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Mizumoto Y, Hirakawa A, Sugiura Y, Nishikawa T, Nishimoto K, Mano Y, Higashi T. Determination of three C18-oxygenated steroids in adrenal lesion segments in primary aldosteronism by super-selective adrenal venous sampling and LC/ESI-MS/MS. Biomed Chromatogr 2024; 38:e5841. [PMID: 38324999 DOI: 10.1002/bmc.5841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/04/2024] [Accepted: 01/21/2024] [Indexed: 02/09/2024]
Abstract
Super-selective adrenal venous sampling (ssAVS) can collect the adrenal tributary venous blood in the aldosterone (ALD)-hypersecreting segments in primary aldosteronism. The concentrations of the C18-oxygenated steroids, especially 18-oxocortisol (18-oxoF), in the lesion segments might be more useful indices than those in the peripheral or adrenal central veins (current candidate indexes) for the differential diagnosis of unilateral ALD-producing adenoma (APA) and bilateral adrenal hyperplasia (BAH). To verify this hypothesis, we developed a liquid chromatography/electrospray ionization-tandem mass spectrometry (LC/ESI-MS/MS) method for simultaneously quantifying ALD, 18-oxoF and 18-hydroxycortisol in the adrenal tributary venous serum sample collected by ssAVS (ssAVS serum) and compared their concentrations between APA and BAH patients. Only deproteinization was required for a 10 μl sample prior to the LC/ESI-MS/MS analysis. Endogenous corticoids did not interfere with the quantifications, and the intra-assay and interassay precisions (≤ 8.3%) and accuracies (94.2-102.7%) were acceptable. The clinical study revealed that the 18-oxoF concentration was significantly higher in the ALD-producing tumor tissues (from APA patients) than in the hyperplastic tissues (from BAH patients). However, in conclusion, the 18-oxoF concentration in the ssAVS serum sample can be a rough indication but cannot be decisive for the differential diagnosis between APA and BAH owing to the significant individual difference.
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Affiliation(s)
- Yuka Mizumoto
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, Noda, Japan
| | - Ayaka Hirakawa
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, Noda, Japan
| | - Yuki Sugiura
- Department of Biochemistry, Keio University School of Medicine, Tokyo, Japan
- Multiomics Platform, Center for Cancer Immunotherapy and Immunobiology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tetsuo Nishikawa
- Endocrinology & Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Koshiro Nishimoto
- Department of Biochemistry, Keio University School of Medicine, Tokyo, Japan
- Department of Urology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yasunari Mano
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, Noda, Japan
| | - Tatsuya Higashi
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, Noda, Japan
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2
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Vogg N, Kürzinger L, Kendl S, Pamporaki C, Eisenhofer G, Adolf C, Hahner S, Fassnacht M, Kurlbaum M. A novel LC-MS/MS-based assay for the simultaneous quantification of aldosterone-related steroids in human urine. Clin Chem Lab Med 2024; 62:919-928. [PMID: 38008792 DOI: 10.1515/cclm-2023-0250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 11/15/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVES Primary aldosteronism is the most common cause of endocrine hypertension and is associated with significant cardiovascular morbidities. The diagnostic workup depends on determinations of plasma aldosterone and renin which are highly variable and associated with false-positive and false-negative results. Quantification of aldosterone in 24 h urine may provide more reliable results, but the methodology is not well established. We aimed to establish an assay for urinary aldosterone and related steroids with suitability for clinical routine implementation. METHODS Here, we report on the development and validation of a quantitative LC-MS/MS method for six urinary steroids: aldosterone, cortisol, 18-hydroxycorticosterone, 18-hydroxycortisol, 18-oxocortisol, tetrahydroaldosterone. After enzymatic deconjugation, total steroids were extracted using SepPak tC18 plates and quantified in positive electrospray ionization mode on a QTRAP 6500+ mass spectrometer. RESULTS Excellent linearity was demonstrated with R2>0.998 for all analytes. Extraction recoveries were 89.8-98.4 % and intra- and inter-day coefficients of variations were <6.4 and <9.0 %, establishing superb precision. Patients with primary aldosteronism (n=10) had higher mean 24 h excretions of aldosterone-related metabolites than normotensive volunteers (n=20): 3.91 (95 % CI 2.27-5.55) vs. 1.92 (1.16-2.68) µmol/mol for aldosterone/creatinine, 2.57 (1.49-3.66) vs. 0.79 (0.48-1.10) µmol/mol for 18-hydroxycorticosterone/creatinine, 37.4 (13.59-61.2) vs. 11.61 (10.24-12.98) µmol/mol for 18-hydroxycortisol/creatinine, 1.56 (0.34-2.78) vs. 0.13 (0.09-0.17) µmol/mol for 18-oxocortisol/creatinine, and 21.5 (13.4-29.6) vs. 7.21 (4.88-9.54) µmol/mol for tetrahydroaldosterone/creatinine. CONCLUSIONS The reported assay is robust and suitable for routine clinical use. First results in patient samples, though promising, require clinical validation in a larger sample set.
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Affiliation(s)
- Nora Vogg
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Central Laboratory, Core Unit Clinical Mass Spectrometry, University Hospital Würzburg, Würzburg, Germany
| | - Lydia Kürzinger
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Sabine Kendl
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Central Laboratory, Core Unit Clinical Mass Spectrometry, University Hospital Würzburg, Würzburg, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Graeme Eisenhofer
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christian Adolf
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Central Laboratory, Core Unit Clinical Mass Spectrometry, University Hospital Würzburg, Würzburg, Germany
| | - Max Kurlbaum
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Central Laboratory, Core Unit Clinical Mass Spectrometry, University Hospital Würzburg, Würzburg, Germany
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3
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Prete A, Lang K, Pavlov D, Rhayem Y, Sitch AJ, Franke AS, Gilligan LC, Shackleton CHL, Hahner S, Quinkler M, Dekkers T, Deinum J, Reincke M, Beuschlein F, Biehl M, Arlt W. Urine steroid metabolomics as a diagnostic tool in primary aldosteronism. J Steroid Biochem Mol Biol 2024; 237:106445. [PMID: 38104729 DOI: 10.1016/j.jsbmb.2023.106445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/03/2023] [Accepted: 12/13/2023] [Indexed: 12/19/2023]
Abstract
Primary aldosteronism (PA) causes 5-10% of hypertension cases, but only a minority of patients are currently diagnosed and treated because of a complex, stepwise, and partly invasive workup. We tested the performance of urine steroid metabolomics, the computational analysis of 24-hour urine steroid metabolome data by machine learning, for the identification and subtyping of PA. Mass spectrometry-based multi-steroid profiling was used to quantify the excretion of 34 steroid metabolites in 24-hour urine samples from 158 adults with PA (88 with unilateral PA [UPA] due to aldosterone-producing adenomas [APAs]; 70 with bilateral PA [BPA]) and 65 sex- and age-matched healthy controls. All APAs were resected and underwent targeted gene sequencing to detect somatic mutations associated with UPA. Patients with PA had increased urinary metabolite excretion of mineralocorticoids, glucocorticoids, and glucocorticoid precursors. Urine steroid metabolomics identified patients with PA with high accuracy, both when applied to all 34 or only the three most discriminative steroid metabolites (average areas under the receiver-operating characteristics curve [AUCs-ROC] 0.95-0.97). Whilst machine learning was suboptimal in differentiating UPA from BPA (average AUCs-ROC 0.65-0.73), it readily identified APA cases harbouring somatic KCNJ5 mutations (average AUCs-ROC 0.79-85). These patients showed a distinctly increased urine excretion of the hybrid steroid 18-hydroxycortisol and its metabolite 18-oxo-tetrahydrocortisol, the latter identified by machine learning as by far the most discriminative steroid. In conclusion, urine steroid metabolomics is a non-invasive candidate test for the accurate identification of PA cases and KCNJ5-mutated APAs.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Katharina Lang
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Pavlov
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, the Netherlands
| | - Yara Rhayem
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany; Service de Biologie Clinique, Hôpital Foch, Suresnes, France
| | - Alice J Sitch
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Anna S Franke
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Lorna C Gilligan
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Cedric H L Shackleton
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; UCSF Benioff Children's Hospital Oakland Research Institute, Oakland, CA, USA
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | | | - Tanja Dekkers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Martin Reincke
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Felix Beuschlein
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany; Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitäts-Spital Zürich (USZ) und Universität Zürich (UZH), Zurich, Switzerland
| | - Michael Biehl
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, the Netherlands; Centre for Systems Modelling and Quantitative Biomedicine, University of Birmingham, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Medical Research Council Laboratory of Medical Sciences, London, UK; Institute of Clinical Sciences, Faculty of Medicine, Imperial College, London, UK
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4
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Ng E, Gwini SM, Zheng W, Fuller PJ, Yang J. Predicting Bilateral Subtypes of Primary Aldosteronism Without Adrenal Vein Sampling: A Systematic Review and Meta-analysis. J Clin Endocrinol Metab 2024; 109:e837-e855. [PMID: 37531636 DOI: 10.1210/clinem/dgad451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/19/2023] [Accepted: 07/31/2023] [Indexed: 08/04/2023]
Abstract
CONTEXT Primary aldosteronism (PA) is the most common endocrine cause of hypertension. The final diagnostic step involves subtyping, using adrenal vein sampling (AVS), to determine if PA is unilateral or bilateral. The complete PA diagnostic process is time and resource intensive, which can impact rates of diagnosis and treatment. Previous studies have developed tools to predict bilateral PA before AVS. OBJECTIVE Evaluate the sensitivity and specificity of published tools that aim to identify bilateral subtypes of PA. METHODS Medline and Embase databases were searched to identify published models that sought to subtype PA, and algorithms to predict bilateral PA are reported. Meta-analysis and meta-regression were then performed. RESULTS There were 35 studies included, evaluating 55 unique algorithms to predict bilateral PA. The algorithms were grouped into 6 categories: those combining biochemical, radiological, and demographic characteristics (A); confirmatory testing alone or combined with biochemical, radiological, and demographic characteristics (B); biochemistry results alone (C); adrenocorticotropic hormone stimulation testing (D); anatomical imaging (E); and functional imaging (F). Across the identified algorithms, sensitivity and specificity ranged from 5% to 100% and 36% to 100%, respectively. Meta-analysis of 30 unique predictive tools from 32 studies showed that the group A algorithms had the highest specificity for predicting bilateral PA, while group F had the highest sensitivity. CONCLUSIONS Despite the variability in published predictive algorithms, they are likely important for decision-making regarding the value of AVS. Prospective validation may enable medical treatment upfront for people with a high likelihood of bilateral PA without the need for an invasive and resource-intensive test.
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Affiliation(s)
- Elisabeth Ng
- Centre for Endocrinology & Metabolism, Hudson Institute of Medical Research, Clayton, Australia
- Department of Endocrinology, Monash Health, Clayton, Australia
- Department of Molecular and Translational Science, Monash University, Clayton, Australia
| | - Stella May Gwini
- Centre for Endocrinology & Metabolism, Hudson Institute of Medical Research, Clayton, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Winston Zheng
- Department of Endocrinology, Monash Health, Clayton, Australia
| | - Peter J Fuller
- Centre for Endocrinology & Metabolism, Hudson Institute of Medical Research, Clayton, Australia
- Department of Endocrinology, Monash Health, Clayton, Australia
- Department of Molecular and Translational Science, Monash University, Clayton, Australia
| | - Jun Yang
- Centre for Endocrinology & Metabolism, Hudson Institute of Medical Research, Clayton, Australia
- Department of Endocrinology, Monash Health, Clayton, Australia
- Department of Molecular and Translational Science, Monash University, Clayton, Australia
- Department of Medicine, Monash University, Clayton, Australia
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5
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Auchus RJ. Approaching Primary Aldosteronism as a Common Disease. Endocr Pract 2023; 29:994-998. [PMID: 37683826 DOI: 10.1016/j.eprac.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/31/2023] [Accepted: 08/31/2023] [Indexed: 09/10/2023]
Abstract
OBJECTIVE To describe the approach to primary aldosteronism as a common disease. METHODS The study methods involved are literature review and personal experience. RESULTS Primary aldosteronism is the most common form of endocrine hypertension, yet screening rates are abysmally low. Major reasons for low screening rates include misconceptions about the drug interference and limited access to adrenal vein sampling expertise for subtyping. The workup of primary aldosteronism is greatly simplified by considering the condition as a continuum with low-renin primary hypertension. Thus, the purpose of the evaluation is not a yes/no dichotomous diagnosis but rather a gauging of how likely the patient has a lateralized source and will benefit from unilateral adrenalectomy. This approach favors the selective rather than universal use of cross-sectional imaging and adrenal vein sampling but promotes the liberal use of mineralocorticoid-receptor antagonists. CONCLUSION The review will develop a practical approach to the patient using a series of questions with answers from the literature.
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Affiliation(s)
- Richard J Auchus
- Division of Endocrinology & Metabolism, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, Michigan, USA; Endocrinology & Metabolism Section, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, Michigan, USA.
