CBN March 2021 | 17

iNteractive quiz

Case 1
Dr. Priya Susan Roy, Dr. Caroline Bachmeier, Dr. Elzahn de Waal, Robert
White and Dr. Carel Pretorius
Department of Chemical Pathology, Pathology Queensland, Brisbane, QLD
E-mail: Priya.Roy@health.qld.gov.au

Case History
A 54-year-old female presented with a hypertensive crisis to the
emergency department on two separate occasions. Biochemistry showed
hypokalaemia dating back over a 10-year period with values as low as 2.7
mmol/L (3.5-5.2 mmol/L), aldosterone was >500 pmol/L (Ambulatory: 30-
800 pmol/L)and aldosterone renin ratio 631 (<55) with suppression of her
renin concentration to <3.4 mU/L(Ambulatory 3-40 mu/L) was noted on
both occasions. Plasma metanephrines and a 1 mg oral dexamethasone
suppression test were unremarkable. A computed tomogram of the
adrenals showed an 8mm nodule in the left adrenal. The diagnosis of
primary hyperaldosteronism was confirmed but unfortunately the results
of the confirmatory tests were not available on our laboratory information
system. She proceeded to an adrenal vein sampling with the following
results:

Questions
1. What biochemical tests would be done prior to doing a dynamic
function test of adrenal venous sampling?

2. What are the criteria for successful cannulation of the adrenal veins?

3. What are the criteria for evidence of lateralisation of aldosterone

production?

Answers on page 20
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iNteractive quiz

Case 1

Discussion

Question 1
Aldosterone-renin ratios are utilised as a screening test for primary hyperaldosteronism. Two elevated values are
useful prior to further confirmatory testing. Hypokalaemia needs to be corrected prior to performing aldosterone-
renin ratios as hypokalaemia suppresses aldosterone secretion and may lead to falsely negative results. Medications
and preanalytical conditions that can affect the ratios must always be considered. Evaluation for other causes of
hypertension including plasma metanephrines (Phaeochromocytoma), a 1mg oral dexamethasone test (for Cushing’s
disease), urea, creatinine and eGFR (for renovascular hypertension) and thyroid function tests (for hyperthyroidism)
should be done. Confirmatory tests are fludrocortisone suppression test and saline suppression test.

Question 2
In patients (who are surgical candidates) with confirmed primary hyperaldosteronism, Adrenal Vein Sampling
(AVS) is the gold standard for lateralisation of the source of aldosterone excess. Unilateral hyperaldosteronism is
potentially curable by surgery and thereby could considerably change management. If the ratio of adrenal vein to
peripheral cortisol is ≥ 3-5 (when ACTH stimulation is used prior to sampling), then there is successful cannulation of
the adrenal vein on the corresponding adrenal. In the above results, there is successful cannulation on all attempts
except right adrenal vein attempt 1.

Question 3
Lateralisation criteria is met if:
• the adrenal venous aldosterone/cortisol ratio on one side is at least 2 times greater than the simultaneous
peripheral venous ratio and
• the contralateral adrenal venous aldosterone/cortisol ratio is no higher than the peripheral venous ratio.

The lateralisation index is the ratio of adrenal venous aldosterone/cortisol on the dominant side to the same
ratio on the contralateral side. The Endocrine Society guidelines recommend a ratio of ≥ 4 as lateralisation (with
ACTH stimulation). As is seen with the results above, there is no clear evidence of lateralisation since there is no
suppression on the contralateral side.

Questions on page 17
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References
1. Wolley M, Thuzar M, Stowasser M. Controversies and advances in adrenal venous sampling in the diagnostic
workup of primary aldosteronism. Best Practice & Research Clinical Endocrinology & Metabolism 2020;
34(3):101400.

2. Young W, Stanson A, Thompson G et al. Role for adrenal venous sampling in primary aldosteronism. Surgery
2004; 136(6):1227-1235.

3. Funder JW, Carey RM, Mantero F, Murad MH, Reincke M, Shibata H. et al. The Management of Primary
Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. The
Journal of Clinical Endocrinology and Metabolism 2016; 101:1889-1916.