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Luo T, Wan J, Liu S, Wang X, Zhou P, Xue Q, Hou J, Wang P. Establishment of a scoring model for predicting clinical outcomes in patients with unilateral primary aldosteronism after superselective adrenal artery embolization. Ir J Med Sci 2024:10.1007/s11845-024-03730-5. [PMID: 38856963 DOI: 10.1007/s11845-024-03730-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/30/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVE Superselective adrenal arterial embolization (SAAE) is a potential alternative treatment for patients with unilateral primary aldosteronism (PA) who refuse unilateral adrenalectomy. Therefore, we aimed to establish a scoring model to differentiate between hypertensive remission after SAAE. METHODS This prospective cohort study involved 240 patients who underwent SAAE for unilateral PA. Patients were randomly divided into a model training set and a validation set at a ratio of 7:3. The clinical outcome was a response to hypertension remission, defined as complete, partial, or absent success at 6 months after SAAE. Multivariate logistic regression was performed to identify independent parameters and develop a nomogram to predict clinical outcomes after SAAE. The discrimination, calibration efficacy, and clinical utility of the predictive model were assessed. RESULTS Five independent predictors were identified: female sex, duration of hypertension, defined daily dose of antihypertensive medication, diabetes, and target organ damage. The above five independent predictors were put into a predictive model that was presented as a nomogram. Using bootstrapping for internal validation, the C-statistic for the predictive model was 0.866 (95% confidence interval [CI]: 0.834 to 0.898). In the validation cohort, the area under the curve (AUC) of the nomogram for predicting hypertension remission after SAAE was 0.809. CONCLUSION The present model is the first nomogram-based score that specifically predicts hypertension remission after SAAE in patients with unilateral PA using conventional parameters. This is an effective risk stratification tool that can be used by clinicians for timely and tailored preoperative risk discussions.
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Affiliation(s)
- Tao Luo
- Department of Cardiology, The First Affiliated Hospital, Chengdu Medical College, 278 Baoguang Avenue, Xindu District, Chengdu, Sichuan, 610500, PR China
- Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, PR China
- Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan, 610500, PR China
| | - Jindong Wan
- Department of Cardiology, The First Affiliated Hospital, Chengdu Medical College, 278 Baoguang Avenue, Xindu District, Chengdu, Sichuan, 610500, PR China
- Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, PR China
- Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan, 610500, PR China
| | - Sen Liu
- Department of Cardiology, The First Affiliated Hospital, Chengdu Medical College, 278 Baoguang Avenue, Xindu District, Chengdu, Sichuan, 610500, PR China
- Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, PR China
- Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan, 610500, PR China
| | - Xinquan Wang
- Department of Cardiology, The First Affiliated Hospital, Chengdu Medical College, 278 Baoguang Avenue, Xindu District, Chengdu, Sichuan, 610500, PR China
- Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, PR China
- Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan, 610500, PR China
| | - Peng Zhou
- Department of Cardiology, The First Affiliated Hospital, Chengdu Medical College, 278 Baoguang Avenue, Xindu District, Chengdu, Sichuan, 610500, PR China
- Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, PR China
- Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan, 610500, PR China
| | - Qiang Xue
- Department of Cardiology, Yan'an Affiliated Hospital of Kunming Medical University, Renmin East Road No. 245, Kunming, Yunnan, 650051, PR China.
| | - Jixin Hou
- Department of Cardiology, The First Affiliated Hospital, Chengdu Medical College, 278 Baoguang Avenue, Xindu District, Chengdu, Sichuan, 610500, PR China.
- Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, PR China.
- Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan, 610500, PR China.
| | - Peijian Wang
- Department of Cardiology, The First Affiliated Hospital, Chengdu Medical College, 278 Baoguang Avenue, Xindu District, Chengdu, Sichuan, 610500, PR China.
- Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, PR China.
- Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan, 610500, PR China.
