Steroid metabolome analysis reveals prevalent glucocorticoid excess in primary aldosteronism

Pathophysiology and evaluation of bone health in adrenal diseases

Adrenal diseases are associated with an increased risk of osteopenia/osteoporosis and fragility fractures. Although dual-energy X-ray absorptiometry remains the gold standard for assessing bone mineral density, its limitations in accurately predicting vertebral fractures underscore the need for complementary diagnostic tools, particularly in the context of adrenal disorders. Vertebral fractures, often asymptomatic, may go undetected without targeted assessments such as morphometric evaluation. Incorporating advanced diagnostic tools, such as the trabecular bone score, into the evaluation of adrenal disorder-related skeletal fragility may enhance the identification of high-risk patients and support tailored therapeutic strategies. This review explores skeletal fragility from pathophysiological, clinical, and diagnostic perspectives and provides guidance to physicians for the management of adrenal disorders to improve bone health outcomes.

Primary Hyperaldosteronism: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment

Primary hyperaldosteronism (PA) is the most common endocrine cause of hypertension, characterized by autonomous aldosterone hormone production from the adrenal glands. It encompasses a wide spectrum of renin-independent aldosterone production with diverse histopathological etiologies. A vast majority of PA is caused by bilateral disease, remains underdiagnosed and is linked to serious cardiometabolic risks. This review outlines our current understanding of the etiopathogenesis of PA, and provides a comprehensive overview of the diagnostic strategies and management of PA.

Unilateral Primary Aldosteronism Lacking KCNJ5 Somatic Mutations Is Associated With an Elevated Risk of New-Onset Diabetes

The association between KCNJ5 mutations and the risk of developing new-onset diabetes (NOD) in patients with unilateral primary aldosteronism (uPA) remains underexplored. To investigate this association, we conducted a longitudinal study using data from the Taiwan Primary Aldosteronism Investigation database. Our sample included 360 patients with uPA who underwent adrenalectomy between 2012 and 2017, 191 (53.1%) of whom had KCNJ5 mutations in their adrenal adenomas. We found that patients with uPA harboring KCNJ5 mutations had a higher rate of complete clinical success (69.5% vs. 43.8%; P < 0.01) and complete biochemical success (93.8% vs. 86.6%; P = 0.04) compared with those without KCNJ5 mutations at 6 months to 1 year after adrenalectomy. Over an average follow-up period of 8.5 years, multivariate Cox regression analysis revealed that patients with uPA with KCNJ5 mutations had a significantly lower risk of developing NOD (hazard ratio [HR] 0.41; 95% CI 0.17-0.996; P = 0.049). Additionally, we identified higher BMI (HR 1.23; 95% CI 1.11-1.37; P < 0.01) and lower estimated glomerular filtration rate (eGFR; HR 0.98; 95% CI 0.97-0.99; P = 0.01) as potential predictors of NOD based on baseline characteristics. The association between patients with uPA without KCNJ5 mutations and higher incidence of NOD was less pronounced in subgroups characterized by younger age, higher BMI, higher eGFR, and lower potassium levels. In conclusion, patients with uPA without KCNJ5 mutations had a higher incidence of NOD, with 13.6% affected during long-term follow-up. Our findings suggest that patients with uPA without KCNJ5 mutations may require more frequent follow-up for NOD after adrenalectomy.

ARTICLE HIGHLIGHTS

Immunohistochemical characterization of normal feline adrenal tissue and adrenal tumors secreting aldosterone

It is suggested that primary hyperaldosteronism (PHA) is an under-diagnosed cause of systemic hypertension in cats. No immunohistochemical markers of aldosterone synthesizing tissues have been identified, meaning that endocrine function cannot be inferred from examining feline tissues. In humans, expression of CYP11B2 (aldosterone synthase) is used for this purpose, but cats have a single CYP11B enzyme responsible for the terminal steps in synthesis of both aldosterone and cortisol, precluding its use as an indicator of steroidogenic function. This study aimed to identify immunohistochemical markers of aldosterone producing tissues. In addition, since there are no existing guidelines for classification of feline adrenal tumors as benign or malignant, this study aimed to investigate potential markers of adrenal tumor malignancy in PHA. Normal adrenals (n = 9) and adrenal tumors secreting aldosterone (n = 31) or cortisol (n = 4) were immunolabeled for steroidogenic enzymes (CYP11B, CYP17A1, and CYB5A), the zona glomerulosa (including KCNJ5 visinin-like 1 (VSNL1), and neuron-specific enolase (NSE)), and proliferation markers (Ki67). Histochemical staining for reticulin was also performed. Transcriptomes of normal (n = 4) and aldosterone secreting tumors (n = 5) were compared. Weak or absent CYP17A1 in conjunction with strong KCNJ5 or VSNL1 immunolabeling was present in aldosterone producing tissues from normal and tumorous cat adrenals. CYP17A1 RNA expression was lower in aldosterone producing tumors compared with normal adrenals (P < .0001). VSNL1 and NSE were not specific markers of aldosterone producing tissue. CYB5A and CYP17A1 were not expressed within the zona reticularis, suggesting minimal adrenal production of androgens. Ki67 proliferative index and reticulin network disruption were not predictive of malignancy.

Advances in the biochemical diagnostics of primary aldosteronism: from immunoassays to steroidomics and proteomics

Primary aldosteronism is the most common cause of secondary hypertension, yet most cases remain unrecognized and left without optimal treatment. The diagnostic inertia may be attributed to the lack of specific symptoms, insufficient awareness among physicians, still conflicting indications for screening for primary aldosteronism and first and foremost challenging diagnostics. This review describes the current challenges of biochemical diagnostics of primary aldosteronism, including screening, case confirmation and subtyping. It also discusses immunoassays widely used in assessment of suspected autonomous aldosterone secretion - recent advances in the field and limitations of the method in comparison to the gold standard - liquid chromatography -tandem mass spectrometry. The review focuses on the application of novel "omics" strategies in the diagnostics of primary aldosteronism. Steroidomics and proteomics offer a possibility to simultaneously assess steroids and protein/peptides on a large scale. This multianalyte approach in comparison to the selective quantification of a chosen compound has been proved useful in the diagnostics of primary aldosteronism. It also offers a unique insight into the individual characteristics, underlying mechanisms and even reflects the genetic alterations of primary aldosteronism cases. The "omics" techniques are associated with large amounts of generated data, the interpretation of which may be troublesome and often necessitates the use of artificial intelligence. The novel advances in the biochemical diagnostics of primary aldosteronism, including "omics" techniques, presented in this review may help to address the most emerging problems, increase the number of diagnosed patients and facilitate the choice of an optimal treatment.

Acid-Sensing Ion Channel 1a Deficiency Drives Endocrine Hypertension in Male Mice

Background

Acid-sensing ion channel 1a (ASIC1a) is an H + -gated cation channel that responds to extracellular acidosis in both normal and pathological states, including ischemia, inflammation, and metabolic disturbances. While ASIC1a regulates vascular reactivity, its role in blood pressure regulation remains unclear, particularly concerning sex, aging, and disease. This study aims to investigate whether ASIC1a: 1) contributes to cardiovascular function in a sex-dependent manner; 2) plays a dynamic role in cardiovascular homeostasis with aging; and 3) modulates the development of angiotensin II-induced systemic hypertension.

Methods

Radiotelemeters were implanted in 6- and 18-month-old male and female wild-type ( Asic1a +/+ ) and ASIC1a knockout ( Asic1a -/- ) mice to monitor mean arterial blood pressure and heart rate under baseline conditions and in response to angiotensin II. Blood gases, electrolytes, hormones, and end-organ injury were also assessed.

Results

Aged male Asic1a -/- mice develop hypertension driven by aldosterone excess and sympathetic overactivity, which is accompanied by cardiac hypertrophy, aortic fibrosis, and glomerular hypertrophy. Female Asic1a -/- mice remain unaffected. In male Asic1a -/- mice, hyperaldosteronism occurs independent of the renin-angiotensin system and mitigates angiotensin II-induced hypertension. Furthermore, 6-month-old male Asic1a -/- mice exhibit elevated corticosterone, hypokalemia, reduced urine osmolality, increased pulse pressure, and cardiomyocyte hypertrophy that precedes hypertension.

Conclusions

These findings establish ASIC1a as a novel, sex-specific regulator of cardiovascular function, linking early corticosterone excess in male mice to hyperaldosteronism and implicating ASIC1a deficiency as a potential driver of endocrine-related hypertension.

GRAPHICAL ABSTRACT

Co-existing autonomous cortisol secretion in primary aldosteronism

AIM

Co-existing primary aldosteronism (PA) and autonomous cortisol secretion (ACS) has been recently recognized as a distinct entity. This study aimed to assess the incidence of ACS in patients with PA, and its impact on clinical and laboratory parameters.

METHODS

Ninety-two patients diagnosed with PA were included. Demographic data, comorbidities, laboratory and imaging results were retrospectively analyzed. Patients with overnight 1mg dexamethasone suppression test>1.8μg/dL were classified as PA with ACS.

RESULTS

Twenty-four patients (26.1%) were in the PA-with-ACS group, and 68 (73.9%) in the PA-without-ACS group. Mean age (P=0.034), body mass index (P=0.034), number of female patients (P=0.012) and maximum adenoma diameter (P<0.001) were higher in the PA-with-ACS group than in the PA-without-ACS group. Basal (P=0.001) and post-saline infusion plasma aldosterone concentrations (PAC) (P=0.009) were higher in the PA-without-ACS group than in the PA-with-ACS group. No significant differences between groups were found in intensity of antihypertensive treatment, presence of type 2 diabetes, coronary artery disease, proteinuria or glomerular filtration rate (P>0.05). Left ventricular hypertrophy (LVH) was detected in 49.4% of patients. Logistic regression demonstrated that PAC and gender were associated factors for LVH.

CONCLUSION

Cortisol co-secretion was identified in approximately one-quarter of patients diagnosed with PA. PA patients without ACS had higher PAC than those with co-existing ACS. According to our results, the co-existing ACS may not seem to have a significant negative impact on clinical parameters in patients with PA.

