Basal and Post-ACTH Aldosterone and Its Ratios Are Useful During Adrenal Vein Sampling in Primary Aldosteronism

Abstract Context: Adrenal vein sampling (AVS) is required to identify a lateralized or bilateral aldosterone source in primary aldosteronism. Objectives: Our objectives were to compare basal and post-ACTH selectivity ratio (SR) and lateralization ratio (LR) and to determine the prevalence of basal contralateral suppression and its effect on surgical outcome. Patients and Intervention: Bilateral simultaneous adrenal vein samples were obtained before and after a 250-μg bolus of ACTH. Analyses were conducted on 171 technically successful AVS and on the subgroup of 66 operated patients with evaluable outcome data. Results: ACTH increased selectivity on both sides from 66.7% in basal samples (SR ≥ 2) to 91.8% poststimulation (SR ≥ 5). A discordance of lateralization between basal (LR ≥ 2) and post-ACTH (LR ≥ 4) values was observed in 28% of cases, which were mostly lateralized cases basally that became bilateral post-ACTH. Basal CL suppression is present in only 30% using absolute ratio of aldosterone between the opposite (nondominant) adrenal vein and the peripheral vein AOPP/AP below 1.5 vs in 77% using aldosterone/cortisol ratio (A/C)OPP/(A/C)P below 1.5. The absence of CL suppression was associated with a lower rate of response to adrenalectomy in terms of clinical and biochemical parameters with difference in clinical cure (55% vs 13% P = .0003) and overall cure (35% vs 9%, P = .0084) using AOPP/AP, but not when using (A/C)OPP/(A/C)P. Conclusions: Stimulation with ACTH is useful to improve selectivity of AVS but can frequently modify interpretation of lateralization. Basal ratios are as important as post-ACTH ratios to set an indication of adrenalectomy. AOPP/AP is superior to (A/C)OPP/(A/C)P to assess contralateral suppression. Infrequent CL suppression reveals frequent occurrence of contralateral hyperplasia in lateralized cases and helps predict postoperative outcomes.

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

Case Reports in Medicine ◽

10.1155/2019/1604367 ◽

2019 ◽

Vol 2019 ◽

pp. 1-4 ◽

Cited By ~ 1

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.

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Lateralization index but not contralateral suppression at adrenal vein sampling predicts improvement in blood pressure after adrenalectomy for primary aldosteronism

Journal of Human Hypertension ◽

10.1038/jhh.2016.92 ◽

2017 ◽

Vol 31 (7) ◽

pp. 444-449 ◽

Cited By ~ 6

Author(s):

M Tagawa ◽

M Ghosn ◽

H Wachtel ◽

D Fraker ◽

R R Townsend ◽

...

Keyword(s):

Blood Pressure ◽

Primary Aldosteronism ◽

Adrenal Vein ◽

Adrenal Vein Sampling ◽

Contralateral Suppression ◽

Lateralization Index

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Effect of Adrenocorticotropic Hormone Stimulation During Simultaneous Bilateral Adrenal Vein Sampling in Primary Aldosteronism

Hormone and Metabolic Research ◽

10.1055/a-1498-6958 ◽

2021 ◽

Vol 53 (06) ◽

pp. 364-370

Author(s):

Wei Liu ◽

Jingjing Zhang ◽

Yaling Yang ◽

Yinxin Jin ◽

Zaizhao Li ◽

...

Keyword(s):

