Comparison between adrenal venous sampling and computed tomography in the diagnosis of primary aldosteronism and in the guidance of adrenalectomy

Abstract

In our series of patients with primary aldosteronism, we compared diagnostic concordance and clinical outcomes after adrenalectomy between adrenal venous sampling (AVS) and computed tomography (CT) imaging.Our retrospective analysis included 886 patients with primary aldosteronism diagnosed in our hospital between 2005 and 2014. Of them, 269 patients with CT unilateral adrenal disease were included in the analysis on the diagnostic concordance and 126 patients with follow-up data in the analysis on clinical outcomes after adrenalectomy. Hypertension was considered cured if systolic/diastolic blood pressure (BP) was controlled (<140/90 mm Hg) without medication and improved if BP was controlled with a reduced number of antihypertensive drugs.In 269 patients with CT unilateral adrenal disease, the overall concordance rate between AVS and CT was 50.5% for lateralization on the same side. The concordance rate decreased with increasing age, with highest rate of 61% in patients aged <30 years (n = 16). In 126 patients with follow-up data after adrenalectomy, the AVS- (n = 96) and CT-guided patients (n = 30) had similar characteristics before adrenalectomy. After andrenalectomy, the AVS-guided patients had a significantly higher serum potassium concentration (4.3 ± 0.3 vs 4.0 ± 0.5 mmol/L, P = 0.04) and rate of cured and improved hypertension (98% vs 87%, P = 0.03). The AVS-guided patients (n = 50) had slightly higher cured rate than the CT-guided patients (n = 11) in those older than 50 years (26.0% vs 18.2%, P = 0.72). The age below which the cured rate in the CT-guided patients was 100% was 30 years.AVS guidance had moderate concordance with CT and slightly improved clinical outcomes after adrenalectomy. The age below which CT unilateralization achieved 100% cured rate was approximately 30 years.

Discordance between imaging and immunohistochemistry in unilateral primary aldosteronism

“…Adrenal vein sampling has been widely accepted as the “gold standard” for lateralization of PA . The basis for recommending AVS in all patients with PA older than 35 who might consider surgery has emerged from numerous studies demonstrating poor correlation of AVS with cross‐sectional imaging . Previous studies have largely focused on success rates after adrenalectomy, but the cases with absent clinical benefit after surgery have been poorly studied.…”

“…Adrenal vein sampling (AVS) is considered the most accurate method for determining whether one or both adrenals produce excess aldosterone . Aside from patients younger than 35 years with unequivocal PA, cross‐sectional adrenal imaging findings are frequently discordant with the aldosterone source as lateralized by AVS . Nevertheless, resolution of PA after unilateral adrenalectomy is not always achieved, even if the decision is based on AVS lateralization, in part because AVS technique and interpretation vary widely between centres .…”

Predicting factors related with uncured hypertension after retroperitoneal laparoscopic adrenalectomy for unilateral primary aldosteronism

“…Due to the relatively high rate of discordance between AVS and imaging, AVS remains the gold standard and the most accurate way to differentiate between the unilateral and bilateral categories of PA. [36,37] It plays a critical role in aiding the clinician to lateralize the aldosterone-producing adenomas. However, it is unclear in this subset of patients how the presence of a contralateral adrenal abnormality affects the results of adrenalectomy for PA. [38] In our cohort, all of the patients who had a bilateral abnormalities were lateralized by AVS.…”

Physiological and Pathological Roles in Human Adrenal of the Glomeruli-Defining Matrix Protein NPNT (Nephronectin)

“…However, benign APAs are much commoner than ACCs, and the main translational potential of NPNT may lie in its use as a diagnostic marker in patients with sub-centimeter APAs, whose CT scan and/or adrenal vein sampling results are inconclusive. Recent publications have reported only 50% concordance between AVS and CT, with >10% of patients aged >50 lateralizing to opposite sides44,45. Therefore, in vivo measurement of adrenal NPNT could be a more accurate predictor of APA presence and even genotype, as the secreted protein may be measurable in adrenal vein samples routinely collected for unilateral APA diagnoses.…”