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Imaging or Adrenal Vein Sampling Approach in Primary Aldosteronism? A Patient-Based Approach. Tomography 2022; 8:2735-2748. [PMID: 36412687 PMCID: PMC9680373 DOI: 10.3390/tomography8060228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/05/2022] [Accepted: 11/08/2022] [Indexed: 11/11/2022] Open
Abstract
Primary aldosteronism (PA) is the most frequent cause of secondary hypertension, associated with an increased risk of cardiovascular and cerebral disease, compared to essential hypertension. Therefore, it is mandatory to promptly recognize the disease and offer to the patient the correct diagnostic-therapeutic process in order to reduce new-onset cardiovascular events. It is fundamental to define subtype classification (unilateral or bilateral disease), in order to provide the best treatment (surgery for unilateral and medical treatment for bilateral disease). Here, we report five clinical cases of different subtypes of PA (patients with monolateral or bilateral PA, nondiagnostic AVS, allergy to iodinated contrast, and patients not suitable for surgery), with particular attention to the diagnostic-therapeutic process and the different approaches tailored to a single case. Since PA is a spectrum of various diseases, it needs a personalized diagnostic-therapeutic process, customized for the individual patient, depending on previous medical history, suitability for the surgery and patient's preferences.
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Younes N, Therasse E, Bourdeau I, Lacroix A. Successful Adrenal Vein Sampling Using Dexamethasone Premedication in Patients With Iodine Contrast Media Allergy. J Endocr Soc 2022; 6:bvac093. [PMID: 35795806 PMCID: PMC9249974 DOI: 10.1210/jendso/bvac093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Indexed: 01/30/2023] Open
Abstract
Abstract
Context
Preparation of patients with iodine contrast media (ICM) allergy who require adrenal vein sampling (AVS) to establish source of aldosterone excess of their confirmed primary aldosteronism (PA) is controversial. Usual premedication with high-dose prednisone can interfere with cortisol determinations, possibly altering the aldosterone to cortisol ratios for the identification of lateralized aldosterone excess.
Objective
We aimed to evaluate the efficacy and safety of premedication with high-dose dexamethasone to perform AVS in patients with ICM.
Methods
One hundred and seventy-seven consecutive patients with confirmed PA who underwent bilateral simultaneous basal and post-ACTH bolus AVS at our center between January 2010 and December 2020 were retrospectively analyzed for history of ICM allergy. A total of 7 patients (4%) with previous allergic reactions to ICM were prepared with 3 doses of 7.5 mg dexamethasone premedication rather than the usual 50 mg of prednisone.
Results
No breakthrough allergic reactions were reported in the 7 patients. Despite adequate serum cortisol suppression following dexamethasone, the basal and post-ACTH selectivity index were respectively > 2 and > 5 bilaterally in all patients, confirming adequate cannulation of both adrenal veins. Four patients had lateralized ratios (A/C ratio > 2 basally and > 4 post-ACTH), while 3 had bilateral source during AVS study. In the 3 patients undergoing unilateral adrenalectomy for lateralized source and contralateral suppression and adequate follow-up data, cure of PA was achieved at mean 58 months postoperatively.
Conclusion
AVS using dexamethasone premedication is safe and accurate for diagnosing the source of aldosterone excess in patients with PA and ICM allergy.
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Affiliation(s)
- Nada Younes
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l’Université de Montréal (CHUM) , Montréal, Québec H2X 0A9 , Canada
| | - Eric Therasse
- Department of Radiology, Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Université de Montréal , Québec H2X 0A9 , Canada
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l’Université de Montréal (CHUM) , Montréal, Québec H2X 0A9 , Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l’Université de Montréal (CHUM) , Montréal, Québec H2X 0A9 , Canada
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Yoshida Y, Nagai S, Shibuta K, Miyamoto S, Maruno M, Takaji R, Hata S, Nishida H, Miyamoto S, Ozeki Y, Okamoto M, Gotoh K, Masaki T, Shin T, Mimata H, Daa T, Asayama Y, Shibata H. Adrenal vein sampling with gadolinium contrast medium in a patient with florid primary aldosteronism and iodine allergy. J Endocr Soc 2022; 6:bvac007. [PMID: 35155972 PMCID: PMC8826024 DOI: 10.1210/jendso/bvac007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Indexed: 11/24/2022] Open
Abstract
We describe a 35-year-old woman who was allergic to iodine contrast medium and was diagnosed with primary aldosteronism (PA) based on functional confirmatory tests. She was suspected to have unilateral PA because of marked hypertension, spontaneous hypokalemia, high plasma aldosterone, reduced plasma renin activity, and a right hypodense adrenal tumor. She wanted to become pregnant and requested adrenalectomy instead of medical treatment with mineralocorticoid receptor antagonists. Localization of PA by adrenal vein sampling (AVS) was necessary, but angiography with iodine contrast medium was not possible because of her allergy. AVS was performed using gadolinium contrast agent (gadoterate meglumine) instead of iodine, in combination with computed tomography angiography (CTA). In AVS, before and after adrenocorticotropin (ACTH) loading, 12 blood samples were drawn from the right adrenal vein, left adrenal central vein, left adrenal common duct, left and right renal veins, and the lower inferior vena cava with only 5 mL of gadolinium medium. There were no complications during AVS. Examination revealed an elevated aldosterone/cortisol ratio on the right side, lateralized ratio of 7.4, and contralateral ratio of 0.76; the patient was diagnosed with right unilateral PA. She underwent right adrenalectomy and showed improvements in aldosterone level from 312.4 pg/mL to 83.0 pg/mL, potassium from 3.0 mEq/L to 3.9 mEq/L, and systolic blood pressure from 138 mm Hg to 117 mm Hg. In PA patients with iodine allergy, AVS can be performed safely and precisely using gadolinium contrast combined with CTA.
