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Vaidya A. The Promise of Nuclear Imaging as an Alternative to Adrenal Venous Sampling for the Detection of Aldosterone-producing Adenomas. J Clin Endocrinol Metab 2024; 109:e1363-e1364. [PMID: 37697945 DOI: 10.1210/clinem/dgad542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/08/2023] [Indexed: 09/13/2023]
Affiliation(s)
- Anand Vaidya
- Center for Adrenal Disorders, Brigham and Women's Hospital, Division of Endocrinology, Diabetes, and Hypertension, Harvard Medical School, Boston, MA 02115, USA
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Pitt B, Vaidya A. Moving Forward by Looking Backwards: The Role of Combination Therapy With a Mineralocorticoid Receptor Antagonist and a Thiazide Diuretic in Patients With Hypertension. Am J Hypertens 2024; 37:261-263. [PMID: 38198751 DOI: 10.1093/ajh/hpae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/06/2024] [Indexed: 01/12/2024] Open
Affiliation(s)
- Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Anand Vaidya
- Division of Endocrinology, Diabetes, and Hypertension, Center for Adrenal Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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Parksook WW, Brown JM, Omata K, Tezuka Y, Ono Y, Satoh F, Tsai LC, Niebuhr Y, Milks J, Moore A, Honzel B, Liu H, Auchus RJ, Sunthornyothin S, Turcu AF, Vaidya A. The Spectrum of Dysregulated Aldosterone Production: An International Human Physiology Study. J Clin Endocrinol Metab 2024:dgae145. [PMID: 38450549 DOI: 10.1210/clinem/dgae145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 03/08/2024]
Abstract
CONTEXT Primary aldosteronism is a form of low-renin hypertension characterized by dysregulated aldosterone production. OBJECTIVE To investigate the contributions of renin-independent aldosteronism, and ACTH-mediated aldosteronism, in individuals with a low-renin phenotype representing the entire continuum of blood pressure.. DESIGN/PARTICIPANTS Human physiology study of 348 participants with a low-renin phenotype with severe and/or resistant hypertension, hypertension with hypokalemia, elevated blood pressure and stage I/II hypertension, and normal blood pressure. SETTING 4 international centers.. INTERVENTIONS/MAIN OUTCOME MEASURES Saline suppression test (SST) to quantify the magnitude of renin-independent aldosteronism; dexamethasone suppression and ACTH-stimulation tests to quantify the magnitude of ACTH-mediated aldosteronism; adrenal venous sampling to determine lateralization. RESULTS There was a continuum of non-suppressible and renin-independent aldosterone production following SST that paralleled the magnitude of the blood pressure continuum and transcended conventional diagnostic thresholds. In parallel, there was a full continuum of ACTH-mediated aldosteronism wherein post-SST aldosterone levels were strongly correlated with ACTH-stimulated aldosterone production (r = 0.75, P < 0.0001) and non-suppressible aldosterone production post-dexamethasone (r = 0.40, P < 0.0001). Beyond participants who met criteria for primary aldosteronism (post-SST aldosterone of ≥10 ng/dL or ≥277 pmol/L), the continuum of non-suppressible and renin-independent aldosterone production persisted below this diagnostic threshold, wherein 15% still had lateralizing aldosteronism amenable to surgical adrenalectomy, and the remainder were treated with mineralocorticoid receptor antagonists. CONCLUSIONS In the context of a low-renin phenotype, there is a continuum of dysregulated aldosterone production that is prominently influenced by ACTH. A large proportion of individuals with low-renin have dysregulated aldosterone production and may benefit from aldosterone-directed therapy.
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Affiliation(s)
- Wasita W Parksook
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Endocrinology and Metabolism and Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Division of General Internal Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kei Omata
- Department of Diabetes, Metabolism and Endocrinology, Tohoku University Hospital, Sendai, Japan
- Division of Nephrology, Rheumatology and Endocrinology, Tohoku University, Sendai, Japan
| | - Yuta Tezuka
- Department of Diabetes, Metabolism and Endocrinology, Tohoku University Hospital, Sendai, Japan
- Division of Nephrology, Rheumatology and Endocrinology, Tohoku University, Sendai, Japan
| | - Yoshikiyo Ono
- Department of Diabetes, Metabolism and Endocrinology, Tohoku University Hospital, Sendai, Japan
- Division of Nephrology, Rheumatology and Endocrinology, Tohoku University, Sendai, Japan
| | - Fumitoshi Satoh
- Division of Nephrology, Rheumatology and Endocrinology, Tohoku University, Sendai, Japan
| | - Laura C Tsai
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yvonne Niebuhr
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julia Milks
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna Moore
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brooke Honzel
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Haiping Liu
- Departments of Internal Medicine and Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Richard J Auchus
- Departments of Internal Medicine and Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI, USA
- Pharmacology and Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI, USA
- Endocrinology & Metabolism Section, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI
| | - Sarat Sunthornyothin
- Division of Endocrinology and Metabolism and Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Adina F Turcu
- Departments of Internal Medicine and Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Turcu AF, Tezuka Y, Lim JS, Salman Z, Sehgal K, Liu H, Larose S, Parksook WW, Williams TA, Cohen DL, Wachtel H, Zhang J, Dorwal P, Satoh F, Yang J, Lacroix A, Reincke M, Giordano T, Udager A, Vaidya A, Rainey WE. Multifocal, Asymmetric Bilateral Primary Aldosteronism Cannot be Excluded by Strong Adrenal Vein Sampling Lateralization: An International Retrospective Cohort Study. Hypertension 2024; 81:604-613. [PMID: 38174562 PMCID: PMC10922262 DOI: 10.1161/hypertensionaha.123.21910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Primary aldosteronism (PA) has been broadly dichotomized into unilateral and bilateral forms. Adrenal vein sampling (AVS) lateralization indices (LI) ≥2 to 4 are the standard-of-care to recommend unilateral adrenalectomy for presumed unilateral PA. We aimed to assess the rates and characteristics of residual PA after AVS-guided adrenalectomy. METHODS We conducted an international, retrospective, cohort study of patients with PA from 7 referral centers who underwent unilateral adrenalectomy based on LI≥4 on baseline and/or cosyntropin-stimulated AVS. Aldosterone synthase (CYP11B2) immunohistochemistry and next generation sequencing were performed on available formalin-fixed paraffin-embedded adrenal tissue. RESULTS The cohort included 283 patients who underwent AVS-guided adrenalectomy, followed for a median of 326 days postoperatively. Lack of PA cure was observed in 16% of consecutive patients, and in 22 patients with lateralized PA on both baseline and cosyntropin-stimulated AVS. Among patients with residual PA postoperatively, 73% had multiple CYP11B2 positive areas within the resected adrenal tissue (versus 23% in those cured), wherein CACNA1D mutations were most prevalent (63% versus 33% in those cured). In adjusted regression models, independent predictors of postoperative residual PA included Black versus White race (odds ratio, 5.10 [95% CI, 1.45-17.86]), AVS lateralization only at baseline (odds ratio, 8.93 [95% CI 3.00-26.32] versus both at baseline and after cosyntropin stimulation), and CT-AVS disagreement (odds ratio, 2.75 [95% CI, 1.20-6.31]). CONCLUSIONS Multifocal, asymmetrical bilateral PA is relatively common, and it cannot be excluded by robust AVS lateralization. Long-term postoperative monitoring should be routinely pursued, to identify residual PA and afford timely initiation of targeted medical therapy.
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Affiliation(s)
- Adina F. Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, USA
| | - Yuta Tezuka
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Jung Soo Lim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Zara Salman
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, USA
| | - Kartik Sehgal
- Centre for Endocrinology and Metabolism, Department of Medicine, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Haiping Liu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, USA
| | - Stéphanie Larose
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Wasita Warachit Parksook
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Tracy Ann Williams
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany
| | - Debbie L Cohen
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Heather Wachtel
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Jinghong Zhang
- Centre for Endocrinology and Metabolism, Department of Medicine, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Pranav Dorwal
- Department of Pathology, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Fumitoshi Satoh
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Department of Medicine, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany
| | - Tom Giordano
- Department of Pathology, University of Michigan, Ann Arbor, USA
| | - Aaron Udager
- Department of Pathology, University of Michigan, Ann Arbor, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - William E. Rainey
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, USA
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Pitt B, Brown JM, Vaidya A, Diez J. Reassessing the management of hypertension: Time to prevent aldosterone-mediated heart failure. Eur J Heart Fail 2024; 26:195-198. [PMID: 38239030 DOI: 10.1002/ejhf.3141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/27/2023] [Accepted: 12/30/2023] [Indexed: 03/27/2024] Open
Affiliation(s)
- Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Javier Diez
- Center for Applied Medical Research (CIMA), and School of Medicine, University of Navarra, Pamplona, Spain
- Center for Network Biomedical Research of Cardiovascular Diseases (CIBERCV), Carlos III Institute of Health, Madrid, Spain
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Hundemer GL, Agharazii M, Madore F, Vaidya A, Brown JM, Leung AA, Kline GA, Larose E, Piché ME, Crean AM, Shaw JLV, Ramsay T, Hametner B, Wassertheurer S, Sood MM, Hiremath S, Ruzicka M, Goupil R. Subclinical Primary Aldosteronism and Cardiovascular Health: A Population-Based Cohort Study. Circulation 2024; 149:124-134. [PMID: 38031887 PMCID: PMC10841691 DOI: 10.1161/circulationaha.123.066389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Primary aldosteronism, characterized by overt renin-independent aldosterone production, is a common but underrecognized form of hypertension and cardiovascular disease. Growing evidence suggests that milder and subclinical forms of primary aldosteronism are highly prevalent, yet their contribution to cardiovascular disease is not well characterized. METHODS This prospective study included 1284 participants between the ages of 40 and 69 years from the randomly sampled population-based CARTaGENE cohort (Québec, Canada). Regression models were used to analyze associations of aldosterone, renin, and the aldosterone-to-renin ratio with the following measures of cardiovascular health: arterial stiffness, assessed by central blood pressure (BP) and pulse wave velocity; adverse cardiac remodeling, captured by cardiac magnetic resonance imaging, including indexed maximum left atrial volume, left ventricular mass index, left ventricular remodeling index, and left ventricular hypertrophy; and incident hypertension. RESULTS The mean (SD) age of participants was 54 (8) years and 51% were men. The mean (SD) systolic and diastolic BP were 123 (15) and 72 (10) mm Hg, respectively. At baseline, 736 participants (57%) had normal BP and 548 (43%) had hypertension. Higher aldosterone-to-renin ratio, indicative of renin-independent aldosteronism (ie, subclinical primary aldosteronism), was associated with increased arterial stiffness, including increased central BP and pulse wave velocity, along with adverse cardiac remodeling, including increased indexed maximum left atrial volume, left ventricular mass index, and left ventricular remodeling index (all P<0.05). Higher aldosterone-to-renin ratio was also associated with higher odds of left ventricular hypertrophy (odds ratio, 1.32 [95% CI, 1.002-1.73]) and higher odds of developing incident hypertension (odds ratio, 1.29 [95% CI, 1.03-1.62]). All the associations were consistent when assessing participants with normal BP in isolation and were independent of brachial BP. CONCLUSIONS Independent of brachial BP, a biochemical phenotype of subclinical primary aldosteronism is negatively associated with cardiovascular health, including greater arterial stiffness, adverse cardiac remodeling, and incident hypertension.
