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Filippo Crimì, Alessandro Spimpolo, Diego Cecchin, and Gian Paolo Rossi

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Teresa M Seccia, Diego Miotto, Michele Battistel, Raffaella Motta, Marlena Barisa, Carmela Maniero, Achille C Pessina, and Gian Paolo Rossi

Background

A stress reaction involving increased cortisol release, which has not been documented thus far, might affect the assessment of selectivity of catheterization during adrenal venous sampling (AVS).

Objective

To investigate whether an ACTH-driven cortisol release occurs during AVS and whether it influences the assessment of selectivity by the step-up of cortisol (plasma cortisol concentrations, PCC) between the adrenal vein blood (PCCSIDE) and the inferior vena cava (PCCIVC), e.g. the selectivity index (SI).

Design and methods

We determined the SI in samples obtained simultaneously at starting AVS (t-15) and again after 15 min (t0) in 34 consecutive patients with proven aldosterone-producing adenoma. We then calculated the SI with PCCSIDE obtained at t-15 and at t0, and the PCCIVC values obtained at the different time point, thus simulating sequential AVS.

Results

The PCCSIDE and the SI fell significantly from t-15 to t0 on both the sides. When PCCSIDE obtained at t-15 was combined with PCCIVC at t0, the SI values were higher than those obtained with simultaneously drawn samples. This led to label as selective more AVS studies than with bilaterally simultaneous data, especially when using higher cutoffs for the SI.

Conclusions

A transient increase in cortisol release from both adrenal glands occurs in the majority of the patients who undergo AVS. This stress reaction can influence the assessment of both the selectivity of the catheterization during the sequential AVS technique and the lateralization of aldosterone excess.

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Teresa M Seccia, Diego Miotto, Renzo De Toni, Valentina Gallina, Matteo Vincenzi, Achille C Pessina, and Gian Paolo Rossi

Background

Adrenal vein sampling (AVS) is the gold standard for identifying the surgically curable forms of primary aldosteronism. Dopamine modulates adrenocortical steroidogenesis and tonically inhibits aldosterone secretion via D2 receptor. However, whether it could also affect the release of cortisol and chromogranin A (ChA), which can be used to assess the selectivity of AVS, is unknown.

Objective

To investigate whether metoclopramide increased the release of cortisol and ChA and could thereby improve assessment of the selectivity at AVS.

Design and methods

We investigated the effect of acute D2 antagonism with metoclopramide on cortisol and ChA release from the adrenal gland by comparing the adrenal vein and infrarenal inferior vena cava (IVC) hormone levels at baseline and after metoclopramide administration in 34 consecutive patients undergoing AVS.

Results

Metoclopramide increased plasma aldosterone in the IVC (P<0.00001) and in the adrenal vein blood (P<0.002) but failed to increase plasma cortisol concentration or ChA levels. Therefore, it did not increase the selectivity index based on the measurement of either hormone.

Conclusions

This study shows that the release of cortisol and ChA is not subjected to tonic D2 dopaminergic inhibition. Therefore, these findings lend no evidence for the usefulness of acute metoclopramide administration for enhancing the assessment of the selectivity of blood sampling during AVS with the use of either cortisol or ChA assay.

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Jaap Deinum, Hans Groenewoud, Gert Jan van der Wilt, Livia Lenzini, and Gian Paolo Rossi

Notwithstanding the high prevalence of primary aldosteronism (PA), probably the most common form of secondary hypertension, the diagnosis of PA is often neglected or delayed, thus precluding target treatment, which is curative in many cases. For selection of the most appropriate treatment, a fundamental step is the distinction between a lateralized form, mainly aldosterone-producing adenoma (APA), and bilateral adrenocortical hyperplasia (BAH), also known as idiopathic hyperaldosteronism (IHA). To this aim all current guidelines recommend adrenal vein sampling (AVS), a technically challenging procedure that often fails, particularly in non-experienced hands. Cosyntropin (synthetic ACTH) is administered in the attempt to maximize adrenal cortisol secretion and avoid pulsatile adrenocortical hormone secretion in about 40% of the referral centres around the world. However, the Endocrine Society guidelines do not advise about the use or not of cosyntropin as stimulus during AVS, as there are arguments in favour and against its use. These arguments are presented in this debate article reflecting the views of groups that currently use and do not use cosyntropin.