G.P. Rossi

Long-Term Control of Arterial Hypertension and Regression of Left Ventricular Hypertrophy With Treatment of Primary Aldosteronism

Primary aldosteronism (PA), a common cause of high blood pressure (BP), induces left ventricular (LV) hypertrophy and an excess rate of cardiovascular events. Whether its treatment provides long-term cure of hypertension and regression of cardiovascular damage remains uncertain. To the aim of assessing the effect of treatment of PA on BP and LV changes, we prospectively recruited 323 patients in a long-term follow-up study entailing serial echocardiography evaluations. Of them, 180 had PA and were assigned to either adrenalectomy (n=110) or medical therapy (n=70) on the basis of the adrenal vein sampling. The remaining 143 were consecutive optimally treated primary hypertensive patients. At baseline, the PA patients had more inappropriate LV mass than PH patients (27.1% versus 16.2%; P=0.020), despite similar BP values. At a median follow-up of 36 months (range, 6–225), BP was lowered (P<0.0001 versus baseline) to similar values in adrenalectomized (135±15/83±9 mm Hg), medically treated PA (133±11/83±7 mm Hg), and PH (139±15/86±9 mm Hg) patients. To this end, the adrenalectomized patients required significantly less drugs than the other groups. In PA patients, the LV mass index and the rate of LV hypertrophy fell through LV inward remodeling to the level of optimally treated PH patients, indicating that the LV work markedly decreased. Findings were similar when long-term (≥5 and ≥10 years) data were examined. Thus, an early diagnosis and a specific treatment of PA warrant normalization of BP and reversal of detrimental LV changes at long term.

Low plasma adiponectin is associated with coronary artery disease but not with hypertension in high-risk nondiabetic patients

Objective.  To investigate the association of plasma adiponectin levels with coronary artery disease (CAD), arterial hypertension (HT), and insulin resistance (IR) in nondiabetic Caucasian patients.

Munchausen syndrome: a novel cause of drug-resistant hypertension.

Case report: A young patient presented with a history of resistant arterial hypertension, associated with disabling symptoms. He was subjected to an enormous number of tests to identify a pheochromocytoma that was never found. He was eventually discovered to make factitious use of amphetamine to mimic this condition in order to gain medical attention. Munchausen syndrome was thus diagnosed. The patient was discharged and was lost to follow-up until he presented again in 2012 for ‘resistant hypertension’ in our outpatient clinic. He reported that because of poor blood pressure, he had been referred to a Cardiology department where transcatheter renal denervation was performed with no effect on blood pressure. Thereafter, he was presented to an Endocrinology unit where a left adrenalectomy was performed with diagnosis of pheochromocytoma that was not found at pathology. Discussion: Munchausen syndrome is a rare psychiatric condition that leads affected patients to cause intentionally signs and symptoms of an illness or injury by inflicting medical harm to their body to attract the attention of the physician and get admission to the hospital. Conclusion: To our knowledge, this is the first case of causing drug-resistant hypertension and leading to unnecessary renal denervation and adrenalectomy.

Antihypertensive therapy in patients on chronic lithium treatment for bipolar disorders.

Bipolar disorders are chronic conditions treated with lithium, which exerts deleterious effects on the kidney, among which nephrogenic diabetes insipidus, tubular acidosis and ultimately chronic kidney disease. Conversely, drugs that alter renal function can modify its serum levels and lead to the potentially fatal lithium intoxication. A search in the main library databases from 1975 to 2015 to identify interactions between antihypertensive drugs and lithium using the Population Intervention Comparison Outcome strategy provided only 30 reports of lithium intoxication. A regression analysis showed that the severity of lithium intoxication was significantly predicted by female, age, and use of certain classes of antihypertensive agents. A model including certain albeit not all diuretics and/or inhibitors of the renin–angiotensin system, but not age, serum lithium or creatinine levels at baseline and/or on admission to the hospital, predicted lithium toxicity. The true incidence of lithium intoxication is unknown but probably low, albeit underestimated. Nonetheless, in patients treated with lithium, monitoring of the serum lithium levels and clinical conditions is mandatory after the introduction of antihypertensive drugs, as diuretics and renin–aldosterone system inhibitors.

8C.07: DETECTION OF FREE-CIRCULATING DNA IN PATIENTS WITH ALDOSTERONE PRODUCING ADENOMA.

