Low-grade Cortisol Cosecretion Has Limited Impact on ACTH-stimulated AVS Parameters in Primary Aldosteronism

Abstract

Context In primary aldosteronism, cosecretion of cortisol may alter cortisol-derived adrenal venous sampling indices. Objective To identify whether cortisol cosecretion in primary aldosteronism alters adrenal venous sampling parameters and interpretation. Design Retrospective case–control study Setting A tertiary referral center Patients 144 adult patients with primary aldosteronism who had undergone both adrenocorticotropic hormone-stimulated adrenal venous sampling and dexamethasone suppression testing between 2004 and 2018. Main Outcome Measures Adrenal venous sampling indices including adrenal vein aldosterone/cortisol ratios and the selectivity, lateralization, and contralateral suppression indices. Results 21 (14.6%) patients had evidence of cortisol cosecretion (defined as a failure to suppress cortisol to ≤50 nmol/L post dexamethasone). Patients with evidence of cortisol cosecretion had a higher inferior vena cava cortisol concentration (P = .01) than those without. No difference was observed between the groups in terms of selectivity index, lateralization index, lateralization of aldosterone excess, or adrenal vein cannulation rate. Conclusions Cortisol cosecretion alters some parameters in adrenocorticotrophic hormone-stimulated adrenal venous sampling but does not result in alterations in patient management.

Cortisol Co-Secretion and Clinical Usefulness of ACTH Stimulation Test in Primary Aldosteronism: A Systematic Review and Biases in Epidemiological Studies

“…We restricted studies to those with a sample size ≥10 (to avoid case reports) and written in English. Flow of studies through review and summary of the identified 16 studies are shown in Figure 1A and Table 1 (6,(10)(11)(12)(13)(14)(15)(27)(28)(29)(30)(31)(32)(33)(34)(35).…”

“…Based on the findings from AVS in patients with CPA, but without PA, Goupil et al, suggested that autonomous unilateral cortisol hypersecretion could confound the accuracy of AVS by affecting the aldosterone/cortisol ratio in the adrenal vein (i.e., selectivity index, lateralization index, and contralateral suppression index), leading to misdiagnosis and suboptimal management ( 42 ). However, a recent single-center study focusing on PA with mildly elevated cortisol levels (mean serum cortisol levels during the 1-mg DST = 3.3 μg/dl) showed that the rates of cannulation success or lateralization did not differ between PA patients with mild cortisol excess and those without cortisol excess during AVS with ACTH stimulation (blood sample was obtained 1 h after the stimulation) ( 35 ). A multi-center cohort study on this topic would help us to validate their findings and further understand which AVS parameters are useful for the management of PA with cortisol cosecretion.…”

Adrenal Venous Sampling for Subtype Diagnosis of Primary Hyperaldosteronism

“…Several steroid metabolites and metanephrines are potential alternative markers verifying the success of adrenal vein cannulation [ 28 , 29 ]. However, a recent report suggested that an increased plasma cortisol level does not affect the SI under ACTH stimulation in PA patients with subclinical Cushing’s syndrome [ 30 ]. Thus, the SI may be adopted even in patients with cortisol-co-secreting APAs.…”

“…As ACS is expected to affect the lateralization diagnosis as well as the success of AVS by altering the cortisol levels in the adrenal veins, the 1 mg Dexamethasone suppression test should be conducted in patients with PA prior to AVS, especially in patients with an apparent adrenal tumor on CT. An increased cortisol level on the tumor side decreases the A/C, while a decreased cortisol level on the contralateral side increases the A/C, which may lead to a decreased LI and an incorrect lateralization diagnosis when using the LI. However, O’Toole et al [ 30 ] reported that mild ACS had a limited impact on AVS parameters when using the A/C with ACTH stimulation. The ratio of the plasma aldosterone concentration (PAC) in the dominant to that in the non-dominant adrenal vein could provide an alternative marker to the LI, although no standard cutoff value has been established for this ratio.…”

Comparison of Bolus and Continuous Infusion of Adrenocorticotropic Hormone During Adrenal Vein Sampling

“…Furthermore, ACTH is necessary for patients with contrast allergy who receive steroid treatment before AVS (13). Recently, a study found that ACTH-stimulated AVS might be useful in PA complicated by cortisol co-secretion (14) which has the potential to affect non-ACTH stimulated AVS results (15)(16)(17).…”