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Sun K, Gong M, Yu Y, Yang M, Zhang Y, Jiang Y, Song W. Comparison of saline infusion test and captopril challenge test in the diagnosis of Chinese with primary aldosteronism in different age groups. Front Endocrinol (Lausanne) 2024; 15:1343704. [PMID: 38586461 PMCID: PMC10995348 DOI: 10.3389/fendo.2024.1343704] [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: 11/24/2023] [Accepted: 03/04/2024] [Indexed: 04/09/2024] Open
Abstract
Background To explore the diagnostic accuracy and the optimal cutoff value between the saline infusion test (SIT) and captopril challenge test (CCT) [including the value and suppression of plasma aldosterone concentration (PAC)] for primary aldosteronism (PA) diagnosing. Methods A total of 318 patients with hypertension were consecutively enrolled, including 126 patients with PA and 192 patients with essential hypertension (EH), in this observational study. The characteristics of patients and laboratory examinations were collected and compared. The comparison between SIT and CCT was carried by drawing the receiver operator characteristic curve (ROC) and calculating the area under the curve (AUC) to explore the diagnostic accuracy and the optimal cutoff value. Results The average age was 51.59 ± 10.43 in the PA group and 45.72 ± 12.44 in the EH group (p<0.05). The optimal cutoff value was 10.7 ng/dL for post-CCT PAC, 6.8 ng/dL for post-SIT PAC, and 26.9% for suppression of post-CCT PAC. The diagnostic value of post-CCT PAC was the highest with 0.831 for the AUC and 0.552 for the Youden index. The optimal cutoff value for patients who were <50 years old was 11.5 ng/dL for post-CCT PAC and 8.4 ng/dL for post-SIT PAC. The suppression of post-CCT PAC turned to 18.2% for those of age 50 or older. Conclusion Compared with SIT, CCT had a higher diagnostic value when post-CCT PAC was used as the diagnostic criterion in Chinese people, while the selection of diagnostic thresholds depended on patient age.
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Affiliation(s)
| | | | | | | | | | - Yinong Jiang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Wei Song
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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Chen ZW, Liao CW, Pan CT, Tsai CH, Chang YY, Chang CC, Lee BC, Chiu YW, Huang WC, Lai TS, Lu CC, Chueh JS, Wu VC, Hung CS, Lin YH. Reversal of arterial stiffness in medically and surgically treated unilateral primary aldosteronism. J Hypertens 2024; 42:538-545. [PMID: 38088428 DOI: 10.1097/hjh.0000000000003631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
OBJECTIVE Hyperaldosteronism has adverse effects on cardiovascular structure and function. Laparoscopic adrenalectomy is the gold standard for patients with unilateral primary aldosteronism. For unilateral primary aldosteronism patients unable or unwilling to undergo surgery, the effects of mineralocorticoid receptor antagonists (MRAs) on the reversibility of arterial stiffness and other clinical data remain unclear. We aimed to compare the reversibility of arterial stiffness using pulse wave velocity (PWV) and other clinical parameters between surgically and medically treated unilateral primary aldosteronism patients. METHODS We prospectively enrolled 306 unilateral primary aldosteronism patients, of whom 247 received adrenalectomy and 59 received medical treatment with MRAs. Detailed medical history, basic biochemistry and PWV data were collected in both groups before treatment and 1 year after treatment. After propensity score matching (PSM) for age, sex, SBP and DBPs, 149 patients receiving adrenalectomy and 54 patients receiving MRAs were included for further analysis. RESULTS After PSM, the patients receiving adrenalectomy had a greater reduction in blood pressure, increase in serum potassium, and change in PWV (ΔPWV, -53 ± 113 vs. -10 ± 140 cm/s, P = 0.028) than those receiving MRAs 1 year after treatment. Multivariable regression analysis further identified that surgery (compared with MRA treatment), baseline PWV, baseline DBP, the change in DBP and the use of diuretics were independently correlated with ΔPWV. CONCLUSION Adrenalectomy is superior to MRA treatment with regards to vascular remodeling when treating unilateral primary aldosteronism patients.