Objective: Tumor cells undergoing apoptosis or necrosis release cell-free DNA fragments (cf-DNA) of different sizes into the bloodstream. Primary aldosteronism (PA) caused by aldosterone-producing adenoma (APA), but not by bilateral hyperplasia (BAH), has somatic mutations in KCNJ5 gene. Hence, the detection of KCNJ5 mutations in cf-DNA from peripheral blood could allow pinpointing PA patients with APA that must be submitted to Adrenal Vein Sampling (AVS). The aim of the study was to investigate the feasibility of using cf-DNA to detect KCNJ5 mutations in plasma of PA patients. Design and method: Plasma was collected from the right/left adrenal veins from 6 APA patients undergoing AVS. Plasma from 7 patients with stomach cancer and from 6 healthy subjects was used as positive/negative control, respectively, for cf-DNA quality. The integrity index (DII) was calculated as a ratio of 400pb/200pb amplicons. A DII cut off equal or greater than 1.0 was assumed to denote cf-DNA integrity. DNA sequences entailing the region with KCNJ5 gene mutations (G151R, L168R, T158A) were amplified using PCR real time (qPCR) to obtain long (400 bp) and short (200 bp) fragments. Results: The DII for KCNJ5 amplicons on average was consistently > 1.0 in gastric cancer samples, 1.0 in healthy subjects whereas it was < 1.0 in APA patients. The cf-DNA concentration of KCNJ5 amplicons was 10-fold higher in gastric cancer patients than in AVS plasma (4.8 ± 1 vs 0.4 ± 0.1 ng/ul p < 0.01). The latter showed no significant differences between the APA and the contralateral side (0.41 ± 0.1 vs 0.36 ± 0.1). Conclusions: These results confirm the feasibility of isolating cf-DNA not only from patients with malignancies, but also with PA. With current technology the cf-DNA amount and integrity that were obtained suggest the feasibility of using this strategy to detect malignancies. However, at present the results obtained in this study do not support the use of this approach to pinpoint PA with APA based on identification of KCNJ5 mutations. Therefore, further work is needed to develop this innovative and non-invasive strategy that could be useful to pinpoint the patients with APA before the AVS.

LB02.07: EFFECT OF ACUTE DA2 DOPAMINERGIC RECEPTOR BLOCKADE ON PERFORMANCE OF ADRENAL VEIN SAMPLING FOR SUBTYPING OF PRIMARY ALDOSTERONISM.

Objective: As dopamine tonically inhibits aldosterone release via DA2 receptors, we hypothesized that acute DA2 blockade during adrenal vein sampling (AVS) might improve the assessment of lateralization of aldosterone excess in the subtyping of primary aldosteronism. Design and method: we prospectively investigated the acute effect of metoclopramide on the lateralization index [LI, defined as the ratio of aldosterone over cortisol plasma concentration (PAC:PCC) in the dominant over the PAC:PCC in the contralateral side] and on the relative aldosterone secretion index in adrenal vein blood [RI, defined as the ratio of plasma aldosterone concentration (PAC) in the adrenal vein over PAC in inferior vena cava (IVC), normalized by the ipsilateral Selectivity Index]. To this end we compared baseline and post-metoclopramide LI and RI values in 92 consecutive patients undergoing AVS from 2008 to 2014. As gold standard we used the diagnosis of aldosterone-producing adenoma (APA), based on pathology and follow-up data according to the four corners criteria. Results: Metoclopramide increased aldosterone in the IVC and in adrenal vein blood of both sides (p < 0.0001 for all). Even though post-metoclopramide LI provided an accurate identification of APA (AUC = 0.880, p = 0.0001 vs identity line; Youden Index >2.7, sensitivity 81%, specificity 83%), it showed no incremental diagnostic gain over baseline LI (p = 0.75 for ROC curves comparison). Metoclopramide also increased the RI (p < 0.001) both from the dominant and the non-dominant side [3.13 (2.53–4.33) to 8.76 (5.31–12.21); 0.91 (0.68–1.36) to 2.19 (1.61–3.23), respectively]. However, metoclopramide raised the RI on the APA side to values > 1.00 in all the 39 unequivocally diagnosed APA patients. Therefore, a post metoclopramide cut-off for the RI < 1.00 offered 100% specificity in excluding an APA on that side. Conclusions: acute DA2 antagonism exerts a prominent secretagogue effect on aldosterone, but due to a proportionally similar effect on the RI of both sides it did not increase the LI. However, it can increase the specificity of the RI for excluding an APA. This finding might be of particular diagnostic value for AVS studies that are not bilaterally selective.

