■原发性醛固酮增多症(PA)已广泛分为单侧和双侧形式。肾上腺静脉采样(AVS)偏侧指数(LI)≥2至4是推荐单侧肾上腺切除术以推定单侧PA的标准护理。我们旨在评估AVS引导下肾上腺切除术后残留PA的发生率和特征。
■我们进行了一次国际,回顾性,对来自7个转诊中心的PA患者进行的队列研究,这些患者在基线和/或共调蛋白刺激的AVS基础上接受了基于LI≥4的单侧肾上腺切除术.在可用的福尔马林固定的石蜡包埋的肾上腺组织上进行醛固酮合酶(CYP11B2)免疫组织化学和下一代测序。
■该队列包括283例接受AVS引导肾上腺切除术的患者,随访中位数为术后326天。在16%的连续患者中观察到PA治愈的缺乏,在22例患者中,PA在基线和共调蛋白刺激的AVS上都有侧向化。在术后残留PA的患者中,73%的患者在切除的肾上腺组织内有多个CYP11B2阳性区域(治愈者为23%),其中CACNA1D突变最普遍(63%对那些治愈的33%)。在调整后的回归模型中,术后残留PA的独立预测因素包括黑人与白人种族(优势比,5.10[95%CI,1.45-17.86]),仅在基线时的AVS偏侧化(赔率比,8.93[95%CI3.00-26.32]相对于基线和共调蛋白刺激后),和CT-AVS分歧(赔率比,2.75[95%CI,1.20-6.31])。
■多焦点,不对称的双边PA相对常见,它不能被健壮的AVS侧向化排除在外。应常规进行术后长期监测,识别残留PA并及时开始靶向药物治疗。
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: 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]).
UNASSIGNED: 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.