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6
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Azizan EAB, Drake WM, Brown MJ. Primary aldosteronism: molecular medicine meets public health. Nat Rev Nephrol 2023; 19:788-806. [PMID: 37612380 PMCID: PMC7615304 DOI: 10.1038/s41581-023-00753-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/25/2023]
Abstract
Primary aldosteronism is the most common single cause of hypertension and is potentially curable when only one adrenal gland is the culprit. The importance of primary aldosteronism to public health derives from its high prevalence but huge under-diagnosis (estimated to be <1% of all affected individuals), despite the consequences of poor blood pressure control by conventional therapy and enhanced cardiovascular risk. This state of affairs is attributable to the fact that the tools used for diagnosis or treatment are still those that originated in the 1970-1990s. Conversely, molecular discoveries have transformed our understanding of adrenal physiology and pathology. Many molecules and processes associated with constant adrenocortical renewal and interzonal metamorphosis also feature in aldosterone-producing adenomas and aldosterone-producing micronodules. The adrenal gland has one of the most significant rates of non-silent somatic mutations, with frequent selection of those driving autonomous aldosterone production, and distinct clinical presentations and outcomes for most genotypes. The disappearance of aldosterone synthesis and cells from most of the adult human zona glomerulosa is the likely driver of the mutational success that causes aldosterone-producing adenomas, but insights into the pathways that lead to constitutive aldosterone production and cell survival may open up opportunities for novel therapies.
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Affiliation(s)
- Elena A B Azizan
- Department of Medicine, Faculty of Medicine, The National University of Malaysia (UKM), Kuala Lumpur, Malaysia
- Endocrine Hypertension, Department of Clinical Pharmacology and Precision Medicine, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - William M Drake
- St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
- NIHR Barts Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Morris J Brown
- Endocrine Hypertension, Department of Clinical Pharmacology and Precision Medicine, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom.
- NIHR Barts Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.
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7
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Rege J, Bandulik S, Nanba K, Kosmann C, Blinder AR, Plain A, Vats P, Kumar-Sinha C, Lerario AM, Else T, Yamazaki Y, Satoh F, Sasano H, Giordano TJ, Williams TA, Reincke M, Turcu AF, Udager AM, Warth R, Rainey WE. Somatic SLC30A1 mutations altering zinc transporter ZnT1 cause aldosterone-producing adenomas and primary aldosteronism. Nat Genet 2023; 55:1623-1631. [PMID: 37709865 DOI: 10.1038/s41588-023-01498-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/08/2023] [Indexed: 09/16/2023]
Abstract
Primary aldosteronism (PA) is the most common form of endocrine hypertension and is characterized by inappropriately elevated aldosterone production via a renin-independent mechanism. Driver somatic mutations for aldosterone excess have been found in approximately 90% of aldosterone-producing adenomas (APAs). Other causes of lateralized adrenal PA include aldosterone-producing nodules (APNs). Using next-generation sequencing, we identified recurrent in-frame deletions in SLC30A1 in four APAs and one APN (p.L51_A57del, n = 3; p.L49_L55del, n = 2). SLC30A1 encodes the ubiquitous zinc efflux transporter ZnT1 (zinc transporter 1). The identified SLC30A1 variants are situated close to the zinc-binding site (His43 and Asp47) in transmembrane domain II and probably cause abnormal ion transport. Cases of PA with SLC30A1 mutations showed male dominance and demonstrated increased aldosterone and 18-oxocortisol concentrations. Functional studies of the SLC30A151_57del variant in a doxycycline-inducible adrenal cell system revealed pathological Na+ influx. An aberrant Na+ current led to depolarization of the resting membrane potential and, thus, to the opening of voltage-gated calcium (Ca2+) channels. This resulted in an increase in cytosolic Ca2+ activity, which stimulated CYP11B2 mRNA expression and aldosterone production. Collectively, these data implicate zinc transporter alterations as a dominant driver of aldosterone excess in PA.
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Affiliation(s)
- Juilee Rege
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, MI, USA
| | - Sascha Bandulik
- Medical Cell Biology, University of Regensburg, Regensburg, Germany
| | - Kazutaka Nanba
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, MI, USA
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Carla Kosmann
- Medical Cell Biology, University of Regensburg, Regensburg, Germany
| | - Amy R Blinder
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, MI, USA
| | - Allein Plain
- Medical Cell Biology, University of Regensburg, Regensburg, Germany
| | - Pankaj Vats
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Chandan Kumar-Sinha
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Antonio M Lerario
- Division of Metabolism, Endocrine, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Tobias Else
- Division of Metabolism, Endocrine, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Tracy Ann Williams
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig Maximilian University of Munich, Munich, Germany
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig Maximilian University of Munich, Munich, Germany
| | - Adina F Turcu
- Division of Metabolism, Endocrine, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Aaron M Udager
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI, USA
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Richard Warth
- Medical Cell Biology, University of Regensburg, Regensburg, Germany
| | - William E Rainey
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, MI, USA.
- Division of Metabolism, Endocrine, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
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8
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Chang YL, Chen GY, Lee BC, Chen PT, Liu KL, Chang CC, Weng TI, Wu VC, Lin YH. Optimizing adrenal vein sampling in primary aldosteronism subtyping through LC-MS/MS and secretion ratios of aldosterone, 18-oxocortisol, and 18-hydroxycortisol. Hypertens Res 2023; 46:1983-1994. [PMID: 37311968 PMCID: PMC10404510 DOI: 10.1038/s41440-023-01347-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 05/21/2023] [Accepted: 05/30/2023] [Indexed: 06/15/2023]
Abstract
Adrenal venous sampling (AVS) is the gold standard for identifying curable unilateral aldosterone excess in primary aldosteronism (PA). Studies have demonstrated the value of steroid profiling through liquid chromatography-tandem mass spectrometry (LC-MS/MS) in AVS interpretation. First, the performance of LC-MS/MS and immunoassay in assessing selectivity and lateralization was compared. Second, the utility of the proportion of individual steroids in adrenal veins in subtyping PA was analyzed. We enrolled 75 consecutive patients with PA who underwent AVS between 2020 and 2021. Fifteen adrenal steroids were analyzed in peripheral and adrenal veins through LC-MS/MS before and after adrenocorticotropic hormone (ACTH) stimulation. Through selectivity index that was based on cortisol and alternative steroids, LC-MS/MS rescued 45% and 66% of failed cases judged by immunoassay in unstimulated and stimulated AVS, respectively. LC-MS/MS identified more unilateral diseases than did immunoassay (76% vs. 45%, P < 0.05) and provided adrenalectomy opportunities to 69% of patients judged through immunoassay to have bilateral disease. The secretion ratios (individual steroid concentration/total steroid concentration) of aldosterone, 18-oxocortisol, and 18-hydroxycortisol were novel indicators for identifying unilateral PA. The 18-oxocortisol secretion ratio of ≥0.785‰ (sensitivity/specificity: 0.90/0.77) at pre-ACTH and aldosterone secretion ratio of ≤0.637‰ (sensitivity/specificity: 0.88/0.85) at post-ACTH enabled optimal accuracy for predicting ipsilateral and contralateral disease, respectively, in robust unilateral PA. LC-MS/MS improved the success rate of AVS and identified more unilateral diseases than immunoassay. The secretion ratios of steroids can be used to discriminate the broad PA spectrum.
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Affiliation(s)
- Yu-Ling Chang
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Guan-Yuan Chen
- Department and Graduate Institute of Forensic Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Bo-Ching Lee
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Po-Ting Chen
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kao-Lang Liu
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chin-Chen Chang
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
- Department and Graduate Institute of Forensic Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Te-I Weng
- Department and Graduate Institute of Forensic Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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9
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Nakai K, Manaka K, Sato J, Takeuchi M, Yamazaki Y, Sasano H, Tsurutani Y, Saito J, Nishikawa T, Iiri T, Nangaku M, Makita N. Aldosterone-Producing Adenomas of Increased Size Are Associated With Higher Steroidogenic Activity. J Clin Endocrinol Metab 2022; 107:3045-3054. [PMID: 36074914 DOI: 10.1210/clinem/dgac530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT There are inconsistent results and insufficient evidence as to whether an association exists between the size and aldosterone-producing ability of aldosterone-producing adenomas. OBJECTIVE We further investigated this possible association retrospectively. METHODS A total of 142 cases of primary aldosteronism diagnosed as unilateral by adrenal venous sampling at 2 referral centers between 2009 and 2019 were included. We classified these individuals into small and large tumor groups using a diameter of 14 mm as a cutoff. This size was the median diameter of the tumor on the affected side of the adrenal gland. We compared plasma aldosterone concentration (PAC), plasma renin activity (PRA), PAC to PRA ratio, PAC from a saline infusion test (SIT), urinary aldosterone secretion (uAld), and serum potassium as indices of aldosterone-producing ability between the 2 groups. In some cases, we conducted histopathological evaluations and detection of the KCNJ5 mutation. RESULTS PAC, PAC to PRA ratio, PAC from SIT, and uAld were higher and serum potassium was lower in the large tumor group. PAC, PAC from SIT, uAld, and serum potassium significantly correlated with tumor diameter. PRA was not associated with tumor diameter. Clear cell-dominant cases were more common in the large tumor group, while cases showing a strong expression of CYP11B2 were not significantly different between the groups. KCNJ5 mutations tended to be more common in the large tumor group. CONCLUSION The higher aldosterone-producing ability in larger adenomas can be used to infer the responsible lesion and disease type.
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Affiliation(s)
- Kazuki Nakai
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, 222-0036, Japan
| | - Katsunori Manaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Junichiro Sato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Maki Takeuchi
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan
| | - Yuya Tsurutani
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, 222-0036, Japan
| | - Jun Saito
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, 222-0036, Japan
| | - Tetsuo Nishikawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, 222-0036, Japan
- Nishikawa Clinic, Yokohama, 222-0033, Japan
| | - Taroh Iiri
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
- Department of Pharmacology, St. Marianna University School of Medicine, Kawasaki, 216-8511, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
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10
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Abstract
Primary aldosteronism is a common cause of hypertension and is a risk factor for cardiovascular and renal morbidity and mortality, via mechanisms mediated by both hypertension and direct insults to target organs. Despite its high prevalence and associated complications, primary aldosteronism remains largely under-recognized, with less than 2% of people in at-risk populations ever tested. Fundamental progress made over the past decade has transformed our understanding of the pathogenesis of primary aldosteronism and of its clinical phenotypes. The dichotomous paradigm of primary aldosteronism diagnosis and subtyping is being redefined into a multidimensional spectrum of disease, which spans subclinical stages to florid primary aldosteronism, and from single-focal or multifocal to diffuse aldosterone-producing areas, which can affect one or both adrenal glands. This Review discusses how redefining the primary aldosteronism syndrome as a multidimensional spectrum will affect the approach to the diagnosis and subtyping of primary aldosteronism.
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Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA.
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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11
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Gomez-Sanchez CE, Sapiro DR, May KV, Rainey WE, Nishimoto K, Gomez-Sanchez EP. Origin of circulating 18-oxocortisol in the normal human adrenal. Mol Cell Endocrinol 2022; 555:111720. [PMID: 35870737 PMCID: PMC10911085 DOI: 10.1016/j.mce.2022.111720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 11/17/2022]
Abstract
18-Oxocortisol is the product of the metabolism of 11-deoxycortisol by the mitochondrial enzyme aldosterone synthase (CYP11B2). The traditional concept is that the CYP11B2 is exclusively expressed in zona glomerulosa cells and the 17α-hydroxylase (CYP17A1) enzyme, required to synthesize 11-deoxycortisol, is in the zona fasciculata of the human adrenal. It has been postulated that the substrate for 18-oxocortisol is either cortisol from the circulation or from zona fasciculata cells adjacent to the zona glomerulosa. P-glycoprotein, which is highly expressed in steroidogenic cells of the adrenal gland, efficiently expels cortisol from the cell. Double immunofluorescence staining for the CYP11B2 and CYP17A1 enzymes in 7 human adrenals demonstrated that a highly variable number of cells in different areas of the zona glomerulosa co-expressed both enzymes. In addition, there were a variable number of cells that exclusively expressed the CYP17A1 embedded within the zona glomerulosa surrounded by CYP11B2-expressing cells. 18-Oxocortisol in the media of human adrenocortical HAC15 cells was measured by ELISA after incubation with and without 10 nM of angiotensin II to stimulate CYP11B2 activity, with and without the 3β-hydroxysteroid dehydrogenase (HSD3B) inhibitor trilostane, and with variable amounts of cortisol or 11-deoxycortisol. Cortisol was a poor substrate, while 11-deoxycortisol was a significant substrate for the synthesis of 18-oxocortisol. These data suggest that the biosynthesis of 18-oxocortisol in the human adrenal is likely catalyzed by co-expression of the two crucial enzymes CYP17A1 and CYP11B2 in a small proportion of cells within the zona glomerulosa. It is also possible that 11-deoxycortisol diffusing from cells expressing only CYP17A1 interspersed with cells expressing the CYP11B2 enzyme may be a paracrine substrate in the synthesis of 18-oxocortisol.
