Unilateral adrenal hyperplasia is a usual cause of primary hyperaldosteronism. Results from a Swedish screening study

BMC Endocrine Disorders

Gudmundur Johannsson⁴  Bo Wangberg⁶  Augustinas Sakinis¹  Hans Herlitz⁷  Robert Eggertsen³  Ove Andersson⁵  Mikael Gronowitz²  Helga Agusta Sigurjonsdottir⁴ 

[1] Dept of Radiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden;Nödinge Primary Health Care Center, Nödinge, Sweden;Department of Medicine Primary Health Care, Mölnlycke Primary Health Care and Research Centre, University of Gothenburg, Gothenburg, Sweden;Department of Medicine, Centrum of Endocrinology and Metabolism, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden;Department of Medicine, Hypertension Outpatient Clinic, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden;Dept of Surgery, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden;Department of Medicine, Nephrology Outpatient Clinic, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden

关键词: Adrenal hyperplasia;    Resistant hypertension;    Hypertension;    Renin;    Aldosterone;    Hyperaldosteronism;    Endocrine hypertension;   

Others  :  1086330
DOI  :  10.1186/1472-6823-12-17

 received in 2011-11-17, accepted in 2012-08-31,  发布年份 2012

【 摘 要 】

Background

The existence of unilateral adrenal hyperplasia (AH) has been considered a rare cause of primary hyperaldosteronism (PA).

Methods

In a prospective study we screened for PA in a non-selected (NSP) and selected hypertensive population (SP), to define the cause of PA. We included 353 consecutive patients with hypertension; age 20 to 88 years, 165 women and 188 men, from a university-based Hypertension and Nephrology Outpatient clinics (123 SP) and two primary care centres, (230 NSP) from the same catch-up area. Serum aldosterone and plasma renin activity (PRA) were measured and the ARR calculated. Verifying diagnostic procedure was performed in patients with both elevated aldosterone and ARR. Patients diagnosed with PA were invited for adrenal venous sampling (AVS) and offered laparoscopic adrenalectomy when AVS found the disease to be unilateral.

Results

After screening, 46 patients, 13% of the whole population (22.8% SP and 7.8% NSP) had aldosterone and ARR above the locally defined cut-off limits (0.43 nmol/l and 1.28 respectively). After diagnostic verification, 20 patients (6%) had PA, (14.5% SP and 1.4% NSP). Imaging diagnostic procedures with CT-scans and scintigraphy were inconclusive. AVS, performed in 15 patients verified bilateral disease in 4 and unilateral in 10 patients. One AVS failed. After laparoscopic adrenalectomy, 4 patients were found to have adenoma and 5 unilateral AH. One patient denied operation.

Conclusion

The prevalence of PA was in agreement with previous studies. The study finds unilateral PA common and unilateral AH as half of those cases. As may be suspected PA is found in much higher frequency in specialised hypertensive units compared to primary care centers. AVS was mandatory in diagnosis of unilateral PA.