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Affiliation(s)
- Gregory L. Hundemer
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mohsen Agharazii
- Department of Medicine, Division of Nephrology, CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - François Madore
- Department of Medicine, Division of Nephrology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, QC, Canada
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jenifer M. Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander A. Leung
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gregory A. Kline
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eric Larose
- Department of Medicine, Division of Cardiology, Université Laval, Quebec City, QC, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Quebec City, QC, Canada
| | - Marie-Eve Piché
- Department of Medicine, Division of Cardiology, Université Laval, Quebec City, QC, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Quebec City, QC, Canada
| | - Andrew M. Crean
- Division of Cardiovascular Medicine, Ottawa Heart Institute, Ottawa, ON, Canada
| | - Julie L. V. Shaw
- Department of Pathology and Laboratory Medicine, Division of Biochemistry, Ottawa Hospital, Ottawa, ON, Canada
- Eastern Ontario Regional Laboratories Association, Ottawa, ON, Canada
| | - Tim Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bernhard Hametner
- Center for Health & Bioresources, AIT Austrian Institute of Technology, Vienna, Austria
| | | | - Manish M. Sood
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Swapnil Hiremath
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marcel Ruzicka
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Rémi Goupil
- Department of Medicine, Division of Nephrology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, QC, Canada
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Hundemer GL, Leung AA, Kline GA, Brown JM, Turcu AF, Vaidya A. Biomarkers to Guide Medical Therapy in Primary Aldosteronism. Endocr Rev 2024; 45:69-94. [PMID: 37439256 PMCID: PMC10765164 DOI: 10.1210/endrev/bnad024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/23/2023] [Accepted: 07/11/2023] [Indexed: 07/14/2023]
Abstract
Primary aldosteronism (PA) is an endocrinopathy characterized by dysregulated aldosterone production that occurs despite suppression of renin and angiotensin II, and that is non-suppressible by volume and sodium loading. The effectiveness of surgical adrenalectomy for patients with lateralizing PA is characterized by the attenuation of excess aldosterone production leading to blood pressure reduction, correction of hypokalemia, and increases in renin-biomarkers that collectively indicate a reversal of PA pathophysiology and restoration of normal physiology. Even though the vast majority of patients with PA will ultimately be treated medically rather than surgically, there is a lack of guidance on how to optimize medical therapy and on key metrics of success. Herein, we review the evidence justifying approaches to medical management of PA and biomarkers that reflect endocrine principles of restoring normal physiology. We review the current arsenal of medical therapies, including dietary sodium restriction, steroidal and nonsteroidal mineralocorticoid receptor antagonists, epithelial sodium channel inhibitors, and aldosterone synthase inhibitors. It is crucial that clinicians recognize that multimodal medical treatment for PA can be highly effective at reducing the risk for adverse cardiovascular and kidney outcomes when titrated with intention. The key biomarkers reflective of optimized medical therapy are unsurprisingly similar to the physiologic expectations following surgical adrenalectomy: control of blood pressure with the fewest number of antihypertensive agents, normalization of serum potassium without supplementation, and a rise in renin. Pragmatic approaches to achieve these objectives while mitigating adverse effects are reviewed.
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Affiliation(s)
- Gregory L Hundemer
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON K1H 8L6, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada
| | - Alexander A Leung
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Gregory A Kline
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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8
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Kovac V, Matias WR, Pyden A, Vaidya A, Johnson J. Uncovering a Hidden Threat. N Engl J Med 2023; 389:e55. [PMID: 38118027 DOI: 10.1056/nejmimc2306268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
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9
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Cohen DL, Wachtel H, Vaidya A, Hundemer GL, Tezuka Y, Davio A, Turcu AF, Cohen JB. Primary Aldosteronism in Chronic Kidney Disease: Blood Pressure Control and Kidney and Cardiovascular Outcomes After Surgical Versus Medical Management. Hypertension 2023; 80:2187-2195. [PMID: 37593884 DOI: 10.1161/hypertensionaha.123.21474] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/07/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Diagnosis and treatment of primary aldosteronism (PA) in chronic kidney disease (CKD) may be deferred due to limited evidence supporting safety and efficacy of treatment. Our goal was to assess clinical outcomes in patients with PA and CKD who received surgical or medical management. METHODS We conducted a multicenter, retrospective cohort study of patients with PA and CKD who underwent adrenal vein sampling from 2009-2019. We characterized clinical outcomes and evaluated differences by surgical versus medical management. Primary outcomes were systolic blood pressure and number of antihypertensive medications. Secondary outcomes were diastolic blood pressure, serum potassium, estimated glomerular filtration rate (eGFR), and kidney and cardiovascular events. Analyses were adjusted for age, sex, race, cardiovascular disease, diabetes, and eGFR. RESULTS Of 239 participants with PA and CKD, 158 (66%) underwent adrenalectomy, and 81 (34%) were treated medically. Mean age was 57±10 years, 67% were female, mean eGFR was 45±12 mL/min per 1.73 m2, and 49% were on potassium supplementation. At 5 years, mean blood pressure decreased from 149±22/85±14 to 131±28/78±16 mm Hg and mean number of antihypertensive medications decreased from 4.0±1.5 to 2.4±1.4. Adrenalectomy, compared to medical management, was associated with similar systolic blood pressure (-0.90 mm Hg [95% CI, -6.99 to 5.07]) but fewer medications (1.7 [95% CI, -2.24 to -1.10]), and no difference in potassium levels or kidney or cardiovascular outcomes. CONCLUSIONS Patients with PA and CKD are likely to benefit from either surgical adrenalectomy or medical management. Detection and treatment of PA may help to reduce blood pressure and medication burden in patients with CKD.
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Affiliation(s)
- Debbie L Cohen
- Renal-Electrolyte and Hypertension Division (D.L.C., J.B.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Heather Wachtel
- Department of Surgery (H.W.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Anand Vaidya
- Division of Endocrinology, Diabetes, and Hypertension, Center for Adrenal Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.V.)
| | - Gregory L Hundemer
- Division of Nephrology, Department of Medicine, Ottawa Hospital, University of Ottawa, ON, Canada (G.L.H.)
| | - Yuta Tezuka
- Division of Clinical Hypertension, Endocrinology and Metabolism (Y.T.), Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
- Division of Nephrology, Endocrinology and Vascular Medicine (Y.T.), Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Angela Davio
- Department of Medicine, University of Michigan, Ann Arbor (A.D., A.F.T.)
| | - Adina F Turcu
- Department of Medicine, University of Michigan, Ann Arbor (A.D., A.F.T.)
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division (D.L.C., J.B.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics (J.B.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Hubbard G, Hubert C, Vudayagiri L, Tullington J, Merino K, Vaidya A, Gemma R. Transversus abdominis plane blocks in laparoscopic inguinal hernia repair: a review. Hernia 2023; 27:1059-1065. [PMID: 37395916 DOI: 10.1007/s10029-023-02831-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/25/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION Throughout its history, there have been significant advances in pain control of inguinal hernia repairs. One of the most recent developments is locoregional pain blocks. There is a multitude of literature available on laparoscopic inguinal hernia repair and transversus abdominis plane (TAP) blocks. OBJECTIVES This paper seeks to provide a thorough and systematic literature review on the role of TAP blocks in laparoscopic inguinal hernia repairs. METHODS PubMed and Google Scholar were searched for relevant literature using predetermined medical subject heading (MeSH) terms: "(TAP block)" AND "(Laparoscopic inguinal hernia repair)". RESULTS A total of 166 publications were identified, from which 18 publications were included in the final review after eligibility criteria were applied. CONCLUSION The majority of studies conclude that TAP blocks performed in the setting of laparoscopic inguinal hernia repair improve post-operative pain and mobility, decrease opiate analgesic usage, and are superior in pain control compared to other modalities of regional anesthesia. Thus, to improve post-operative outcomes and patient satisfaction, TAP blocks should be heavily considered for routine use in surgical practice for laparoscopic inguinal hernia repair.
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Affiliation(s)
- G Hubbard
- Department of Surgery, Western Reserve Hospital, 1900 23rd St, Cuyahoga Falls, OH, 44223, USA.