Unmasking primary aldosteronism: Transforming disease management with advanced steroid profiling

Primary aldosteronism (PA) is traditionally thought to result from the overproduction of aldosterone which is unregulated by the renin-angiotensin system. It leads to a significantly increased risk of cardiovascular and metabolic complications as compared to primary hypertension. However, approximately one-third of patients diagnosed with PA according to the traditional guidelines have been found to exhibit low aldosterone levels and other steroid hormones may also play a potentially critical role in PA development. Early diagnosis of PA remains challenging due to low screening rates and the complex diagnostic procedures. The need for invasive adrenal vein sampling for PA subtyping also leads to a dilemma in therapeutic strategy selection. With advances in techniques, an increasing number of steroid hormones have been discovered to be associated with PA, potentially optimizing the PA diagnostic procedures. Herein, we review the cutting-edge advances in steroid hormones, including aberrant hormone synthesis and metabolism related to the pathophysiological development of PA, quantitative assays, and potential clinical value. Mass spectrometry provides a robust technical foundation for the simultaneous profiling of a panel of steroid hormones. Steroid hormone profiling combined with machine learning algorithms holds great research promise for facilitating early diagnosis and minimally invasive subtyping of PA. Thus, current progress and future expectations in combining steroid hormones with advanced technologies for early disease diagnosis and management are also reviewed. Research Agenda. 1) Identify changes in steroid hormones and the underlying biochemical mechanisms associated with PA. 2) Investigate the role of advanced mass spectrometry techniques in steroid hormone profiling. 3) Discuss current advances and future expectations in combining machine learning algorithms with MS-based steroid hormone profiling for PA's systematic and practical management.

Clinical significance of parathyroid hormone in mineral and glucose metabolism disorders among patients with primary aldosteronism

Objective

To investigate the differences in mineral and glucose metabolic disorders among patients with primary aldosteronism, nonfunctional adrenal tumors, and controls.

Methods

A retrospective analysis was conducted on clinical data from 578 patients, including those with primary aldosteronism, nonfunctional adrenal tumors, and control subjects, at our hospital between January 2013 and December 2023. Biochemical indices including parathyroid hormone, serum potassium, serum calcium, urine potassium, urine calcium, plasma renin, plasma aldosterone, glycosylated hemoglobin, insulin resistance index, and pancreatic beta cell function index were compared among the three groups.

Results

Compared with the nonfunctional adrenal tumors and control groups, primary aldosteronism patients exhibited significantly higher levels of parathyroid hormone, urinary potassium, and aldosterone (p < 0.05), while their serum potassium and serum calcium levels were significantly lower (p < 0.05). Additionally, primary aldosteronism patients had higher glycosylated hemoglobin levels, lower HOMA-IR, and lower HOMA-β levels (p < 0.05). Pearson's correlation analysis revealed that serum parathyroid hormone levels were negatively correlated with serum potassium, serum calcium, serum renin activity, and HOMA-β levels, while positively correlated with urinary potassium, urine calcium, blood carbon dioxide combining power, urine pH, serum aldosterone, and HOMA-IR levels. Stepwise regression analysis indicated that HOMA-IR and aldosterone were the main factors influencing parathyroid hormone levels. Based on receiver operating characteristic curve analysis, the optimal cut-off value for parathyroid hormone in diagnosing primary aldosteronism was 62.1 pg/ml, with a sensitivity of 94.4% and specificity of 81.0%.

Conclusion

Primary aldosteronism is often characterized by elevated parathyroid hormone levels, which can exert direct adverse effects on mineral and glucose metabolism. Elevated parathyroid hormone levels serve as a valuable indicator in the screening of primary aldosteronism.

Multiomics analysis unveils the cellular ecosystem with clinical relevance in aldosterone-producing adenomas with KCNJ5 mutations

Aldosterone-producing adenomas (APA), a major endocrine tumor and leading subtype of primary aldosteronism, cause secondary hypertension with high cardiometabolic risks. Despite potentially producing multiple steroid hormones, detailed cellular mechanisms in APA remain insufficiently studied. Our multiomics analysis focusing on APA with KCNJ5 mutations, which represent the most common genetic form, revealed marked cellular heterogeneity. Tumor cell reprogramming initiated from stress-responsive cells to aldosterone-producing or cortisol-producing cells, with the latter progressing to proliferative stromal-like cells. These cell subtypes showed spatial segregation, and APA exhibited genomic intratumor heterogeneity. Among the nonparenchymal cells, lipid-associated macrophages, which were abundant in APA, might promote the progression of cortisol-producing and stromal-like cells, suggesting their role in the tumor microenvironment. Intratumor cortisol synthesis was correlated with increased blood cortisol levels, which were associated with the development of vertebral fractures, a hallmark of osteoporosis. This study unveils the complex cellular ecosystem with clinical relevance in APA with KCNJ5 mutations, providing insights into tumor biology that could inform future clinical approaches.

Discordance between adrenal vein sampling and imaging: the role of unilateral cortisol excess

OBJECTIVE

Adrenal vein sampling (AVS) is considered the gold-standard for identifying unilateral primary aldosteronism (PA), but is sensitive to any asymmetry in cortisol production. Subclinical autonomous cortisol production likely contributes to discordance between cross-sectional imaging and AVS.

DESIGN AND METHODS

Retrospective chart review was performed of patients in Calgary, Alberta who (1) had a diagnosis of PA with clear adrenal mass, (2) had discordant AVS and cross-sectional imaging, and (3) underwent dexamethasone-suppressed NP59-iodocholesterol adrenal scintigraphy (n = 25). Postoperative biochemical and clinical outcomes were evaluated. Surgical pathology was analyzed with immunohistochemical staining for CYP11B1 and CYP11B2.

RESULTS

NP59 scanning demonstrated autonomous steroidogenesis from the same side as the computed tomography (CT)-identified lesion, despite discordant AVS results, in 19/25 cases. Out of the 16 patients who underwent adrenalectomy (guided by NP59), 11 cases had a final diagnosis of cortisol-producing adenoma with bilateral PA, while the final diagnosis in the remaining 5 cases was cortisol-producing adenoma with unilateral PA (defined by a complete biochemical response). All cases preoperatively had low/suppressed adrenocorticotropin hormone that rose postadrenalectomy, in keeping with the resolution of cortisol autonomy. Adrenal vein sampling incorrectly diagnosed the subtype of PA or falsely localized the side of aldosterone excess in 10/16 cases.

CONCLUSIONS

Discordant CT and AVS results in patients with PA and obvious adrenal mass are often explained by subclinical asymmetric cortisol excess. Clinicians should be aware of the limitations of AVS in the presence of subtle autonomous cortisol secretion and must be able to counsel patients regarding the possible outcomes from surgery when discordant lateralization is present.

Occurrence of Metabolic Disorders in Bilateral Primary Aldosteronism Compared to Unilateral Primary Aldosteronism

BACKGROUND

Metabolic syndrome (MetS) is a common comorbidity associated with hypertension that occurs more often in primary aldosteronism (PA). Our work aims to investigate the prevalence of MetS and its determinants in unilateral PA and bilateral PA, as confirmed by adrenal venous sampling (AVS).

METHODS

This was a retrospective, cross-sectional study. We investigated metabolic indicators in 160 cases of PA, categorized by AVS-82 with unilateral PA and 78 with bilateral PA. A control group of 80 non-PA patients with essential hypertension, matched for age and sex, was also included.

RESULTS

Unilateral PA had a higher aldosterone-renin ratio and lower serum potassium levels than bilateral PA. Nevertheless, bilateral PA exhibited a higher prevalence of MetS (41% vs. 30.5%; p = 0.001), obesity, BMI, LDL hypercholesterolemia, and hypertriglyceridemia than unilateral PA.

CONCLUSIONS

Bilateral PA presents a greater incidence of MetS than unilateral PA, in spite of the latter showing a higher aldosterone-renin ratio and lower serum potassium levels. The results suggest that the mechanisms underlying MetS may differ between unilateral and bilateral PA.

Major Adverse Cardiovascular Events in Primary Aldosteronism After Adrenalectomy or Mineralocorticoid Receptor Antagonist Treatment: A Systematic Review and Meta-Analysis

BACKGROUND

The object of this study was to investigate the incidence rate of major adverse cardiovascular event (MACE) among patients with primary aldosteronism (PA) after adrenalectomy or mineralocorticoid receptor antagonist (MRA) treatment.

METHODS AND RESULTS

A systematic review and meta-analysis was conducted by searching PubMed, Embase, Cochrane Library, Web of Science, CINAHL, and Scopus through April 15, 2024. Studies reporting the MACE incidence rate in patients with PA after treatment were included. We adapted the random-effects model and performed subgroup and meta-regression analyses. A total of 20 studies involving 16 927 patients with PA were included. There were 5939 patients with PA who underwent adrenalectomy. A total of 10 474 patients received MRA treatment. Additionally, 546 patients received either adrenalectomy or MRA treatment. The pooled incidence rate of MACE among patients with PA after treatment was 2.20/100 patient-years (95% CI, 1.70-2.80), higher than that of non-PA hypertension (1.20/100 patient-years [95% CI, 0.70-2.10]). Patients with PA after adrenalectomy had a lower MACE incidence rate (2.00/100 patient-years [95% CI, 1.40-2.60]) compared with those undergoing MRA treatment (3.30/100 patient-years [95% CI, 2.40-4.10], P=0.017). Advanced age (coefficient: 0.071, P<0.001) and diabetes (coefficient: 0.070, P=0.001) increased the risk of posttreatment MACE. A curvilinear dose-response relationship between the posttreatment plasma renin activity and the MACE incidence was observed, with the lowest risks at plasma renin activity of 1.0 to 2.0 ng/mL per hour (Pnonlinearity<0.001).

CONCLUSIONS

The MACE incidence in treated patients with PA was 2.20 per 100 patient-years, higher than in patients with hypertension without PA. Maintaining posttreatment plasma renin activity between 1.0 and 2.0 ng/mL per hour appears crucial for minimizing cardiovascular risk. Adrenalectomy proved more effective than MRA treatment in reducing MACE risk. Advanced age and diabetes significantly increased the risk of posttreatment MACE.

