Первичный гиперальдостеронизм (ПГА) – клинический синдром, развивающийся в результате избыточной секреции альдостерона функционально автономным от ренин-ангиотензин-альдостероновой системы опухолевым или гиперпластическим процессом в коре надпочечника. Являясь крайне распространенной формой вторичной артериальной гипертензии, ПГА может быть представлен нозологиями как с односторонней, так и с двусторонней гиперпродукцией альдостерона, дифференциальная диагностика между которыми является ключевым моментом для определения лечебной тактики и показаний к оперативному лечению, целесообразному лишь при одностороннем варианте ПГА. В настоящее время сравнительный селективный венозный забор крови (ССВЗК) из надпочечниковых вен является «золотым стандартом» в дифференциальной диагностике нозологических форм ПГА, в отличие от визуализирующих методов, не обладающих достаточной чувствительностью и специфичностью. За исключением определенных случаев, ССВЗК рекомендован к проведению всем пациентам с подтвержденным ПГА, планирующим оперативное лечение. На примере представленного клинического наблюдения пациентки с подтвержденной односторонней гиперпродукцией альдостерона, картиной неизмененного надпочечника по данным визуализирующих исследований и наличием гормонально-неактивного образования контралатерального надпочечника подчеркивается важность проведения ССВЗК для решения вопроса об оперативном лечении.
Ключевые слова: первичный гиперальдостеронизм, сравнительный селективный венозный забор крови из надпочечниковых вен, альдостерон-продуцирующая аденома, двусторонняя гиперплазия надпочечников, клинический случай.
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Primary hyperaldosteronism (PA) – is the clinical syndrome, results from autonomous of the major regulators of secretion, aldosterone overproduction by a tumorous or hyperplastic tissue in adrenal cortex. Being the most frequent cause of secondary hypertension, PA may be represented by disorders with unilateral or bilateral aldosterone overproduction and differential diagnosis between them is crucial for choosing a right therapeutic approache: lifelong medical therapy with mineralocorticoid receptor antagonists or unilateral adrenalectomy. Adrenal venous sampling (AVS) is currently the «gold standard» test for identifying laterality of excess hormone production, unlike imaging tests, sensitivity and specificity of which is not enough, due to inability to evaluate functional activity with confidence, and also to limitations in detecting tiny abnormalities of adrenals, such as microadenoma or hyperplasia. Excluding certain cases, AVS is recommended to patients with confirmed PA, planning surgical treatment, to determine the lateralization of aldosterone hypersecretion. Described clinical case of patient with confirmed lateralization from adrenal without any detected lesions on CT-imaging and nonfunctioning tumour on contralateral side, highlights the importance of using AVS for decision to refer patients for surgery.
1. Молашенко Н.В., Платонова Н.М., Юкина М.Ю. и др. Первичный гиперальдостеронизм (современный алгоритм диагностики и лечения). В кн.: Трошина Е.А., ред. Сборник методических рекомендаций (в помощь практикующему врачу). Тверь: Триада, 2017. C. 95-124 [Molashenko NV, Platonova NM, Yukina MYu, et al. Primary hyper aldosteronism (modern diagnostic and treatment algorithm). In: Troshina E.A., editor. Collection of guidelines (to help the practitioner). Tver: Triada, 2017. P. 95-124 (In Russ.)].