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Affiliation(s)
- Celso E Gomez-Sanchez
- Endocrine Section, G.V. Sonny Montgomery VA Medical Center, USA; Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, MS, USA.
| | - Dina R Sapiro
- Department of Integrative and Molecular Physiology, University of Michigan, Ann Arbor, MI, USA
| | - Katie V May
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - William E Rainey
- Department of Integrative and Molecular Physiology, University of Michigan, Ann Arbor, MI, USA
| | - Koshiro Nishimoto
- Department of Uro-Oncology, International Medical Center Saitama Medical University, Saitama, 350-1298, Japan; Department of Biochemistry, Keio University School of Medicine, Tokyo, 160-8582, Japan
| | - Elise P Gomez-Sanchez
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
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12
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Kocjan T, Vidmar G, Popović P, Stanković M. Validation of three novel clinical prediction tools for primary aldosteronism subtyping. Endocr Connect 2022; 11:e210532. [PMID: 35521815 PMCID: PMC9175612 DOI: 10.1530/ec-21-0532] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 04/11/2022] [Indexed: 12/03/2022]
Abstract
The 20-point clinical prediction SPACE score, the aldosterone-to-lowest potassium ratio (APR), aldosterone concentration (AC) and the AC relative reduction rate after saline infusion test (SIT) have recently been proposed for primary aldosteronism (PA) subtyping prior to adrenal vein sampling (AVS). To validate those claims, we performed a retrospective cross-sectional study that included all patients at our center who had positive SIT to confirm PA and were diagnosed with either bilateral disease (BPA) according to AVS or with lateralized disease (LPA) if biochemically cured after adrenalectomy from November 2004 to the end of 2019. Final diagnoses were used to evaluate the diagnostic performance of proposed clinical prediction tools. Our cohort included 144 patients (40 females), aged 32-72 years (mean 54 years); 59 with LPA and 85 with BPA. The originally suggested SPACE score ≤8 and SPACE score >16 rules yielded about 80% positive predictive value (PPV) for BPA and LPA, respectively. Multivariate analyses with the predictors constituting the SPACE score highlighted post-SIT AC as the most important predictor of PA subtype for our cohort. APR-based tool of <5 for BPA and >15 for LPA yielded about 75% PPV for LPA and BPA. The proposed post-SIT AC <8.79 ng/dL criterion yielded 41% sensitivity and 90% specificity, while the relative post-SIT AC reduction rate of >33.8% criterion yielded 80% sensitivity and 51% specificity for BPA prediction. The application of any of the validated clinical prediction tools to our cohort did not predict the PA subtype with the high diagnostic performance originally reported.
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Affiliation(s)
- Tomaž Kocjan
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Gaj Vidmar
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- University Rehabilitation Institute, Ljubljana, Slovenia
- FAMNIT, University of Primorska, Koper, Slovenia
| | - Peter Popović
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Clinical Institute of Radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Milenko Stanković
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Clinical Institute of Radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
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13
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Naruse M, Katabami T, Shibata H, Sone M, Takahashi K, Tanabe A, Izawa S, Ichijo T, Otsuki M, Omura M, Ogawa Y, Oki Y, Kurihara I, Kobayashi H, Sakamoto R, Satoh F, Takeda Y, Tanaka T, Tamura K, Tsuiki M, Hashimoto S, Hasegawa T, Yoshimoto T, Yoneda T, Yamamoto K, Rakugi H, Wada N, Saiki A, Ohno Y, Haze T. Japan Endocrine Society clinical practice guideline for the diagnosis and management of primary aldosteronism 2021. Endocr J 2022; 69:327-359. [PMID: 35418526 DOI: 10.1507/endocrj.ej21-0508] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Primary aldosteronism (PA) is associated with higher cardiovascular morbidity and mortality rates than essential hypertension. The Japan Endocrine Society (JES) has developed an updated guideline for PA, based on the evidence, especially from Japan. We should preferentially screen hypertensive patients with a high prevalence of PA with aldosterone to renin ratio ≥200 and plasma aldosterone concentrations (PAC) ≥60 pg/mL as a cut-off of positive results. While we should confirm excess aldosterone secretion by one positive confirmatory test, we could bypass patients with typical PA findings. Since PAC became lower due to a change in assay methods from radioimmunoassay to chemiluminescent enzyme immunoassay, borderline ranges were set for screening and confirmatory tests and provisionally designated as positive. We recommend individualized medicine for those in the borderline range for the next step. We recommend evaluating cortisol co-secretion in patients with adrenal macroadenomas. Although we recommend adrenal venous sampling for lateralization before adrenalectomy, we should carefully select patients rather than all patients, and we suggest bypassing in young patients with typical PA findings. A selectivity index ≥5 and a lateralization index >4 after adrenocorticotropic hormone stimulation defines successful catheterization and unilateral subtype diagnosis. We recommend adrenalectomy for unilateral PA and mineralocorticoid receptor antagonists for bilateral PA. Systematic as well as individualized clinical practice is always warranted. This JES guideline 2021 provides updated rational evidence and recommendations for the clinical practice of PA, leading to improved quality of the clinical practice of hypertension.
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Affiliation(s)
- Mitsuhide Naruse
- Endocrine Center and Clinical Research Center, Ijinkai Takeda General Hospital, Kyoto 601-1495, Japan
- Clinical Research Institute of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University, Yokohama City Seibu Hospital, Yokohama 241-0811, Japan
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Yufu 879-5593, Japan
| | - Masakatsu Sone
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University, Kawasaki 216-8511, Japan
| | | | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Shoichiro Izawa
- Division of Endocrinology and Metabolism, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Takamasa Ichijo
- Department of Diabetes and Endocrinology, Saiseikai Yokohamashi Tobu Hospital, Yokohama 230-0012, Japan
| | - Michio Otsuki
- Department of Endocrinology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Masao Omura
- Minato Mirai Medical Square, Yokohama, 220-0012 Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
- Department of Endocrine and Metabolic Diseases/Diabetes Mellitus, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Yutaka Oki
- Department of Metabolism and Endocrinology, Hamamatsu Kita Hospital, Hamamatsu 431-3113, Japan
| | - Isao Kurihara
- Department of Medical Education, National Defense Medical College, Tokorozawa 359-8513, Japan
- Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Hiroki Kobayashi
- Division of Nephrology, Hypertension and Endocrinology, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Ryuichi Sakamoto
- Department of Endocrine and Metabolic Diseases/Diabetes Mellitus, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Yoshiyu Takeda
- Department of Endocrinology and Metabolism, Kanazawa University Hospital, Kanazawa 920-8641, Japan
| | - Tomoaki Tanaka
- Department of Molecular Diagnosis, Chiba University, Chiba 260-8677, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan
| | - Mika Tsuiki
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| | - Shigeatsu Hashimoto
- Department of Endocrinology, Metabolism, Diabetology and Nephrology, Fukushima Medical University Aizu Medical Center, Aizu 969-3492, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo 160-0016, Japan
| | - Takanobu Yoshimoto
- Department of Diabetes and Endocrinology, Tokyo Metropolitan Hiroo Hospital, Tokyo 150-0013, Japan
| | - Takashi Yoneda
- Department of Health Promotion and Medicine of the Future, Graduate School of Medical Sciences, Kanazawa University, Kanazawa 920-8641, Japan
| | - Koichi Yamamoto
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Aya Saiki
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Youichi Ohno
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
| | - Tatsuya Haze
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, Yokohama 232-0024, Japan
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14
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Characteristics of aldosterone-producing adenomas in patients without plasma renin activity suppression. PLoS One 2022; 17:e0267732. [PMID: 35482752 PMCID: PMC9049528 DOI: 10.1371/journal.pone.0267732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 04/13/2022] [Indexed: 01/13/2023] Open
Abstract
Primary aldosteronism (PA) usually accompanies suppressed plasma renin activity (PRA) through a negative feedback mechanism. While some cases of PA with unsuppressed PRA were reported, there have been no studies about the characteristics of PA with unsuppressed PRA; thus, these characteristics were examined herein. Nine patients with unsuppressed PRA and 86 patients with suppressed PRA were examined. All patients underwent segmental adrenal venous sampling (sAVS) and adrenalectomy, and were pathologically confirmed to have cytochrome P450 11B2 (CYP11B2)-positive aldosterone-producing adenoma according to international histopathology consensus criteria. Unsuppressed and suppressed PRA were defined as PRA levels of > 1.0 and ≤ 1.0 ng/mL/hr, respectively, in multiple blood samples obtained in the resting position. The unsuppressed PRA group had higher morning cortisol levels (12.6 [8.5, 13.5] vs. 8.5 [7.1, 11.0] μg/dL, P = 0.03) and higher cortisol levels after a 1 mg dexamethasone suppression test (DST) (2.2 [1.6, 2.5] vs. 1.3 [1.0, 1.9] μ g/dL, P = 0.004) than the suppressed PRA group. The unsuppressed PRA group also showed higher aldosterone levels on the non-surgical side during sAVS (P = 0.02 before adrenocorticotropic hormone (ACTH) stimulation, P = 0.002 after ACTH stimulation), a higher intensity of CYP17 expression in the resected adrenal gland (P = 0.02), and a lower clinical complete success rate 1 year after surgery (P = 0.04) compared with those in the suppressed PRA group. These findings suggest that PA should not be ruled out by unsuppressed PRA among patients with hypertension, particularly when their cortisol levels remain unsuppressed in the 1 mg DST. Meanwhile, it should be acknowledged that patients with unsuppressed PRA have higher aldosterone levels on the non-surgical side, and a lower likelihood of postoperative complete clinical success is to be expected.
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15
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Berke K, Constantinescu G, Masjkur J, Kimpel O, Dischinger U, Peitzsch M, Kwapiszewska A, Dobrowolski P, Nölting S, Reincke M, Beuschlein F, Bornstein SR, Prejbisz A, Lenders JWM, Fassnacht M, Eisenhofer G. Plasma Steroid Profiling in Patients With Adrenal Incidentaloma. J Clin Endocrinol Metab 2022; 107:e1181-e1192. [PMID: 34665854 DOI: 10.1210/clinem/dgab751] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Indexed: 01/13/2023]
Abstract
CONTEXT Most patients with adrenal incidentaloma have nonfunctional lesions that do not require treatment, while others have functional or malignant tumors that require intervention. The plasma steroid metabolome may be useful to assess therapeutic need. OBJECTIVE This work aimed to establish the utility of plasma steroid profiling combined with metanephrines and adrenal tumor size for the differential diagnosis of patients with adrenal incidentaloma. METHODS This retrospective cross-sectional study, which took place at 7 European tertiary-care centers, comprised 577 patients with adrenal incidentaloma, including 19, 77, 65, 104 and 312 respective patients with adrenocortical carcinoma (ACC), pheochromocytoma (PHEO), primary aldosteronism (PA), autonomous cortisol secretion (ACS), and nonfunctional adrenal incidentaloma (NFAI). Mesaures of diagnostic performance were assessed (with [95% CIs]) for discriminating different subgroups of patients with adrenal incidentaloma. RESULTS Patients with ACC were characterized by elevated plasma concentrations of 11-deoxycortisol, 11-deoxycorticosterone, 17-hydroxyprogesterone, androstenedione, and dehydroepiandrosterone-sulfate, whereas patients with PA had elevations of aldosterone, 18-oxocortisol, and 18-hydroxycortisol. A selection of those 8 steroids, combined with 3 others (cortisol, corticosterone, and dehydroepiandrosterone) and plasma metanephrines, proved optimal for identifying patients with ACC, PA, and PHEO at respective sensitivities of 83.3% (66.1%-100%), 90.8% (83.7%-97.8%), and 94.8% (89.8%-99.8%); and specificities of 98.0% (96.9%-99.2%), 92.0% (89.6%-94.3%), and 98.6% (97.6%-99.6%). With the addition of tumor size, discrimination improved further, particularly for ACC (100% [100%-100%] sensitivity, 99.5% [98.9%-100%] specificity). In contrast, discrimination of ACS and NFAI remained suboptimal (70%-71% sensitivity, 89%-90% specificity). CONCLUSION Among patients with adrenal incidentaloma, the combination of plasma steroid metabolomics with routinely available plasma free metanephrines and data from imaging studies may facilitate the identification of almost all clinically relevant adrenal tumors.
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Affiliation(s)
- Kristina Berke
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Georgiana Constantinescu
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jimmy Masjkur
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Otilia Kimpel
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97082 Würzburg, Germany
| | - Ulrich Dischinger
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97082 Würzburg, Germany
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | | | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, 04-828 Warsaw, Poland
| | - Svenja Nölting
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), 8057 Zurich, Switzerland
- Department of Medicine IV, University Hospital, Ludwig Maximilian University of Munich, 80539 Munich, Germany
| | - Martin Reincke
- Department of Medicine IV, University Hospital, Ludwig Maximilian University of Munich, 80539 Munich, Germany
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), 8057 Zurich, Switzerland
- Department of Medicine IV, University Hospital, Ludwig Maximilian University of Munich, 80539 Munich, Germany
| | - Stefan R Bornstein
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, 04-828 Warsaw, Poland
| | - Jacques W M Lenders
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Center, 6500 HB Nijmegen, the Netherlands
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97082 Würzburg, Germany
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
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16
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Asbach E, Reincke M. [Diagnosis and therapy of primary aldosteronism: new aspects]. Dtsch Med Wochenschr 2022; 147:92-97. [PMID: 35100641 DOI: 10.1055/a-1370-5935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Primary aldosteronism represents the most frequent cause of endocrine hypertension. It is associated with a higher morbidity and mortality compared to essential hypertension. Early identification of the affected patients is crucial, as the adequate therapy leads to an excellent long-term prognosis, especially after unilateral adrenalectomy. Diagnosis consists of three steps: diagnosis, confirmation test and subtype differentiation. The 2 most frequent causes of primary aldosteronism are aldosterone producing adenoma, which can be cured by surgery, and idiopathic bilateral adrenal hyperplasia, which is treated with mineralocorticoid receptor antagonists.Screening by aldosterone-to-renin ratio is recommended in designed risk populations. As the aldosterone-to-renin ratio displays a limited sensitivity and specificity, confirmatory testing is recommended in most patients with positive screening test. Prediction scores allow to skip confirmatory testing under certain circumstances. Adrenal vein sampling still represents the gold standard in subtype differentiation of primary aldosteronism. Steroid profiling could possibly make dispensable adrenal vein sampling in patients with bilateral hyperplasia. Different studies investigate the potential of functional imaging for differential diagnosis of primary aldosteronism.
