Primary aldosteronism: making sense of partial data sets from failed adrenal venous sampling-suppression of adrenal aldosterone production can be used in clinical decision making

Surgery ◽  
2018 ◽  
Vol 163 (4) ◽  
pp. 801-806 ◽  
Author(s):  
Veljko Strajina ◽  
Zahraa Al-Hilli ◽  
James C. Andrews ◽  
Irina Bancos ◽  
Geoffrey B. Thompson ◽  
...  
Keyword(s):  
Decision Making ◽  
Primary Aldosteronism ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Adrenal Venous Sampling ◽  
Data Sets ◽  
Venous Sampling ◽  
Making Sense ◽  
Partial Data ◽  
Aldosterone Production

scholarly journals Comparison of Cortisol, Androstenedione and Metanephrines to Assess Selectivity and Lateralization of Adrenal Vein Sampling in Primary Aldosteronism

2021 ◽  
Vol 10 (20) ◽  
pp. 4755
Author(s):  
Giulio Ceolotto ◽  
Giorgia Antonelli ◽  
Brasilina Caroccia ◽  
Michele Battistel ◽  
Giulio Barbiero ◽  
...  
Keyword(s):  
Decision Making ◽  
Primary Aldosteronism ◽  
Inferior Vena ◽  
Clinical Decision Making ◽  
Vena Cava ◽  
Clinical Decision ◽  
Selectivity Index ◽  
Adrenal Vein ◽  
Adrenal Vein Sampling ◽  
The Right

Success of adrenal vein sampling (AVS) is verified by the selectivity index (SI), i.e., by a step-up of cortisol levels between the adrenal vein and the infrarenal inferior vena cava samples, beyond a given cut-off. We tested the hypothesis that androstenedione, metanephrine, and normetanephrine, which have higher gradients than cortisol, could increase the rate of AVS studies judged to be bilaterally successful and usable for the clinical decision making. We prospectively compared within-patient, head-to-head, the selectivity index of androstenedione (SIA), metanephrine (SIM), and normetanephrine (SINM), and cortisol (SIC) in consecutive hypertensive patients with primary aldosteronism submitted to AVS. Main outcome measures were rate of bilateral success, SI values, and identification of unilateral PA. We recruited 136 patients (55 + 10 years, 35% women). Compared to the SIC, the SIA values were 3.5-fold higher bilaterally, and the SIM values were 7-fold and 4.4-fold higher on the right and the left side, respectively. With the SIA and the SIM the rate of bilaterally successful AVS increased by 14% and 15%, respectively without impairing the identification of unilateral PA. We concluded that androstenedione and metanephrine outperformed cortisol for ascertaining AVS success, thus increasing the AVS studies useable for the clinical decision making.

scholarly journals OR34-04 Efficiency of Adrenal Venous Sampling in the Treatment Choice of Primary Aldosteronism (AVSTAT Study)

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Mitsuhide Naruse ◽  
Felix Beuschlein ◽  
Mirko Parasiliti Caprino ◽  
Jaap Deinum ◽  
William Drake ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Clinical Decision ◽  
Pressure Control ◽  
Primary Objective ◽  
Adrenal Venous Sampling ◽  
Venous Sampling ◽  
Bilateral Disease ◽  
Good Blood Pressure Control ◽  
Number Of Patients ◽  
Unilateral Disease

