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Canadian Journal of Cardiology

Unilateral Disease Is Common in Patients With Primary Aldosteronism Without Adrenal Nodules

      Abstract

      Background

      Patients with primary aldosteronism (PA) without apparent adrenal nodularity have not been well characterised in the literature. The aim of this study was to assess for unilateral aldosterone hypersecretion among patients with primary aldosteronism with normal-appearing adrenals using adrenal vein sampling (AVS).

      Methods

      In this cross-sectional study performed at a Canadian tertiary care centre, we reviewed all consecutive PA patients lacking a definitive adrenal nodule who were referred for AVS in the work-up of PA between January 2006 and May 2018. AVS indications included an elevated aldosterone-to-renin ratio and high-probability features of PA.

      Results

      In total, 174 patients were included (mean age, 52.0 years; 62.6% male), and 70 (40.2%) had unilateral aldosterone hypersecretion. There was a positive linear association between higher age categories (by decade) and lateralisation (P = 0.03). For every decade of age, there was a 30% higher odds of lateralisation (odds ratio, 1.03 per year; 95% confidence interval, 1.00-1.05). The frequency of lateralisation was higher in males compared with females (47.7% vs 27.7%), with a 2-fold greater odds of unilateral disease (odds ratio, 2.38; 95% confidence interval, 1.23-4.61). Traditional biomarkers of lateralisation among patients with adrenal nodules (eg, serum potassium and aldosterone-to-renin ratio levels) were not predictive of lateralisation in this population.

      Conclusions

      Many patients with PA who lack definitive adrenal nodules have lateralising disease. Efforts to optimise referrals for AVS may be prioritised by focusing on patients most likely to have unilateral disease, especially males and older adults.

      Résumé

      Contexte

      Les patients atteints d’aldostéronisme primaire (AP) en l’absence de nodularité surrénalienne apparente ne sont pas bien décrits dans la littérature médicale. Nous avons tenté d'évaluer l’hypersécrétion unilatérale d’aldostérone chez les patients atteints d’AP présentant des glandes surrénaliennes en apparence normales à l’aide des résultats d’un cathétérisme veineux surrénalien (CVS).

      Méthodologie

      Dans le cadre de cette étude transversale réalisée dans un centre de soins tertiaires canadien, nous avons examiné le cas de tous les patients consécutifs atteints d’AP ne présentant pas de nodules surrénaliens apparents qui ont été dirigés pour subir un CVS aux fins d’investigation diagnostique d’AP entre janvier 2006 et mai 2018. Les indications pour la réalisation d’un CVS comprenaient un rapport aldostérone/rénine élevé et des caractéristiques fortement évocatrices de l’AP.

      Résultats

      Au total, 174 patients ont été admis dans l’étude (âge moyen : 52,0 ans; 62,6 % étaient des hommes); 70 (40,2 %) d’entre eux présentaient une hypersécrétion unilatérale d’aldostérone. Une relation linéaire positive a été établie entre les groupes d’âge plus avancé (par décennie) et la latéralisation (p = 0,03). Pour chaque décennie d’âge, le risque de latéralisation augmentait de 30 % (risque relatif approché : 1,03 par année; intervalle de confiance à 95 % : de 1,00 à 1,05). La latéralisation était plus fréquente chez les hommes que chez les femmes (47,7 % vs 27,7 %); de fait, les hommes étaient deux fois plus susceptibles de présenter une atteinte unilatérale (risque relatif approché : 2,38; intervalle de confiance à 95 % : de 1,23 à 4,61). Les biomarqueurs classiques de la latéralisation chez les patients présentant des nodules surrénaliens (p. ex. potassium sérique et rapport aldostérone/rénine) ne permettaient pas de prédire la latéralisation dans cette population.

      Conclusions

      Les patients atteints d’AP n’ayant pas de nodules surrénaliens apparents sont nombreux à présenter une atteinte latéralisée. Les mesures visant à optimiser les demandes de CVS devraient tenir compte en priorité des patients les plus susceptibles de présenter une atteinte unilatérale, notamment les hommes et les adultes plus âgés.
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