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Eisenhofer G, Pamporaki C, Lenders JWM. Biochemical Assessment of Pheochromocytoma and Paraganglioma. Endocr Rev 2023; 44:862-909. [PMID: 36996131 DOI: 10.1210/endrev/bnad011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/24/2023] [Accepted: 03/29/2023] [Indexed: 03/31/2023]
Abstract
Pheochromocytoma and paraganglioma (PPGL) require prompt consideration and efficient diagnosis and treatment to minimize associated morbidity and mortality. Once considered, appropriate biochemical testing is key to diagnosis. Advances in understanding catecholamine metabolism have clarified why measurements of the O-methylated catecholamine metabolites rather than the catecholamines themselves are important for effective diagnosis. These metabolites, normetanephrine and metanephrine, produced respectively from norepinephrine and epinephrine, can be measured in plasma or urine, with choice according to available methods or presentation of patients. For patients with signs and symptoms of catecholamine excess, either test will invariably establish the diagnosis, whereas the plasma test provides higher sensitivity than urinary metanephrines for patients screened due to an incidentaloma or genetic predisposition, particularly for small tumors or in patients with an asymptomatic presentation. Additional measurements of plasma methoxytyramine can be important for some tumors, such as paragangliomas, and for surveillance of patients at risk of metastatic disease. Avoidance of false-positive test results is best achieved by plasma measurements with appropriate reference intervals and preanalytical precautions, including sampling blood in the fully supine position. Follow-up of positive results, including optimization of preanalytics for repeat tests or whether to proceed directly to anatomic imaging or confirmatory clonidine tests, depends on the test results, which can also suggest likely size, adrenal vs extra-adrenal location, underlying biology, or even metastatic involvement of a suspected tumor. Modern biochemical testing now makes diagnosis of PPGL relatively simple. Integration of artificial intelligence into the process should make it possible to fine-tune these advances.
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Affiliation(s)
- Graeme Eisenhofer
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jacques W M Lenders
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands
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Pamporaki C, Prejbisz A, Małecki R, Pistrosch F, Peitzsch M, Bishoff S, Mueller P, Meyer I, Reimann D, Hanus K, Januszewicz A, Bornstein SR, Parmentier S, Kunath C, Lenders JWM, Eisenhofer G, Passauer J. Optimized procedures for testing plasma metanephrines in patients on hemodialysis. Sci Rep 2021; 11:14706. [PMID: 34282182 PMCID: PMC8290036 DOI: 10.1038/s41598-021-94104-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/05/2021] [Indexed: 11/15/2022] Open
Abstract
Diagnosis of pheochromocytomas and paragangliomas in patients receiving hemodialysis is troublesome. The aim of the study was to establish optimal conditions for blood sampling for mass spectrometric measurements of normetanephrine, metanephrine and 3-methoxytyramine in patients on hemodialysis and specific reference intervals for plasma metanephrines under the most optimal sampling conditions. Blood was sampled before and near the end of dialysis, including different sampling sites in 170 patients on hemodialysis. Plasma normetanephrine concentrations were lower (P < 0.0001) and metanephrine concentrations higher (P < 0.0001) in shunt than in venous blood, with no differences for 3-methoxytyramine. Normetanephrine, metanephrine and 3-methoxytyramine concentrations in shunt and venous blood were lower (P < 0.0001) near the end than before hemodialysis. Upper cut-offs for normetanephrine were 34% lower when the blood was drawn from the shunt and near the end of hemodialysis compared to blood drawn before hemodialysis. This study establishes optimal sampling conditions using blood from the dialysis shunt near the end of hemodialysis with optimal reference intervals for plasma metanephrines for the diagnosis of pheochromocytomas/paragangliomas among patients on hemodialysis.
