Adrenal vein sampling versus CT scan to determine treatment in primary aldosteronism: an outcome-based randomised diagnostic trial

Dekkers, Tanja; Prejbisz, Aleksander; Kool, Leo J. Schultze; Groenewoud, Hans; Velema, Marieke; Spiering, Wilko; Kołodziejczyk-Kruk, Sylwia; Arntz, Mark; Kądziela, Jacek; Langenhuijsen, J.F.; Kerstens, Michiel N.; Meiracker, Anton H. van den; Born, Bert‐Jan H. van den; Sweep, Fred C.G.J.; Hermus, A.R.M.M.; Januszewicz, Andrzej; Ligthart-Naber, Alike F; Makai, Péter; Wilt, Gert-Jan van der; Lenders, Jacques W.M.; Deinum, Jaap

doi:10.1016/s2213-8587(16)30100-0

Cited by 221 publications

(205 citation statements)

References 26 publications

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“…Moreover, there was no difference in the frequency of adrenalectomy and no statistically significant difference in biochemical failure in operated patients (11% in the AVS group vs. 20% in the CT group; p = 0.25) [40]. The outcome of this study is unexpected and challenges current guidelines.…”

Section: Clinical Management Of Adrenal Tumors 70contrasting

confidence: 61%

“…This is a patient group not covered by the trial, and caution should be used in generalizing these findings [41]. In addition, when considering persistent vs. resolved PA, a nonsignificant trend in favor of AVS was found that might become statistically significant in a larger cohort [40].Regardless of its diagnostic value, AVS has several drawbacks, in particular the lack of a standardized procedure, variable handling of cutoffs, high cost, and invasiveness. It has a reputation as a technically difficult procedure with the average success rate for cannulating the right adrenal vein of only 74% [42].…”

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confidence: 99%

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Rational Approach to a Patient with Suspected Primary Aldosteronism

Kocjan¹

2017

Clinical Management of Adrenal Tumors

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Primary aldosteronism (PA) is the most common form of secondary hypertension that causes higher morbidity and mortality than equally severe essential hypertension. Bilateral PA should be treated medically with spironolactone or eplerenone, the mineralocorticoid receptor antagonists (MRA), while unilateral laparoscopic adrenalectomy is recommended for unilateral disease. Surgery cures hypertension in around 40% of patients with confirmed PA and reliably demonstrated unilateral autonomous aldosterone secretion by adrenal venous sampling (AVS). Regardless of its diagnostic value, AVS has several drawbacks, in particular high cost and invasiveness. Furthermore, only a limited number of referral centers worldwide routinely carry out the procedure. On the other hand, a small number of studies that compared the effects of surgery and MRA on the incidence of cardiovascular and renal outcomes in patients with PA found no difference between the two therapeutic options. In addition, spironolactone has been recently found to be the most effective add-on drug for the treatment of resistant hypertension. Therefore, rational selection of patients with suspected PA for AVS and surgery is of utmost importance.Keywords: adrenalectomy, adrenal venous sampling, hypertension, mineralocorticoid receptor antagonists, primary aldosteronism IntroductionPrimary aldosteronism (PA) is a group of disorders in which aldosterone production is inappropriately high for sodium status, relatively autonomous and nonsuppressible by sodium loading. Such inappropriate production of aldosterone causes hypertension, sodium retention, suppression of plasma renin, and increased potassium excretion [1]. Once thought to be rare, PA is now considered the most common form of secondary hypertension with an © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. estimated prevalence of 4.3% in primary care and of 9.5% among referred hypertensive patients [2]. Accumulated experimental and clinical evidence clearly shows that prolonged exposure to elevated aldosterone levels causes excess cardiovascular and renal damage which is partly independent of blood pressure (BP) levels [3]. Consequently, this endocrine condition is far from being benign, and patients with PA appear to have higher rates of cardiac arrhythmia, coronary heart disease, heart failure, stroke, proteinuria, and renal impairment compared to matched patients with essential hypertension (EH) [4][5][6]. Their cardiovascular mortality might be also increased [7]. Targeted treatment of PA is possible and is of obvious benefit to affected patients.The Endocrine Society now explicitly recognizes PA as a major public health issue and recommends extensive screening for this disorder using the plasma aldosterone/renin ratio (ARR) in high-risk populations, inclu...

