Rational Approach to a Patient with Suspected Primary Aldosteronism

Primary aldosteronism (PA) is the most common form of secondary hypertension that causes higher morbidity and mortality than equally severe essential hypertension. Bilateral PA should be treated medically with spironolactone or eplerenone, the mineralocorticoid receptor antagonists (MRA), while unilateral laparoscopic adrenalectomy is recommended for unilateral disease. Surgery cures hypertension in around 40% of patients with confirmed PA and reliably demonstrated unilateral autonomous aldosterone secretion by adrenal venous sampling (AVS). Regardless of its diagnostic value, AVS has several drawbacks, in particular high cost and invasiveness. Furthermore, only a limited number of referral centers worldwide routinely carry out the procedure. On the other hand, a small number of studies that compared the effects of surgery and MRA on the incidence of cardiovascular and renal outcomes in patients with PA found no difference between the two therapeutic options. In addition, spironolactone has been recently found to be the most effective add-on drug for the treatment of resistant hypertension. Therefore, rational selection of patients with suspected PA for AVS and surgery is of utmost importance

Limited diagnostic utility of partially successful adrenal vein sampling for primary aldosteronism subtyping

Introduction: Failure of adrenal vein sampling (AVS) due to difficult cannulation of the right adrenal vein (AV) frequently precludes subtyping of patients with primary aldosteronism (PA) before adrenalectomy. According to a recent study, lateralized PA could be accurately predicted from partial AVS data based on the gradient of the aldosterone-to-cortisol ratios (ACR) between left AV and inferior vena cava (IVC) (LAV/IVC index). We aimed to validate the diagnostic utility of this index for PA subtyping in our cohort. Material and methods: A retrospective cross-sectional study included all patients who underwent bilaterally successful AVS at our centre and were diagnosed with either bilateral PA according to AVS or with lateralized PA after successful adrenalectomy from November 2004 to the end of 2019. Final diagnoses were compared to originally suggested LAV/IVC index cut-offs of ≥ 5.5 for ipsilateral disease and of ≤ 0.5 for contralateral disease, respectively. Results: The inclusion criteria were met in 168 patients: 46 women and 122 men, aged 54 years on average (range 32–72 years); 67 with lateralized and 101 with bilateral PA. LAV/IVC index using cut-offs of ≥ 5.5 or ≤ 0.5 anticipated ipsilateral (left lateralized) PA with a sensitivity of 32% and specificity of 97%, while a sensitivity of 47% and specificity of 95%, were found for contralateral (right lateralized) PA in our cohort. The overall inappropriate adrenalectomy rate was 29.7% (p = 0.314 for comparison between sides). When ascertaining ipsilateral disease (LAV/IVC index ≥ 5.5), 4 out of 16 patients (25%) would have been incorrectly sent to left adrenalectomy. Inappropriate right adrenalectomy would have occurred in 7 out of 21 patients (33.3%) when predicting contralateral disease (LAV/IVC index of ≤ 0.5). Thus, 11 patients with bilateral PA (6.5% of the entire cohort) would have been misclassified as lateralized PA and referred to surgery. Failed lateralization would have occurred in 61.2% of patients overall (53.3% for overlooked contralateral disease, 67.6% for missed ipsilateral disease; p = 0.723 for comparison between sides). Conclusions: Based on our cohort, we conclude that application of the suggested LAV/IVC index cut-offs did not predict lateralized PA with the high accuracy previously reported.