Primary Aldosteronism ◽

Adrenocorticotropic Hormone ◽

Base Excess ◽

Serum Potassium Level ◽

Adrenal Vein ◽

Acth Stimulation ◽

Adrenal Vein Sampling ◽

Before And After ◽

Carbon Dioxide Combining Power ◽

Lateralization Index

AbstractThe aim of the study was to investigate the significance and influence of adrenocorticotropic hormone (ACTH) stimulation in primary aldosteronism (PA) patients with simultaneous bilateral adrenal vein sampling (AVS). All patients diagnosed with PA underwent simultaneous bilateral AVS with ACTH. In 95 patients, the post-ACTH SI significantly increased (p<0.001), and it gradually decreased from t10–t30 after ACTH stimulation (p<0.001). The unsuccessful catheterization decreased after ACTH stimulation. Time points within 20 min after ACTH stimulation were better for sampling, and the selectivity did not increase over longer periods. According to lateralization before and after ACTH stimulation, the patients could be divided into 3 groups (U, unilateral; B, bilateral): U/U , U/B or B/U, and B/B. Compared with the U/U group, in the U/B or B/U and B/B groups, the lateralization index (LI) was lower both at baseline and after ACTH stimulation (p<0.0001), the contralateral index (CLI) was higher after ACTH stimulation (p<0.003), the serum potassium level was higher (p<0.001), and the carbon dioxide combining power (CO2CP) and base excess (BE) levels were lower. In conclusion, in simultaneous bilateral AVS, ACTH stimulation had significant effects on increasing the catheterization selectivity. Lateralization change was observed after stimulation. After ACTH stimulation, fewer patients could be diagnosed with lateralized PA. Patients with consistent lateralized PA showed a more serious phenotype.

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Metoclopramide unmasks potentially misleading contralateral suppression in patients undergoing adrenal vein sampling for primary aldosteronism

Journal of Hypertension ◽

10.1097/hjh.0000000000001082 ◽

2016 ◽

Vol 34 (11) ◽

pp. 2258-2265 ◽

Cited By ~ 14

Author(s):

Giacomo Rossitto ◽

Diego Miotto ◽

Michele Battistel ◽

Giulio Barbiero ◽

Giuseppe Maiolino ◽

...

Keyword(s):

Primary Aldosteronism ◽

Adrenal Vein ◽

Adrenal Vein Sampling ◽

Contralateral Suppression

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The Concordance Between Imaging and Adrenal Vein Sampling Varies With Aldosterone-Driver Somatic Mutation

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/clinem/dgaa482 ◽

2020 ◽

Vol 105 (10) ◽

pp. e3628-e3637

Author(s):

Taweesak Wannachalee ◽

Elaine Caoili ◽

Kazutaka Nanba ◽

Aya Nanba ◽

William E Rainey ◽

...

Keyword(s):

Adrenal Vein ◽

Adrenal Vein Sampling ◽

Cross Sectional ◽

Tertiary Referral Center ◽

Asian Patients ◽

Contralateral Suppression ◽

Adrenal Imaging ◽

Before And After ◽

Cross Sectional Imaging ◽

Generation Sequencing

Abstract Background Correct subtyping of primary aldosteronism (PA) is critical for guiding clinical management. Adrenal imaging is less accurate than adrenal vein sampling (AVS); nonetheless, AVS is invasive, technically challenging, and scarcely available. Objective To identify predictors of concordance between cross-sectional imaging and lateralized AVS in patients with PA that could help circumvent AVS in a subset of patients. Methods We retrospectively studied all patients with PA who underwent AVS in a tertiary referral center from 2009 to 2019. AVS was performed before and after cosyntropin stimulation. Patients with lateralized AVS in at least one condition were included. Aldosterone synthase-guided next-generation sequencing was performed on available adrenal tissue. Logistic regression was implemented to identify predictors of imaging-AVS lateralization concordance. Results A total of 234 patients (62% men), age 20 to 79 years, 73% white, 23% black, and 2% Asian were included. AVS lateralization was found: 1) both pre- and post-cosyntropin (Uni/Uni) in 138 patients; 2) only at baseline (Uni/Bi) in 39 patients; 3) only after cosyntropin stimulation (Bi/Uni) in 29 patients. Catheterization partially failed in 28 patients. AVS-imaging agreement was higher in patients with KCNJ5 versus other aldosterone-driver somatic mutations (90.3% versus 64.6%; P < 0.001); in Asian and white versus black Americans (75%, 70%, and 36%, respectively); in younger patients; and those with left adrenal nodules and contralateral suppression. Conversely, AVS-imaging agreement was lowest in Uni/Bi patients (38% vs. 69% in Uni/Uni, and 62% in Bi/Uni; P = 0.007). Conclusions While AVS-imaging agreement is higher in young white and Asian patients, who have KCNJ5-mutated aldosterone producing adenomas, no predictor confers absolute imaging accuracy.

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