Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan.
Division of Endocrinology and Metabolism, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
J Clin Endocrinol Metab. 2020 Oct 1;105(10):e3628-37. doi: 10.1210/clinem/dgaa482.
Correct subtyping of primary aldosteronism (PA) is critical for guiding clinical management. Adrenal imaging is less accurate than adrenal vein sampling (AVS); nonetheless, AVS is invasive, technically challenging, and scarcely available.
To identify predictors of concordance between cross-sectional imaging and lateralized AVS in patients with PA that could help circumvent AVS in a subset of patients.
We retrospectively studied all patients with PA who underwent AVS in a tertiary referral center from 2009 to 2019. AVS was performed before and after cosyntropin stimulation. Patients with lateralized AVS in at least one condition were included. Aldosterone synthase-guided next-generation sequencing was performed on available adrenal tissue. Logistic regression was implemented to identify predictors of imaging-AVS lateralization concordance.
A total of 234 patients (62% men), age 20 to 79 years, 73% white, 23% black, and 2% Asian were included. AVS lateralization was found: 1) both pre- and post-cosyntropin (Uni/Uni) in 138 patients; 2) only at baseline (Uni/Bi) in 39 patients; 3) only after cosyntropin stimulation (Bi/Uni) in 29 patients. Catheterization partially failed in 28 patients. AVS-imaging agreement was higher in patients with KCNJ5 versus other aldosterone-driver somatic mutations (90.3% versus 64.6%; P < 0.001); in Asian and white versus black Americans (75%, 70%, and 36%, respectively); in younger patients; and those with left adrenal nodules and contralateral suppression. Conversely, AVS-imaging agreement was lowest in Uni/Bi patients (38% vs. 69% in Uni/Uni, and 62% in Bi/Uni; P = 0.007).
While AVS-imaging agreement is higher in young white and Asian patients, who have KCNJ5-mutated aldosterone producing adenomas, no predictor confers absolute imaging accuracy.
正确的原发性醛固酮增多症（PA）亚型分类对于指导临床管理至关重要。肾上腺影像学检查不如肾上腺静脉采样（AVS）准确；尽管如此，AVS 具有侵袭性、技术挑战性，并且难以获得。
确定 PA 患者的横断面成像与 AVS 之间的一致性的预测因素，这些预测因素可能有助于在一部分患者中规避 AVS。
我们回顾性研究了 2009 年至 2019 年在一家三级转诊中心接受 AVS 的所有 PA 患者。AVS 在促皮质素兴奋前后进行。在至少一种情况下存在 AVS 侧化的患者被纳入研究。对可用肾上腺组织进行醛固酮合酶指导的下一代测序。实施逻辑回归以确定影像学与 AVS 侧化一致性的预测因素。
共纳入 234 名患者（62%为男性），年龄 20 至 79 岁，73%为白人，23%为黑人，2%为亚洲人。发现 AVS 侧化如下：1）促皮质素前后均存在（Uni/Uni），138 例；2）仅基线存在（Uni/Bi），39 例；3）仅在促皮质素刺激后存在（Bi/Uni），29 例。在 28 例患者中导管插入术部分失败。与其他醛固酮驱动的体细胞突变（90.3%对 64.6%；P < 0.001）相比，KCNJ5 患者的 AVS 成像一致性更高；与白种人和亚洲人相比，黑种美国人（分别为 75%、70%和 36%）的 AVS 成像一致性更高；与年轻患者相比，A VS 成像一致性更高；与左侧肾上腺结节和对侧抑制的患者相比，A VS 成像一致性更高。相反，Uni/Bi 患者的 AVS 成像一致性最低（Uni/Uni 为 38%，Bi/Uni 为 69%，Uni/Uni 为 62%；P = 0.007）。
虽然年轻的白种人和亚洲患者的 AVS 成像一致性更高，他们有 KCNJ5 突变的醛固酮产生腺瘤，但没有预测因素能保证绝对的成像准确性。