- Department of Graduate Medical Education, Western Reserve Hospital, 1900 23rd St, Cuyahoga Falls, OH, 44223, USA.
| | - C Hubert
- Kirksville College of Osteopathic Medicine, A.T. Still University, 800 W. Jefferson St, Kirksville, MO, 63501, USA
| | - L Vudayagiri
- Department of Surgery, Western Reserve Hospital, 1900 23rd St, Cuyahoga Falls, OH, 44223, USA
| | - J Tullington
- Department of Surgery, University of Nevada-Las Vegas, 4505 S. Maryland Pkwy, Las Vegas, NV, 89154, USA
| | - K Merino
- Department of Surgery, Western Reserve Hospital, 1900 23rd St, Cuyahoga Falls, OH, 44223, USA
| | - A Vaidya
- Department of Surgery, Western Reserve Hospital, 1900 23rd St, Cuyahoga Falls, OH, 44223, USA
| | - R Gemma
- Department of Surgery, Western Reserve Hospital, 1900 23rd St, Cuyahoga Falls, OH, 44223, USA
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11
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Laffin LJ, Rodman D, Luther JM, Vaidya A, Weir MR, Rajicic N, Slingsby BT, Nissen SE. Aldosterone Synthase Inhibition With Lorundrostat for Uncontrolled Hypertension: The Target-HTN Randomized Clinical Trial. JAMA 2023; 330:1140-1150. [PMID: 37690061 PMCID: PMC10493865 DOI: 10.1001/jama.2023.16029] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023]
Abstract
Importance Excess aldosterone production contributes to hypertension in both classical hyperaldosteronism and obesity-associated hypertension. Therapies that reduce aldosterone synthesis may lower blood pressure. Objective To compare the safety and efficacy of lorundrostat, an aldosterone synthase inhibitor, with placebo, and characterize dose-dependent safety and efficacy to inform dose selection in future trials. Design, Setting, and Participants Randomized, placebo-controlled, dose-ranging trial among adults with uncontrolled hypertension taking 2 or more antihypertensive medications. An initial cohort of 163 participants with suppressed plasma renin (plasma renin activity [PRA] ≤1.0 ng/mL/h) and elevated plasma aldosterone (≥1.0 ng/dL) were enrolled, with subsequent enrollment of 37 participants with PRA greater than 1.0 ng/mL/h. Interventions Participants were randomized to placebo or 1 of 5 dosages of lorundrostat in the initial cohort (12.5 mg, 50 mg, or 100 mg once daily or 12.5 mg or 25 mg twice daily). In the second cohort, participants were randomized in a 1:6 ratio to placebo or lorundrostat, 100 mg once daily. Main Outcomes and Measures The primary end point was change in automated office systolic blood pressure from baseline to study week 8. Results Between July 2021 and June 2022, 200 participants were randomized, with final follow-up in September 2022. Following 8 weeks of treatment in participants with suppressed PRA, changes in office systolic blood pressure of -14.1, -13.2, -6.9, and -4.1 mm Hg were observed with 100 mg, 50 mg, and 12.5 mg once daily of lorundrostat and placebo, respectively. Observed reductions in systolic blood pressure in individuals receiving twice-daily doses of 25 mg and 12.5 mg of lorundrostat were -10.1 and -13.8 mm Hg, respectively. The least-squares mean difference between placebo and treatment in systolic blood pressure was -9.6 mm Hg (90% CI, -15.8 to -3.4 mm Hg; P = .01) for the 50-mg once-daily dose and -7.8 mm Hg (90% CI, -14.1 to -1.5 mm Hg; P = .04) for 100 mg daily. Among participants without suppressed PRA, 100 mg once daily of lorundrostat decreased systolic blood pressure by 11.4 mm Hg (SD, 2.5 mm Hg), which was similar to blood pressure reduction among participants with suppressed PRA receiving the same dose. Six participants had increases in serum potassium above 6.0 mmol/L that corrected with dose reduction or drug discontinuation. No instances of cortisol insufficiency occurred. Conclusions and Relevance Among individuals with uncontrolled hypertension, use of lorundrostat was effective at lowering blood pressure compared with placebo, which will require further confirmatory studies. Trial Registration ClinicalTrials.gov Identifier: NCT05001945.
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Affiliation(s)
- Luke J Laffin
- Cleveland Clinic Foundation, Cleveland, Ohio
- C5 Research, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - James M Luther
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anand Vaidya
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Steven E Nissen
- Cleveland Clinic Foundation, Cleveland, Ohio
- C5 Research, Cleveland Clinic Foundation, Cleveland, Ohio
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12
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Garfinkel AC, Vaidya A, Strymish J, Brecher SM, Saukkonen J. From the Heart. N Engl J Med 2023; 389:e14. [PMID: 37611125 DOI: 10.1056/nejmimc2214471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
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13
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Mansur A, Vaidya A, Turchin A. Using Renin Activity to Guide Mineralocorticoid Receptor Antagonist Therapy in Patients with Low Renin and Hypertension. Am J Hypertens 2023; 36:455-461. [PMID: 37013957 PMCID: PMC10345476 DOI: 10.1093/ajh/hpad032] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/21/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Mineralocorticoid receptor antagonists (MRAs) are often empirically used for patients with low-renin hypertension (LRH) or probable primary aldosteronism (PA) who decline surgery. However, the optimal approach to MRA therapy is unknown. Studies have shown that a rise in renin is an effective biomarker of prevention of cardiovascular complications of PA. This study aimed to determine whether empiric MRA therapy in patients with LRH or probable PA targeting unsuppressed renin is associated with a decrease in blood pressure and/or proteinuria. METHODS Retrospective single-center cohort study from 2005 to 2021 included adults with LRH or probable PA (renin activity <1.0 ng/ml/h and detectable aldosterone levels). All patients were empirically treated with an MRA, targeting renin ≥1.0 ng/ml/h. RESULTS Out of 39 patients studied, 32 (82.1%) achieved unsuppressed renin. Systolic and diastolic blood pressure decreased from 148.0 and 81.2 to 125.8 and 71.6 mm Hg, respectively (P < 0.001 for both). Similar blood pressure reductions were seen whether patients had high (>10 ng/dl) or low (<10 ng/dl) aldosterone levels. The majority (24/39; 61.5%) of patients had at least one baseline anti-hypertensive medication stopped. Among the six patients who had detectable proteinuria and albumin-to-creatinine (ACR) measurements post-treatment, the mean ACR decreased from 179.0 to 36.1 mg/g (P = 0.03). None of the patients studied had to completely stop treatment due to adverse reactions. CONCLUSIONS Empiric MRA therapy in patients with LRH or probable PA targeting unsuppressed renin can safely and effectively improve blood pressure control and reduce proteinuria.
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Affiliation(s)
- Arian Mansur
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Anand Vaidya
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander Turchin
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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14
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Valtis YK, Vaidya A, Azang-Njaah N, Boland MV. A Blurry Picture. N Engl J Med 2023; 388:e81. [PMID: 37379138 DOI: 10.1056/nejmimc2214278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
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15
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Hundemer GL, Imsirovic H, Kendzerska T, Vaidya A, Leung AA, Kline GA, Goupil R, Madore F, Agharazii M, Knoll G, Sood MM. Screening for Primary Aldosteronism Among Hypertensive Adults with Obstructive Sleep Apnea: A Retrospective Population-Based Study. Am J Hypertens 2023; 36:363-371. [PMID: 36827468 PMCID: PMC10267649 DOI: 10.1093/ajh/hpad022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/20/2023] [Accepted: 02/22/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Hypertension plus obstructive sleep apnea (OSA) is recommended in some guidelines as an indication to screen for primary aldosteronism (PA), yet prior data has brought the validity of this recommendation into question. Given this context, it remains unknown whether this screening recommendation is being implemented into clinical practice. METHODS We conducted a population-based retrospective cohort study of all adult Ontario (Canada) residents with hypertension plus OSA from 2009 to 2020 with follow-up through 2021 utilizing provincial health administrative data. We measured the proportion of individuals who underwent PA screening via the aldosterone-to-renin ratio by year. We further examined screening rates among patients with hypertension plus OSA by the presence of concurrent hypokalemia and resistant hypertension. Clinical predictors associated with screening were assessed via Cox regression modeling. RESULTS The study cohort included 53,130 adults with both hypertension and OSA, of which only 634 (1.2%) underwent PA screening. Among patients with hypertension, OSA, and hypokalemia, the proportion of eligible patients screened increased to 2.8%. Among patients ≥65 years with hypertension, OSA, and prescription of ≥4 antihypertensive medications, the proportion of eligible patients screened was 1.8%. Older age was associated with a decreased likelihood of screening while hypokalemia and subspecialty care with internal medicine, cardiology, endocrinology, or nephrology were associated with an increased likelihood of screening. No associations with screening were identified with sex, rural residence, cardiovascular disease, diabetes, or respirology subspecialty care. CONCLUSIONS The population-level uptake of the guideline recommendation to screen all patients with hypertension plus OSA for PA is exceedingly low.
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Affiliation(s)
- Gregory L Hundemer
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- ICES (formerly Institute for Clinical Evaluative Sciences), Ottawa, Canada
| | - Haris Imsirovic
- ICES (formerly Institute for Clinical Evaluative Sciences), Ottawa, Canada
| | - Tetyana Kendzerska
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- ICES (formerly Institute for Clinical Evaluative Sciences), Ottawa, Canada
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander A Leung
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregory A Kline
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rémi Goupil
- Division of Nephrology, Department of Medicine, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - François Madore
- Division of Nephrology, Department of Medicine, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Mohsen Agharazii
- Division of Nephrology, Department of Medicine, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Greg Knoll
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Manish M Sood
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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16
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Denu RA, Vaidya A, Pryor KP, Mitchell RN, Solomon DH. Thinking Outside the Heart. N Engl J Med 2023; 388:e60. [PMID: 37099344 DOI: 10.1056/nejmimc2214268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
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17
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Miklin D, Ravi K, Wolf-Doty T, Shekhtman G, Kobulnik J, Salimbangon A, Cartus R, Cochran A, Berg A, Ackerman M, Wolfson A, Vaidya A, Nattiv J, DePasquale E. Path to Eliminating Surveillance Endomyocardial Biopsies in Heart Transplant: Early Use of Donor Derived Cell-Free DNA - One Year Follow Up. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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18
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Nattiv J, Pandya K, Fong M, Vucicevic D, Hsu J, Lee R, Wolfson A, Deng M, Vaidya A, DePasquale E, Kamath M. A Multicenter Experience in the Use of Allomap and Allosure Surveillance Strategies in Multiorgan Heart-Kidney and Heart-Liver Transplantation. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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19
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Parksook WW, Heydarpour M, Brown JM, Turchin A, Mannstadt M, Vaidya A. Evaluating the clinical and mechanistic effects of eplerenone and amiloride monotherapy, and combination therapy with cinacalcet, in primary hyperparathyroidism: A placebo-controlled randomized trial. Clin Endocrinol (Oxf) 2023; 98:516-526. [PMID: 36316798 PMCID: PMC10006290 DOI: 10.1111/cen.14840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/23/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Human physiology and epidemiology studies have demonstrated complex interactions between the renin-angiotensin-aldosterone system, parathyroid hormone and calcium homeostasis. Several of these studies have suggested that aldosterone inhibition may lower parathyroid hormone (PTH) levels. The objective of this study was to assess the effect of 4 weeks of maximally tolerated mineralocorticoid receptor antagonist therapy with eplerenone on PTH levels in patients with primary hyperparathyroidism (P-HPT) when compared to amiloride and placebo. We also investigated the synergistic effect of these interventions when combined with cinacalcet for an additional 2 weeks. DESIGN Randomized, double-blinded, three parallel-group, placebo-controlled trial. PATIENTS Patients with P-HPT. RESULTS Most patients were women (83%) and White (76%). Maximally tolerated doses of eplerenone and amiloride induced significant reductions in blood pressure and increases in renin and aldosterone production; however, despite these physiologic changes, neither intervention induced significant changes in PTH or calcium levels when compared to the placebo. Both eplerenone and amiloride therapy induced significant reductions in procollagen type 1 N-terminal propeptide levels when compared to placebo. When cinacalcet therapy was added, PTH and calcium levels were markedly reduced in all groups; however, there was no significant difference in PTH or serum calcium reductions between groups. CONCLUSIONS Although maximally tolerated therapy with eplerenone and amiloride induced expected changes in renin, aldosterone and blood pressure, there were no meaningful changes in PTH or serum calcium levels in P-HPT patients. These results suggest that inhibition of aldosterone action does not have a clinically meaningful role in medical therapy for P-HPT.
