The diagnosis and treatment of primary hyperaldosteronism in Germany: results on 555 patients from the German Conn Registry

Etiology and Management of Treatment-Resistant Hypertension in African American Adults ≥18 Years: A Literature Review

Treatment-resistant hypertension (TRH) is defined as blood pressure levels that remain above the therapeutic goal despite concurrent use of three or more antihypertensive medications taken at maximally tolerated doses, one of which should be a diuretic. Additionally, individuals on four or more antihypertensive agents regardless of blood pressure are also considered to have TRH. Amongst people diagnosed with TRH, African American adults face a huge management gap, resulting in increased cardiovascular disease risk. The primary objective of this review was to identify the commonly encountered etiologies and extensively discuss the current management strategies of TRH with a particular focus on African Americans. Relevant studies were identified by analyzing scientific databases and journals such as PubMed, Cochrane, MEDLINE, Cureus, and American Heart Association (AHA). The studies identified and examined common causes of TRH, describing their pathophysiology and highlighting different treatment options for the respective etiologies. The most prevalent etiologies of TRH amongst African Americans were chronic kidney disease (CKD), renal artery stenosis (RAS), fibromuscular dysplasia, obstructive sleep apnea (OSA), endocrine causes (Conn syndrome, Cushing syndrome, etc.), sympathetic nervous system overactivity, lifestyle factors, inaccurate blood pressure measurement, and inappropriate treatment. Of the etiologies reviewed, OSA, lifestyle factors, and CKD exhibited a striking prevalence among the subpopulation studied. Unfortunately, there was a paucity of articles addressing this topic amongst African Americans, and therefore there was not a substantial appreciation of the prevalence of some of the identified etiologies in the population of interest. Thorough diagnostic testing for associated or underlying conditions provides a basis for successful management. This review brought to the fore the need for doctors and patients to collaborate in order to improve TRH management and help patients lead healthier lives.

Reversible facial nerve paralysis in a cat suspected to be associated with systemic hypertension

Case summary

This report describes the appearance of facial nerve paralysis in a 16-year-old hypertensive cat. MRI was helpful in visualising and characterising mesencephalic and facial nerve lesions thought to be induced by hypertension. Neurological signs rapidly resolved under antihypertensive therapy.

Relevance and novel information

Systemic hypertension is an important medical condition in geriatric cats causing damage in various target organs, including the brain. Hypertensive encephalopathy is an umbrella term for a multitude of different clinical manifestations of cerebral target organ damage. Facial nerve paralysis secondary to hypertension is recognised in human medicine, particularly in children, but so far has not been reported in veterinary medicine.

The Management of Primary Hyperaldosteronism in a Poor Technology Environment

We report a case of Conn's adenoma in a 35-year-old female successfully managed in a poor hospital technology environment.

Survey of renin and aldosterone testing practices by Ontario laboratories - Providing insight into best practices

Objectives

Testing for renin and aldosterone in clinical laboratories is complicated by pre-analytical considerations such as the posture for blood collection and susceptibility to cryoactivation of renin. From an analytical perspective, there are both renin activity and renin mass or concentration assays available. There can also be variability in result reporting practices and the aldosterone-renin ratio (ARR) cut-off applied to screen for primary aldosteronism (PA). The Institute for Quality Management in Healthcare (IQMH) Centre for Proficiency Testing surveyed laboratories on their handling of renin and aldosterone testing to better understand current practices.

Design and methods

An online survey was prepared and sent to 134 Canadian laboratories enrolled in endocrinology proficiency testing with IQMH.

Results

One hundred twenty Ontario laboratories submitted responses. While only six (5%) laboratories perform testing for both renin and aldosterone, 108 (90%) collect and process specimens to be tested by reference laboratories. The survey revealed considerable variation in practices including the recommended state of patients prior to sample collection (for example, regarding medications or salt intake), the patient posture specifications for sample collection, the precautions taken against cryoactivation of renin, the choice of renin activity or mass assay, and the ARR cut-off used. The available literature on these factors was then reviewed.

Conclusions

Although there is no standardized procedure for specimen collection, analysis, or result reporting for renin or aldosterone testing, we have attempted to summarize the available literature to develop evidence-based recommendations. Where laboratory practice differs from peers and/or recommended protocols, laboratories should review their practices.