HIGH EXPRESSION OF THE PRO-RENIN RECEPTOR IN ALDOSTERONE PRODUCING ADENOMA CAUSING HUMAN PRIMARY ALDOSTERONISM: 4D.02

Objective: Primary Aldosteronism (PA) is the most prevalent form of endocrine hypertension but its underlying mechanisms are unknown. The detection of prorenin, despite the suppression of renin, in plasma of PA patients suggests that prorenin, by acting via the Pro-Renin Receptor (PRR), could play a pathophysiologic role in PA by causing adrenocortical cell growth and hyperaldosteronism. Hence, we hypothesized that the PRR is expressed in the human zona glomerulosa (ZG) and in aldosterone producing adenoma (APA). Design and Method: To test this hypothesis we investigated the presence of the PRR by using beforehand a whole transcriptome analysis approach (in 24 APA). We then used Real time RT-PCR to quantify more precisely the PRR transcript in APA (n = 12), in two adrenocortical carcinoma cell lines (H295 and HAC15) and in immunomagnetic bead separated CD56+ human adrenocortical ZG cells (Caroccia, Endocrinology 2010). To confirm the expression of the PRR at the protein level immunohistochemistry and immunoblotting were also performed. Results and Conclusions: Microarray analysis evidenced the expression of PRR in all APAs. Quantitative gene expression studies demonstrated a level of expression of the PRR gene in APA which was on average much higher than that of the established adrenocortical house-keeping gene PBGD (PRR Ct = 22,69 ± 1,11; PBGD Ct = 27,49 ± 1,69 p < 0.0001). The expression of the PRR in the human adrenal cortical tissue was confirmed in CD56+ ZG cells, and in H295 and HAC15 cells. Immunohistochemistry confirmed the expression of the PRR at the protein level in all these cells. It also allowed to localize it more precisely to the adrenocortical ZG. These results are consistent with the hypothesis that circulating prorenin can activate the PRR in PA patients. Therefore, experiments are ongoing to investigate the functional relevance of these findings with the ultimate goal of demonstrating the role of the PRR in human PA.

IMPACT OF SLEEP DISORDERS ON THE PREVALENCE OF TARGET ORGAN DAMAGE IN ADULT HYPERTENSIVE PATIENTS

Objective: Prolonged short sleep duration and poor sleep quality may lead to the onset and/or maintenance of arterial hypertension. Patients with obstructive sleep apnoea (OSA) and high blood pressure (BP), compared with hypertensive subjects without OSA, show increased prevalence of left ventricular hypertrophy (LVH) and increased urinary albumin excretion (UAE). Nevertheless, data linking other common sleep disorders, such as insomnia and restless legs syndrome (RLS) and the onset of hypertensive-related organ damage (OD) are lacking. The aim of the present study was to assess the association of OSA, insomnia, and RLS with cardiac and renal OD in a cohort of adults with hypertension. Design and method: In a prospective-observational study, we enrolled 160 consecutive patients aged between 18 and 60 years old, who underwent full assessment for OD by means of transthoracic echocardiography, UAE, and estimated glomerular filtration rate measurement. All patients were also screened to evaluate the risk of insomnia with the Insomnia Severity Index (ISI), OSA with the STOP-Bang, and RLS using the RLS Rating Score. Results: 99 males and 61 females, with median age 47 (11) years, body mass index 25.5 (5.8) kg/m2, office systolic BP 144 (24) mmHg and diastolic BP 92 (12) mmHg, have been studied. In the group with high risk of OSA (STOP-Bang score > or = 4) we observed an increased left ventricular mass index (LVMI) [119 (35) vs. 104 (26) g/m2, p = 0.002] and diastolic dysfunction parameters [left atrium volume index 27.5 (6.0) vs 24.0 (5.0) ml/m2, p = 0.005; mitral E/A ratio 1.1 (0.2) vs 1.0 (1.8), p = 0.01]. At multivariate analysis office systolic BP values and STOP-Bang score were independent predictors of LVMI (&bgr; = 0.18, p = 0.023 and &bgr; = 0.23, p = 0.003, respectively). No association with cardiac OD was seen in patients at increased risk of insomnia and RLS. No correlation was observed with renal OD for all subgroups. Conclusions: The STOP-Bang, a simple, validated, and reproducible questionnaire, which predicts a high risk of OSA, is associated with hypertension-related heart remodelling in a cohort of hypertensive subjects and might be used to predict patients at risk of developing cardiac OD.

