scholarly journals Physiologic variance of corticotropin affects diagnosis in adrenal vein sampling

2009 ◽  
Vol 160 (3) ◽  
pp. 459-463 ◽  
Author(s):  
Masayuki Tanemoto ◽  
Takehiro Suzuki ◽  
Michiaki Abe ◽  
Takaaki Abe ◽  
Sadayoshi Ito
Keyword(s):  
Low Dose ◽  
Standard Dose ◽  
Vena Cava ◽  
Adrenal Vein ◽  
Acth Stimulation ◽  
Adrenal Vein Sampling ◽  
High Prevalence ◽  
Design And Methods ◽  
Diagnostic Step ◽  
Cortisol Ratio

ObjectiveDifferentiating unilateral form from bilateral is a critical diagnostic step in primary aldosteronism (PA), for which adrenal vein sampling (AVS) is accepted to be the most reliable. However, variance of corticotropin could affect the diagnosis in AVS.Design and methodsWe conducted simultaneous bilateral AVS on ten biochemically diagnosed PA cases, and used the aldosterone-to-cortisol ratio (A/C) of the samples for the diagnosis. The diagnosis by AVS after a low-dose (0.1 μg) ACTH stimulation, which can provoke maximum-physiologic corticotropic response, was compared with those before the stimulation and after the standard-dose (250 μg) ACTH stimulation.ResultsIn half of the cases, the low-dose pre-stimulation affected the diagnosis. In four out of ten cases, the side-to-side ratios of A/C were changed in the basal/low-dose/standard-dose AVS as 6.62/2.46/0.63, 2.13/0.41/0.14, 1.88/2.38/2.40, and 1.96/2.27/1.90 respectively. In three out of ten cases, the adrenal vein to the matching inferior vena cava ratio of A/C was also changed across 1, the cut-off to indicate suppression of aldosterone secretion. Additionally, the confirmation of successful sampling was difficult in five out of ten and two out of ten cases of the basal and low-dose AVS respectively, whereas it was easy in all the cases of the standard-dose AVS.ConclusionsThe diagnosis in the basal AVS could be affected by the physiologic fluctuation of ACTH at relatively high prevalence. The basal AVS would be unreliable to differentiate two forms of PA.

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 Subtyping of primary aldosteronism by adrenal vein sampling: effect of acute D2 receptor dopaminergic blockade on adrenal vein cortisol and chromogranin A levels

2011 ◽  
Vol 165 (1) ◽  
pp. 85-90 ◽  
Author(s):  
Teresa M Seccia ◽  
Diego Miotto ◽  
Renzo De Toni ◽  
Valentina Gallina ◽  
Matteo Vincenzi ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Chromogranin A ◽  
Inferior Vena ◽  
D2 Receptor ◽  
Vena Cava ◽  
Adrenal Vein ◽  
Aldosterone Secretion ◽  
Adrenal Vein Sampling ◽  
Plasma Cortisol Concentration ◽  
Design And Methods

BackgroundAdrenal vein sampling (AVS) is the gold standard for identifying the surgically curable forms of primary aldosteronism. Dopamine modulates adrenocortical steroidogenesis and tonically inhibits aldosterone secretion via D2 receptor. However, whether it could also affect the release of cortisol and chromogranin A (ChA), which can be used to assess the selectivity of AVS, is unknown.ObjectiveTo investigate whether metoclopramide increased the release of cortisol and ChA and could thereby improve assessment of the selectivity at AVS.Design and methodsWe investigated the effect of acute D2 antagonism with metoclopramide on cortisol and ChA release from the adrenal gland by comparing the adrenal vein and infrarenal inferior vena cava (IVC) hormone levels at baseline and after metoclopramide administration in 34 consecutive patients undergoing AVS.ResultsMetoclopramide increased plasma aldosterone in the IVC (P<0.00001) and in the adrenal vein blood (P<0.002) but failed to increase plasma cortisol concentration or ChA levels. Therefore, it did not increase the selectivity index based on the measurement of either hormone.ConclusionsThis study shows that the release of cortisol and ChA is not subjected to tonic D2 dopaminergic inhibition. Therefore, these findings lend no evidence for the usefulness of acute metoclopramide administration for enhancing the assessment of the selectivity of blood sampling during AVS with the use of either cortisol or ChA assay.

scholarly journals Radiation exposure of adrenal vein sampling: a German Multicenter Study

2018 ◽  
Vol 179 (4) ◽  
pp. 261-267 ◽  
Author(s):  
C T Fuss ◽  
M Treitl ◽  
N Rayes ◽  
P Podrabsky ◽  
W K Fenske ◽  
...  
Keyword(s):  
Radiation Exposure ◽  
Adrenal Vein ◽  
University Hospitals ◽  
Adrenal Vein Sampling ◽  
Dose Area Product ◽  
Systematic Assessment ◽  
Sampling Locations ◽  
Subtype Differentiation ◽  
Area Product ◽  
Design And Methods