【 授权许可】

   
2012 Sigurjonsdottir et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Milliez P, Girerd X, Plouin PF, Blacher J, Safar ME, Mourad JJ: Evidence for an increased rate of cardiovascular events in patients with primary aldosteronism. J Am Coll Cardiol 2005, 45(8):1243-1248.
• [2]Loh KC, Koay ES, Khaw MC, Emmanuel SC, Young WF Jr: Prevalence of primary aldosteronism among Asian hypertensive patients in Singapore. J Clin Endocrinol Metab 2000, 85(8):2854-2859.
• [3]Nishizaka MK, Pratt-Ubunama M, Zaman MA, Cofield S, Calhoun DA: Validity of plasma aldosterone-to-renin activity ratio in African American and white subjects with resistant hypertension. Am J Hypertens 2005, 18(6):805-812.
• [4]Fardella CE, Mosso L, Gomez-Sanchez C, Cortes P, Soto J, Gomez L, Pinto M, Huete A, Oestreicher E, Foradori A, et al.: Primary hyperaldosteronism in essential hypertensives: prevalence, biochemical profile, and molecular biology. J Clin Endocrinol Metab 2000, 85(5):1863-1867.
• [5]Schwartz GL, Turner ST: Screening for primary aldosteronism in essential hypertension: diagnostic accuracy of the ratio of plasma aldosterone concentration to plasma renin activity. Clin Chem 2005, 51(2):386-394.
• [6]Grim CE, Cowley AW Jr, Hamet P, Gaudet D, Kaldunski ML, Kotchen JM, Krishnaswami S, Pausova Z, Roman R, Trembley J, et al.: Hyperaldosteronism and Hypertension. Ethnic differences. Hypertension 2005, 45:766-772.
• [7]Williams JS, Williams GH, Raji A, Jeunemaitre X, Brown NJ, Hopkins PN: Prevalence of primary hyperaldosteronism in mild to moderate hypertension without hypokalaemia. J Hum Hypertens 2006, 20:129-136.
• [8]Unger N, Lopez Schmidt I, Pitt C, Walz MK, Philipp T, Mann K, Petersenn S: Comparison of active renin concentration and plasma renin activity for the diagnosis of primary hyperaldosteronism in patients with an adrenal mass. Eur J Endocrinol 2004, 150:517-523.
• [9]Gordon RD, Stowasser M, Tunny TJ, Klemm SA, Rutherford JC: High incidence of primary aldosteronism in 199 patients referred with hypertension. Clin Exp Pharmacol Physiol 1994, 21(4):315-318.
• [10]Kumar A, Lall SB, Ammini A, Peshin SS, Karmarkar MG, Talwar KK, Seth SD: Screening of a population of young hypertensives for primary hyperaldosteronism. J Hum Hypertens 1994, 8(9):731-732.
• [11]Lim PO, Dow E, Brennan G, Jung RT, MacDonald TM: High prevalence of primary aldosteronism in the Tayside hypertension clinic population. J Hum Hypertens 2000., 14
• [12]Mulatero P, Stowasser M, Loh KC, Fardella CE, Gordon RD, Mosso L, Gomez-Sanchez CE, Veglio F, Young WF Jr: Increased diagnosis of primary aldosteronism, including surgically correctabel forms, in centers from five continents. J Clin Endocrinol Metab 2004, 89(3):1045-1050.
• [13]Seiler L, Rump LC, Schulte-Mönting J, Slawik M, Borm K, Pavenstädt H, Beuschlein F, Reincke M: Diagnosis of primary aldosteronism: value of different screening parameters and influence of antihypertensive medication. Eur J Endocrinol 2004, 150:329-337.
• [14]Strauch B, Zelinka T, Hampf M, Bernhardt R, Widimsky J Jr: Prevalence of primary hyperaldoteronism in moderate to severe hypertension in the Central Europe region. J Hum Hypertens 2003, 17:349-352.
• [15]Rossi GP, Bernini G, Caliumi C, Desideri G, Fabris B, Ferri C, Ganzaroli C, Giacchetti G, Letizia C, Maccario M, et al.: A prospective study of the prevalence of primary aldosteronism in 1,125 hypertensive patients. J Am Coll Cardiol 2006, 48(11):2293-2300.
• [16]Shigematsu K, Yamaguchi N, Nakagaki T, Sakai H: A case of unilateral adrenal hyperplasia being difficult to distinguish from aldosterone-producing adenoma. Exp Clin Endocrinol Diabetes 2008, 117(3):124-128.
• [17]Morioka M, Kobayashi T, Sone A, Furukawa Y, Tanaka H: Primary aldosteronism due to unilateral adrenal hyperplasia: report of two cases and review of the literature. Endocr J 2000, 47(4):443-449.
• [18]Tan Y, Ogilvie J, Triponez F, Caron N, Kebebew E, Clark O, Duh Q: Selective use of adrenal venous sampling in the lateralization of aldosterone-producing adenomas. World J Surg 2006, 30(5):879-885.
• [19]Omura M, Sasano H, Fujiwara T, Yamaguchi K, Nishikawa T: Unique cases of unilateral hyperaldosteronemia due to multiple adrenocortical micronodules, which can only be detected by selective adrenal venous sampling. Metabolism 2002, 51(3):350-355.
• [20]Mathur A, Kemp C, Dutta U, Baid S, Ayla A, Chang R, Steinberg S, Papademetriou V, Lange E, Libutti S, et al.: Consequences of Adrenal Venous Sampling in Primary Hyperaldosteronism and Predictors of Unilateral Adrenal Disease. J Am Coll Surg 2010, 211(3):384-390.
• [21]Bravo EL, Tarazi RC, Dustan HP, Fouad FM, Textor SC, Gifford RW, Vidt DG: The changing clinical spectrum of primary aldosteronism. Am J Med 1983, 74(4):641-651.
• [22]Vallotton MB: Primary aldosteronism. Part I diagnosis of primary hyperaldosteronism. Clin Endocrinol 1996, 45:47-52.