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Affiliation(s)
- Wasita W. Parksook
- Center for Adrenal Disorders, Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Diabetes, and Hypertension, Harvard Medical School, Boston, MA, USA
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine (Division of Endocrinology and Metabolism, and Division of General Internal Medicine), Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Mahyar Heydarpour
- Division of Endocrinology, Diabetes, and Hypertension, Harvard Medical School, Boston, MA, USA
- Division of Cardiovascular Medicine, Harvard Medical School, Boston, MA, USA
| | - Jenifer M. Brown
- Center for Adrenal Disorders, Harvard Medical School, Boston, MA, USA
- Division of Cardiovascular Medicine, Harvard Medical School, Boston, MA, USA
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Turchin
- Division of Endocrinology, Diabetes, and Hypertension, Harvard Medical School, Boston, MA, USA
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Diabetes, and Hypertension, Harvard Medical School, Boston, MA, USA
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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20
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Pitt B, Vaidya A. Early Implementation of Aldosterone-Targeted Therapy in Patients With Hypertension. Circulation 2023; 147:991-992. [PMID: 36972341 DOI: 10.1161/circulationaha.123.064318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Affiliation(s)
- Bertram Pitt
- Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Anand Vaidya
- Center for Adrenal Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.V.)
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21
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Malishchak L, Vaidya A, Ostrominski J, Bry L, Maguire JH. A Rocky Resurgence. N Engl J Med 2023; 388:e20. [PMID: 36812437 DOI: 10.1056/nejmimc2204270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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22
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Wrenn SM, Moore AL, Shah HJ, Barletta JA, Vaidya A, Kilbridge KL, Doherty GM, Jacene HA, Nehs MA. Higher SUV max on FDG-PET is associated with shorter survival in adrenocortical carcinoma. Am J Surg 2023; 225:309-314. [PMID: 36137821 DOI: 10.1016/j.amjsurg.2022.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/29/2022] [Accepted: 08/27/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is an aggressive, rare malignancy. 2-deoxy-2-[18F]-fluoro-d-glucose positron emission tomography (FDG-PET) assesses tumor metabolism and glucose utilization. We hypothesized that higher maximum standard uptake value (SUVmax) is associated with decreased survival. METHODS We performed a retrospective analysis of patients with ACC. Included patients (n = 26) had an FDG-PET scan available with a documentable SUVmax. Patients were dichotomized into "High" (≥8.4, n = 12) and "Low" (<8.4, n = 14) SUVmax. Univariate analysis and survival analysis were performed to compare groups. RESULTS Demographics between groups were equivalent. The high SUVmax cohort demonstrated lower survival (median 479 days or 15.7 months) compared to the low group (median 1490 days or 48.6 months, p = .01). Log-Rank curve confirmed differences in survival (p = .007). CONCLUSIONS Higher SUVmax was associated with significantly worse survival in ACC and may reflect a more aggressive phenotype. FDG-PET may provide clinically useful information to determine prognosis and treatment. Further studies should prospectively evaluate using FDG-PET/CT in ACC.
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Affiliation(s)
- Sean M Wrenn
- .Brigham and Women's Hospital, Boston, MA, USA; .Rush University Medical Center, Chicago, IL, USA
| | | | - Hina J Shah
- .Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Kerry L Kilbridge
- .Brigham and Women's Hospital, Boston, MA, USA; .Dana-Farber Cancer Institute Lank Center for Genitourinary Oncology, USA.
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23
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Patel B, Pabon MA, Divakaran S, Vaidya A, Stewart G. A Brewing Storm. N Engl J Med 2022; 387:e72. [PMID: 36577102 DOI: 10.1056/nejmimc2117467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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24
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Vaidya A, Hundemer GL, Nanba K, Parksook WW, Brown JM. Primary Aldosteronism: State-of-the-Art Review. Am J Hypertens 2022; 35:967-988. [PMID: 35767459 PMCID: PMC9729786 DOI: 10.1093/ajh/hpac079] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022] Open
Abstract
We are witnessing a revolution in our understanding of primary aldosteronism (PA). In the past 2 decades, we have learned that PA is a highly prevalent syndrome that is largely attributable to pathogenic somatic mutations, that contributes to cardiovascular, metabolic, and kidney disease, and that when recognized, can be adequately treated with widely available mineralocorticoid receptor antagonists and/or surgical adrenalectomy. Unfortunately, PA is rarely diagnosed, or adequately treated, mainly because of a lack of awareness and education. Most clinicians still possess an outdated understanding of PA; from primary care physicians to hypertension specialists, there is an urgent need to redefine and reintroduce PA to clinicians with a modern and practical approach. In this state-of-the-art review, we provide readers with the most updated knowledge on the pathogenesis, prevalence, diagnosis, and treatment of PA. In particular, we underscore the public health importance of promptly recognizing and treating PA and provide pragmatic solutions to modify clinical practices to achieve this.
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Affiliation(s)
- Anand Vaidya
- Department of Medicine, Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Kazutaka Nanba
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Wasita W Parksook
- Department of Medicine, Division of Endocrinology and Metabolism, and Division of General Internal Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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25
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Auchus RJ, Bay CP, Honzel B, Luther JM, Peng D, Vaidya A, Yozamp N, Brown JM. OR20-3 Characterization of the Pathophysiologic Spectrum of Subclinical Primary Aldosteronism in Normotension. J Endocr Soc 2022. [PMCID: PMC9629410 DOI: 10.1210/jendso/bvac150.515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Abstract
Context
Accumulating evidence suggests that primary aldosteronism can manifest across a broad phenotypic spectrum and that its origins can at times be detected among normotensive individuals. Herein, we conducted deep-phenotyping studies to interrogate the pathophysiologic continuum of the primary aldosteronism phenotype among normotensive participants.
Methods
Normotensive participants with obesity, metabolic syndrome, and/or high-normal untreated blood pressure underwent dietary sodium loading and restriction protocols (to maximally suppress and stimulate angiotensin II-mediated aldosterone production), dexamethasone suppression and cosyntropin stimulation protocols (to maximally suppress and stimulate ACTH-mediated aldosterone production), and 24h ambulatory blood pressure monitoring. Measurement of aldosterone and 18-hybrid steroids via LC-MS/MS was conducted to quantify the degree of dysregulated CYP11B2 expression. Urinary extracellular vesicles (uEV) were isolated to measure renal tubular protein content associated with mineralocorticoid receptor activation. In order to characterize parameters across the severity spectrum of non-suppressible and renin-independent aldosterone production, participants with suppressed renin activity were categorized by tertile of 24h urinary aldosterone production following oral sodium suppression testing. Repeated measures linear mixed models were used to analyze trends for each parameter across tertiles of autonomous aldosterone production; for ease of presentation, the mean [SD] of the first vs. third tertile are presented for selected parameters.
Results
Following oral sodium loading, greater non-suppressible renin-independent aldosterone production was associated with greater kaliuresis, higher daytime ambulatory systolic blood pressure within the normal range, and a progressive impairment in the ability to suppress production of serum aldosterone (P-trend=0.009), 18-hydroxycorticosterone (9.3 [5.0] vs. 19.6 [6.5] ng/dL, P-trend=0.004), 18-hydroxycortisol (45.0 [25.4] vs. 70.9 [29.9] ng/dL, P-trend=0.03), and 18-oxocortisol (1.2 [0.03] vs. 3.4 [7.2], P-trend=0.01). Similarly, following dexamethasone suppression testing, there was a progressive inability to suppress 18-hydroxycorticosterone (8.3 [5.0] vs. 15.4 [8.2] ng/dL, P-trend=0.004), 18-hydroxycortisol (6.6 [3.8] vs. 10.2 [3.6] ng/dL, P-trend=0.03), and 18-oxocortisol (1.2 [0.01] vs. 1.4 [0.6] ng/dL, P-trend=0.01) in parallel with greater renin-independent aldosterone production. In contrast, following stimulation with cosyntropin, greater non-suppressible and renin-independent aldosterone production was associated with progressively enhanced production of 18-hydroxycorticosterone (77.6 [25.4] vs. 121.1 [31.1] ng/dL, P-trend=0.004), 18-hydroxycortisol (68.5 [28.4] vs. 86.2 [26.3] ng/dL, P-trend=0.03), and 18-oxocortisol (3.2 [2.8] vs. 7.3 [3.5] ng/dL, P-trend=0.01). Excretion of uEV's of pendrin (P=0.002) and aquaporin 2 (P=0.002) all increased with greater non-suppressible aldosterone production.
Conclusions
Dynamic phenotyping studies in normotensive individuals demonstrate a continuum of non-suppressible and renin-independent aldosterone production that parallels higher blood pressure, greater kaliuresis, increased 18-hybrid steroid production indicative of dysregulated CYP11B2 expression, and increased uEV excretion indicative of renal mineralocorticoid receptor activation. This pathophysiologic continuum of normotensive primary aldosteronism provides phenotypic support for histopathology studies showing ectopic CYP11B2 expression within adrenal glands of normotensive humans, and for epidemiologic studies demonstrating renin-independent aldosterone production in normotensive populations increases risk for developing hypertension.
Presentation: Monday, June 13, 2022 11:30 a.m. - 11:45 a.m.
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Yu K, Yu K, Ebbehoj AL, Obeid H, Vaidya A, Else T, Wachtel H, Main AM, Sondergaard E, Christensen LL, Juhlin C, Calissendorff J, Cohen D, Bennett B, Andersen MS, Larsson C, Almeida MQ, Boorjian SA, Young WF, Bancos I. RF33 | PSUN02 Presentation, Management, and Outcomes of Urinary Bladder Paraganglioma: Results from a Multi-center Study. J Endocr Soc 2022. [DOI: 10.1210/jendso/bvac150.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Abstract
Context and Objectives
Urinary bladder paraganglioma (UBPGL) is rare. We aimed to characterize the presentation and outcomes of patients diagnosed with UBPGL.