Metabolomics studies in cushing's syndrome: recent developments and perspectives

INTRODUCTION

Exogenous Cushing's syndrome is the result of long-term exposure to glucocorticoids, while endogenous Cushing's syndrome occurs due to excessive production of glucocorticoids within the body. Cushing's syndrome remains a diagnostic challenge for the treating physician.Mass spectrometry, with its better resolution, detectability, and specificity, paved the way to understanding the cellular and molecular mechanisms involved in several diseases that facilitated the evolution of biomarkers and personalized medicine, which can be applicable to manage Cushing's syndrome as well.

AREAS COVERED

There are only a few reports of mass spectrometry-based metabolomic approaches to endogenous Cushing's syndrome of certain etiologies. However, the application of this approach in the diagnosis of exogenous Cushing has not been explored much. This review attempts to discuss the application of the mass spectrometry-based metabolomic approach in the evaluation of Cushing's syndrome.

EXPERT OPINION

Global metabolomics has the potential to discover altered metabolites and associated signaling and metabolic pathways, which may serve as potential biomarkers that would help in developing tools to accelerate precision medicine. Multi-omics approaches will provide innovative solutions to develop molecular tests for multi-molecule panel assays.

Mild autonomous cortisol secretion leads to reduced volumetric BMD at lumbar spine in patients with primary aldosteronism

Objectives

Glucocorticoid cosecretion is more common in primary aldosteronism (PA) than previously thought. Chronic subtle cortisol excess in patients with mild autonomous cortisol secretion (MACS) negatively affects bone health. This study aimed to evaluate the impact of MACS on bone density and turnover markers in PA patients.

Methods

Patients with PA and MACS (n = 50), confirmed by a 1-mg dexamethasone suppression test (DST) with a cortisol cutoff of ≥1.8 µg/dL without symptoms of overt Cushing, were compared to age- and sex-matched patients with PA without MACS (non-MACS, n = 50). Lumbar volumetric bone mineral density (vBMD) was extracted by a novel convolutional neural network (CNN)-based framework (SpineQ software v1.0) applied to routine CT data, incorporated into the diagnostic protocol for PA. Additionally, bone turnover markers-including osteocalcin, bone-specific alkaline phosphatase, N-terminal propeptide of type I collagen, and carboxy-terminal crosslinked telopeptide of type I collagen were evaluated between the groups.

Results

Median cortisol after DST was 1.1 µg/dL (30.3 nmol/L) [IQR: 0.5 µg/dL (13.8 nmol/L)] in the non-MACS group and 2.5 µg/dL (69.0 nmol/L) [IQR: 1.4 µg/dL (38.5 nmol/L)] in the MACS group (p < 0.001). Patients with MACS had significantly lower vBMD values compared to the non-MACS group (106.4 mg/cm³ vs. 116.6 mg/cm³, p = 0.038). Cortisol after DST negatively correlated with vBMD (Spearman's r=-0.33, p=0.00042). No significant differences in bone turnover markers were found, and classifications based on visible lesions on CT or PA-lateralization via adrenal venous sampling did not reveal any significant differences in these markers (p > 0.05 for all comparisons).

Conclusion

Despite non-significant differences in bone turnover markers between patients with PA with or without MACS, CT scans revealed significantly reduced vBMD in PA and MACS patients, indicating compromised bone health and vBMD significantly negatively correlated with cortisol post DST. Thus, opportunistic evaluation of vBMD in routine CT screenings could aid in the early detection of bone alterations in MACS and help mitigate potential long-term adverse effects on bone health.

Cardiovascular status in endogenous cortisol excess: the prospective CV-CORT-EX study

OBJECTIVE

Cushing's syndrome (CS) results in increased cardiovascular (CV) morbidity and mortality. Subtype-specific differences and possible reversibility after biochemical cure are not well investigated.

DESIGN

Prospective cohort study evaluating the CV status in different forms of endogenous cortisol excess.

METHODS

Patients with overt CS (n = 40, 47 ± 13 years, 75% women; 18 pituitary, 13 adrenal, and 9 ectopic), biochemically cured CS (n = 56, 53 ± 12 years, 79% women; 30 pituitary, 21 adrenal, and 5 ectopic), and adrenal incidentalomas with mild autonomous cortisol secretion (MACS) (n = 18, 62 ± 11 years, 56% women) underwent comprehensive biochemical, metabolic, and CV assessment. Results were compared with a representative sample of the general population of Würzburg (n = 4965, 55 ± 12 years, 52% women).

RESULTS

Overt CS was associated with left ventricular (LV) remodeling along with hypertrophy and impaired longitudinal systolic/diastolic function at echocardiography. In 20 CS patients followed for a median of 8 (quartiles: 6, 11) months after biochemical remission, hypertension, and hyperglycemia were better controlled, while cardiac alterations only partially improved. Patients with previous CS (median time of biochemical remission: 95 [36, 201] months) had worse diastolic function than the general population (LV relaxation velocity e' 0.08 [0.07, 0.10] ms-1 vs 0.10 [0.08, 0.12] ms-1, P < .001). In MACS, cardiac remodeling was even more pronounced than in individuals with metabolic syndrome.

CONCLUSIONS

In patients with overt CS, cured CS, and MACS, we found a sizable and significant deviation from the general population mean regarding cardiac structure and function. Even mild cortisol excess is associated with glucocorticoid-induced cardiac alterations, which appear to persist despite long-term biochemical remission.

The interpretation of immunometric, chromatographic and mass spectrometric data for steroids in diagnosis of endocrine disorders

The analysis of steroids for endocrine disorders is in transition from immunoassay of individual steroids to more specific chromatographic and mass spectrometric methods with simultaneous determination of several steroids. Gas chromatography (GC) and liquid chromatography (LC) coupled with mass spectrometry (MS) offer unrivalled analytical capability for steroid analysis. These specialist techniques were often judged to be valuable only in a research laboratory but this is no longer the case. In a urinary steroid profile up to 30 steroids are identified with concentrations and excretion rates reported in a number of ways. The assays must accommodate the wide range in steroid concentrations in biological fluids from micromolar for dehydroepiandrosterone sulphate (DHEAS) to picomolar for oestradiol and aldosterone. For plasma concentrations, panels of 5-20 steroids are reported. The profile results are complex and interpretation is a real challenge in order to inform clinicians of likely implications. Although artificial intelligence and machine learning will in time generate reports from the analysis this is a way off being adopted into clinical practice. This review offers guidance on current interpretation of the data from steroid determinations in clinical practice. Using this approach more laboratories can use the techniques to answer clinical questions and offer broader interpretation of the results so that the clinician can understand the conclusion for the steroid defect, and can be advised to program further tests if necessary and instigate treatment. The biochemistry is part of the patient workup and a clinician led multidisciplinary team discussion of the results will be required for challenging patients. The laboratory will have to consider cost implications, bearing in mind that staff costs are the highest component. GC-MS and LC-MS/MS analysis of steroids are the choices. Steroid profiling has enormous potential to improve diagnosis of adrenal disorders and should be adopted in more laboratories in favour of the cheap, non-specific immunological methods.

Fast and reliable quantification of aldosterone, cortisol and cortisone via LC-MS/MS to study 11β-hydroxysteroid dehydrogenase activities in primary cell cultures

Cell culture experiments can support characterization of enzymatic activities in healthy and tumorous human tissues. Liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) enables simultaneous measurement of several steroids from a single sample, facilitating analysis of molecular pathways involved in steroid biosynthesis. We developed a reliable but fast method for quantification of cortisol, cortisone and aldosterone in cell culture supernatant. Validation, including investigation of matrix-matched calibration, was performed for two different cell types. Utility of the method was demonstrated in the study of 11β-hydroxysteroid dehydrogenase type 2 (HSD11B2) activity under conditions of glucocorticoid and mineralocorticoid excess in different cell types. Aldosterone, cortisol and cortisone were extracted by liquid-liquid extraction (LLE) with methyl tert-butyl ether from 1 mL of cell culture supernatant. Steroids were separated on a Kinetex biphenyl column (50 ×2.1 mm, 2.6 µm) with gradient elution of water and methanol containing 2 mM ammonium format and analysed in multiple reaction monitoring mode after positive electrospray ionization. Application of the method included cell culture experiments with two different primary cell types, human coronary artery smooth muscle cells (HCSMC) and human coronary artery endothelial cells (EC). Cells were treated with different concentrations of cortisol, aldosterone and mifepristone, a glucocorticoid receptor antagonist and quantitative PCR was performed. The method exhibits high precision (CV ≤ 6 %) and accuracy (deviation from nominal concentration ≤ 6 %) for concentrations above the limit of quantification (LoQ) which is 0.11, 0.56 and 0.69 nmol/L for aldosterone, cortisone and cortisol, respectively. Calibration curves did not differ when prepared in media or solvent. The method enabled us to confirm activity of HSD11B2 and concentration dependent conversion of cortisol to cortisone in HCSMC (median conversion ratio at 140 nM cortisol = 1.46 %). In contrast we did not observe any HSD11B2 activity in EC. Neither addition of high aldosterone, nor addition of 1 µM mifepristone had impact on glucocorticoid concentrations. Quantitative PCR revealed expression of HSD11B1 and HSD11B2 in HCSMC but not in EC. We present a fast and reliable method for quantification of cortisol, cortisone and aldosterone in cell culture supernatants. The method enabled us to study HSD11B2 activity in two different cell types and will support future experiments investigating mechanisms of target organ damage in conditions of glucocorticoid and mineralocorticoid excess.

Cardiovascular and all-cause mortality outcomes of adrenalectomy versus medical treatment in primary aldosteronism: an umbrella review

BACKGROUND

Primary aldosteronism (PA) is now recognized as the most prevalent form of secondary hypertension globally, contributing significantly to cardiovascular morbidity and mortality. This umbrella review aims to systematically compare cardiovascular outcomes and all-cause mortality in PA patients undergoing adrenalectomy versus mineralocorticoid receptor antagonist (MRA) treatment, aiming to inform optimal management strategies.

