scholarly journals Variability of Aldosterone Measurements During Adrenal Venous Sampling for Primary Aldosteronism

2020 ◽  
Author(s):  
Nicholas Yozamp ◽  
Gregory L Hundemer ◽  
Marwan Moussa ◽  
Johnathan Underhill ◽  
Tali Fudim ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Vena Cava ◽  
Adrenal Venous Sampling ◽  
Venous Sampling ◽  
Tertiary Referral Center ◽  
Percentage Difference ◽  
Left And Right ◽  
The Mean ◽  
Lateralization Index ◽  
Cortisol Ratio

Abstract BACKGROUND Variability of aldosterone concentrations has been described in patients with primary aldosteronism. METHODS We performed a retrospective cohort study of 340 patients with primary aldosteronism who underwent adrenal venous sampling (AVS) at a tertiary referral center, 116 of whom also had a peripheral venous aldosterone measured hours before the procedure. AVS was performed by the same interventional radiologist using bilateral, simultaneous sampling, under unstimulated and then stimulated conditions, and each sample was obtained in triplicate. Main outcome measures were: (i) change in day of AVS venous aldosterone from pre-AVS to intra-AVS and (ii) variability of triplicate adrenal venous aldosterone concentrations during AVS. RESULTS Within an average duration of 131 minutes, 81% of patients had a decline in circulating aldosterone concentrations (relative decrease of 51% and median decrease of 7.0 ng/dl). More than a quarter (26%) of all patients had an inferior vena cava aldosterone of ≤5 ng/dl at AVS initiation. The mean coefficient of variation of triplicate adrenal aldosterone concentrations was 30% and 39%, in the left and right veins, respectively (corresponding to a percentage difference of 57% and 73%), resulting in lateralization discordance in up to 17% of patients if the lateralization index were calculated using only one unstimulated aldosterone-to-cortisol ratio rather than the average of triplicate measures. CONCLUSIONS Circulating aldosterone levels can reach nadirs conventionally considered incompatible with the primary aldosteronism diagnosis, and adrenal venous aldosterone concentrations exhibit acute variability that can confound AVS interpretation. A single venous aldosterone measurement lacks precision and reproducibility in primary aldosteronism.

scholarly journals Adrenal Venous Sampling in Primary Aldosteronism: The Usefulness of Contralateral Suppression Index

2019 ◽  
Vol 2019 ◽  
pp. 1-4 ◽  
Author(s):  
Natalia Treistman ◽  
Aline Barbosa Moraes ◽  
Stéphanie Cozzolino ◽  
Patrícia de Fatima dos Santos Teixeira ◽  
Leonardo Vieira Neto
Keyword(s):  
Primary Aldosteronism ◽  
Vena Cava ◽  
Adrenal Vein ◽  
Adrenal Venous Sampling ◽  
Venous Sampling ◽  
Successful Cannulation ◽  
Contralateral Suppression ◽  
The Right ◽  
Cortisol Ratio ◽  
Suppression Index

Adrenal venous sampling (AVS) is the gold standard test to differentiate the unilateral from the bilateral form in patients with primary aldosteronism (PA) although it may be a difficult procedure, especially the successful cannulation of the right adrenal vein. In this report, we describe a 49-year-old female patient diagnosed with PA, after investigating resistant hypertension and refractory hypokalemia. Abdominal computed tomography scan revealed a 2.5 cm adenoma on the right adrenal vein. AVS was performed under cosyntropin infusion. Aldosterone and cortisol concentrations were obtained from the right and left adrenal veins and inferior vena cava (IVC). Cortisol on each adrenal vein divided by cortisol on IVC confirmed successful cannulation of the left side only, which makes it impossible to calculate the lateralization index (LI). From the data on the left adrenal vein and IVC, the aldosterone-to-cortisol ratio divided by the IVC aldosterone-to-cortisol ratio was less than 1.0, suggesting that the left adrenal vein was suppressed with the excess aldosterone originating from the contralateral side (contralateral suppression index (CSI)). Right adrenalectomy was performed; postoperative hypoaldosteronism was confirmed. This report highlights the importance of CSI obtained in AVS when technical difficulties occur making it impossible to obtain LI, which is most commonly used to decide between surgical and clinical management of PA.