Methods
We conducted a multi-center study of consecutive patients with pathologically-confirmed UBPGL evaluated between 1971 and 2021. Outcomes included repeat bladder surgery, metastases, and disease-specific mortality.
Results
110 patients (56, 51% women) were diagnosed with UBPGL at a median age of 50 years (IQR, 36-61 years). Median tumor size was 2 cm (IQR, 1-4 cm). UBPGL was diagnosed prior to biopsy in only 37 (34%), and only 69 (63%) patients had evaluation for catecholamine excess. In addition to the initial bladder surgery, 26 (25%) required multiple therapies, including repeat surgery in 10 (9%). Synchronous metastases were present in 9 (8%) patients, and 24 (22%) other patients with UBPGL developed metachronous metastases at a median of 4 years (IQR, 2-10 years) after initial diagnosis. Development of metachronous metastases was associated with younger age (Hazard ratio, HR 0.97, 95%CI 0.94-0.99), UBPGL size (HR of 1.69, 95%CI of 1.31-2.17), and a higher degree of catecholamine excess (HR of 5.48, 95%CI of 1.40-21.39). Disease-specific mortality was higher in patients with synchronous metastases (HR of 20.80, 95%CI, 1.30-332.91). Choice of initial surgery, genetic association, sex, or presence of muscular involvement on pathology were not associated with development of metastases or mortality.
Conclusions
Only a minority of patients were diagnosed before biopsy/surgery, reflecting the need of better diagnostic strategies. All patients with UBPGL should be monitored life-long for development of recurrence and metastases.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Monday, June 13, 2022 12:48 p.m. - 12:53 p.m.
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Brown JM, Auchus RJ, Honzel B, Luther JM, Yozamp N, Vaidya A. PSUN51 Re-Calibrating Aldosterone Assay Interpretations: Immunoassay and Liquid Chromatography-Tandem Mass Spectrometry Measurements Across Multiple Controlled Physiologic Conditions. J Endocr Soc 2022. [PMCID: PMC9628008 DOI: 10.1210/jendso/bvac150.522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Abstract
Background
Clinicians frequently rely on aldosterone thresholds derived from older immunoassays to diagnose primary aldosteronism. However, liquid chromatography tandem mass spectrometry (LC-MS/MS) is in increasingly widespread clinical use and has been reported to yield lower aldosterone concentrations. Given that primary aldosteronism is highly prevalent and morbid, yet rarely diagnosed, incorrect interpretations of aldosterone levels can have significant public health impact. To address the potential for incorrect interpretations across the entire dynamic range of aldosterone physiology, we compared aldosterone measurements using LC-MS/MS and immunoassay under controlled physiologic conditions.
Methods
Untreated, normotensive, overweight volunteers (n=48) underwent prospective characterization of aldosterone production during four controlled conditions: oral sodium suppression and dietary sodium restriction (to capture the full range of Angiotensin II-mediated aldosterone production) and dexamethasone suppression and cosyntropin stimulation (to capture the full range of ACTH-mediated aldosterone production). Serum aldosterone from each condition (n=188 samples) was measured by both immunoassay and LC-MS/MS.
Results
Serum aldosterone concentrations by LC-MS/MS and immunoassay had a Pearson correlation of 0.69 (p<0.001), with good agreement (intraclass correlation coefficient 0.76 [95% CI 0.52-0.87]). Overall, aldosterone was 37.2% lower by LC-MS/MS than immunoassay (median 10.5 [IQR 3.8, 21.9] vs. 19.6 [9.5, 28.0] ng/dL; p<0.001) with an average bias of 7.2 (SD 12.0) ng/dL by Bland-Altman analysis. The most notable discrepancy was observed in the clinically discriminatory range below 20 ng/dL: 9.9 [7.1, 13.8] ng/dL by immunoassay corresponded to 5.5 [1.4, 8.9] ng/dL by LC-MS/MS (p<0.001), a median difference of 49.6% [20.6, 75.2%] higher by immunoassay. Following oral sodium suppression testing, the aldosterone-to-renin ratio was 4-fold higher by immunoassay than by LC-MS/MS (27.2 [19.7, 62.4] vs. 6.4 [3.5, 19.1] ng/dL per ng/mL/h; p<0.001).
Conclusions
Aldosterone measurements are systematically lower by LC-MS/MS than by immunoassay across the entire physiologic spectrum of aldosterone production; this effect was especially pronounced – up to 50-65% lower – when aldosterone levels were less than 20 ng/dL, meaning that clinicians should be careful to verify the assay used and the clinical context before excluding the diagnosis of primary aldosteronism. Our findings highlight the risk for false negative interpretations with increasingly common LC-MS/MS assays, thereby underscoring the urgent need to raise awareness among clinicians that interpretations of circulating aldosterone and aldosterone-to-renin ratio values need to be re-calibrated to include much lower values than previously recommended.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
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Mansur A, Vaidya A, Turchin A. PSUN53 Using Renin Activity to Guide Mineralocorticoid Receptor Antagonist Therapy in Patients with Low-Renin Hypertension. J Endocr Soc 2022. [PMCID: PMC9624601 DOI: 10.1210/jendso/bvac150.524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Emerging studies show that beyond a phenotype of overt primary aldosteronism, there exists a prevalent phenotype of renin-independent aldosterone production among patients with low-renin hypertension (LRH). Mineralocorticoid receptor antagonist (MRA) therapy to induce an increase in renin is associated with favorable outcomes in primary aldosteronism. Whether a similar approach is beneficial for all patients with low-renin hypertension is not known. We evaluated whether treatment of patients with LRH with MRAs to increase renin is associated with a decrease in blood pressure and/or proteinuria. We have conducted a prospective observational cohort study of consecutive patients from the practice of co-author A.T. between 2005 and 2021. Patients were included if they had hypertension with suppressed (< 1.0 ng/ml/h) plasma renin activity (PRA) and detectable aldosterone levels but favored empiric medical therapy over further diagnostic testing. All patients were subsequently treated with an MRA. MRA was started at 25-50 mg daily of spironolactone (women) or eplerenone (men) and the dose was gradually increased in 25-50 mg increments to target a PRA ≥ 1.0 ng/ml/h or the maximal tolerated dose. Blood pressure, albumin-to-creatinine ratio (ACR), and other patient characteristics at baseline vs. after unsuppressed renin was achieved were compared using a paired-samples t-test. The mean age of 31 study patients who achieved unsuppressed PRA was 67.9 (SD 11.9) and 14 (45.2%) were women. The mean baseline aldosterone was 14.9 ng/dL (SD 9.4); 13 (41.9%) patients had baseline aldosterone < 10.0 ng/dL. Most (21/31; 67.7%) patients had baseline PRA below the assay detection limit. The mean baseline potassium was 4.2 (SD 0.46); one (3.2%) patient had baseline hypokalemia (K < 3.5 mEql/dL). The mean final PRA was 4.78 (SD 5.64) ng/ml/h. The median (IQR) MRA dose required to achieve unsuppressed PRA was 75 (50 to 200) mg. The mean systolic and diastolic blood pressure decreased from 144.9 (SD 14.9) and 79.2 mm Hg (SD 15.0) at baseline to 124.7 (SD 11.1) and 71.5 mm Hg (SD 10.8), respectively, after achievement of unsuppressed PRA (P < 0.001 for both). The mean number of anti-hypertensive medications decreased from 3.4 (SD 1.3) at baseline to 2.5 (SD 1.5) after achievement of unsuppressed PRA (P < 0.001). Among the six (19.4%) patients who had proteinuria, the mean ACR decreased from 179.0 (SD 102.1) at baseline to 36.1 (SD 49.2) mg/g after achievement of unsuppressed PRA (P = 0.007). Three (9.7%) and seven (22.6%) patients had to have their MRA dose decreased due to symptomatic hypotension and hyperkalemia, respectively. These findings suggest that suppressed renin may be sufficient to identify patients who could benefit from MR blockade. Treatment of patients with suppressed renin with sufficient MRA dose to achieve its unsuppression could lower both elevated blood pressure and proteinuria. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
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Abstract
Primary aldosteronism is a common cause of hypertension and is a risk factor for cardiovascular and renal morbidity and mortality, via mechanisms mediated by both hypertension and direct insults to target organs. Despite its high prevalence and associated complications, primary aldosteronism remains largely under-recognized, with less than 2% of people in at-risk populations ever tested. Fundamental progress made over the past decade has transformed our understanding of the pathogenesis of primary aldosteronism and of its clinical phenotypes. The dichotomous paradigm of primary aldosteronism diagnosis and subtyping is being redefined into a multidimensional spectrum of disease, which spans subclinical stages to florid primary aldosteronism, and from single-focal or multifocal to diffuse aldosterone-producing areas, which can affect one or both adrenal glands. This Review discusses how redefining the primary aldosteronism syndrome as a multidimensional spectrum will affect the approach to the diagnosis and subtyping of primary aldosteronism.
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Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA.
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Ostrominski JW, Vaidya A, Parnes AD, Tyan K, Tsai FD. A Shear Decline. N Engl J Med 2022; 387:e41. [PMID: 36300977 DOI: 10.1056/nejmimc2117464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
AIMS Randomized controlled trials have demonstrated the efficacy of mineralocorticoid receptor (MR) antagonism in delaying chronic kidney disease (CKD) progression in diabetes; however, they have not investigated the role of aldosterone or whether these beneficial effects could be achieved in individuals without diabetes. METHODS AND RESULTS The association between serum aldosterone concentrations and kidney disease progression was investigated among 3680 participants in the Chronic Renal Insufficiency Cohort. The primary outcome was CKD progression [defined as the composite of 50% decline in estimated glomerular filtration rate (eGFR) or end-stage kidney disease, whichever occurred first]. The associations between serum aldosterone and kidney disease outcomes were assessed using Cox proportional hazard models. At baseline, higher aldosterone concentrations were associated with a lower eGFR, lower serum potassium, greater urinary potassium, and protein excretion. Over a median follow-up of 9.6 years, 1412 participants developed CKD progression. In adjusted models, each doubling of serum aldosterone was associated with a 11% increased risk of CKD progression [hazard ratio (HR) 1.11, 95% confidence interval (CI) 1.04-1.18]. Individuals with the highest quartile of serum aldosterone had a 45% increased risk of CKD progression (HR 1.45, 95% CI 1.22-1.73) compared with the lowest quartile. The risk for CKD progression was similar regardless of whether patients had concomitant diabetes (P-interaction = 0.10). CONCLUSION Higher serum aldosterone levels among individuals with CKD are independently associated with an increased risk for kidney disease progression, irrespective of concomitant diabetes. These findings provide mechanistic support for MR antagonists in delaying CKD progression and suggest that they may also have a role in those without diabetes.
