肾上腺静脉取血对原发性醛固酮增多症定位诊断的临床价值及其指导手术预后

The clinical value of adrenal vein sampling for subtype diagnosis of primary aldosteronism and the prognosis of adrenalectomy guided by adrenal vein sampling

目的探讨肾上腺CT/磁共振成像(MRI)与肾上腺静脉取血(AVS)在原发性醛固酮增多症(PA)定位诊断中的一致性和符合率,分析不同定位诊断方法指导手术治疗后的预后情况。方法(1)纳入2019年3月至2022年8月在河南省人民医院高血压科确诊PA且成功行AVS检查的患者147例,收集所有患者的临床和生化资料,比较肾上腺CT/MRI或结合低钾和AVS对PA定位的诊断符合率。(2)从上述147例行AVS检查的患者中筛选出79例行肾上腺手术治疗的PA患者纳入AVS指导组,选择同期未接受AVS指导且行肾上腺手术治疗的27例PA患者纳入非AVS指导组,比较两组患者术后临床及生化指标的差异。结果(1)在PA定位诊断中,肾上腺CT/MRI和AVS的符合率为55.8%,一致性检验Kappa值为0.311;在低钾患者中,肾上腺影像和AVS的符合率为63.5%,Kappa值为0.429。(2)AVS指导组和非AVS指导组术后随访时间中位数(P_(25),P_(75))分别为10.9(4.5,17.6)和11.0(5.6,18.0)月。两组患者的术后血压和生化指标均较术前明显改善(均P<0.05),并且AVS指导组高血压的治愈率高于非AVS指导组[51.9%(41/79)比29.6%(8/27),χ^(2)=4.014,P=0.045],诊室收缩压较基线下降值大于非AVS指导组[(23.2±24.5)比(11.3±29.2)mmHg,t=2.013,P=0.047]。依据AVS行肾上腺手术治疗的患者降压药减少量较非AVS指导组更大(P<0.05)。两组患者术后生化缓解率差异无统计学意义(P>0.05)。结论肾上腺CT/MRI和AVS的符合率低,虽然在低钾患者中肾上腺影像与AVS的符合率有所提高,但一致性程度中等,AVS仍是PA定位诊断的重要手段。AVS指导下行肾上腺手术治疗可以提高PA患者高血压的治愈率,同时减少降压药的需求,但在生化缓解方面与非AVS指导手术组差异无统计学意义。

Objective To investigate the concordance and coincidence rate of adrenal computed tomography(CT)/magnetic resonance imaging(MRI)and adrenal venous sampling(AVS)in the subtype diagnosis of primary hyperaldosteronism(PA),and the prognosis of surgical treatment guided by different diagnostic methods.Methods(1)One hundred and forty-seven patients diagnosed with PA and successfully underwent AVS examination at the Department of Hypertension,Henan Provincial People's Hospital from March 2019 to August 2022 were included.Clinical and biochemical data of all patients were collected,and the coincidence rates between adrenal CT/MRI or combined with hypokalemia and AVS for the subtype diagnosis of PA were analysed.(2)Seventy-nine PA patients screened out from the above 147 patients who underwent adrenal surgery were included in AVS-guidance group,and 27 PA patients who did not receive AVS but underwent adrenal surgery during the same period were included in non-AVS-guidance group.The postoperative clinical and biochemical indicators of the two groups were analyzed.Results(1)The concordance rate between adrenal CT/MRI and AVS for PA subtype diagnosis was 55.8%,and Kappa value was 0.311 in concordance test.The concordance rate of adrenal CT/MRI and AVS was 63.5%and Kappa value was 0.429 in patients with hypokalemia.(2)The median(P_(25),P_(75))of postoperative follow-up time in the AVS-guidance group and non-AVS-guidance group was 10.9(4.5,17.6)and 11.0(5.6,18.0)months respectively.The postoperative blood pressure and biochemical indicators were both significantly improved compared to preoperative levels in two groups(P<0.05).Compared with non-AVS-guidance group,the cure rate of hypertension[51.9%(41/79)vs 29.6%(8/27),χ^(2)=4.014,P=0.045]and the decline in office systolic blood pressure from baseline[(23.2±24.5)vs(11.3±29.2)mmHg,t=2.013,P=0.047]were higher in the AVS-guidance group.Patients who underwent AVS-guided adrenal surgery had a significantly greater reduction in antihypertensive drugs compared to the non-AVS-guidance group(P<0.05).There was no statistical difference in biochemical remission between the two groups(P>0.05).Conclusions The concordance rates of adrenal CT/MRI and AVS are low.Although the coincidence rate has improved in patients with hypokalemia,the degree of consistency is moderate.AVS remains an important diagnostic tool in PA subtyping.AVS-guided adrenal surgery can improve the cure rate of hypertension in PA patients and reduce the antihypertensive drugs,but there is no statistically significant difference in biochemical remission compared to the non-AVS-guided surgery group.