Department of Medicine, DIMED, Clinica dell'Ipertensione Arteriosa.
Department of Medicine, DIMED, Institute of Radiology, University of Padua, Padua, Italy.
J Hypertens. 2018 Feb;36(2):335-343. doi: 10.1097/HJH.0000000000001564.
The pulsatile secretion of adrenocortical hormones and a stress reaction occurring when starting adrenal vein sampling (AVS) can affect the selectivity and also the assessment of lateralization when sequential blood sampling is used. We therefore tested the hypothesis that a simulated sequential blood sampling could decrease the diagnostic accuracy of lateralization index for identification of aldosterone-producing adenoma (APA), as compared with bilaterally simultaneous AVS.
In 138 consecutive patients who underwent subtyping of primary aldosteronism, we compared the results obtained simultaneously bilaterally when starting AVS (t-15) and 15 min after (t0), with those gained with a simulated sequential right-to-left AVS technique (R ⇒ L) created by combining hormonal values obtained at t-15 and at t0. The concordance between simultaneously obtained values at t-15 and t0, and between simultaneously obtained values and values gained with a sequential R ⇒ L technique, was also assessed. We found a marked interindividual variability of lateralization index values in the patients with bilaterally selective AVS at both time point. However, overall the lateralization index simultaneously determined at t0 provided a more accurate identification of APA than the simulated sequential lateralization indexR ⇒ L (P = 0.001). Moreover, regardless of which side was sampled first, the sequential AVS technique induced a sequence-dependent overestimation of lateralization index. While in APA patients the concordance between simultaneous AVS at t0 and t-15 and between simultaneous t0 and sequential technique was moderate-to-good (K = 0.55 and 0.66, respectively), in non-APA patients, it was poor (K = 0.12 and 0.13, respectively).
Sequential AVS generates factitious between-sides gradients, which lower its diagnostic accuracy, likely because of the stress reaction arising upon starting AVS.
当开始进行肾上腺静脉采样（AVS）时，肾上腺皮质激素的脉冲分泌和应激反应会影响使用顺序采血时的选择性和侧化评估。因此，我们检验了一个假设，即与双侧同时 AVS 相比，模拟的顺序采血可能会降低用于识别产生醛固酮的腺瘤（APA）的侧化指数的诊断准确性。
在 138 例连续接受原发性醛固酮增多症亚型分类的患者中，我们比较了同时双侧开始 AVS 时（t-15）和 15 分钟后（t0）获得的结果，以及通过组合 t-15 和 t0 时获得的激素值创建的模拟顺序从右到左 AVS 技术（R ⇒ L）获得的结果。还评估了同时在 t-15 和 t0 获得的值之间以及同时获得的值与通过顺序 R ⇒ L 技术获得的值之间的一致性。我们发现，在双侧选择性 AVS 的患者中，侧化指数值存在明显的个体间变异性。然而，总体而言，在 t0 同时确定的侧化指数比模拟的顺序侧化指数 R ⇒ L 更能准确识别 APA（P=0.001）。此外，无论先采样哪一侧，顺序 AVS 技术都会导致侧化指数的顺序依赖性高估。在 APA 患者中，同时在 t0 和 t-15 进行 AVS 以及同时在 t0 和顺序技术之间的一致性为中等至良好（K 值分别为 0.55 和 0.66），而非 APA 患者的一致性较差（K 值分别为 0.12 和 0.13）。
顺序 AVS 会产生人为的双侧梯度，从而降低其诊断准确性，这可能是由于开始 AVS 时产生的应激反应所致。
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