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Affiliation(s)
- Ashish Verma
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Renal Section, Evans Biomedical Research Center, 650 Albany Street, X504, Boston, MA 02118, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Sonu Subudhi
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Renal Section, Evans Biomedical Research Center, 650 Albany Street, X504, Boston, MA 02118, USA
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Yu K, Ebbehøj AL, Obeid H, Vaidya A, Else T, Wachtel H, Main AM, Søndergaard E, Lehmann Christensen L, Juhlin C, Calissendorff J, Cohen DL, Bennett B, Andersen MS, Larsson C, Almeida MQ, Fishbein L, Boorjian SA, Young WF, Bancos I. Presentation, Management, and Outcomes of Urinary Bladder Paraganglioma: Results From a Multicenter Study. J Clin Endocrinol Metab 2022; 107:2811-2821. [PMID: 35882219 PMCID: PMC9516048 DOI: 10.1210/clinem/dgac427] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Indexed: 02/08/2023]
Abstract
CONTEXT Urinary bladder paraganglioma (UBPGL) is rare. OBJECTIVE We aimed to characterize the presentation and outcomes of patients diagnosed with UBPGL. METHODS We conducted a multicenter study of consecutive patients with pathologically confirmed UBPGL evaluated between 1971 and 2021. Outcomes included repeat bladder surgery, metastases, and disease-specific mortality. RESULTS Patients (n=110 total; n=56 [51%] women) were diagnosed with UBPGL at a median age of 50 years (interquartile range [IQR], 36-61 years). Median tumor size was 2 cm (IQR, 1-4 cm). UBPGL was diagnosed prior to biopsy in only 37 (34%), and only 69 (63%) patients had evaluation for catecholamine excess. In addition to the initial bladder surgery, 26 (25%) required multiple therapies, including repeat surgery in 10 (9%). Synchronous metastases were present in 9 (8%) patients, and 24 (22%) other patients with UBPGL developed metachronous metastases at a median of 4 years (IQR, 2-10 years) after the initial diagnosis. Development of metachronous metastases was associated with younger age (hazard ratio [HR] 0.97; 95% CI, 0.94-0.99), UBPGL size (HR 1.69; 95% CI, 1.31-2.17), and a higher degree of catecholamine excess (HR 5.48; 95% CI, 1.40-21.39). Disease-specific mortality was higher in patients with synchronous metastases (HR 20.80; 95% CI, 1.30-332.91). Choice of initial surgery, genetic association, sex, or presence of muscular involvement on pathology were not associated with development of metastases or mortality. CONCLUSIONS Only a minority of patients were diagnosed before biopsy/surgery, reflecting need for better diagnostic strategies. All patients with UBPGL should have lifelong monitoring for development of recurrence and metastases.
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Affiliation(s)
- Kai Yu
- Adrenal Center, Division of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, 55905, USA
| | - Andreas Ladefoged Ebbehøj
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, 8200, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, 8200, Denmark
| | - Hiba Obeid
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, 48105, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, MA, 02115, USA
| | - Tobias Else
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, 48105, USA
| | - Heather Wachtel
- Department of Surgery, Division of Endocrine and Oncologic Surgery, University of Pennsylvania, PA, 19104, USA
| | - Ailsa Maria Main
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, Copenhagen, 2100, Denmark
- Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, 2100, Denmark
| | - Esben Søndergaard
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, 8200, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, 8200, Denmark
| | | | - Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institute, Solna, 17164, Sweden
- Department of Pathology and Cancer Diagnostics, Karolinska University Hospital, Solna, 17176, Sweden
| | - Jan Calissendorff
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, 17176, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, 17176, Sweden
| | - Debbie L Cohen
- Department of Medicine, Renal Division, University of Pennsylvania, PA, 19104, USA
| | - Bonita Bennett
- Department of Medicine, Renal Division, University of Pennsylvania, PA, 19104, USA
| | | | - Catharina Larsson
- Department of Oncology-Pathology, Karolinska Institute, Solna, 17164, Sweden
| | - Madson Q Almeida
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-900, Brasil
- Servico de Endocrinologia, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-900, Brasil
| | - Lauren Fishbein
- Division of Endocrinology, University of Colorado, Denver, CO, 80045, USA
| | | | - William F Young
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, 55905, USA
| | - Irina Bancos
- Correspondence: Irina Bancos, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA.
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Brown JM, Wijkman MO, Claggett BL, Shah AM, Ballantyne CM, Coresh J, Grams ME, Wang Z, Yu B, Boerwinkle E, Vaidya A, Solomon SD. Cardiac Structure and Function Across the Spectrum of Aldosteronism: the Atherosclerosis Risk in Communities Study. Hypertension 2022; 79:1984-1993. [PMID: 35582954 PMCID: PMC9759338 DOI: 10.1161/hypertensionaha.122.19134] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aldosterone production and mineralocorticoid receptor activation are implicated in myocardial fibrosis and cardiovascular events. METHODS Cardiac structure and function were assessed in 4547 participants without prevalent heart failure (HF) in the ARIC study (Atherosclerosis Risk in Communities), with echocardiography, aldosterone, and plasma renin activity measurement (2011-2013). Subjects were characterized by plasma renin activity as suppressed (≤0.5 ng/mL per hour) or unsuppressed (>0.5 ng/mL per hour). Cross-sectional relationships with cardiac structure and function, and longitudinal relationships with outcomes (HF hospitalization; HF and all-cause death; HF, death, myocardial infarction, and stroke; and incident atrial fibrillation) were assessed. Models were adjusted for demographic and anthropometric characteristics and additively, for blood pressure and antihypertensives. RESULTS Evidence of primary aldosteronism physiology was prevalent (11.6% with positive screen) and associated with echocardiographic parameters. Renin suppression was associated with greater left ventricular mass, left ventricular volumes, and left atrial volume index, and a lower E/A ratio (adjusted P<0.001 for all). Higher aldosterone was associated with greater left ventricular mass and lower global longitudinal strain and lateral E'. The highest tertile of aldosterone was associated with a hazard ratio of 1.37 (95% CI, 1.06-1.77; 5.5-year follow-up) for incident atrial fibrillation relative to the lowest. Renin suppression was associated with HF (hazard ratio, 1.34 [95% CI, 1.05-1.72]; 7.3-year follow-up), although these relationships did not remain statistically significant after additional adjustment for hypertension. CONCLUSIONS Renin suppression and aldosterone excess, consistent with primary aldosteronism pathophysiology, were associated with cardiac structural and functional alterations and may represent an early target for mitigation of fibrosis with mineralocorticoid receptor antagonists.
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Affiliation(s)
- Jenifer M. Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Magnus O. Wijkman
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
- Department of Internal Medicine and Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden
| | - Brian L. Claggett
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Amil M. Shah
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
| | | | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Zhiying Wang
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center, Houston, TX
| | - Bing Yu
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center, Houston, TX
| | - Eric Boerwinkle
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center, Houston, TX
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA
| | - Scott D. Solomon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
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Kraft AW, Vaidya A, Bilodeau PA, Balaban D, Arnold SE. More Than a Little Unsteady. N Engl J Med 2022; 387:e9. [PMID: 35921454 DOI: 10.1056/nejmimc2117465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Koirala B, Adhikari SR, Shrestha A, Vaidya A, Aryal KK, Kalaunee SP, Shrestha A, Mishra SR, Sharma SK, Karki A, Maharjan B, Singh S, Schwarz D, Gupta N, Bukhman G, Karmacharya BM. A National Equity Initiative to Address Noncommunicable Diseases and Injuries: Findings and Recommendation from the Nepal NCDI Poverty Commission. Kathmandu Univ Med J (KUMJ) 2022; 20:376-383. [PMID: 37042383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
We aimed to assess the burden of NCDIs across socioeconomic groups, their economic impact, existing health service readiness and availability, current policy frameworks and national investment, and planned programmatic initiatives in Nepal through a comprehensive literature review. Secondary data from Global Burden of Disease estimates from GBD 2015 and National Living Standard Survey 2011 were used to estimate the burden of NCDI and present the relationship of NCDI burden with socioeconomic status. The Commission used these data to define priority NCDI conditions and recommend potential cost-effective, poverty-averting, and equity-promoting health system interventions. NCDIs disproportionately affect the health and well-being of poorer populations in Nepal and cause significant impoverishment. The Commission found a high diversity of NCDIs in Nepal, with approximately 60% of the morbidity and mortality caused by NCDIs without primary quantified behavioral or metabolic risk factors, and nearly half of all NCDI-related DALYs occurring in Nepalese younger than 40 years. The Commission prioritized an expanded set of twenty-five NCDI conditions and recommended introduction or scale-up of twenty-three evidence-based health sector interventions. Implementation of these interventions would avert an estimated 9680 premature deaths per annum by 2030 and would cost approximately $8.76 per capita. The Commission modelled potential financing mechanisms, including increased excise taxation on tobacco, alcohol, and sugar-sweetened beverages, which would provide significant revenue for NCDI-related expenditures. Overall, the Commission's conclusions are expected to be a valuable contribution to equitable NCDI planning in Nepal and similar resource-constrained settings globally.