2. Monticone S, Burrello J, Tizzani D, et al. Prevalence and Clinical Manifestations of Primary Aldosteronism Encountered in Primary Care Practice. J Am Coll Cardiol. 2017;69(14):1811-20. doi: 10.1016/j.jacc.2017.01.052
3. Fogari R, Preti P, Zoppi A, et al. Prevalence of Primary Aldosteronism among Unselected Hypertensive Patients: A Prospective Study Based on the Use of an Aldosterone/Renin Ratio above 25 as a Screening Test. Hypertens Res. 2007;30(2):111-7. doi: 10.1291/hypres.30.111
4. Chao C-T, Wu V-C, Kuo C-C, et al. Diagnosis and management of primary aldosteronism: An updated review. Ann Med. 2013;45(4):375-83. doi: 10.3109/07853890.2013.785234
5. Iacobone M, Citton M, Viel G, et al. Unilateral adrenal hyperplasia: A novel cause of surgically correctable primary hyperaldosteronism. Surgery. 2012;152(6):1248-55. doi: 10.1016/j.surg.2012.08.042
6. Seccia TM, Fassina A, Nussdorfer GG, et al. Aldosterone-producing adrenocortical carcinoma: an unusual cause of Conn’s syndrome with an ominous clinical course. Endocr Relat Cancer. 2005;12(1):149-59. doi: 10.1677/erc.1.00867
7. Abdelhamid S, Müller-Lobeck H, Pahl S, et al. Prevalence of adrenal and extra-adrenal Conn syndrome in hypertensive patients. Arch Intern Med. 1996;156(11):1190-5. doi: 10.1001/archinte.1996.00440100086010
8. Mulatero P, Tizzani D, Viola A, et al. Prevalence and Characteristics of Familial Hyperaldosteronism: The PATOGEN Study (Primary Aldosteronism in TOrino-GENetic forms). Hypertension. 2011;58(5):797-803. doi: 10.1161/HYPERTENSIONAHA.111.175083
9. Mulatero P, Tauber P, Zennaro M-C, et al. KCNJ5 Mutations in European Families With Nonglucocorticoid Remediable Familial Hyperaldosteronism. Hypertension. 2012;59(2):235-40. doi: 10.1161/
HYPERTENSIONAHA.111.183996
10. Geller DS, Zhang J, Wisgerhof MV, et al. A novel form of human mendelian hypertension featuring nonglucocorticoid-remediable aldosteronism. J Clin Endocrinol Metab. 2008;93(8):3117-23. doi: 10.1210/jc.2008-0594
11. Milliez P, Girerd X, Plouin P-F, et al. Evidence for an increased rate of cardiovascular events in patients with primary aldosteronism. J Am Coll Cardiol. 2005;45(8):1243-8. doi: 10.1016/j.jacc.2005.01.015
12. Mulatero P, Monticone S, Bertello C, et al. Long-Term Cardio- and Cerebrovascular Events in Patients With Primary Aldosteronism.
J Clin Endocrinol Metab. 2013;98(12):4826-33. doi: 10.1210/jc.2013-2805
13. Funder JW, Carey RM, Mantero F, et al. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(5):1889-916. doi: 10.1210/jc.2015-4061
14. Мельниченко Г.А., Платонова Н.М., Бельцевич Д.Г. и др. Первичный гиперальдостеронизм: диагностика и лечение. Новый взгляд на проблему. По материалам Проекта клинических рекомендаций Российской ассоциации эндокринологов по диагностике и лечению первичного гиперальдостеронизма. Consilium Medicum. 2017;19(4):75-85 [Melnichenko GA, Platonova NM, Beltsevich DG, et al. Primary Hyperaldosteronism: Diagnosis and Treatment. A New Look at the Problem. According to the Materials of the Russian Association of Endocrinologists Clinical Guidelines for Primary Hyperaldosteronism Diagnosis and Treatment. Consilium Medicum. 2017;19(4):75-85 (In Russ.)]. doi: 10.26442/2075-1753_19.4.75-85
15. Эндокринная хирургия. Под ред. И.И. Дедова, Н.С. Кузнецова, Г.А. Мельниченко. М.: Литтерра, 2011. 352 с. (Серия «Практические руководства») [Dedov II, Kuznetsov NS, Mel'nichenko GA, editors. Endocrine surgery. Moscow: Litterra, 2011. 352 p. (In Russ.)].