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Affiliation(s)
- Christina Pamporaki
- Department of Medicine ΙΙI, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
| | | | - Robert Małecki
- Department of Nephrology, Centre of Uronephrology, Międzylesie Clinical Hospital, Warsaw, Poland
| | | | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | | | | | - Iris Meyer
- Dialysis Center Heidenau, Heidenau, Germany
| | - Doreen Reimann
- Kidney/Hypertension/Rheumatology Center, Dresden, Germany
| | | | | | - Stefan R Bornstein
- Department of Medicine ΙΙI, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Simon Parmentier
- Department of Medicine ΙΙI, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Carola Kunath
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Jacques W M Lenders
- Department of Medicine ΙΙI, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany.,Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Graeme Eisenhofer
- Department of Medicine ΙΙI, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany.,Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Jens Passauer
- Department of Medicine ΙΙI, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
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Kline GA, Boyd J, Leung AA, Tang A, Sadrzadeh HM. Moderate renal impairment does not preclude the accuracy of 24-hour urine normetanephrine measurements for suspected pheochromoctyoma. Clin Endocrinol (Oxf) 2020; 92:518-524. [PMID: 32133686 DOI: 10.1111/cen.14180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/19/2020] [Accepted: 02/26/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE A 24-hour urine nor/metanephrine (urine NM-MN) measurements are a recommended first step in pheochromocytoma diagnosis. We hypothesized the presence of renal impairment (CKD) significantly confounds the results obtained in a urine NM-MN collection, giving artificially lower measurements. DESIGN Retrospective review of a comprehensive laboratory database with all urine NM-MN results from Southern Alberta from 2010 to 2018 (n = 15 505). After excluding high probability pheochromocytoma cases, results from patients with three levels of CKD (n = 796) were compared to those without CKD to determine the potential CKD effect. PATIENTS All patients having urine NM-MN collection during the time period, irrespective of ordering physician or test indication. MEASUREMENTS Urine NM-MN was measured by liquid chromatography-tandem mass spectrometry and glomerular filtration rate determined within a median of 1.9 days, as estimated by CKD-EPI equation. RESULTS In subjects with mild-to-moderate renal impairment, there was no continuous gradient between subnormal renal function and urine NM-MN measures. When the estimated GFR was < 15 mL/min/m2 , the hypothesized effect on lowered urine NM-MN became apparent. CONCLUSIONS A 24-hour urine NM-MN measurement is unlikely to be affected by mild-to-moderate renal impairment and may be used as a reliable diagnostic test. With more advanced renal impairment, CKD-specific reference ranges or an alternative test may be needed.
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Affiliation(s)
- Gregory A Kline
- Department of Medicine/Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jessica Boyd
- Department of Clinical Pathology and Lab Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Public Laboratories, Calgary, AB, Canada
| | - Alex A Leung
- Department of Medicine/Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew Tang
- Department of Medicine/Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Hossein M Sadrzadeh
- Department of Clinical Pathology and Lab Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Public Laboratories, Calgary, AB, Canada
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Pires NM, Igreja B, Moura E, Wright LC, Serrão MP, Soares-da-Silva P. Blood pressure decrease in spontaneously hypertensive rats folowing renal denervation or dopamine β-hydroxylase inhibition with etamicastat. Hypertens Res 2015; 38:605-12. [PMID: 25854989 DOI: 10.1038/hr.2015.50] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 02/01/2015] [Accepted: 02/20/2015] [Indexed: 01/04/2023]
Abstract
Overactivity of the sympathetic nervous system has an important role in the development and progression of arterial hypertension. Catheter-based renal nerve ablation for the treatment of drug-resistant hypertension has recently been developed. An alternative strategy for the modulation of sympathetic nerve function is to reduce the biosynthesis of noradrenaline (NA) by inhibiting dopamine β-hydroxylase (DβH), the enzyme that catalyzes the conversion of dopamine (DA) to NA in the sympathetic nerves. Renal denervation (RDN) surgery was performed in spontaneously hypertensive rats (SHR) to evaluate the effect of RDN on the DA and NA levels and on blood pressure over a 28-day period. The selective peripheral DβH inhibitor etamicastat (30 mg kg (-1)day(-1)) was administered to another cohort of SHR. RDN and etamicastat treatment had no effect on the renal function, as assessed by measuring the water balance response, renal function and urinary electrolyte levels. RDN significantly decreased the systolic blood pressure (SBP) and the diastolic blood pressure (DBP). A gradual return of the SBP and the DBP to the high baseline levels was observed over time. Conversely, treatment with etamicastat resulted in a significant decrease in the SBP and the DBP at all time points. On the last day of the assessment, NA levels in renal tissue were significantly decreased in both RDN and etamicastat-treated groups. In contrast, the NA levels in the left ventricle were decreased only in the etamicastat-treated group. Thus, RDN produces transitory decreases in blood pressure, whereas prolonged downregulation of sympathetic drive with the DβH inhibitor etamicastat results in a sustained decrease in the SBP and the DBP.