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Affiliation(s)
- Zheng-Wei Chen
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University
| | - Che-Wei Liao
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
- Department of Medicine, National Taiwan University Cancer Center, Taipei
| | - Chien-Ting Pan
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin
| | - Cheng-Hsuan Tsai
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University
| | - Yi-Yao Chang
- Department of Cardiovascular Medicine, Far Eastern Memorial Hospital, New Taipei City
- Graduate Institute of Medicine, Yuan Ze University, Taoyuan City
| | - Chin-Chen Chang
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Bo-Ching Lee
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Yu-Wei Chiu
- Department of Cardiovascular Medicine, Far Eastern Memorial Hospital, New Taipei City
- Department of Computer Science and Engineering, Yuan Ze University, Taoyuan City
| | - Wei-Chieh Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital
| | - Tai-Shuan Lai
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Ching-Chu Lu
- Department of Nuclear Medicine, National Taiwan University Hospital
| | - Jeff S Chueh
- Department of Urology, National Taiwan University Hospital and 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
| | - Chi-Sheng Hung
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
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Feldman JM, Frishman WH, Aronow WS. Emerging Therapies for Treatment-Resistant Hypertension: A Review of Lorundrostat and Related Selective Aldosterone Synthase Inhibitors. Cardiol Rev 2024:00045415-990000000-00213. [PMID: 38358268 DOI: 10.1097/crd.0000000000000665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
The target-hypertension (Target-HTN) trial investigated the efficacy and safety of lorundrostat, an aldosterone synthase inhibitor, as an antihypertensive. Cohort 1 of the trial includes patients with suppressed plasma renin activity and elevated aldosterone levels. Lorundrostat doses of 100 mg and 50 mg daily significantly decreased systolic blood pressure compared to the placebo group. Cohort 2 also demonstrated a reduction in systolic blood pressure with the 100 mg daily dose of lorundrostat. Lorundrostat is more selective for the inhibition of CYP11B2 versus CYP11B1, which makes it preferable to other aldosterone synthase inhibitors that inhibit cortisol synthesis, such as osilodrostat. Phase 3 trials are needed to validate the safety and efficacy of lorundrostat, and further research should be performed on other selective aldosterone synthase inhibitors such as baxdrostat, dexfadrostat, and BI 690517.
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Affiliation(s)
- Jared M Feldman
- From the Division of Hospital Medicine, Long Island Jewish Medical Center and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - William H Frishman
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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Ekman N, Grossman AB, Dworakowska D. What We Know about and What Is New in Primary Aldosteronism. Int J Mol Sci 2024; 25:900. [PMID: 38255973 PMCID: PMC10815558 DOI: 10.3390/ijms25020900] [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: 12/14/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Primary aldosteronism (PA), a significant and curable cause of secondary hypertension, is seen in 5-10% of hypertensive patients, with its prevalence contingent upon the severity of the hypertension. The principal aetiologies of PA include bilateral idiopathic hypertrophy (BIH) and aldosterone-producing adenomas (APAs), while the less frequent causes include unilateral hyperplasia, familial hyperaldosteronism (FH) types I-IV, aldosterone-producing carcinoma, and ectopic aldosterone synthesis. This condition, characterised by excessive aldosterone secretion, leads to augmented sodium and water reabsorption alongside potassium loss, culminating in distinct clinical hallmarks: elevated aldosterone levels, suppressed renin levels, and hypertension. Notably, hypokalaemia is present in only 28% of patients with PA and is not a primary indicator. The association of PA with an escalated cardiovascular risk profile, independent of blood pressure levels, is notable. Patients with PA exhibit a heightened incidence of cardiovascular events compared to counterparts with essential hypertension, matched for age, sex, and blood pressure levels. Despite its prevalence, PA remains frequently undiagnosed, underscoring the imperative for enhanced screening protocols. The diagnostic process for PA entails a tripartite assessment: the aldosterone/renin ratio (ARR) as the initial screening tool, followed by confirmatory and subtyping tests. A positive ARR necessitates confirmatory testing to rule out false positives. Subtyping, achieved through computed tomography and adrenal vein sampling, aims to distinguish between unilateral and bilateral PA forms, guiding targeted therapeutic strategies. New radionuclide imaging may facilitate and accelerate such subtyping and localisation. For unilateral adrenal adenoma or hyperplasia, surgical intervention is optimal, whereas bilateral idiopathic hyperplasia warrants treatment with mineralocorticoid antagonists (MRAs). This review amalgamates established and emerging insights into the management of primary aldosteronism.