Abstract BACKGROUND: Adrenal venous sampling (AVS) is strongly recommended for a subtype diagnosis of primary aldosteronism (PA) if adrenalectomy (ADX) is desired by the patient. Given various issues related to AVS such as technical demand, invasive nature, expensive cost and radiation exposure, AVS is expected to lead efficiently to the subtype diagnosis and ADX. Aim: Primary objective was to assess the performance of AVS to determine treatment of PA by investigating the ratio of unilateral disease and rate of ADX following AVS in patients with unilateral disease. Methods: Sixteen major referral centers in ENS@T (n=10) and Japan (n=6) participated in the study. Study period was from 2006 to 2018. Data on total number of PA patients, AVS (total number and number of successful procedures), number of patients with unilateral diseases, and number of patients that underwent ADX were collected by a questionnaire-based survey. In addition, reasons for not proceeding to ADX in patients with a unilateral diagnosis were investigated. The diagnosis of PA was based on the positive case detection and at least one positive result in confirmatory testing. Results: Total number of confirmed PA patients and conducted AVS showed a dramatic increase during the past decade (PA: 1061 pts/ 2006–2011 to 3718 pts/ 2012–2018; AVS: 720/ 2006–2011 to 2448/ 2012–2018). Success rate of AVS was improved from 79.0% (2006–2011) to 92.5% (2012–2018). Both rate of unilateral PA and ADX of successful procedures decreased from 42.7% (2006–2011) to 37.3% (2012–2018) and from 40.8% (2006–2011) to 34.9% (2012–2018), respectively. Of the patients with successful AVS, bilateral disease was diagnosed in 63.5% (1812/2854 pts). Of the unilateral PA patients, 11.9% (125/ 1054 pts) were not subjected to ADX. The rate of the patients not subjected to ADX was significantly higher in Japan than in ENS@T centers both in patients with successful AVS (75.8% vs. 53.4%) and with unilateral disease (19.9% vs. 8.6%). Clinical decision against ADX in unilateral disease was made by the physicians in 33.3%, the patients in 33.3%, and both in 33.3%. Medical factors for Dr.’s decision against ADX in unilateral disease included good blood pressure control, normokalemia, comorbidities (e.g. DM, CKD), non-lateralized CT findings (e.g. no tumor, contralateral tumor), and discordant results among different criteria of AVS. Conclusions: High prevalence of bilateral disease and change of treatment policy after implementation affected the efficiency of AVS as an essential diagnostic procedure prior to ADX. Development of non-invasive procedures to exclude bilateral PA and more strict indication of AVS are warranted.

Adrenal Venous Sampling in Young Patients with Primary Aldosteronism. Extravagance or Irreplaceable?

2021 ◽  
Author(s):  
Eleftheria Gkaniatsa ◽  
Augustinas Sakinis ◽  
Magnus Palmér ◽  
Andreas Muth ◽  
Penelope Trimpou ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Clinical Guidelines ◽  
Clinical Success ◽  
Adrenal Adenoma ◽  
Young Patients ◽  
Adrenal Venous Sampling ◽  
Imaging Studies ◽  
Venous Sampling ◽  
Unilateral Adrenalectomy ◽  
Aldosterone Production

Abstract Context Current clinical guidelines suggest that adrenal venous sampling (AVS) may not be mandatory in young patients with primary aldosteronism (PA) and a solitary adrenal adenoma on imaging. Objective The aim of this study was to further elucidate whether conventional imaging alone is sufficient to distinguish unilateral from bilateral PA among patients aged 40 years or younger. Methods This was a retrospective study where data from 45 patients with PA, aged between 26 and 40 years, who underwent successful AVS between 2005 and 2019, were analyzed. Results concerning laterality on imaging studies and AVS were recorded. Outcome in surgically treated patients was assessed according to the Primary Aldosteronism Surgical Outcomes criteria. Results In 4 of 25 patients with unilateral aldosterone production according to AVS, computed tomography inaccurately suggested bilateral disease. Following unilateral adrenalectomy, all 4 patients showed complete clinical success. Five of 20 patients with bilateral aldosterone production according to AVS had a solitary adrenal nodule (8-19 mm) on imaging. Two of these 5 patients were treated with unilateral adrenalectomy, neither having complete biochemical and/or clinical success postoperatively. Two of 16 patients younger than 35 years had discordant results, 1 with unilateral and 1 with bilateral aldosterone production, according to AVS. Conclusion Imaging studies inaccurately predicted laterality in a significant number of young patients with PA. In contrast to current clinical guidelines, our results support AVS for subtype evaluation in young adults with PA, including patients 35 years or younger.

scholarly journals Combined Ovarian and Adrenal Venous Sampling in the Localization of Adrenocorticotropic Hormone-Independent Ectopic Cushing Syndrome

