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Mullen N, Curneen J, Donlon PT, Prakash P, Bancos I, Gurnell M, Dennedy MC. Treating Primary Aldosteronism-Induced Hypertension: Novel Approaches and Future Outlooks. Endocr Rev 2024; 45:125-170. [PMID: 37556722 PMCID: PMC10765166 DOI: 10.1210/endrev/bnad026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 07/11/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023]
Abstract
Primary aldosteronism (PA) is the most common cause of secondary hypertension and is associated with increased morbidity and mortality when compared with blood pressure-matched cases of primary hypertension. Current limitations in patient care stem from delayed recognition of the condition, limited access to key diagnostic procedures, and lack of a definitive therapy option for nonsurgical candidates. However, several recent advances have the potential to address these barriers to optimal care. From a diagnostic perspective, machine-learning algorithms have shown promise in the prediction of PA subtypes, while the development of noninvasive alternatives to adrenal vein sampling (including molecular positron emission tomography imaging) has made accurate localization of functioning adrenal nodules possible. In parallel, more selective approaches to targeting the causative aldosterone-producing adrenal adenoma/nodule (APA/APN) have emerged with the advent of partial adrenalectomy or precision ablation. Additionally, the development of novel pharmacological agents may help to mitigate off-target effects of aldosterone and improve clinical efficacy and outcomes. Here, we consider how each of these innovations might change our approach to the patient with PA, to allow more tailored investigation and treatment plans, with corresponding improvement in clinical outcomes and resource utilization, for this highly prevalent disorder.
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Affiliation(s)
- Nathan Mullen
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| | - James Curneen
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| | - Padraig T Donlon
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| | - Punit Prakash
- Department of Electrical and Computer Engineering, Kansas State University, Manhattan, KS 66506, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Mark Gurnell
- Wellcome-MRC Institute of Metabolic Science, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK
| | - Michael C Dennedy
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
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2
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Maier P, Heinze B, Gabor S, Reese S, Hahner S, Schirbel A. Fluorinated aldosterone synthase (CYP11B2)-inhibitors for differential diagnosis between bilateral and unilateral conditions of primary aldosteronism. Bioorg Med Chem Lett 2023; 96:129501. [PMID: 37804995 DOI: 10.1016/j.bmcl.2023.129501] [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: 08/14/2023] [Revised: 09/25/2023] [Accepted: 10/04/2023] [Indexed: 10/09/2023]
Abstract
The enzyme aldosterone synthase (CYP11B2) is specifically expressed in aldosterone-producing tissue of the adrenal cortex and is overexpressed in aldosterone-producing adenomas (APA). It therefore represents an ideal target for molecular imaging, particularly for the differential diagnosis between bilateral hyperplasia and unilateral APA in primary aldosteronism. However, the presence of the cortisol-producing enzyme 11β-hydroxylase (CYP11B1) in the adrenal cortex remains very challenging owing to its high homology to CYP11B2. Within this study, we efficiently synthesized a variety of disubstituted fluorinated pyridines and pyrazines by Suzuki coupling reactions. These compounds were evaluated for their ability to inhibit CYP11B1 and CYP11B2 in transfected Y1 cells and in NCI-h295 cells. Several compounds were found to exhibit excellent affinity (IC50 < 10 nM) to CYP11B2 as well as strong selectivity (up to 125-fold) over CYP11B1. These findings support the further development of an analogous 18F-labelled PET tracer.
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Affiliation(s)
- Philipp Maier
- Department of Nuclear Medicine, University Hospital of Würzburg, University of Würzburg, 97080 Würzburg, Germany; University Clinic for Radiology and Nuclear Medicine, Otto von Guericke University (OvGU), 39120 Magdeburg, Germany; Division of Endocrinology & Diabetes, Department of Medicine I, University Hospital of Würzburg, University of Würzburg, 97080 Würzburg, Germany
| | - Britta Heinze
- Division of Endocrinology & Diabetes, Department of Medicine I, University Hospital of Würzburg, University of Würzburg, 97080 Würzburg, Germany
| | - Sabine Gabor
- Division of Endocrinology & Diabetes, Department of Medicine I, University Hospital of Würzburg, University of Würzburg, 97080 Würzburg, Germany
| | - Samario Reese
- Division of Endocrinology & Diabetes, Department of Medicine I, University Hospital of Würzburg, University of Würzburg, 97080 Würzburg, Germany
| | - Stefanie Hahner
- Division of Endocrinology & Diabetes, Department of Medicine I, University Hospital of Würzburg, University of Würzburg, 97080 Würzburg, Germany
| | - Andreas Schirbel
- Department of Nuclear Medicine, University Hospital of Würzburg, University of Würzburg, 97080 Würzburg, Germany.
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3
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Wang Y, Chen X, Lu G, Su Y, Yang L, Shi G, Zhang F, Zhuo J, Duan X, Hu H. Improving the Visualization of the Adrenal Veins Using Virtual Monoenergetic Images from Dual-Energy Computed Tomography before Adrenal Venous Sampling. Tomography 2023; 9:485-496. [PMID: 36960999 PMCID: PMC10037600 DOI: 10.3390/tomography9020040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/15/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
(1) Background: This study explored the optimal energy level in advanced virtual monoenergetic images (VMI+) from dual-energy computed tomography angiography (DE-CTA) for adrenal veins visualization before adrenal venous sampling (AVS). (2) Methods: Thirty-nine patients were included in this prospective single-center study. The CT value, noise, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were measured in both adrenal veins and abdominal solid organs and were then compared between VMI+ within the range of 40-80 kiloelectron volt (keV). The visualization rate of the adrenal veins and the overall image quality of solid organs were subjectively compared among different keV VMI+. The AVS success rate was recorded for 20 patients. (3) Results: For the adrenal veins, 40 keV VMI+ had the peak CT value, noise and CNR (p < 0.05). Subjectively, the visualization rate was the highest at 40 keV (100% for the right adrenal vein, and 97.4% for the left adrenal vein) (p < 0.05). For solid organs, the CT value, noise and CNR at 50 keV were lower than those at 40 keV (p < 0.05), but the SNR was similar between 40 keV and 50 keV. The overall subjective image quality of solid organs at 50 keV was the best (p < 0.05). The AVS success rate was 95%. (4) Conclusions: For VMI+, 40 keV was the preferential energy level to obtain a high visualization rate of the adrenal veins and a high success rate of AVS, while 50 keV was the favorable energy level for the depiction of abdominal organs.
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Affiliation(s)
- Yu Wang
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang Road West, Guangzhou 510120, China
| | - Xiaohong Chen
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang Road West, Guangzhou 510120, China
| | - Guoxiong Lu
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang Road West, Guangzhou 510120, China
| | - Yun Su
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang Road West, Guangzhou 510120, China
| | - Lingjie Yang
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang Road West, Guangzhou 510120, China
| | - Guangzi Shi
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang Road West, Guangzhou 510120, China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Fang Zhang
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang Road West, Guangzhou 510120, China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Jiayi Zhuo
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang Road West, Guangzhou 510120, China
| | - Xiaohui Duan
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang Road West, Guangzhou 510120, China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Huijun Hu
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang Road West, Guangzhou 510120, China
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Naruse M, Murakami M, Katabami T, Kocjan T, Parasiliti-Caprino M, Quinkler M, St-Jean M, O'Toole S, Ceccato F, Kraljevic I, Kastelan D, Tsuiki M, Deinum J, Torre EM, Puar T, Markou A, Piaditis G, Laycock K, Wada N, Grytaas MA, Kobayashi H, Tanabe A, Tong CV, Gallego NV, Gruber S, Beuschlein F, Kürzinger L, Sukor N, Azizan EABA, Ragnarsson O, Nijhoff MF, Maiolino G, Dalmazi GD, Kalugina V, Lacroix A, Furnica RM, Suzuki T. International multicenter survey on screening and confirmatory testing in primary aldosteronism. Eur J Endocrinol 2023; 188:6986591. [PMID: 36726325 DOI: 10.1093/ejendo/lvac002] [Citation(s) in RCA: 4] [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: 07/10/2022] [Revised: 10/31/2022] [Accepted: 11/16/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Primary aldosteronism (PA) is one of the most frequent causes of secondary hypertension. Although clinical practice guidelines recommend a diagnostic process, details of the steps remain incompletely standardized. DESIGN In the present SCOT-PA survey, we have investigated the diversity of approaches utilized for each diagnostic step in different expert centers through a survey using Google questionnaires. A total of 33 centers from 3 continents participated. RESULTS We demonstrated a prominent diversity in the conditions of blood sampling, assay methods for aldosterone and renin, and the methods and diagnostic cutoff for screening and confirmatory tests. The most standard measures were modification of antihypertensive medication and sitting posture for blood sampling, measurement of plasma aldosterone concentration (PAC) and active renin concentration by chemiluminescence enzyme immunoassay, a combination of aldosterone-to-renin ratio with PAC as an index for screening, and saline infusion test in a seated position for confirmatory testing. The cutoff values for screening and confirmatory testing showed significant variation among centers. CONCLUSIONS Diversity of the diagnostic steps may lead to an inconsistent diagnosis of PA among centers and limit comparison of evidence for PA between different centers. We expect the impact of this diversity to be most prominent in patients with mild PA. The survey raises 2 issues: the need for standardization of the diagnostic process and revisiting the concept of mild PA. Further standardization of the diagnostic process/criteria will improve the quality of evidence and management of patients with PA.