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Affiliation(s)
- Natalia Ekman
- Department of Hypertension & Diabetology, Medical University of Gdańsk, 80-214 Gdańsk, Poland;
| | - Ashley B. Grossman
- Centre for Endocrinology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 4NS, UK;
| | - Dorota Dworakowska
- Department of Hypertension & Diabetology, Medical University of Gdańsk, 80-214 Gdańsk, Poland;
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Yang W, Hao Y, Mu K, Li J, Tao Z, Ma D, Xu A. Application of a Radiomics Machine Learning Model for Differentiating Aldosterone-Producing Adenoma from Non-Functioning Adrenal Adenoma. Bioengineering (Basel) 2023; 10:1423. [PMID: 38136014 PMCID: PMC10740639 DOI: 10.3390/bioengineering10121423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/23/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
To evaluate the secretory function of adrenal incidentaloma, this study explored the usefulness of a contrast-enhanced computed tomography (CECT)-based radiomics model for distinguishing aldosterone-producing adenoma (APA) from non-functioning adrenal adenoma (NAA). Overall, 68 APA and 60 NAA patients were randomly assigned (8:2 ratio) to either a training or a test cohort. In the training cohort, univariate and least absolute shrinkage and selection operator regression analyses were conducted to select the significant features. A logistic regression machine learning (ML) model was then constructed based on the radiomics score and clinical features. Model effectiveness was evaluated according to the receiver operating characteristic, accuracy, sensitivity, specificity, F1 score, calibration plots, and decision curve analysis. In the test cohort, the area under the curve (AUC) of the Radscore model was 0.869 [95% confidence interval (CI), 0.734-1.000], and the accuracy, sensitivity, specificity, and F1 score were 0.731, 1.000, 0.583, and 0.900, respectively. The Clinic-Radscore model had an AUC of 0.994 [95% CI, 0.978-1.000], and the accuracy, sensitivity, specificity, and F1 score values were 0.962, 0.929, 1.000, and 0.931, respectively. In conclusion, the CECT-based radiomics and clinical radiomics ML model exhibited good diagnostic efficacy in differentiating APAs from NAAs; this non-invasive, cost-effective, and efficient method is important for the management of adrenal incidentaloma.
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Affiliation(s)
- Wenhua Yang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (W.Y.); (Y.H.); (K.M.); (J.L.); (Z.T.)
| | - Yonghong Hao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (W.Y.); (Y.H.); (K.M.); (J.L.); (Z.T.)
| | - Ketao Mu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (W.Y.); (Y.H.); (K.M.); (J.L.); (Z.T.)
| | - Jianjun Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (W.Y.); (Y.H.); (K.M.); (J.L.); (Z.T.)
| | - Zihui Tao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (W.Y.); (Y.H.); (K.M.); (J.L.); (Z.T.)
| | - Delin Ma
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Anhui Xu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (W.Y.); (Y.H.); (K.M.); (J.L.); (Z.T.)
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Liu Z, Jin L, Zeng J, Zhang T, Zhang J, Zhou W, Zhang C. Poor comparability of plasma renin activity measurement in determining patient samples: the status quo and recommendations for harmonization. Clin Chem Lab Med 2023; 61:1770-1779. [PMID: 37053598 DOI: 10.1515/cclm-2023-0117] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/04/2023] [Indexed: 04/15/2023]
Abstract
OBJECTIVES This study aims to investigate and update the consistency and comparability of plasma renin activity (PRA) assays in measuring clinical samples. The contributions of recalibration, blank subtraction, and incubation strategies to interchangeability were also explored. METHODS Five different laboratories were evaluated using forty-six individual plasma samples, including four liquid chromatography-tandem mass spectrometry (LC‒MS/MS) assays and one chemiluminescence immunoassay (CLIA). Spearman correlation coefficient (R), Passing-Bablok regression, and Bland‒Altman plot analyses were used to evaluate the consistency among assays. Consistency before and after recalibration, blank subtraction, and incubation strategy unification was compared. RESULTS A good correlation was observed among all assays (R>0.93). None of the samples measured by all assays showed coefficient variation (CV) <10 %, and 37 % of samples showed overall CVs >20 %. The 95 % confidence intervals (CIs) for slopes did not contain 1 for most assay pairs. Large relative biases (-85.1-104.2 %) were found, and 76 % (52-93 %) of samples had unacceptable biases. Recalibration reduced the calibration bias. Ignoring blank subtraction improved the comparability across all assays while unifying incubation did not. CONCLUSIONS The interchangeability of PRA measurement was unsatisfying. Harmonization on calibrator and ignoring blank were recommended. Unifying incubation strategy was unnecessary.