PROSPECTIVE APPRAISAL ON THE PREVALENCE OF PRIMARY ALDOSTERONISM AND ITS SUTYPES IN HYPERTENSIVE PATIENTS PRESENTING WITH ATRIAL FLUTTER OR FIBRILLATION: PAPPHY STUDY

Objective: Excess aldosterone has been suggested to favour and/or cause atrial fibrillation (AF), particularly in the patients with arterial hypertension, but the relationship between AF and primary aldosteronism (PA) remains uncertain. Hence, we tested the hypothesis that AF is one of the presenting signs of unrecognized PA, and investigated the prevalence of PA and its subtypes in hypertensive patients presenting with lone AF. Design and method: Consecutive patients with an unambiguous diagnosis of arterial hypertension presenting with ECG-confirmed AF and no obvious causes of the arrhythmia were recruited and submitted to the screening and subtyping for PA according to the Endocrine Society PA current guidelines, including measurement of plasma renin activity and aldosterone levels after appropriate pharmacological preparation, and adrenal vein sampling (Funder J. JCEM 2016). The diagnosis of aldosterone-producing adenoma followed the four corner criteria, which imply cure of PA after adrenalectomy (Rossi GP. JACC 2006). Results: From 2015 to 2017, 296 patients (age 76 ± 12 years; 48/52 F/M, %) were recruited in three ESH centers of Excellence for arterial hypertension in Italy (Padua, Brescia and Rome). Fifty-five patients, who met the inclusion criteria and had no exclusion criteria, underwent the entire diagnostic work-up for PA. This allowed to ascertain that the overall prevalence of PA was 34.5%, 42% of the cases being accounted for by aldosterone-producing adenoma and the rest by bilateral forms. Conclusions: By providing compelling evidence for a high prevalence of PA in hypertensive patients presenting with the so-called “lone” AF, these results can lead to changing clinical practice in the management of these patients in that they indicate the need to carefully searching for PA and undertaking subtyping with the aim of pinpointing those who can be cured with unilateral laparoscopic adrenalectomy.

[BP.08.05] SUBTYPING OF PRIMARY ALDOSTERONISM BY AVS: HORMONE- AND SIDE-SPECIFIC EFFECTS OF COSYNTROPIN AND METOCLOPRAMIDE

Objective: Objectives: Whether cosyntropin and metoclopramide exert hormone- and side-specific secretagogue effects on cortisol and aldosterone secretion and how they affect the subtyping of primary aldosteronism (PA) with adrenal vein sampling (AVS) is unclear. Design and method: Design and Methods: Aldosterone-producing adenoma (APA) patients undergoing AVS before and after cosyntropin (250 &mgr;g IV), or metoclopramide (10 mg IV) stimulation were compared for Selectivity Index (SI), Relative Aldosterone Secretion Index (RASI), and Lateralization index (LI). The relative gene expression of Dopamine (DR2D2), Melanocortin 2 (MC2R) and 5-hydroxytryptamine (serotonin) 4 (HTR4B) receptor was also investigated with oligo-microarrays. Results: Results: 171 patients were studied, of which 139 with AVS at baseline and during stimulation with cosyntropin (n = 45) or metoclopramide (n = 93); APA was conclusively diagnosed in 26 and 47 of each group, respectively. Cosyntropin increased the SI similarly on both sides; metoclopramide did not. With cosyntropin the RASI dropped on the APA side and did not change contralaterally, thus significantly decreasing the LI. Metoclopramide increased the RASI similarly on both sides leaving the LI unaffected. The relative gene expression of DRD2 and HTR4B receptor was similar while that of MC2R was 35% lower (p < 0.0001) in the APA than in the normal adrenal cortex. Conclusions: cosyntropin facilitates the ascertainment of selectivity, but does not enhance lateralization due to a blunted MC2R expression in the APA. The similar expression of DRD2 and HTR4B receptor in the APA and the normal adrenal cortex can explain why metoclopramide increased the RASI symmetrically and, therefore, failed to increase the LI; however, unlike cosyntropin, it unmasks factitious suppression. Conclusions: Conclusions: Cosyntropin facilitates the ascertainment of selectivity, but does not enhance lateralization due to a blunted MC2R expression in the APA. The similar expression of DRD2 and HTR4B receptor in the APA and the normal adrenal cortex can explain why metoclopramide increased the RASI symmetrically and, therefore, failed to increase the LI; however, unlike cosyntropin, it unmasks factitious suppression.