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17
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Abstract
Primary aldosteronism, the most common secondary form of hypertension, is thought to be present in ≈5% to 10% of hypertensive adults. However, recent studies indicate that its prevalence may be at least 3-fold higher based on the identification of renin-independent (autonomous) aldosterone production that is not suppressible with dietary sodium loading in a large fraction of adults with primary hypertension. Currently, the screening rate for primary aldosteronism in adults with primary hypertension is <1%. This review summarizes current thinking about primary aldosteronism from the standpoint of 3 key questions: Where are we now? Where to from here? So how do we get there?
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Affiliation(s)
- John W. Funder
- Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia. Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville
| | - Robert M. Carey
- Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia. Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville
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18
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Williams TA, Reincke M. Pathophysiology and histopathology of primary aldosteronism. Trends Endocrinol Metab 2022; 33:36-49. [PMID: 34743804 DOI: 10.1016/j.tem.2021.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/30/2021] [Accepted: 10/09/2021] [Indexed: 10/19/2022]
Abstract
Primary aldosteronism (PA) can be sporadic or familial and classified into unilateral and bilateral forms. Sporadic PA predominates with excessive aldosterone production usually arising from a unilateral aldosterone-producing adenoma (APA) or bilateral adrenocortical hyperplasia. Familial PA is rare and caused by germline variants, that partly correspond to somatic alterations in APAs. Classification into unilateral and bilateral PA determines the treatment approach but does not accurately mirror disease pathology. Some evidence indicates a disease continuum ranging from balanced aldosterone production from each adrenal to extreme asymmetrical bilateral aldosterone production. Nonetheless, surgical removal of the overactive adrenal in unilateral PA achieves highly successful outcomes and almost all patients are biochemically cured of their aldosteronism.
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Affiliation(s)
- Tracy Ann Williams
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany
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Shi S, Tian Y, Ren Y, Li Q, Li L, Yu M, Wang J, Gao L, Xu S. A new machine learning-based prediction model for subtype diagnosis in primary aldosteronism. Front Endocrinol (Lausanne) 2022; 13:1005934. [PMID: 36506080 PMCID: PMC9728523 DOI: 10.3389/fendo.2022.1005934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Unilateral primary aldosteronism (UPA) and bilateral primary aldosteronism (BPA) are the two subtypes of PA. Discriminating UPA from BPA is of great significance. Although adrenal venous sampling (AVS) is the gold standard for diagnosis, it has shortcomings. Thus, improved methods are needed. METHODS The original data were extracted from the public database "Dryad". Ten parameters were included to develop prediction models for PA subtype diagnosis using machine learning technology. Moreover, the optimal model was chose and validated in an external dataset. RESULTS In the modeling dataset, 165 patients (71 UPA, 94 BPA) were included, while in the external dataset, 43 consecutive patients (20 UPA, 23 BPA) were included. The ten parameters utilized in the prediction model include age, sex, systolic and diastolic blood pressure, aldosterone to renin ratio (ARR), serum potassium, ARR after 50 mg captopril challenge test (CCT), primary aldosterone concentration (PAC) after saline infusion test (SIT), PAC reduction rate after SIT, and number of types of antihypertensive agents at diagnosis. The accuracy, sensitivity, specificity, F1 score, and AUC for the optimal model using the random forest classifier were 90.0%, 81.8%, 96.4%, 0.878, and 0.938, respectively, in the testing dataset and 81.4%, 90.0%, 73.9%, 0.818 and 0.887, respectively, in the validating external dataset. The most important variables contributing to the prediction model were PAC after SIT, ARR, and ARR after CCT. DISCUSSION We developed a machine learning-based predictive model for PA subtype diagnosis based on ten clinical parameters without CT imaging. In the future, artificial intelligence-based prediction models might become a robust prediction tool for PA subtype diagnosis, thereby, might reducing at least some of the requests for CT or AVS and assisting clinical decision-making.
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Affiliation(s)
- Shaomin Shi
- Department of Endocrinology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Yuan Tian
- Department of Endocrinology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Yong Ren
- Department of Cardiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Qing’an Li
- Department of General Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Luhong Li
- Department of General Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Ming Yu
- Department of General Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Jingzhong Wang
- Department of Interventional Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Ling Gao
- Department of Endocrinology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
- *Correspondence: Shaoyong Xu, ; Ling Gao,
| | - Shaoyong Xu
- Department of Endocrinology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
- Center for Clinical Evidence-Based and Translational Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
- *Correspondence: Shaoyong Xu, ; Ling Gao,
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Reincke M, Bancos I, Mulatero P, Scholl UI, Stowasser M, Williams TA. Diagnosis and treatment of primary aldosteronism. Lancet Diabetes Endocrinol 2021; 9:876-892. [PMID: 34798068 DOI: 10.1016/s2213-8587(21)00210-2] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023]
Abstract
Primary aldosteronism is a common cause of secondary hypertension associated with excess cardiovascular morbidities. Primary aldosteronism is underdiagnosed because it does not have a specific, easily identifiable feature and clinicians can be poorly aware of the disease. The diagnostic investigation is a multistep process of screening, confirmatory testing, and subtype differentiation of unilateral from bilateral forms for therapeutic management. Adrenal venous sampling is key for reliable subtype identification, but can be bypassed in patients with specific characteristics. For unilateral disease, surgery offers the possibility of cure, with total laparoscopic unilateral adrenalectomy being the treatment of choice. Bilateral forms are treated mainly with mineralocorticoid receptor antagonists. The goals of treatment are to normalise both blood pressure and excessive aldosterone production, and the primary aims are to reduce associated comorbidities, improve quality of life, and reduce mortality. Prompt diagnosis of primary aldosteronism and the use of targeted treatment strategies mitigate aldosterone-specific target organ damage and with appropriate patient management outcomes can be excellent. Advances in molecular histopathology challenge the traditional concept of primary aldosteronism as a binary disease, caused by either a unilateral aldosterone-producing adenoma or bilateral adrenal hyperplasia. Somatic mutations drive autonomous aldosterone production in most adenomas. Many of these same mutations have been identified in nodular lesions adjacent to an aldosterone-producing adenoma and in patients with bilateral disease. In addition, germline mutations cause rare familial forms of aldosteronism (familial hyperaldosteronism types 1-4). Genetic testing for inherited forms in suspected cases of familial hyperaldosteronism avoids the burdensome diagnostic investigation in positive patients. In this Review, we discuss advances and future management approaches in the diagnosis of primary aldosteronism.
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Affiliation(s)
- Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany.
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ute I Scholl
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Center of Functional Genomics, Berlin, Germany
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland Diamantina Institute, Greenslopes and Princess Alexandra Hospitals, Brisbane, QLD, Australia
| | - Tracy Ann Williams
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy
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21
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Chen F, Cheng Z, Wang Z, Peng Y, Wang B, Guo W, Pan B. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) based assay for the simultaneous quantification of 18-hydroxycorticosterone, 18-hydroxycortisol and 18-oxocortisol in human plasma. J Chromatogr B Analyt Technol Biomed Life Sci 2021; 1188:123030. [PMID: 34871919 DOI: 10.1016/j.jchromb.2021.123030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/25/2021] [Accepted: 11/07/2021] [Indexed: 10/19/2022]
Abstract
18-hydroxycorticosterone (18-OHB), 18-hydroxycortisol (18-OHF) and 18-oxocortisol (18-OXOF) are important biomarkers for the diagnosis of subtypes of primary aldosteronism. The detection of these three analytes by liquid chromatography-tandem mass spectrometry (LC-MS/MS) is free from structurally similar compounds. The aim of this study was to develop and validate a new LC-MS/MS assay for the simultaneous quantification of 18-OHB, 18-OHF and 18-OXOF in plasma and to establish a reference intervals for apparently healthy population. Plasma samples were prepared by solid phase extraction and separated in an ultra-high performance reversed phase column. MS detection was achieved using a triple quadrupole mass spectrometer in both positive and negative ionization modes. The developed assay was then validated against standard guidelines. We collected 691 plasma samples from apparently healthy individuals (M:398, F:293) to establish the reference intervals. The analytes were separated and quantified within 5 min. The newly developed method demonstrated linearity for the detected steroid concentration in range of 5 to 3000 pg/ml for 18-OXOF (r2 = 0.999) and 20 to 3000 pg/ml for 18-OHB (r2 = 0.997) and 18-OHF (r2 = 0.997). The lower limit of quantification (LLOQ) was 2.5 pg/ml, 20 pg/ml and 20 pg/m for 18-OXOF, 18-OHB and 18-OHF respectively. Specificity, precision, accuracy and stability were tested, and met the requirements of the guidelines. 18-OHB was higher in females than in males, but 18-OHF were higher in males than females. The reference intervals of 18-OHB, 18-OHF and 18-OXOF for both genders together were 90.5-1040.6 pg/ml, 224.4-1685.2 pg/ml, 4.0-70.5 pg/ml, respectively. Age was also an important factor influencing the levels of these three hormones. We have developed a sensitive and reliable method for the simultaneous quantification of 18-OHB, 18-OHF, and 18-OXOF. Our work provides a reference interval for the clinical application of these three steroid hormones.
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Affiliation(s)
- Fangjun Chen
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Road, Shanghai 200032, PR China
| | - Ziyun Cheng
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Road, Shanghai 200032, PR China
| | - Zhenxin Wang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Road, Shanghai 200032, PR China
| | - Yingfei Peng
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Road, Shanghai 200032, PR China
| | - Beili Wang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Road, Shanghai 200032, PR China
| | - Wei Guo
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Road, Shanghai 200032, PR China.
| | - Baishen Pan
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Road, Shanghai 200032, PR China.
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Transcriptomics, Epigenetics, and Metabolomics of Primary Aldosteronism. Cancers (Basel) 2021; 13:cancers13215582. [PMID: 34771744 PMCID: PMC8583505 DOI: 10.3390/cancers13215582] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/17/2021] [Accepted: 11/05/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Primary aldosteronism (PA) is the most common cause of endocrine hypertension, mainly caused by aldosterone-producing adenomas or hyperplasia; understanding its pathophysiological background is important in order to provide ameliorative treatment strategies. Over the past several years, significant progress has been documented in this field, in particular in the clarification of the genetic and molecular mechanisms responsible for the pathogenesis of aldosterone-producing adenomas (APAs). METHODS Systematic searches of the PubMed and Cochrane databases were performed for all human studies applying transcriptomic, epigenetic or metabolomic analyses to PA subjects. Studies involving serial analysis of gene expression and microarray, epigenetic studies with methylome analyses and micro-RNA expression profiles, and metabolomic studies focused on improving understanding of the regulation of autonomous aldosterone production in PA were all included. RESULTS In this review we summarize the main findings in this area and analyze the interplay between primary aldosteronism and several signaling pathways with differential regulation of the RNA and protein expression of several factors involved in, among others, steroidogenesis, calcium signaling, and nuclear, membrane and G-coupled protein receptors. Distinct transcriptomic and metabolomic patterns are also presented herein, depending on the mutational status of APAs. In particular, two partially opposite transcriptional and steroidogenic profiles appear to distinguish APAs carrying a KCNJ5 mutation from all other APAs, which carry different mutations. CONCLUSIONS These findings can substantially contribute to the development of personalized treatment in patients with PA.
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23
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Ku EJ, Lee C, Shim J, Lee S, Kim KA, Kim SW, Rhee Y, Kim HJ, Lim JS, Chung CH, Chun SW, Yoo SJ, Ryu OH, Cho HC, Hong AR, Ahn CH, Kim JH, Choi MH. Metabolic Subtyping of Adrenal Tumors: Prospective Multi-Center Cohort Study in Korea. Endocrinol Metab (Seoul) 2021; 36:1131-1141. [PMID: 34674508 PMCID: PMC8566125 DOI: 10.3803/enm.2021.1149] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/10/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Conventional diagnostic approaches for adrenal tumors require multi-step processes, including imaging studies and dynamic hormone tests. Therefore, this study aimed to discriminate adrenal tumors from a single blood sample based on the combination of liquid chromatography-mass spectrometry (LC-MS) and machine learning algorithms in serum profiling of adrenal steroids. METHODS The LC-MS-based steroid profiling was applied to serum samples obtained from patients with nonfunctioning adenoma (NFA, n=73), Cushing's syndrome (CS, n=30), and primary aldosteronism (PA, n=40) in a prospective multicenter study of adrenal disease. The decision tree (DT), random forest (RF), and extreme gradient boost (XGBoost) were performed to categorize the subtypes of adrenal tumors. RESULTS The CS group showed higher serum levels of 11-deoxycortisol than the NFA group, and increased levels of tetrahydrocortisone (THE), 20α-dihydrocortisol, and 6β-hydroxycortisol were found in the PA group. However, the CS group showed lower levels of dehydroepiandrosterone (DHEA) and its sulfate derivative (DHEA-S) than both the NFA and PA groups. Patients with PA expressed higher serum 18-hydroxycortisol and DHEA but lower THE than NFA patients. The balanced accuracies of DT, RF, and XGBoost for classifying each type were 78%, 96%, and 97%, respectively. In receiver operating characteristics (ROC) analysis for CS, XGBoost, and RF showed a significantly greater diagnostic power than the DT. However, in ROC analysis for PA, only RF exhibited better diagnostic performance than DT. CONCLUSION The combination of LC-MS-based steroid profiling with machine learning algorithms could be a promising one-step diagnostic approach for the classification of adrenal tumor subtypes.
