Role for adrenal venous sampling in primary aldosteronism

doi:10.1016/j.surg.2004.06.051

Surgery

Volume 136, Issue 6, December 2004, Pages 1227-1235

https://doi.org/10.1016/j.surg.2004.06.051 Get rights and content

Background

The aim of this study was to determine the effect of adrenal venous sampling (AVS) on the management of patients with primary aldosteronism.

Methods

From September 1990 through October 2003, 203 patients with primary aldosteronism (mean age, 53 years; range, 17-80; 163 men) were selected prospectively for AVS on the basis of degree of aldosterone excess, age, desire for surgical treatment, and computed tomographic (CT) findings.

Results

Both adrenal veins were catheterized in 194 patients (95.6%). Notable among the 110 patients (56.7%) with unilateral aldosterone hypersecretion were 24 (41.4%) of 58 patients with normal adrenal CT findings, 24 (51.1%) of 47 with unilateral micronodule (≤10 mm) apparent on CT (7 had unilateral aldosterone hypersecretion from the contralateral adrenal), 21 (65.6%) of 32 with unilateral macronodule (>10 mm) apparent on CT (1 had unilateral aldosterone hypersecretion from the contralateral adrenal), 16 (48.5%) of 33 with bilateral micronodules, and 2 (33%) of 6 with bilateral macronodules.

Conclusions

On the basis of CT findings alone, 42 patients (21.7%) would have been incorrectly excluded as candidates for adrenalectomy, and 48 (24.7%) might have had unnecessary or inappropriate adrenalectomy. AVS is an essential diagnostic step in most patients to distinguish between unilateral and bilateral adrenal aldosterone hypersecretion.

Section snippets

Patients

The 203 patients selected for AVS were from the group of patients in whom PA was diagnosed at the Mayo Clinic in Rochester from September 1990 through October 2003. Selection for AVS was based on the degree of aldosterone excess, age, desire for surgical treatment, and computed tomographic (CT) findings. Thirty-four of these patients have been reported on previously in an article describing our initial experience with AVS.⁶ To qualify for this study, patients had to exhibit the following

Results

The study group consisted of 163 men and 40 women (mean age, 53 years; range, 17-80 years). The average blood pressure was 158/95 mm Hg (maximum, 210/120 mm Hg) while the patients were taking antihypertensive medication (Fig 1). The random ambulatory PRA was undetectable (<0.6 ng/mL per hour) in all but 14 patients (highest value, 1.3 ng/mL per hour). The mean PAC/PRA ratio was 41.7 (range, 14.0-482). The 24-hour urinary aldosterone excretion during a high-salt diet was 35.1 ± 25.6 μg (mean

Discussion

Distinguishing the subtype of PA is critical in assessing treatment options. Unilateral adrenalectomy in patients with APA or PAH results in normalization of hypokalemia in all of the patients, normalization of blood pressure in at least one third of them, and mitigated hypertension in nearly all.¹¹ In IHA, unilateral or bilateral adrenalectomy seldom corrects hypertension.⁴

Initially, adrenal CT was thought to be a good test to distinguish among the subtypes of PA. However, because of the

Conclusion

AVS for aldosterone is helpful in directing therapeutic decisions for patients with PA. A unilateral source of aldosterone excess may be found in selected patients who have normal-appearing or thickened limbs of the adrenal glands on CT. In addition, AVS distinguishes between APA and nonfunctioning cortical adenomas found on CT.

