Adrenal Vein Sampling Without Discontinuation of Mineralocorticoid Receptor Antagonist Therapy

Ganesh, Malini; Abadin, Shabirhusain S.; Fogelfeld, Leon

doi:10.4158/ep-2019-0599

Cited by 6 publications

(8 citation statements)

References 18 publications

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“…Recently, the results of the prospective EMIRA study (Effects of Mineralocorticoid and AT1 Receptor Antagonism on The Aldosterone-Renin Ratio In Primary Aldosteronism) indicated the possibility of avoiding these risks with MRAs administration, administered at doses that effectively controlled BP values and hypokalemia, without jeopardizing the diagnosis of surgically curable PA. 3 Moreover, observational studies suggested that MRAs would not preclude the identification of unilateral PA (uPA). [4][5][6][7] Therefore, we set out to investigate the hypothesis that MRA treatment does not preclude an unambiguous diagnosis of uPA by means of AVS in the AVIS-2 (Adrenal Vein Sampling International Study 2), a large database of consecutive patients with PA submitted to AVS in referral centers of 4 continents, 8 and in patients referred to the Hypertension Center of the University of Padua.…”

Section: Original Articlementioning

confidence: 99%

Subtype Identification of Surgically Curable Primary Aldosteronism During Treatment With Mineralocorticoid Receptor Blockade

Pintus,

Seccia,

Amar

et al. 2024

Hypertension

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BACKGROUND: Current guidelines and consensus documents recommend withdrawal of mineralocorticoid receptor antagonists (MRAs) before primary aldosteronism (PA) subtyping by adrenal vein sampling (AVS), but this practice can cause severe hypokalemia and uncontrolled high blood pressure. Our aim was to investigate if unilateral PA can be identified by AVS during MRA treatment. METHODS: We compared the rate of unilateral PA identification between patients with and without MRA treatment in large data sets of patients submitted to AVS while off renin-angiotensin system blockers and β-blockers. In sensitivity analyses, the between-group differences of lateralization index values after propensity score matching and the rate of unilateral PA identification in subgroups with undetectable (≤2 mUI/L), suppressed (<8.2 mUI/L), and unsuppressed (≥8.2 mUI/L) direct renin concentration levels were also evaluated. RESULTS: Plasma aldosterone concentration, direct renin concentration, and blood pressure values were similar in non-MRA-treated (n=779) and MRA-treated (n=61) patients with PA, but the latter required more antihypertensive agents ( P =0.001) and showed a higher rate of adrenal nodules (82% versus 67%; P =0.022) and adrenalectomy (72% versus 54%; P =0.01). However, they exhibited no significant differences in commonly used AVS indices and the area under the receiving operating characteristic curve of lateralization index, both under unstimulated conditions and postcosyntropin. Several sensitivity analyses confirmed these results in propensity score matching adjusted models and in patients with undetectable, or suppressed or unsuppressed renin levels. CONCLUSIONS: At doses that controlled blood pressure and potassium levels, MRAs did not preclude the identification of unilateral PA at AVS. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01234220.

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Section: Original Articlementioning

confidence: 99%

Subtype Identification of Surgically Curable Primary Aldosteronism During Treatment With Mineralocorticoid Receptor Blockade

Pintus,

Seccia,

Amar

et al. 2024

Hypertension

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“…Se la sospensione dei farmaci interferenti non è possibile, il risultato del rapporto aldosterone/renina dovrà essere valutato alla luce degli effetti dei farmaci assunti. Ad esempio, in pazienti in terapia con antialdosteronico che non possa essere sospeso, i test potranno essere effettuati a patto che i valori di renina rimangano soppressi (vedi cateterismo delle vene surrenaliche) [9].…”

Section: Eccesso DI Aldosteroneunclassified

Screening and treatment of hypertension in patients with adrenal mass

Canu

2023

L'Endocrinologo

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SommarioIl riscontro di incidentaloma surrenalico è un’evenienza sempre più frequente a causa del sempre più largo utilizzo di esami radiologici e spesso, poiché sia gli incidentalomi surrenalici che l’ipertensione sono entrambi più frequenti con l’avanzare dell’età, le due affezioni coesistono. In tutti i pazienti è necessario effettuare una corretta valutazione biochimica che nel paziente iperteso comprende anche la diagnosi di iperaldosteronismo primitivo, oltre a quella di ipercortisolismo ed eccesso di catecolamine. Nelle forme secernenti l’indicazione è chirurgica dopo adeguata preparazione del paziente.

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“…Anti-hypertensive drugs like mineralocorticoids receptors antagonists should be stopped one month prior to AVS which is not feasible in severe HBP [ 106 , 107 ]. Not all studies agree that discontinuation of such medication as spironolactone impairs the lateralization index [ 107 ].…”

Section: Approach Of Connshing Syndromementioning

confidence: 99%

The Entity of Connshing Syndrome: Primary Aldosteronism with Autonomous Cortisol Secretion

Cârșote¹

2022

Diagnostics

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Connshing syndrome (CoSh) (adrenal-related synchronous aldosterone (A) and cortisol (C) excess) represents a distinct entity among PA (primary hyperaldosteronisms) named by W. Arlt et al. in 2017, but the condition has been studied for more than 4 decades. Within the last few years, this is one of the most dynamic topics in hormonally active adrenal lesions due to massive advances in steroids metabolomics, molecular genetics from CYP11B1/B2 immunostaining to genes constellations, as well as newly designated pathological categories according to the 2022 WHO classification. In gross, PA causes 4–10% of all high blood pressure (HBP) cases, and 20% of resistant HBP; subclinical Cushing syndrome (SCS) is identified in one-third of adrenal incidentalomas (AI), while CoSh accounts for 20–30% to 77% of PA subjects, depending on the tests used to confirm autonomous C secretion (ACS). The clinical picture overlaps with PA, hypercortisolemia being mild. ACS is suspected in PA if a more severe glucose and cardiovascular profile is identified, or there are larger tumours, ACS being an independent factor risk for kidney damage, and probably also for depression/anxiety and osteoporotic fractures. It seems that one-third of the PA-ACS group harbours mutations of C-related lines like PRKACA and GNAS. A novel approach means we should perform CYP11B2/CYP11B1 immunostaining; sometimes negative aldosteronoma for CYP11B1 is surrounded by micronodules or cell clusters with positive CYP11B1 to sustain the C excess. Pitfalls of hormonal assessments in CoSh include the index of suspicion (check for ACS in PA patients) and the interpretation of A/C ratio during adrenal venous sample. Laparoscopic adrenalectomy is the treatment of choice. Post-operative clinical remission rate is lower in CoSh than PA. The risk of clinically manifested adrenal insufficiency is low, but a synthetic ACTH stimulating testing might help to avoid unnecessary exposure to glucocorticoids therapy. Finally, postponing the choice of surgery may impair the outcome, having noted that long-term therapy with mineralocorticoids receptors antagonists might not act against excessive amounts of C. Awareness of CoSh improves management and overall prognosis.

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Adrenal Vein Sampling Without Discontinuation of Mineralocorticoid Receptor Antagonist Therapy

Cited by 6 publications

References 18 publications

Subtype Identification of Surgically Curable Primary Aldosteronism During Treatment With Mineralocorticoid Receptor Blockade

Subtype Identification of Surgically Curable Primary Aldosteronism During Treatment With Mineralocorticoid Receptor Blockade

Screening and treatment of hypertension in patients with adrenal mass

The Entity of Connshing Syndrome: Primary Aldosteronism with Autonomous Cortisol Secretion

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