results and imaging, and describe the approach for the PA patient in whom bilateral AVS is unsuccessful. We reviewed the medical records of 85 patients with PA and compared patients who were treated medically and surgically on pre-procedure presentation and post-treatment outcomes, and evaluated how technically unsuccessful AVS results were used in further patient management. Out of the 92 AVS performed in 85 patients, AVS was technically successful bilaterally in 58 (63%) of cases. Either unsuccessful AVS prompted a repeat AVS, or results from the contralateral side and from CT imaging were used to guide further therapy. Patients who were managed surgically with adrenalectomy had higher initial blood pressure and lower potassium levels compared with patients who were managed medically. Adrenalectomy results in significantly decreased blood pressure and normalization of potassium levels. AVS can identify surgically curable causes of PA, but can be technically challenging. When one adrenal vein fails to be cannulated, results from the contralateral vein can be useful in conjunction with imaging and clinical findings to suggest further management.
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