What We Still do not Know About Adrenal Vein Sampling for Primary Aldosteronism

Abstract

During the last two decades, primary aldosteronism has emerged as the most common cause of secondary hypertension, and advances in the diagnosis and treatment of this condition have improved patient care substantially. A major stumbling block in the evaluation and management of these patients, which ultimately guides treatment and prognosis, is answering the question, "Which adrenal gland(s) produce aldosterone?" Adrenal vein sampling has emerged as the only reliable method to determine the answer to this question; however, the methodology and criteria for lateralization have been determined empirically with little prospective data. The major remaining controversies surrounding adrenal vein sampling include: who should perform and who should undergo the procedure; what criteria should be used to define a successful study and lateralization of aldosterone production; whether cosyntropin should be infused during the procedure and how; and what to do when results are ambiguous? This article reviews some of the advances in the execution of this procedure, the variations in procedure, the data that fuel the controversies, and the issues that need to be resolved in the future.

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

“…To minimize the impact of these factors, ACTH infusion was introduced by Weinberger et al (22) and widely used thereafter (21,23,24), thus being held as an essential part of the sequential AVS (11,19,21,25), or even of bilaterally simultaneous AVS (5,26,27). In our hands, cosyntropin stimulation confounded the assessment of lateralization and led to misclassification of the APA side (8,17).…”

“…Hence, the Endocrine Society practice guidelines endorse its systematic use in the PA patients who seek surgical cure (1,2). However, notwithstanding recent improvements (3), unresolved issues concerning the performance and interpretation of AVS still remain (4,5,6,7,8). This prompted a concerted international effort -the Adrenal Vein Sampling International Study (AVIS; http://clinicaltrials.gov/ct2/show/ NCT01234220) -that showed that the major referral centers worldwide are almost equally split between those that have adopted the bilaterally simultaneous catheterization (9) and those using the more traditional sequential technique.…”

Subtyping of primary aldosteronism by adrenal vein sampling: effect of acute D2 receptor dopaminergic blockade on adrenal vein cortisol and chromogranin A levels

“…As the assessment of selectivity of adrenal vein catheterization remains challenging (17), this study investigated the hypothesis that cortisol and ChA could be under tonic D 2 receptor-mediated dopaminergic control (9), and therefore, that metoclopramide could facilitate the ascertainment of the selectivity of AVS by increasing PCC and ChA release, and thus their step-up between the IVC and the adrenal vein blood. In this regard, we recently reported that ChA is tonically released from the adrenal gland (13).…”

“…Considering the crucial role of AVS for the identification of surgically curable subtypes of PA (5,17), it is worth mentioning that acute D 2 receptor blockade markedly increases aldosterone release in PA patients (7) and, therefore, could enhance the lateralization of aldosterone excess. It is noteworthy that this study by showing that metoclopramide increased the plasma adrenal vein level of aldosterone demonstrates that this hormone is under tonic dopaminergic D 2 receptormediated inhibition and confirms previous limited observations (7).…”

Primary aldosteronism — recent progress and current concepts

“…It was emphasised that the test can be performed only in specialist centres by properly trained staff [4]. In recent years, there have been many publications devoted to assessing the diagnostic usefulness of this method [42][43][44][45][46][47][48][49].…”