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Affiliation(s)
- B Koirala
- Tribhuvan University, Institute of Medicine, Department of Cardiothoracic and Vascular Surgery,Maharajgunj, Kathmandu. and Kathmandu Institute of Child Health, Budhanilkantha, Kathmandu
| | - S R Adhikari
- Tribhuvan University Faculty of Humanities and Social Sciences, Central Department of Economics, Kritipur, Kathmandu
| | - A Shrestha
- Dhulikhel Hospital, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre
| | - A Vaidya
- Kathmandu Medical College and Teaching Hospital, Department of Community Medicine, Sinamangal, Kathmandu
| | - K K Aryal
- Bergen Center for Ethics and Priority Setting in Health, Department of Global Public Health and Primary Care, University of Bergen
| | | | - A Shrestha
- Dhulikhel Hospital, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre
| | - S R Mishra
- Nepal Development Society, Chitwan, Nepal
| | - S K Sharma
- B.P. Koirala Institute of Health Sciences, Dharan
| | - A Karki
- School of Health, Medical and Applied Sciences, Central Queensland University
| | - B Maharjan
- Kathmandu Institute of Child Health, Budhanilkantha, Kathmandu
| | - S Singh
- Kathmandu Institute of Child Health, Budhanilkantha, Kathmandu
| | - D Schwarz
- Brigham and Women's Hospital, Division of Global Health Equity; Harvard Medical School, Department of Medicine
| | - N Gupta
- Center for Integration Science, Brigham and Women's Hospital; Program in Global NCDs and Social Change, Harvard Medical School; NCD Synergies Project, Partners In Health; NCDI Poverty Network, Boston, USA
| | - G Bukhman
- Center for Integration Science, Brigham and Women's Hospital; Program in Global NCDs and Social Change, Harvard Medical School; NCD Synergies Project, Partners In Health; NCDI Poverty Network, Boston, USA
| | - B M Karmacharya
- Dhulikhel Hospital, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre
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Ostrominski JW, Hsu TY, Garza-Mayers AC, Vaidya A, Todd DJ. Bumps in the Road. N Engl J Med 2022; 386:e68. [PMID: 35731656 DOI: 10.1056/nejmimc2117331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Li D, Brand S, Hamidi O, Westfall AA, Suresh M, Else T, Vaidya A, Bancos I. Quality of Life and its Determinants in Patients With Adrenal Insufficiency: A Survey Study at 3 Centers in the United States. J Clin Endocrinol Metab 2022; 107:e2851-e2861. [PMID: 35350067 PMCID: PMC9202727 DOI: 10.1210/clinem/dgac175] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Current evidence on determinants of quality of life (QoL) in patients with adrenal insufficiency (AI) is limited. OBJECTIVE This work aimed to identify the determinants of QoL in different subtypes of AI. METHODS This multicenter cross-sectional survey study was conducted using a patient-centered questionnaire, the Short Form-36. RESULTS Of 529 participants, 223 (42.2%) had primary AI, 190 (35.9%) had secondary AI, and 116 (21.9%) had glucocorticoid-induced AI. Median age was 58 years (interquartile range: 43-68 years) and 342 (64.8%) were women. In multivariable analyses, patients were more likely to report worse physical scores if they were women (odds ratio [OR]: 3.3; 95% CI, 1.8-6.0), had secondary AI or glucocorticoid-induced AI (OR: 2.5; 95% CI, 1.4-4.3), had shorter duration of AI (OR: 2.0; 95% CI, 1.1-3.6), were treated with more than 25 mg hydrocortisone equivalent daily (OR: 2.3; 95% CI, 1.2-4.6), had more comorbidities related to glucocorticoid excess (OR: 2.3; 95% CI, 1.3-4.0), reported a higher financial burden from AI (OR: 2.1; 95% CI, 1.3-3.6), and reported difficulties with AI management (OR: 2.5; 95% CI, 1.2-5.2). Women (OR: 2.1; 95% CI, 1.08-4.0), shorter duration of AI (OR: 2.4; 95% CI, 1.4-4.3), higher financial burden (OR: 2.3; 95% CI, 1.3-4.0), difficulties with AI management (OR: 2.6; 95% CI, 1.4-4.9), and lack of family support (OR: 9.1; 95% CI, 2.3-33.3) were associated with worse mental component scores. CONCLUSION In patients with AI, QoL could be improved by addressing certain determinants, such as avoiding GC overreplacement, providing in-depth education on self-management, offering more comprehensive insurance coverage, and ensuring better family support.
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Affiliation(s)
- Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Sarah Brand
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA
| | - Ashleigh A Westfall
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA
| | - Malavika Suresh
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Tobias Else
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts 02115, USA
| | - Irina Bancos
- Correspondence: Irina Bancos, MD, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Greenberg S, Yozamp N, Anson A, Brand S, Buchmann L, Kohlmann W, Low S, Wong B, Else T, Vaidya A, Fishbein L. Impact of COVID-19 on individuals with paraganglioma/pheochromocytoma history and/or hereditary risk. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.10613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10613 Background: Patients with paraganglioma/pheochromocytoma (PPGL) or hereditary predisposition to PPGL often need screening with biochemical labs, imaging and physical exam. Given the rarity of PPGL and hereditary PPGL, care is often provided through specialty centers. Subsequently, patients may have experienced restrictions on travel and delayed scheduling of non-elective procedures due to COVID-19. This study aimed to analyze the impact of COVID-19 on seeking PPGL management. Methods: Patients with a personal history of PPGL or hereditary PPGL risk from the University of Michigan, Brigham Women’s Hospital, and Huntsman Cancer Institute were sent a survey in 2021. The survey included questions regarding tumor history (Y/N), gene status, demographics, and experience with COVID. The survey assessed whether they missed any exams related to PPGL diagnosis or screening. Comparative analyses utilized regression and chi-square tests. Patient factors measured in analyses evaluated COVID surveillance (labs, imaging, doctor visit) as the primary outcome and age, institution, gene status, sex, and PPGL history as predicting variables. Results: In total, 241 respondents across three institutions completed the survey. The cohort was primarily female (n = 158, 65.6%). A majority of the cohort identified as White (n = 222, 92%) and non-Hispanic (n = 226, 93.8%). PPGL history was reported in 158 patients (65.6%), 43 of which were pheochromocytoma and 113 were paraganglioma, primarily in the head and neck (n = 78). At time of survey completion, 209 (87%) respondents answered COVID-related questions. Thirty-nine respondents (19.2%) reported missing doctor visits, while 31 (15.3%) report missing HPPGL imaging and 33 (16.3%) report missing lab tests. There were no differences by institution (p > 0.05) on patient reported missed visits. Logistic regression analysis showed no difference in missing visits based on having a hereditary PPGL predisposition gene or sex of respondent (all p-values > 0.05). There was no difference based on PPGL history, though it is unknown if patients missed PGL follow-up or screening. Individuals who missed imaging (Y/N) were more likely to report missing their lab tests (OR = 1.8, p < 0.01) and doctor visit (OR = 1.25, p < 0.01). Age was a significant predictor for missing doctor visits (p = 0.02) with an odds ratio of 1.002 per 1 year increase in age. Conclusions: Though institutions had different COVID-19 restrictions and guidelines by state, there was no difference on missing surveillance or screening. Over 15% of respondents reported missing at least one aspect of PPGL care, indicating a need to re-engage those with PPGL and hereditary PPGL to return to typical screening and surveillance. Patients who miss one aspect of surveillance are likely to have missed other aspects of surveillance and will require evaluation of all aspects of screening to return up to date on needed visits and procedures.
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Affiliation(s)
| | | | | | | | | | - Wendy Kohlmann
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Sara Low
- Huntsman Cancer Institute, Salt Lake City, UT
| | - Bob Wong
- University of Utah, Salt Lake City, UT
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Suwal PS, Prajapati D, Bajracharya S, Shrestha A, Maharjan R, Shrestha S, Jha N, Koju RP, Vaidya A. Assessment of Health Service Delivery to Address Cardiovascular Diseases in Nepal. Kathmandu Univ Med J (KUMJ) 2022; 19:40-50. [PMID: 35526135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Background A health care delivery system is the organization of people, institutions, and resources designed to deliver health services. A comprehensive study to explore cardiovascular health service delivery in Nepal is lacking. Objective This study attempted to assess Nepal's health system gap on organization and delivery of cardiovascular disease prevention and management services. Method This mixed-method study used the six building blocks of the World Health Organization health system framework: organization; access; coverage, utilization and demand; equity; quality of services; and outcomes. We conducted the desk reviews of national and international documents, performed several key informant interviews, calculated the relevant indicators, and assessed the Strengths, Weaknesses, Opportunities, and Threats of the cardiovascular health service delivery. Result We found that most of the cardiovascular services are concentrated in urban areas, and suffer from poor access, quality, utilization, and coverage in most of the areas resulting in poor health outcomes. Though the services have recently improved due to increased primary care interventions, there is scope for the development of competent human resources, advancement of technologies, development of national protocols, and improved monitoring and supervision. Improved disease system including the medical recording and reporting mechanism to incorporate and reflect the true burden of CVD in Nepal is lacking. Conclusion Despite having health facilities from grassroots to the central level, availability, access, and quality of cardiovascular health services are poor. Further improvement and equitable expansion of promotive, preventive, diagnostic, referral, and rehabilitative cardiovascular services are needed to ensure universal health coverage.