Ten tips for a text-mining-ready article: How to improve automated discoverability and interpretability

Data-driven research in biomedical science requires structured, computable data. Increasingly, these data are created with support from automated text mining. Text-mining tools have rapidly matured: although not perfect, they now frequently provide outstanding results. We describe 10 straightforward writing tips—and a web tool, PubReCheck—guiding authors to help address the most common cases that remain difficult for text-mining tools. We anticipate these guides will help authors’ work be found more readily and used more widely, ultimately increasing the impact of their work and the overall benefit to both authors and readers. PubReCheck is available at http://www.ncbi.nlm.nih.gov/research/pubrecheck.

Your published research is already being processed with automated tools, and text mining will become more common; this Community Page article describes how you can help these tools process your work more accurately, including a web tool, PubReCheck.

The Impact of Glucocorticoid Co-Secretion in Primary Aldosteronism on Thyroid Autoantibody Titers During the Course of Disease

Excess aldosterone is associated with the increased risk of cardio-/cerebrovascular events as well as metabolic comorbidities not only due to its hypertensive effect but also due to its proinflammatory action. Autonomous cortisol secretion (ACS) in the setting of primary aldosteronism (PA) is known to worsen cardiovascular outcome and potentially exhibit immunosuppressive effects. The aim of this study was to determine the impact of ACS status in patients with PA on kinetics of thyroid autoantibodies (anti-TPO, anti-TG) pre and post therapy initiation. Ninety-seven PA patients (43 unilateral, 54 with bilateral PA) from the database of the German Conn's Registry were included. Anti-TPO and anti-TG levels were measured pre and 6-12 months post therapeutic intervention. Patients were assessed for ACS according to their 24- hour urinary cortisol excretion, late night salivary cortisol and low-dose dexamethasone suppression test. Abnormal test results in line with ACS were identified in 74.2% of patients with PA. Following adrenalectomy, significant increases in anti-TPO levels were observed in patients with at least one abnormal test (p = 0.049), adrenalectomized patients with at least two pathological ACS tests (p = 0.015) and adrenalectomized patients with pathologic dexamethasone suppression tests (p = 0.018). No antibody increases were observed in unilateral PA patients without ACS and in patients with bilateral PA receiving mineralocorticoid antagonist therapy (MRA). Our data are in line with an immunosuppressive effect of mild glucocorticoid excess in PA on thyroid autoantibody titers. This effect is uncovered by adrenalectomy, but not by MRA treatment.

Adrenal Tumors: Are Gender Aspects Relevant?

The distribution of malignant tumors is strongly related to gender due to sex-related organ and tissue differentiation. Neoplasias of the adrenal glands are relatively common and typically benign. Mainly based on our recently published contributions, we analyzed the influence of gender on type of tumors, complexity of surgery, and long-term outcome. Cortisol-secreting adrenal tumors are more often diagnosed in female patients, while the incidence of Conn's syndrome and pheochromocytoma is similar between male and female patients. Adrenalectomy is more difficult in male patients because of longer operating time and higher blood loss. The probability of cure in male patients with Conn's syndrome is significantly lower. Gender does not influence long-term results in adrenal hypercortisolism and pheochromocytomas.

Effects of chronically high levels of aldosterone on different cognitive dimensions: an investigation in patients with primary aldosteronism

Primary aldosteronism is a natural model for chronic aldosterone excess in humans and associated with symptoms of anxiety and depression. Cognitive deficits are inherent to the symptomatology of depression and anxiety disorders. Mineralocorticoid receptors and aldosterone appear to play a role in memory. Aldosterone was additionally supposed to be a risk factor for cognitive decline in patients with essential hypertension. The objective of this study was to investigate possible effects of chronically high aldosterone concentrations on cognitive function. A range of cognitive dimensions were assessed in 19 patients (9 males, 10 females); mean age 47.1 (12.5) under standardized treatment and several rating scales for anxiety, depression, quality of life and sleep were administered. Cognitive parameters were compared to standard norms from a large, healthy standardization sample. Patients showed increased levels of anxiety and depression without meeting diagnostic criteria for a disorder. Besides a numerically lower attention score, patients did not show any significant differences in the cognitive dimensions. Anxiety and depression were negatively correlated with quantitative performance in males. In females, a negative correlation between sleep disturbances and abstract reasoning and a positive correlation with quantitative performance were found. Our data showed no specific effect of chronic aldosterone in the tested cognitive parameters overall at least in younger patients, but they indicate sexually dimorphic regulation processes.

Panic Attacks in HYPERALDOSTERONISM

Panic attacks and panic disorders are common in the general population. However, the presence of panic attacks associated with primary hyperaldosteronism has been rarely documented. We describe a patient with new-onset hyperaldosteronism secondary to adrenal adenoma who presented with recurrent panic attacks. The patient underwent adenoma resection, which was the definitive cure for the patient's hyperaldosteronism and panic attacks. Clinicians should include hyperaldosteronism on the differential for medical etiologies of panic attacks. Further research is needed to elucidate the mechanistic relationship between primary hyperaldosteronism and panic attacks.

