Adrenal Vein Sampling to Distinguish Between Unilateral and Bilateral Primary Hyperaldosteronism: To ACTH Stimulate or Not?

Tae-Yon Sung,Chandrayee Ghosh,Monica Varun Tyagi,Electron Kebebew,Wilson Mawutor Alobuia

doi:10.3390/jcm9051447

Abstract

The aim of this study is to determine the accuracy of adrenal vein sampling (AVS) with and without adrenocorticotropic hormone (ACTH) stimulation to distinguish between unilateral and bilateral primary hyperaldosteronism (PA). Retrospective analysis of a prospective database from a referral center between 1984 and 2009, 76 patients had simultaneous cannulation of bilateral adrenal veins and AVS with and without ACTH stimulation. All patients had adrenalectomies. The selectivity index (SI, cut-off value ≥2) was used for confirmation of successful cannulation of the adrenal vein. The lateralization index (LI, cut-off value >2 and >4) was used for distinguishing between unilateral and bilateral PA. The SI ratio was higher with ACTH stimulation compared to without for the right adrenal vein (p = 0.027). The LI > 2 ratio was higher with ACTH stimulation compared to without (p = 0.007). For the LI > 4 ratio, there was no difference between with and without ACTH stimulation (p = 0.239). However, for a LI > 4, 7 patients (9.2%) were not lateralized with ACTH stimulation, but they did lateralize without ACTH stimulation. AVS with ACTH stimulation is associated with a higher SI ratio compared to AVS without ACTH stimulation. However, when using LI > 4 for AVS, samples without ACTH stimulation should also be included to detect a subset of patients with unilateral disease that are not detected with ACTH stimulation.

Highlights

Primary hyperaldosteronism (PA) results from excessive aldosterone production from the adrenal cortex and it affects 4.3%–10% of general hypertensive patients [1,2] and up to 20% of patients with resistant hypertension [3]
Among the 76 patients, 74 lateralized using LI > 2 and 72 lateralized using LI > 4 with and/or without adrenocorticotropic hormone (ACTH) stimulation. (Figure 1) All patients who had an adrenalectomy had a biochemical cure based on normal postoperative measurements of serum aldosterone and plasma renin activity levels
For the left adrenal vein, the SI ratio was higher with ACTH stimulation compared to without (97.4% vs. 59.2%) with no statistically significant difference (p = 0.084)

Summary

Introduction

Primary hyperaldosteronism (PA) results from excessive aldosterone production from the adrenal cortex and it affects 4.3%–10% of general hypertensive patients [1,2] and up to 20% of patients with resistant hypertension [3]. Differentiating unilateral from bilateral disease is important because patients who have unilateral PA can be cured with unilateral adrenalectomy, while medical treatment is recommended for bilateral PA [2,5,6]. Adrenal vein sampling (AVS) is recommended to distinguish between unilateral and bilateral PA before adrenalectomy in patients older than 35 years old, and in patients younger than 35 years with bilateral normal adrenal glands or bilateral adrenal nodules [6,7,8,9,10,11,12]. Some centers prefer the selective use of AVS only when preoperative anatomic imaging cannot definitively lateralize the aldosteronoma (patients with bilateral normal adrenal glands or bilateral adrenal masses), because

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