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Affiliation(s)
- Mitsuhide Naruse
- Endocrine Center and Clinical Research Center, Ijinkai Takeda General Hospital, Kyoto, 601-1495, Japan
| | - Masanori Murakami
- Department of Molecular Endocrinology and Metabolism, Tokyo Medical and Dental University, Tokyo, 113-8510, Japan
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University Yokohama City Seibu Hospital, Yokohama, 241-0811, Japan
| | - Tomaz Kocjan
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Medical Centre Ljubljana, Ljubljana, 1000, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, 1000, Slovenia
| | - Mirko Parasiliti-Caprino
- Endocrinology, Diabetes, and Metabolism; Department of Medical Sciences; University of Turin, Turin, 10126, Italy
| | | | - Matthieu St-Jean
- Division of Endocrinology, Department of Medicine, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, J1H 5N4, Canada
| | - Sam O'Toole
- Department of Endocrinology, The Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padova, 35128, Italy
| | - Ivana Kraljevic
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, 10 000, Croatia
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, 10 000, Croatia
| | - Mika Tsuiki
- Department of Endocrinology and Metabolism, NHO Kyoto Medical Center, Kyoto, 612-8555, Japan
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, 6525 GA, Netherlands
| | - Edelmiro Menéndez Torre
- Servicio de Endocrinología, Hospital Universitario Central de Asturias, Oviedo, 33011, Spain
| | - Troy Puar
- Department of Endocrinology, Changi General Hospital, Singapore, 529889, Singapore
| | - Athina Markou
- Endocrinology Department and Diabetes Center, 'G. Gennimatas' General Hospital of Athens, Athens, 115 28, Greece
| | - George Piaditis
- Endocrinology Department and Diabetes Center, 'G. Gennimatas' General Hospital of Athens, Athens, 115 28, Greece
| | - Kate Laycock
- Department of Diabetes & Metabolism, Barts Health NHS Trust, St Bartholomew's and Royal London Hospital, London, E1 1BB, UK
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, 060-8604, Japan
| | | | - Hiroki Kobayashi
- Division of Nephrology, Hypertension, and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, 173-8610, Japan
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology, and Metabolism, National Center for Global Health and Medicine, Tokyo, 162-8655, Japan
| | - Chin Voon Tong
- Department of Medicine, Hospital Melaka, Melaka, 75400, Malaysia
| | - Nuria Valdés Gallego
- Department of Internal Medicine, Section of Endocrinology and Nutrition, Hospital Universitario de Cabueñes, Gijón, 33394, Spain
| | - Sven Gruber
- Department of Endocrinology, Diabetology and Clinical Nutrition, Clinic for Endocrinology and Diabetology, University Hospital Zurich, CH-8091, Switzerland
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, Clinic for Endocrinology and Diabetology, University Hospital Zurich, CH-8091, Switzerland
| | - Lydia Kürzinger
- Department of Internal Medicine, Division of Endocrinology and Diabetes, University Hospital Würzburg, Würzburg, 97082, Germany
| | - Norlela Sukor
- Department of Medicine, The National University of Malaysia (UKM) Medical Centre, Kuala Lumpur, 59200, Malaysia
| | - Elena A B Aisha Azizan
- Department of Medicine, The National University of Malaysia (UKM) Medical Centre, Kuala Lumpur, 59200, Malaysia
| | - Oskar Ragnarsson
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg,413 45, Sweden
| | - Michiel F Nijhoff
- Department of Internal Medicine, Division of Endocrinology and Diabetes, Leiden University Medical Center, Leiden, 2333 ZA, The Netherlands
| | - Giuseppe Maiolino
- Clinica Medica 3, Department of Medicine - DIMED, University of Padova, Padova, 35126, Italy
| | - Guido Di Dalmazi
- Unit of Endocrinology and Diabetes Prevention and Care, University of Bologna, Bologna, 40126, Italy
| | - Valentina Kalugina
- Endocrinology Department, North-Western State Medical University named after I.I. Mechnikov, St Petersburg, 191015, Russia
| | - André Lacroix
- Endocrine Division, Department of Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, H2X 3E4, Canada
| | - Raluca Maria Furnica
- Department of Endocrinologie, Cliniques Universitaires Saint Luc, Bruxelles, 1200, Belgium
| | - Tomoko Suzuki
- Department of Public Health, International University of Health and Welfare School of Medicine, Chiba, 286-8686, Japan
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Predicting Treatment Response in Primary Aldosteronism Using 11C-Metomidate Positron Emission Tomography. Clin Nucl Med 2022; 47:936-942. [DOI: 10.1097/rlu.0000000000004369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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6
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Yan Y, Sun H, Qi Y. Prognosis of adrenalectomy guided by computed tomography versus adrenal vein sampling in patients with primary aldosteronism: A systematic review and meta‐analysis. J Clin Hypertens (Greenwich) 2022; 24:106-115. [PMID: 35064745 PMCID: PMC8845452 DOI: 10.1111/jch.14395] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/24/2021] [Accepted: 09/20/2021] [Indexed: 12/29/2022]
Abstract
Adrenal vein sampling (AVS) is recommended to be the gold standard for patients with unilateral subtypes of primary aldosteronism to clinical diagnosis and surgery therapy. However, it is uncertain whether AVS is better for prognosis than computed tomography (CT), which is the most widely used. Pubmed, Embase, and Cochrane Library were searched for articles with no start date restriction. The last search was conducted on Jun 15, 2021. Eligible studies compared the distinct subtypes of primary aldosteronism by AVS with CT (as a control group) and reported the prognosis at follow‐up. Evaluation of cohort studies referred to Newcastle ‐ Ottawa Quality Assessment Scale, and randomized controlled trials referred to Updated Cochrane Collaboration tool. A random‐effect model or fixed‐effect model was chosen according to the heterogeneity test. All processes were performed following the PRISMA 2020 statement. Eleven studies were identified, including 1325 patients based on AVS and 907 patients based on CT. Compared with patients guided by CT, patients who underwent AVS had an increased possibility of complete biochemical success (odds ratio [OR] 2.78, 95% CI 1.88–4.12) and a decreased chance of absent biochemical success (OR 0.23, 95% CI 0.13–0.40) at follow‐up. Nevertheless, the rate of complete clinical success (OR 1.09, 95% CI 0.89–1.35) and absent clinical success (OR 0.96, 95% CI 0.68–1.33) had no significant difference. Therefore, distinguishing subtypes by AVS for early treatment may be crucial since it can promote biochemical improvement.
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Affiliation(s)
- Yi Yan
- Beijing An Zhen Hospital Capital Medical University Beijing China
| | - Hui‐Wen Sun
- Beijing An Zhen Hospital Capital Medical University Beijing China
| | - Yue Qi
- Beijing An Zhen Hospital Capital Medical University Beijing China
- Beijing Institute of Heart Lung and Blood Vessel Diseases Beijing China
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Augustin AM, Dalla Torre G, Fuss CT, Fassnacht M, Bley TA, Kickuth R. Reduction of Radiation Exposure in Adrenal Vein Sampling: Impact of the Rapid Cortisol Assay. ROFO-FORTSCHR RONTG 2021; 193:1392-1402. [PMID: 34384111 DOI: 10.1055/a-1535-2566] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To determine radiation exposure associated with adrenal vein sampling and its reduction by implementing the rapid cortisol assay and modification of the sampling protocol. MATERIALS AND METHODS A single-center retrospective study of adrenal vein sampling performed between August 2009 and March 2020 revealed data from 151 procedures. Three subgroups were determined. In group I, a sampling protocol including sampling from the renal veins without the rapid cortisol assay was applied. In group II, blood was sampled using the same protocol but applying the rapid cortisol assay. In group III, a modified sampling protocol was used, in which the additional sampling from the renal veins was dispensed with, while the rapid cortisol assay was retained. Primary endpoints were radiation exposure parameters with dose area product, fluoroscopy time, and effective dose. As secondary endpoints, procedural data including technical success, lateralization, the correlation between patient BMI and radiation exposure, and concordance of lateralization with cross-sectional imaging were investigated. Furthermore, the correlation of aldosterone-cortisol ratios between the adrenal and ipsilateral renal vein was calculated to assess the benefit of sampling from the renal veins. RESULTS For all procedures performed in the study collective, the median dose area product was 60.01 Gy*cm2 (5.71-789.31), the median fluoroscopy time was 14.90 min (3.27-80.90), and the calculated median effective dose was 12.60 mSv (1.20-165.76). Significant differences in radiation exposure parameters between the study subgroups could be revealed. Dose area product resulted in reductions of 57.94 % after implementation of the rapid cortisol assay and a further 40.44 % after revision of the sampling protocol. Fluoroscopy time was reduced by 40.48 % after integration of the rapid cortisol assay and a further 40.47 % after protocol refinement. Radiation doses were increased in cases of resampling (dose area product 51.31 vs. 118.11 Gy*cm2, fluoroscopy time of 12.48 vs. 28.70 min). A strong correlation between patient BMI and procedural dose area product could be found. After the introduction of the rapid cortisol assay, successive improvement of the technical success rate could be found (33.33 % in group I, 90.22 % in group II and 92.11 % in group III). The correlation of aldosterone-cortisol ratios between adrenal and renal veins was poor. CONCLUSION The introduction of the rapid cortisol assay significantly decreased the radiation exposure and increased the technical success rate. Renal vein sampling did not provide further benefit in the evaluation of primary aldosteronism subtype and its omission resulted in a further reduction of radiation dose. KEY POINTS · The rapid cortisol assay significantly reduces the procedure-related radiation dose in adrenal vein sampling and increases the procedural technical success.. · Since additional sampling from the renal veins offers no further diagnostic benefit, a refinement of the sampling protocol can enable a further reduction of radiation dose.. · Resampling, technical unsuccessful procedures, and higher patients' BMI are associated with higher radiation exposures.. CITATION FORMAT · Augustin A, Dalla Torre G, Fuss CT et al. Reduction of Radiation Exposure in Adrenal Vein Sampling: Impact of the Rapid Cortisol Assay. Fortschr Röntgenstr 2021; 193: 1392 - 1402.
