Influence of Diagnostic Criteria on the Interpretation of Adrenal Vein Sampling

Abstract

P atients with primary aldosteronism (PA) have either bilateral (idiopathic hyperplasia) or unilateral (aldosterone-producing adenoma or unilateral hyperplasia) adrenal disease. 1,2 Localizing the source of excessive aldosterone secretion is critical to select the appropriate therapy. Unilateral PA can be treated by laparoscopic adrenalectomy, which normalizes serum potassium concentrations in almost all cases and cures or improves hypertension in >80% of patients.3,4 By contrast, medical management with mineralocorticoid receptor antagonists is recommended as the first-line treatment in bilateral PA. 5Adrenal vein sampling (AVS) is currently considered the gold standard to differentiate unilateral from bilateral aldosterone hypersecretion and is recommended in almost all patients with PA who are eligible for surgical management. 5,6 The accuracy of catheter placement in the adrenal veins can be verified from the cortisol concentration in the adrenal veins divided by that in the inferior vena cava or a peripheral vein (selectivity index [SI]). If the SI reaches the predefined cut-off, the lateralization index (LI) is then used to classify PA into unilateral or bilateral disease. The LI is defined as the highest aldosterone/ cortisol concentration ratio (dominant adrenal vein) divided by the lowest aldosterone/cortisol concentration ratio (nondominant adrenal vein). Some investigators also propose the use of the contralateral suppression index, defined by the aldosterone/ cortisol concentration ratio of the nondominant adrenal vein divided by the peripheral aldosterone/cortisol concentration ratio.7 However, the protocol of AVS (simultaneous or sequential bilateral AVS, use of cosyntropin or not, and the protocol of cosyntropin infusion) and the SI and LI cut-offs used to interpret the results are not currently standardized. 7-9We have interpreted a large number of AVS procedures with criteria used in 4 reference centers or proposed by a recent consensus statement. 6,[10][11][12] The first objective of this study was to examine to which extent the interpretation of AVS may differ according to the criteria used for its interpretation. The second goal was to assess the reproducibility of this interpretation when multiple blood samples were drawn from the same adrenal vein. Methods PatientsThis retrospective study included all patients who underwent AVS in our hypertension referral center between January 2001 and July Abstract-Guidelines promote the use of adrenal vein sampling (AVS) to document lateralized aldosterone hypersecretion in primary aldosteronism. However, there are large discrepancies between institutions in the criteria used to interpret its results. This study evaluates the consequences of these differences on the classification and management of patients. The results of all 537 AVS procedures performed between January 2001 and July 2010 in our institution were interpreted with 4 diagnostic criteria used in experienced institutions where AVS is performed without cosyntropin (Brisbane, Padua, Paris, an...

Mass Spectrometry–Based Adrenal and Peripheral Venous Steroid Profiling for Subtyping Primary Aldosteronism

“…Thus, for some patients designated with BAH with immunoassay measurements, lateralization ratios on the basis of LC-MS/MS measurements were above the usual cutoff of 4.0, and it remains unclear whether these patients may have benefited from adrenalectomy. As pointed out elsewhere (40 ), such cutoffs are somewhat arbitrary and potentially misleading. For example, therapeutic responses to adrenalectomy among patients of the present study were highly variable and included treatment failure in 7 patients, presumably a consequence of asymmetric bilateral disease.…”

Suppression of Aldosterone Secretion After Recumbent Saline Infusion Does Not Exclude Lateralized Primary Aldosteronism

“…4 The interpretation of AVS differs among centers. 19 We used the selectivity and lateralization indices advocated by the guidelines. 1 Use of the AVS prevented the circular reasoning associated with the use of another nonvalidated suppression test as gold standard.…”

Clinical impact of strict criteria for selectivity and lateralization in adrenal vein sampling

“…These findings are consistent with multiple studies that pointed out the unreliability of SI and LI below the recommended criteria (RC) (SIpre-stimuli≥2, SIpost-stimuli≥3 and LIpre-stimuli≥2, LIpost-stimuli≥4). 5,9,[18][19] Given the distribution of the data with just one AVS falling in the "gray area" with LI and SI between the RC and SC, it is possible that one or, more likely, a multitude of factors influenced such a wide diagnostic overlapping that brought the benefit of drastically reducing the doubts at the time of interpretation of the AVS. The purpose of using SC was to attain reasonable consistency and possibly outrank the performance of other criteria with lower LI and SI thresholds.…”