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Affiliation(s)
- Eu Jeong Ku
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju,
Korea
| | - Chaelin Lee
- Molecular Recognition Research Center, Korea Institute of Science and Technology, Seoul,
Korea
| | - Jaeyoon Shim
- Molecular Recognition Research Center, Korea Institute of Science and Technology, Seoul,
Korea
| | - Sihoon Lee
- Department of Internal Medicine, Gachon University College of Medicine, Incheon,
Korea
| | - Kyoung-Ah Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang,
Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul,
Korea
| | - Yumie Rhee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul,
Korea
| | - Hyo-Jeong Kim
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University, Seoul,
Korea
| | - Jung Soo Lim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju,
Korea
| | - Choon Hee Chung
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju,
Korea
| | - Sung Wan Chun
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan,
Korea
| | - Soon-Jib Yoo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon,
Korea
| | - Ohk-Hyun Ryu
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon,
Korea
| | - Ho Chan Cho
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu,
Korea
| | - A Ram Hong
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju,
Korea
| | - Chang Ho Ahn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul,
Korea
| | - Man Ho Choi
- Molecular Recognition Research Center, Korea Institute of Science and Technology, Seoul,
Korea
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Naruse M, Tanabe A, Yamamoto K, Rakugi H, Kometani M, Yoneda T, Kobayashi H, Abe M, Ohno Y, Inagaki N, Izawa S, Sone M. Adrenal Venous Sampling for Subtype Diagnosis of Primary Hyperaldosteronism. Endocrinol Metab (Seoul) 2021; 36:965-973. [PMID: 34674504 PMCID: PMC8566130 DOI: 10.3803/enm.2021.1192] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/11/2021] [Indexed: 12/01/2022] Open
Abstract
Adrenal venous sampling (AVS) is the key procedure for lateralization of primary hyperaldosteronism (PA) before surgery. Identification of the adrenal veins using computed tomography (CT) and intraoperative cortisol assay facilitates the success of catheterization. Although administration of adrenocorticotropic hormone (ACTH) has benefits such as improving the success rate, some unilateral cases could be falsely diagnosed as bilateral. Selectivity index of 5 with ACTH stimulation to assess the selectivity of catheterization and lateralization index (LI) >4 with ACTH stimulation for unilateral diagnosis is used in many centers. Co-secretion of cortisol from the tumor potentially affects the lateralization by the LI. Patients aged <35 years with hypokalemia, marked aldosterone excess, and unilateral adrenal nodule on CT have a higher probability of unilateral disease. Patients with normokalemia, mild aldosterone excess, and no adrenal tumor on CT have a higher probability of bilateral disease. Although no methods have 100% specificity for subtype diagnosis that would allow bypassing AVS, prediction of the subtype should be considered when recommending AVS to patients. Methodological standardization and strict indication improve diagnostic quality of AVS. Development of non-invasive imaging and biochemical markers will drive a paradigm shift in the clinical practice of PA.
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Affiliation(s)
- Mitsuhide Naruse
- Endocrine Center and Clinical Research Center, Ijinkai Takeda General Hospital, Kyoto,
Japan
- Clinical Research Institute of Endocrinology and Metabolism, NHO Kyoto Medical Center, Tokyo,
Japan
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Tokyo,
Japan
| | - Koichi Yamamoto
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka,
Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka,
Japan
| | - Mitsuhiro Kometani
- Department of Health Promotion and Medicine of the Future, Graduate School of Medical Sciences, Kanazawa University, Kanazawa,
Japan
| | - Takashi Yoneda
- Department of Health Promotion and Medicine of the Future, Graduate School of Medical Sciences, Kanazawa University, Kanazawa,
Japan
| | - Hiroki Kobayashi
- Division of Nephrology, Hypertension and Endocrinology, Nihon University School of Medicine, Tokyo,
Japan
| | - Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Nihon University School of Medicine, Tokyo,
Japan
| | - Youichi Ohno
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto,
Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto,
Japan
| | - Shoichiro Izawa
- Division of Endocrinology and Metabolism, Tottori University Faculty of Medicine, Yonago,
Japan
| | - Masakatsu Sone
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki,
Japan
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Tezuka Y, Ishii K, Zhao L, Yamazaki Y, Morimoto R, Sasano H, Udager AM, Satoh F, Turcu AF. ACTH Stimulation Maximizes the Accuracy of Peripheral Steroid Profiling in Primary Aldosteronism Subtyping. J Clin Endocrinol Metab 2021; 106:e3969-e3978. [PMID: 34117870 PMCID: PMC8475211 DOI: 10.1210/clinem/dgab420] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Adrenocorticotropic hormone (ACTH) can contribute to aldosterone excess in primary aldosteronism (PA) via increased melanocortin type 2 receptor expression. Dynamic manipulation of the hypothalamic-pituitary-adrenal (HPA) axis could assist PA subtyping, but a direct comparison of dynamic tests is lacking. OBJECTIVE To investigate plasma steroid differences between aldosterone-producing adenoma (APA) and bilateral PA (BPA) relative to ACTH variations. METHODS We conducted comprehensive dynamic testing in 80 patients: 40 with APA and 40 with BPA. Peripheral plasma was collected from each patient at 6 time points: morning; midnight; after 1 mg dexamethasone suppression; and 15, 30, and 60 minutes after ACTH stimulation. We quantified 17 steroids by mass spectrometry in response to ACTH variations in all patients and compared their discriminative power between the 2 PA subtypes. RESULTS Patients with APA had higher morning and midnight concentrations of 18-hydroxycortisol, 18-oxocortisol, aldosterone, and 18-hydroxycorticosterone than those with BPA (P < 0.001 for all). In response to cosyntropin stimulation, the APA group had larger increments of aldosterone, 18-oxocortisol, 11-deoxycorticosterone, corticosterone, and 11-deoxycortisol (P < 0.05 for all). Following dexamethasone suppression, the APA group had larger decrements of aldosterone, 18-hydroxycortisol, and 18-oxocortisol (P < 0.05 for all), but their concentrations remained higher than in the BPA group (P < 0.01 for all). The highest discriminatory performance between the PA subtypes was achieved using steroids measured 15 minutes post-ACTH stimulation (area under receiver operating characteristic curve 0.957). CONCLUSION Steroid differences between APA and BPA are enhanced by dynamic HPA testing; such noninvasive tests could circumvent the need for adrenal vein sampling in a subset of patients with PA.
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Affiliation(s)
- Yuta Tezuka
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Miyagi 980-8576, Japan
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi 980-8576, Japan
| | - Kae Ishii
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Miyagi 980-8576, Japan
| | - Lili Zhao
- School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Miyagi 980-8576, Japan
| | - Ryo Morimoto
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi 980-8576, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Miyagi 980-8576, Japan
| | - Aaron M Udager
- Department of Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Miyagi 980-8576, Japan
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi 980-8576, Japan
| | - Adina F Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
- Correspondence: Adina F. Turcu, MD, MS, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, 1150 W Medical Center Drive, MSRB II, 5570B, Ann Arbor, MI, 48109.
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Mirfakhraee S, Rodriguez M, Ganji N, Auchus RJ, Hamidi O. A Real Saline Challenge: Diagnosing Primary Aldosteronism in the Setting of Chronic Kidney Disease. J Investig Med High Impact Case Rep 2021; 9:23247096211034337. [PMID: 34293951 PMCID: PMC8312167 DOI: 10.1177/23247096211034337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Primary aldosteronism (PA) is the most common cause of secondary hypertension but remains largely undiagnosed. Chronic kidney disease (CKD) complicates the diagnosis of PA by affecting the biochemical screening evaluation and confirmatory testing, and by increasing the complication rate of adrenal venous sampling (AVS). To raise clinician awareness of the challenges of PA diagnosis in CKD, we present an illustrative case with subsequent review of the literature and discuss some recent developments in PA diagnostic strategies particularly applicable to the CKD population. A 67-year-old man with stage IIIb CKD was suspected of having PA due to treatment with 6 antihypertensive agents and the presence of intermittent hypokalemia. He had a positive biochemical screen for PA, and AVS demonstrated unilateral aldosterone excess. Subsequently, unilateral adrenalectomy resolved his PA, eliminating the patient’s hypokalemia and improving his blood pressure. A MEDLINE literature search revealed 10 studies totaling 11 cases (including our own) of PA diagnosed in the setting of CKD. For each case, the clinical presentation, biochemical data, results of cross-sectional imaging, AVS details, and clinical response to surgery or medical therapy were characterized. The optimal strategy for the diagnosis and management of PA patients with CKD is not known. Although CKD patients often receive screening and subtype testing for PA similar to non-CKD patients, there are challenges in the interpretation of these tests. Novel strategies may include less invasive subtype testing or empiric treatment with mineralocorticoid receptor antagonists but additional studies are necessary.
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Affiliation(s)
| | - Maria Rodriguez
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Oksana Hamidi
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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The Management of Primary Hyperaldosteronism in a Poor Technology Environment. Case Rep Urol 2021; 2021:6672052. [PMID: 34055447 PMCID: PMC8131141 DOI: 10.1155/2021/6672052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/04/2021] [Indexed: 11/18/2022] Open
Abstract
We report a case of Conn's adenoma in a 35-year-old female successfully managed in a poor hospital technology environment.
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Kidoguchi S, Sugano N, Kawauchi R, Nakashima D, Hayashi-Ishikawa N, Tokudome G, Yokoo T. Evaluation of various confirmatory tests for the diagnosis of aldosterone-producing adenoma. J Renin Angiotensin Aldosterone Syst 2021; 21:1470320320919610. [PMID: 32370649 PMCID: PMC7227155 DOI: 10.1177/1470320320919610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Introduction: Adrenal venous sampling is useful for discriminating unilateral and bilateral hypersecretion in patients with primary aldosteronism, but it is relatively invasive. To determine the site of hypersecretion more non-invasively, we evaluated predictors of unilateral hypersecretion. Materials and methods: We evaluated the baseline characteristics and the results of confirmatory tests of 123 patients with primary aldosteronism who underwent adrenal venous sampling. Results: Unilateral hypersecretion was identified in 22.0%. The plasma aldosterone concentration and aldosterone–renin ratio were significantly higher and serum potassium concentration and plasma renin activity were significantly lower in patients with unilateral hypersecretion. Plasma aldosterone concentrations after captopril challenge test, saline infusion test and rapid adrenocorticotropic hormone stimulation test were significantly higher among patients with unilateral hypersecretion. The plasma aldosterone concentration reduction ratio in saline infusion test and plasma aldosterone concentration elevation ratio during rapid adrenocorticotropic hormone stimulation test were significantly higher in patients with unilateral hypersecretion. However, areas under the curve for these parameters were not superior to the values after confirmatory tests. Conclusions: The plasma aldosterone concentration values after captopril challenge test, saline infusion test and rapid adrenocorticotropic hormone stimulation test were useful for identifying patients with unilateral hypersecretion. However, value changes or ratios during confirmatory tests are less useful for this aim.
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Affiliation(s)
- Satoshi Kidoguchi
- Division of Nephrology and Hypertension, The Jikei University School of Medicine, Japan
| | - Naoki Sugano
- Division of Nephrology and Hypertension, The Jikei University School of Medicine, Japan
| | - Ruri Kawauchi
- Division of Nephrology and Hypertension, The Jikei University School of Medicine, Japan
| | - Daisuke Nakashima
- Division of Nephrology and Hypertension, The Jikei University School of Medicine, Japan
| | | | - Goro Tokudome
- Division of Nephrology and Hypertension, The Jikei University School of Medicine, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, The Jikei University School of Medicine, Japan
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Nanba K, Rainey WE. GENETICS IN ENDOCRINOLOGY: Impact of race and sex on genetic causes of aldosterone-producing adenomas. Eur J Endocrinol 2021; 185:R1-R11. [PMID: 33900205 PMCID: PMC8480207 DOI: 10.1530/eje-21-0031] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/26/2021] [Indexed: 11/08/2022]
Abstract
Primary aldosteronism (PA) is a common cause of secondary hypertension. Recent technological advances in genetic analysis have provided a better understanding of the molecular pathogenesis of this disease. The application of next-generation sequencing has resulted in the identification of somatic mutations in aldosterone-producing adenoma (APA), a major subtype of PA. Based on the recent findings using a sequencing method that selectively targets the tumor region where aldosterone synthase (CYP11B2) is expressed, the vast majority of APAs appear to harbor a somatic mutation in one of the aldosterone-driver genes, including KCNJ5, ATP1A1, ATP2B3, CACNA1D, CACNA1H, and CLCN2. Mutations in these genes alter intracellular ion homeostasis and enhance aldosterone production. In a small subset of APAs, somatic activating mutations in the CTNNB1 gene, which encodes β-catenin, have also been detected. Accumulating evidence suggests that race and sex impact the somatic mutation spectrum of APA. Specifically, somatic mutations in the KCNJ5 gene, encoding an inwardly rectifying K+ channel, are common in APAs from Asian populations as well as women regardless of race. Associations between APA histology, genotype, and patient clinical characteristics have also been proposed, suggesting a potential need to consider race and sex for the management of PA patients. Herein, we review recent findings regarding somatic mutations in APA and discuss potential roles of race and sex on the pathophysiology of APA as well as possible clinical implications.
