"PA is a group of disorders in which aldosterone production is inappropriately high, relatively autonomous from the renin-angiotensin system, and nonsuppressible by sodium loading," write John W. Funder, from Prince Henry's Institute of Medical Research in Clayton, Australia, and colleagues. "Such inappropriate production of aldosterone causes cardiovascular damage, suppression of plasma renin, hypertension, sodium retention, and potassium excretion that if prolonged and severe may lead to hypokalemia. PA is commonly caused by an adrenal adenoma, by unilateral or bilateral adrenal hyperplasia, or in rare cases by the inherited condition of glucocorticoid-remediable aldosteronism (GRA)."
The goal of The Endocrine Society was to generate clinical practice guidelines for the diagnosis and treatment of patients with PA. The Clinical Guidelines Subcommittee of The Endocrine Society selected a task force chair to oversee 6 additional experts, 1 methodologist, and a medical writer. No corporate funding or remuneration was provided to the task force.
Key recommendations for treatment and prevention were developed from systematic reviews of available evidence, followed by a consensus process including discussions during 1 group meeting, several conference calls, and multiple email communications. Recommendations were graded with the Grading of Recommendations, Assessment, Development, and Evaluation group criteria, which characterize the quality of evidence as well as the strength of recommendations. The task force used the term recommend for strong recommendations and the term suggest for weak recommendations.
With the assistance of a medical writer, the task force prepared drafts that were reviewed successively by the Endocrine Society's Clinical Guidelines Subcommittee, Clinical Affairs Committee, and Council. The version approved by the Clinical Guidelines Subcommittee and Clinical Affairs Committee was posted on The Endocrine Society's Web site, and comments were invited from members. Written comments at each stage of review allowed the task force to incorporate needed changes.
"We recommend case detection of primary aldosteronism be sought in higher risk groups of hypertensive patients and those with hypokalemia by determining the aldosterone-renin ratio under standard conditions, and that the condition be confirmed/excluded by one of four commonly used confirmatory tests," the task force writes. "We recommend that all patients with primary aldosteronism undergo adrenal computed tomography as the initial study in subtype testing and to exclude adrenocortical carcinoma."
Specific guidelines regarding diagnosis of PA are as follows:
Case detection of PA is recommended in patient groups with relatively high prevalence of PA, including patients with Joint National Commission stage I (> 160 - 179/100 - 109 mm Hg), stage II (> 180/110 mm Hg), or drug-resistant hypertension; hypertension and spontaneous or diuretic induced hypokalemia; hypertension with adrenal incidentaloma; or hypertension and a family history of early-onset hypertension or cerebrovascular accident at age younger than 40 years. Case detection is also recommended for all hypertensive first-degree relatives of patients with PA.
To detect cases of PA in the patient groups just mentioned, use of the plasma aldosterone-renin ratio (ARR) is recommended.
To definitively confirm or rule out the diagnosis of PA, it is recommended that patients with a positive ARR undergo testing by any of 4 confirmatory tests instead of proceeding directly to subtype classification.
As the initial study in subtype testing, an adrenal computed tomography scan is recommended in all patients with PA. This test also excludes large masses that may represent adrenocortical carcinoma.
Adrenal venous sampling by an experienced radiologist is recommended to distinguish between unilateral and bilateral adrenal disease, when surgical treatment is feasible, and the patient is willing to undergo the procedure.
Genetic testing for GRA is suggested in patients in whom confirmed PA begins before 20 years of age and in those with a family history of PA or strokes at 40 years of age or younger.
Specific guidelines regarding treatment of PA are as follows:
For patients with documented unilateral PA, treatment by unilateral laparoscopic adrenalectomy is recommended. Medical treatment with a mineralocorticoid receptor antagonist is recommended for patients who cannot or who do not wish to undergo surgery.
Medical treatment with a mineralocorticoid receptor antagonist is recommended for patients with PA caused by bilateral adrenal disease. Spironolactone is suggested as the primary agent, with eplerenone as an alternative.
作者:admin@医学,生命科学 2011-02-16 17:14