Hypertension (Dallas, Tex. : 1979) · 2025
Cosyntropin-Stimulated Aldosterone Reserve of the Nondominant Adrenal Predicts Surgical Outcomes in Primary Aldosteronism.
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Vibhatavata Peeradon, Shields James J, Rege Juilee, Udager Aaron M, Rainey William E, Turcu Adina F
Аннотация
BACKGROUND: Adrenal vein sampling (AVS) is commonly used to direct therapy of primary aldosteronism (PA). We hypothesized that cosyntropin stimulation during AVS exposes the reserve of aldosterone-producing cells in the nondominant adrenal gland and might predict postoperative outcomes.
METHODS: Patients with PA who underwent successful AVS before and after cosyntropin stimulation between January 2015 and December 2024 in a tertiary-referral center were included. The nondominant adrenal aldosterone reserve was assessed with (1) contralateral aldosterone reserve ratio (=aldosterone postcosyntropin-to-baseline ratio in the nondominant adrenal vein) and (2) lateralization index (LI) ratio (=LIpost-cosyntropin/LIbaseline). Lateralization was based on LI ≥4.
RESULTS: Four hundred thirty-four patients (57% men; mean age, 53±12 years) were included. AVS lateralized only at baseline in 52 (12%) patients, only after cosyntropin in 46 (11%), and in both protocols in 166 (38%); 170 (39%) patients had bilateral PA. PA severity decreased from cases lateralized in both protocols, to postcosyntropin only, baseline only, and consistently bilateral; conversely, the contralateral aldosterone reserve increased across these groups. The contralateral aldosterone reserve ratio was higher in patients without PA cure and bilateral PA (median [interquartile range], 11.2 [5.0-23.5] and 17.8 [9.1-32.0], respectively, versus 4.9 [2.5-9.4] in those cured; P<0.01) and in Black individuals, those aged ≥45 years, and with CACNA1D mutations. Contralateral aldosterone reserve and postcosyntropin lateralization and contralateral suppression were predictive of residual PA, while baseline parameters were not.
CONCLUSIONS: Cosyntropin stimulation during AVS unveils the aldosterone reserve of the nondominant adrenal gland, exposing the risk of residual disease after adrenalectomy.
METHODS: Patients with PA who underwent successful AVS before and after cosyntropin stimulation between January 2015 and December 2024 in a tertiary-referral center were included. The nondominant adrenal aldosterone reserve was assessed with (1) contralateral aldosterone reserve ratio (=aldosterone postcosyntropin-to-baseline ratio in the nondominant adrenal vein) and (2) lateralization index (LI) ratio (=LIpost-cosyntropin/LIbaseline). Lateralization was based on LI ≥4.
RESULTS: Four hundred thirty-four patients (57% men; mean age, 53±12 years) were included. AVS lateralized only at baseline in 52 (12%) patients, only after cosyntropin in 46 (11%), and in both protocols in 166 (38%); 170 (39%) patients had bilateral PA. PA severity decreased from cases lateralized in both protocols, to postcosyntropin only, baseline only, and consistently bilateral; conversely, the contralateral aldosterone reserve increased across these groups. The contralateral aldosterone reserve ratio was higher in patients without PA cure and bilateral PA (median [interquartile range], 11.2 [5.0-23.5] and 17.8 [9.1-32.0], respectively, versus 4.9 [2.5-9.4] in those cured; P<0.01) and in Black individuals, those aged ≥45 years, and with CACNA1D mutations. Contralateral aldosterone reserve and postcosyntropin lateralization and contralateral suppression were predictive of residual PA, while baseline parameters were not.
CONCLUSIONS: Cosyntropin stimulation during AVS unveils the aldosterone reserve of the nondominant adrenal gland, exposing the risk of residual disease after adrenalectomy.