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Adrenal Vein Sampling for Primary Aldosteronism: A 2-Week Protocol for Withdrawal of Renin-Stimulating Antihypertensives

  • Clinical Investigation
  • Published:
CardioVascular and Interventional Radiology Aims and scope Submit manuscript

Abstract

Objective

For evaluation of primary aldosteronism, international guidelines recommend a 4–6 week withdrawal of spironolactone, eplerenone, and amiloride prior to adrenal vein sampling (AVS). It is not always feasible to withdraw these drugs in patients with severe hypertension and hypokalemia. We present our experience evaluating the efficacy and clinical outcomes of a 2-week protocol for withdrawal of renin-stimulating antihypertensives prior to AVS.

Design

A single-center retrospective review of all patients who underwent AVS for primary aldosteronism between January 2014 and December 2015.

Patients

32 patients (24 M:8F, mean age 54y) underwent AVS with the 2-week protocol, and 32 held their renin-stimulating antihypertensives for 2 weeks instead of the recommended 4–6 weeks.

Measurements

Plasma renin activity (PRA) was measured immediately before venous sampling to assess for renin suppression (PRA < 0.5 ng/ml/hr). Demographics, antihypertensive medications, plasma aldosterone, plasma renin activity, and outcomes were reviewed.

Results

100% of procedures were diagnostic (selectivity index ≥ 3) and lateralization (lateralization index ≥ 4) was confirmed in 22/32 patients. 19/32 patients had contralateral suppression. PRA confirmed to be suppressed in 30/32 (94%) of patients. Of the 2 patients with unsuppressed renin, 1/2 lateralized diagnosing an aldosterone producing adenoma.

Conclusions

Renin was suppressed in nearly all patients following a 2-week withdrawal of renin-stimulating antihypertensives. Patients who cannot tolerate stopping these medications for 4–6 weeks as recommended by current guidelines may undergo a 2-week withdrawal without affecting the diagnostic outcome of AVS, provided renin suppression is confirmed.

Level of Evidence

Level 4, Case Series.

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Abbreviations

AVS:

Adrenal vein sampling

PRA:

Plasma renin activity

MRA:

Mineralocorticoid receptor antagonists

SI:

Selectivity index

LI:

Lateralization index

ACR:

Aldosterone-to-cortisol ratio

PAC:

Plasma aldosterone concentration

ARR:

Aldosterone–renin ratio

RAAS:

Renin-angiotensin-aldosterone system

DRC:

Direct renin concentration

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Authors and Affiliations

  1. Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA

    Kevin C. Ching

  2. Department of Medicine, Division of Nephrology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA

    Debbie L. Cohen

  3. Department of Surgery, Division of Surgical Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA

    Douglas L. Fraker

  4. Department of Radiology, Hospital of the University of Pennsylvania, 1 Silverstein, 3400 Spruce St, Philadelphia, PA, 19104, USA

    Scott O. Trerotola

Authors
  1. Kevin C. Ching
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  2. Debbie L. Cohen
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  3. Douglas L. Fraker
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  4. Scott O. Trerotola
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Corresponding author

Correspondence to Scott O. Trerotola.

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Conflict of interest

The authors declare that they have no conflict of interest.

Human and Animal Rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

Informed Consent

The study was approved by the institutional review board, and requirement for informed consent was waived.

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Ching, K.C., Cohen, D.L., Fraker, D.L. et al. Adrenal Vein Sampling for Primary Aldosteronism: A 2-Week Protocol for Withdrawal of Renin-Stimulating Antihypertensives. Cardiovasc Intervent Radiol 40, 1367–1371 (2017). https://doi.org/10.1007/s00270-017-1637-x

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  • DOI: https://doi.org/10.1007/s00270-017-1637-x

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