Clinical Outcomes of 1625 Patients With Primary Aldosteronism Subtyped With Adrenal Vein Sampling.

We sought to measure the clinical benefits of adrenal venous sampling (AVS), a test recommended by guidelines for primary aldosteronism (PA) patients seeking surgical cure, in a large registry of PA patients submitted to AVS. Data of 1625 consecutive patients submitted to AVS in 19 tertiary referral centers located in Asia, Australia, Europe, and North America were collected in a large multicenter international registry. The primary end points were the rate of bilateral success, ascertained lateralization of PA, adrenalectomy, and of cured arterial hypertension among AVS-guided and non AVS-guided adrenalectomy patients. AVS was successful in 80.1% of all cases but allowed identification of unilateral PA in only 45.5% by the criteria in use at each center. Adrenalectomy was performed in 41.8% of all patients and cured arterial hypertension in 19.6% of the patients, 2-fold more frequently in women than men (P<0.001). When AVS-guided, surgery provided a higher rate of cure of hypertension than when non-AVS-guided (40.0% versus 30.5%; P=0.027). Compared with surgical cases, patients treated medically needed more antihypertensive medications (P<0.001) and exhibited a higher rate of persistent hypokalemia requiring potassium supplementation (4.9% versus 2.3%; P<0.01). The low rate of adrenalectomy and cure of hypertension in PA patients seeking surgical cure indicates suboptimal AVS use, possibly related to issues in patient selection, technical success, and AVS data interpretation. Given the better outcomes of AVS-guided adrenalectomy, these results call for actions to improve the diagnostic use of this test that is necessary for detection of surgical PA candidates. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01234220.

Age below 40 or a recently proposed clinical prediction score cannot bypass adrenal venous sampling in primary aldosteronism.

CONTEXT: Adrenal venous sampling (AVS) is used to distinguish bilateral from unilateral primary aldosteronism (PA). Due to its limited availability, clinical prediction scores have been proposed to diagnose unilateral disease without AVS. OBJECTIVE: Our goal was to test 2 recently proposed predictors of unilateral PA: 1) a clinical prediction score using imaging, serum potassium, and glomerular filtration rate and 2) the combination of visible unilateral adenoma on imaging and age <40 years. DESIGN AND SETTING: We used the data of all patients with PA of the prospective German Conn's Registry treated in Munich and Berlin since 2008. PATIENTS AND INTERVENTION: Of 205 patients with PA, 194 had a successful AVS and were included. MAIN OUTCOME MEASURES: Parameters were compared between patients with lateralized and nonlateralized AVS. Specificity and sensitivity of the proposed predictors were calculated. RESULTS: A total of 130 patients (67%) had unilateral PA according to AVS. Patients with unilateral PA showed a significantly lower estimated glomerular filtration rate compared with patients with bilateral disease (P < .05). The cohorts differed significantly in potassium supplementation, serum potassium, baseline and post-saline plasma aldosterone, baseline aldosterone to renin ratio, and adenoma in imaging. The proposed prediction score had a sensitivity of 46% (58 of 127) and a specificity of 80% (53 of 66). In patients below 40 years (n = 28), the prediction score achieved a specificity of 100%; however, relying only on imaging in this young cohort, the specificity dropped to 83%. CONCLUSIONS: The suggested prediction score has high accuracy only in young patients but cannot substitute for AVS in the elderly.