Primary hyperaldosteronism(PA) detection test : ARR > 20 (PAC ≥ 15 ng/dL, PRA < 1 ng/mL per hour)입니다. Adrenal CT에서 nonfunctioning nodules을 나타내고 adenoma로 잘못 제시하기도 하지만 adrenal mass가 있고 현저한 aldosteronism이 있으며 35세 미만인 경우에는 추가 검사는 권고되지 않습니다[Goldman-Cecil 26th edition]
그러나 40세 이상, CT 상에서 unilateral mass 또는 병변이 보이지 않는 surgical candidate라면 adrenal venous sampling이 필요합니다.
Management of patients with suspected mineralocorticoid excess. *Perform adrenal tumor workup (see Fig. 379-13). BP, blood pressure; CAH, congenital adrenal hyperplasia; CT, computed tomography; GC/MS, gas chromatography/mass spectrometry; PRA, plasma renin activity.
After the diagnosis of hyperaldosteronism is established, the next step is to use adrenal imaging to further assess the cause. Fine-cut CT scanning of the adrenal region is the method of choice because it provides excellent visualization of adrenal morphology. CT will readily identify larger tumors suspicious of malignancy but may miss lesions <5 mm. The differentiation between bilateral micronodular hyperplasia and a unilateral adenoma is only required if a surgical approach is feasible and desired. Consequently, selective adrenal vein sampling (AVS) should only be carried out in surgical candidates with either no obvious lesion on CT or evidence of a unilateral lesion in patients >40 years, because the latter patients have a high likelihood of harboring a coincidental, endocrine-inactive adrenal adenoma. AVS is used to compare levels in aldosteronethe inferior vena cava and between the right and left adrenal veins. AVS requires concurrent measurement of cortisol to document correct placement of the catheter in the adrenal veins and should demonstrate a cortisol gradient >3 between the vena cava and each adrenal vein. Lateralization is confirmed by an aldosterone/cortisol ratio that is at least twofold higher on one side than the other. AVS is a complex procedure that requires a highly skilled interventional radiologist. Even then, the right adrenal vein can be difficult to cannulate correctly, which, if not achieved, invalidates the procedure. There is also no agreement as to whether the two adrenal veins should be cannulated simultaneously or successively and whether ACTH stimulation enhances the diagnostic value of AVS.
Patients >40 years with confirmed mineralocorticoid excess and a unilateral lesion on CT can go straight to surgery, which is also indicated in patients with confirmed lateralization documented by a valid AVS procedure. Laparoscopic adrenalectomy is the preferred approach. Patients who are not surgical candidates, or with evidence of bilateral hyperplasia based on CT or AVS, should be treated medically. [Harrison's internal medicine, 20th edition]
REF. Harrison's internal medicien 20th edition
Goldman-Cecil 26th edition