16. Молашенко Н.В., Трошина Е.А. Первичный идиопатический гиперальдостеронизм в клинической практике. Ожирение и метаболизм. 2012;9(4):3-9 [Molashenko NV, Troshina EA. Primary
idiopathic hyperaldosteronism in clinical practice Ožirenie i metabolizm. 2012;9(4):3-9 (In Russ.)]. doi: 10.14341/2071-8713-5122
17. Семенов Д.Ю., Панкова П.А., Османов З.Х. и др. Сравнительная оценка различных объемов операций при опухолевых заболеваниях надпочечников. Эндокринная хирургия. 2016;10(2):34-43 [Semenov DYu, Pankova PA, Osmanov ZH, et al. Comparison of Adrenal Tumor Treatment Results by Different Volume of Surgical Interventions. Endokrinnaya Khirurgiya = Endocrine Surgery. 2016;10(2):34-43 (In Russ.)]. doi: 10.14341/serg2016234-43
18. Mulatero P, Bertello C, Rossato D, et al. Roles of Clinical Criteria, Computed Tomography Scan, and Adrenal Vein Sampling in Differential Diagnosis of Primary Aldosteronism Subtypes. J Clin Endocrinol Metab. 2008;93(4):1366-71. doi: 10.1210/jc.2007-2055
19. Ситкин И.И., Фадеев В.В., Бельцевич Д.Г. и др. Дифференциальная диагностика первичного гиперальдостеронизма: роль и место сравнительного селективного забора крови из надпочечниковых вен. Проблемы эндокринологии. 2011;57(2):52-6 [Sitkin II, Fadeev VV, Bel’tsevich DG, et al. Differential Diagnostics of Primary Hyperaldosteronism: The Role and Significance of Comparative Selective Blood Sampling from Adrenal Veins. Problemy Endokrinologii = Problems of Endocrinology. 2011;57(2):52-6 (In Russ.)]. doi: 10.14341/probl201157252-56
20. Nwariaku FE, Miller BS, Auchus R, et al. Primary Hyperaldosteronism: effect of adrenal vein sampling on surgical outcome. Arch Surg. 2006;141(5):497. doi: 10.1001/archsurg.141.5.497
21. Young WF, Stanson AW, Thompson GB, et al. Role for adrenal venous sampling in primary aldosteronism. Surgery. 2004;136(6):1227-35. doi: 10.1016/j.surg.2004.06.051
22. Buffolo F, Monticone S, Williams TA, et al. Subtype Diagnosis of Primary Aldosteronism: Is Adrenal Vein Sampling Always Necessary? Int J Mol Sci. 2017;18(4):848. doi: 10.3390/ijms18040848
23. Lim V, Guo Q, Grant CS, et al. Accuracy of Adrenal Imaging and Adrenal Venous Sampling in Predicting Surgical Cure of Primary Aldosteronism. J Clin Endocrinol Metab. 2014;99(8):2712-9. doi: 10.1210/jc.2013-4146
24. Dick SM, Queiroz M, Bernardi BL, et al. Update in diagnosis and management of primary aldosteronism. Clin Chem Lab Med. 2018;56(3):360-72. doi: 10.1515/cclm-2017-0217
25. Küpers EM, Amar L, Raynaud A, et al. A Clinical Prediction Score to Diagnose Unilateral Primary Aldosteronism. J Clin Endocrinol Metab. 2012;97(10):3530-7. doi: 10.1210/jc.2012-1917
26. Rossi GP, Auchus RJ, Brown M, et al. An Expert Consensus Statement on Use of Adrenal Vein Sampling for the Subtyping of Primary AldosteronismNovelty and Significance. Hypertension. 2014;63(1):151-60. doi: 10.1161/hypertensionaha.113.02097
27. Nieman LK, Biller BMK, Findling JW, et al. The Diagnosis of Cushing’s Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2008;93(5):1526-40. doi: 10.1210/jc.2008-0125
28. Reznik Y, Amar L, Tabarin A. SFE/SFHTA/AFCE consensus on primary aldosteronism, part 3: Confirmatory testing. Ann Endocrinol (Paris). 2016;77(3):202-7. doi: 10.1016/j.ando.2016.01.007
29. Kloos RT, Gross MD, Francis IR, et al. Incidentally Discovered Adrenal Masses*. Endocr Rev. 1995;16(4):460-84. doi: 10.1210/edrv-16-4-460
30. Reincke M, Rump LC, Quinkler M, et al. Risk Factors Associated with a Low Glomerular Filtration Rate in Primary Aldosteronism. J Clin Endocrinol Metab. 2009;94(3):869-75. doi: 10.1210/jc.2008-1851
31. Sechi LA, Novello M, Lapenna R, et al. Long-term Renal Outcomes in Patients With Primary Aldosteronism. JAMA. 2006;295(22):2638-45. doi: 10.1001/jama.295.22.2638
32. Дедов И.И., Бельцевич Д.Г., Молашенко Н.В. и др. Патент на изобретение РФ №2444983/ 03.06.2010. Способ стандартизованной двухэтапной диагностики первичного гиперальдостеронизма у пациентов с сочетанным наличием объемного образования надпочечника и артериальной гипертензии. Доступно по ссылке: http://www.findpatent.
ru/patent/244/2444983.html Ссылка активна на 13.06.18 [Dedov II, Bel'tsevich DG, Molashenko NV, et al. RF patent RUS №2444983 03.06.2010. A method for a standardized two-stage diagnosis of primary hyperaldosteronism in patients with the combined presence of volumetric formation of the adrenal gland and arterial hypertension. Available from: http://www.findpatent.ru/patent/244/2444983.html Link active at 13.06.18 (In Russ.)].