Computed Tomography and Adrenal Venous Sampling in the Diagnosis of Unilateral Primary Aldosteronism

Unilateral primary aldosteronism is the most common surgically correctable form of endocrine hypertension and is usually differentiated from bilateral forms by adrenal venous sampling (AVS) or computed tomography (CT). Our objective was to compare clinical and biochemical postsurgical outcomes of patients with unilateral primary aldosteronism diagnosed by CT or AVS and identify predictors of surgical outcomes. Patient data were obtained from 18 internationally distributed centers and retrospectively analyzed for clinical and biochemical outcomes of adrenalectomy of patients with surgical management based on CT (n=235 patients, diagnosed from 1994-2016) or AVS (526 patients, diagnosed from 1994-2015) using the standardized PASO (Primary Aldosteronism Surgical Outcome) criteria. Biochemical outcomes were highly different according to surgical management approach with a smaller proportion in the CT group achieving complete biochemical success (188 of 235 [80%] patients versus 491 of 526 [93%], P<0.001) and a greater proportion with absent biochemical success (29 of 235 [12%] versus 10 of 526 [2%], P<0.001). A diagnosis by CT was associated with a decreased likelihood of complete biochemical success compared with AVS (odds ratio, 0.28; 0.16-0.50; P<0.001). Clinical outcomes were not significantly different, but the absence of a postsurgical elevated aldosterone-to-renin ratio was a strong marker of complete clinical success (odds ratio, 14.81; 1.76-124.53; P=0.013) in the CT but not in the AVS group. In conclusion, patients diagnosed by CT have a decreased likelihood of achieving complete biochemical success compared with a diagnosis by AVS

Outcome parameters in orthogeriatric co-management - a mini-review

Recognizing hip and other fragility fractures as an adverse event of chronic geriatric conditions led to the concept of orthogeriatric co-management (OGC). OGC today represents various forms of structural cooperation between orthopedic trauma surgeons and multiprofessional geriatric teams taking care of frail elderly patients. The models are country specific. Despite several published models there are still no clear recommendations on how this service should be best organized. The 12 outcome parameters published by the Experts' Roundtable in 2013 were recommended to be used for the further assessment of different OCG models. This literature review was prepared accordingly and showed the need for further studies to determine the best OGC model and to define a uniform set of outcome parameters for use in future clinical studies

Adrenal vein sampling for primary aldosteronism: a 15-year national referral center experience

Adrenal vein sampling (AVS) is essential for diagnostics of primary aldosteronism, distinguishing unilateral from bilateral disease and determining treatment options. We reviewed the performance of AVS for primary aldosteronism at our center during first 15 years, comparing the initial period to the period after the introduction of a dedicated radiologist. Additionally, AVS outcomes were checked against CT findings and the proportion of operated patients with proven unilateral disease was estimated

Optimal scan time for evaluation of parathyroid adenoma with [18F]-fluorocholine PET/CT

Background. Parathyroid adenomas, the most common cause of primary hyperparathyroidism, are benign tumours which autonomously produce and secrete parathyroid hormone. [18F]-fluorocholine (FCH), PET marker of cellular proliferation, was recently demonstrated to accumulate in lesions representing enlarged parathyroid tissue; however, the optimal time to perform FCH PET/CT after FCH administration is not known. The aim of this study was to determine the optimal scan time of FCH PET/CT in patients with primary hyperparathyroidism

Decreased Androgen Levels and Improved Menstrual Pattern after Angiotensin II Receptor Antagonist Telmisartan Treatment in Four Hypertensive Patients with Polycystic Ovary Syndrome: Case Series

We describe 4 consecutive hypertensive women with polycystic ovary syndrome, classified according to the National Institute of Child Health and Human Development (NICHD) criteria, treated with telmisartan 40 mg/d for six months. Blood pressure, menstrual pattern, body mass index (BMI), homeostasis model assessment of insulin resistance, testosterone, dehydroepiandrosterone sulfate (DHEAS), and androstenedione were recorded and measured before and after telmisartan treatment. Obese hypertensive polycystic ovary syndrome patients had a decrease in systolic blood pressure. Marked drop-off in serum androgen concentrations was observed in all four patients. Three patients improved their menstrual cyclicity. The improvements were independent of changes in weight. The reduction of androgen concentrations and improvement in menstrual pattern was achieved despite a non-significant change of fasting insulin levels in patients, who were not considered severely insulin resistant at baseline. These findings may provide a new basis for a proper choice of the antihypertensive drug in hypertensive women with polycystic ovary syndrome