Dynamic testing with high-dose adrenocorticotrophic hormone does not improve lateralization of aldosterone oversecretion in primary aldosteronism patients

Rossi, Gian Paolo; Ganzaroli, C.; Miotto, Diego; Toni, Renzo De; Palumbo, Gaetana; Feltrin, Gian Pietro; Mantero, Franco; Pessina, Achille C.

doi:10.1097/01.hjh.0000202818.10459.96

Cited by 104 publications

(93 citation statements)

References 30 publications

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“…Its values from O1.1 to O5 are used for the judgment with lower values for the basal AVS than the pre-stimulated AVS (7,11,21,22); the ratio O3 and O5 can be considered as conservative cut-offs for the former and the latter respectively. Using these conservative cut-offs, 9 out of 20 of the basal AVS samples and 3 out of 20 of the low-dose AVS samples are taken as unsuccessful, whereas all the standard-dose AVS samples are taken as successful.…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, some investigators advocated pre-stimulation with synthetic corticotropin to ensure active adrenal secretion at the time of AVS (7)(8)(9)(10). However, others expressed concern that the prestimulation could abolish the laterality of aldosterone secretion (11); the dose of synthetic corticotropin generally used for the pre-stimulation is extra-physiologically high (12,13), and the exaggerated corticotropic response by it could conceal the laterality.…”

Section: Introductionmentioning

confidence: 99%

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Physiologic variance of corticotropin affects diagnosis in adrenal vein sampling

Tanemoto

Suzuki²,

Abe³

et al. 2009

European Journal of Endocrinology

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Objective: Differentiating unilateral form from bilateral is a critical diagnostic step in primary aldosteronism (PA), for which adrenal vein sampling (AVS) is accepted to be the most reliable. However, variance of corticotropin could affect the diagnosis in AVS. Design and methods: We conducted simultaneous bilateral AVS on ten biochemically diagnosed PA cases, and used the aldosterone-to-cortisol ratio (A/C) of the samples for the diagnosis. The diagnosis by AVS after a low-dose (0.1 mg) ACTH stimulation, which can provoke maximum-physiologic corticotropic response, was compared with those before the stimulation and after the standard-dose (250 mg) ACTH stimulation. Results: In half of the cases, the low-dose pre-stimulation affected the diagnosis. In four out of ten cases, the side-to-side ratios of A/C were changed in the basal/low-dose/standard-dose AVS as 6.62/2.46/0.63, 2.13/0.41/0.14, 1.88/2.38/2.40, and 1.96/2.27/1.90 respectively. In three out of ten cases, the adrenal vein to the matching inferior vena cava ratio of A/C was also changed across 1, the cut-off to indicate suppression of aldosterone secretion. Additionally, the confirmation of successful sampling was difficult in five out of ten and two out of ten cases of the basal and low-dose AVS respectively, whereas it was easy in all the cases of the standard-dose AVS. Conclusions: The diagnosis in the basal AVS could be affected by the physiologic fluctuation of ACTH at relatively high prevalence. The basal AVS would be unreliable to differentiate two forms of PA.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Physiologic variance of corticotropin affects diagnosis in adrenal vein sampling

Tanemoto

Suzuki²,

Abe³

et al. 2009

European Journal of Endocrinology

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“…Weinberger et al 11 proposed the use of stimulation with adrenocorticotropic hormone (ACTH) throughout AVS, to improve the detection of a lateralization in PA, particularly in those cases with cyclic secretion of aldosterone. Stimulation of adrenal activity with ACTH was not included in the protocol used by us at the time, because a later report by Rossi et al 12 did not find any benefit in the ACTH-related stimulation of aldosterone secretion, even when using simultaneously placed adrenal vein catheters.…”

Section: 10mentioning

confidence: 99%

Long-term Outcomes of Unilateral Adrenalectomy in Patients with Dominant-side Adrenal Hyperplasia

Paran¹,

Elad²,

Benchetrit³

et al. 2017

World Journal of Endocrine Surgery

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Introduction:Usual treatment for patients with aldosteroneproducing adrenal adenoma is adrenalectomy, whereas adrenal hyperplasia is generally treated medically. Selective adrenal venous sampling (AVS) has been adopted to differentiate between adenoma and hyperplasia. A previous ratio used in our institution for the diagnosis of adenoma proved to be too low. As a result, a disproportionate number of patients with a preoperative diagnosis of adenoma were operated and subsequently found to have hyperplasia.

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“…While facilitating the ascertainment of selectivity, it did not eliminate the problems inherent to the stress reaction, particularly when using the sequential AVS technique. Moreover, given the high levels of endogenous ACTH occurring when starting AVS (12), cosyntropin likely acts in the context of an already maximally stimulated ACTHcortisol axis and might therefore compete with endogenous ACTH. This can contribute to the unpredictable effects on aldosterone secretion (8).…”

Section: Impact Of Sequential or Simultaneous Avs On Si Valuementioning

confidence: 99%

“…By enhancing cortisol release, the latter facilitates the ascertainment of selectivity (12), but its usefulness is limited by its confounding effect on the assessment of lateralization of aldosterone excess (8). Hence, it is unlikely that cosyntropin stimulation can provide a final solution to the issue of time-dependent stressrelated effects on AVS results (8).…”

Section: Introductionmentioning

confidence: 99%

A stress reaction affects assessment of selectivity of adrenal venous sampling and of lateralization of aldosterone excess in primary aldosteronism

Seccia

Miotto²,

Battistel³

et al. 2012

European Journal of Endocrinology

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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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Dynamic testing with high-dose adrenocorticotrophic hormone does not improve lateralization of aldosterone oversecretion in primary aldosteronism patients

Abstract: AVS is safe and accurate for identifying APA. However, at a statistical power of 99%, these results do not support the usefulness of high-dose ACTH testing to improve the diagnostic accuracy of AVS.

Cited by 104 publications

References 30 publications

Physiologic variance of corticotropin affects diagnosis in adrenal vein sampling

Physiologic variance of corticotropin affects diagnosis in adrenal vein sampling

Long-term Outcomes of Unilateral Adrenalectomy in Patients with Dominant-side Adrenal Hyperplasia

A stress reaction affects assessment of selectivity of adrenal venous sampling and of lateralization of aldosterone excess in primary aldosteronism

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