33. Palumbo A, Borge M, Molvar C. Adrenal vein sampling: a simple method to increase the technical success rate. J Vasc Interv Radiol. 2015;26(2):S141-S142. doi: 10.1016/j.jvir.2014.12.380
34. Rossi GP, Barisa M, Allolio B, et al. The Adrenal Vein Sampling International Study (AVIS) for Identifying the Major Subtypes of Primary Aldosteronism. J Clin Endocrinol Metab. 2012;97(5):1606-14. doi: 10.1210/jc.2011-2830
35. Rossi GP, Bernini G, Caliumi C, et al. A Prospective Study of the Prevalence of Primary Aldosteronism in 1,125 Hypertensive Patients. J Am Coll Cardiol. 2006;48(11):2293-300. doi: 10.1016/ j.jacc.2006.07.059
36. Рогаль Е.Ю., Бельцевич Д.Г., Фадеев В.В. и др. Диагностика первичного гиперальдостеронизма. Проблемы эндокринологии. 2010;56(2):47-52 [Rogal' EYu, Bel'tsevich DG, Fadeev VV, et al. Diagnosis of Primary Hyperaldosteronism. Problemy Endokrinologii = Problems of Endocrinology. 2010;56(2):47-52 (In Russ.)]. doi: 10.14341/probl201056247-52
37. Wu J, Tang Z, Zhang W, et al. Clinical characteristics and surgery outcomes of unilateral nodular adrenal hyperplasia in primary aldosteronism: study of 145 cases. Zhonghua Yi Xue Za Zhi. 2006;86(46):3302-5. PMID: 17313818
38. Fujiwara M, Murao K, Imachi H, et al. Misdiagnosis of Two Cases of Primary Aldosteronism Owing to Failure of Computed Tomography to Detect Adrenal Microadenoma. Am J Med Sci. 2010;340(4):335-7. doi: 10.1097/MAJ.0b013e3181e95587
39. Kempers MJE, Lenders JWM, van Outheusden L, et al. Systematic review: diagnostic procedures to differentiate unilateral from bilateral adrenal abnormality in primary aldosteronism. Ann Intern Med. 2009;151(5):329-37. doi: 10.7326/0003-4819-151-5-200909010-00007
40. Piaditis GP, Kaltsas GA, Androulakis II, et al. High prevalence of autonomous cortisol and aldosterone secretion from adrenal adenomas. Clin Endocrinol (Oxford). 2009;71(6):772-8. doi: 10.1111/j.1365-2265.2009.03551.x
41. Allan CA, Kaltsas G, Perry L, et al. Concurrent secretion of aldosterone and cortisol from an adrenal adenoma – value of MRI in diagnosis. Clin Endocrinol (Oxford). 2000;53(6):749-53. doi: 10.1046/j.1365-2265.2000.01022.x
42. Späth M, Korovkin S, Antke C, et al. Aldosterone- and cortisol-co-secreting adrenal tumors: the lost subtype of primary aldosteronism. Eur J Endocrinol. 2011;164(4):447-55. doi: 10.1530/EJE-10-1070
43. Lenders JWM, Williams TA, Reincke M, Gomez-Sanchez CE. Diagnosis of endocrine disease: 18-Oxocortisol and 18-hydroxycortisol: is there clinical utility of these steroids? Eur J Endocrinol. 2018;178(1):R1-R9. doi: 10.1530/EJE-17-0563
44. Goupil R, Wolley M, Ahmed AH, et al. Does concomitant autonomous adrenal cortisol overproduction have the potential to confound the interpretation of adrenal venous sampling in primary aldosteronism? Clin Endocrinol (Oxford). 2015;83(4):456-61. doi: 10.1111/cen.12750
45. Kishino M, Yoshimoto T, Nakadate M, et al. Optimization of left adrenal vein sampling in primary aldosteronism: Coping with asymmetrical cortisol secretion. Endocr J. 2017;64(3):347-55. doi: 10.1507/
endocrj.EJ16-0433
46. Goupil R, Wolley M, Ungerer J, et al. Use of plasma metanephrine to aid adrenal venous sampling in combined aldosterone and cortisol over-secretion. Endocrinol Diabet Metab Case Rep. 2015;2015:150075. doi: 10.1530/EDM-15-0075
47. Burton TJ, Mackenzie IS, Balan K, et al. Evaluation of the Sensitivity and Specificity of 11 C-Metomidate Positron Emission Tomography (PET)-CT for Lateralizing Aldosterone Secretion by Conn’s Adenomas. J Clin Endocrinol Metab. 2012;97(1):100-9. doi: 10.1210/jc.2011-1537
48. Abe T, Naruse M, Young WF, et al. A Novel CYP11B2-Specific Imaging Agent for Detection of Unilateral Subtypes of Primary Aldosteronism. J Clin Endocrinol Metab. 2016;101(3):1008-15. doi: 10.1210/jc.2015-3431
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1. Molashenko NV, Platonova NM, Yukina MYu, et al. Primary hyper aldosteronism (modern diagnostic and treatment algorithm). In: Troshina E.A., editor. Collection of guidelines (to help the practitioner). Tver: Triada, 2017. P. 95-124 (In Russ.)