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Affiliation(s)
- Kazutaka Nanba
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, 48109
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555, Japan
| | - William E. Rainey
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, 48109
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109
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Update on Genetics of Primary Aldosteronism. Biomedicines 2021; 9:biomedicines9040409. [PMID: 33920271 PMCID: PMC8069207 DOI: 10.3390/biomedicines9040409] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022] Open
Abstract
Primary aldosteronism (PA) is the most common form of secondary hypertension, with a prevalence of 5–10% among patients with hypertension. PA is mainly classified into two subtypes: aldosterone-producing adenoma (APA) and bilateral idiopathic hyperaldosteronism. Recent developments in genetic analysis have facilitated the discovery of mutations in KCNJ5, ATP1A1, ATP2B3, CACNA1D, CACNA1H, CLCN2, and CTNNB1 in sporadic or familial forms of PA in the last decade. These findings have greatly advanced our understanding of the mechanism of excess aldosterone synthesis, particularly in APA. Most of the causative genes encode ion channels or pumps, and their mutations lead to depolarization of the cell membrane due to impairment of ion transport. Depolarization activates voltage-gated Ca2+ channels and intracellular calcium signaling and promotes the transcription of aldosterone synthase, resulting in overproduction of aldosterone. In this article, we review recent findings on the genetic and molecular mechanisms of PA.
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Nakai K, Tsurutani Y, Inoue K, Matsui S, Makita K, Yamazaki Y, Sasano H, Makita N, Nangaku M, Saito J, Omura M, Nishikawa T. Steroidogenic Activity in Unresected Adrenals Associated With Surgical Outcomes in Primary Aldosteronism. Hypertension 2021; 77:1638-1646. [PMID: 33775128 DOI: 10.1161/hypertensionaha.120.16335] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Kazuki Nakai
- Endocrinology and Diabetes Center (K.N., Y.T., K.I., J.S., T.N.), Yokohama Rosai Hospital, Japan.,Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Japan (K.N., N.M., M.N.)
| | - Yuya Tsurutani
- Endocrinology and Diabetes Center (K.N., Y.T., K.I., J.S., T.N.), Yokohama Rosai Hospital, Japan
| | - Kosuke Inoue
- Endocrinology and Diabetes Center (K.N., Y.T., K.I., J.S., T.N.), Yokohama Rosai Hospital, Japan.,Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles (K.I.)
| | - Seishi Matsui
- Department of Radiology (S.M.), Yokohama Rosai Hospital, Japan
| | - Kohzoh Makita
- Department of Radiology, Nerima Hikarigaoka Hospital, Tokyo, Japan (K.M.)
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan (Y.Y., H.S.)
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan (Y.Y., H.S.)
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Japan (K.N., N.M., M.N.)
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Japan (K.N., N.M., M.N.)
| | - Jun Saito
- Endocrinology and Diabetes Center (K.N., Y.T., K.I., J.S., T.N.), Yokohama Rosai Hospital, Japan
| | - Masao Omura
- Minato Mirai Medical Square, Yokohama, Japan (M.O.)
| | - Tetsuo Nishikawa
- Endocrinology and Diabetes Center (K.N., Y.T., K.I., J.S., T.N.), Yokohama Rosai Hospital, Japan.,Nishikawa Clinic, Yokohama, Japan (T.N.)
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Turcu AF, Auchus R. Approach to the Patient with Primary Aldosteronism: Utility and Limitations of Adrenal Vein Sampling. J Clin Endocrinol Metab 2021; 106:1195-1208. [PMID: 33382421 PMCID: PMC7993592 DOI: 10.1210/clinem/dgaa952] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Indexed: 11/19/2022]
Abstract
Several studies over the past 3 decades document a higher prevalence of primary aldosteronism (PA) among hypertensive patients than generally presumed. PA exists as a spectrum from mild to severe aldosterone excess. Although a variety of PA subtypes exist, the 2 most common are aldosterone-producing adenomas (APAs) and bilateral hyperaldosteronism (BHA). The distinction is important, because APA-and other subtypes, with aldosterone production mostly from 1 adrenal-can be cured surgically, and BHA should be treated medically with mineralocorticoid-receptor antagonists (MRAs). The major shortcomings in the tailored management of patients with possible PA are the low rates of screening for case identification and the expensive and technically challenging imaging and interventional procedures required to distinguish APA from BHA, especially adrenal vein sampling (AVS). When AVS identifies an APA and allows the patient to be cured surgically, the procedure is of great value. In contrast, the patient with BHA is treated with MRA whether AVS is performed or not. Consequently, it is prudent to gauge how likely it is to benefit from imaging and AVS in each case prior to embarking on these studies. The explosion of information about PA in the past decade, including predictors of APA and of surgical benefit, are useful in limiting the evaluation for some patients with a positive PA screening test. This article will review our suggestions for approaching these patients in a pragmatic style, recognizing the limitations to even the best resources and facilities.
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Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Ann Arbor, Michigan, USA
| | - Richard Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Ann Arbor, Michigan, USA
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan, USA
- Ann Arbor Veterans Affairs Hospital, Ann Arbor, Michigan, USA
- Correspondence: Richard Auchus, MD, PhD, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, 1150 W Medical Center Dr, MSRB II, 5560A, Ann Arbor, Michigan 48109 USA. E-mail:
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Tezuka Y, Yamazaki Y, Nakamura Y, Sasano H, Satoh F. Recent Development toward the Next Clinical Practice of Primary Aldosteronism: A Literature Review. Biomedicines 2021; 9:biomedicines9030310. [PMID: 33802814 PMCID: PMC8002562 DOI: 10.3390/biomedicines9030310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/08/2021] [Accepted: 03/15/2021] [Indexed: 11/24/2022] Open
Abstract
For the last seven decades, primary aldosteronism (PA) has been gradually recognized as a leading cause of secondary hypertension harboring increased risks of cardiovascular incidents compared to essential hypertension. Clinically, PA consists of two major subtypes, surgically curable and uncurable phenotypes, determined as unilateral or bilateral PA by adrenal venous sampling. In order to further optimize the treatment, surgery or medications, diagnostic procedures from screening to subtype differentiation is indispensable, while in the general clinical practice, the work-up rate is extremely low even in the patients with refractory hypertension because of the time-consuming and labor-intensive nature of the procedures. Therefore, a novel tool to simplify the diagnostic flow has been recently in enormous demand. In this review, we focus on recent progress in the following clinically important topics of PA: prevalence of PA and its subtypes, newly revealed histopathological classification of aldosterone-producing lesions, novel diagnostic biomarkers and prediction scores. More effective strategy to diagnose PA based on better understanding of its epidemiology and pathology should lead to early detection of PA and could decrease the cardiovascular and renal complications of the patients.
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Affiliation(s)
- Yuta Tezuka
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan; (Y.Y.); (H.S.)
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai 981-8558, Japan;
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan; (Y.Y.); (H.S.)
| | - Fumitoshi Satoh
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan
- Correspondence:
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Abstract
Despite ongoing concerns regarding its clinical application, mass spectrometry (MS)-based steroid assay represents a promising tool in endocrine research. Recent studies indicate that monitoring the blood levels of individual sterols provides improved diagnostic insight into hyperlipidemia compared with immunoassays routinely used in clinical practice. Hypercortisolism and hyperaldosteronism can also be easily evaluated along with successful subtyping of adrenal diseases using MS-based methods, while metabolic signatures of sex steroids provide experimental evidence of abnormal puberty and male infertility. Many MS-based biological and clinical studies are based on liquid chromatography-mass spectrometry (LC-MS) coupled to electrospray ionization and tandem MS scan modes. However, gas chromatography-mass spectrometry (GC-MS) provides better chromatographic separation. Improved chromatographic resolution enables large-scale steroid profiling to allow a bird-eye view and increase the chances of identifying potent biomarkers in endocrine research. In addition to the technical advantages of MS-based assays over immunoassays, minimizing the sample amounts with acceptable analytical sensitivity and standardization of surrogate materials provides cutting-edge tools for precision and personalized medicine.
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Affiliation(s)
- Man Ho Choi
- Molecular Recognition Research Center, Korea Institute of Science and Technology
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35
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Zhou Y, Wang D, Jiang L, Ran F, Chen S, Zhou P, Wang P. Diagnostic accuracy of adrenal imaging for subtype diagnosis in primary aldosteronism: systematic review and meta-analysis. BMJ Open 2020; 10:e038489. [PMID: 33384386 PMCID: PMC7780716 DOI: 10.1136/bmjopen-2020-038489] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES Accurate subtype classification in primary aldosteronism (PA) is critical in assessing the optimal treatment options. This study aimed to evaluate the diagnostic accuracy of adrenal imaging for unilateral PA classification. METHODS Systematic searches of PubMed, EMBASE and the Cochrane databases were performed from 1 January 2000 to 1 February 2020, for all studies that used CT or MRI in determining unilateral PA and validated the results against invasive adrenal vein sampling (AVS). Summary diagnostic accuracies were assessed using a bivariate random-effects model. Subgroup analyses, meta-regression and sensitivity analysis were performed to explore the possible sources of heterogeneity. RESULT A total of 25 studies, involving a total of 4669 subjects, were identified. The overall analysis revealed a pooled sensitivity of 68% (95% CI: 61% to 74%) and specificity of 57% (95% CI 50% to 65%) for CT/MRI in identifying unilateral PA. Sensitivity was higher in the contrast-enhanced (CT) group versus the traditional CT group (77% (95% CI 66% to 85%) vs 58% (95% CI 50% to 66%). Subgroup analysis stratified by screening test for PA showed that the sensitivity of the aldosterone-to-renin ratio (ARR) group was higher than that of the non-ARR group (78% (95% CI 69% to 84%) vs 66% (95% CI 58% to 72%)). The diagnostic accuracy of PA patients aged ≤40 years was reported in four studies, and the overall sensitivity was 71%, with 79% specificity. Meta-regression revealed a significant impact of sample size on sensitivity and of age and study quality on specificity. CONCLUSION CT/MRI is not a reliable alternative to invasive AVS without excellent sensitivity or specificity for correctly identifying unilateral PA. Even in young patients (≤40 years), 21% of patients would have undergone unnecessary adrenalectomy based on imaging results alone.
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Affiliation(s)
- Yaqiong Zhou
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Dan Wang
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Licheng Jiang
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Fei Ran
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Sichao Chen
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Peng Zhou
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Peijian Wang
- Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
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Nanba K, Yamazaki Y, Bick N, Onodera K, Tezuka Y, Omata K, Ono Y, Blinder AR, Tomlins SA, Rainey WE, Satoh F, Sasano H. Prevalence of Somatic Mutations in Aldosterone-Producing Adenomas in Japanese Patients. J Clin Endocrinol Metab 2020; 105:5897223. [PMID: 32844168 PMCID: PMC7947976 DOI: 10.1210/clinem/dgaa595] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/24/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Results of previous studies demonstrated clear racial differences in the prevalence of somatic mutations among patients with aldosterone-producing adenoma (APA). For instance, those in East Asian countries have a high prevalence of somatic mutations in KCNJ5, whereas somatic mutations in other aldosterone-driving genes are rare. OBJECTIVES To determine somatic mutation prevalence in Japanese APA patients using an aldosterone synthase (CYP11B2) immunohistochemistry (IHC)-guided sequencing approach. METHOD Patients with a unilateral form of primary aldosteronism who underwent adrenalectomy at the Tohoku University Hospital were studied. Based on CYP11B2 immunolocalization of resected adrenals, genomic DNA was isolated from the relevant positive area of 10% formalin-fixed, paraffin-embedded tissue of the APAs. Somatic mutations in aldosterone-driving genes were studied in APAs by direct Sanger sequencing and targeted next-generation sequencing. RESULTS CYP11B2 IHC-guided sequencing determined APA-related somatic mutations in 102 out of 106 APAs (96%). Somatic KCNJ5 mutation was the most frequent genetic alteration (73%) in this cohort of Japanese patients. Somatic mutations in other aldosterone-driving genes were also identified: CACNA1D (14%), ATP1A1 (5%), ATP2B3 (4%), and CACNA1H (1%), including 2 previously unreported mutations. KCNJ5 mutations were more often detected in APAs from female patients compared with those from male patients [95% (36/38) vs 60% (41/68); P < 0.0001]. CONCLUSION IHC-guided sequencing defined somatic mutations in over 95% of Japanese APAs. While the dominance of KCNJ5 mutations in this particular cohort was confirmed, a significantly higher KCNJ5 prevalence was detected in female patients. This study provides a better understanding of genetic spectrum of Japanese APA patients.