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Affiliation(s)
- Anne Marie Augustin
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Würzburg, Germany
| | - Giulia Dalla Torre
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Würzburg, Germany
| | - Carmina Teresa Fuss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, Würzburg, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, Würzburg, Germany
| | - Thorsten Alexander Bley
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Würzburg, Germany
| | - Ralph Kickuth
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Würzburg, Germany
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8
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Tulin R, Tulin A, Tomescu LF, Mihaly E, Avino A, Socea B, Jecan CR, Stiru O, Spataru RI. The importance of adrenal venous sampling in ACTH-independent Cushing syndrome: A case report and literature review. Exp Ther Med 2021; 22:772. [PMID: 34055071 PMCID: PMC8145433 DOI: 10.3892/etm.2021.10204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/30/2021] [Indexed: 11/28/2022] Open
Abstract
Independent Cushing's adrenocorticotropic hormone (ACTH) syndrome can have several causes, including adrenal carcinoma or simple adrenal hyperplasia. Although the distinction between malignant and benign can be effectively made through imaging investigations, in the situation where there are bilateral formations, their hormonal activity is impossible to appreciate via non-invasive techniques. The present study includes the presentation of a clinical case on the basis of which a literature review was made. The clinical case pertains to a 32-year-old patient with ACTH-independent Cushing's syndrome and bilateral adrenal tumor formations leading to the utility of adrenal venous sampling to avoid bilateral adrenalectomy. A literature review was subsequently conducted focusing on articles pertaining to the PICO criteria in order to describe: The diagnosis of adrenal tumor masses, the decision on the type of surgery and most importantly, the impact of adrenal venous sampling in avoiding surgical resection. These interventions severely limit the patients' quality of life.
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Affiliation(s)
- Raluca Tulin
- Department of Embryology, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Endocrinology, 'Prof. Dr. Agrippa Ionescu' Clinical Emergency Hospital, 011356 Bucharest, Romania
| | - Adrian Tulin
- Department of Anatomy, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, 'Prof. Dr. Agrippa Ionescu' Clinical Emergency Hospital, 011356 Bucharest, Romania
| | - Luminita Florentina Tomescu
- Department of Cardiovascular Surgery, 'Prof. Dr. Agrippa Ionescu' Clinical Emergency Hospital, 011356 Bucharest, Romania
| | - Enyedi Mihaly
- Department of Anatomy, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Adelaida Avino
- Department of Plastic and Reconstructive Surgery, 'Prof. Dr. Agrippa Ionescu' Clinical Emergency Hospital, 011356 Bucharest, Romania.,Department of Plastic and Reconstructive Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Bogdan Socea
- Department of Surgery, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Surgery, 'Sf. Pantelimon' Emergency Clinical Hospital, 021659 Bucharest, Romania
| | - Cristian-Radu Jecan
- Department of Plastic and Reconstructive Surgery, 'Prof. Dr. Agrippa Ionescu' Clinical Emergency Hospital, 011356 Bucharest, Romania.,Department of Plastic and Reconstructive Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Ovidiu Stiru
- Department of Cardiovascular Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Cardiovascular Surgery 'Prof. Dr. C. C. Iliescu' Emergency Institute for Cardiovascular Diseases, 022328 Bucharest, Romania
| | - Radu-Iulian Spataru
- Discipline of Pediatric Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Pediatric Surgery, Emergency Clinical Hospital for Children 'Marie S. Curie', 41451 Bucharest, Romania
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9
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Lee J, Ha J, Lee SK, Park HL, Kim SH, Lim DJ, Lee JM, Chang SA, Kang MI, Kim MH. Feasibility of Iodine-131 6β-Methyl-Iodo-19 Norcholesterol (NP-59) Scintigraphy to Complement Adrenal Venous Sampling in Management of Primary Aldosteronism: A Case Series. Int J Gen Med 2021; 14:673-680. [PMID: 33688238 PMCID: PMC7935438 DOI: 10.2147/ijgm.s288774] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/08/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Primary aldosteronism (PA) is mainly comprised of aldosterone-producing adenoma and bilateral idiopathic adrenal hyperplasia. Current guidelines recommend adrenal venous sampling (AVS) as a gold standard method to classify the subtypes. However, because of technical challenges in AVS including invasiveness of AVS and a wide range of success rate for cannulation, it is not uncommon that appropriate decisions could not be made depending on AVS. The aim of this study is to elucidate the proper role of I‑131‑6β‑iodomethyl‑norcholesterol (NP-59) scintigraphy in management of PA. Patients and Methods Between January 2009 and October 2018, patients with PA were retrospectively reviewed for the study. Five patients were included in the study who had NP-59 scintigraphy with non-conclusive AVS results or without AVS. We described the clinical outcome of patients in whom clinical decisions were made according to NP-59 scintigraphy results. Results Patients in the presenting cases were diagnosed for PA. AVS, the most reliable test to identify unilateral APA, were not applicable because of hypersensitivity to contrast dye (patient 1), and use of antiplatelet agents after acute cerebral infarction (patient 2). NP-59 scintigraphy was performed in patients 3 and 4 whose result of AVS and CT scan were inconsistent. In patient 5, who had bilateral adrenal adenomas (two in the left and one in the right adrenal gland), both unsuccessful catheterization and coexistence of cortisol overproduction made AVS results unreliable. Conclusion Based on clinical outcomes of these case series, it is noticeable that NP-59 scintigraphy could play a substantial role in management of PA in selected cases.
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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
| | - 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
| | - Sang-Kuon Lee
- Division of Pancreatobiliary Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hye Lim Park
- Division of Nuclear Medicine, Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Hoon Kim
- Division of Nuclear Medicine, Department of Radiology, 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
| | - Jung Min 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
| | - Sang-Ah Chang
- 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
| | - 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
| | - 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
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10
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Rossi GP. Heterogenous Responses to Cosyntropin in Primary Aldosteronism. J Clin Endocrinol Metab 2020; 105:5608053. [PMID: 31665321 DOI: 10.1210/clinem/dgz133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 10/12/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Gian Paolo Rossi
- Department of Medicine-DIMED, University of Padova, Hypertension Unit, University Hospital, Padova, Italy
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11
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Leung HT, Woo YC, Fong CHY, Tan KCB, Lau EYF, Chan KW, Leung JYY. A clinical prediction score using age at diagnosis and saline infusion test parameters can predict aldosterone-producing adenoma from idiopathic adrenal hyperplasia. J Endocrinol Invest 2020; 43:347-355. [PMID: 31529391 DOI: 10.1007/s40618-019-01114-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 09/07/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Accurate subtyping of the primary aldosteronism into aldosterone-producing adenoma (APA) and idiopathic adrenal hyperplasia (IAH) is important to direct for specific treatment modalities. The objective of the study was to compare the clinical and biochemical parameters of APA and IAH patients to derive a Clinical Prediction Score reliably predicting APA from IAH. METHODS This was a retrospective multi-centre study recruiting 38 APA patients and 42 IAH patients from four major hospitals in Hong Kong using database from Surgical Outcomes Monitoring and Improvement Programme and Clinical Data Analysis and Reporting System. Their clinical and biochemical parameters were evaluated. RESULTS Patients in APA group were younger than IAH group (mean age 48.6 ± 9.2 vs. 57.1 ± 7.3 years old, p < 0.001), had more suppressed renin before saline infusion in saline infusion test (SIT) (median 0.19 [IQR 0.15-0.37] vs. 0.39 [IQR 0.19-0.69] ng/mL/h, p = 0.01), and higher aldosterone level after saline infusion in SIT (median 674 [IQR 498-1000] vs. 327 [IQR 242-483] pmol/L, p < 0.001). A clinical prediction score using three parameters was devised, comprising age at diagnosis < 50 years, PRA before saline infusion in SIT ≤ 0.26 ng/mL/h, and aldosterone level after saline infusion in SIT ≥ 424 pmol/L. A score of 2 would predict APA with a sensitivity of 84.2% and specificity of 88.1%, and a score of 3 would predict APA with a sensitivity of 31.6% and specificity of 100%. CONCLUSIONS Clinical Prediction Score based on the combination of age at diagnosis, PRA, and aldosterone level in the saline infusion tests could reliably predict APA from IAH.