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Affiliation(s)
- Nuno Miguel Pires
- Department of Research & Development, BIAL-Portela & Ca, S.A., S. Mamede do Coronado, Portugal
| | - Bruno Igreja
- Department of Research & Development, BIAL-Portela & Ca, S.A., S. Mamede do Coronado, Portugal
| | - Eduardo Moura
- Department of Research & Development, BIAL-Portela & Ca, S.A., S. Mamede do Coronado, Portugal
| | | | - Maria Paula Serrão
- Department of Pharmacology & Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal.,MedInUP - Center for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal
| | - Patrício Soares-da-Silva
- Department of Research & Development, BIAL-Portela & Ca, S.A., S. Mamede do Coronado, Portugal.,Department of Pharmacology & Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal.,MedInUP - Center for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal
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Roberts NB, Higgins G, Sargazi M. A study on the stability of urinary free catecholamines and free methyl-derivatives at different pH, temperature and time of storage. Clin Chem Lab Med 2010; 48:81-7. [DOI: 10.1515/cclm.2010.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Eisenhofer G, Huysmans F, Pacak K, Walther MM, Sweep FCGJ, Lenders JWM. Plasma metanephrines in renal failure. Kidney Int 2005; 67:668-77. [PMID: 15673315 DOI: 10.1111/j.1523-1755.2005.67123.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Diagnosis of pheochromocytoma in renal failure poses a diagnostic dilemma due to lack of reliability of conventional urinary measurements of catecholamine excess. Measurements of the plasma metanephrines, normetanephrine and metanephrine (the O-methylated metabolites of norepinephrine and epinephrine), provide an alternative diagnostic test. The metanephrines may be measured as free metabolites or after a deconjugation step where measurements reflect mainly sulfate-conjugated metabolites. The influence of renal insufficiency states on these various measurements is unclear. METHODS Plasma free and deconjugated metanephrines and catecholamines in 17 patients on dialysis with end-stage renal disease and 19 patients with renal insufficiency (creatinine clearance, 5-78 mL/min) were compared with levels in 89 hypertensives, 68 healthy normotensives, and 51 patients with von Hippel-Lindau syndrome. RESULTS Patients with renal failure had up to two-fold higher plasma concentrations of catecholamines and free metanephrines, and more than 12-fold higher plasma concentrations of deconjugated metanephrines than comparison groups. Plasma free metanephrines and catecholamines were, respectively, within the 95% confidence intervals of reference groups in 75% and 42% of the dialysis patients, and in 74% and 68% of patients with renal insufficiency. In contrast, no dialysis patient and only half the renal insufficiency patients had plasma levels of deconjugated metanephrines within the reference intervals. Plasma levels of deconjugated metanephrines, but not free metanephrines, showed strong inverse relationships with creatinine clearance. CONCLUSION Plasma concentrations of free metanephrines are relatively independent of renal function and are, therefore, more suitable for diagnosis of pheochromocytoma among patients with renal failure than measurements of deconjugated metanephrines.
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Affiliation(s)
- Graeme Eisenhofer
- Clinical Neurocardiology Section, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland 20892-1620, USA.
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Abbott KC, Bakris GL. Treatment of the diabetic patient: focus on cardiovascular and renal risk reduction. PROGRESS IN BRAIN RESEARCH 2002; 139:289-98. [PMID: 12436944 DOI: 10.1016/s0079-6123(02)39025-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Diabetes mellitus increases the risk for hypertension and associated cardiovascular diseases, including coronary, cerebrovascular, renal and peripheral vascular disease. The risk for developing cardiovascular disease is increased when both diabetes and hypertension co-exist; in fact, over 11 million Americans have both diabetes and hypertension. These numbers will continue to climb, internationally, since the leading associated risk for diabetes development, obesity, has reached epidemic proportions, globally. Moreover, the frequent association of diabetes with dyslipidemia, as well as coagulation, endothelial, and metabolic abnormalities also aggravates the underlying vascular disease process in patients who possess these comorbid conditions. The renin-angiotensin-aldosterone system (RAS) and arginine vasopressin (AVP) are overactivated in both hypertension and diabetes. Drugs that inhibit this system, such as ACE inhibitors and more recently angiotensin receptor antagonists (ARBs), have proven beneficial effects on the micro- and macrovascular complications of diabetes, especially the kidney. The BRILLIANT study showed that lisinopril reduces microalbuminuria better than CCB therapy. Numerous other long-term studies confirm this association with ACE inhibitors including the HOPE trial. Furthermore, the European Controlled trial of Lisinopril in Insulin-dependent Diabetes (EUCLID) study, showed that lisinopril slowed the progression of renal disease, even in individuals with mild albuminuria. In fact, there are now five appropriately powered randomized placebo-controlled trials to show that both ACE inhibitors and ARBs slow progression of diabetic nephropathy in people with type 2 diabetes. These effects were shown to be better than conventional blood pressure lowering therapy, including dihydropyridine CCBs. In patients with microalbuminuria, ACE inhibitors and ARBs reduce the progression of microalbuminuria to proteinuria and provide a risk reduction of between 38 and 60% for progression to proteinuria. This is important since microalbuminuria is known to be associated with increased vascular permeability and decreased responsiveness to vasodilatory stimuli. Recently, increased AVP levels have been lined to microalbuminuria and hyperfiltration in diabetes. The microvascular and macrovascular benefits of ACE inhibition, ARBs and possible role of AVP antagonists in diabetic patients will be discussed, as will be recommendations for its clinical use.
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Affiliation(s)
- Kevin C Abbott
- Nephrology Service, Walter Reed Army Medical Center, Washington, DC, USA
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