METHOD

Following PRISMA guidelines (Supplemental Digital Content 1, http://links.lww.com/JS9/D386 ) (Supplemental Digital Content 2, http://links.lww.com/JS9/D387 ), a comprehensive search strategy was employed across multiple databases. Meta-analyses focusing on cardiovascular outcomes or all-cause mortality, comparing adrenalectomy and MRAs treatment in PA patients, were included. Studies were independently screened and assessed for quality using AMSTAR 2 (Supplemental Digital Content 3, http://links.lww.com/JS9/D388 ) and GRADE checklists.

RESULTS

A total of eight studies met the inclusion criteria. Adrenalectomy showed potential benefits over MRAs in reducing the risk of arrhythmias (OR=2.17; 95% CI: 1.25-3.76) and major adverse cardiovascular events (OR=1.81; 95% CI: 1.33-2.46). Patients treated with MRAs exhibited a higher risk of cardiovascular events (OR=1.23; 95% CI: 1.05-1.44), hypertension (OR=3.22; 95% CI: 1.15-8.97), and all-cause mortality (OR=3.03; 95% CI: 1.36-6.70) compared to adrenalectomy.

CONCLUSION

Adrenalectomy appears to offer favorable outcomes compared to MRAs treatment in PA patients, particularly in reducing the risk of major adverse cardiovascular events and all-cause mortality. These findings suggest the importance of considering surgical intervention as a primary treatment modality for PA.

Impact of Cortisol-Cosecretion on Adrenal Venous Sampling Results in Primary Aldosteronism: Study of 225 Cases

Background/Objectives: Mild autonomous cortisol secretion (MACS) can coexist with primary aldosteronism (PA). The purpose of our study was to evaluate whether (MACS) influences parameters analyzed during adrenal venous sampling (AVS) in patients with PA. Methods: Patients with PA from the SPAIN-ALDO Registry and the German Conn's Registry with available 1 mg-dexamethasone suppression test (DST) and AVS were included. MACS was defined as a post-DST cortisol > 1.8 µg/dL in the absence of specific signs and symptoms of Cushing's syndrome. Results: Two-hundred and twenty-five patients were included, 98 (43.6%) of whom had concomitant MACS. The mean age was 54 ± 10 years and 37.3% were women. AVS was performed by simultaneous catheterization of both adrenal veins and analysis of basal samples in 157 patients (69.8%), with both basal and post-ACTH samples in 15 patients (6.7%), and during continuous ACTH infusion in 53 patients (23.6%). AVS was considered technically unsuccessful in 40 cases (17.8%), suggesting unilateral secretion in 106 (47.1%) and bilateral secretion in 79 (35.1%). We did not find significant differences in the percentage of unilateral and bilateral results, cortisol, corrected aldosterone, or selectivity indices in the dominant and non-dominant veins, nor in the lateralization index or the contralateral suppression index between patients with and without MACS. They also had similar rates of surgical treatment and biochemical and clinical response. Conclusions: Although pathophysiological reasoning suggests that MACS could hinder AVS identification of unilateral forms of PA, our data suggest that such interference, if it exists, is of moderate clinical relevance.

Clinical Review: The Approach to the Evaluation and Management of Bilateral Adrenal Masses

OBJECTIVE

This white paper provides practical guidance for clinicians encountering bilateral adrenal masses.

METHODS

A case-based approach to the evaluation and management of bilateral adrenal masses. Specific clinical scenarios presented here include cases of bilateral adrenal adenomas, hemorrhage, pheochromocytomas, metastatic disease, myelolipomas, as well as primary bilateral macronodular adrenal hyperplasia.

RESULTS

Bilateral adrenal masses represent approximately 10% to 20% of incidentally discovered adrenal masses. The general approach to the evaluation and management of bilateral adrenal masses follows the same protocol as the evaluation of unilateral adrenal masses, determined based on the patient's clinical history and examination as well as the imaging characteristics of each lesion, whether the lesions could represent a malignancy, demonstrate hormone excess, or possibly represent a familial syndrome. Furthermore, there are features unique to bilateral adrenal masses that must be considered, including the differential diagnosis, the evaluation, and the management depending on the etiology. Therefore, considerations for the optimal imaging modality, treatment (medical vs surgical therapy), and surveillance are included. These recommendations were developed through careful examination of existing published studies as well as expert clinical opinion consensus.

CONCLUSION

The evaluation and management of bilateral adrenal masses require a comprehensive systematic approach which includes the assessment and interpretation of the patient's clinical history, physical examination, dynamic hormone evaluation, and imaging modalities to determine the key radiographic features of each adrenal nodule. In addition, familial syndromes should be considered. Any final treatment options and approaches should always be considered individually.

NT-proBNP levels in patients with primary hyperaldosteronism and autonomous cortisol cosecretion

CONTEXT

Patients with primary aldosteronism (PA) have higher cardiac comorbidities including more pronounced left ventricular hypertrophy than patients with essential hypertension.

OBJECTIVE

Autonomous cortisol cosecretion (ACS) is a common subtype in PA associated with a worse metabolic profile.

HYPOTHESIS

Autonomous cortisol cosecretion may affect myocardial parameters and result in a worse cardiac outcome compared to patients with PA and without ACS.

METHODS

Three hundred and sixty-seven patients with PA undergoing 1 mg dexamethasone suppression test (DST) and echocardiography at baseline from 2 centers of the German Conn's Registry were included. Follow-up for up to 3.8 years was available in 192 patients.

RESULTS

Patients with PA and ACS had higher NT-proBNP levels at baseline compared to patients with PA without ACS (114 vs 75.6 pg/mL, P = .02), but showed no difference in echocardiography values. NT-proBNP levels showed a significant positive correlation (r = 0.141, P = .011) with cortisol levels after DST at baseline. In response to therapy of PA, NT-proBNP levels decreased, but remained significantly higher in patients with ACS compared to patients without ACS. At follow-up, left ventricle end-diastolic dimension (LVEDD) decreased significantly only in patients without ACS. Left atrial diameter (LAD) decreased significantly in patients without ACS and in female patients with ACS but not in male patients. Left ventricular mass index (LVMI) significantly improved in female patients without ACS but remained unchanged in female patients with ACS as well as in male patients at follow-up.

CONCLUSIONS

In patients with PA, concomitant ACS is associated with a worse cardiac profile and only partial recovery even years after initiation of targeted PA therapy.

[131I]6ß-Iodomethyl-19-norcholesterol SPECT/CT for the Lateralization of Mineralocorticoid Overproduction in Primary Aldosteronism

Primary: aldosteronism is a frequent cause of secondary hypertension. With access to specialized care, an increasing number of patients with aldosteronism are being identified. Primary aldosteronism is treatable by adrenal surgery if aldosterone excess originates from one of the two, and not from both, adrenals. Bilateral hyperplasia requires lifelong mineralocorticoid receptor antagonist treatment. Up till now, adrenal venous sampling (AVS) has been widely used to distinguish between one-sided and two-sided aldosterone overproduction and patient selection for surgery. AVS is an invasive technique, and the unsuccessful sampling of the right adrenal vein during AVS often prevents side comparison, making the AVS procedure useless. Molecular imaging using [131I]6ß-iodomethyl-19-norcholesterol with SPECT CT imaging (SPECT/CT) may be a potential alternative.

METHODS

In 42 consecutive patients with confirmed primary aldosteronism, molecular imaging has been performed. After dexamethasone suppression of the non-affected adrenal tissue, 37 MBq [131I]6ß-iodomethyl-19-norcholesterol was injected i.v., and SPECT/CT images were taken 7 days later. Based on the visual evaluation of the images by two nuclear medicine specialists, patients with one-sided tracer accumulation underwent adrenalectomy. To identify a SPECT/CT parameter that best characterizes the side difference, the maximum counts and the mean counts of spherical VOIs were analyzed.

RESULTS

Of the 42 patients, 24 had one-sided aldosterone overproduction by SPECT/CT. After surgical removal of the involved adrenal, all 24 patients with SPECT/CT-identified unilateral aldosteronism achieved biochemical cure, defined as a normalized potassium level combined with an aldosterone-to-renin ratio ≤ 30. To identify the best measurable parameter of SPECT/CT side difference, the mean counts and maximum counts of a series of spherical VOIs of different diameters were analyzed. The ratio of the mean counts of 3 cm spherical VOIs of the right and left adrenal regions (lateralization index) was the best discriminator; a ratio of ≥1.29 was characteristic of one-sided disease, without overlap between the one-sided and two-sided patient groups.

CONCLUSIONS

[131I]6ß-iodomethyl-19-norcholesterol SPECT/CT with a count-based image interpretation and side-ratio calculation may be an equipollent non-invasive substitute for adrenal venous sampling in the lateralization of mineralocorticoid overproduction. It reliably identifies unilateral disease and facilitates patients' selection for surgical intervention. If confirmed by others, this functional imaging may replace AVS when lateralization is required for management decisions in primary aldosteronism.

Primary unilateral macronodular adrenal hyperplasia with concomitant glucocorticoid and androgen excess and KDM1A inactivation

BACKGROUND

Primary bilateral macronodular adrenal hyperplasia (PBMAH) is a rare cause of Cushing's syndrome. Individuals with PBMAH and glucose-dependent insulinotropic polypeptide (GIP)-dependent Cushing's syndrome due to ectopic expression of the GIP receptor (GIPR) typically harbor inactivating KDM1A sequence variants. Primary unilateral macronodular adrenal hyperplasia (PUMAH) with concomitant glucocorticoid and androgen excess has never been encountered or studied.

METHODS

We investigated a woman with a large, heterogeneous adrenal mass and severe adrenocorticotropic hormone-independent glucocorticoid and androgen excess, a biochemical presentation typically suggestive of adrenocortical carcinoma. The patient presented during pregnancy (22nd week of gestation) and reported an 18-month history of oligomenorrhea, hirsutism, and weight gain. We undertook an exploratory study with detailed histopathological and genetic analysis of the resected adrenal mass and leukocyte DNA collected from the patient and her parents.

