Effect of adrenocorticotropic hormone stimulation during adrenal vein sampling in primary aldosteronism

Adrenal vein sampling (AVS) is fundamental for subtype diagnosis in patients with primary aldosteronism. AVS protocols vary between centers, especially for diagnostic indices and for use of adrenocorticotropic hormone (ACTH) stimulation. We investigated the role of both continuous ACTH infusion and bolus on the performance and interpretation of AVS in a sample of 76 patients with confirmed primary aldosteronism. In 36 primary aldosteronism patients, AVS was performed both under basal conditions and after continuous ACTH infusion, and in 40 primary aldosteronism patients, AVS was performed both under basal conditions and after ACTH IV bolus. Both ACTH protocols determined an increase in the rate of successful cannulation of the adrenal veins. Both ACTH infusion and bolus determined a significant increase in selectivity index for the right adrenal vein and ACTH bolus for the left adrenal vein. Lateralization index was not significantly different after continuous ACTH infusion and IV bolus. In 88% and 78% of the patients, the diagnosis obtained was the same before and after ACTH infusion and IV bolus, respectively. However, the reproducibility of the diagnosis was reduced using less stringent criteria for successful cannulation of the adrenal veins. This study shows that ACTH use during AVS may be of help for centers with lower success rates, because a successful adrenal cannulation is more easily obtained with this protocol; moreover, this technique performs at least as well as the unstimulated strategy and in some cases may be even better. Stringent criteria for cannulation should be used to have a high consistency of the diagnosis.     

New concepts in adrenal vein sampling for aldosterone in the diagnosis of primary aldosteronism

Improved diagnostic techniques and adoption of a systematic and thorough diagnostic workup can lead to identification of the surgically correctable forms of primary aldosteronism (PA) far more frequently than expected. Adrenalectomy can provide long-term normalization of blood pressure and correction of PA in most patients with an aldosterone-producing adenoma. Forms needing surgical correction are generally held to be less common than forms requiring medical therapy; however, this can be a misconception arising from the lack of systematic use of adrenal vein sampling (AVS). Currently AVS still remains the “gold standard” for identifying unilateral causes of PA that are surgically curable. The criteria for selecting patients to undergo AVS, the technique for performing AVS, and the criteria for analyzing and interpreting its results are summarized here.     

肾上腺静脉采血在原发性醛固酮增多症分型诊断中的价值

肾上腺静脉采血是近年来在我国兴起的一项新技术，本文通过不同方案，采用不同的参数及切点，分析其在原发性醛固酮增多症分型诊断中的敏感性和特异性，并与肾上腺计算机断层扫描（CT）等手段相比较，阐明其在分型诊断中的地位和价值。     

Comparison of adrenal vein sampling and computed tomography in the differentiation of primary aldosteronism

Determination of the etiology of primary aldosteronism remains a diagnostic challenge. The most common types of primary aldosteronism are bilateral adrenal hyperplasia (BAH), aldosterone-producing adenomas (APA), and primary adrenal hyperplasia. Computed tomography (CT) and adrenal vein sampling (AVS) are the primary modalities used to differentiate these subtypes. The purpose of this study was to compare AVS and CT imaging of the adrenal glands in patients with hyperaldosteronism in whom CT imaging was normal or in whom focal unilateral or bilateral adrenal abnormalities were detected. The diagnosis of primary aldosteronism was made in 62 patients based on an elevated plasma aldosterone to PRA ratio and an elevated urinary aldosterone excretion rate. Thirty-eight patients had CT imaging and successful bilateral adrenal vein sampling and were included in the final analysis. AVS was considered the gold standard in determining the specific subtype of primary aldosteronism. There were 15 patients with APA, 21 patients with BAH, and 2 patients with primary adrenal hyperplasia. Plasma aldosterone was significantly higher in patients with APA (46.3 +/- 8.5 ng/dL; 1284 +/- 235 pmol/L) than in those with BAH (29.3 +/- 2.4 ng/dL; 813 +/- 11 pmol/L; P < 0.05). Plasma potassium was significantly lower in patients with APA (3.1 +/- 0.1 mmol/L) than in patients with BAH (3.5 +/- 0.1 mmol/L; P < 0.02). There was considerable overlap in the other biochemical indices (e.g. PRA and urinary aldosterone) in patients with the different subtypes. In patients with APA proven by AVS, eight had concordant findings with CT imaging, four had discordant findings, and three had normal CT imaging. In patients with BAH proven by AVS, four had concordant findings with CT imaging, eight had discordant findings, and nine had normal CT imaging. Compared with AVS, CT imaging was either inaccurate or provided no additional information in 68% of the patients with primary aldosteronism. We conclude that adrenal CT imaging is not a reliable method to differentiate primary aldosteronism. Adrenal vein sampling is essential to establish the correct diagnosis of primary aldosteronism.     

