Hyperalsosteronism- Adrenal / Renal Vein Sampling


Question

I have a patient with a 1.2 right adrenal mass, hypertension and hypokalemia. Chemistries were consistent with a diagnosis of primary hyperaldosteronism and I had radiology do AVS. The results are puzzling to me:

Left adrenal Left renal Right adrenal Right renal IVC
PRA: 0.12 0.25 0.1 0.92 0.22
Aldo: 204 50 36 42 45
Cort: 15.1 3 3.3 2.8 3.4
Aldo/Cort: 13.5 16.7 10.9 15 13.2

It appears that this is a bilateral situation. Is that your reading? The mass is again on the right but must be an “incidentaloma” Thank you for your help. Ann Ward

Response

Thank you for your case and your thoughtful questions. From the information you have provided, we gather that your patient presented with hypertension, hypokalemia, and a 1.2 cm right adrenal mass on CT scan. There was biochemical evidence of primary hyperaldosteronism, although we do not have the primary data. The patient underwent AVS. From the information provided, it looks as though ACTH was not used in the sampling protocol. The data generated from the procedure are listed above.:

If ACTH is not used during AVS, a side-to-side ratio of more than 2:1 (comparing cortisol-corrected aldosterone ratios) is considered consistent with unilateral disease. This is clearly not the case in the numbers you have provided, so we agree that these data are most consistent with bilateral disease. However, we note that the right adrenal sample looks very similar biochemically to the right renal sample, and so the right adrenal may not have been successfully cannulated (sometimes the radiologist who performed the procedure can tell you if it was technically challenging). But given that there is also no evidence of suppression of the contralateral (left) adrenal (the left cortisol-corrected aldosterone ratio compared to the IVC is about 1), this also supports the lack of unilateral disease.

As you know, non-functioning adrenal ‘incidentalomas’ are not rare, especially in patients above the age of 40 . We know that adrenal anatomy determined by CT scanning may wrongly predict etiology (or lateralization) of hyperaldosteronism in a significant proportion of patients, and that may be the case here from the information you have presented us.

We hope this is helpful in the management of your case. Florencia Halperin, MD, Erik K. Alexander, MD, Robert D. Dluhy, MD