scholarly journals Use of plasma metanephrine to aid adrenal venous sampling in combined aldosterone and cortisol over-secretion

2015 ◽  
Vol 2015 ◽  
Author(s):  
Rémi Goupil ◽  
Martin Wolley ◽  
Jacobus Ungerer ◽  
Brett McWhinney ◽  
Kuniaki Mukai ◽  
...  
Keyword(s):  
Venous Blood ◽  
Adrenal Venous Sampling ◽  
Pathological Examination ◽  
List Type ◽  
Venous Sampling ◽  
Contralateral Suppression ◽  
Aldosterone Production ◽  
Cortisol Levels ◽  
Dexamethasone Suppression ◽  
Learning Points

Summary In patients with primary aldosteronism (PA) undergoing adrenal venous sampling (AVS), cortisol levels are measured to assess lateralization of aldosterone overproduction. Concomitant adrenal autonomous cortisol and aldosterone secretion therefore have the potential to confound AVS results. We describe a case where metanephrine was measured during AVS to successfully circumvent this problem. A 55-year-old hypertensive male had raised plasma aldosterone/renin ratios and PA confirmed by fludrocortisone suppression testing. Failure of plasma cortisol to suppress overnight following dexamethasone and persistently suppressed corticotrophin were consistent with adrenal hypercortisolism. On AVS, comparison of adrenal and peripheral A/F ratios (left 5.7 vs peripheral 1.0; right 1.7 vs peripheral 1.1) suggested bilateral aldosterone production, with the left gland dominant but without contralateral suppression. However, using aldosterone/metanephrine ratios (left 9.7 vs peripheral 2.4; right 1.3 vs peripheral 2.5), aldosterone production lateralized to the left with good contralateral suppression. The patient underwent left laparoscopic adrenalectomy with peri-operative glucocorticoid supplementation to prevent adrenal insufficiency. Pathological examination revealed adrenal cortical adenomas producing both cortisol and aldosterone within a background of aldosterone-producing cell clusters. Hypertension improved and cured of PA and hypercortisolism were confirmed by negative post-operative fludrocortisone suppression and overnight 1 mg dexamethasone suppression testing. Routine dexamethasone suppression testing in patients with PA permits detection of concurrent hypercortisolism which can confound AVS results and cause unilateral PA to be misdiagnosed as bilateral with patients thereby denied potentially curative surgical treatment. In such patients, measurement of plasma metanephrine during AVS may overcome this issue. Learning points Simultaneous autonomous overproduction of cortisol and aldosterone is increasingly recognised although still apparently uncommon. Because cortisol levels are used during AVS to correct for differences in dilution of adrenal with non-adrenal venous blood when assessing for lateralisation, unilateral cortisol overproduction with contralateral suppression could confound the interpretation of AVS results Measuring plasma metanephrine during AVS to calculate lateralisation ratios may circumvent this problem.

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.

Intraprocedural Cortisol Levels in the Evaluation of Proper Catheter Placement in Adrenal Venous Sampling

2011 ◽  
Vol 22 (11) ◽  
pp. 1575-1580 ◽  
Author(s):  
Michael A. Reardon ◽  
John F. Angle ◽  
Nadine Abi-Jaoudeh ◽  
David E. Bruns ◽  
Doris M. Haverstick ◽  
...  
Keyword(s):  
Catheter Placement ◽  
Adrenal Venous Sampling ◽  
Venous Sampling ◽  
Cortisol Levels

Contralateral suppression of aldosterone at adrenal venous sampling predicts hyperkalemia following adrenalectomy for primary aldosteronism

Surgery ◽  
2018 ◽  
Vol 163 (1) ◽  
pp. 183-190 ◽  
Author(s):  
Omair A. Shariq ◽  
Irina Bancos ◽  
Patricia A. Cronin ◽  
David R. Farley ◽  
Melanie L. Richards ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Adrenal Venous Sampling ◽  
Venous Sampling ◽  
Contralateral Suppression

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 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 Pseudohyperkalaemia in essential thrombocytosis: an important clinical reminder

2021 ◽  
Vol 2021 ◽  
Author(s):  
Jean Marc Mizzi ◽  
Christopher Rizzo ◽  
Stephen Fava
Keyword(s):  
Venous Blood ◽  
Elevated Serum ◽  
Plasma Potassium ◽  
List Type ◽  
Limb Weakness ◽  
Clinical Reminder ◽  
Bilateral Lower Limb ◽  
Venous Blood Gas ◽  
Learning Points ◽  
Rule Out

Summary An 82-year-old female was admitted to a general hospital due to progressive bilateral lower limb weakness. A T8–T9 extramedullary meningioma was diagnosed by MRI, and the patient was referred for excision of the tumour. During the patient’s admission, she was noted to have persistent hyperkalaemia which was refractory to treatment. Following a review by an endocrinology team, a diagnosis of pseudohyperkalaemia secondary to thrombocytosis was made. This case demonstrates the importance of promptly identifying patients who are susceptible to pseudohyperkalaemia, in order to prevent its potentially serious consequences. Learning points Pseudohyperkalaemia should be considered in patients with unexplained or asymptomatic hyperkalaemia. It should also be considered in those patients who are resistant to the classical treatment of hyperkalaemia. A diagnosis of pseudohyperkalaemia is considered when there is a difference of >0.4 mmol/L of potassium between serum and plasma potassium in the absence of symptoms and ECG changes. In patients who are presenting with consistently elevated serum potassium levels, it may be beneficial to take venous blood gas and/ or plasma potassium levels to rule out pseudohyperkalaemia. Pseudohyperkalaemia may subject patients to iatrogenic hypokalaemia which can be potentially fatal. Pseudohyperkalaemia can occur secondary to thrombocytosis, red cell haemolysis due to improper blood letting techniques, leukaemia and lymphoma.

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 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 A case of primary aldosteronism with secondary hyperparathyroidism and bilateral adrenal tumors

2015 ◽  
Vol 2015 ◽  
Author(s):  
Tohru Eguchi ◽  
Shozo Miyauchi
Keyword(s):  
Secondary Hyperparathyroidism ◽  
Primary Aldosteronism ◽  
Japanese Woman ◽  
Adrenal Tumors ◽  
List Type ◽  
Venous Sampling ◽  
Laboratory Findings ◽  
Old Japanese ◽  
Learning Points ◽  
Bilateral Adrenal Tumors

Summary A 43-year-old Japanese woman was admitted to our hospital with weakness. Laboratory findings showed hypokalemia, hypocalcemia and elevation of the serum creatinine phosphokinase levels, but intact parathyroid hormone levels. Further evaluations suggested that she had primary aldosteronism (PA), secondary hyperparathyroidism and bilateral adrenal tumors. She was treated successfully by laparoscopic right adrenalectomy. This case not only serves to the diagnosis of bilateral adrenal tumors in which selective adrenal venous sampling (SAVS) proved to be useful, but also for physicians to be aware of secondary hyperparathyroidism and the risk of secondary osteoporosis caused by PA. Learning points The classic presenting signs of PA are hypertension and hypokalemia. Hypokalemia can induce rhabdomyolysis. PA causes secondary hyperparathyroidism. Patients with PA have the risk of osteoporosis with secondary hyperparathyroidism. SAVS is useful in bilateral adrenal tumors.

Sign in / Sign up

Export Citation Format

Share Document