The prediction of anatomical morphology of primary aldosteronism using serum 18-hydroxycorticosterone levels

Serum 18-hydroxycorticosterone, aldosterone, and potassium were measured under basal conditions in 34 patients with documented primary aldosteronism, 10 patients with essential hypertension, and 9 normal subjects. The results revealed that 22 of 23 patients with aldosterone-producing adenomas had 18-hydroxycorticosterone levels greater than 100 ng/dl, and all 9 patients with idiopathic adrenal hyperplasia had plasma levels less than 100 ng/dl. Two patients with unusual macromicronodular hyperplasia of the adrenal glands had levels greater than 100 ng/dl. We found a significant relationship between serum potassium and the ratio of 18-hydroxycorticosterone to aldosterone in patients with idiopathic adrenal hyperplasia, but not in those with an aldosterone-producing adenoma. We conclude that measurement of serum 18-hydroxycorticosterone is a useful predictor of the etiology of primary aldosteronism.     

Predicting surgically remedial primary aldosteronism: role of adrenal scanning,posture testing,and adrenal vein sampling

Distinguishing surgically remedial forms from other causes of primary aldosteronism (PA) may be difficult, and it is made more challenging by the earlier detection of milder disease. The technical demands of bilateral adrenal vein sampling (AVS)-increasingly advocated for localizing a unilateral autonomous lesion (UAL)- and lack of agreed criteria for establishing unilateral autonomy, add further to the diagnostic challenge. This retrospective review of 49 hypokalemic patients with unequivocal PA (41 with surgically proven and remedial UAL, eight patients with bilateral adrenal hyperplasia) analyzes the value of computerized tomography adrenal scanning (n = 32), 4 h erect posture testing (n = 42), and AVS (n = 27) in predicting and lateralizing a surgically remedial lesion. A fall in plasma aldosterone during 4 h erect posture (positive test) occurred in 63% of patients with UAL and in none with bilateral adrenal hyperplasia. A positive posture test or computerized tomography adrenal scan (single focal macroadenoma) both had high positive predictive value (100% and 89% respectively), but low sensitivity for diagnosis of UAL. AVS, undertaken during low dose ACTH stimulation, localized the UAL in all cases (positive predictive value 100%) where the aldosterone/cortisol ratio of blood drawn from the uninvolved gland was less than that of peripheral blood (contralateral ratio <1). Biochemical severity, reflected by overnight supine plasma aldosterone, was strongly correlated with the degree of contralateral gland suppression (n = 16, r = 0.79, P < 0.001). Importantly, the AVS findings show that when bilateral access is not possible, UAL can be successfully lateralized when only one adrenal vein (the contralateral) is accessed, or the ipsilateral vein is sampled in subjects whose posture test was positive. In this series of patients with overt (hypokalemic) PA, preoperative testing successfully identified a surgically remedial lesion in 39 of 41 cases. Confirmation of the recommended diagnostic approach must now await larger prospective studies.     