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Affiliation(s)
- Kazutaka Nanba
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Nolan Bick
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Kei Onodera
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuta Tezuka
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Omata
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshikiyo Ono
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Amy R Blinder
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan
| | - Scott A Tomlins
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, Michigan
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - William E Rainey
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Fumitoshi Satoh
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Correspondence and Reprint Requests: Hironobu Sasano, MD, PhD, Department of Pathology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan. E-mail:
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Eisenhofer G, Durán C, Cannistraci CV, Peitzsch M, Williams TA, Riester A, Burrello J, Buffolo F, Prejbisz A, Beuschlein F, Januszewicz A, Mulatero P, Lenders JWM, Reincke M. Use of Steroid Profiling Combined With Machine Learning for Identification and Subtype Classification in Primary Aldosteronism. JAMA Netw Open 2020; 3:e2016209. [PMID: 32990741 PMCID: PMC7525346 DOI: 10.1001/jamanetworkopen.2020.16209] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Most patients with primary aldosteronism, a major cause of secondary hypertension, are not identified or appropriately treated because of difficulties in diagnosis and subtype classification. Applications of artificial intelligence combined with mass spectrometry-based steroid profiling could address this problem. OBJECTIVE To assess whether plasma steroid profiling combined with machine learning might facilitate diagnosis and treatment stratification of primary aldosteronism, particularly for patients with unilateral adenomas due to pathogenic KCNJ5 sequence variants. DESIGN, SETTING, AND PARTICIPANTS This diagnostic study was conducted at multiple tertiary care referral centers. Steroid profiles were measured from June 2013 to March 2017 in 462 patients tested for primary aldosteronism and 201 patients with hypertension. Data analyses were performed from September 2018 to August 2019. MAIN OUTCOMES AND MEASURES The aldosterone to renin ratio and saline infusion tests were used to diagnose primary aldosteronism. Subtyping was done by adrenal venous sampling and follow-up of patients who underwent adrenalectomy. Statistical tests and machine-learning algorithms were applied to plasma steroid profiles. Areas under receiver operating characteristic curves, sensitivity, specificity, and other diagnostic performance measures were calculated. RESULTS Primary aldosteronism was confirmed in 273 patients (165 men [60%]; mean [SD] age, 51 [10] years), including 134 with bilateral disease and 139 with unilateral adenomas (58 with and 81 without somatic KCNJ5 sequence variants). Plasma steroid profiles varied according to disease subtype and were particularly distinctive in patients with adenomas due to KCNJ5 variants, who showed better rates of biochemical cure after adrenalectomy than other patients. Among patients tested for primary aldosteronism, a selection of 8 steroids in combination with the aldosterone to renin ratio showed improved effectiveness for diagnosis over either strategy alone. In contrast, the steroid profile alone showed superior performance over the aldosterone to renin ratio for identifying unilateral disease, particularly adenomas due to KCNJ5 variants. Among 632 patients included in the analysis, machine learning-designed combinatorial marker profiles of 7 steroids alone both predicted primary aldosteronism in 1 step and subtyped patients with unilateral adenomas due to KCNJ5 variants at diagnostic sensitivities of 69% (95% CI, 68%-71%) and 85% (95% CI, 81%-88%), respectively, and at specificities of 94% (95% CI, 93%-94%) and 97% (95% CI, 97%-98%), respectively. The validation series yielded comparable diagnostic performance. CONCLUSIONS AND RELEVANCE Machine learning-designed combinatorial plasma steroid profiles may facilitate both screening for primary aldosteronism and identification of patients with unilateral adenomas due to pathogenic KCNJ5 variants, who are most likely to show benefit from surgical intervention.
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Affiliation(s)
- Graeme Eisenhofer
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Claudio Durán
- Biomedical Cybernetics Group, Biotechnology Center, Center for Molecular and Cellular Bioengineering, Center for Systems Biology Dresden, Department of Physics, Technische Universität Dresden, Dresden, Germany
| | - Carlo Vittorio Cannistraci
- Biomedical Cybernetics Group, Biotechnology Center, Center for Molecular and Cellular Bioengineering, Center for Systems Biology Dresden, Department of Physics, Technische Universität Dresden, Dresden, Germany
- Center for Complex Network Intelligence Laboratory at the Tsinghua Laboratory of Brain and Intelligence, Department of Bioengineering, Tsinghua University, Beijing, China
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Tracy Ann Williams
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jacopo Burrello
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Fabrizio Buffolo
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
- Department of Endocrinology, Diabetology, and Clinical Nutrition, UniversitätsSpital Zürich, Zürich, Switzerland
| | | | - Paolo Mulatero
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Jacques W. M. Lenders
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
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Impact of adrenocorticotropic hormone stimulation during adrenal venous sampling on outcomes of primary aldosteronism. J Hypertens 2020; 37:1077-1082. [PMID: 30601318 DOI: 10.1097/hjh.0000000000001964] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adrenal venous sampling (AVS) is essential for identifying a surgically curable form of primary aldosteronism. Adrenocorticotropic hormone (ACTH) infusion or bolus has been reported to improve the success rate of AVS, although the effects on lateralization and its outcomes in unilateral primary aldosteronism are unclear. METHODS The success rate and lateralization indices were examined in a cohort of 2197 Japanese patients with primary aldosteronism from 28 centres who underwent AVS. Outcomes were analysed in 267 patients with aldosterone-producing adenomas (APAs). RESULTS ACTH loading during AVS improved the success rate from 67 to 89%, while lateralization indices decreased from 62 to 28%. Bolus, bolus along with continuous infusion or continuous infusion of ACTH did not affect both indices. The absence of clinical success (i.e. unchanged or increased blood pressure) was 33% and absence of biochemical success (persistent hypokalaemia or persistently raised aldosterone-to-renin ratio, or both) was 15%. The clinical and biochemical success rates did not differ between the three groups [lateralization index >2 in basal condition (LIb) and lateralization index >4 after ACTH loading (lateralization indices), and LIb >2 + lateralization indices<4, LIb<2+lateralization indices>4]. The three groups (LIb>4+lateralization indices>4, LIb>4+lateralization indices<4 and LIb<4+lateralization indices>4) did not show any significant differences of clinical and biochemical outcome. CONCLUSION ACTH loading during AVS improved the success rate but decreased laterality. ACTH did not affect the clinical and biochemical outcomes in APA patients. These data showed that the use of ACTH during AVS was helpful for improving the success rate, but did not contribute to better outcomes.
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Abstract
Adrenal venous sampling is the standard of care for identifying patients with unilateral primary aldosteronism, which is often caused by an aldosterone producing adenoma and can be cured with surgery. The numerous limitations of adrenal venous sampling, including its high cost, scarce availability, technical challenges, and lack of standardized protocols, have driven efforts to develop alternative, non-invasive tools for the diagnosis of aldosterone producing adenomas. Seminal discoveries regarding the pathogenesis of aldosterone producing adenomas made over the past decade have leveraged hypotheses-driven research of steroid phenotypes characteristic of various aldosterone producing adenomas. In parallel, the expanding availability of mass spectrometry has enabled the simultaneous quantitation of many steroids in single assays from small volume biosamples. Steroid profiling has contributed to our evolving understanding about the pathophysiology of primary aldosteronism and its subtypes. Herein, we review the current state of knowledge regarding the application of multi-steroid panels in assisting with primary aldosteronism subtyping.
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Affiliation(s)
- Taweesak Wannachalee
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA
- Division of Endocrinology and Metabolism, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA
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40
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Abstract
The past nine years have seen major advances in establishing the etiology of unilateral primary aldosteronism, and very possibly that of bilateral hyperaldosteronism, in response to somatic mutations in aldosterone synthase expressing cells. Though there have been important advances in the management of primary aldosteronism, in small but convincing studies, they represent minor changes to current guidelines. What has been totally absent is consideration of the public health issue that primary aldosterone represents, and the public policy issues that would be involved in addressing the disorder. In his introduction to PiPA 6, Martin Reincke calculated that only one in a thousand patients in Germany with primary aldosteronism were treated appropriately, an astounding figure for any disease in the 21st century. Towards remedying this totally unacceptable public health issue, the author proposes a radical simplification and streamlining of screening for primary aldosteronism, and the management of most patients by general practitioners. The second bottle-neck in current management is that of mandatory adrenal venous sampling for all but 1-2% of patients, a costly procedure requiring rare expertise. Ideally, it should be reserved - on the basis of likelihood, enhanced imaging, or peripheral steroid profiles - for a small minority of patients with clear evidence for unilateral disease. Only when costs are minimized and roadblocks removed will primary aldosteronism be properly treated as the public health issue that it is.
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Affiliation(s)
- John Watson Funder
- Hudson Institute of Medical Research and Monash University, Clayton, Victoria, Australia
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41
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Primary aldosteronism is a public health issue: challenges and opportunities. J Hum Hypertens 2020; 34:478-486. [PMID: 32341439 DOI: 10.1038/s41371-020-0336-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/23/2020] [Accepted: 03/27/2020] [Indexed: 12/26/2022]
Abstract
A significant proportion of hypertension (potentially more than 5% in the general population) is due to primary aldosteronism (PA) which carries a worse prognosis when compared with blood pressure-matched essential hypertension. Effective targeted treatments are available which mitigate many of the cardiovascular complications of untreated PA. Despite this, the detection rate of PA in primary care is sub-optimal. In this review, we explore the challenges contributing to the under-diagnosis of PA in the community, including uncertainties regarding its actual prevalence. In order to detect PA early and offer targeted treatment before adverse cardiovascular consequences develop, routine screening for PA at the time of a diagnosis of hypertension would seem desirable. However, this is limited by a lack of studies to establish whether routine screening in primary care is cost-effective. Newer techniques are also being developed which could lessen the complexity of diagnosing PA. Most importantly, a dramatic increase in awareness of PA, as a treatable cause of hypertension, is needed amongst clinicians who manage hypertension.
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Rege J, Turcu AF, Rainey WE. Primary aldosteronism diagnostics: KCNJ5 mutations and hybrid steroid synthesis in aldosterone-producing adenomas. Gland Surg 2020; 9:3-13. [PMID: 32206594 DOI: 10.21037/gs.2019.10.22] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Primary aldosteronism (PA) is characterized by autonomous aldosterone production by renin-independent mechanisms and is most commonly sporadic. While 60-70% of sporadic PA can be attributed to bilateral hyperaldosteronism, the remaining 30-40% is caused by a unilateral aldosterone-producing adenoma (APA). Somatic mutations in or near the selectivity filter the KCNJ5 gene (encoding the potassium channel GIRK4) have been implicated in the pathogenesis of both sporadic and familial PA. Several studies using tumor tissue, peripheral and adrenal vein samples from PA patients have demonstrated that along with aldosterone, the hybrid steroids 18-hydroxycortisol (18OHF) and 18-oxocortisol (18oxoF) are a hallmark of APA harboring KCNJ5 mutations. Herein, we review the recent advances with respect to the molecular mechanisms underlying the pathogenesis of PA and the steroidogenic fingerprints of KCNJ5 mutations. In addition, we present an outlook toward the future of PA subtyping and diagnostic work-up utilizing steroid profiling.
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Affiliation(s)
- Juilee Rege
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - William E Rainey
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, USA.,Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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43
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Abstract
Primary aldosteronism is currently considered to represent 5-13% of hypertension, yet fewer than 1% of patients with the disorder are ever diagnosed and treated. Current management of patients screened and confirmed positive for primary aldosteronism involves imaging, and with very few exceptions adrenal venous sampling to lateralize (or not) hyperaldosteronism. Unilateral disease is treated by adrenalectomy: bilateral disease by mineralocorticoid receptor antagonists and conventional antihypertensives as/if required. New therapeutic approaches include (i) routine screening on first presentation for hypertension; (ii) harmonisation of cut-offs for renin and aldosterone, plus use of 24-h urinary rather than spot plasma values for the latter; (iii) adoption of a dexamethasone enhanced seated saline suppression test for confirmation exclusion; (iv) enhanced imaging and steroid profiles as partial replacement for adrenal venous sampling; and finally (v), inclusion of low dose spironolactone in first-line therapy for hypertension.
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Affiliation(s)
- John Funder
- Hudson Institute of Medical Research and Monash University, Clayton, Victoria, Australia.
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44
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Yang Y, Reincke M, Williams TA. Prevalence, diagnosis and outcomes of treatment for primary aldosteronism. Best Pract Res Clin Endocrinol Metab 2020; 34:101365. [PMID: 31837980 DOI: 10.1016/j.beem.2019.101365] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Primary aldosteronism (PA) is the most common potentially curable form of hypertension. The overproduction of aldosterone leads to an increased risk of cardiovascular and cerebrovascular events as well as adverse effects to the heart and kidney and psychological disorders. PA is mainly caused by unilateral aldosterone excess due to an aldosterone-producing adenoma or bilateral excess due to bilateral adrenocortical hyperplasia. The diagnostic work-up of PA comprises three steps: screening, confirmatory testing and differentiation of unilateral surgically-correctable forms from medically treated bilateral PA. These specific treatments can mitigate or reverse the increased risks associated with PA. Herein we summarise the prevalence, outcomes and current and future clinical approaches for the diagnosis of primary aldosteronism.
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Affiliation(s)
- Yuhong Yang
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany
| | - Tracy Ann Williams
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy.
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45
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Turcu AF, Wannachalee T, Tsodikov A, Nanba AT, Ren J, Shields JJ, O'Day PJ, Giacherio D, Rainey WE, Auchus RJ. Comprehensive Analysis of Steroid Biomarkers for Guiding Primary Aldosteronism Subtyping. Hypertension 2019; 75:183-192. [PMID: 31786984 DOI: 10.1161/hypertensionaha.119.13866] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Adrenal vein sampling (AVS) is required to distinguish unilateral from bilateral aldosterone sources in primary aldosteronism (PA), and cortisol is used for AVS data interpretation, but cortisol has several pitfalls. In this study, we present the utility of several other steroids in PA subtyping, both during AVS, as well as in peripheral serum. We included patients with PA who underwent AVS at University of Michigan between 2012 and 2018. We used mass spectrometry to simultaneously quantify 17 steroids in adrenal veins (AV) and periphery, both at baseline and after cosyntropin administration. PA was classified as unilateral or bilateral based on a lateralization index ≥ or <4, respectively, separately for baseline and post-cosyntropin administration. Of 131 participants, AV catheterizations was deemed failed in 28 (21 %) patients (36 AVs) at baseline. Eight steroids demonstrated higher AV/periphery ratios than cortisol (P<0.01 for all); 11β-hydroxyandrostenedione, 11-deoxycortisol, and corticosterone rescued most failed baseline catheterizations. Lateralization was generally consistent when using these alternative steroids. Based on pre- and post-cosyntropin data, the remaining 103 patients were classified as: U/U, 37; B/B, 32; U/B, 20; B/U, 14. Discriminant analysis of multi-steroid panels from peripheral serum showed distinct profiles across the 4 groups, with highest aldosterone, 18-oxocortisol and 11-deoxycorticosterone in U/U patients. In conclusion, 11β-hydroxyandrostenedione and 11-deoxycortisol are superior to cortisol for AVS data interpretation. Single assay multi-steroid panels measured in peripheral serum are helpful in stratified PA subtyping and have the potential to circumvent AVS in a subset of patients with PA.
