Should Adrenal Venous Sampling Be Performed in PA Patients Without Apparent Adrenal Tumors?

Mitsuhide Naruse,Mika Tsuiki,Shoichiro Izawa,Youichi Ohno,Nobuya Inagaki,Norio Wada,Kouichi Tamura,Kenji Oki,Akiyo Tanabe,Masakatsu Sone,Hiroki Kobayashi,Kentaro Okamoto,Takashi Yoneda,Takamasa Ichijo

doi:10.3389/fendo.2021.645395

Abstract

IntroductionSome aldosterone-producing micro-adenomas cannot be detected through image inspection. Therefore, adrenal venous sampling (AVS) is often performed, even in primary aldosteronism (PA) patients who have no apparent adrenal tumors (ATs) on imaging. In most of these cases, however, the PA is bilateral.ObjectiveTo clarify the clinical need for AVS in PA patients without apparent ATs, taking into consideration the rates of adrenalectomy.MethodsThis is a retrospective cross-sectional study assessing 1586 PA patients without apparent ATs in the multicenter Japan PA study (JPAS). We analyzed which parameters could be used to distinguish unilateral PA patients without apparent ATs from bilateral patients. We also analyzed the prevalences of adrenalectomy in unilateral PA patients.ResultsThe unilateral subtype without an apparent AT was diagnosed in 200 (12.6%) of 1586 PA patients. Being young and female with a short hypertension duration, normokalemia, low creatinine level, low plasma aldosterone concentration, and low aldosterone-to-renin ratio (ARR) was significantly more common in bilateral than unilateral PA patients. If PA patients without apparent ATs were female and normokalemic with a low ARR (<560 pg/ml per ng/ml/h), the rate of unilateral PA was only 5 (1.1%) out of 444. Moreover, 77 (38.5%) of the 200 did not receive adrenalectomy, despite being diagnosed with the unilateral subtype based on AVS.ConclusionThe low prevalence of the unilateral subtype in PA patients without apparent ATs suggests AVS is not indicated for all of these patients. AVS could be skipped in female normokalemic PA patients without apparent ATs if their ARRs are not high. However, AVS should be considered for male hypokalemic PA patients with high ARRs because the rates of the unilateral subtype are high in these patients.

Highlights

Some aldosterone-producing micro-adenomas cannot be detected through image inspection
Primary aldosteronism (PA) is characterized by inappropriate aldosterone production leading to renin suppression, which, if prolonged and severe, may in turn lead to hypertension and hypokalemia
Among the 1,586 PA patients without apparent adrenal tumors (ATs) enrolled in the Japan PA study (JPAS) study, 200 were diagnosed with unilateral PA and 1386 were diagnosed with bilateral PA (Figure 1; Table 1)

Summary

Introduction

Some aldosterone-producing micro-adenomas cannot be detected through image inspection. Adrenal venous sampling (AVS) is often performed, even in primary aldosteronism (PA) patients who have no apparent adrenal tumors (ATs) on imaging. In most of these cases, the PA is bilateral. Aldosterone is reported to do substantial damage to cardiovascular organs under conditions of high salt intake [3], and previous clinical studies have reported that the prevalence of cardiovascular disease (CVD) was higher in PA patients than patients with essential hypertension [4]. Among patients with unilateral PA, which is often caused by an aldosterone producing adenoma, the prevalence of CVD is reportedly higher than among those with bilateral PA [4]. Because unilateral PA patients can be treated with adrenalectomy, a diagnosis of PA subtype is relevant

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