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Affiliation(s)
- P S Suwal
- Nepal Institute of Health Sciences, Jorpati Kathmandu, Nepal. and Fellow, CVD Translational Research Program, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| | - D Prajapati
- Fellow, CVD Translational Research Program, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal. and Shahid Gangalal National Heart Centre, and National Academy of Medical Sciences, Kathmandu, Nepal
| | - S Bajracharya
- Department of Community Programs, Dhulikhel Hospital, Kathmandu University Hospital, Kavrepalanchowk, Nepal
| | - A Shrestha
- Department of Community Programs, Dhulikhel Hospital, Kathmandu University Hospital, Kavrepalanchowk, Nepal. Department of Public Health, Kathmandu University School of Medical Sciences, Kavrepalanchowk, Nepal. Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, USA. and Institute for Implementation Science and Health, Kathmandu, Nepal
| | - R Maharjan
- Fellow, CVD Translational Research Program, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal. Department of Community Programs, Dhulikhel Hospital, Kathmandu University Hospital, Kavrepalanchowk, Nepal. and Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, USA
| | - S Shrestha
- Department of Community Programs, Dhulikhel Hospital, Kathmandu University Hospital, Kavrepalanchowk, Nepal
| | - N Jha
- Department of Community Programs, Dhulikhel Hospital, Kathmandu University Hospital, Kavrepalanchowk, Nepal
| | - R P Koju
- Dean, Kathmandu University School of Medical Sciences, Kavrepalanchowk, Nepal. and Department of Internal Medicine, Dhulikhel Hospital, Kathmandu University Hospital, Kavrepalanchowk, Nepal
| | - A Vaidya
- Department of Community Medicine, Kathmandu Medical College Public Limited, Kathmandu, Nepal
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Vaidya A. New Villages for Old: Collective Action and Conditional Futures after India's Forest Rights Act. PoLAR 2022. [DOI: 10.1111/plar.12466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Olmos R, Mertens N, Vaidya A, Uslar T, Fernandez P, Guarda FJ, Zúñiga Á, San Francisco I, Huete A, Baudrand R. Discriminative Capacity of CT Volumetry to Identify Autonomous Cortisol Secretion in Incidental Adrenal Adenomas. J Clin Endocrinol Metab 2022; 107:e1946-e1953. [PMID: 35020922 PMCID: PMC9272424 DOI: 10.1210/clinem/dgac005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Indexed: 01/12/2023]
Abstract
CONTEXT Incidentally discovered adrenal adenomas are common. Assessment for possible autonomous cortisol excess (ACS) is warranted for all adrenal adenomas, given the association with increased cardiometabolic disease. OBJECTIVE To evaluate the discriminatory capacity of 3-dimensional volumetry on computed tomography (CT) to identify ACS. METHODS Two radiologists, blinded to hormonal levels, prospectively analyzed CT images of 149 adult patients with unilateral, incidentally discovered, adrenal adenomas. Diameter and volumetry of the adenoma, volumetry of the contralateral adrenal gland, and the adenoma volume-to-contralateral gland volume (AV/CV) ratio were measured. ACS was defined as cortisol ≥ 1.8 mcg/dL after 1-mg dexamethasone suppression test (DST) and a morning ACTH ≤ 15. pg/mL. RESULTS We observed that ACS was diagnosed in 35 (23.4%) patients. Cortisol post-DST was positively correlated with adenoma diameter and volume, and inversely correlated with contralateral adrenal gland volume. Cortisol post-DST was positively correlated with the AV/CV ratio (r = 0.46, P < 0.001) and ACTH was inversely correlated (r = -0.28, P < 0.001). The AV/CV ratio displayed the highest odds ratio (1.40; 95% CI, 1.18-1.65) and area under curve (0.91; 95% CI, 0.86-0.96) for predicting ACS. An AV/CV ratio ≥ 1 (48% of the cohort) had a sensitivity of 97% and a specificity of 70% to identify ACS. CONCLUSION CT volumetry of adrenal adenomas and contralateral adrenal glands has a high discriminatory capacity to identify ACS. The combination of this simple and low-cost radiological phenotyping can supplement biochemical testing to substantially improve the identification of ACS.
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Affiliation(s)
| | | | - Anand Vaidya
- Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Thomas Uslar
- Department of Endocrinology, Pontificia Universidad Catolica de Chile, Santiago, 8330077, Chile
- Program for Adrenal Disorders, CETREN UC, Pontificia Universidad Catolica de Chile, Santiago, 8330077, Chile
| | - Paula Fernandez
- Program for Adrenal Disorders, CETREN UC, Pontificia Universidad Catolica de Chile, Santiago, 8330077, Chile
| | - Francisco J Guarda
- Department of Endocrinology, Pontificia Universidad Catolica de Chile, Santiago, 8330077, Chile
| | - Álvaro Zúñiga
- Department of Urology, Pontificia Universidad Catolica de Chile, Santiago 8330077, Chile
| | - Ignacio San Francisco
- Department of Urology, Pontificia Universidad Catolica de Chile, Santiago 8330077, Chile
| | | | - René Baudrand
- Correspondence: René Baudrand, M.D., Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 4th FL, RM, Santiago, Chile, 8330077, USA.
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Lee R, Kan C, Nadeswaran P, Kingsford P, Singh V, Doshi P, Aldea D, Yang M, Martinez T, Vaidya A, Wolfson A, DePasquale E. Evaluation of Donor Glomerular Filtration Rate on Survival Outcomes among Simultaneous Heart and Kidney Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Lee E, Lee R, Vaidya A, Wolfson A, Depasquale E. Impact of Length of Diabetes in Donor Hearts on Post-Transplant Survival. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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DePasquale E, Kingsford P, Miklin D, Wolfson A, Vaidya A, Cunningham M, Lee R. Heart Transplant Outcomes with Donation After Cardiac Death: UNOS Registry Analysis. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Oli N, Pradhan PM, Sagtani RA, Shrestha A, Jaacks LM, Karmacharya BM, Danaei G, Vaidya A. Research Capacity for Prevention and Control of Non-communicable Diseases and their Risk Factors in Nepal: Findings of a Needs Assessment Study. Kathmandu Univ Med J (KUMJ) 2022; 20:147-154. [PMID: 37017157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
Background Despite a high burden, there are limited trainings in non-communicable disease research in Nepal. Objective We conducted a needs assessment to assess existing research training capacity in academic health institutions of Nepal for the prevention and control of noncommunicable diseases, identify gaps in research, and explore the feasibility of developing research training program in Nepal targeting non-communicable diseases. Method We did mixed-method research and reviewed academic institution curricula and scientific articles authored by Nepali researchers. We conducted 14 Focus Group Discussions with bachelor and masters level students of public health and community medicine; 25 In-depth Interviews with department heads and faculties, and government stakeholders. We surveyed medical and public health students on their research knowledge and skills development. Result Research methodology component was addressed differently across academic programs. One-third (33.7%) of students expressed lack of skills for analysis and interpretation of data. They felt that there is a wide scope and career-interest in non-communicable diseases research in Nepal. However, specific objectives in the curriculum and practical aspects regarding non-communicable diseases were lacking. Most of the non-communicable diseases research in Nepal are prevalence studies. Lack of funding, conflicting priorities with curative services, and inadequate training for advanced research tools were reported as major barriers. Conclusion Nepal must strengthen the whole spectrum of research capacity: epidemiological skills, research management, and fund development. Generation of a critical mass of non-communicable disease researchers must go together with improved funding from the government, non-governmental, and external funding organizations.
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Affiliation(s)
- N Oli
- Department of Community Medicine, Kathmandu Medical College Public Limited, Sinamangal, Kathmandu, Nepal
| | - P Ms Pradhan
- Department of Community Medicine, Institute of Medicine, Maharajganj, Kathmandu, Nepal
| | - R A Sagtani
- Department of Community Health, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - A Shrestha
- Department of Public Health, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| | - L M Jaacks
- Global Academy of Agriculture and Food Security, The University of Edinburgh, Midlothian, UK
| | - B M Karmacharya
- Department of Community Medicine, Dhulikhel Hospital-Kathmandu University Hospital, Dhulikhel, Kavre, Nepal
| | - G Danaei
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - A Vaidya
- Department of Community Medicine, Kathmandu Medical College Public Limited, Sinamangal, Kathmandu, Nepal
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Patel S, Kingsford P, Valdivia D, Singhal P, Lee R, Cunningham M, Wolfson A, Vaidya A, DePasquale E. Outcomes of Patients Bridged to Heart Transplantation with ECMO Following the UNOS Allocation Policy Change. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Valdivia D, Singhal P, Hashmi S, Patel S, Kingsford P, Lee R, Vaidya A, Wolfson A, DePasquale E. Heart Transplant Outcomes and Trends in Pre-Transplant Impella Use. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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DePasquale E, Fong M, Pandya K, Cunningham M, Dhillon A, Wolfson A, Vaidya A, Lee R. Impact of the 2018 UNOS Heart Allocation Policy Change on Post-Transplant Outcomes: Intermediate Term Analysis. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Singh V, Doshi P, Kingsford P, Miklin D, Nadeswaran P, Kan C, Lee R, Wolfson A, Vaidya A, Depasquale E. Rethinking the Impact of Donor eGFR on Heart Transplant Outcomes. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Srougi V, Bancos I, Daher M, Lee JE, Graham PH, Karam JA, Henriquez A, Mckenzie TJ, Sada A, Bourdeau I, Poirier J, Vaidya A, Abbondanza T, Kiernan CM, Rao SN, Hamidi O, Sachithanandan N, Hoff AO, Chambo JL, Almeida MQ, Habra MA, Fragoso MCBV. Cytoreductive Surgery of the Primary Tumor in Metastatic Adrenocortical Carcinoma: Impact on Patients' Survival. J Clin Endocrinol Metab 2022; 107:964-971. [PMID: 34850915 PMCID: PMC9122637 DOI: 10.1210/clinem/dgab865] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The role of cytoreduction of adrenocortical carcinoma (ACC) remains poorly understood. OBJECTIVE To analyze the impact of cytoreductive surgery of the primary tumor in patients with metastatic ACC. DESIGN AND SETTING We performed a multicentric, retrospective paired cohort study comparing the overall survival (OS) in patients with metastatic ACC who were treated either with cytoreductive surgery (CR group) or without cytoreductive surgery (no-CR group) of the primary tumor. Data were retrieved from 9 referral centers in the American-Australian-Asian Adrenal Alliance collaborative research group. PATIENTS Patients aged ≥18 years with metastatic ACC at initial presentation who were treated between January 1, 1995, and May 31, 2019. INTERVENTION Performance (or not) of cytoreductive surgery of the primary tumor. MAIN OUTCOME AND MEASURES A propensity score match was done using age and the number of organs with metastasis (≤2 or >2). The main outcome was OS, determined from the date of diagnosis until death or until last follow-up for living patients. RESULTS Of 339 patients pooled, 239 were paired and included: 128 in the CR group and 111 in the no-CR group. The mean follow-up was 67 months. Patients in the no-CR group had greater risk of death than did patients in the CR group (hazard ratio [HR] = 3.18; 95% CI, 2.34-4.32). Independent predictors of survival included age (HR = 1.02; 95% CI, 1.00-1.03), hormone excess (HR = 2.56; 95% CI, 1.66-3.92), and local metastasis therapy (HR = 0.41; 95% CI, 0.47-0.65). CONCLUSION Cytoreductive surgery of the primary tumor in patients with metastatic ACC is associated with prolonged survival.
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Affiliation(s)
- Victor Srougi
- Division of Urology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Division of Urology, Hospital Moriah, São Paulo, Brazil
| | - Irina Bancos
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - Marilyne Daher
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul H Graham
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose A Karam
- Department of Urology and Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Travis J Mckenzie
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alaa Sada
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Isabelle Bourdeau
- Division of Endocrinology and Research Center, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
| | - Jonathan Poirier
- Division of Endocrinology and Research Center, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Tiffany Abbondanza
- Center for Adrenal Disorders, Division of Endocrinology Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarika N Rao
- Division of Endocrinology, Mayo Clinic, Jacksonville, FL, USA
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nirupa Sachithanandan
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
| | - Ana O Hoff
- Unidade de Suprarrenal, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jose L Chambo
- Division of Urology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Madson Q Almeida
- Unidade de Suprarrenal, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria C B V Fragoso
- Unidade de Suprarrenal, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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