CONTEXT: Adrenal venous sampling (AVS) is the key test for subtyping primary aldosteronism (PA), but its interpretation varies widely across referral centers and this can adversely affect the management of PA patients. OBJECTIVES: To investigate in a real-life study the rate of bilateral success and identification of unilateral aldosteronism and their impact on blood pressure outcomes in PA subtyped by AVS. DESIGN AND SETTINGS: In a retrospective analysis of the largest international registry of individual AVS data (AVIS-2 study), we investigated how different cut-off values of the selectivity index (SI) and lateralization index (LI) affected rate of bilateral success, identification of unilateral aldosteronism, and blood pressure outcomes. RESULTS: AVIS-2 recruited 1625 individual AVS studies performed between 2000 and 2015 in 19 tertiary referral centers. Under unstimulated conditions, the rate of biochemically confirmed bilateral AVS success progressively decreased with increasing SI cut-offs; furthermore, with currently used LI cut-offs, the rate of identified unilateral PA leading to adrenalectomy was as low as <25%. A within-patient pairwise comparison of 402 AVS performed both under unstimulated and cosyntropin-stimulated conditions showed that cosyntropin increased the confirmed rate of bilateral selectivity for SI cut-offs ≥ 2.0, but reduced lateralization rates (P < 0.001). Post-adrenalectomy outcomes were not improved by use of cosyntropin or more restrictive diagnostic criteria. CONCLUSION: Commonly used SI and LI cut-offs are associated with disappointingly low rates of biochemically defined AVS success and identified unilateral PA. Evidence-based protocols entailing less restrictive interpretative cut-offs might optimize the clinical use of this costly and invasive test. (J Clin Endocrinol Metab XX: 0-0, 2020).

3rd Department of Medicine Charles University Prague General Hospital Prague Czech Republic

Department of Diabetes Endocrinology and Metabolism National Center for Global Health and Medicine Tokyo Japan

Department of Endocrinology Clinical Research Institute NHO Kyoto Medical Center and Endocrine Center Ijinkai Takeda General Hospital Kyoto Japan

Department of Endocrinology Diabetes and Metabolic Diseases Faculty of Medicine University of Ljubljana Ljubljana Slovenia

Department of Endocrinology Monash Health Clayton Australia

Department of Endocrinology North Western State Medical University named after 1 I Mechnikov St Petersburg Russia

Department of Internal Medicine Azienda Unità Sanitaria Locale IRCCS Arcispedale S Maria Nuova Reggio Emilia Italy

Department of Internal Medicine National Taiwan University Hospital Taipei Taiwan

Department of Medicine DIMED University Hospital Padova Italy

Department of Nephrology Heinrich Heine University Düsseldorf Düsseldorf Germany

Department of Nephrology Tohoku University Hospital Endocrinology and Vascular Medicine Sendai Japan

Departments of Internal Medicine and Radiology Radboud University Nijmegen Nijmegen The Netherlands

Division of Endocrinology and Metabolism Rostock University Medical Center Rostock Germany

Endocrinology in Charlottenburg Berlin Germany

Hypertension unit Université de Paris Inserm UMR970 and CIC1418 Hôpital Européen Georges Pompidou Paris France

Institute of Cardiovascular and Medical Sciences University of Glasgow Glasgow UK

Institute of Radiology University of Padova Padova Italy

Medical College of Wisconsin Endocrinology Center North Hills Health Center Menomonee Falls Wisconsin

Medizinische Klinik und Poliklinik 4 Klinikum der Universität München LMU München München Germany

Nephrology Department Hospital del Mar Universitat Autònoma de Barcelona Barcelona Spain

University of Calgary Foothills Medical Centre Calgary Canada

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Subtype Identification of Surgically Curable Primary Aldosteronism During Treatment With Mineralocorticoid Receptor Blockade

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ClinicalTrials.gov
NCT01234220