Abstract
Aldosterone producing adenoma and bilateral adrenal hyperplasia are the two most common subtypes of primary aldosteronism (PA) that require targeted and distinct therapeutic approaches: unilateral adrenalectomy or lifelong medical therapy with mineralocorticoid receptor antagonists. According to the 2016 Endocrine Society Guideline, adrenal venous sampling (AVS) is the gold standard test to distinguish between unilateral and bilateral aldosterone overproduction and therefore, to safely refer patients with PA to surgery. Despite significant advances in the optimization of the AVS procedure and the interpretation of hormonal data, a standardized protocol across centers is still lacking. Alternative methods are sought to either localize an aldosterone producing adenoma or to predict the presence of unilateral disease and thereby substantially reduce the number of patients with PA who proceed to AVS. In this review, we summarize the recent advances in subtyping PA for the diagnosis of unilateral and bilateral disease. We focus on the developments in the AVS procedure, the interpretation criteria, and comparisons of the performance of AVS with the alternative methods that are currently available.
Highlights
In the affected patients should not be denied an adrenal venous sampling (AVS) procedure, which remains the most reliable means to refer them for a unilateral adrenalectomy or medical therapy
ACTH 1-24 is a synthetic derivate of the adrenocorticotropic hormone (ACTH), whose infusion during the AVS procedure was introduced by Melby et al in 1967 [55]
ACTH (1-24) infusion is necessary for patients at a high risk of allergic reaction, in which steroidal prophylaxis is required, in patients with subclinical hypercortisolism, and when the AVS procedure is not performed in the early morning, when cortisol secretion in higher
Summary
Primary aldosteronism (PA) is the most frequent cause of endocrine hypertension, with a prevalence of around 6% in patients from primary care and up to 30% in referral units [1,2]. Despite recent expert consensus, intended to address several issues concerning performance and interpretation [7,8], AVS remains a poorly standardized procedure across centers This issue, together with reports [9,10] indicating high complication rates, has fostered several attempts to develop clinical and biochemical prediction models of unilateral PA, “ancillary” hormonal testings, or innovative targeted imaging techniques to overcome the need for AVS, at least in a proportion of patients, and to use this procedure in patients with a high probability of unilateral PA. We critically review AVS performance in comparison with alternative tests or clinical criteria in PA subtype diagnosis
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