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Affiliation(s)
- H T Leung
- Department of Medicine and Geriatrics, Ruttonjee Hospital, Wan Chai, Hong Kong.
| | - Y C Woo
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - C H Y Fong
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - K C B Tan
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - E Y F Lau
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - K W Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Lai Chi Kok, Hong Kong
| | - J Y Y Leung
- Department of Medicine and Geriatrics, Ruttonjee Hospital, Wan Chai, Hong Kong
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12
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Fuss CT, Treitl M, Rayes N, Podrabsky P, Fenske WK, Heinrich DA, Reincke M, Petersen TO, Fassnacht M, Quinkler M, Kickuth R, Hahner S. Radiation exposure of adrenal vein sampling: a German Multicenter Study. Eur J Endocrinol 2018; 179:261-267. [PMID: 30299899 PMCID: PMC6182189 DOI: 10.1530/eje-18-0328] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Adrenal vein sampling (AVS) represents the current diagnostic standard for subtype differentiation in primary aldosteronism (PA). However, AVS has its drawbacks. It is invasive, expensive, requires an experienced interventional radiologist and comes with radiation exposure. However, exact radiation exposure of patients undergoing AVS has never been examined. DESIGN AND METHODS We retrospectively analyzed radiation exposure of 656 AVS performed between 1999 and 2017 at four university hospitals. The primary outcomes were dose area product (DAP) and fluoroscopy time (FT). Consecutively the effective dose (ED) was approximately calculated. RESULTS Median DAP was found to be 32.5 Gy*cm2 (0.3–3181) and FT 18 min (0.3–184). The calculated ED was 6.4 mSv (0.1–636). Remarkably, values between participating centers highly varied: Median DAP ranged from 16 to 147 Gy*cm2, FT from 16 to 27 min, and ED from 3.2 to 29 mSv. As main reason for this variation, differences regarding AVS protocols between centers could be identified, such as number of sampling locations, frames per second and the use of digital subtraction angiographies. CONCLUSIONS This first systematic assessment of radiation exposure in AVS not only shows fairly high values for patients, but also states notable differences among the centers. Thus, we not only recommend taking into account the risk of radiation exposure, when referring patients to undergo AVS, but also to establish improved standard operating procedures to prevent unnecessary radiation exposure.
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Affiliation(s)
- C T Fuss
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital, University of Würzburg, Würzburg, Germany
| | - M Treitl
- Department of Clinical Radiology, Ludwig-Maximilians-University, Munich, Germany
| | - N Rayes
- Department of General, Visceral and Transplant Surgery, University Hospital Leipzig, Leipzig, Germany
| | - P Podrabsky
- Department of Radiology, Charité Campus Virchow Klinikum, Berlin, Germany
| | - W K Fenske
- Leipzig University Medical Center, Integrated Center for Research and Treatment Adiposity Diseases, Leipzig, Germany
- Internal Medicine (Endocrinology and Nephrology), University of Leipzig, Leipzig, Germany
| | - D A Heinrich
- Department of Endocrinology, Ludwig-Maximilians-University, Munich, Germany
| | - M Reincke
- Department of Endocrinology, Ludwig-Maximilians-University, Munich, Germany
| | - T-O Petersen
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - M Fassnacht
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital, University of Würzburg, Würzburg, Germany
| | - M Quinkler
- Endokrinologie in Charlottenburg, Endokrinologie Praxis am Stuttgarter Platz, Berlin, Germany
| | - R Kickuth
- Department of Radiology, University Hospital Würzburg, Würzburg, Germany
| | - S Hahner
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital, University of Würzburg, Würzburg, Germany
- Correspondence should be addressed to S Hahner;
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13
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Li H, Zhang X, Shen S, Zhang Y, Zhang W, Feng W, Li P, Zhu D. Adrenal androgen measurement for assessing the selectivity of adrenal venous sampling in primary aldosteronism. Steroids 2018; 134:16-21. [PMID: 29653114 DOI: 10.1016/j.steroids.2018.04.002] [Citation(s) in RCA: 6] [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: 01/27/2018] [Revised: 03/27/2018] [Accepted: 04/05/2018] [Indexed: 10/17/2022]
Abstract
Adrenal venous sampling (AVS) is the reference standard for primary aldosteronism (PA) subtyping. Cortisol is widely used to assess the success of selective AVS, but it is not always reliable. The aim of the present study was to investigate the usefulness of adrenal androgens, compared to cortisol, in assessing the selectivity of AVS. We consecutively recruited 37 patients with PA undergoing AVS. AVS procedures were performed with the bilateral simultaneous technique without cosyntropin stimulation. We collected two baseline blood samples from 10 patients with a 15-min interval between time-15 (t-15) and time 0 (t0) to measure the variability in the levels of the tested hormones over time. Cortisol, androstenedione, dehydroepiandrosterone (DHEA), and DHEA sulfate (DHEAS) concentrations were measured in adrenal and peripheral venous (AV and PV, respectively) samples. The selectivity index (SI) values for androstenedione and DHEA were on average 3.0- and 2.0-fold higher, respectively, than those for cortisol, respectively (P < 0.05). However, the SI for DHEAS was 5.0-fold lower than the SI for cortisol (P < 0.05). Plasma androstenedione and DHEA concentrations positively correlated with cortisol and aldosterone concentrations in AV samples (P < 0.01). Compared to cortisol, the variation ratio of AV androstenedione and DHEA decreased from t-15 to t0 (0.23 and 0.43 vs. 0.52; P = 0.001 and P = 0.061, respectively). Using receiver operating characteristic curves, an SI ≥ 3 for androstenedione or DHEA provided optimal sensitivity and specificity in AVS. Given the much larger AV/PV ratios and reduced variability compared to cortisol, the adrenal androgens androstenedione and DHEA are useful for assessing the selectivity of AVS without cosyntropin stimulation and may be superior analytes in conditions with marked variability of cortisol levels or with adrenocortical tumors cosecreting cortisol and aldosterone.
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Affiliation(s)
- Hongyun Li
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing 210008, PR China
| | - Xuebin Zhang
- Department of Imaging, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing 210008, PR China
| | - Shanmei Shen
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing 210008, PR China
| | - Yan Zhang
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing 210008, PR China
| | - Wenjing Zhang
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing 210008, PR China
| | - Wenhuan Feng
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing 210008, PR China
| | - Ping Li
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing 210008, PR China.
| | - Dalong Zhu
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing 210008, PR China.
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14
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Heinze B, Fuss CT, Mulatero P, Beuschlein F, Reincke M, Mustafa M, Schirbel A, Deutschbein T, Williams TA, Rhayem Y, Quinkler M, Rayes N, Monticone S, Wild V, Gomez-Sanchez CE, Reis AC, Petersenn S, Wester HJ, Kropf S, Fassnacht M, Lang K, Herrmann K, Buck AK, Bluemel C, Hahner S. Targeting CXCR4 (CXC Chemokine Receptor Type 4) for Molecular Imaging of Aldosterone-Producing Adenoma. Hypertension 2017; 71:317-325. [PMID: 29279316 DOI: 10.1161/hypertensionaha.117.09975] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 07/25/2017] [Accepted: 11/28/2017] [Indexed: 12/20/2022]
Abstract
Primary aldosteronism is the most frequent cause of secondary hypertension and is associated with increased morbidity and mortality compared with hypertensive controls. The central diagnostic challenge is the differentiation between bilateral and unilateral disease, which determines treatment options. Bilateral adrenal venous sampling, currently recommended for differential diagnosis, is an invasive procedure with several drawbacks, making it desirable to develop novel noninvasive diagnostic tools. When investigating the expression pattern of chemokine receptors by quantitative real-time polymerase chain reaction and immunohistochemistry, we observed high expression of CXCR4 (CXC chemokine receptor type 4) in aldosterone-producing tissue in normal adrenals, adjacent adrenal cortex from adrenocortical adenomas, and in aldosterone-producing adenomas (APA), correlating strongly with the expression of CYP11B2 (aldosterone synthase). In contrast, CXCR4 was not detected in the majority of nonfunctioning adenomas that are frequently found coincidently. The specific CXCR4 ligand 68Ga-pentixafor has recently been established as radiotracer for molecular imaging of CXCR4 expression and showed strong and specific binding to cryosections of APAs in our study. We further investigated 9 patients with primary aldosteronism because of APA by 68Ga-pentixafor-positron emission tomography. The tracer uptake was significantly higher on the side of increased adrenocortical aldosterone secretion in patients with APAs compared with patients investigated by 68Ga-pentixafor-positron emission tomography for other causes. Molecular imaging of aldosterone-producing tissue by a CXCR4-specific ligand may, therefore, be a highly promising tool for noninvasive characterization of patients with APAs.
