Rossi Gian Paolo, Ganzaroli Chiara, Miotto Diego, De Toni Renzo, Palumbo Gaetana, Feltrin Gian Pietro, Mantero Franco, Pessina Achille C
DMCS Internal Medicine 4 bInstitute of Radiology, Legnano, Italy.
J Hypertens. 2006 Feb;24(2):371-9. doi: 10.1097/01.hjh.0000202818.10459.96.
Diagnosing aldosterone-producing adenoma (APA) involves a demonstration of the lateralization of aldosterone oversecretion because adrenal incidentalomas are common in hypertensive individuals and many small-sized APA escape identification with available imaging techniques. However, because of the pulsatile pattern of aldosterone secretion this can be a difficult undertaking. Stimulation of aldosterone secretion before adrenal vein sampling (AVS) can overcome this difficulty, but anecdotal data exist. We, therefore, prospectively investigated the usefulness of AVS with dynamic testing in primary aldosteronism (PA) patients.
We enrolled 24 consecutive consenting patients with a biochemical diagnosis of PA from a tertiary referral centre to measure the effects of adrenocorticotrophic hormone (ACTH) on selectivity, the lateralization of aldosterone secretion to the APA side, and adverse effects. After correcting the hypokalemia we performed bilateral AVS. After 3 h supine resting, blood was simultaneously obtained from both sides. A high-dose ACTH (250 mug intravenous) bolus was then administered and AVS was repeated after 30 min.
AVS was bilaterally selective in 88% of patients; no adverse effects occurred. Of the 21 patients with bilaterally selective AVS, three had idiopathic hyperaldosteronism and 18 an APA that was surgically removed in 12 with an ensuing fall in blood pressure at follow-up. After ACTH patients showed a significant increase (P = 0.007) of aldosterone from contralateral adrenal vein blood, but not from the APA gland. Therefore, lateralization of aldosterone secretion on the APA side did not improve.
AVS is safe and accurate for identifying APA. However, at a statistical power of 99%, these results do not support the usefulness of high-dose ACTH testing to improve the diagnostic accuracy of AVS.
诊断醛固酮瘤（APA）需要证明醛固酮分泌的侧别化，因为肾上腺偶发瘤在高血压患者中很常见，而且许多小尺寸的APA难以通过现有成像技术识别。然而，由于醛固酮分泌的脉冲模式，这可能是一项困难的任务。在肾上腺静脉采样（AVS）前刺激醛固酮分泌可以克服这一困难，但仅有轶事性数据。因此，我们前瞻性地研究了动态测试下AVS在原发性醛固酮增多症（PA）患者中的效用。
我们从一家三级转诊中心连续招募了24名同意参与的PA生化诊断患者，以测量促肾上腺皮质激素（ACTH）对选择性、醛固酮分泌向APA侧的侧别化以及不良反应的影响。纠正低钾血症后，我们进行了双侧AVS。仰卧休息3小时后，同时从双侧采集血液。然后静脉推注大剂量ACTH（250微克），30分钟后重复AVS。
88%的患者AVS具有双侧选择性；未发生不良反应。在21例具有双侧选择性AVS的患者中，3例患有特发性醛固酮增多症，18例患有APA，其中12例接受了手术切除，随访时血压随之下降。给予ACTH后，对侧肾上腺静脉血中的醛固酮显著增加（P = 0.007），但APA腺体中的醛固酮未增加。因此，醛固酮分泌在APA侧的侧别化并未改善。
AVS对于识别APA是安全且准确的。然而，在99%的统计效能下，这些结果不支持大剂量ACTH测试有助于提高AVS诊断准确性的观点。