Objective Adrenal vein sampling (AVS) represents the current diagnostic standard for subtype differentiation in primary aldosteronism (PA). However, AVS has its drawbacks. It is invasive, expensive, requires an experienced interventional radiologist and comes with radiation exposure. However, exact radiation exposure of patients undergoing AVS has never been examined. Design and methods We retrospectively analyzed radiation exposure of 656 AVS performed between 1999 and 2017 at four university hospitals. The primary outcomes were dose area product (DAP) and fluoroscopy time (FT). Consecutively the effective dose (ED) was approximately calculated. Results Median DAP was found to be 32.5 Gy*cm2 (0.3–3181) and FT 18 min (0.3–184). The calculated ED was 6.4 mSv (0.1–636). Remarkably, values between participating centers highly varied: Median DAP ranged from 16 to 147 Gy*cm2, FT from 16 to 27 min, and ED from 3.2 to 29 mSv. As main reason for this variation, differences regarding AVS protocols between centers could be identified, such as number of sampling locations, frames per second and the use of digital subtraction angiographies. Conclusion This first systematic assessment of radiation exposure in AVS not only shows fairly high values for patients, but also states notable differences among the centers. Thus, we not only recommend taking into account the risk of radiation exposure, when referring patients to undergo AVS, but also to establish improved standard operating procedures to prevent unnecessary radiation exposure.

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.

Reproducibility of the cortisol response to stimulation with a low dose of ACTH(1–24): the effect of basal cortisol levels and comparison of low-dose with high-dose secretory dynamics

1993 ◽  
Vol 136 (1) ◽  
pp. 167-172 ◽  
Author(s):  
S. Crowley ◽  
P. C. Hindmarsh ◽  
J. W. Honour ◽  
C. G. D. Brook
Keyword(s):  
Cortisol Level ◽  
Low Dose ◽  
Standard Dose ◽  
Serum Cortisol ◽  
Cortisol Concentration ◽  
Acth Stimulation ◽  
Basal Cortisol ◽  
Basal Cortisol Level ◽  
Adrenal Response ◽  
Serum Cortisol Concentration

ABSTRACT We compared the reproducibility and repeatability of the acute adrenal response to low doses (90 and 500 ng/1·73 m2) of Synacthen (ACTH(1–24)) with that of the standard dose (250 μg/1·73 m2). We also examined the effect of basal cortisol levels on peak values achieved after stimulation with a low dose. ACTH(1–24) was given to six male volunteers: 90 ng/1·73 m2 twice at 90-min intervals on day 1, and 90 and 500 ng/1·73 m2 once on day 2 and 250 μg/1·73 m2 once on day 3. The rise in serum cortisol concentration with repeated low doses of ACTH was not attenuated (161 ± 49 (s.d.) nmol/l on initial vs 150 ± 41 nmol/l on repeat stimulation; P = 0·5) and this was reproducible (161 ± 49 nmol/l on day 1 vs 148 ± 15 nmol/l on day 2; P = 0·6). A dose of 500 ng ACTH(1–24)/1·73 m2 produced a maximal adrenal response in that the rise in serum cortisol concentration at 20 min was identical with that produced at the same time by the standard dose of 250 μg/1·73 m2. There was a strong positive correlation between the basal cortisol level and peak cortisol concentration after low-dose ACTH stimulation (r = 0·93, P < 0·001) but not between the basal cortisol level and the incremental rise (r= −0·1, P = 0·69). These results suggest that the cortisol response to low-dose ACTH stimulation is reproducible and not attenuated by repeat stimulation at 90-min intervals. The incremental rise in serum cortisol concentration after ACTH stimulation appears constant in these situations and is not influenced by the basal cortisol level. When there is concern that the standard dose may be excessive and mask subtle but important changes in adrenal function, the low dose (500 ng) of ACTH should be used. Journal of Endocrinology (1993) 136, 167–172

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

2016 ◽  
Vol 101 (4) ◽  
pp. 1826-1835 ◽  
Author(s):  
Nada El Ghorayeb ◽  
Tânia L. Mazzuco ◽  
Isabelle Bourdeau ◽  
Jean-Philippe Mailhot ◽  
Ping Shi Zhu ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Outcome Data ◽  
Adrenal Vein ◽  
Selectivity Ratio ◽  
Peripheral Vein ◽  
Adrenal Vein Sampling ◽  
Contralateral Suppression ◽  
Before And After ◽  
Cortisol Ratio ◽  
Rate Of Response

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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