2. Monticone S, Burrello J, Tizzani D, et al. Prevalence and Clinical Manifestations of Primary Aldosteronism Encountered in Primary Care Practice. J Am Coll Cardiol. 2017;69(14):1811-20. doi: 10.1016/j.jacc.2017.01.052
3. Fogari R, Preti P, Zoppi A, et al. Prevalence of Primary Aldosteronism among Unselected Hypertensive Patients: A Prospective Study Based on the Use of an Aldosterone/Renin Ratio above 25 as a Screening Test. Hypertens Res. 2007;30(2):111-7. doi: 10.1291/hypres.30.111
4. Chao C-T, Wu V-C, Kuo C-C, et al. Diagnosis and management of primary aldosteronism: An updated review. Ann Med. 2013;45(4):375-83. doi: 10.3109/07853890.2013.785234
5. Iacobone M, Citton M, Viel G, et al. Unilateral adrenal hyperplasia: A novel cause of surgically correctable primary hyperaldosteronism. Surgery. 2012;152(6):1248-55. doi: 10.1016/j.surg.2012.08.042
6. Seccia TM, Fassina A, Nussdorfer GG, et al. Aldosterone-producing adrenocortical carcinoma: an unusual cause of Conn’s syndrome with an ominous clinical course. Endocr Relat Cancer. 2005;12(1):149-59. doi: 10.1677/erc.1.00867
7. Abdelhamid S, Müller-Lobeck H, Pahl S, et al. Prevalence of adrenal and extra-adrenal Conn syndrome in hypertensive patients. Arch Intern Med. 1996;156(11):1190-5. doi: 10.1001/archinte.1996.00440100086010
8. Mulatero P, Tizzani D, Viola A, et al. Prevalence and Characteristics of Familial Hyperaldosteronism: The PATOGEN Study (Primary Aldosteronism in TOrino-GENetic forms). Hypertension. 2011;58(5):797-803. doi: 10.1161/HYPERTENSIONAHA.111.175083
9. Mulatero P, Tauber P, Zennaro M-C, et al. KCNJ5 Mutations in European Families With Nonglucocorticoid Remediable Familial Hyperaldosteronism. Hypertension. 2012;59(2):235-40. doi: 10.1161/
HYPERTENSIONAHA.111.183996
10. Geller DS, Zhang J, Wisgerhof MV, et al. A novel form of human mendelian hypertension featuring nonglucocorticoid-remediable aldosteronism. J Clin Endocrinol Metab. 2008;93(8):3117-23. doi: 10.1210/jc.2008-0594
11. Milliez P, Girerd X, Plouin P-F, et al. Evidence for an increased rate of cardiovascular events in patients with primary aldosteronism. J Am Coll Cardiol. 2005;45(8):1243-8. doi: 10.1016/j.jacc.2005.01.015
12. Mulatero P, Monticone S, Bertello C, et al. Long-Term Cardio- and Cerebrovascular Events in Patients With Primary Aldosteronism.
