肾上腺静脉采血在原发性醛固酮增多症分型诊断中的价值

Value of adrenal venous sampling in the subtypic diagnosis of primary aldosteronism

目的评价肾上腺静脉采血（AVS）在原发性醛固酮增多症（原醛）分型诊断中的价值。方法近3年来，共有36例患者通过血浆醛固酮／肾素活性比值（ARR）筛查和盐水输注试验或卡托普利抑制试验确诊为原醛，所有患者均接受肾上腺CT扫描和AVS检查，然后通过比较CT表现、AVS结果和临床最终结局之间的差异来评价CT和AVS在原醛分型诊断中的准确度。结果36例患者中，15例（42％）临床最终确诊为醛固酮腺瘤（APA），另外21例（58％）为双侧肾上腺增生（BAH）。APA组血浆醛固酮（ALD）水平（298．9±91．0）ng／L，显著高于BAH组（226．3±59．0）ng／L，（P〈0．05）；血浆肾素活性（PRA）（0．18±0．14）ng·ml-1·h-1，显著低于BAH组（0．28±0．29）ng·m1-1·h-1（P〈0．01）；ARR（2444．7±1405．2）显著高于BAH组（1550．0±1059．8）（P〈0．01）；血钾水平（2．71±0．57）mmol／L，虽然低于BAH组（3．17±0．40）mmol／L，但差异无统计学意义（P〉0．05）。27．8％（10／36）的患者CT表现与AVS结果不符，CT在原醛分型诊断中的准确度为72．2％，仅仅依赖CT检查，将有25％（9／36）的患者接受不恰当的治疗。94．4％（34／36）的患者AVS结果与临床最终诊断相符，其准确度明显高于CT。结论肾上腺CT扫描在原醛分型诊断方面不如AVS准确和可靠，对于有手术意愿的原醛患者因常规开展术前AVS检查。

Objective To assess the diagnostic value of adrenal venous sampling （AVS） in the subtype diagnosis of primary aldosteronism （PA）. Methods The diagnosis of PA was made in 36 patients based on an elevated ratio of plasma aldosterone （ALD） to plasma rennin activity （PRA） （ARR） and confirmed tests （ saline infusion or captopril challenge） in recent 3 years. All PA patients underwent adrenal computed tomographic scan （CT） and AVS. The diagnostic accuracy of CT and AVS in the subtype differentiation of PA were evaluated by comparing the differences of CT findings, AVS results and clinical outcomes. Results Fifteen of 36 patients （42%） had a final diagnosis of aldosterone-producing adenoma （APA） and aother 21 patients （58%） with bilateral adrenal hyperplasia （BAH）. The level of ALD was significantly higher in APA group than that in BAH group （298.9 ±91.0 vs 226. 3 ±59 ng/L, P 〈0.05）. PRA （ng- ml-1 · h-1） in APA patients were markedly lower than that in BAH counterparts （0. 18 ± 0. 14 vs 0. 28 ±0. 29 ng · ml-1 · h-1 ,P 〈0. 01 ）. Consequently, ARR in APA group was evidently higher than that in BAH group （ 2444. 7 ± 1405.2 vs 1550.0 ± 1059.8, P 〈 0. 05 ）. Plasma potassium in APA patients was lower than that in those with BAH （2. 71 ±0. 57 vs 3. 17 ±0. 40 retool/L）. But there was no statistic significance （ P 〉 0. 05 ）. The CT findings were discordant with the AVS resuhs in 27. 8% of patients （10/36）. The accuracy of adrenal CT scan was only 72.2% in the subtypic diagnosis of PA, provided AVS was the gold standard for distinguishing between APA and BAH. Reliance on CT findings could lead to inappropriate management in 25% of PA patients. Conversely, the AVS results were concordant with the clinical outcomes in 94. 4% of all patients. Conclusion CT scan is not a reliablemethod of differentiating primary aldosteronism. Compared with CT, AVS is more accurate in establishing a correct diagnosis of primary aldosteronism. AVS should be performed routinely before operation in PA patients opting for adrenalectomy.