Prevalence of Somatic KCNJ5 Mutations in Thai Patients With Aldosterone-Producing Adrenal Adenomas

Somatic KCNJ5 mutations result in excess aldosterone production and are reported to be more common in Asia than elsewhere. To assess the prevalence of somatic KCNJ5 mutations in Thai patients with aldosterone-producing adrenal adenomas (APAs) in a single tertiary center, we analyzed the paraffin-embedded tissue of KCNJ5 mutations from 96 patients with sporadic APAs who underwent unilateral laparoscopic adrenalectomy at our center during 2007 to 2016. We also assessed the clinical characteristics, treatment outcomes, and biochemistry and histologic differences among patients with and without somatic KCNJ5 mutations. Of the 96 patients with APA, 67 (70%) had somatic mutations of the KCNJ5 gene: 39 patients with p.G151R, 26 patients with p.L168R, one patient with p.T158A, and one patient with p.W126R. All patients presented with hypertension. Hypokalemia was documented in 98% of patients. The hypertension cure rate at 1 year after surgery was 35%. Patients with somatic KCNJ5 mutations required more potassium supplementation and had adrenal histology compatible with zona fasciculata–like cells compared with patients without the mutations (all P < 0.05). There were no significant differences in preoperative plasma aldosterone concentration (PAC), plasma renin activity, aldosterone/renin ratio, potassium level, treatment of hypertension, tumor size, and hypertension cure rate among patients in the KCNJ5-mutant and nonmutant groups. In a multivariate analysis, a higher PAC was associated with the presence of somatic KCNJ5 mutations. In summary, the prevalence of somatic KCNJ5 mutations in patients with sporadic APAs in Thailand, an Asian country with residents of different ethnic backgrounds, is comparable to previous reports in Asia.

CT mapping of the vertebral level of right adrenal vein

PURPOSE

We aimed to evaluate the accuracy of multidetector computed tomography (MDCT) venous mapping for the localization of the right adrenal veins (RAV) in patients suffering from primary aldosteronism.

METHODS

MDCT scans of 75 patients with primary aldosteronism between March 2008 and November 2011 were evaluated by two readers (a junior [R1] and a senior [R2] radiologist) according to the following criteria: quality of RAV depiction (scale, 1-5), localization of the RAV confluence with regard to the inferior vena cava, and depiction of anatomical variants. Results were compared with RAV venograms obtained during adrenal vein sampling and corroborated by laboratory testing of cortisol in selective RAV blood samples. Kappa statistics were calculated for interobserver agreement and for concordance of MDCT mapping with the gold standard.

RESULTS

Successful RAV sampling was achieved in 69 of 75 patients (92%). Using MDCT mapping, adrenal veins could be visualized in 78% (R1, 54/69) and 77% (R2, 53/69) of patients. MDCT mapping led to correct identification of RAV in 70% (R1, 48/69) and 88% (R2, 61/69) of patients. Venograms revealed five cases of anatomical variants, which were correctly identified in 60% (R1, R2). MDCT-based localizations were false or misleading in 16% (R1, 11/69) and 7% (R2, 5/69) of cases.

CONCLUSION

Preinterventional MDCT mapping may facilitate successful catheterization in adrenal vein sampling.

Clinical Outcomes following Percutaneous Radiofrequency Ablation of Unilateral Aldosterone-Producing Adenoma: Comparison with Adrenalectomy

PURPOSE

To compare adrenal radiofrequency (RF) ablation with adrenalectomy in treating unilateral aldosterone-producing adenoma (APA).

MATERIALS AND METHODS

Between April 2008 and September 2013, 44 patients with adrenal venous sampling-confirmed (lateralization index ≥ 4) unilateral APA underwent adrenal RF ablation (12/44 [27%]) or adrenalectomy (32/44 [73%]). Outcomes of adrenal RF ablation (patient age, 51 y ± 11; 4/12 men) were compared with adrenalectomy (patient age, 50 y ± 11; 19/32 men). Blood pressure (145/94 mm Hg ± 19/13 vs 144/89 mm Hg ± 10/8, P = .92), number of antihypertensives (3.0 ± 1.3 vs 2.7 ± 0.89, P = .38), and serum potassium (3.2 mEq/L ± 0.6 vs 3.5 mEq/L ± 0.6, P = .65) of patients were similar before treatment.

