Outcome of adrenal vein sampling performed during concurrent mineralocorticoid receptor antagonist therapy

Abstract

Context: Pharmacological inhibition of mineralocorticoid receptor (MR) signaling in patients with primary aldosteronism (PA) reestablishes aldosterone synthesis by nondiseased zona glomerulosa cells through activation of the renin-angiotensin-aldosterone system. In this context, current guidelines recommend discontinuing MR blockade for diagnostic procedures, including adrenal vein sampling (AVS). Discontinuation of MR blockade in high-risk patients may be harmful because of uncontrolled hypertension and severe hypokalemia. We hypothesize that MR antagonist therapy can be continued during AVS as long as renin levels remain suppressed.

Objective: The objective of this study was to assess the validity of AVS results in the context of MR antagonistic therapy.

Design: We retrospectively analyzed all AVS studies in Munich (since 2008) and Düsseldorf (since 2011) and identified four of 237 (1.7%) patients with PA who underwent AVS while treated with an MR antagonist. Adrenalectomy was recommended based on the results of AVS in all four patients. After adrenalectomy, follow-up data were obtained to confirm improvement or remission of PA. Main outcome measures included blood pressure values, daily defined doses of antihypertensive medication, as well as levels of aldosterone, renin, and potassium, and the aldosterone/renin ratio.

Results: In all patients, renin remained low or suppressed during AVS despite MR antagonist treatment. AVS clearly demonstrated unilateral aldosterone excess in each case. After adrenalectomy, all patients showed remission of PA as demonstrated by blood pressure values, potassium levels, and the aldosterone/renin ratio.

Conclusion: In selected cases of PA, MR antagonist therapy might be continued during AVS, provided that renin values remain low.