Present Status of Clinical Practice of Primary Aldosteronism in East ASIA

Presentation Number: SUN 524
Date of Presentation: April 2nd, 2017

Mitsuhide Naruse*1, Michael Stowasser2, Takuyuki Katabami3, Isao Kurihara4, Nanfang Li5, Walter van der Merwe6, Yumie Rhee7, Norlela Sukor8, Nalini Samir Shah9, Yoshiyu Takeda10, Norio Wada11, Vincent Wu12, Takanobu Yoshimoto13, Hironobu Umakoshi1 and Jpas Group14
1National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 2University of Queensland School of Medicine, Greenslopes and Princess Alexandra Hospitals, Brisbane, Australia, 3St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama-shi Kanagawa, Japan, 4Keio University School of Medicine, Tokyo, Japan, 5Hypertension Institute of Xinjiang, Urumqi, Xinjiang, China, 6Hypertension Clinic, Auckland, New Zealand, 7Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 8NATIONAL UNIVERSITY OF MALAYSIA (HUKM), Kuala Lumpur, Malaysia, 9KEM Hospital, Mumbai, Maharashtra, India, 10Kanazawa University, Ishikawa, Japan, 11Sapporo City General Hospital, Sapporo, Japan, 12Taiwan Aldosteronism Investigator, National Taiwan University Hospital, Taipei, Taiwan, 13Tokyo Medical and Dental University, Tokyo, Japan, 14Kyoto Medical Center, Kyoto, Japan

Abstract

Primary aldosteronism (PA) is the most common curable and specifically treatable cause of endocrine hypertension, associated with increased risk of cardio-metabolic complications. Although detection and management of PA has become widespread around the world after the first clinical guideline for PA by the Endocrine Society, PA remains an underdiagnosed disorder and there are widespread differences in diagnostic approaches. Objectives: Document the present status of clinical practice of PA in East ASIA. Methods: A questionnaire-based survey was conducted involving experts in centres in East ASIA including Oceania between Aug and Oct, 2016. The questionnaire included questions related to diagnosis and treatment. Results: A total of 13 centres participated in the survey. About 60% of the centres focused their case detection on hypertensive patients at high risk for PA, rather than all hypertensive patients. Although the conditions of blood sampling varied between centres, it was mainly in the morning and seated position after changing antihypertensive medication to a Ca channel blocker and/or alpha-adrenergic blocker. For case detection, the aldosterone to renin ratio (ARR) was most commonly used followed by a combination of ARR and plasma aldosterone concentration (PAC). The diagnostic cut-off values of ARR and PAC varied between centres. Of the confirmatory tests, the saline infusion test was most commonly used followed by the captopril challenge test. Confirmatory test was judged as positive if at least one of the tests showed positive result. For subtype testing, about 3/4 of centres performed AVS in all the patients prior to adrenal surgery, while 1/4 of the centres performed AVS only in selected patients. ACTH loading before AVS was used in 70% of the centres. Three major reasons to use ACTH were to: minimize stress-induced fluctuation in PAC; maximize the gradient of cortisol from adrenal vein to IVC and thus confirm successful catheterization; and, improve success rate of sampling. A rapid turn-around cortisol assay was used in half of the centres. Successful catheterization was validated by a selectivity index (SI) > 5 after ACTH in 45% of the centres followed by SI > 2 before ACTH in 30% of the centres. An aldosterone lateralization ratio (LR) and contralateral ratio (CR) were the main criteria to predict unilateral adrenal disease. A LR >4.0 after ACTH was used in half of the centres as the cut-off, while <1.0 was the cut-off for the CR. Conclusions: There are clinically significant differences in the methods of and cut-offs used for the diagnosis between the participating centres, resulting in a heterogeneous clinical practice of PA in East ASIA. The current survey is the first step to establish the platform to enhance the quality of clinical practice of PA in East ASIA. (Supported by AMED:15Aek0109122)

 

Disclosure: TK: , ONO-Pharma, , ONO-Pharma. Nothing to Disclose: MN, MS, IK, NL, WV, YR, NS, NSS, YT, NW, VW, TY, HU, JG