J Clin Endocrinol Metab. 2013;98(12):4826-33. doi: 10.1210/jc.2013-2805
13. Funder JW, Carey RM, Mantero F, et al. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(5):1889-916. doi: 10.1210/jc.2015-4061
14. Melnichenko GA, Platonova NM, Beltsevich DG, et al. Primary Hyperaldosteronism: Diagnosis and Treatment. A New Look at the Problem. According to the Materials of the Russian Association of Endocrinologists Clinical Guidelines for Primary Hyperaldosteronism Diagnosis and Treatment. Consilium Medicum. 2017;19(4):75-85 (In Russ.) doi: 10.26442/2075-1753_19.4.75-85
15. Dedov II, Kuznetsov NS, Mel'nichenko GA, editors. Endocrine surgery. Moscow: Litterra, 2011. 352 p. (In Russ.)
16. Molashenko NV, Troshina EA. Primary
idiopathic hyperaldosteronism in clinical practice Ožirenie i metabolizm. 2012;9(4):3-9 (In Russ.) doi: 10.14341/2071-8713-5122
17. Semenov DYu, Pankova PA, Osmanov ZH, et al. Comparison of Adrenal Tumor Treatment Results by Different Volume of Surgical Interventions. Endokrinnaya Khirurgiya = Endocrine Surgery. 2016;10(2):34-43 (In Russ.) doi: 10.14341/serg2016234-43
18. Mulatero P, Bertello C, Rossato D, et al. Roles of Clinical Criteria, Computed Tomography Scan, and Adrenal Vein Sampling in Differential Diagnosis of Primary Aldosteronism Subtypes. J Clin Endocrinol Metab. 2008;93(4):1366-71. doi: 10.1210/jc.2007-2055
19. Sitkin II, Fadeev VV, Bel’tsevich DG, et al. Differential Diagnostics of Primary Hyperaldosteronism: The Role and Significance of Comparative Selective Blood Sampling from Adrenal Veins. Problemy Endokrinologii = Problems of Endocrinology. 2011;57(2):52-6 (In Russ.) doi: 10.14341/probl201157252-56
20. Nwariaku FE, Miller BS, Auchus R, et al. Primary Hyperaldosteronism: effect of adrenal vein sampling on surgical outcome. Arch Surg. 2006;141(5):497. doi: 10.1001/archsurg.141.5.497
21. Young WF, Stanson AW, Thompson GB, et al. Role for adrenal venous sampling in primary aldosteronism. Surgery. 2004;136(6):1227-35. doi: 10.1016/j.surg.2004.06.051
22. Buffolo F, Monticone S, Williams TA, et al. Subtype Diagnosis of Primary Aldosteronism: Is Adrenal Vein Sampling Always Necessary? Int J Mol Sci. 2017;18(4):848. doi: 10.3390/ijms18040848
23. Lim V, Guo Q, Grant CS, et al. Accuracy of Adrenal Imaging and Adrenal Venous Sampling in Predicting Surgical Cure of Primary Aldosteronism. J Clin Endocrinol Metab. 2014;99(8):2712-9. doi: 10.1210/jc.2013-4146
24. Dick SM, Queiroz M, Bernardi BL, et al. Update in diagnosis and management of primary aldosteronism. Clin Chem Lab Med. 2018;56(3):360-72. doi: 10.1515/cclm-2017-0217
25. Küpers EM, Amar L, Raynaud A, et al. A Clinical Prediction Score to Diagnose Unilateral Primary Aldosteronism. J Clin Endocrinol Metab. 2012;97(10):3530-7. doi: 10.1210/jc.2012-1917
26. Rossi GP, Auchus RJ, Brown M, et al. An Expert Consensus Statement on Use of Adrenal Vein Sampling for the Subtyping of Primary AldosteronismNovelty and Significance. Hypertension. 2014;63(1):151-60. doi: 10.1161/hypertensionaha.113.02097
27. Nieman LK, Biller BMK, Findling JW, et al. The Diagnosis of Cushing’s Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2008;93(5):1526-40. doi: 10.1210/jc.2008-0125
28. Reznik Y, Amar L, Tabarin A. SFE/SFHTA/AFCE consensus on primary aldosteronism, part 3: Confirmatory testing. Ann Endocrinol (Paris). 2016;77(3):202-7. doi: 10.1016/j.ando.2016.01.007
29. Kloos RT, Gross MD, Francis IR, et al. Incidentally Discovered Adrenal Masses*. Endocr Rev. 1995;16(4):460-84. doi: 10.1210/edrv-16-4-460
30. Reincke M, Rump LC, Quinkler M, et al. Risk Factors Associated with a Low Glomerular Filtration Rate in Primary Aldosteronism. J Clin Endocrinol Metab. 2009;94(3):869-75. doi: 10.1210/jc.2008-1851
31. Sechi LA, Novello M, Lapenna R, et al. Long-term Renal Outcomes in Patients With Primary Aldosteronism. JAMA. 2006;295(22):2638-45. doi: 10.1001/jama.295.22.2638
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