• [23]Arteaga E, Klein R, Biglieri EG: Use of the saline infusion test to diagnose the cause of primary aldosteronism. Am J Med 1985, 79:722-728.
• [24]Mulatero P, Milan A, Fallo F, Regolisti G, Pizzolo F, Fardella CE, Mosso L, Marafetti L, Veglio F, Maccario M: Comparison of confirmatory tests for the diagnosis of primary aldosteronism. J Clin Endocr Metab 2006, 91(7):2618-2623.
• [25]Dunnick NR, Doppman JL, Mills SR, Gill JR: Preoperative diagnosis and localization of aldosteronomas by measurement of corticosteroids in adrenal venous blood. Radiology 1979, 133:331-333.
• [26]Young WF, Stanson AW, Grant CS, Thompson GB, van Heerden JA: Primary aldosteronism: adrenal venous sampling. Surgery 1996, 120:913-920.
• [27]Doppman JL: Hyperaldosteronism: sampling the adrenal veins. Radiology 1996, 198:309-312.
• [28]Doppman JL, Gill JRJ, Miller DL, Chang R, Gupta R, Friedman TC, Choyke PL, Feuerstein IM, Dwyer AJ, Jicha DL: Distinction between hyperaldosteronism due to bilateral hyperplasia and unilateral aldosteronoma: reliability of CT. Radiology 1992, 184(3):677-682.
• [29]Weiss LM: Comparative histologic study of 43 metastasizing and nonmetastasizing adrenocortical tumors. Am J Surg Pathol 1984, 8:163-169.
• [30]Fuhrman SA, Lasky LC, Limas C: Prognostic significance of morphologic parameters in renal cell carcinoma. Am J Surg Pathol 1982, 6(7):655-663.
• [31]Letavernier E, Peyrard S, Amar L, Zinzindohoué F, Fiquet B, Plouin P-F: Blood pressure outcome of adrenalectomy in patients with primary hyperaldosteronism with or without unilateral adenoma. J Hypertens 2008, 26(9):1816-1823.
• [32]Young WF: Primary aldosteronism: renaissance of a syndrome. Clin Endocrinol (Oxf) 2007, 66(5):607-618.
• [33]Funder JW, Carey RM, Fardella CE, Gomez-Sanchez C, Mantero F, Stowasser M, Young WF Jr, Montori VM: Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2008, 93:3266-3281.
• [34]Sywak M, Pasieka JL: Long-term follow-up and cost benefit of adrenalectomy in patients with primary hyperaldosteronism. Br J Surg 2002, 89:1587-1593.
• [35]Lin YH, Lee HH, Liu KL, Shih SR, Chueh SC, Lin WC, Lin LC, Lin LY, Chung SD, Wu VC, et al.: Reversal of myocardial fibrosis in patients with unilateral hyperaldosteronism receiving adrenalectomy. Surgery 2011, 150(3):526-533.
• [36]Sukor N, Kogovsek C, Gordon RD, Robson D, Stowasser M: Improved quality of life, blood pressure, and biochemical status following laparoscopic adrenalectomy for unilateral primary aldosteronism. J Clin Endocr Metab 2010, 95(3):1360-1364.
• [37]Rossito G, Toniato A, Rossi GP: Adrenal venous sampling but not computed tomography is essential before undertaking adrenalectomy for primary aldosteronism. Surgery 2010, 149(6):852.
• [38]Amar L, Plouin PE, Steichen O: Aldosterone-producing adenoma and other surgically correctable forms of primary aldosteronism. Orphanet J Rare Dis 2010, 19:5-9.
• [39]Mattsson C, Young W Jr: Primary aldosteronism: diagnostic and treatment strategies. Nat Clin Pract Nephrol 2006, 2(4):198-208.
• [40]Nagata D, Takahashi M, Sawai K, Tagami T, Usui T, Shimatsu A, Hirata Y, Naruse M: Molecular mechanism of the inhibitory effect of aldosterone on endothelial NO synthase activity. Hypertension 2006, 48(1):165-171.
• [41]Hashikabe Y, Suzuki K, Jojima T, Uchida K, Hattori Y: Aldosterone impairs vascular endothelial cell function. J Cardiovasc Pharmacol 2006, 47:609-613.
• [42]Oberleithner H: Aldosterone makes human endothelium stiff and vulnerable. Kidney Int 2005, 67(5):1680-1682.
• [43]Rizzoni D, Paiardi S, Rodella L, Porteri E, De Ciuceis C, Rezzani R, Boari G, Zani F, Miclini M, Tiberio G, et al.: Changes in extracellular matrix in subcutaneous small resistance arteries of patients with primary aldosteronism. J Clin Endocr Metab 2006, 91(7):2638-2642.
• [44]Campbell SE, Diaz-Arias AA, Weber KT: Fibrosis of the human heart and systemic organs in adrenal adenoma. Blood Press 1992, 1:149-156.
• [45]Rossi GP, Bernini G, Desideri G, Fabris B, Ferri C, Giacchetti G, Letizia C, Maccario M, Mannelli M, Matterello M-J, et al.: Renal damage in primary aldosteronism. Hypertension 2006, 48:232-238.
• [46]Stowasser M, Sharman J, Leano R, Gordon RD, Ward G, Cowley D, Marwick TH: Evidence for abnormal left ventricular structure and function in normotensive individuals with familial hyperaldosteronism type I. J Clin Endocr Metab 2005, 90:5070-5076.
• [47]Milliez P, Giererd X, Plouin PE, Blacher J, Safar ME, Mourad JJ: Evidence for an increased rate of cardiovascualr events in patients with primary aldosteronism. J Am Coll Cardiol 2005, 45:1243-1248.
• [48]Fujiwara M, Murao K, Imachi H, Yoshida K, Muraoka T, Ohyama T, Kushida Y, Haba R, Kakehi Y, Ishida T: Misdiagnosis of two cases of primary aldosteronism owing to failure of computed tomography to detect adrenal microadenoma. Am J Med Sci 2010, 340(4):335-337.