Endocrinol Metab.  2021 Oct;36(5):965-973. 10.3803/EnM.2021.1192.

Adrenal Venous Sampling for Subtype Diagnosis of Primary Hyperaldosteronism

• Naruse M
• Tanabe A
• Yamamoto K
• Rakugi H
• Kometani M
• Yoneda T
• Kobayashi H
• Abe M
• Ohno Y
• Inagaki N
• Izawa S
• Sone M

• KMID: 2521944
• DOI: http://doi.org/10.3803/EnM.2021.1192

Abstract

Adrenal venous sampling (AVS) is the key procedure for lateralization of primary hyperaldosteronism (PA) before surgery. Identification of the adrenal veins using computed tomography (CT) and intraoperative cortisol assay facilitates the success of catheterization. Although administration of adrenocorticotropic hormone (ACTH) has benefits such as improving the success rate, some unilateral cases could be falsely diagnosed as bilateral. Selectivity index of 5 with ACTH stimulation to assess the selectivity of catheterization and lateralization index (LI) >4 with ACTH stimulation for unilateral diagnosis is used in many centers. Co-secretion of cortisol from the tumor potentially affects the lateralization by the LI. Patients aged <35 years with hypokalemia, marked aldosterone excess, and unilateral adrenal nodule on CT have a higher probability of unilateral disease. Patients with normokalemia, mild aldosterone excess, and no adrenal tumor on CT have a higher probability of bilateral disease. Although no methods have 100% specificity for subtype diagnosis that would allow bypassing AVS, prediction of the subtype should be considered when recommending AVS to patients. Methodological standardization and strict indication improve diagnostic quality of AVS. Development of non-invasive imaging and biochemical markers will drive a paradigm shift in the clinical practice of PA.

Keyword

Aldosterone; Adrenocorticotropic hormone; Adenoma; Catherterization; Hyperaldosteronism

Figure

• 

  Fig. 1 Clinical findings to bypass adrenal venous sampling (AVS) and select the appropriate treatment. As no method has 100% specificity for subtype diagnosis, AVS is indicated if the patient agrees to undergo AVS. PA, primary aldosteronism; BMI, body mass index; CT, computed tomography.

• 

  Fig. 2 Strategic and organized implementation of adrenal venous sampling (AVS) based on stricter indications and standardized methods and decision criteria for evaluation of the results. PA, primary aldosteronism; MDCT, multi-detector row computed tomography; ACTH, adrenocorticotropic hormone; SI, selectivity index; LI, lateralization index; CR, contralateral suppression.

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