Dataset Information

Utility of Adrenal Vein Sampling With and Without Ultra-Low Dose ACTH Infusion in the Diagnostic Evaluation of Primary Aldosteronism.

ABSTRACT:

Background

Adrenal vein sampling (AVS), integral to identifying surgically remediable unilateral primary aldosteronism (PA), is technically challenging and subject to fluctuations in cortisol and aldosterone secretion. Intra-procedural adrenocorticotropic hormone (ACTH), conventionally administered as a 250-μg bolus and/or 50 μg per hour infusion, increases cortisol and aldosterone secretion and can improve AVS success, but may cause discordant lateralisation compared to unstimulated AVS.

Aims

To assess if AVS performed with ultra-low dose ACTH infusion causes discordant lateralisation.

Methods

Here, we describe our preliminary experience using an ultra-low dose ACTH infusion AVS protocol. We retrospectively reviewed the results of consecutive AVS procedures (n = 37) performed with and without ultra-low dose ACTH (1-μg bolus followed by 1.25 μg per hour infusion).

Results

Bilateral AV cannulation was successful in 70% of procedures pre-ACTH and 89% post-ACTH (p < 0.01). Sixty-nine percent of studies lateralised pre-ACTH and 55% post-ACTH, improving to 79% when both groups were combined. Lateralisation was discordant in 11 cases, including eight in which lateralisation was present only on basal sampling, and three in which lateralisation occurred only with ACTH stimulation.

Discussion

Overall, the decrease in lateralisation rates with ACTH was higher than previously reported for some protocols utilising conventional doses of ACTH. Our results suggest that AVS performed with ultra-low dose ACTH can cause discordant lateralisation similar to AVS performed with conventional doses of ACTH.

Conclusion

Prospective studies directly comparing low and conventional dose ACTH AVS protocols and long-term patient outcomes are needed to help define the optimal ACTH dose for accurate PA subtyping.

SUBMITTER: Preston CA

PROVIDER: S-EPMC11361314 | biostudies-literature | 2024 Sep

REPOSITORIES: biostudies-literature

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Publications

Utility of Adrenal Vein Sampling With and Without Ultra-Low Dose ACTH Infusion in the Diagnostic Evaluation of Primary Aldosteronism.

Preston Christopher A CA Yong Eric X Z EXZ Marginson Benjamin B Farrell Stephen G SG Sawyer Matthew P MP Hashimura Hikaru H Derbyshire Maresa M MM MacIsaac Richard J RJ Sachithanandan Nirupa N

Endocrinology, diabetes & metabolism 20240901 5

<h4>Background</h4>Adrenal vein sampling (AVS), integral to identifying surgically remediable unilateral primary aldosteronism (PA), is technically challenging and subject to fluctuations in cortisol and aldosterone secretion. Intra-procedural adrenocorticotropic hormone (ACTH), conventionally administered as a 250-μg bolus and/or 50 μg per hour infusion, increases cortisol and aldosterone secretion and can improve AVS success, but may cause discordant lateralisation compared to unstimulated AVS ...[more]

PMID: 39207956

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Project description:ContextThe reproducibility of adrenal vein sampling (AVS) is unknown.ObjectiveThis work aimed to determine reproducibility of biochemical results and diagnostic lateralization in patients undergoing repeat AVS.MethodsA retrospective chart review was conducted of single-center, single-operator AVS procedures at a tertiary care center. Included were patients with confirmed primary aldosteronism (PA) undergoing repeat AVS because of concerns about technical success or discordant diagnostic results. Simultaneous AVS was performed by an experienced operator using a consistent protocol of precosyntropin and postcosyntropin infusion. Among successfully catheterized adrenal veins (selectivity index ≥ 2), the correlation of the adrenalaldosterone/cortisol (A/C) ratio was measured between the first and second AVS. The secondary outcome measure was diagnostic agreement on repeat AVS lateralization (lateralization index ≥ 3).ResultsThere were 46 sets of AVS from 23 patients at a median of 3 months apart. There was moderate correlation in A/C ratios in the adrenal veins and inferior vena cava (Spearman r = 0.49-0.59, P < .05) pre cosyntropin. Post cosyntropin, the correlation was better (Spearman r = 0.67-0.76, P < .05). In technically successful AVS, there was moderate correlation between the repeated lateralization indices (Spearman r = 0.53, P < .05). In 15 patients in whom repeat AVS was performed because of apparent lateralization discordance with computed tomography imaging, the final diagnosis was the same in the second AVS procedure. Initial failed AVS was successful 75% of the time on repeat attempt.ConclusionRepeat AVS was feasible and usually successful when an initial attempt failed. There was modest correlation between individual repeat adrenal A/C ratios and lateralization indices when AVS was performed twice. The final lateralization diagnosis was identical in all cases. This demonstrates that AVS is a reliable and reproducible localizing test in PA.

Project description:Purpose The purpose of this study was to assess the surgical outcomes of patients with primary aldosteronism when surgery was based only on CT finding of unilateral adenoma without adrenal vein sampling (AVS). Methods This is a retrospective review of the records of patients who had undergone retroperitoneal laparoscopic adrenalectomy for primary aldosteronism based on CT scan finding of unilateral adenoma and had a follow-up of at least 6–12 months from January 2012 to December 2020 in a single center; decision for adrenalectomy was based on CT scan, and AVS was not used. The clinical and biochemical outcomes were accessed using the standardized primary aldosteronism surgical outcome (PASO) criteria. Patient’s demographics and preoperative factors were analyzed to assess for independent predictor of surgical success. Results According to the PASO criteria, 172 patients finally enrolled in the training dataset, and 20 patients enrolled in the validation dataset. In the training dataset, complete clinical success was achieved in 71 patients (41.3%), partial success in 87 (50.6%), and absent success in 14 (8.1%). Biochemical outcomes showed that 151 patients (87.8%) were completely cured, 14 patients (8.1%) got a partial biochemical success, and an absent biochemical success was found in seven patients (4.1%). Multivariate logistic regression analysis showed that age, body mass index (BMI), tumor size, mean arterial pressure (MAP), and serum potassium were the most independent factors for incomplete biochemical success. Based on the results of statistical analysis, our study constructed a nomogram prognostic evaluation model for patients after unilateral primary aldosterone surgery. Conclusions Laparoscopic adrenalectomy for patients with primary aldosteronism base on CT scan finding of a unilateral adenoma without AVS had a high rate of complete biochemical cure at 12 months. Risk factors for incomplete biochemical success include age, BMI, tumor size, MAP, and serum potassium. Our study constructed a nomogram prognostic evaluation model for patients after unilateral primary aldosterone surgery. The nomogram accurately and reliably predicted the incomplete biochemical success.

Dataset Information

Utility of Adrenal Vein Sampling With and Without Ultra-Low Dose ACTH Infusion in the Diagnostic Evaluation of Primary Aldosteronism.

Background

Aims

Methods

Results

Discussion

Conclusion

Publications

Utility of Adrenal Vein Sampling With and Without Ultra-Low Dose ACTH Infusion in the Diagnostic Evaluation of Primary Aldosteronism.

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