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Affiliation(s)
- Zhenni Liu
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology, Beijing, P.R. China
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Lizi Jin
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology, Beijing, P.R. China
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Jie Zeng
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology, Beijing, P.R. China
| | - Tianjiao Zhang
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology, Beijing, P.R. China
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Jiangtao Zhang
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology, Beijing, P.R. China
| | - Weiyan Zhou
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology, Beijing, P.R. China
| | - Chuanbao Zhang
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology, Beijing, P.R. China
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
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Laffin LJ, Rodman D, Luther JM, Vaidya A, Weir MR, Rajicic N, Slingsby BT, Nissen SE. Aldosterone Synthase Inhibition With Lorundrostat for Uncontrolled Hypertension: The Target-HTN Randomized Clinical Trial. JAMA 2023; 330:1140-1150. [PMID: 37690061 PMCID: PMC10493865 DOI: 10.1001/jama.2023.16029] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023]
Abstract
Importance Excess aldosterone production contributes to hypertension in both classical hyperaldosteronism and obesity-associated hypertension. Therapies that reduce aldosterone synthesis may lower blood pressure. Objective To compare the safety and efficacy of lorundrostat, an aldosterone synthase inhibitor, with placebo, and characterize dose-dependent safety and efficacy to inform dose selection in future trials. Design, Setting, and Participants Randomized, placebo-controlled, dose-ranging trial among adults with uncontrolled hypertension taking 2 or more antihypertensive medications. An initial cohort of 163 participants with suppressed plasma renin (plasma renin activity [PRA] ≤1.0 ng/mL/h) and elevated plasma aldosterone (≥1.0 ng/dL) were enrolled, with subsequent enrollment of 37 participants with PRA greater than 1.0 ng/mL/h. Interventions Participants were randomized to placebo or 1 of 5 dosages of lorundrostat in the initial cohort (12.5 mg, 50 mg, or 100 mg once daily or 12.5 mg or 25 mg twice daily). In the second cohort, participants were randomized in a 1:6 ratio to placebo or lorundrostat, 100 mg once daily. Main Outcomes and Measures The primary end point was change in automated office systolic blood pressure from baseline to study week 8. Results Between July 2021 and June 2022, 200 participants were randomized, with final follow-up in September 2022. Following 8 weeks of treatment in participants with suppressed PRA, changes in office systolic blood pressure of -14.1, -13.2, -6.9, and -4.1 mm Hg were observed with 100 mg, 50 mg, and 12.5 mg once daily of lorundrostat and placebo, respectively. Observed reductions in systolic blood pressure in individuals receiving twice-daily doses of 25 mg and 12.5 mg of lorundrostat were -10.1 and -13.8 mm Hg, respectively. The least-squares mean difference between placebo and treatment in systolic blood pressure was -9.6 mm Hg (90% CI, -15.8 to -3.4 mm Hg; P = .01) for the 50-mg once-daily dose and -7.8 mm Hg (90% CI, -14.1 to -1.5 mm Hg; P = .04) for 100 mg daily. Among participants without suppressed PRA, 100 mg once daily of lorundrostat decreased systolic blood pressure by 11.4 mm Hg (SD, 2.5 mm Hg), which was similar to blood pressure reduction among participants with suppressed PRA receiving the same dose. Six participants had increases in serum potassium above 6.0 mmol/L that corrected with dose reduction or drug discontinuation. No instances of cortisol insufficiency occurred. Conclusions and Relevance Among individuals with uncontrolled hypertension, use of lorundrostat was effective at lowering blood pressure compared with placebo, which will require further confirmatory studies. Trial Registration ClinicalTrials.gov Identifier: NCT05001945.