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Affiliation(s)
- Britta Heinze
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Carmina T Fuss
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Paolo Mulatero
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Felix Beuschlein
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Martin Reincke
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Mona Mustafa
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Andreas Schirbel
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Timo Deutschbein
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Tracy Ann Williams
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Yara Rhayem
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Marcus Quinkler
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Nada Rayes
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Silvia Monticone
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Vanessa Wild
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Celso E Gomez-Sanchez
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Anna-Carinna Reis
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Stephan Petersenn
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Hans-Juergen Wester
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Saskia Kropf
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Martin Fassnacht
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Katharina Lang
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Ken Herrmann
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Andreas K Buck
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Christina Bluemel
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.)
| | - Stefanie Hahner
- From the Department of Internal Medicine I, Endocrinology and Diabetes Unit (B.H., C.T.F., M.F., K.L., S.H.), Department of Nuclear Medicine (A.S., K.H., A.K.B., C.B.), and Comprehensive Cancer Center Wuerzburg (T.D., M.F.), University Hospital of Wuerzburg, University of Wuerzburg, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Italy (P.M., T.A.W., S.M.); Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany (F.B., M.R., T.A.W., Y.R.); Department of Nuclear Medicine, Klinikum rechts der Isar der Technischen Universität München, Germany (M.M.); Endocrinology in Charlottenburg, Berlin, Germany (M.Q.); Department of General, Visceral, and Transplant Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Germany (N.R.); Department of Pathology, University of Würzburg, Germany (V.W.); Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, MS (C.E.G.-S.); Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Germany (A.-C.R.); ENDOC, Center for Endocrine Tumors, Hamburg, Germany (S.P.); Pharmaceutical Radiochemistry, Technische Universität München, Garching bei München, Germany (H.-J.W.); and Scintomics GmbH, Fürstenfeldbruck, Germany (S.K.).
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Reincke M. Adrenal vein sampling for subtyping in primary aldosteronism. Lancet Diabetes Endocrinol 2016; 4:718-719. [PMID: 27325146 DOI: 10.1016/s2213-8587(16)30113-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/01/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, 80336 München, Germany.
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Dekkers T, Prejbisz A, Kool LJS, Groenewoud HJMM, Velema M, Spiering W, Kołodziejczyk-Kruk S, Arntz M, Kądziela J, Langenhuijsen JF, Kerstens MN, van den Meiracker AH, van den Born BJ, Sweep FCGJ, Hermus ARMM, Januszewicz A, Ligthart-Naber AF, Makai P, van der Wilt GJ, Lenders JWM, Deinum J. Adrenal vein sampling versus CT scan to determine treatment in primary aldosteronism: an outcome-based randomised diagnostic trial. Lancet Diabetes Endocrinol 2016; 4:739-746. [PMID: 27325147 DOI: 10.1016/s2213-8587(16)30100-0] [Citation(s) in RCA: 174] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 05/12/2016] [Accepted: 05/16/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND The distinction between unilateral aldosterone-producing adenoma or bilateral adrenal hyperplasia as causes of primary aldosteronism is usually made by adrenal CT or by adrenal vein sampling (AVS). Whether CT or AVS represents the best test for diagnosis remains unknown. We aimed to compare the outcome of CT-based management with AVS-based management for patients with primary aldosteronism. METHODS In a randomised controlled trial, we randomly assigned patients with aldosteronism to undergo either adrenal CT or AVS to determine the presence of aldosterone-producing adenoma (with subsequent treatment consisting of adrenalectomy) or bilateral adrenal hyperplasia (subsequent treatment with mineralocorticoid receptor antagonists). The primary endpoint was the intensity of drug treatment for obtaining target blood pressure after 1 year of follow-up, in the intention-to-diagnose population. Intensity of drug treatment was expressed as daily defined doses. Key secondary endpoints included biochemical outcome in patients who received adrenalectomy, health-related quality of life, cost-effectiveness, and adverse events. This trial is registered with ClinicalTrials.gov, number NCT01096654. FINDINGS We recruited 200 patients between July 6, 2010, and May 30, 2013. Of the 184 patients that completed follow-up, 92 received CT-based treatment (46 adrenalectomy and 46 mineralocorticoid receptor antagonist) and 92 received AVS-based treatment (46 adrenalectomy and 46 mineralocorticoid receptor antagonist). We found no differences in the intensity of antihypertensive medication required to control blood pressure between patients with CT-based treatment and those with AVS-based treatment (median daily defined doses 3·0 [IQR 1·0-5·0] vs 3·0 [1·1-5·9], p=0·52; median number of drugs 2 [IQR 1-3] vs 2 [1-3], p=0·87). Target blood pressure was reached in 39 (42%) patients and 41 (45%) patients, respectively (p=0·82). On secondary endpoints we found no differences in health-related quality of life (median RAND-36 physical scores 52·7 [IQR 43·9-56·8] vs 53·2 [44·0-56·8], p=0·83; RAND-36 mental scores 49·8 [43·1-54·6] vs 52·7 [44·9-55·5], p=0·17) for CT-based and AVS-based treatment. Biochemically, 37 (80%) of patients with CT-based adrenalectomy and 41 (89%) of those with AVS-based adrenalectomy had resolved hyperaldosteronism (p=0·25). A non-significant mean difference of 0·05 (95% CI -0·04 to 0·13) in quality-adjusted life-years (QALYs) was found to the advantage of the AVS group, associated with a significant increase in mean health-care costs of €2285 per patient (95% CI 1323-3248). At a willingness-to-pay value of €30 000 per QALY, the probability that AVS compared with CT constitutes an efficient use of health-care resources in the diagnostic work-up of patients with primary aldosteronism is less than 0·2. There was no difference in adverse events between groups (159 events of which nine were serious vs 187 events of which 12 were serious) for CT-based and AVS-based treatment. INTERPRETATION Treatment of primary aldosteronism based on CT or AVS did not show significant differences in intensity of antihypertensive medication or clinical benefits for patients after 1 year of follow-up. This finding challenges the current recommendation to perform AVS in all patients with primary aldosteronism. FUNDING Netherlands Organisation for Health Research and Development-Medical Sciences, Institute of Cardiology, Warsaw.
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Affiliation(s)
- Tanja Dekkers
- Department of Internal Medicine, Division of Vascular Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Leo J Schultze Kool
- Department of Radiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hans J M M Groenewoud
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marieke Velema
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Mark Arntz
- Department of Radiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | | | - Michiel N Kerstens
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Anton H van den Meiracker
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Bert-Jan van den Born
- Department of Internal and Vascular Medicine, Academic Medical Center, Amsterdam, Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ad R M M Hermus
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Alike F Ligthart-Naber
- Department of Internal Medicine, Division of Vascular Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Peter Makai
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gert-Jan van der Wilt
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jacques W M Lenders
- Department of Internal Medicine, Division of Vascular Medicine, Radboud University Medical Center, Nijmegen, Netherlands; Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Jaap Deinum
- Department of Internal Medicine, Division of Vascular Medicine, Radboud University Medical Center, Nijmegen, Netherlands.
