From the Clinica dell'Ipertensione Arteriosa (G.C., G.M., M.C., G.R., V.B., G.P.R.) and Laboratory Medicine (G.A., M.P.), Department of Medicine, DIMED-University of Padua, Italy.
Hypertension. 2017 Aug;70(2):342-346. doi: 10.1161/HYPERTENSIONAHA.117.09415. Epub 2017 Jun 5.
For identification of potentially surgically curable primary aldosteronism, guidelines recommend use of adrenal vein sampling (AVS) that requires selective catheterization of both adrenal veins as verified by using the cortisol-derived selectivity index. Unfortunately, bilaterally selective studies are not obtained under unstimulated conditions in a proportion of the cases ranging between 15% and 50% depending on the cutoff used. We therefore investigated whether 17-α-hydroxyprogesterone and androstenedione, which showed a higher step-up between adrenal vein and inferior vena cava blood than cortisol, can ascertain selectivity when cortisol failed to do so. We prospectively recruited 32 hypertensive patients with confirmed primary aldosteronism, who underwent bilaterally simultaneous sampling without cosyntropin stimulation and with the same predefined AVS protocol. All were consecutively selected because of a cortisol-based selectivity index <2.00 in at least one of the paired adrenal vein blood samples collected as per protocol. Results showed that the values of the selectivity index based on 17-α-hydroxyprogesterone and androstenedione were higher (<0.01) on average by 1.6- and 12-fold, respectively, than those based on cortisol. With use of these steroids, we rescued 43% and 73% of the AVS, respectively, from being judged nonselective. Thus, in challenging patients with primary aldosteronism submitted to AVS use of 17-α-hydroxyprogesterone, and even more so of androstenedione, for ascertaining selectivity allows demonstration of correct catheter placement in a proportion of AVS studies better than cortisol. Thus, replacing cortisol measurement with these steroids, and particularly androstenedione, can improve the diagnostic yield of AVS.
为了确定潜在可通过手术治愈的原发性醛固酮增多症，指南建议使用肾上腺静脉采样（AVS），这需要通过使用皮质醇衍生的选择性指数来验证对双侧肾上腺静脉的选择性导管插入。不幸的是，根据所使用的截止值，在未受刺激的情况下，有 15%至 50%的情况下无法获得双侧选择性研究。因此，我们研究了 17-α-羟孕酮和雄烯二酮，它们在肾上腺静脉和下腔静脉血液之间的上升幅度高于皮质醇，在皮质醇无法确定选择性时，是否可以确定选择性。我们前瞻性招募了 32 名经证实患有原发性醛固酮增多症的高血压患者，他们在未接受促皮质素刺激的情况下同时进行双侧采样，并采用相同的预设 AVS 方案。所有患者均因至少有一份按方案采集的配对肾上腺静脉血样的基于皮质醇的选择性指数<2.00 而被连续选择。结果表明，基于 17-α-羟孕酮和雄烯二酮的选择性指数值平均分别高出基于皮质醇的选择性指数值 1.6 倍和 12 倍。使用这些类固醇，我们分别挽救了 43%和 73%的 AVS，使其免于被判断为非选择性。因此，在接受 AVS 的原发性醛固酮增多症挑战性患者中，使用 17-α-羟孕酮，甚至更使用雄烯二酮来确定选择性，可以在比皮质醇更好的比例上证明正确的导管放置。因此，用这些类固醇替代皮质醇测量，特别是雄烯二酮，可以提高 AVS 的诊断效果。