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Affiliation(s)
- Adina F Turcu
- From the Division of Metabolism, Endocrinology, and Diabetes (A.F.T., T.W., A.T.N., J.R., P.J.O., W.E.R., R.J.A.), University of Michigan, Ann Arbor
| | - Taweesak Wannachalee
- From the Division of Metabolism, Endocrinology, and Diabetes (A.F.T., T.W., A.T.N., J.R., P.J.O., W.E.R., R.J.A.), University of Michigan, Ann Arbor.,Division of Endocrinology and Metabolism, Siriraj Hospital, Mahidol University, Thailand (T.W.)
| | | | - Aya T Nanba
- From the Division of Metabolism, Endocrinology, and Diabetes (A.F.T., T.W., A.T.N., J.R., P.J.O., W.E.R., R.J.A.), University of Michigan, Ann Arbor
| | - Jianwei Ren
- From the Division of Metabolism, Endocrinology, and Diabetes (A.F.T., T.W., A.T.N., J.R., P.J.O., W.E.R., R.J.A.), University of Michigan, Ann Arbor
| | - James J Shields
- Department of Radiology (J.J.S.), University of Michigan, Ann Arbor
| | - Patrick J O'Day
- From the Division of Metabolism, Endocrinology, and Diabetes (A.F.T., T.W., A.T.N., J.R., P.J.O., W.E.R., R.J.A.), University of Michigan, Ann Arbor
| | - Donald Giacherio
- Department of Pathology (D.G.), University of Michigan, Ann Arbor
| | - William E Rainey
- From the Division of Metabolism, Endocrinology, and Diabetes (A.F.T., T.W., A.T.N., J.R., P.J.O., W.E.R., R.J.A.), University of Michigan, Ann Arbor.,Department of Molecular and Integrative Physiology (W.E.R.), University of Michigan, Ann Arbor
| | - Richard J Auchus
- From the Division of Metabolism, Endocrinology, and Diabetes (A.F.T., T.W., A.T.N., J.R., P.J.O., W.E.R., R.J.A.), University of Michigan, Ann Arbor.,Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor
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46
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Wannachalee T, Zhao L, Nanba K, Nanba AT, Shields JJ, Rainey WE, Auchus RJ, Turcu AF. Three Discrete Patterns of Primary Aldosteronism Lateralization in Response to Cosyntropin During Adrenal Vein Sampling. J Clin Endocrinol Metab 2019; 104:5867-5876. [PMID: 31408156 PMCID: PMC6800532 DOI: 10.1210/jc.2019-01182] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/07/2019] [Indexed: 01/12/2023]
Abstract
CONTEXT Cosyntropin [ACTH (1-24)] stimulation during adrenal vein (AV) sampling (AVS) enhances the confidence in the success of AV cannulation and circumvents intraprocedure hormonal fluctuations. Cosyntropin's effect on primary aldosteronism (PA) lateralization, however, is controversial. OBJECTIVES To define the major patterns of time-dependent lateralization, and their determinants, after cosyntropin stimulation during AVS. METHODS We retrospectively studied patients with PA who underwent AVS before, 10, and 20 minutes after cosyntropin stimulation between 2009 and 2018. Unilateral (U) or bilateral (B) PA was determined on the basis of a lateralization index (LI) value ≥4 or <4, respectively. Available adrenal tissue underwent aldosterone synthase-guided next-generation sequencing. RESULTS PA lateralization was concordant between basal and cosyntropin-stimulated AVS in 169 of 222 patients (76%; U/U, n = 110; B/B, n = 59) and discordant in 53 patients (24%; U/B, n = 32; B/U, n = 21). Peripheral and dominant AV aldosterone concentrations and LI were highest in U/U patients and progressively lower across intermediate and B/B groups. LI response to cosyntropin increased in 27% of patients, decreased in 33%, and remained stable in 40%. Baseline aldosterone concentrations predicted the LI pattern across time (P < 0.001). Mutation status was defined in 61 patients. Most patients with KCNJ5 mutations had descending LI, whereas those with ATP1A1 and ATP2B3 mutations had ascending LI after cosyntropin stimulation. CONCLUSION Patients with severe PA lateralized robustly regardless of cosyntropin use. Cosyntropin stimulation reveals intermediate PA subtypes; its impact on LI varies with baseline aldosterone concentrations and aldosterone-driver mutations.
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Affiliation(s)
- Taweesak Wannachalee
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
- Division of Endocrinology and Metabolism, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Lili Zhao
- School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Kazutaka Nanba
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan
| | - Aya T Nanba
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
| | - James J Shields
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - William E Rainey
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
- Correspondence and Reprint Requests: Adina F. Turcu, MD, MS, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, 1150 West Medical Center Drive, MSRB II, 5570B, Ann Arbor, Michigan 48109. E-mail:
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47
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Tezuka Y, Yamazaki Y, Kitada M, Morimoto R, Kudo M, Seiji K, Takase K, Kawasaki Y, Mitsuzuka K, Ito A, Nishikawa J, Asai N, Nakamura Y, Gomez-Sanchez CE, Ito S, Dezawa M, Sasano H, Satoh F. 18-Oxocortisol Synthesis in Aldosterone-Producing Adrenocortical Adenoma and Significance of KCNJ5 Mutation Status. Hypertension 2019; 73:1283-1290. [PMID: 31006333 DOI: 10.1161/hypertensionaha.118.12064] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Peripheral 18-oxocortisol (18oxoF) level could contribute to the detection of aldosterone-producing adenoma (APA) in patients with primary aldosteronism. However, peripheral 18oxoF varies among such patients, which is a big drawback concerning its clinical application. We studied 48 cases of APA, 35 harboring KCNJ5 mutation, to clarify the significance of clinical and pathological parameters about peripheral 18oxoF. Peripheral 18oxoF concentration ranged widely from 0.50 to 183.13 ng/dL and correlated positively with intratumoral areas stained positively for steroidogenic enzymes ( P<0.0001). The peripheral 18oxoF level also correlated significantly with that of circulating aldosterone ( P<0.0001) but not with that of cortisol, a precursor of 18oxoF. However, a significant correlation was detected between peripheral 18oxoF and intratumoral glucocorticoids ( P<0.05). In addition, peripheral 18oxoF correlated positively with the number of hybrid cells double positive for 11β-hydroxylase and aldosterone synthase ( P<0.0001). Comparing between the cases with and those without KCNJ5 mutation, the KCNJ5-mutated group demonstrated a significantly higher concentration of peripheral 18oxoF (28.4±5.6 versus 3.0±0.9 ng/dL, P<0.0001) and a larger intratumoral environment including the hybrid cells ( P<0.001), possibly representing a deviation from normal aldosterone biosynthesis. After multivariate analysis, KCNJ5 mutation status turned out to be the most associated factor involved in 18oxoF synthesis in APA ( P<0.0001). Results of our present study first revealed that enhanced 18oxoF synthesis in APA could come from a functional deviation of aldosterone biosynthesis from the normal zona glomerulosa and the utility of peripheral 18oxoF measurement could be influenced by the prevalence of KCNJ5 mutation in an APA.
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Affiliation(s)
- Yuta Tezuka
- From the Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine (Y.T., R.M., M.K., S.I., F.S.).,Division of Clinical Hypertension, Endocrinology and Metabolism (Y.T., F.S.), Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yuto Yamazaki
- Department of Pathology (Y.Y., H.S.), Tohoku University Hospital, Sendai, Miyagi, Japan
| | | | - Ryo Morimoto
- From the Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine (Y.T., R.M., M.K., S.I., F.S.)
| | - Masataka Kudo
- From the Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine (Y.T., R.M., M.K., S.I., F.S.).,Department of Stem Cell Biology and Histology (M.K., M.D.), Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Kazumasa Seiji
- Department of Diagnostic Radiology (K.S., K.T.), Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Kei Takase
- Department of Diagnostic Radiology (K.S., K.T.), Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yoshihide Kawasaki
- Department of Urology (Y.K., K.M., A.I.), Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Koji Mitsuzuka
- Department of Urology (Y.K., K.M., A.I.), Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Akihiro Ito
- Department of Urology (Y.K., K.M., A.I.), Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Jun Nishikawa
- Aska Pharma Medical Co Ltd, Kawasaki, Japan (J. Nishikawa, N.A.)
| | - Noriko Asai
- Aska Pharma Medical Co Ltd, Kawasaki, Japan (J. Nishikawa, N.A.)
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan (Y. Nakamura)
| | - Celso E Gomez-Sanchez
- Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center and University of Mississippi Medical Center, Jackson (C.E.G.-S.)
| | - Sadayoshi Ito
- From the Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine (Y.T., R.M., M.K., S.I., F.S.)
| | - Mari Dezawa
- Department of Stem Cell Biology and Histology (M.K., M.D.), Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hironobu Sasano
- Department of Pathology (Y.Y., H.S.), Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Fumitoshi Satoh
- From the Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine (Y.T., R.M., M.K., S.I., F.S.).,Division of Clinical Hypertension, Endocrinology and Metabolism (Y.T., F.S.), Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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48
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Abstract
Primary aldosteronism (PA) is the most common form of secondary hypertension. In many cases, somatic mutations in ion channels and pumps within adrenal cells initiate the pathogenesis of PA, and this mechanism might explain why PA is so common and suggests that milder and evolving forms of PA must exist. Compared with primary hypertension, PA causes more end-organ damage and is associated with excess cardiovascular morbidity, including heart failure, stroke, nonfatal myocardial infarction, and atrial fibrillation. Screening is simple and readily available, and targeted therapy improves blood pressure control and mitigates cardiovascular morbidity. Despite these imperatives, screening rates for PA are low, and mineralocorticoid-receptor antagonists are underused for hypertension treatment. After the evidence for the prevalence of PA and its associated cardiovascular morbidity is summarized, a practical approach to PA screening, referral, and management is described. All physicians who treat hypertension should routinely screen appropriate patients for PA.
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Affiliation(s)
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., R.J.A.)
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., R.J.A.).,Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor
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49
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Steroid Profiling and Immunohistochemistry for Subtyping and Outcome Prediction in Primary Aldosteronism-a Review. Curr Hypertens Rep 2019; 21:77. [PMID: 31482378 DOI: 10.1007/s11906-019-0985-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Steroid profiling and immunohistochemistry are both promising new tools used to improve diagnostic accuracy in the work-up of primary aldosteronism (PA) and to predict treatment outcomes. Herein, we review the recent literature and present an outlook to the future of diagnostics and therapeutic decision-making in patients with PA. RECENT FINDING PA is the most common endocrine cause of arterial hypertension and unilateral forms of the disease are potentially curable by surgical resection of the overactive adrenal. Recent studies have shown that adrenal steroid profiling by liquid chromatography-tandem mass spectrometry (LC-MS/MS) can be helpful for subtyping unilateral and bilateral forms of PA, classifying patients with a unilateral aldosterone-producing adenoma (APA) according to the presence of driver mutations of aldosterone production in APAs, and potentially predicting the outcomes of surgical treatment for unilateral PA. Following adrenalectomy, immunohistochemistry of aldosterone synthase (CYP11B2) in resected adrenals is a new tool to analyze "functional" histopathology and may be an indicator of biochemical outcomes after surgery. Biochemical and clinical outcomes of therapy in PA vary widely among patients. Peripheral venous steroid profiling at baseline could improve diagnostic accuracy and help in surgical decision-making in cases of a suspected APA; results of "functional" histopathology could help determine which patients are likely to need close post-surgical follow-up for persistent aldosteronism.
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50
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Rege J, Turcu AF, Else T, Auchus RJ, Rainey WE. Steroid biomarkers in human adrenal disease. J Steroid Biochem Mol Biol 2019; 190:273-280. [PMID: 30707926 PMCID: PMC6707065 DOI: 10.1016/j.jsbmb.2019.01.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/24/2019] [Accepted: 01/27/2019] [Indexed: 01/24/2023]
Abstract
Adrenal steroidogenesis is a robust process, involving a series of enzymatic reactions that facilitate conversion of cholesterol into biologically active steroid hormones under the stimulation of angiotensin II, adrenocorticotropic hormone and other regulators. The biosynthesis of mineralocorticoids, glucocorticoids, and adrenal-derived androgens occur in separate adrenocortical zones as a result of the segregated expression of steroidogenic enzymes and cofactors. This mini review provides the principles of adrenal steroidogenesis, including the classic and under-appreciated 11-oxygenated androgen pathways. Several adrenal diseases result from dysregulated adrenal steroid synthesis. Herein, we review growing evidence that adrenal diseases exhibit characteristic modifications from normal adrenal steroid pathways that provide opportunities for the discovery of biomarker steroids that would improve diagnosis and monitoring of adrenal disorders.
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Affiliation(s)
- Juilee Rege
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48109, United States
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, United States
| | - Tobias Else
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, United States
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, United States; Department of Pharmacology, University of Michigan, Ann Arbor, MI 48109, United States
| | - William E Rainey
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48109, United States; Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, United States.
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