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Guo YW, Hwu CM, Won JGS, Chu CH, Lin LY. A case of adrenal Cushing's syndrome with bilateral adrenal masses. Endocrinol Diabetes Metab Case Rep 2016; 2016:150118. [PMID: 27252858 PMCID: PMC4870494 DOI: 10.1530/edm-15-0118] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 04/18/2016] [Indexed: 11/08/2022] Open
Abstract
UNLABELLED A functional lesion in corticotrophin (ACTH)-independent Cushing's syndrome is difficult to distinguish from lesions of bilateral adrenal masses. Methods for distinguishing these lesions include adrenal venous sampling and (131)I-6β-iodomethyl-19-norcholesterol ((131)I-NP-59) scintigraphy. We present a case of a 29-year-old Han Chinese female patient with a history of hypercholesterolaemia and polycystic ovary syndrome. She presented with a 6month history of an 8kg body weight gain and gradual rounding of the face. Serial examinations revealed loss of circadian rhythm of cortisol, elevated urinary free-cortisol level and undetectable ACTH level (<5pg/mL). No suppression was observed in both the low- and high-dose dexamethasone suppression tests. Adrenal computed tomography revealed bilateral adrenal masses. Adrenal venous sampling was performed, and the right-to-left lateralisation ratio was 14.29. The finding from adrenal scintigraphy with NP-59 was consistent with right adrenal adenoma. The patient underwent laparoscopic right adrenalectomy, and the pathology report showed adrenocortical adenoma. Her postoperative cortisol level was 3.2μg/dL, and her Cushingoid appearance improved. In sum, both adrenal venous sampling and (131)I-NP-59 scintigraphy are good diagnostic methods for Cushing's syndrome presenting with bilateral adrenal masses. LEARNING POINTS The clinical presentation of Cushing' syndrome includes symptoms and signs of fat redistribution and protein-wasting features.The diagnosis of patients with ACTH-independent Cushing's syndrome with bilateral adrenal masses is challenging for localisation of the lesion.Both adrenal venous sampling and (131)I-NP-59 scintigraphy are good methods to use in these patients with Cushing's syndrome presenting with bilateral adrenal masses.
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Affiliation(s)
- Ya-Wun Guo
- Department of Medicine, Taipei City Hospital, Zhongxing Branch, Taipei, Taiwan; Department of Medicine, Division of Endocrinology and Metabolism, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chii-Min Hwu
- Department of Medicine, Division of Endocrinology and Metabolism, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Justin Ging-Shing Won
- Department of Medicine, Division of Endocrinology and Metabolism, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chia-Huei Chu
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Otorhinolaryngology-Head and Neck Surgery, Division of Otology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Liang-Yu Lin
- Department of Medicine, Division of Endocrinology and Metabolism, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
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18
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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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Umakoshi H, Wada N, Ichijo T, Kamemura K, Matsuda Y, Fuji Y, Kai T, Fukuoka T, Sakamoto R, Ogo A, Suzuki T, Tsuiki M, Naruse M. Optimum position of left adrenal vein sampling for subtype diagnosis in primary aldosteronism. Clin Endocrinol (Oxf) 2015; 83:768-73. [PMID: 26123796 DOI: 10.1111/cen.12847] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 04/20/2015] [Accepted: 06/26/2015] [Indexed: 01/08/2023]
Abstract
CONTEXT Although adrenal vein sampling (AVS) is the standard method for subtype diagnosis in primary aldosteronism (PA), protocol details including the sampling position in the adrenal vein are not standardized. OBJECTIVE To establish the optimum sampling position in the left adrenal vein based on postoperative outcome in PA patients. DESIGN AND SETTING Retrospective study in nine referral centres. PARTICIPANTS Of 496 consecutive PA patients who underwent AVS between 2006 and 2013, 217 with successful AVS under cosyntropin stimulation, and with concomitant data from two positions: proximal (common trunk) and distal (central vein) to the junction with the inferior phrenic vein, were included. MAIN OUTCOME MEASURES Discordant rate of subtype diagnosis between common trunk and central vein, and postoperative outcomes in patients with discordant results. RESULTS Subtype diagnosis using common trunk and central vein was discordant in 10 (4·6%) of the 217 patients (κ = 0·87, P < 0·05). Of these 10 patients, eight with left unilateral subtype and two with bilateral subtype using common trunk data showed bilateral subtype and unilateral subtype, respectively, using central vein data. Five patients with left unilateral subtype and one with bilateral subtype by common trunk data underwent unilateral adrenalectomy. All six patients were cured of PA after adrenalectomy, resulting in false-negative rates of 17% (1/6) by common trunk data, and 83% (5/6) by central vein data. CONCLUSION In view of its better potential diagnostic accuracy, technical ease, lower cost and lower risk of vein rupture, blood sampling from the common trunk of the left adrenal vein may be preferable as the standard method of AVS in patients with PA, although additional studies in a larger number of cases are required.
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Affiliation(s)
- Hironobu Umakoshi
- Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organisation Kyoto Medical Centre, Kyoto, Japan
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City Hospital, Sapporo, Japan
| | - Takamasa Ichijo
- Department of Diabetes and Endocrinology, Saiseikai Yokohama City Toubu Hospital, Yokohama, Japan
| | - Kohei Kamemura
- Department of Cardiology, Akashi Medical Centre, Akashi, Japan
| | - Yuichi Matsuda
- Department of Cardiology, Sanda City Hospital, Sanda, Japan
| | - Yuichi Fuji
- 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 Endocrinology and Metabolism, National Hospital Organisation, Kyushu Medical Centre, Fukuoka, Japan
| | - Atsushi Ogo
- Department of Endocrinology and Metabolism, National Hospital Organisation, Kyushu Medical Centre, Fukuoka, Japan
| | - Tomoko Suzuki
- Department of Public Health, Kitasato University School of Medicine, Tokyo, Japan
| | - Mika Tsuiki
- Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organisation Kyoto Medical Centre, Kyoto, Japan
| | - Mitsuhide Naruse
- Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organisation Kyoto Medical Centre, Kyoto, Japan
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Lubitz CC, Economopoulos KP, Sy S, Johanson C, Kunzel HE, Reincke M, Gazelle GS, Weinstein MC, Gaziano TA. Cost-Effectiveness of Screening for Primary Aldosteronism and Subtype Diagnosis in the Resistant Hypertensive Patients. Circ Cardiovasc Qual Outcomes 2015; 8:621-30. [PMID: 26555126 PMCID: PMC4651757 DOI: 10.1161/circoutcomes.115.002002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 10/13/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary aldosteronism (PA) is a common and underdiagnosed disease with significant morbidity potentially cured by surgery. We aim to assess if the long-term cardiovascular benefits of identifying and treating surgically correctable PA outweigh the upfront increased costs in patients at the time patients are diagnosed with resistant hypertension (RH). METHODS AND RESULTS A decision-analytic model compares aggregate costs and systolic blood pressure changes of 6 recommended or implemented diagnostic strategies for PA in a simulated population of at-risk RH patients. We also evaluate a 7th "treat all" strategy wherein all patients with RH are treated with a mineralocorticoid-receptor antagonist without further testing at RH diagnosis. Changes in systolic blood pressure are subsequently converted into gains in quality-adjusted life years (QALYs) by applying National Health and Nutrition Examination Survey data on concomitant risk factors to an existing cardiovascular disease simulation model. QALYs and lifetime costs were then used to calculate incremental cost-effectiveness ratios for the competing strategies. The incremental cost-effectiveness ratio for the strategy of computerized tomography (CT) followed by adrenal venous sampling (AVS) was $82,000/QALY compared with treat all. Incremental cost-effectiveness ratios for CT alone and AVS alone were $200,000/QALY and $492,000/QALY; the other strategies were more costly and less effective. Integrating differential patient-reported health-related quality of life adjustments for patients with PA, and incremental cost-effectiveness ratios for screening patients with CT followed by AVS, CT alone, and AVS alone were $52,000/QALY, $114,000/QALY, and $269,000/QALY gained. CONCLUSIONS CT scanning followed by AVS was a cost-effective strategy to screen for PA among patients with RH.
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Affiliation(s)
- Carrie C Lubitz
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.).
| | - Konstantinos P Economopoulos
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - Stephen Sy
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - Colden Johanson
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - Heike E Kunzel
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - Martin Reincke
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - G Scott Gazelle
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - Milton C Weinstein
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - Thomas A Gaziano
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
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Ardhanari S, Kannuswamy R, Chaudhary K, Lockette W, Whaley-Connell A. Mineralocorticoid and apparent mineralocorticoid syndromes of secondary hypertension. Adv Chronic Kidney Dis 2015; 22:185-95. [PMID: 25908467 DOI: 10.1053/j.ackd.2015.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 03/02/2015] [Accepted: 03/04/2015] [Indexed: 11/11/2022]
Abstract
The mineralocorticoid aldosterone is a key hormone in the regulation of plasma volume and blood pressure in man. Excessive levels of this mineralocorticoid have been shown to mediate metabolic disorders and end-organ damage more than what can be attributed to its effects on blood pressure alone. Inappropriate excess levels of aldosterone contribute significantly to the cardiorenal metabolic syndrome and target organ injury that include atherosclerosis, myocardial hypertrophy, fibrosis, heart failure, and kidney disease. The importance of understanding the role of excess mineralocorticoid hormones such as aldosterone in resistant hypertension and in those with secondary hypertension should be visited. Primary aldosteronism is one of the commonly identified causes of hypertension and is treatable and/or potentially curable. We intend to review the management of mineralocorticoid-induced hypertension in the adult population along with other disease entities that mimic primary aldosteronism.