2017 ◽  
Vol 103 (3) ◽  
pp. 803-808
Author(s):  
Shi Chen ◽  
Ran Li ◽  
Xiaobo Zhang ◽  
Lin Lu ◽  
Ji Li ◽  
...  
Keyword(s):  
Adrenocorticotropic Hormone ◽  
Clinical Decision Making ◽  
Cushing Syndrome ◽  
Somatostatin Receptor ◽  
Clinical Decision ◽  
Adrenal Venous Sampling ◽  
Ovarian Vein ◽  
Venous Sampling ◽  
Pelvic Ultrasonography ◽  
The Right

Abstract Context Cushing syndrome is rarely caused by the secretion of cortisol from ovarian tumors. In clinical decision-making, it is important to determine whether the ovarian tumor is capable of secreting cortisol. Selective ovarian and adrenal venous sampling is scarcely reported in the localization of ACTH-independent ectopic Cushing syndrome. Case Description We present a case of 40-year-old Chinese woman who had weight gain, hirsutism, hypertension, and menstrual disorder over 6 months. Her physical examination and biochemical assessment revealed adrenocorticotropic hormone-independent Cushing syndrome. Adrenal computed tomography scan indicated no abnormality. A mass of 5.7 cm × 4.2 cm × 3.4 cm was discovered by pelvic ultrasonography. Somatostatin receptor scintigraphy revealed no abnormal radioactivity intake. Combined ovarian and adrenal venous sampling together with a cortisol assay were conducted. Results revealed cortisol concentration of the right-side ovarian vein, left-side ovarian vein, and peripheral vein of 268.60, 29.00, and 35.18 μg/dL, respectively, suggesting a right-side ovarian origin. A right-side salpingo-oophorectomy was performed and the pathological diagnosis revealed ovarian steroid cell tumor, not otherwise specified. The cortisol level was substantially lower after the patient underwent surgery and symptoms of Cushing syndrome disappeared. At 3-year follow-up, the patient remained disease free, and no tumor was observed on pelvic ultrasonogram. Conclusion Combined ovarian and adrenal venous sampling is valuable in the localization of adrenocorticotropic hormone–independent ectopic Cushing syndrome.

scholarly journals Utility of Plasma Metanephrines in Adrenal Venous Sampling in Primary Aldosteronism

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A303-A304
Author(s):  
Aditi Sharma ◽  
Zaineb Amin Mohsin ◽  
Claudia Moore-Gillon ◽  
Joseph Derry ◽  
Kate Thomas ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Half Life ◽  
Adrenal Venous Sampling ◽  
Venous Sampling ◽  
High Concentration ◽  
Affected Side ◽  
Aldosterone Production ◽  
Unilateral Disease ◽  
Plasma Metanephrines ◽  
Cannulation Success

Abstract Introduction: Adrenal Venous Sampling (AVS) is the most reliable means of identifying surgically curable subtypes of primary aldosteronism (PA). Cortisol levels are used to determine cannulation success and lateralization. However, cortisol has a variable secretion pattern and long-half life, and can be co-secreted by adrenal adenomas, leading to misinterpretation of results. Plasma metanephrines (MN) are a possible alternative analyte. MN levels are unaffected by stress, have a short half-life of 3–6 minutes and are released continuously by the adrenals, resulting in very high concentration gradients between the adrenal veins (AV) and peripheral veins (PV), thus providing a sensitive means to determine cannulation success. Premise:The objective of this study was to see if MN can be used in lieu of cortisol in AVS. A secondary end-point was to see if the data was particularly useful in patients who are known co-secretors of cortisol. Methods: Data from AVS carried out without cosyntropin stimulation, from October 2018 to March 2020, were analysed retrospectively. Of these, 51 had additional samples drawn for MN at the time of the procedure and were recruited. Six patients were identified as having autonomous cortisol secretion as they failed an overnight dexamethasone suppression test (ONDST). The data was analysed using cortisol and MN separately and then compared with regards to their selectivity and lateralization index. Data was also analysed to see if known co-secretors had an elevated cortisol/MN ratio of more than 2 on the affected side as described in previous papers. Results: When compared to cannulation and lateralization outcomes using cortisol, similar results were obtained using, a MN AV/PV ratio of more than 12 to indicate successful cannulation and an aldosterone/MN ratios of greater than 5 to confirm lateralization. Contralateral suppression to less than 0.5 for aldosterone/MN below the PV was seen in unilateral disease. With regards to the six co-secretors, all had elevated cortisol/MN ratios of more than 2 on the affected side. Three had concordant results but the other three had discrepant results, with MN analysis suggesting unilateral disease and cortisol measurements suggesting bilateral disease. Two had undergone surgery with biopsy confirming unilateral disease that correlated with MN analysis. The third is under medical management. Conclusion: This is the first study evaluating the use of MN to determine lateralisation of aldosterone production in PA. Further studies are needed, but using MN may be a more reliable alternative to cortisol in the analysis of AVS before definitive surgery in particular in patients with cortisol co-secretion.

