Importance of contralateral aldosterone suppression during adrenal vein sampling in the subtype evaluation of primary aldosteronism

Umakoshi, Hironobu; Tanase-Nakao, Kanako; Wada, Norio; Ichijo, Takamasa; Sone, Masakatsu; Inagaki, Nobuya; Katabami, Takuyuki; Kamemura, Kohei; Matsuda, Yuichi; Fujii, Yukihiko; Kai, Tatsuya; Fukuoka, Tatsunari; Sakamoto, Ryuichi; Ogo, Atsushi; Suzuki, Tomoko; Tsuiki, Mika; Shimatsu, Akira; Naruse, Mitsuhide

doi:10.1111/cen.12761

Cited by 46 publications

(47 citation statements)

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“…The aldosterone gradient in the gray zone (LI=2-4) should be carefully interpreted in the subtype diagnosis of PA to avoid inappropriate adrenalectomy. 13 Additional criteria such as contralateral adrenal aldosterone suppression 15 and clinical and biochemical findings 11 should be taken into account when considering patients for adrenal surgery.…”

Section: Discussionmentioning

confidence: 99%

“…Young et al 24 demonstrated that contralateral adrenal aldosterone suppression is seen in 95% of the patients with unilateral PA. In addition, Umakoshi et al 15 demonstrated a clinical significance of contralateral adrenal aldosterone suppression for prediction of unilateral PA especially when LI is <4. It is, therefore, suggested that the 2 patients with contralateral adrenal aldosterone suppression could be PA with false-negative results in both of CCT and SIT.…”

Section: Discussionmentioning

confidence: 99%

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Adrenal Venous Sampling in Patients With Positive Screening but Negative Confirmatory Testing for Primary Aldosteronism

et al. 2016

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Adrenal venous sampling is considered to be the most reliable diagnostic procedure to lateralize aldosterone excess in primary aldosteronism (PA). However, normative criteria have not been established partially because of a lack of data in non-PA hypertensive patients. The aim of the study was to investigate aldosterone concentration and its gradient in the adrenal vein of non-PA hypertensive patients. We retrospectively studied the results of cosyntropin-stimulated adrenal venous sampling in 40 hypertensive patients who showed positive screening testing but negative results in 2 confirmatory tests/captopril challenge test and saline infusion test. Plasma aldosterone concentration, aldosterone/cortisol ratio, its higher/lower ratio (lateralization index) in the adrenal vein with cosyntropin stimulation were measured. Median plasma aldosterone concentration in the adrenal vein was 25 819 pg/mL (range, 5154–69 920) in the higher side and 12 953 (range, 1866–36 190) pg/mL in the lower side ( P <0.001). There was a significant gradient in aldosterone/cortisol ratio between the higher and the lower sides (27.2 [5.4–66.0] versus 17.3 [4.0–59.0] pg/mL per μg/dL; P <0.001) with lateralization index ranging from 1.01 to 3.87. The aldosterone lateralization gradient was between 1 to 2 in 32 patients and 2 to 4 in 8 patients. None of the patients showed lateralization index ≥4. The present study demonstrated that plasma aldosterone concentration in the adrenal veins showed significant variation and lateralization gradient even in non-PA hypertensive patients. Adrenal venous sampling aldosterone lateralization gradients between 2 and 4 should be interpreted with caution in patients with PA because these gradients can be found even in patients with negative confirmatory testing for PA.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Adrenal Venous Sampling in Patients With Positive Screening but Negative Confirmatory Testing for Primary Aldosteronism

et al. 2016

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“…Monticone et al, in a large multicenter study, reported no significant differences in terms of the biochemical and clinical response after an adrenalectomy between patients with and without contralateral aldosterone suppression and an LI ≥ 4 [72]. The clinical significance of CR < 1 in patients with a 2 < LI < 4 was investigated by Umakoshi et al in a small cohort of 29 patients [73]. The authors reported a significant difference in terms of the overall cure rate of PA between patients with and without contralateral suppression (81% versus 31%), pointing out a possible major usefulness of CR in evaluating the “grey zone” of AVS results.…”

Section: Avs Interpretation Criteriamentioning

confidence: 99%

Subtype Diagnosis of Primary Aldosteronism: Is Adrenal Vein Sampling Always Necessary?

Buffolo

Monticone

Williams

et al. 2017

IJMS

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Aldosterone producing adenoma and bilateral adrenal hyperplasia are the two most common subtypes of primary aldosteronism (PA) that require targeted and distinct therapeutic approaches: unilateral adrenalectomy or lifelong medical therapy with mineralocorticoid receptor antagonists. According to the 2016 Endocrine Society Guideline, adrenal venous sampling (AVS) is the gold standard test to distinguish between unilateral and bilateral aldosterone overproduction and therefore, to safely refer patients with PA to surgery. Despite significant advances in the optimization of the AVS procedure and the interpretation of hormonal data, a standardized protocol across centers is still lacking. Alternative methods are sought to either localize an aldosterone producing adenoma or to predict the presence of unilateral disease and thereby substantially reduce the number of patients with PA who proceed to AVS. In this review, we summarize the recent advances in subtyping PA for the diagnosis of unilateral and bilateral disease. We focus on the developments in the AVS procedure, the interpretation criteria, and comparisons of the performance of AVS with the alternative methods that are currently available.

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“…Interestingly, diagnosis of unilateral PA confirmed by AVS was never found to be a predictor of good outcome after surgery, and patients with a higher lateralization index on AVS do not have a better outcome [29]. Contralateral suppression on AVS correlated with good BP and biochemical outcomes from surgery in some [33,34], but not in all studies [35].…”

Section: Predictors Of Cure or Persistent Hypertensionmentioning

confidence: 99%

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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Importance of contralateral aldosterone suppression during adrenal vein sampling in the subtype evaluation of primary aldosteronism

Abstract: In patients with PA, where the LI is <4 on AVS, CL suppression of aldosterone is an accurate predictor of a unilateral source of aldosterone excess. CL suppression data should be interpreted in conjunction with computed tomographic adrenal imaging findings to guide surgical management.

Cited by 46 publications

References 29 publications

Adrenal Venous Sampling in Patients With Positive Screening but Negative Confirmatory Testing for Primary Aldosteronism

Adrenal Venous Sampling in Patients With Positive Screening but Negative Confirmatory Testing for Primary Aldosteronism

Subtype Diagnosis of Primary Aldosteronism: Is Adrenal Vein Sampling Always Necessary?

Rational Approach to a Patient with Suspected Primary Aldosteronism

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