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Affiliation(s)
- Yuichi Yoshida
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University
| | - Satoshi Nagai
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University
| | - Kanako Shibuta
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University
| | - Shuhei Miyamoto
- Department of Radiology, Faculty of Medicine, Oita University
| | - Miyuki Maruno
- Department of Radiology, Faculty of Medicine, Oita University
| | - Ryo Takaji
- Department of Radiology, Faculty of Medicine, Oita University
| | - Shinro Hata
- Department of Urology, Faculty of Medicine, Oita University
| | - Haruto Nishida
- Department of Pathology, Faculty of Medicine, Oita University
| | - Shotaro Miyamoto
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University
| | - Yoshinori Ozeki
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University
| | - Mitsuhiro Okamoto
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University
| | - Koro Gotoh
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University
| | - Takayuki Masaki
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University
| | - Toshitaka Shin
- Department of Urology, Faculty of Medicine, Oita University
| | | | - Tsutomu Daa
- Department of Pathology, Faculty of Medicine, Oita University
| | - Yoshiki Asayama
- Department of Radiology, Faculty of Medicine, Oita University
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University
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Prins MLM, Ballieux BEPB, Meijer OC, Pereira AM, Nijhoff MF. Adrenal Vein Sampling in a Patient With Primary Hyperaldosteronism and Severe Contrast Allergy. J Endocr Soc 2021; 5:bvab122. [PMID: 34350369 PMCID: PMC8328093 DOI: 10.1210/jendso/bvab122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Indexed: 11/25/2022] Open
Abstract
We report on a case of a 50-year-old female patient with primary hyperaldosteronism, in whom adrenal venous sampling was required to differentiate between unilateral and bilateral disease. Because of a history of severe allergy to iodinated contrast media, premedication with glucocorticoids was indicated. Exogenous glucocorticoids, however, can affect measurements of serum cortisol. To avoid this potential confounding effects on the cortisol assay, we decided to use dexamethasone instead of prednisolone or hydrocortisone. A high-dose adrenocorticotropin (ACTH) stimulation test with the simultaneous use of dexamethasone revealed an adequate adrenal cortisol response. ACTH-stimulated adrenal venous sampling showed reliable results, which provided a solid basis for further clinical decision-making.
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Affiliation(s)
- Margaretha L M Prins
- Department of Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Bartholomeus E P B Ballieux
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Onno C Meijer
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Alberto M Pereira
- Department of Medicine, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Michiel F Nijhoff
- Department of Medicine, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, The Netherlands
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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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Villegas MG, Ceballos MT, Urquijo J, Torres EY, Ortiz-Reyes BL, Arnache-Olmos OL, López MR. Poly(acrylic acid)-Coated Iron Oxide Nanoparticles interact with mononuclear phagocytes and decrease platelet aggregation. Cell Immunol 2019; 338:51-62. [DOI: 10.1016/j.cellimm.2019.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/18/2019] [Accepted: 03/25/2019] [Indexed: 01/28/2023]
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Hirono Y, Doi M, Yoshimoto T, Kanno K, Himeno Y, Taki K, Sasano H, Hirata Y. A case with primary aldosteronism due to unilateral multiple adrenocortical micronodules. Endocr J 2005; 52:435-9. [PMID: 16127211 DOI: 10.1507/endocrj.52.435] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 46-year-old male with long-term treatment-resistant hypertension and past history of cerebral hemorrhage was found to have suppressed plasma renin activity (PRA) and normal plasma aldosterone concentration (PAC) with aldosterone/renin ratio of 25.3. Furosemide plus upright test did not stimulate PRA, but computed tomography scan of the abdomen revealed no abnormal lesions in either adrenal gland. Selective adrenal venous sampling (SAVS) showed that PAC in the left and the right adrenal vein were 1000 ng/dl and 230 ng/dl, respectively, which increased to 1500 ng/dl and 620 ng/dl, respectively, after ACTH stimulation. Diagnosis of primary aldosteronism due to hypersecretion of aldosterone from the left adrenal gland was made, and laparoscopic left adrenalectomy was performed. Pathological examination of the 'apparently normal' adrenal tissue resected revealed the presence of poorly encapsulated multiple adrenocortical micronodules which showed positive immunoreactivity for 3beta-hydroxysteroid dehydrogenase by immunohistochemical study, but negative immunoreactivity in the hyperplastic zona glomerulosa consistent with paradoxical hyperplasia associated with primary aldosteronism. Postoperatively, PRA was normalized and his high blood pressure was well controlled with lower doses of antihypertensive drugs than those used before surgery. The clinicopathological features of our case are consistent with the diagnosis of unilateral multiple adrenocortical micronodules (UMN), a new subset of primary aldosteronism, in which SAVS proved to be a useful diagnostic tool for its localization.
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Affiliation(s)
- Yuki Hirono
- Department of Clinical and Molecular Endocrinology, Tokyo Medical and Dental University Graduate School, Tokyo
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