Management of primary aldosteronism in patients with adrenal hemorrhage following adrenal vein sampling: A brief review with illustrative cases

The authors describe the clinical investigation of two cases of primary aldosteronism with adrenal hemorrhage (AH) following adrenal vein sampling. A literature review was conducted regarding the medical management of primary aldosteronism in patients with AH following adrenal vein sampling. Guidelines on the management of primary aldosteronism with AH following adrenal vein sampling are lacking. The two patients were followed with serial imaging to document resolution of AH and treated medically with excellent blood pressure response. Resolution of AH was achieved, but a repeat adrenal vein sampling was deferred given the increased morbidity risk associated with a repeat procedure.     

The significance of elevated levels of plasma 18-hydroxycorticosterone in patients with primary aldosteronism.

Plasma 18-hydroxycorticosterone (180HB) concentration was measured in 23 patients with primary aldosteronism. After overnight recumbency, the levels were markedly elevated and were 6 times higher in patients with aldosterone-producing adenomas than in patients with hyperplasia. A value of 100 ng/dl or greater at 0800 h after overnight recumbency distinguished an adenoma from hyperplasia. There was no overlap of values, as was observed with plasma aldosterone concentration (PAC) at 0800 h and after 4 h of upright posture at 1200 h. There was a significant negative correlation between the ratio of 180HB to PAC and the potassium concentration in patients with primary aldosteronism due to hyperplasia. Potassium repletion with potassium chloride and/or spironolactone in patients with aldosterone-producing adenomas decreased the 180HB:PAC ratio by decreasing 180HB and increasing PAC. 180HB is an effective discriminator of an adenoma and may be a useful marker of the events in late aldosterone synthesis.     

Roles of clinical criteria, computed tomography scan, and adrenal vein sampling in differential diagnosis of primary aldosteronism subtypes

CONTEXT: In patients with primary aldosteronism (PA), it is fundamental to distinguish between subtypes that benefit from different therapies. Computed tomography (CT) scans lack sensitivity and specificity and must be followed by adrenal venous sampling (AVS). Because AVS is not widely available, a list of clinical criteria that indicate the presence of an aldosterone-producing adenoma (APA) has been suggested. OBJECTIVE AND DESIGN: The objective of the study was to test the sensitivity and specificity of the last generation CT scans, test prospectively the usefulness of clinical criteria in the diagnosis of APA, and develop a flow chart to be used when AVS is not easily available. SETTING: Hypertensive patients referred to our hypertension unit were included in our study. PATIENTS: Seventy-one patients with confirmed PA participated in our study. Intervention: All patients had a CT scan and underwent AVS. MAIN OUTCOME MEASURE: Final diagnosis of APA was the main measure. RESULTS: A total of 44 and 56% of patients were diagnosed as having an APA and a bilateral adrenal hyperplasia (BAH), respectively. Twenty percent of patients with PA displayed hypokalemia. CT scans displayed a sensitivity of 0.87 and a specificity of 0.71. The posture test displayed a lower sensitivity and specificity (0.64 and 0.70, respectively). The distribution grades of hypertension were not significantly different between APA and BAH. Biochemical criteria of high probability of APA displayed a sensitivity of 0.32 and a specificity of 0.95. CONCLUSIONS: This study underlines the central role of AVS in the subtype diagnosis of PA. The use of the clinical criteria to distinguish between APA and BAH did not display a satisfactory diagnostic power.     

探讨促肾上腺皮质激素兴奋在肾上腺静脉取血中的应用价值

目的:探讨促肾上腺皮质激素(ACTH)兴奋在肾上腺静脉取血(AVS)中的应用价值。方法:纳入完成常规AVS和ACTH兴奋的AVS,且至少有一种AVS双侧肾上腺静脉插管成功的原发性醛固酮增多症(原醛症)患者。计算选择指数(SI)、优势侧指数(LI),比较ACTH兴奋与否对插管成功率及优势侧判断的影响。结果:共纳入73名原...