RESULTS

Histopathology revealed benign macronodular adrenal hyperplasia. Imaging showed a persistently normal contralateral adrenal gland. Whole-exome sequencing of 4 representative nodules detected KDM1A germline variants, benign NM_001009999.3:c.136G > A:p.G46S, and likely pathogenic NM_001009999.3:exon6:c.865_866del:p.R289Dfs*7. Copy number variation analysis demonstrated an additional somatic loss of the KDM1A wild-type allele on chromosome 1p36.12 in all nodules. RNA sequencing of a representative nodule showed low/absent KDM1A expression and increased GIPR expression compared with 52 unilateral sporadic adenomas and 4 normal adrenal glands. Luteinizing hormone/chorionic gonadotropin receptor expression was normal. Sanger sequencing confirmed heterozygous KDM1A variants in both parents (father: p.R289Dfs*7 and mother: p.G46S) who showed no clinical features suggestive of glucocorticoid or androgen excess.

CONCLUSIONS

We investigated the first PUMAH associated with severe Cushing's syndrome and concomitant androgen excess, suggesting pathogenic mechanisms involving KDM1A.

Usefulness of the Upright Posture Test in the Diagnosis of Primary Aldosteronism

Objective

To assess the usefulness of the upright posture stimulation test (UPT) in the confirmation of primary aldosteronism (PA) in patients in whom saline tests (ST) were inconclusive.

Methods

One hundred eighty-seven adult patients with possible PA were retrospectively included and compared to 25 control subjects. Blood samples were obtained after a 1-hour supine posture and during 2 hours of ambulation. An increase in plasma aldosterone concentration (PAC) ≥ 50% with a suppressed renin (≤10.1 ng/L; ≤1 ng/mL/hour) and a cortisol increase ≤50% were considered abnormal.

Results

PA patients had higher basal PAC and lower basal direct renin concentration (DRC) (P < .0001) and a higher maximal PAC (P = .0025) and lower maximal DRC (DRCmax) (P < .0001) during UPT compared to controls. PA was confirmed in 145 patients (77.5%), based on either oral/IV ST or UPT. DRCmax ≤12 ng/L during UPT was a predictor of PA (receiver operating characteristic curve sensitivity 93.8%, specificity 88%), and 95.6% of PA patients increased PAC ≥50% on UPT (median 222.2%), while renin remained suppressed. All 41 PA patients with false-negative IV ST (PAC < 162 pmol/L) and 88.9% with borderline response (162-240 pmol/L) had a DRCmax ≤12, while, respectively, 97.6% and 100% increased aldosterone by ≥50%. Similar responses to UPT were found in lateralized (28/63) and bilateral PA source (35/63). PA diagnosis increased from 23.6% to 88.8% using UPT results instead of IV ST and were confirmed at pathology and clinical outcome after adrenalectomy (n = 22).

Conclusion

UPT can be useful to confirm PA, particularly in patients with suspected false-negative ST.

Mild autonomous cortisol secretion: pathophysiology, comorbidities and management approaches

The majority of incidentally discovered adrenal tumours are benign adrenocortical adenomas and the prevalence of adrenocortical adenomas is around 1-7% on cross-sectional abdominal imaging. These can be non-functioning adrenal tumours or they can be associated with autonomous cortisol secretion on a spectrum that ranges from rare clinically overt adrenal Cushing syndrome to the much more prevalent mild autonomous cortisol secretion (MACS) without signs of Cushing syndrome. MACS is diagnosed (based on an abnormal overnight dexamethasone suppression test) in 20-50% of patients with adrenal adenomas. MACS is associated with cardiovascular morbidity, frailty, fragility fractures, decreased quality of life and increased mortality. Management of MACS should be individualized based on patient characteristics and includes adrenalectomy or conservative follow-up with treatment of associated comorbidities. Identifying patients with MACS who are most likely to benefit from adrenalectomy is challenging, as adrenalectomy results in improvement of cardiovascular morbidity in some, but not all, patients with MACS. Of note, diagnosis and management of patients with bilateral MACS is especially challenging. Current gaps in MACS clinical practice include a lack of specific biomarkers diagnostic of MACS-related health outcomes and a paucity of clinical trials demonstrating the efficacy of adrenalectomy on comorbidities associated with MACS. In addition, little evidence exists to demonstrate the efficacy and safety of long-term medical therapy in patients with MACS.

Rare correlation of somatic PRKACA mutations with pregnancy-associated aldosterone- and cortisol-producing adenomas: a case report and literature review

BACKGROUND

Somatic mutations have been observed to induce aldosterone-producing adenomas (APAs). These may be accelerated during pregnancy. Somatic PRKACA mutations are common in cortisol-producing adenomas (CPAs). However, their role in APAs, particularly aldosterone- and cortisol-producing adenomas (A/CPAs), is not well understood. This study aims to investigate the association between PRKACA mutations and the accelerated development of A/CPAs during pregnancy.

CASE PRESENTATION

A patient with primary aldosteronism (PA) associated with severe Cushing's syndrome (CS) underwent surgical resection of an adrenal tumor one year after delivery. Pathologic examination revealed an adrenocortical adenoma characterized primarily by zona glomerulosa hyperplasia. Somatic mutation analysis revealed the presence of the somatic PRKACA mutation, which was validated as a deleterious mutation by various computational databases. Immunohistochemical results showed positive staining for cytochrome P450 family 11 subfamily B member 1 (CYP11B1), cytochrome P450 family 11 subfamily B member 2 (CYP11B2), and luteinizing hormone/chorionic gonadotropin receptor (LHCGR). Our study included a review of 20 previously documented cases of aldosterone- and cortisol-producing adenomas (A/CPAs), two of which were concurrently positive for both CYP11B1 and CYP11B2, consistent with our findings.

CONCLUSION

Somatic mutations in PRKACA may correlate with the upregulation of LHCGR, which synergistically drives the accelerated growth of co-secretion tumors during pregnancy, thereby exacerbating disease progression.

Clinical and imaging presentations are associated with function in incidental adrenocortical adenomas: a retrospective cohort study

OBJECTIVE

The aim of this study is to assess whether clinical and imaging characteristics are associated with the hormonal subtype, growth, and adrenalectomy for incidental adrenal cortical adenomas (ACAs).

DESIGN

This is a single-center cohort study.

METHODS

Consecutive adult patients with incidental ACA were diagnosed between 2000 and 2016.

RESULTS

Of the 1516 patients with incidental ACA (median age 59 years, 62% women), 699 (46%) had nonfunctioning adenomas (NFAs), 482 (31%) had mild autonomous cortisol secretion (MACS), 62 (4%) had primary aldosteronism (PA), 39 (3%) had Cushing syndrome, 18 (1%) had PA and MACS, and 226 (15%) had incomplete work-up. Age, sex, tumor size, and tumor laterality, but not unenhanced computed tomography Hounsfield units (HU), were associated with hormonal subtypes. In a multivariable analysis, ≥1 cm growth was associated with younger age (odds ratio [OR] = 0.8 per 5-year increase, P = .0047) and longer imaging follow-up (OR = 1.2 per year, P < .0001). Adrenalectomy was performed in 355 (23%) patients, including 38% of MACS and 15% of NFA. Adrenalectomy for NFA and MACS was more common in younger patients (OR = 0.79 per 5-year increase, P = .002), larger initial tumor size (OR = 2.3 per 1 cm increase, P < .0001), ≥1 cm growth (OR = 15.3, P < .0001), and higher postdexamethasone cortisol (OR = 6.6 for >5 vs <1.8 μg/dL, P = .002).

CONCLUSIONS

Age, sex, tumor size, and laterality were associated with ACA hormonal subtype and can guide diagnosis and management. Tumor growth was more common with younger age and longer follow-up. Unenhanced HU did not predict hormonal subtype or growth. Adrenalectomy for MACS and NFA was mainly performed in younger patients with larger tumor size, growth, and elevated postdexamethasone cortisol.

Selective venous sampling for secondary hypertension

Selective venous sampling (SVS), an invasive radiographic procedure that depends on contrast media, holds a unique role in diagnosing and guiding the treatment of certain types of secondary hypertension, particularly in patients who may be candidates for curative surgery. The adrenal venous sampling (AVS), in particular, is established as the gold standard for localizing and subtyping primary aldosteronism (PA). Throughout decades of clinical practice, AVS could be applied not only to PA but also to other endocrine diseases, such as adrenal Cushing syndrome (ACS) and Pheochromocytomas (PCCs). Notably, the application of AVS in ACS and PCCs remains less recognized compared to PA, with the low success rate of catheterization, the controversy of results interpretation, and the absence of a standardized protocol. Additionally, the AVS procedure necessitates enhancements to boost its success rate, with several helpful but imperfect methods emerging, yet continued exploration remains essential. We also observed renal venous sampling (RVS), an operation akin to AVS in principle, serves as an effective means of diagnosing renin-dependent hypertension, aiding in the identification of precise sources of renin excess and helping the selection of surgical candidates with renin angiotensin aldosterone system (RAAS) abnormal activation. Nonetheless, further basic and clinical research is needed. Selective venous sampling (SVS) can be used in identifying cases of secondary hypertension that are curable by surgical intervention. Adrenal venous sampling (AVS) and aldosterone measurement for classificatory diagnosis of primary aldosteronism (PA) are established worldwide. While its primary application is for PA, AVS also holds the potential for diagnosing other endocrine disorders, including adrenal Cushing's syndrome (ACS) and pheochromocytomas (PCCs) through the measurements of cortisol and catecholamine respectively. In addition, renal venous sampling and renin measurement can help to diagnose renovascular hypertension and reninoma.

Comparison of adrenalectomy with conservative treatment on mild autonomous cortisol secretion: a systematic review and meta-analysis

Objective

This systematic review and meta-analysis was conducted to compare the benefits of adrenalectomy and conservative treatment for comorbidities associated with mild autonomous cortisol secretion (MACS) in patients diagnosed with MACS.