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Affiliation(s)
- Luke J Laffin
- Cleveland Clinic Foundation, Cleveland, Ohio
- C5 Research, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - James M Luther
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anand Vaidya
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Steven E Nissen
- Cleveland Clinic Foundation, Cleveland, Ohio
- C5 Research, Cleveland Clinic Foundation, Cleveland, Ohio
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Ng E, Gwini SM, Stowasser M, Young MJ, Fuller PJ, Singh GR, Yang J. Aldosterone and renin concentrations and blood pressure in young Indigenous and non-Indigenous adults in the Northern Territory: a cross-sectional study. Med J Aust 2023; 219:263-269. [PMID: 37573148 DOI: 10.5694/mja2.52062] [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: 02/01/2023] [Revised: 06/20/2023] [Accepted: 06/20/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVES To evaluate aldosterone and renin levels and aldosterone-to-renin ratios (ARRs) in young Indigenous and non-Indigenous adults in the Northern Territory, and their association with blood pressure levels. DESIGN Cross-sectional study; single time point sub-study of two prospective birth cohort studies. SETTING, PARTICIPANTS Participants in the Aboriginal Birth Cohort (ABC) - born to Indigenous mothers at the Royal Darwin Hospital during 1987-1990 - and the Top End Cohort (TEC) - people born to non-Indigenous mothers in Darwin, recruited during 2007-2009 - aged 32-35 years at the time of this sub-study. MAIN OUTCOME MEASURES Plasma aldosterone and direct renin concentrations; ARRs (positive screening test result for primary aldosteronism defined as > 70 pmol/mU); systolic and diastolic blood pressure. RESULTS A total of 255 ABC (205 in remote, 50 in urban locations) and 76 TEC members participated. Median aldosterone concentration was similar for all three groups. The median renin concentration was 7.5 mU/L (interquartile range [IQR], 4.1-12.4 mU/L) in the TEC group, 12.4 mU/L (IQR, 5.1-19 mU/L) in the urban ABC group, and 29.3 mU/L (IQR, 15.0-52.9 mU/L) in the remote ABC group. The median ARR was 10 pmol/mU (IQR, 6-19 pmol/mU) in the remote ABC group, 28 pmol/mU (IQR, 16-70 pmol/mU) in the urban ABC group, and 43 pmol/mU (IQR, 26-74 pmol/mU) in the TEC group. Thirteen urban ABC participants (26%), 21 TEC participants (28%), and six people in the remote ABC group (3%) had ARR values above 70 pmol/mU. Adjusted for age and body mass index (BMI), mean systolic and diastolic blood pressure were lower for women than men in all participant groups; after adjusting for age, sex, and BMI, larger ARR was associated with higher systolic blood pressure in the TEC group but not the two ABC groups. CONCLUSION Screening test results for primary aldosteronism were positive for about one-quarter of urban Indigenous and non-Indigenous participants. A prospective study that includes confirmatory testing would more accurately assess the prevalence of primary aldosteronism among Indigenous Australians in the Northern Territory.
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Affiliation(s)
- Elisabeth Ng
- Monash Health, Melbourne, VIC
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, VIC
| | - Stella M Gwini
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, VIC
- Monash University, Melbourne, VIC
| | | | | | - Peter J Fuller
- Monash Health, Melbourne, VIC
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, VIC
| | | | - Jun Yang
- Monash Health, Melbourne, VIC
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, VIC
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10
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Funder JW. Recognising primary aldosteronism as a disorder in its own right. Med J Aust 2023; 219:259-260. [PMID: 37593913 DOI: 10.5694/mja2.52082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/21/2023] [Accepted: 07/31/2023] [Indexed: 08/19/2023]
Affiliation(s)
- John W Funder
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC
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11
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Dogra P, Bancos I, Young WF. Primary Aldosteronism: A Pragmatic Approach to Diagnosis and Management. Mayo Clin Proc 2023; 98:1207-1215. [PMID: 37536806 DOI: 10.1016/j.mayocp.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/17/2023] [Accepted: 04/20/2023] [Indexed: 08/05/2023]
Abstract
Primary aldosteronism is a prevalent but underdiagnosed cause of hypertension, contributing to increased cardiovascular and cerebrovascular events and end-organ damage independent of blood pressure. Prompt diagnosis and treatment with targeted surgical or medical therapy reduce the risk of complications and improve prognosis. This review outlines a practical approach to diagnosis and management of primary aldosteronism for global practitioners.
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Affiliation(s)
- Prerna Dogra
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN.
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12
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Libianto R, Stowasser M, Russell G, Fuller PJ, Yang J. Improving Detection Rates for Primary Aldosteronism. Exp Clin Endocrinol Diabetes 2023; 131:402-408. [PMID: 37160153 DOI: 10.1055/a-2048-6213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Primary aldosteronism (PA), once considered a rare disease, is being increasingly recognized as an important cause of hypertension. It is associated with higher rates of cardiovascular complications compared to blood pressure-matched essential hypertension. Targeted treatments are available which can mitigate the excess cardiovascular risks and, in some cases, cure hypertension. Making a timely diagnosis of PA is, therefore, highly beneficial for patients. Furthermore, numerous studies from different parts of the world have found PA to be a relatively common disease that can affect patients in any stage of hypertension, regardless of their age or potassium levels. Despite this well-established data, the current rate of PA detection is appallingly low, much below its actual prevalence. This review explores the challenges that clinicians often face in diagnosing PA and offers strategies that may improve the detection of this potentially curable form of hypertension.