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Monticone S, Viola A, Rossato D, Veglio F, Reincke M, Gomez-Sanchez C, Mulatero P. Adrenal vein sampling in primary aldosteronism: towards a standardised protocol. Lancet Diabetes Endocrinol 2015; 3:296-303. [PMID: 24831990 DOI: 10.1016/s2213-8587(14)70069-5] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Primary aldosteronism comprises subtypes that need different therapeutic strategies. Adrenal vein sampling is recognised by Endocrine Society guidelines as the only reliable way to correctly diagnose the subtype of primary aldosteronism. Unfortunately, despite being the gold-standard procedure, no standardised procedure exists either in terms of performance or interpretation criteria. In this Personal View, we address several questions that clinicians are presented with when considering adrenal vein sampling. For each of these questions we provide responses based on the available evidence, and opinions based on our experience. In particular, we discuss the most appropriate way to prepare the patient, whether adrenal vein sampling can be avoided for some subgroups of patients, the use of ACTH (1-24) during the procedure, the most appropriate criteria for interpretation of adrenal vein cannulation and lateralisation, the use of contralateral suppression, and strategies to improve success rates of adrenal vein sampling in centres with little experience.
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Affiliation(s)
- Silvia Monticone
- Department of Medical Sciences, Division of Internal Medicine and Hypertension Unit, University of Torino, Torino, Italy
| | - Andrea Viola
- Department of Medical Sciences, Division of Internal Medicine and Hypertension Unit, University of Torino, Torino, Italy
| | - Denis Rossato
- Service of Radiology, University of Torino, Torino, Italy
| | - Franco Veglio
- Department of Medical Sciences, Division of Internal Medicine and Hypertension Unit, University of Torino, Torino, Italy
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Ludwig Maximilians University Hospital, Munich, Germany
| | - Celso Gomez-Sanchez
- Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center and University of Mississippi Medical Center, Jackson, MS, USA
| | - Paolo Mulatero
- Department of Medical Sciences, Division of Internal Medicine and Hypertension Unit, University of Torino, Torino, Italy.
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Freel EM. Adrenal vein sampling: is there now a consensus? Clin Endocrinol (Oxf) 2015; 82:35-6. [PMID: 25399523 DOI: 10.1111/cen.12675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 11/12/2014] [Indexed: 11/29/2022]
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Abstract
Arterial hypertension is a major cardiovascular risk factor that affects between 10 and 40% of the population in industrialized countries. Primary aldosteronism (PA) is the most common form of secondary hypertension with an estimated prevalence of around 10% in referral centers and 4% in a primary care setting. Despite its high prevalence until recently, the underlying genetic and molecular basis of this common disease had remained largely obscure. Over the past decade, a number of insights have been achieved that have relied on in vitro cellular systems, wild-type and genetically modified in vivo models, as well as clinical studies in well-characterized patient populations. This progress has been made possible by a number of independent technical developments including that of specific hormone assays that allow measurement in small sample volumes as well as genetic techniques that enable high-throughput sequencing of a large number of samples. Furthermore, animal models have provided important insights into the physiology of aldosterone regulation that have served as a starting point for investigation of mechanisms involved in autonomous aldosterone secretion. Finally, national and international networks that have built up registries and biobanks have been instrumental in fostering translational research endeavors in PA. Therefore, it is to be expected that in the near future, further pathophysiological mechanisms that result in autonomous aldosterone secretion will be unraveled.
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Affiliation(s)
- Felix Beuschlein
- Endocrine Research Unit, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ziemssenstrasse 1, D-80336 Munich, Germany.
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Takada A, Suzuki K, Mori Y, Hyodo R, Kawakami K, Okochi Y, Naganawa S. Comparison of the Central Adrenal Vein and the Common Trunk of the Left Adrenal Vein for Adrenal Venous Sampling. J Vasc Interv Radiol 2013; 24:550-7. [DOI: 10.1016/j.jvir.2013.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 12/24/2012] [Accepted: 01/08/2013] [Indexed: 11/15/2022] Open
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Küpers EM, Amar L, Raynaud A, Plouin PF, Steichen O. A clinical prediction score to diagnose unilateral primary aldosteronism. J Clin Endocrinol Metab 2012; 97:3530-7. [PMID: 22918872 DOI: 10.1210/jc.2012-1917] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CONTEXT Adrenal venous sampling is recommended to assess whether aldosterone hypersecretion is lateralized in patients with primary aldosteronism. However, this procedure is invasive, poorly standardized, and not widely available. OBJECTIVE Our goal was to identify patients' characteristics that can predict unilateral aldosterone hypersecretion in some patients who could hence bypass adrenal venous sampling before surgery. DESIGN AND SETTING A cross-sectional diagnostic study was performed from February 2009 to July 2010 at a single center specialized in hypertension care. PATIENTS A total of 101 consecutive patients with primary aldosteronism who underwent adrenal venous sampling participated in the study. The autonomy of aldosterone hypersecretion was assessed with the saline infusion test. INTERVENTION Adrenal venous sampling was performed without ACTH infusion but with simultaneous bilateral sampling. MAIN OUTCOME MEASURES Variables independently associated with a lateralized adrenal venous sampling in multivariate logistic regression were used to derive a clinical prediction rule. RESULTS Adrenal venous sampling was successful in 87 patients and lateralized in 49. All 26 patients with a typical Conn's adenoma plus serum potassium of less than 3.5 mmol/liter or estimated glomerular filtration rate of at least 100 ml/min/1.73 m2 (or both) had unilateral primary aldosteronism; this rule had 100% specificity (95% confidence interval, 91-100) and 53% sensitivity (95% confidence interval, 38-68). CONCLUSIONS If our results are validated on an independent sample, adrenal venous sampling could be omitted before surgery in patients with a typical Conn's adenoma if they meet at least one of two supplementary biochemical characteristics (serum potassium<3.5 mmol/liter or estimated glomerular filtration rate ≥100 ml/min/1.73 m2).
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Affiliation(s)
- Elselien M Küpers
- Assistance Publique-Hôpitaux de Paris, Hypertension Unit, and Université Paris-Descartes, Faculty of Medicine, 4 rue de la Chine, F-75020 Paris, France
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Fischer E, Degenhart C, Reincke M. Improving adrenal venous sampling in primary aldosteronism. Expert Rev Endocrinol Metab 2012; 7:531-540. [PMID: 30780896 DOI: 10.1586/eem.12.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Primary aldosteronism is the most frequent cause of secondary arterial hypertension. As adrenal imaging has been shown to have only limited value for differential diagnosis, adrenal vein sampling (AVS) has been implemented as a gold standard in the guidelines. However, AVS is a not well-standardized technique, and success rates vary in a wide range. Successful AVS procedures presuppose careful preparation and operational efficiency in an interdisciplinary team. Besides ruling out malignancy, multidetector-row helical computed tomography facilitates the localization of the adrenal veins. Rapid cortisol measurement has been shown to increase cannulation rates. The values of cosyntropin stimulation and bilateral simultaneous versus sequential catheterization remain unclear, but consistency is important. AVS should be performed in specialized centers by a limited number of radiologists in order to ensure success rates of at least 70%. Standardization of cutoff values should be accomplished through a consensus statement for consistent decision-making in patient care.
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Affiliation(s)
- Evelyn Fischer
- a Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ziemssenstr. 1,80336 München, Germany
| | - Christoph Degenhart
- b Institut für Klinische Radiologie, Klinikum der Ludwig-Maximilians-Universität München, Germany
| | - Martin Reincke
- a Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ziemssenstr. 1,80336 München, Germany
- c Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ziemssenstr. 1,80336 München, Germany.
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van der Linden P, Steichen O, Zinzindohoué F, Plouin PF. Blood pressure and medication changes following adrenalectomy for unilateral primary aldosteronism: a follow-up study. J Hypertens 2012; 30:761-9. [PMID: 22252482 DOI: 10.1097/hjh.0b013e328350225d] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Adrenalectomy for unilateral primary aldosteronism cures hypertension in less than 50% of patients, but improvement is observed in most of the remaining ones. Our goal was to quantify the blood pressure (BP) decrease adjusted for medication changes following adrenalectomy and to identify preoperative predictors of this outcome. METHODS We analyzed simultaneous changes in BP and medication by reviewing the records of 156 consecutive patients who had undergone adrenalectomy for unilateral primary aldosteronism in one center between 2001 and 2009 for whom postoperative follow-up data were available. RESULTS Median [interquartile range] baseline SBP was 149 [135-160] mmHg on drugs from two [1-3] different classes. After adrenalectomy, SBP decreased by 21 [5-31] mmHg and the number of drug classes administered, by one [0-2]. The decrease in SBP, adjusted for the change in the number of drug classes, was 26 [14-36] mmHg. Each drug class dropped after surgery was equivalent to a 5 mmHg SBP decrease. Patients with higher preoperative BP or serum sodium levels experienced a greater BP decrease after adrenalectomy. Adrenalectomy cured hypertension in 68 (44%) patients. Hypertension was less likely to be cured in patients with a longer history of hypertension, higher preoperative BP levels, larger number of drug classes, or lower urinary aldosterone levels. CONCLUSION Although patients with severe hypertension are likely to derive considerable benefits from adrenalectomy in terms of BP or treatment reduction, they should be warned that hypertension cure is unlikely.