Background

MACS is the most common benign hormone-secreting functional adrenal incidentaloma. Overproduction of cortisol is observed in MACS patients, resulting in a variety of long-term health issues, including arterial hypertension (HTN), diabetes mellitus (DM), dyslipidemia, obesity, and osteoporosis; however, the classic clinical manifestations of Cushing's syndrome (CS) are not present.

Methods

A systematic search was conducted using MEDLINE, Embase, Web of Sciences, and Scopus databases on December, 2023. Two reviewers independently extracted data and assessed the quality of the included articles. A meta-analysis was performed to compare the beneficial effects of adrenalectomy versus conservative management for MACS-related comorbidities.

Results

Fifteen articles were included in this study, which evaluated 933 MACS patients (384 Adrenalectomy and 501 Conservative treatment, and 48 excluded due to incomplete follow-up duration). MACS diagnosis criteria were different among the included articles. All studies, however, stated that there must be no overt CS symptoms. Meta-analysis demonstrates the overall advantage of adrenalectomy over conservative treatment for MACS-related comorbidities (Cohen's d = -0.49, 95% CI [-0.64, -0.34], p = 0.00). Subgroup analysis indicated that the systolic blood pressure (pooled effect size = -0.81, 95% CI [-1.19, -0.42], p = 0.03), diastolic blood pressure (pooled effect size = -0.63, 95% CI [-1.05, -0.21], p = 0.01), and BMD (pooled effect size = -0.40, 95% CI [-0.73, -0.07], p = 0.02) were significantly in favor of adrenalectomy group rather than conservative treatment but no significant differences between the two treatment groups in other MACS-related comorbidities were reported.

Conclusion

Despite the limited and diverse data, this study demonstrates the advantage of adrenalectomy over conservative treatment for MACS-related comorbidities.

Characterization of a Biochemical Mouse Model of Primary Aldosteronism for Thermal Therapies

Introduction

Aldosterone-producing adenoma (APA) is the most common cause of endocrine-related hypertension but surgery is not always feasible. Current medical interventions are associated with significant side effects and poor patient compliance. New APA animal models that replicate basic characteristics of APA and give physical and biochemical feedback are needed to test new non-surgical treatment methods, such as image-guided thermal ablation.

Methods

A model of APA was developed in nude mice using HAC15 cells, a human adrenal carcinoma cell line. Tumor growth, aldosterone production, and sensitivity to angiotensin II were characterized in the model. The utility of the model was validated via treatment with microwave ablation and characterization of the resulting physical and biochemical changes in the tumor.

Results

The APA model showed rapid and relatively homogeneous growth. The tumors produced aldosterone and steroid precursors in response to angiotensin II challenge, and plasma aldosterone levels were significantly higher in tumor bearing mice two hours after challenge verses non-tumor bearing mice. The model was useful for testing microwave ablation therapy, reducing aldosterone production by 80% in treated mice.

Conclusion

The HAC15 model is a useful tumor model to study and develop localized treatment methods for APA.

The influence of cortisol co-secretion on clinical characteristics and postoperative outcomes in unilateral primary aldosteronism

Context

The prevalence of unilateral primary aldosteronism (UPA) with cortisol co-secretion varies geographically.

Objective

To investigate the prevalence and clinical characteristics of UPA with cortisol co-secretion in a Chinese population.

Design

Retrospective cohort study.

Methods

We recruited 580 patients with UPA who underwent cosyntropin stimulation test (CST) after the 1-mg dexamethasone suppression test (DST) and retrospectively analyzed the clinical characteristics and postoperative outcomes of UPA with and without cortisol co-secretion.

Results

UPA with cortisol co-secretion (1 mg DST>1.8 ug/dL) was identified in 65 of 580 (11.2%) patients. These patients were characterized by older age, longer duration of hypertension, higher concentration of plasma aldosterone and midnight cortisol, lower adrenocorticotropic hormone (ACTH) and dehydroepiandrosterone sulfate (DHEAS), larger tumor diameter, and more history of diabetes mellitus. Cortisol and aldosterone levels were higher and DHEAS level was lower in UPA with cortisol co-secretion at 0-120 min after CST. Among 342 UPA patients with KCNJ5 gene sequencing and follow-up results, the complete clinical success rate was lower in UPA with cortisol co-secretion (33.3% vs. 56.4%, P<0.05); the complete biochemical success rate and KCNJ5 mutation did not differ between the two groups. Age, tumor size, and ACTH were independent predictors of UPA with cortisol co-secretion. Sex, BMI, duration of hypertension, KCNJ5 mutation, and cortisol co-secretion were independent predictors for complete clinical success in UPA after surgery.

Conclusions

UPA with cortisol co-secretion is not uncommon in China, but the clinical features were distinctly different from those without co-secretion. Cortisol co-secretion is an independent risk factor for incomplete clinical success after surgery in UPA.

A novel LC-MS/MS-based assay for the simultaneous quantification of aldosterone-related steroids in human urine

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.

Screening parameters for diagnosing primary aldosteronism in patients with moderate to severe obstructive sleep apnea hypopnea syndrome and resistant hypertension

Background

Patients with obstructive sleep apnea hypopnea syndrome (OSAHS) combined with resistant hypertension (RH) have a high risk of developing primary aldosteronism (PA). This study investigated the aldosterone-renin ratio (ARR), plasma aldosterone concentration (PAC), and plasma renin activity (PRA) to determine the optimal cutoff values for PA diagnosis in patients with OSAHS combined with RH.

Methods

Patients diagnosed with moderate and severe OSAHS combined with RH were recruited from the inpatient clinic of the Department of Endocrinology at Ji'an Central Hospital between October 2020 and April 2023. The included patients were divided into PA and no-PA groups. Diagnostic accuracy measures were calculated for each group, and receiver operating characteristic (ROC) curves were generated.

Results

A total of 241 patients were included, of which 103 had positive ARR screening results in the diagnostic accuracy analysis and 66 were diagnosed with PA. PAC and ARR showed moderate predictive capacity for PA, with area under the curve (AUC) values of 0.66 [95% confidence interval (CI): 0.55-0.77] and 0.72 (95% CI: 0.63-0.82), respectively, while PRA exhibited a limited predictive capacity (AUC = 0.51, 95% CI: 0.40-0.63). Using 45 as the optimal cutoff value for ARR, the sensitivity was 86% and the specificity was 52%. The optimal cutoff value for PAC was 17, with a sensitivity of 78% and a specificity of 55%. Notably, in patients with severe OSAHS, ARR at screening demonstrated significant predictive value for PA, with an AUC of 0.84 (95% CI: 0.72-0.96), a sensitivity of 85%, and a specificity of 76%. Conversely, in patients with moderate OSAHS, only ARR demonstrated significant predictive value for PA diagnosis, while PAC did not demonstrate notable diagnostic value.

Conclusion

ARR and PAC are initial screening tools for PA, facilitating early detection, particularly in low-resource settings. In patients with OSAHS and RH, the ARR and PAC thresholds for PA diagnosis may require more stringent adjustment.

Iatrogenic adrenal insufficiency in adults

Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.

Moderate salt restriction in primary aldosteronism improves bone metabolism through attenuation of urinary calcium and phosphate losses

Accumulating evidence links osteoporosis and dietary salt consumption. Primary aldosteronism (PA) is a model disease with increased dietary salt intake and constitutes an independent risk factor for osteoporosis. We, thus, assessed whether a short-term moderate reduction in salt intake in PA results in detectable osteoanabolic effects. Forty-one patients with PA on stable mineralocorticoid receptor antagonist therapy were subjected to a 12-week salt restriction. Serum and urinary electrolytes, markers of bone turnover, and a 15 steroids plasma profile were registered. After 12 weeks, urinary calcium and phosphate decreased, while plasma testosterone, serum phosphate, and bone alkaline phosphatase (BAP) all increased significantly. Longitudinal changes in BAP were independently correlated with changes in serum phosphate, parathyroid hormone, and urinary calcium in multivariate analysis. Salt restriction in PA limits urinary calcium and phosphate losses and may confer favorable osteoanabolic effects. Our findings suggest that salt restriction should be considered in patients with PA to improve bone health.

Association of adrenal steroids with metabolomic profiles in patients with primary and endocrine hypertension

Introduction

Endocrine hypertension (EHT) due to pheochromocytoma/paraganglioma (PPGL), Cushing's syndrome (CS), or primary aldosteronism (PA) is linked to a variety of metabolic alterations and comorbidities. Accordingly, patients with EHT and primary hypertension (PHT) are characterized by distinct metabolic profiles. However, it remains unclear whether the metabolomic differences relate solely to the disease-defining hormonal parameters. Therefore, our objective was to study the association of disease defining hormonal excess and concomitant adrenal steroids with metabolomic alterations in patients with EHT.

Methods

Retrospective European multicenter study of 263 patients (mean age 49 years, 50% females; 58 PHT, 69 PPGL, 37 CS, 99 PA) in whom targeted metabolomic and adrenal steroid profiling was available. The association of 13 adrenal steroids with differences in 79 metabolites between PPGL, CS, PA and PHT was examined after correction for age, sex, BMI, and presence of diabetes mellitus.

Results

After adjustment for BMI and diabetes mellitus significant association between adrenal steroids and metabolites - 18 in PPGL, 15 in CS, and 23 in PA - were revealed. In PPGL, the majority of metabolite associations were linked to catecholamine excess, whereas in PA, only one metabolite was associated with aldosterone. In contrast, cortisone (16 metabolites), cortisol (6 metabolites), and DHEA (8 metabolites) had the highest number of associated metabolites in PA. In CS, 18-hydroxycortisol significantly influenced 5 metabolites, cortisol affected 4, and cortisone, 11-deoxycortisol, and DHEA each were linked to 3 metabolites.

Discussions

Our study indicates cortisol, cortisone, and catecholamine excess are significantly associated with metabolomic variances in EHT versus PHT patients. Notably, catecholamine excess is key to PPGL's metabolomic changes, whereas in PA, other non-defining adrenal steroids mainly account for metabolomic differences. In CS, cortisol, alongside other non-defining adrenal hormones, contributes to these differences, suggesting that metabolic disorders and cardiovascular morbidity in these conditions could also be affected by various adrenal steroids.

