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1.
Lancet Diabetes Endocrinol ; 8(9): 773-781, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32711725

RESUMO

BACKGROUND: Cross-sectional imaging regularly results in incidental discovery of adrenal tumours, requiring exclusion of adrenocortical carcinoma (ACC). However, differentiation is hampered by poor specificity of imaging characteristics. We aimed to validate a urine steroid metabolomics approach, using steroid profiling as the diagnostic basis for ACC. METHODS: We did a prospective multicentre study in adult participants (age ≥18 years) with newly diagnosed adrenal masses. We assessed the accuracy of diagnostic imaging strategies based on maximum tumour diameter (≥4 cm vs <4 cm), imaging characteristics (positive vs negative), and urine steroid metabolomics (low, medium, or high risk of ACC), separately and in combination, using a reference standard of histopathology and follow-up investigations. With respect to imaging characteristics, we also assessed the diagnostic utility of increasing the unenhanced CT tumour attenuation threshold from the recommended 10 Hounsfield units (HU) to 20 HU. FINDINGS: Of 2169 participants recruited between Jan 17, 2011, and July 15, 2016, we included 2017 from 14 specialist centres in 11 countries in the final analysis. 98 (4·9%) had histopathologically or clinically and biochemically confirmed ACC. Tumours with diameters of 4 cm or larger were identified in 488 participants (24·2%), including 96 of the 98 with ACC (positive predictive value [PPV] 19·7%, 95% CI 16·2-23·5). For imaging characteristics, increasing the unenhanced CT tumour attenuation threshold to 20 HU from the recommended 10 HU increased specificity for ACC (80·0% [95% CI 77·9-82·0] vs 64·0% [61·4-66.4]) while maintaining sensitivity (99·0% [94·4-100·0] vs 100·0% [96·3-100·0]; PPV 19·7%, 16·3-23·5). A urine steroid metabolomics result indicating high risk of ACC had a PPV of 34·6% (95% CI 28·6-41·0). When the three tests were combined, in the order of tumour diameter, positive imaging characteristics, and urine steroid metabolomics, 106 (5·3%) participants had the result maximum tumour diameter of 4 cm or larger, positive imaging characteristics (with the 20 HU cutoff), and urine steroid metabolomics indicating high risk of ACC, for which the PPV was 76·4% (95% CI 67·2-84·1). 70 (3·5%) were classified as being at moderate risk of ACC and 1841 (91·3%) at low risk (negative predictive value 99·7%, 99·4-100·0). INTERPRETATION: An unenhanced CT tumour attenuation cutoff of 20 HU should replace that of 10 HU for exclusion of ACC. A triple test strategy of tumour diameter, imaging characteristics, and urine steroid metabolomics improves detection of ACC, which could shorten time to surgery for patients with ACC and help to avoid unnecessary surgery in patients with benign tumours. FUNDING: European Commission, UK Medical Research Council, Wellcome Trust, and UK National Institute for Health Research, US National Institutes of Health, the Claire Khan Trust Fund at University Hospitals Birmingham Charities, and the Mayo Clinic Foundation for Medical Education and Research.


Assuntos
Neoplasias das Glândulas Suprarrenais/epidemiologia , Neoplasias das Glândulas Suprarrenais/urina , Metabolômica/métodos , Esteroides/urina , Neoplasias das Glândulas Suprarrenais/diagnóstico , Adulto , Idoso , Diagnóstico Diferencial , Europa (Continente)/epidemiologia , Feminino , Seguimentos , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
2.
Nephron ; 138(4): 275-279, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29301131

RESUMO

BACKGROUND: Kidney biopsy is frequently performed in our centre as an outpatient procedure. The aim of this study was to evaluate the safety of biopsy in the outpatient setting. METHODS: We analysed kidney biopsies performed from March 2013 to February 2017. Seven hundred twenty-five biopsies performed in the outpatient setting were identified: There were 592 transplant and 133 native biopsies including 3 solitary kidney biopsies. All were performed under ultrasound guidance using a 16G or 18G needle, with freehand technique. In all patients with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 desmopressin was administered. Patients were observed for 6h before discharge, with a complete blood count and urine test after 4 h. Major complications were haemorrhage requiring therapeutic intervention or transfusion. Minor complications were significant reduction in haemoglobin (Hb) levels (>10%), without need for transfusion or intervention and macrohaematuria. RESULTS: There were 506 (69.8%) male patients. Average age was 50.3 ± 12.7 years. Indications for native kidney biopsy included nephrotic syndrome (39.8%), nephritic syndrome (42.9%), follow-up biopsy (15.8%), and other (1.5%). There were no major complications. A decline in Hb was observed in 72% of patients. Average Hb decline was 4.2 ± 6.3 g/L. In 10.1% patients there was >10% reduction in Hb level, with no evident bleeding, including by ultrasonography. In 2.5% of patients, macrohaematuria was present. In a multivariate analysis, male gender, lower eGFR, higher pre-biopsy Hb and native kidney biopsy were predictive for Hb decline. No therapeutic interventions were required. CONCLUSION: We found that kidney biopsy performed in an outpatient setting in select patients is only rarely associated with adverse events and is a safe procedure.


Assuntos
Biópsia/efeitos adversos , Rim/patologia , Adulto , Idoso , Biópsia/estatística & dados numéricos , Feminino , Taxa de Filtração Glomerular , Hematúria/etiologia , Hemoglobinas/análise , Hemoglobinas/metabolismo , Hemorragia/etiologia , Humanos , Biópsia Guiada por Imagem , Nefropatias/diagnóstico , Nefropatias/patologia , Transplante de Rim , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Segurança do Paciente , Estudos Retrospectivos , Ultrassonografia de Intervenção
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