Adrenal Vein Sampling Is the Preferred Method to Select Patients With Primary Aldosteronism for AdrenalectomyResponse to Adrenal Vein Sampling Is the Preferred Method to Select Patients With Primary Aldosteronism for Adrenalectomy: Con Side of the Argument
Con Side of the Argument
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Primary aldosteronism (PA) is a secondary form of hypertension caused by autonomous secretion of the sodium-retaining hormone aldosterone by one or both adrenal glands, leading to hypertension and in a subset of patients to hypokalemia.1 PA can be cured by adrenalectomy in patients who have a unilateral aldosterone-producing adrenocortical adenoma (APA), present in about half of patients. Cure has 2 aspects in this disease: most, but not all, patients are cured biochemically, that is, have normalization of aldosterone secretion, whereas only a minority will be cured from hypertension.2 The majority of patients who remain hypertensive after adrenalectomy will reach lower blood pressure levels with less medication. They will rarely need mineralocorticoid receptor antagonists like spironolactone. These mineralocorticoid receptor antagonists are indicated for the other half of patients with PA, who are thought to have bilateral adrenocortical hyperplasia. Although blood pressure and hypokalemia can be controlled in almost all patients by adrenalectomy or mineralocorticoid receptor antagonists, quality of life improves most after adrenalectomy.3 Hence, proper selection of patients for adrenalectomy is of critical importance to achieve an optimal outcome for patients.
The Endocrine Society Clinical Practice guideline (guideline)1 recommends adrenal vein sampling (AVS) as the preferred method to select patients with PA for adrenalectomy. In AVS, adrenal veins are cannulated and from each a blood sample is drawn that is used to determine cortisol and aldosterone. Measurement of cortisol is critical to assess selectivity of cannulation of an adrenal vein and to correct for admixture of nonadrenal blood.
The widely available and most frequently used alternative to AVS, the adrenal computed tomographic (CT) scan, is considered by the guideline to be inferior to identify APA. Indeed, the results of CT scanning and AVS differ in their conclusion on the presence of APA in almost 40% of cases …