scholarly journals Accessing Artificial Intelligence for Clinical Decision-Making

2021 ◽  
Vol 3 ◽  
Author(s):  
Chris Giordano ◽  
Meghan Brennan ◽  
Basma Mohamed ◽  
Parisa Rashidi ◽  
François Modave ◽  
...  
Keyword(s):  
Artificial Intelligence ◽  
Decision Making ◽  
Patient Care ◽  
Clinical Decision Making ◽  
Clinical Medicine ◽  
Clinical Decision ◽  
Disruptive Innovation ◽  
Decision Makers ◽  
Data Sets ◽  
Sequential Decision

Advancements in computing and data from the near universal acceptance and implementation of electronic health records has been formative for the growth of personalized, automated, and immediate patient care models that were not previously possible. Artificial intelligence (AI) and its subfields of machine learning, reinforcement learning, and deep learning are well-suited to deal with such data. The authors in this paper review current applications of AI in clinical medicine and discuss the most likely future contributions that AI will provide to the healthcare industry. For instance, in response to the need to risk stratify patients, appropriately cultivated and curated data can assist decision-makers in stratifying preoperative patients into risk categories, as well as categorizing the severity of ailments and health for non-operative patients admitted to hospitals. Previous overt, traditional vital signs and laboratory values that are used to signal alarms for an acutely decompensating patient may be replaced by continuously monitoring and updating AI tools that can pick up early imperceptible patterns predicting subtle health deterioration. Furthermore, AI may help overcome challenges with multiple outcome optimization limitations or sequential decision-making protocols that limit individualized patient care. Despite these tremendously helpful advancements, the data sets that AI models train on and develop have the potential for misapplication and thereby create concerns for application bias. Subsequently, the mechanisms governing this disruptive innovation must be understood by clinical decision-makers to prevent unnecessary harm. This need will force physicians to change their educational infrastructure to facilitate understanding AI platforms, modeling, and limitations to best acclimate practice in the age of AI. By performing a thorough narrative review, this paper examines these specific AI applications, limitations, and requisites while reviewing a few examples of major data sets that are being cultivated and curated in the US.

scholarly journals Adrenal vein sampling in a patient with primary hyperaldosteronism and severe contrast allergy

2021 ◽  
Author(s):  
Margaretha L M Prins ◽  
Bartholomeus E P B Ballieux ◽  
Onno C Meijer ◽  
Alberto M Pereira ◽  
Michiel F Nijhoff
Keyword(s):  
Clinical Decision Making ◽  
Serum Cortisol ◽  
Clinical Decision ◽  
Primary Hyperaldosteronism ◽  
Adrenal Venous Sampling ◽  
High Dose ◽  
Venous Sampling ◽  
Acth Stimulation ◽  
Iodinated Contrast ◽  
History Of

Abstract We report on a case of a 50-year-old female patient with primary hyperaldosteronism, in whom adrenal venous sampling was required to differentiate between unilateral and bilateral disease. Because of a history of severe allergy to iodinated contrast media, premedication with glucocorticoids was indicated. Exogenous glucocorticoids, however, can affect measurements of serum cortisol. To avoid this potential confounding effects on the cortisol assay, we decided to use dexamethasone instead of prednisolone or hydrocortisone. A high-dose ACTH stimulation test with the simultaneous use of dexamethasone revealed an adequate adrenal cortisol response. ACTH-stimulated adrenal venous sampling showed reliable results, which provided a solid basis for further clinical decision-making.

Sign in / Sign up

Export Citation Format

Share Document