RESULTS

RF ablation and adrenalectomy resulted in normokalemia (RF ablation, 4.2 mEq/L ± 0.1, P = .0004; adrenalectomy, 4.3 mEq/L ± 0.6, P < .0001) and normotension (RF ablation, 129/81 mm Hg ± 11/11, P = .02/P = .001; adrenalectomy, 128/85 mm Hg ± 13/12, P < .0001/P = .07) in all patients. Proportions of RF ablation and adrenalectomy patients cured of hypertension (2/12 [17%] vs 12/32 [38%], P = .28) or requiring fewer antihypertensives (7/12 [58%] vs 13/32 [40%], P = .29) were similar. RF ablation patients had a shorter length of stay (0.6 d ± 0.8 [range, 0-2 d] vs 1.7 d ± 1.4 [range, 0-7 d]; P = .01) and less intraoperative blood loss (1.2 mL ± 3 vs 40 mL ±85; P = .01). Procedural complications occurred in 5/32 (15%) adrenalectomy patients (2 major, 3 minor) and in 0/12 RF ablation patients.

CONCLUSIONS

RF ablation to treat APA can achieve similar clinical outcomes as adrenalectomy and results in shorter hospital stays. Larger, prospective trials are needed to validate these results.

European Adrenal Insufficiency Registry (EU-AIR): a comparative observational study of glucocorticoid replacement therapy

BACKGROUND

Increased morbidity and mortality associated with conventional glucocorticoid replacement therapy for primary adrenal insufficiency (primary AI; estimated prevalence 93-140/million), secondary AI (estimated prevalence, 150-280/million, respectively) or congenital adrenal hyperplasia (estimated prevalence, approximately 65/million) may be due to the inability of typical glucocorticoid treatment regimens to reproduce the normal circadian profile of plasma cortisol. A once-daily modified-release formulation of hydrocortisone has been developed to provide a plasma cortisol profile that better mimics the daytime endogenous profile of cortisol. Here, we describe the protocol for the European Adrenal Insufficiency Registry (EU-AIR), an observational study to assess the long-term safety of modified-release hydrocortisone compared with conventional glucocorticoid replacement therapies in routine clinical practice (ClinicalTrials.gov identifier: NCT01661387).

METHODS

Patients enrolled in EU-AIR have primary or secondary AI and are receiving either modified-release or conventional glucocorticoid replacement therapy. The primary endpoints of EU-AIR are the incidence of intercurrent illness, adrenal crisis and serious adverse events (SAEs), as well as the duration of SAEs and dose changes related to SAEs. Data relating to morbidity, mortality, adverse drug reactions, dosing and concomitant therapies will be collected. Patient diaries will record illness-related dose changes between visits. All decisions concerning medical care are made by the registry physician and patient. Enrolment is targeted at achieving 3600 patient-years of treatment (1800 patient-years per group) for the primary analysis, which is focused on determining the non-inferiority of once-daily modified-release replacement therapy compared with conventional glucocorticoid therapy.

RESULTS

Recruitment began in August 2012 and, as of March 2014, 801 patients have been enrolled. Fifteen centres are participating in Germany, the UK and Sweden, with recruitment soon to be initiated in the Netherlands.

CONCLUSIONS

EU-AIR will provide a unique opportunity not only to collect long-term safety data on a modified-release preparation of glucocorticoid but also to evaluate baseline data on conventional glucocorticoid replacement. Such data should help to improve the treatment of AI.

Could mineralocorticoids play a role in the pathophysiology of open angle glaucoma?

Since the pathomechanisms of primary open angle glaucoma are still not defined, different aspects related to this topic have to be discussed and further investigated. Possible candidates are the mineralocorticoids, which are known to lower intraocular pressure. A data search and personal investigations assume a limited role of mineralocorticoids for the development of glaucoma. Specific experiments for a final conclusion are, however, not yet performed.

[Use of C-arm CT for improving the hit rate for selective blood sampling from adrenal veins]

Primary hyperaldosteronism is the most common curable cause of hypertension with a prevalence of up to 12% among patients with hypertension. Selective blood sampling from adrenal veins is considered the diagnostic gold standard. However, it is underutilized due to the high technical failure rate. The use of C-arm CT during the sampling procedure can reduce or even eliminate this failure rate. If adrenal vein sampling is augmented by native C-arm CT to check for the correct catheter position, the technical success rate increases substantially. General use of this technique will result in correct diagnosis and treatment for patients with primary hyperaldosteronism.