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El hiperaldosteronismo primario (HAP) es una causa importante de hipertensión arterial (HTA) secundaria. El estudio del mismo precisa de una alta sospecha clínica, además de un estudio hormonal que confirme la hipersecreción hormonal. Es importante iniciar el tratamiento adecuado una vez se confirma el diagnóstico, y para ello es preciso demostrar si la hipersecreción hormonal es unilateral (pacientes que podrían ser tributarios a tratamiento quirúrgico) o bilateral (pacientes que son tributarios a tratamiento únicamente farmacológico).
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Primary hyperaldosteronism (PAH) is an important cause of secondary hypertension (HTN). The study of the same requires a high clinical suspicion in addition to a hormonal study that confirms hormonal hypersecretion. It is important to start the appropriate treatment once the diagnosis is confirmed, and for this is necessary to demonstrate whether the hormonal hypersecretion is unilateral (patients who could be candidates for surgical treatment) or bilateral (patients who are candidates for pharmacological treatment only).
At the Hospital del Mar since 2016 there has been a multidisciplinary work team in which Nephrologists, Endocrinologists, Radiologists and Surgeons participate to evaluate cases with suspected hyperaldosteronism and agree on the best diagnostic-therapeutic approach for these patients, including the need for adrenal vein sampling, which is a technique that in recent years has become the gold standard for the study of PAH.
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A clinical condition may be missed due to its higher-than-recognized prevalence or inadequate diagnostic screening. Both factors apply to primary aldosteronism, which is woefully underdiagnosed as a cause of hypertension and end-organ damage. Screening tests should be strongly considered for diseases that pose significant morbidity or mortality if left untreated, that have a high prevalence, and that have treatments that lead to improvement or cure. In this review we present the evidence for each of these points. We outline studies that estimate the prevalence of primary aldosteronism in different at-risk populations and how its recognition has changed over time. We also evaluate myriad studies of screening rates for primary aldosteronism and what factors do and do not influence current screening practices. We discuss the ideal conditions for screening, measuring the aldosterone to renin ratio in different populations that use plasma renin activity or direct renin concentration, and the steps for diagnostic workup of primary aldosteronism. Finally, we conclude with potential strategies to implement higher rates of screening and diagnosis of this common, consequential, and treatable disease.
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To analyze contrast free adrenal vein sampling (AVS) for differentiating unilateral from bilateral disease in patients diagnosed with hypertension due to primary aldosteronism (PA).
Consecutive patients with PA and subsequent contrast medium free AVS between April 2015 and March 2020 were retrospectively included. Cross-sectional imaging (CSI), AVS and clinical data were analyzed regarding diagnostic performance. In addition, patients with lateralisation receiving adrenalectomy were compared to a control group treated with mineralocorticoid antagonists.
In total 186 patients with AVS were included. The success rate for bilateral catheterization was 88% (median effective dose 2.8 mSv). CSI had an accuracy of 60% (CI: 0.52–0.67) in the detection of lateralization compared to AVS. Patients with bilateral adrenal hyperplasia and those with aldosterone-producing adenoma did not differ in systolic blood pressure (sBP) (p = 0.63) or number of antihypertensive drugs (NAD) (p = 0.11). After adrenalectomy, 28 patients were cured (51%; sBP ≤130 mmHg, NAD = 0), 18 were improved (33%; decrease of sBP ≥20 mmHg and NAD), and 8 were unchanged (15%). Serum renin increased significantly after treatment (p < 0.01).
Contrast medium free AVS is a reliable procedure in the diagnostic management of patients with PA with high technical success rate. The accordance between CSI and results from AVS was only moderate indicating the central role of AVS in the diagnostic work-up of patients with PA. Patients with predominant disease diagnosed with AVS had a high cure rate and/or significant improvement after adrenalectomy.
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The objective was to determine the clinical and biochemical success rates and assess the nature of follow-up after adrenalectomy in patients with unilateral primary aldosteronism (PA), subtyped by adrenal vein sampling (AVS) in West Australia (WA) using the Primary Aldosteronism Surgical Outcome (PASO) criteria. Clinical and biochemical outcomes were retrospectively evaluated in patients with unilateral PA who underwent adrenalectomy according to AVS between September 2017 and September 2020. Pre- and post-surgical data were collected using a standardised questionnaire, review of clinic letters and examination of private and public pathology results and radiological reports. Follow-up data were available for 47 patients post-adrenalectomy; biochemical outcome data were available for 37 patients, clinical outcome data for 40 patients, with 30 patients having both outcomes available. Final assessment was performed between 0 to 3 months in 23/37 (62.2%) patients with biochemical outcomes, 15/40 (37.5%) with clinical outcomes, and 17/30 (56.7%) with both clinical and biochemical outcomes. Complete biochemical success was achieved in 83.8% (31/37) of patients, with 26.7% (8/30) obtaining both complete clinical and biochemical success. Complete clinical success was achieved in 35.0% (14/40) of patients, with 47.5% (19/40) obtaining partial clinical success. Overall, 93.6% (44/47) of patients derived benefit from adrenalectomy.
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View all citing articles on Scopus

: Presented at the 25th Annual Meeting of the American Association of Endocrine Surgeons, Charlottesville, Virginia, April 4-6, 2004.

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American Association of Endocrine SurgeonRole for adrenal venous sampling in primary aldosteronism

Background

Methods

Results

Conclusions

Section snippets

Patients

Results

Discussion

Conclusion

Endocrinol Metab Clin North Amer

Surgery

Trends Endocrinol Metab

Presidential address: Part I. Painting background, Part II. Primary aldosteronism, a new clinical syndrome

J Lab Clin Med

Minireview: primary aldosteronism-changing concepts in diagnosis and treatment

Endocrinology

Increased diagnosis of primary aldosteronism, including surgically correctable forms, in centers from five continents

J Clin Endocrinol Metab

Diagnosis and localization of aldosterone-producing adenomas by adrenal-vein catheterization

N Engl J Med

Primary aldosteronism: diagnosis, localization, and treatment

Ann Intern Med

Clinical evaluation of urinary cortisol determinations by competitive protein-binding radioassay

J Clin Endocrinol Metab

Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure

Hypertension

Coexistence of bilateral adrenal phaeochromocytomas and idiopathic hyperaldosteronism

Clin Endocrinol

American Association of Endocrine Surgeon
Role for adrenal venous sampling in primary aldosteronism