Primary aldosteronism: making sense of partial data sets from failed adrenal venous sampling-suppression of adrenal aldosterone production can be used in clinical decision making

Strajina, Veljko; Al‐Hilli, Zahraa; Andrews, James C.; Bancos, Irina; Thompson, Geoffrey B.; Farley, David R.; Lyden, Melanie L.; Dy, Benzon M.; Young, William F.; McKenzie, Travis J.

doi:10.1016/j.surg.2017.10.012

Cited by 45 publications

(60 citation statements)

References 18 publications

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“…For example, when the ALR is in the grey zone (3.0–<4.0), a CSI of <1.0 is predictive of good surgical outcomes . In addition, if AVS is not bilaterally successful, a CSI of <0.5 is highly predictive of contralateral disease . Also, patients with a CSI of <0.47 are at increased risk for postoperative hyperkalemia (see treatment section below) .…”

Section: Diagnosismentioning

confidence: 99%

Diagnosis and treatment of primary aldosteronism: practical clinical perspectives

2018

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Primary aldosteronism (PA), the most common form of secondary hypertension, can be either surgically cured or treated with targeted pharmacotherapy. PA is frequently undiagnosed and untreated, leading to aldosterone‐specific cardiovascular morbidity and nephrotoxicity. Thus, clinicians should perform case detection testing for PA at least once in all patients with hypertension. Confirmatory testing is indicated in most patients with positive case detection testing results. The next step is to determine whether patients with confirmed PA have a disease that can be cured with surgery or whether it should be treated medically; this step is guided by computed tomography scan of the adrenal glands and adrenal venous sampling. With appropriate surgical expertise, laparoscopic unilateral adrenalectomy is safe, efficient and curative in patients with unilateral adrenal disease. In patients who have bilateral aldosterone hypersecretion, the optimal management is a low‐sodium diet and lifelong treatment with a mineralocorticoid receptor antagonist administered at a dosage to maintain a high–normal serum potassium concentration without the aid of oral potassium supplements.

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Section: Diagnosismentioning

confidence: 99%

Diagnosis and treatment of primary aldosteronism: practical clinical perspectives

2018

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“…A low CR has also been associated with primary aldosteronism cure in patients with an LR <4 on AVS who underwent unilateral adrenalectomy [ 32 ]. Strajina et al [ 33 ] also showed that a CR ≤0.5 in patients with failed cannulation of one of the adrenal veins in AVS was predictive of unilateral primary aldosteronism. In our study, a CR ≤0.5 was not associated with hypertension resolution after surgery; however, our study is likely to be underpowered to detect any significance due to the lack of patients who underwent surgery with a CR >1 and the small sample size.…”

Section: Discussionmentioning

confidence: 99%

Factors Associated with Resolution of Hypertension after Adrenalectomy in Patients with Primary Aldosteronism

et al. 2018

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BackgroundThe aim of this study was to investigate the factors associated with resolution of hypertension after adrenalectomy in patients with primary aldosteronism. A secondary aim was to describe our use of the contralateral ratio in adrenal venous sampling (AVS) in the setting of suboptimal successful cannulation rates.MethodsA retrospective review of patients who underwent AVS followed by unilateral adrenalectomy for primary aldosteronism was performed.ResultsComplete resolution of hypertension and hypokalemia was seen in 17 of 40 patients (42.5%), while a clinical improvement in hypertension was seen in 38 of 40 (95%). Shorter duration of hypertension, mean aldosteronoma resolution score (ARS), and a high ARS of 3 to 5 were associated with resolution of hypertension after adrenalectomy (P=0.02, P=0.02, and P=0.004, respectively). Of the individual components of ARS, only a duration of hypertension of ≤6 years was associated with resolution of hypertension after adrenalectomy (P=0.03).ConclusionA shorter duration of hypertension was significantly associated with resolution of hypertension after adrenalectomy in patients with primary aldosteronism.

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“…The aldosterone concentration and aldosterone to cortisol ratio was clearly highest in the left adrenal, and also higher at all left renal vein locations compared to those on the right side. Although this confirmed hypersecretion by the left adrenal harboring the adenoma, the failure to properly cannulate the right adrenal vein left the possibility that there was also hypersecretion on the right side (15).…”

Section: Case Presentationmentioning

confidence: 92%

Steroid Profiling as an Additional Tool to Confirm One-Sided Hormone Overproduction in Primary Aldosteronism: A Case Report

et al. 2019

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Primary aldosteronism (PA) is the leading cause of secondary hypertension. The source of aldosterone hypersecretion is often due to a unilateral aldosterone-producing adenoma, and unilateral laparoscopic adrenalectomy is recommended in such patients. Before surgery, confirmation of unilateral hypersecretion is necessary. This is optimally performed by adrenal venous sampling (AVS). However, AVS is not always successful e.g., due to difficulties in the cannulation of the right adrenal vein. Here we present the case of a 53-year-old female patient with primary aldosteronism, a left-sided adrenal mass and an inconspicuous right adrenal. AVS was performed, but cannulation of the right adrenal vein failed. Therefore, aldosterone hypersecretion also of the right adrenal could not be excluded despite higher aldosterone concentrations in the left renal and adrenal vein. To increase the certainty that the left sided adrenal mass was the source of aldosterone hypersecretion, steroid profiling was performed in a sample from the inferior vena cava. This revealed markedly elevated levels of 18-oxocortisol, 18-hydroxycortisol, 11-deoxycorticosterone, and 11-deoxycortisol, a steroid profile that strongly suggested that the left sided adrenal mass was an aldosterone producing adenoma, most likely due to a somatic KCNJ5 mutation. Following unilateral adrenalectomy, CYP11B2 immunohistochemistry, and genetics analysis of the resected adrenal confirmed a solitary aldosterone-producing adenoma with intense aldosterone synthase expression, which harbored a previously described KCNJ5 Phe154Cys mutation. Biochemical and clinical cure was confirmed 6 months postoperatively.

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Primary aldosteronism: making sense of partial data sets from failed adrenal venous sampling-suppression of adrenal aldosterone production can be used in clinical decision making

Cited by 45 publications

References 18 publications

Diagnosis and treatment of primary aldosteronism: practical clinical perspectives

Diagnosis and treatment of primary aldosteronism: practical clinical perspectives

Factors Associated with Resolution of Hypertension after Adrenalectomy in Patients with Primary Aldosteronism

Steroid Profiling as an Additional Tool to Confirm One-Sided Hormone Overproduction in Primary Aldosteronism: A Case Report

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