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

2020 ◽  
Vol 105 (10) ◽  
pp. e3776-e3784 ◽  
Author(s):  
Samuel Matthew O’Toole ◽  
Wing-Chiu Candy Sze ◽  
Teng-Teng Chung ◽  
Scott Alexander Akker ◽  
Maralyn Rose Druce ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Vena Cava ◽  
Adrenal Vein ◽  
Adrenal Venous Sampling ◽  
Low Grade ◽  
Venous Sampling ◽  
Retrospective Case ◽  
Tertiary Referral Center ◽  
Contralateral Suppression ◽  
Control Study

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.

scholarly journals Laterality Diagnosis of Adrenal Vein Sampling for Primary Aldosteronism Using Aldosterone Alone

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A291-A291
Author(s):  
Norio Wada ◽  
Shuhei Baba ◽  
Hajime Sugawara ◽  
Arina Miyoshi ◽  
Shinji Obara ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Roc Analysis ◽  
Vena Cava ◽  
Area Under The Curve ◽  
Adrenal Vein ◽  
Acth Stimulation ◽  
Adrenal Vein Sampling ◽  
Left And Right ◽  
Lateralization Index

Abstract Background: In adrenal vein sampling (AVS) for primary aldosteronism (PA), cortisol concentration is used to determine successful AVS, and laterality diagnosis is performed using a combination of aldosterone and cortisol concentrations. In this study, we examined the comparison with the conventional method when AVS was determined by aldosterone alone. Subjects and methods: We studied the data from 277 patients with PA who underwent AVS in Sapporo City General Hospital from July 2007 to April 2020. The patients with autonomous cortisol production were excluded. Using the blood samples from adrenal veins and inferior vena cava (IVC) after ACTH stimulation, the predicting ability of the left and right ratio of aldosterone concentration (aldosterone ratio, AR) for lateralization Index (LI) was examined by Receiver operating characteristic (ROC) analysis. The predicting abilities of the ratio of aldosterone concentration between adrenal vein and IVC (aldosterone index, AI) and aldosterone concentration for selectivity index (SI) and contralateral ratio (CR) were also examined by ROC analysis. Results: Six samples (0.01%) with SI <5 after ACTH stimulation those were determined unsuccessful AVS. The results of the area under the curve (AUC) in ROC analysis of aldosterone concentration and AI for prediction of SI>5 was 0.998, 0.990, respectively, p=0.39. The optimal cut-off values of aldosterone concentration and AI for prediction successful AVS were 1700 pg/ml (sensitivity 99.5%, specificity 100%), 7.44 (sensitivity 94.0%, specificity 100%), respectively. Seventy-two patients (27.3%) had LI >4 who were diagnosed as unilateral aldosterone excess. AR had 0.94 of AUC for prediction of LR >4. The optimal cut-off value of AR was 3.53 (sensitivity 86.1%, specificity 94.8%). Eighty-two patients (31.1%) had unilateral CR<1. The AUC of aldosterone concentration and AI for prediction of CR<1 was 0.96, 0.98, respectively, p=0.07. The optimal cut-off values of aldosterone concentration and AI were 13600 pg/ml, 42, respectively. The sensitivity and the specificity at the optimal cut-off points of aldosterone concentration and AI were 91.5%, 91.5% and 91.5%, 94.8%, respectively. Conclusions: The determination of successful AVS and unilateral result in AVS can be predicted using aldosterone alone. It was suggested that AR is useful for tentative interpretation in the cases where the results of aldosterone were previously reported and lateralizing diagnosis of the cases with autonomous cortisol production.

scholarly journals Adrenocorticotropic Hormone–Stimulated Adrenal Venous Sampling Underestimates Surgically Curable Primary Aldosteronism: A Retrospective Cohort Study and Review of Contemporary Studies

Hypertension ◽  
2021 ◽  
Author(s):  
Nicholas Yozamp ◽  
Gregory L. Hundemer ◽  
Marwan Moussa ◽  
Jonathan Underhill ◽  
Tali Fudim ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Adrenocorticotropic Hormone ◽  
Adrenal Venous Sampling ◽  
Original Research ◽  
Venous Sampling ◽  
Acth Stimulation ◽  
The Past ◽  
Unilateral Disease ◽  
The Impact ◽  
Lateralization Index

Guidelines recommend adrenal venous sampling to determine disease laterality in primary aldosteronism. Adrenocorticotropic hormone (ACTH) stimulation clearly improves the likelihood of successful adrenal vein catheterization but may lead to a decrease in lateralization rates. To examine the impact of ACTH on lateralization, we performed a retrospective analysis of 340 patients with confirmed primary aldosteronism who underwent adrenal venous sampling with a single interventional radiology team using a protocol of sampling both before and after an ACTH bolus. In addition to this original research, we conducted a review of similar studies from the past 5 years to develop a consensus on the impact of ACTH on lateralization for primary aldosteronism. In the original research analysis, following a bolus of ACTH, 58% of patients had a decline in lateralization index which led to discordance between the pre-ACTH and post-ACTH classifications of lateralization in up to 26% of cases. The majority of discordant cases were due to reclassification from unilateral disease pre-ACTH to bilateral disease post-ACTH. In patients who already lateralized with unstimulated sampling, the response to ACTH did not have any impact on surgical outcomes. In a review of contemporary studies, we identified 11 similar studies in the past 5 years, of which 10 reported either no change or a decrease in lateralization index following ACTH, resulting in ≈25% discordance between unstimulated and stimulated lateralization rates. We conclude that ACTH stimulation during adrenal venous sampling can underestimate surgically remediable primary aldosteronism and recommend that the role of ACTH be limited primarily to enhancing selectivity.