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Affiliation(s)
- Renata Libianto
- Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Monash Health, Clayton, Victoria
- Monash University, Clayton, Victoria, Australia
| | | | | | - Peter J Fuller
- Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Monash Health, Clayton, Victoria
| | - Jun Yang
- Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Monash Health, Clayton, Victoria
- Monash University, Clayton, Victoria, Australia
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13
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Sugawara A, Shimada H, Otsubo Y, Kouketsu T, Yokoyama A. Primary aldosteronism and obstructive sleep apnea: the strong ties between them. Hypertens Res 2023; 46:1712-1713. [PMID: 37160968 DOI: 10.1038/s41440-023-01303-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 05/11/2023]
Affiliation(s)
- Akira Sugawara
- Department of Molecular Endocrinology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Hiroki Shimada
- Department of Molecular Endocrinology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yuri Otsubo
- Department of Molecular Endocrinology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takumi Kouketsu
- Department of Molecular Endocrinology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Atsushi Yokoyama
- Department of Molecular Endocrinology, Tohoku University Graduate School of Medicine, Sendai, Japan
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14
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Mitchell BD, Whitlatch HB. Decoding Hypertension Through Primary Aldosteronism. Circulation 2023; 147:1110-1111. [PMID: 37011072 DOI: 10.1161/circulationaha.123.064028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Affiliation(s)
- Braxton D Mitchell
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore (B.D.M., H.B.W.)
- Geriatrics Research and Education Clinical Center, Baltimore Veterans Administration Medical Center, MD (B.D.M.)
| | - Hilary B Whitlatch
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore (B.D.M., H.B.W.)
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15
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Takeda Y, Demura M, Kometani M, Karashima S, Yoneda T, Takeda Y. Molecular and Epigenetic Control of Aldosterone Synthase, CYP11B2 and 11-Hydroxylase, CYP11B1. Int J Mol Sci 2023; 24:ijms24065782. [PMID: 36982850 PMCID: PMC10054571 DOI: 10.3390/ijms24065782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Aldosterone and cortisol serve important roles in the pathogenesis of cardiovascular diseases and metabolic disorders. Epigenetics is a mechanism to control enzyme expression by genes without changing the gene sequence. Steroid hormone synthase gene expression is regulated by transcription factors specific to each gene, and methylation has been reported to be involved in steroid hormone production and disease. Angiotensin II or potassium regulates the aldosterone synthase gene, CYP11B2. The adrenocorticotropic hormone controls the 11b-hydroxylase, CYP11B1. DNA methylation negatively controls the CYP11B2 and CYP11B1 expression and dynamically changes the expression responsive to continuous stimulation of the promoter gene. Hypomethylation status of the CYP11B2 promoter region is seen in aldosterone-producing adenomas. Methylation of recognition sites of transcription factors, including cyclic AMP responsive element binding protein 1 or nerve growth factor-induced clone B, diminish their DNA-binding activity. A methyl-CpG-binding protein 2 cooperates directly with the methylated CpG dinucleotides of CYP11B2. A low-salt diet, treatment with angiotensin II, and potassium increase the CYP11B2 mRNA levels and induce DNA hypomethylation in the adrenal gland. A close association between a low DNA methylation ratio and an increased CYP11B1 expression is seen in Cushing's adenoma and aldosterone-producing adenoma with autonomous cortisol secretion. Epigenetic control of CYP11B2 or CYP11B1 plays an important role in autonomic aldosterone or cortisol synthesis.
