肾上腺静脉采血在原发性醛固酮增多症分型诊断中的应用价值  

Role of adrenal vein sampling in differential diagnosis of primary aldosteronism subtypes

作　　者：李洪运 李平[1] 沈山梅[1] 张雪斌[2] 冯文焕[1] 黄洪[1] 陈炜[1] 朱大龙[1] 

机构地区：[1]南京大学医学院附属鼓楼医院内分泌科,210008 [2]南京大学医学院附属鼓楼医院放射科,210008

出　　处：《中华医学杂志》2017年第42期3291-3296,共6页National Medical Journal of China

基　　金：江苏省“科教强卫工程”青年医学人才项目（QNRC2016020）;南京大学中央高校项目（021414380160）

摘　　要：目的 探讨肾上腺静脉采血（AVS）在原发性醛固酮增多症（原醛）分型诊断中的应用.方法 回顾性收集2010年9月至2016年9月南京鼓楼医院内分泌科确诊原醛并且行AVS的50例患者的临床、病理及随访资料.AVS采取双侧同步非促肾上腺皮质激素（ACTH）刺激的采血法,同时进行术中皮质醇测定.选择性指数（SI）≥1.5提示插管成功,优势分泌指数（LI）≥2提示存在单侧优势分泌.进一步对相关临床资料及AVS结果进行分析.结果 50例患者中,41例采血成功,成功率82%.41例采血成功病例根据是否有优势分泌及术后病理结果分为醛固酮瘤（APA）/单侧性肾上腺皮质增生（UAH）组24例及特发性醛固酮增多症（IHA）组17例.与IHA患者相比,APA/UAH患者高血压病程更长[10.0（5.0,13.0）年比4.0（2.0,8.0）年,P=0.046],低血钾比例更高（95.8%比64.7%,P=0.009）,基础肾素活性较低（P=0.089）,基础醛固酮及醛固酮肾素活性比值（ARR）水平更高（均P〈0.05）.将APA/UAH患者根据优势分泌指数中位数分为两组,优势分泌指数高和低的患者之间的临床特征、影像学表现及手术预后差异均无统计学意义（均P〉0.05）.CT与AVS对原醛分型诊断一致者仅占48.8%（20/41）.结论 采取双侧同步采血及术中皮质醇测定可提高AVS的成功率及诊断准确率.AVS在影像学无法确定分型的原醛患者的诊断中具有优势.Objective To investigate the role of adrenal vein sampling （AVS） in identifying the subtype of primary aldosteronism （PA）. Methods AVS was performed in 50 patients who were confirmed as PA between September 2010 and September 2016 in Nanjing Drum Tower Hospital. Clinical, biochemical and follow-up data were reviewed retrospectively. Bilaterally simultaneous catheterization without cosyntropin stimulation and contemporaneous cortisol measurement during AVS were used. Selectivity index （SI） ≥ 1.5 suggested that the sample was from the adrenal vein. Lateralization index （LI） ≥ 2 suggested unilateral disease. Clinical data was further compared and the AVS findings were analyzed. Results AVS was successful performed in 41 cases of 50 patients, and the success rate was 82%. According to the results of AVS and postoperative pathology, 41 cases were divided into aldosterone-producing adenoma （APA）/ unilateral adrenal hyperplasia （UAH） group （24 cases） and idiopathic hyperaldosteronism （IHA） group （17 cases）. Compared with IHA group, patients with APA/UAH showed longer duration of hypertension [10.0 （5.0, 13.0） yvs4.0 （2.0, 8.0） y, P=0.046], higher proportion ofhypokalemia （95.8% vs 64. 7% , P = 0. 009 ）. Furthermore, patients with APA/UAH demonstrated lower plasma renin activity （P = 0. 089 ）, higher plasma aldosterone concentration and aldosterone to renin ratio （ARR） （ both P 〈 0.05 ）. The diagnostic concordance between CT and adrenal vein sampling was only 48.8% （20/41）. Conclusions The application of bilaterally simultaneous catheterization and contemporaneous cortisol measurement improves success rate and diagnostic accuracy of AVS. AVS is useful in subtype diagnosis of PA with equivocal imaging findings.

关 键 词：醛固酮增多症 肾上腺静脉采血 醛固酮瘤 特发性醛固酮增多症 

分 类 号：R586.24[医药卫生—内分泌]