scholarly journals Adrenal venous sampling in primary aldosteronism: a low dilution of adrenal venous blood is crucial for a correct interpretation of the results

2010 ◽  
Vol 162 (1) ◽  
pp. 101-107 ◽  
Author(s):  
Jiri Ceral ◽  
Miroslav Solar ◽  
Antonin Krajina ◽  
Marek Ballon ◽  
Petr Suba ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Venous Blood ◽  
Vena Cava ◽  
Adrenal Venous Sampling ◽  
Venous Sampling ◽  
Aldosterone Secretion ◽  
Consistent Information ◽  
Design And Methods ◽  
The Impact ◽  
Reference Samples

ObjectiveIn primary aldosteronism, adrenal venous sampling (AVS) is essential for subtype differentiation as it evaluates aldosterone secretion from both adrenals. Selectivity of adrenal sampling is assessed by the ratio of cortisol concentrations in adrenal venous blood and inferior vena cava blood (Cadrenal/Civc). Since the criteria for selective adrenal sampling differ among the reported literature, we performed a study to evaluate the influence of different selectivity criteria on AVS results.Design and methodsReports of AVS were screened retrospectively. All AVS were performed with cosyntrophin infusion. Reports containing samples with Cadrenal/Civc≥10 taken from both adrenals and at least one other adrenal sample characterised by Cadrenal/Civc≥1.1 were enrolled. For each individual, we chose reference samples that were defined by the highest Cadrenal/Civc achieved from each adrenal. The significance of the remaining samples with Cadrenal/Civc≥1.1 was analysed in regard to their respective reference samples. We assessed the impact of analysed samples on identification of lateralisation of aldosterone secretion that is crucial for decisions concerning adrenalectomy.ResultsAVS reports of 87 patients were enrolled. A total of 225 adrenal samples were analysed and divided into five groups according to Cadrenal/Civc:1.1–1.99, 2–2.99, 3–4.99, 5–9.99 and ≥10. By comparing reference with analysed samples, a concordant assessment with respect to lateralisation of aldosterone secretion was observed in 39, 52, 72, 85 and 94% of the respective groups of analysed samples.ConclusionAVS provides consistent information when adrenal samples with high cortisol concentrations are used.

scholarly journals Correlation Between Lateralization Index of Adrenal Venous Sampling and Standardized Outcome in Primary Aldosteronism

2018 ◽  
Vol 2 (8) ◽  
pp. 893-902 ◽  
Author(s):  
Hironobu Umakoshi ◽  
Mika Tsuiki ◽  
Maki Yokomoto-Umakoshi ◽  
Yoshiyu Takeda ◽  
Yoneda Takashi ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Adrenal Venous Sampling ◽  
Venous Sampling ◽  
Lateralization Index

scholarly journals Effect of cosyntropin during adrenal venous sampling on subtype of primary aldosteronism: analysis of surgical outcome

2020 ◽  
Vol 182 (3) ◽  
pp. 265-273
Author(s):  
Hiroki Kobayashi ◽  
Yoshihiro Nakamura ◽  
Masanori Abe ◽  
Isao Kurihara ◽  
Hiroshi Itoh ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Surgical Outcomes ◽  
Surgical Outcome ◽  
Adrenal Adenoma ◽  
Adrenal Venous Sampling ◽  
Pathological Findings ◽  
Venous Sampling ◽  
Acth Stimulation ◽  
Well Differentiated ◽  
Lateralization Index

Objectives We investigated the clinical significance of ACTH stimulation during adrenal venous sampling (AVS) by surgical outcome of primary aldosteronism (PA). Design Multicenter retrospective study by Japan PA study. Method We allocated 314 patients with both basal and ACTH-stimulated AVS data who underwent adrenalectomy to three groups: basal lateralization index (LI) ≥2 with ACTH-stimulated LI ≥4 on the ipsilateral side (Unilateral (U) to U group, n = 245); basal LI <2 with ACTH-stimulated LI ≥4 (Bilateral (B) to U group, n = 15); and basal LI ≥2 with ACTH-stimulated LI <4 (U to B group, n = 54). We compared surgical outcomes among the groups using the Primary Aldosteronism Surgical Outcome (PASO) criteria. Results Compared with U to U group, U to B group had poor clinical and biochemical outcomes and low rates of adrenal adenoma as pathological findings (P = 0.044, 0.006, and 0.048, respectively), although there were no significant differences between U to U and B to U groups. All patients in U to B group with clinical and biochemical benefits, however, had adrenal adenoma as pathological findings and could be well differentiated from those with poor surgical outcomes via basal LI (>8.3), but not ACTH-stimulated LI. These results were similar even when we defined each group based on a cut-off value of 4 for basal LI. Conclusions Although PA patients in U to B group had worse surgical outcomes than did those in U to U group, basal LI could discriminate among patients with better surgical outcomes in U to B group.

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