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Affiliation(s)
- Yoshimichi Takeda
- Endocrinology and Metabolism, Kanazawa University Hospital, Kanazawa 920-8641, Japan
- Department of Hygiene, Graduate School of Medical Science, Kanazawa University, Kanazawa 920-1192, Japan
| | - Masashi Demura
- Department of Hygiene, Graduate School of Medical Science, Kanazawa University, Kanazawa 920-1192, Japan
| | - Mitsuhiro Kometani
- Endocrinology and Metabolism, Kanazawa University Hospital, Kanazawa 920-8641, Japan
| | - Shigehiro Karashima
- Institute of Liberal Arts and Science, Kanazawa University, Kanazawa 920-1192, Japan
| | - Takashi Yoneda
- Institute of Liberal Arts and Science, Kanazawa University, Kanazawa 920-1192, Japan
| | - Yoshiyu Takeda
- Endocrinology and Metabolism, Kanazawa University Hospital, Kanazawa 920-8641, Japan
- Endocrine and Diabetes Center, Asanogawa General Hospital, Kanazawa 920-0811, Japan
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16
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Araos P, Amador CA. Neutrophil gelatinase-associated lipocalin as an immunomodulator in endocrine hypertension. Front Endocrinol (Lausanne) 2022; 13:1006790. [PMID: 36387895 PMCID: PMC9640732 DOI: 10.3389/fendo.2022.1006790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/04/2022] [Indexed: 12/04/2022] Open
Abstract
In recent studies, primary aldosteronism (PA) has been reported as the most common etiology for secondary hypertension of endocrine origin, accounting for approximately 10% of cases. In PA, excess aldosterone production can lead to deleterious effects at the cardiovascular (CV) and renal levels by activating mineralocorticoid receptors, which involves an increase in pro-inflammatory and pro-fibrotic mediators. Among these mediators, neutrophil gelatinase-associated lipocalin (NGAL), a secretion glycoprotein belonging to the lipocalin superfamily, has been closely linked to CV and renal damage in several pathological conditions. Because NGAL can be detected in biofluids such as plasma and urine, it has been proposed as a damage biomarker for target tissues and has also been studied for its role in hypertension and associated with PA. NGAL is produced by many different cell types, can be carried on extracellular vesicles, and is modulated by microRNAs, which would support its use as a biomarker for endocrine hypertension due to PA. Over the last decade, studies have shown that NGAL is necessary for the development of aldosterone-induced hypertension and that is associated with end-organ damage. In addition, it has been proposed that some mechanisms are dependent on the activation of immune cells, such as dendritic cells and macrophages, where the release of specific cytokines (i.e., interleukin [IL]-23) or chemokines (i.e., CCL-5) induced by aldosterone would depend on NGAL. Subsequently, this activates the T helper (Th) lymphocytes, such as Th17 and Th2, resulting in CV and renal fibrosis due to the high aldosterone levels. Although the immune system has been closely associated with essential hypertension, its participation in endocrine hypertension has not been fully elucidated. This review discusses the link between NGAL and endocrine hypertension, particularly in the context of PA, and their possible regulators and mechanisms, with a focus on its role as an immunomodulator.
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Affiliation(s)
- Patricio Araos
- Laboratorio de Fisiopatología Renal, Instituto de Ciencias Biomédicas, Universidad Autónoma de Chile, Santiago, Chile
| | - Cristián A. Amador
- Laboratorio de Fisiopatología Renal, Instituto de Ciencias Biomédicas, Universidad Autónoma de Chile, Santiago, Chile
- Facultad de Medicina y Ciencia, Universidad San Sebastián, Santiago, Chile
- *Correspondence: Cristián A. Amador,
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Al Refaie A, Baldassini L, De Vita M, Gonnelli S, Caffarelli C. Vitamin D and adrenal gland: Myth or reality? A systematic review. Front Endocrinol (Lausanne) 2022; 13:1001065. [PMID: 36313775 PMCID: PMC9606701 DOI: 10.3389/fendo.2022.1001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/28/2022] [Indexed: 11/23/2022] Open
Abstract
In recent years, vitamin D has become the protagonist in many studies. From cardiology to oncology the spotlight was on this vitamin. While in the past it was considered for its important role in phospho-calcium metabolism and skeletal disorders; today by studying it better, thousands of scenarios and facets have opened up on this vitamin which is actually a hormone in all respects. There are authoritative studies that demonstrate its activity in vitro and in vivo on: carcinogenesis, inflammation, autoimmunity and endocrinopathies. Its role has been studied in type 1 and type 2 diabetes mellitus, in Hashimoto or Graves' thyroiditis and even in adrenal gland diseases. In fact, there are several studies that demonstrate the possible correlations between vitamin D and: Addison's disease, Cushing disease, hyperaldosteronism or adrenocortical tumors. Moreover, this fascinating hormone and adrenal gland even seem to be deeply connected by common genetic pathways. This review aimed to analyze the works that have tried to study the possible influence of vitamin D on adrenal diseases. In this review we analyze the works that have tried to study the possible influence of vita-min D on adrenal disease.
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