Wannachalee Taweesak, Vibhatavata Peeradon, Konzen Sonja, Lee Chaelin, Gherasim Carmen, Shields James J, Turcu Adina F
Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, United States.
Division of Endocrinology and Metabolism, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
Eur J Endocrinol. 2025 Mar 27;192(4):511-518. doi: 10.1093/ejendo/lvaf079.
Adrenal vein sampling (AVS) is the standard-of-care for primary aldosteronism (PA) subtyping. Paradoxical bilateral aldosterone suppression (BAS), defined by lower aldosterone/cortisol ratio in both adrenal veins compared to peripheral circulation, has been reported in AVS studies, but the underlying causes remain poorly understood. We aimed to assess the prevalence of BAS in AVS without and with cosyntropin stimulation based on clinical immunoassays, and to probe the BAS results using liquid chromatography mass spectrometry (LC-MS/MS).
We retrospectively assessed the BAS prevalence among patients with confirmed PA who underwent AVS in a referral center between 2015 and 2023. Simultaneous AVS was performed both before and after cosyntropin stimulation. LC-MS/MS quantitation of cortisol and aldosterone was performed in patients with serum available.
Of 402 patients, BAS was observed in 102 (25%): Pre-cosyntropin in 31, post-cosyntropin in 48 (including 10 who did not meet successful catheterization criteria in baseline samples), and both pre- and post- cosyntropin in 23. Paradoxically, AVS indicated lateralized PA in 36% and 43% of patients with BAS based on pre- and post-cosyntropin data, respectively. Using LC-MS/MS, BAS was not present in 42/53 (79%) patients with serum available. Compared to LC-MS/MS, immunoassays overestimated cortisol across the analytical range. In contrast, for aldosterone, immunoassays overestimated low concentrations, but underestimated high concentrations, such as those measured in adrenal veins.
Apparent BAS derives primarily from artifacts in clinical immunoassays. These data caution against assuming that aldosterone suppression indicates contralateral aldosterone lateralization in cases with partial adrenal vein catheterization failure.
肾上腺静脉采血（AVS）是原发性醛固酮增多症（PA）亚型分型的标准治疗方法。在AVS研究中，已报道了矛盾性双侧醛固酮抑制（BAS），即与外周循环相比，双侧肾上腺静脉中的醛固酮/皮质醇比值降低，但其潜在原因仍知之甚少。我们旨在基于临床免疫测定评估有无促肾上腺皮质激素刺激时AVS中BAS的患病率，并使用液相色谱质谱联用（LC-MS/MS）对BAS结果进行探究。
我们回顾性评估了2015年至2023年在一家转诊中心接受AVS的确诊PA患者中BAS的患病率。在促肾上腺皮质激素刺激前后均进行同步AVS。对有血清样本的患者进行皮质醇和醛固酮的LC-MS/MS定量分析。
在402例患者中，102例（25%）观察到BAS：促肾上腺皮质激素刺激前31例，刺激后48例（包括10例基线样本未达到成功插管标准的患者），刺激前后均为23例。矛盾的是，根据促肾上腺皮质激素刺激前和刺激后的数据分析，分别有36%和43%的BAS患者AVS显示为单侧PA。使用LC-MS/MS，53例有血清样本的患者中有42例（79%）不存在BAS。与LC-MS/MS相比，免疫测定在整个分析范围内高估了皮质醇。相比之下，对于醛固酮，免疫测定高估了低浓度，但低估了高浓度，如肾上腺静脉中测得的浓度。
明显的BAS主要源于临床免疫测定中的假象。这些数据提醒我们，在部分肾上腺静脉插管失败的病例中，不要假定醛固酮抑制表明对侧醛固酮侧化。