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Küpers E, Amar L, Raynaud A, Plouin PF, Steichen O. Dérivation d’un critère de prédiction clinique pour le diagnostic de latéralisation dans l’hyperaldostéronisme primaire. Rev Med Interne 2012. [DOI: 10.1016/j.revmed.2012.03.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Seccia TM, Miotto D, Battistel M, Motta R, Barisa M, Maniero C, Pessina AC, Rossi GP. A stress reaction affects assessment of selectivity of adrenal venous sampling and of lateralization of aldosterone excess in primary aldosteronism. Eur J Endocrinol 2012; 166:869-75. [PMID: 22330150 DOI: 10.1530/eje-11-0972] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND A stress reaction involving increased cortisol release, which has not been documented thus far, might affect the assessment of selectivity of catheterization during adrenal venous sampling (AVS). OBJECTIVE To investigate whether an ACTH-driven cortisol release occurs during AVS and whether it influences the assessment of selectivity by the step-up of cortisol (plasma cortisol concentrations, PCC) between the adrenal vein blood (PCC(SIDE)) and the inferior vena cava (PCC(IVC)), e.g. the selectivity index (SI). DESIGN AND METHODS We determined the SI in samples obtained simultaneously at starting AVS (t-15) and again after 15 min (t0) in 34 consecutive patients with proven aldosterone-producing adenoma. We then calculated the SI with PCC(SIDE) obtained at t-15 and at t0, and the PCC(IVC) values obtained at the different time point, thus simulating sequential AVS. RESULTS The PCC(SIDE) and the SI fell significantly from t-15 to t0 on both the sides. When PCC(SIDE) obtained at t-15 was combined with PCC(IVC) at t0, the SI values were higher than those obtained with simultaneously drawn samples. This led to label as selective more AVS studies than with bilaterally simultaneous data, especially when using higher cutoffs for the SI. CONCLUSIONS A transient increase in cortisol release from both adrenal glands occurs in the majority of the patients who undergo AVS. This stress reaction can influence the assessment of both the selectivity of the catheterization during the sequential AVS technique and the lateralization of aldosterone excess.
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Affiliation(s)
- Teresa M Seccia
- Department of Medicine, DIMED - Internal Medicine 4, University of Padua, via Giustiniani, 2, 35126 Padua, Italy
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Zelinka T, Mašek M, Vlková J, Kasalický M, Michalský D, Holaj R, Petrák O, Štrauch B, Rosa J, Dvořáková J, Widimský, Jr. J. Discrepant Results of Adrenal Venous Sampling in Seven Patients with Primary Aldosteronism. ACTA ACUST UNITED AC 2012; 35:205-10. [DOI: 10.1159/000330720] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 07/05/2011] [Indexed: 11/19/2022]
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Betz MJ, Degenhart C, Fischer E, Pallauf A, Brand V, Linsenmaier U, Beuschlein F, Bidlingmaier M, Reincke M. Adrenal vein sampling using rapid cortisol assays in primary aldosteronism is useful in centers with low success rates. Eur J Endocrinol 2011; 165:301-6. [PMID: 21602315 DOI: 10.1530/eje-11-0287] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Adrenal vein sampling (AVS) is considered the gold standard in the differential diagnosis of primary aldosteronism (PA), but success rates vary between centers. We hypothesized that rapid (intraprocedure) cortisol measurement can improve performance in a center with initially low AVS success rate. DESIGN We analyzed 46 patients with confirmed PA studied between 2008 and 2010. Forty-seven PA patients studied between 2004 and 2008 identified by retrospective chart review served as controls. All patients were treated at a single tertiary care university hospital. METHODS Starting in 2008, rapid cortisol assays (RCA) were performed in all patients during the AVS procedure. A cortisol gradient of ≥2.0 between adrenal vein and a femoral vein sample was used as success criterion. Up to two repeat samples were drawn if adrenal vein cortisol was below this threshold. Results During the control period 26 of 47 AVS were successful (55%). After introduction of RCA, 39 out of 46 AVS (85%) were successful (P=0.003). In 21 of the 46 cases (46%) a resampling was necessary. The increase in overall success was due to an increase in successful right AVS (85 vs 62% before introduction of RCA; P=0.02) and a training effect (P=0.024 for trend). CONCLUSION RCA during AVS are useful in centers with an initially low AVS success rate.
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Affiliation(s)
- Matthias J Betz
- Department of Medicine, University Hospital Innenstadt, Ludwig Maximilians University, Ziemssenstrasse 1, D-80336 Munich, Germany
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Abstract
A few simple rules can allow physicians to successfully identify many patients with arterial hypertension caused by PA among the so-called essential hypertensive patients. The hyperaldosteronism and the hypokalemia can be cured with adrenalectomy in practically all of these patients. Moreover, in a substantial proportion of them, the blood pressure can be normalized or markedly lowered if a unilateral cause of PA is discovered. Hence, the screening for PA can be rewarding both for the patient and for the clinician, particularly in those cases where hypertension is severe and/or resistant to treatment, in which the removal of an APA can allow blood pressure to be brought under control despite withdrawal of, or a prominent reduction in, the number and doses of antihypertensive medications.
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Affiliation(s)
- Gian Paolo Rossi
- Molecular Hypertension Laboratory, Dipartimento di Medicina Clinica e Sperimentale G. Patrassi - Internal Medicine 4, University of Padua, University Hospital Padua, Via Giustiniani, 2, 35126 Padua, Italy.
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Abstract
This paper provides evidence that primary aldosteronism is likely much less common than is believed by the other authors of this collection. The basis for this contrarian view is simple: there is no way to know the true prevalence of PA because of the uncertain validity of all of the diagnostic procedures used to find and characterize this disease. Moreover, even if these uncertainties are overcome, the eventual treatment of most who have PA can be provided without the need for extensive testing and expensive treatment.
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Affiliation(s)
- Norman M Kaplan
- University of Texas Southwestern Medical School, Dallas, TX 75390, USA.
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Abstract
Primary aldosteronism is unquestionably the most common secondary cause of hypertension, and effective approaches to diagnosis and targeted treatments exist. Even the most conservative estimates of the prevalence of primary aldosteronism, however, indicate that the condition is grossly underdiagnosed. Part of the reason why diagnosis and treatment lag far behind is the lack of expertise, even among endocrinologists and hypertension specialists, in the approach to the patient with possible primary aldosteronism. We will never make an impression on this important problem unless general internists and primary care physicians actively participate in the screening and referral process. A healthcare delivery team need not fear an overwhelming and fruitless battle with an intractable conundrum if a practical and staged approach to workup and treatment is taken. This review discusses the approach we have taken in Dallas, a strategy of targeted screening, referral for positive screens, and individualized management.
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Affiliation(s)
- Richard J Auchus
- Division of Endocrinology and Metabolism, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8857, USA.
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37
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Abstract
Primary Aldosteronism (PA) is characterized by inappropriate aldosterone production partially autonomous of the renin-angiotensin system. Since the ARR ratio was introduced a much higher prevalence of this disease is recognized. PA could be the most common identifiable, specifically treatable and potentially curable form of hypertension so the need of a clinical practice guideline on primary aldosteronism becomes mandatory. Recently the Endocrine Society USA published clinical practice guidelines for the diagnosis and treatment of patients with primary hyperaldosteronism. Systematic reviews of available evidence were used to formulate the key treatment and prevention recommendations. Actually the Endocrine Society consensus is the most used guidelines in diagnosis and treatment of hyperaldosteronism. However, there remains a few unresolved issues, which unfortunately require more of a detour guide and cannot be easily addressed by a straight forward guideline.
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Affiliation(s)
- Maria-Verena Cicala
- Division of Endocrinology, Department of Medical and Surgical Sciences, University of Padua, Via Ospedale 105, 35128 Padova, Italy.
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38
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Abstract
Primary aldosteronism is more common than previously recognized but much less common than most experts in this arena have recently stated. The recognition of autonomous hyperaldosteronism is not difficult but the identification of the source of excess aldosterone requires a costly and difficult procedure. Most patients with hyperaldosteronism turn out to have bilateral adrenal hyperplasia for which medical therapy with an aldosterone blocker is indicated. Many of these patients are not hypokalemic and can safely be treated without the need for a costly and usually negative work-up.
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Affiliation(s)
- Norman M Kaplan
- University of Texas Southwestern Medical Center at Dallas, TX 75390-8586, USA.
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39
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Impact of Different Diagnostic Criteria During Adrenal Vein Sampling on Reproducibility of Subtype Diagnosis in Patients With Primary Aldosteronism. Hypertension 2010; 55:667-73. [DOI: 10.1161/hypertensionaha.109.146613] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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