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Section: Clinical Management Of Adrenal Tumors 70contrasting

confidence: 61%

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confidence: 99%

Rational Approach to a Patient with Suspected Primary Aldosteronism

Kocjan¹

2017

Clinical Management of Adrenal Tumors

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“…6,11,12 Moreover, AVS is an invasive technique that is not well standardized between centers and heavily depends on the expertise of the interventional radiologist. 13,14 AVS furthermore requires the use of contrast agents in a patient population that often experiences impaired renal function.…”

Section: Hypertensionmentioning

confidence: 99%

Targeting CXCR4 (CXC Chemokine Receptor Type 4) for Molecular Imaging of Aldosterone-Producing Adenoma

Heinze¹,

Fuß²,

Mulatero³

et al. 2018

Hypertension

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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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“…Patients with bilateral hyperplasia are treated with a mineralocorticoid receptor antagonist, whereas the subjects with a unilateral adenoma undergo adrenalectomy [8,9]. Because aldosterone-producing microadenomas and multiple bilateral lesions are often undetectable on computed tomography (CT), there is a substantial risk of misdiagnosis when using only CT scanning [10][11][12][13][14][15][16]. The current guidelines on the management of PA recommend adrenal vein sampling (AVS) as a "gold standard" procedure to differentiate between both subtypes in the majority of patients with PA [15].…”

Section: Introductionmentioning

confidence: 99%

A single-centre experience of the implementation of adrenal vein sampling procedure: the impact on the diagnostic work-up in primary aldosteronism

et al. 2017

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A b s t r a c tBackground: Primary aldosteronism is one of the most common causes of secondary hypertension. Adrenal vein sampling (AVS) remains a "gold standard" procedure in differentiation between unilateral (adenoma) and bilateral (hyperplasia) disease. Aim:The aim of this study was to present our single-centre experience in establishing and implementating the AVS procedure. Methods:All patients had primary aldosteronism confirmed in a salt-infusion test. AVS was performed sequentially during a continuous intravenous infusion of cosyntropin and was preceded by multislice contrast-enhanced computed tomography (CT) examination of adrenal glands performed a few weeks before AVS in the majority of patients. AVS was regarded as successful if the ratio of each adrenal vein cortisol to inferior vena cava cortisol levels (selectivity index [SI]) was higher than 3.0. In the case of failure, a second attempt was considered in a few weeks. Patients were divided into four groups according to the order of the procedure by quartiles.Results: Between 31 May, 2012 and 5 May, 2016, AVS was performed in 124 patients (69% males, aged 55.3 ± 10.3 years) and was successful in 120 (96.8%) patients. All failed cases were due to the failure of cannulation of the right adrenal vein. The first-attempt success rate was 94.3% (117 of 124 patients) and increased from 83.9% in the first 31 patients to 100% in the last 31 patients. Similarly, the overall success rate increased from 93.5% to 100%. The right SI was significantly higher than the left one (26.4 vs. 11.0, p < 0.0001). Both indices did not differ across quartiles of patients. No complications occurred during the procedure. Conclusions:The AVS procedure, preceded by adrenal CT, may be implemented into daily diagnostic practice safely with an excellent success rate.

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Adrenal vein sampling versus CT scan to determine treatment in primary aldosteronism: an outcome-based randomised diagnostic trial

Cited by 221 publications

References 26 publications

Rational Approach to a Patient with Suspected Primary Aldosteronism

Rational Approach to a Patient with Suspected Primary Aldosteronism

Targeting CXCR4 (CXC Chemokine Receptor Type 4) for Molecular Imaging of Aldosterone-Producing Adenoma

A single-centre experience of the implementation of adrenal vein sampling procedure: the impact on the diagnostic work-up in primary aldosteronism

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