Effect of mild cortisol cosecretion on body composition and metabolic parameters in patients with primary hyperaldosteronism

OBJECTIVE

To investigate the effects of simultaneous cortisol cosecretion (CCS) on body composition in computed tomography (CT)-imaging and metabolic parameters in patients with primary aldosteronism (PA) with the objective of facilitating early detection.

DESIGN

Retrospective cohort study.

PATIENTS

Forty-seven patients with PA and CCS confirmed by 1-mg dexamethasone suppression test (DST) with a cutoff of ≥1.8 µg/dL were compared with PA patients with excluded CCS (non-CCS, n = 47) matched by age and sex.

METHODS

Segmentation of the fat compartments and muscle area at the third lumbar region was performed on non-contrast-enhanced CT images with dedicated segmentation software. Additionally, liver, spleen, pancreas and muscle attenuation were compared between the two groups.

RESULTS

Mean cortisol after DST was 1.2 µg/dL (33.1 nmol/L) in the non-CCS group and 3.2 µg/dL (88.3 nmol/L) in the CCS group with mild autonomous cortisol excess (MACE). No difference in total, visceral and subcutaneous fat volumes was observed between the CCS and non-CCS group (p = .7, .6 and .8, respectively). However, a multivariable regression analysis revealed a significant correlation between total serum cholesterol and results of serum cortisol after 1-mg DST (p = .026). Classification of the patients based on visible lesion on CT and PA-lateralization via adrenal venous sampling also did not show any significant differences in body composition.

CONCLUSION

MACE in PA patients does not translate into body composition changes on CT-imaging. Therefore, early detection of concurrent CCS in PA is currently only attainable through biochemical tests. Further investigation of the long-term clinical adverse effects of MACE in PA is necessary.

Urine steroid metabolomics as a diagnostic tool in primary aldosteronism

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.

The value of plasma metanephrine measurements during adrenal vein sampling

Objective

The assessment of primary aldosteronism incorporates adrenal vein sampling (AVS) to lateralize aldosterone excess. Current adrenal vein sampling protocols rely on concurrent cortisol measurements to assess successful cannulation and lateralization and may be inaccurate in the setting of autonomous cortisol secretion. We aimed to compare the measurement of plasma cortisol and metanephrine concentrations to assess cannulation and lateralization during AVS.

Design

This is a diagnostic accuracy study in a tertiary referral endocrinology department.

Methods

Forty-one consecutive patients with confirmed primary aldosteronism undergoing AVS (49 procedures) were included. None had cortisol autonomy. The use of plasma metanephrine-based ratios were compared with standard cortisol-based ratios to assess cannulation and lateralization during ACTH-stimulated AVS.

Results

There was strong agreement between a cortisol selectivity index (SI) ≥5.0 and an adrenal vein (AV) to peripheral vein (PV) plasma metanephrine ratio (AVmet-PVmet) of ≥12.0 to indicate successful cannulation of the AV (n = 117, sensitivity 98%, specificity 89%, positive predictive value (PPV) 95%, negative predictive value (NPV) 94%). There was strong agreement between the standard cortisol-based SI and an AV plasma metanephrine-to-normetanephrine ratio (AVmet-AVnormet) of ≥2.0 to indicate successful cannulation (n = 117, sensitivity 93%, specificity 86%, PPV 94%, NPV 84%). There was strong agreement between the cortisol- or metanephrine-derived lateralization index (LI) > 4.0 for determining lateralization (n = 26, sensitivity 100%, specificity 94.1%, PPV 91.6%, NPV 100%).

Conclusions

Ratios incorporating plasma metanephrines provide comparable outcomes to standard cortisol-based measurements for interpretation of AVS. Further studies are required to assess the use of metanephrine-derived ratios in the context of confirmed cortisol autonomy.

Significance statement

Primary aldosteronism is a common cause of secondary hypertension, and adrenal vein sampling remains the gold standard test to assess lateralization. Cortisol-derived ratios to assess cannulation and lateralization may be affected by concurrent cortisol dysfunction, which is not uncommon in the context of primary aldosteronism. Our study showed comparable outcomes when using accepted cortisol-derived or metanephrine-derived ratios to determine cannulation and lateralization during adrenal vein sampling. Further research is required to validate these findings and to assess the use of metanephrine-derived ratios in the context of confirmed concurrent cortisol dysfunction.

Single-Nucleus Analysis Reveals Tumor Heterogeneity of Aldosterone-Producing Adenoma

BACKGROUND

Recent advances in omics techniques have allowed detailed genetic characterization of aldosterone-producing adenoma (APA). The pathogenesis of APA is characterized by tumorigenesis-associated aldosterone synthesis. The pathophysiological intricacies of APAs have not yet been elucidated at the level of individual cells. Therefore, a single-cell level analysis is speculated to be valuable in studying the differentiation process of APA.

METHODS

We conducted single-nucleus RNA sequencing of APAs with KCNJ5 mutation and nonfunctional adenomas obtained from 3 and 2 patients, respectively.

RESULTS

The single-nucleus RNA sequencing revealed the intratumoral heterogeneity of APA and identified cell populations consisting of a shared cluster of nonfunctional adenoma and APA. In addition, we extracted 2 cell fates in APA and obtained a cell population specialized in aldosterone synthesis. Genes related to ribosomes and neurodegenerative diseases were upregulated in 1 of these fates, whereas those related to the regulation of glycolysis were upregulated in the other fate. Furthermore, the total RNA reads in the nucleus were higher in hormonally activated clusters, indicating a marked activation of transcription per cell.

CONCLUSIONS

The single-nucleus RNA sequencing revealed intratumoral heterogeneity of APA with KCNJ5 mutation. The observation of 2 cell fates in KCNJ5-mutated APAs provides the postulation that a heterogeneous process of cellular differentiation was implicated in the pathophysiological mechanisms underlying APA tumors.

Clinical significance of CYP11B2 immunostaining in unilateral primary aldosteronism

Objective

The associations between adrenal histopathology, lateralization studies, and surgical outcomes in primary aldosteronism remain poorly characterized. We examined the value of immunohistochemical analysis of CYP11B2 for evaluation of adrenalectomy outcomes after anatomical versus functional subtyping.

Design

A retrospective multicenter study of 277 patients operated for primary aldosteronism who had an adrenalectomy sample available in the Finnish biobanks from 1 January 2000 to 31 December 2019. Adrenal slides from biobanks were analyzed centrally after CYP11B2 and CYP11B1 staining. Clinical data were obtained from patient registries. Histopathological diagnosis and cure after surgery were assessed as outcome measures.

Results

Re-evaluation with CYP11B2 staining changed the histopathological diagnosis in 91 patients (33%). The presence of a CYP11B2-positive adenoma and the use of functional subtyping independently predicted clinical cure of primary aldosteronism. CYP11B2-positive <7 mm nodules were more frequent in patients without clinical cure, whereas CYP11B2-positive micronodules were common in all patients and had no impact on adrenalectomy outcomes. Small CYP11B2-positive nodules and micronodules were equally prevalent regardless of the subtyping method applied. Clinical cure rates were lower and CYP11B2-negative adenomas more common after adrenalectomy based on anatomical imaging than functional studies.

Conclusions

Incorporating CYP11B2 staining in histopathological diagnosis enhances the prediction of surgical outcomes in primary aldosteronism. A finding of CYP11B2-positive adenoma is indicative of cure of primary aldosteronism, whereas smaller CYP11B2-positive nodules associate with poorer results at postoperative evaluation. Functional subtyping methods decrease the operations of CYP11B2-negative adenomas and are superior to anatomical imaging in identifying unilateral primary aldosteronism.

Steroid profiling in adrenal disease

The measurement of steroid hormones in blood and urine, which reflects steroid biosynthesis and metabolism, has been recognized as a valuable tool for identifying and distinguishing steroidogenic disorders. The application of mass spectrometry enables the reliable and simultaneous analysis of large panels of steroids, ushering in a new era for diagnosing adrenal diseases. However, the interpretation of complex hormone results necessitates the expertise and experience of skilled clinicians. In this scenario, machine learning techniques are gaining worldwide attention within healthcare fields. The clinical values of combining mass spectrometry-based steroid profiles analysis with machine learning models, also known as steroid metabolomics, have been investigated for identifying and discriminating adrenal disorders such as adrenocortical carcinomas, adrenocortical adenomas, and congenital adrenal hyperplasia. This promising approach is expected to lead to enhanced clinical decision-making in the field of adrenal diseases. This review will focus on the clinical performances of steroid profiling, which is measured using mass spectrometry and analyzed by machine learning techniques, in the realm of decision-making for adrenal diseases.

Treating Primary Aldosteronism-Induced Hypertension: Novel Approaches and Future Outlooks

Primary aldosteronism (PA) is the most common cause of secondary hypertension and is associated with increased morbidity and mortality when compared with blood pressure-matched cases of primary hypertension. Current limitations in patient care stem from delayed recognition of the condition, limited access to key diagnostic procedures, and lack of a definitive therapy option for nonsurgical candidates. However, several recent advances have the potential to address these barriers to optimal care. From a diagnostic perspective, machine-learning algorithms have shown promise in the prediction of PA subtypes, while the development of noninvasive alternatives to adrenal vein sampling (including molecular positron emission tomography imaging) has made accurate localization of functioning adrenal nodules possible. In parallel, more selective approaches to targeting the causative aldosterone-producing adrenal adenoma/nodule (APA/APN) have emerged with the advent of partial adrenalectomy or precision ablation. Additionally, the development of novel pharmacological agents may help to mitigate off-target effects of aldosterone and improve clinical efficacy and outcomes. Here, we consider how each of these innovations might change our approach to the patient with PA, to allow more tailored investigation and treatment plans, with corresponding improvement in clinical outcomes and resource utilization, for this highly prevalent disorder.

Cross-Disciplinary Approach of Adrenal Tumors: Insights into Primary Aldosteronism-Related Mineral Metabolism Status and Osteoporotic Fracture Risk

Our objective was to overview the novel aspects in the field of adrenal gland neoplasms, namely, the management of bone status with respect to primary aldosteronism (PA). In the current narrative review, a PubMed study was conducted from inception until June 2023. The inclusion criteria were: human (clinically relevant) studies of any study design (at least 10 patients per study); English papers; and the following combination of key words within the title and/or abstract: "aldosterone" AND "bone", "skeleton", "osteoporosis", "fracture", "calcium", "parathyroid", "DXA", "osteocalcin", "P1NP", "alkaline phosphatase", "bone marker", "trabecular bone score", or "FRAX". The exclusion criteria were in vitro or animal studies, reviews, and case reports/series. We screened 1027 articles and finally included 23 studies (13 of case-control type, 3 cross-sectional, 5 prospective, 1 observational cohort, and 1 retrospective study). The assessments provided in these studies were as follows: nine studies addressed Dual-Energy X-ray Absorptiometry (DXA), another study pointed out a bone microarchitecture evaluation underlying trabecular bone score (TBS), and seven studies investigated the bone turnover markers (BTMs) profile. Moreover, 14 studies followed the subjects after adrenalectomy versus medical treatment, and 21 studies addressed secondary hyperparathyroidism in PA patients. According to our study on published data during a period of almost 40 years (n = 23, N = 3965 subjects aged between 38 and 64, with a mean age 56.75, and a female-to-male ratio of 1.05), a higher PTH in PA versus controls (healthy persons or subjects with essential hypertension) is expected, secondary hyperparathyroidism being associated in almost half of the adults diagnosed with PA. Additionally, mineral metabolism anomalies in PA may include lower serum calcium and higher urinary calcium output, all these three parameters being reversible under specific therapy for PA, regardless medical or surgical. The PA subgroup with high PTH seems at higher cardiovascular risk, while unilateral rather than bilateral disease was prone to this PTH anomaly. Moreover, bone mineral density (BMD) according to central DXA might show a higher fracture risk only in certain adults, TBS being a promising alternative (with a still unknown perspective of diabetes' influence on DXA-TBS results in PA). However, an overall increased fracture prevalence in PA is described in most studies, especially with respect to the vertebral site, the fracture risk that seems correctable upon aldosterone excess remission. These data recommend PA as a cause of secondary osteoporosis, a treatable one via PA intervention. There is still an area of debate the way to address BMTs profile in PA, the case's selection toward specific bone evaluation in every day practice, and further on, the understanding of the potential genetic influence at the level of bone and mineral complications in PA patients.

Assessing the cardiovascular events and clinical outcomes of COVID-19 on patients with primary aldosteronism

BACKGROUND

Primary Aldosteronism (PA) is a common subtype of hypertension that increases the risk of adverse cardiovascular and kidney events. The impact of COVID-19 on patients with PA is not well understood. This study aimed to investigate the impact of COVID-19 on patients with PA and compare their outcomes with hypertensive patients with essential hypertension.

METHODS

A cohort study was conducted using data from the Trinetx platform, including 9,817,307 participants enrolled between January 1, 2020, and July 31, 2022. The study group consisted of participants who tested positive for PCR SARS-CoV-2. The primary outcome was critical care and all-cause mortality, while the secondary outcomes were major adverse cardiac events (MACE) or major adverse kidney events (MAKE). The study included 4814 patients with PA and 4814 hypertensive controls.

RESULTS

Patients with PA had a higher risk of critical outcomes than the hypertensive control group (adjusted hazard ratio [aHR] 1.14, p = 0.001). Moreover, they had higher risks of MACE (aHR 1.32, p < 0.001) and MAKE (aHR 1.36, p < 0.001) for up to 180 days after COVID-19. The analysis of the aHR as a horizon plot after discharge showed that patients with pre-existing PA and COVID-19 had the highest risk of critical outcomes at 7 months (aHR = 1.21), MACE (aHR = 1.35) at 9 months, and MAKE (aHR = 1.47) at 10 months compared to those with EH.

CONCLUSIONS

This study provides a comprehensive analysis of the cardiovascular impact of the COVID-19 pandemic on individuals with PA. The findings underscore the increased risk of mortality, critical care, MACE, and MAKE among patients with PA and COVID-19. The study highlights the need for continued optimization of strategies for follow-up care for patients with PA after SARS-CoV-2 infections.

Approaching Primary Aldosteronism as a Common Disease

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.

The prevalence of primary and secondary hyperparathyroidism and its cardiometabolic implications in primary aldosteronism

BACKGROUND

The aim of this study was to analyze the prevalence of primary and secondary hyperparathyroidism in patients with primary aldosteronism (PA), and its implication on cardiovascular and metabolic outcomes.

METHODS

A retrospective study of patients with PA (exposed cohort, N.=44) and all hypertensive (EH) patients with adrenal lesions without PA nor other adrenal hypersecretion (non-exposed cohort, N.=41) on follow-up at our center between 2016 and 2020.

RESULTS

The mean age of patients with PA and EH was 55.1±14.13 and 66.3±10.93 (P<0.001), and 50% of PA and 39.0% of EH were women (P=0.309). At diagnosis, the prevalence of primary hyperparathyroidism in PA was of 18.2%, and all were normocalcemic hyperparathyroidism cases. Globally, no differences were found in the prevalence of primary hyperparathyroidism compared to EH (18.2% vs. 29.3%, P=0.229), but hypercalcemic primary hyperparathyroidism was significantly more prevalent in EH patients than in PA (22.0% vs. 0%, P=0.001). There were 47.7% (N.=21) cases of secondary hyperparathyroidism in patients with PA (4 due to chronic kidney disease (CKD) and vitamin D deficiency, and 17 due to vitamin D deficiency alone). The cardiometabolic profile of patients with PA and hyperparathyroidism (N.=29) was similar to of those patients without hyperparathyroidism (N.=15) at diagnosis and after a median follow-up of 3.6 years (interquartile range 1.1-5.9).

CONCLUSIONS

Although primary and secondary hyperparathyroidism are common in patients with PA, their prevalence was similar than the observed in EH patients. Primary hyperparathyroidism is usually mild in PA, appearing as normocalcemic forms. No negative implications of the hyperparathyroidism in the cardiometabolic profile of PA were observed.

Epidemiology and Management of Hypertension and Diabetes Mellitus in Patients with Mild Autonomous Cortisol Secretion: A Review

Mild autonomous cortisol secretion (MACS) is associated with a higher cardiometabolic risk than that observed in patients with nonfunctioning adrenal adenomas and in the general population. In patients with MACS, the excess of glucocorticoids affects various metabolic pathways, leading to different manifestations of metabolic syndrome and other comorbidities. Hypertension and diabetes mellitus are two of the most common cardiometabolic comorbidities associated with MACS, reaching a prevalence of up to 80% and up to 40%, respectively. In addition, they are the comorbidities that experienced a greater improvement after adrenalectomy in patients with MACS. Hypertension pathogenesis is multifactorial, including the coexistence of comorbidities such as obesity or diabetes and the role of the different polymorphisms of the glucocorticoid receptor gene, among others. Glucocorticoid-induced diabetes mellitus is mainly related to the detrimental effects of glucocorticoids on insulin-dependent glucose uptake in peripheral tissues, gluconeogenesis and insulin secretion. There are no specific recommendations for hypertension and diabetes treatment in patients with MACS. Thus, considering the similar underlying pathogenesis of hypertension and diabetes mellitus in overt and mild hypercortisolism, our recommendation is to follow this general stepwise approach: surgically remove the adrenal culprit lesion to induce remission from hypercortisolism; control hypercortisolism with steroidogenesis inhibitors; and treat elevated blood pressure or high glucose levels using carefully selected anti-hypertensives and glucose-lowering medications if blood pressure and glucose levels remain uncontrolled, respectively. In this review, we summarize the epidemiology, physiopathology and management of diabetes mellitus and hypertension in patients with MACS.

Developmental programming: Impact of preconceptional and gestational exposure to a real-life environmental chemical mixture on maternal steroid, cytokine and oxidative stress milieus in sheep

BACKGROUND

Gestational exposure to environmental chemicals (ECs) is associated with adverse, sex-specific offspring health effects of global concern. As the maternal steroid, cytokine and oxidative stress milieus can have critical effects on pregnancy outcomes and the programming of diseases in offspring, it is important to study the impact of real-life EC exposure, i.e., chronic low levels of mixtures of ECs on these milieus. Sheep exposed to biosolids, derived from human waste, is an impactful model representing the ECs humans are exposed to in real-life. Offspring of sheep grazed on biosolids-treated pasture are characterized by reproductive and metabolic disruptions.

OBJECTIVE

To determine if biosolids exposure disrupts the maternal steroid, cytokine and oxidative stress milieus, in a fetal sex-specific manner.

METHODS

Ewes were maintained before mating and through gestation on pastures fertilized with biosolids (BTP), or inorganic fertilizer (Control). From maternal plasma collected mid-gestation, 19 steroids, 14 cytokines, 6 oxidative stress markers were quantified. Unpaired t-test and ANOVA were used to test for differences between control and BTP groups (n = 15/group) and between groups based on fetal sex, respectively. Correlation between the different markers was assessed by Spearman correlation.

RESULTS

Concentrations of the mineralocorticoids - deoxycorticosterone, corticosterone, the glucocorticoids - deoxycortisol, cortisol, cortisone, the sex steroids - androstenedione, dehydroepiandrosterone, 16-OH-progesterone and reactive oxygen metabolites were higher in the BTP ewes compared to Controls, while the proinflammatory cytokines IL-1β and IL-17A and anti-inflammatory IL-36RA were decreased in the BTP group. BTP ewes with a female fetus had lower levels of IP-10.

DISCUSSION

These findings suggest that pre-conceptional and gestational exposure to ECs in biosolids increases steroids, reactive oxygen metabolites and disrupts cytokines in maternal circulation, likely contributors to the aberrant phenotypic outcomes seen in offspring of BTP sheep - a translationally relevant precocial model.