SS Special Session: ESROC-KES Joint Symposium

SS-1

PRIMARY ALDOSTERONISM IN KOREA

JUNG HEE KIM

Seoul National University College of Medicine

The first case of PA in Korea was reported in 1968. In the past, hypokalemia was considered to be a prerequisite, and less than 1% of all hypertensive patients were thought to be. However, several cross-sectional and prospective studies have reported prevalence of PA in more than 10% of hypertensive patients. There is no nationwide survey in Korea, but only about 30 cases were only diagnosed in Seoul National University Hospital (SNUH), and unilateral lesions were more dominant than bilateral ones. PA was still underdiagnosed in Korea.

In keeping with recent genetic developments, we performed targeted gene sequencing in 66 patients with APA to detect somatic mutations in KCNJ5, ATP1A1, ATP2B3, and CACNA1D genes. Similar to other Asian countries, somatic KCNJ5 mutations were found in 47 (71.2%) of the 66 patients with APA (31 cases of p.G151R and 16 cases of p.L168R). Carriers of somatic KCNJ5 mutations were more likely to be female and young.

The aldosterone-to-renin ratio (ARR) has been introduced as a screening test for PA, but a subtle change in low PRA exaggerates ARR, leading to misdiagnose low-renin hypertension as PA. In Korea, captopril challenge test (CCT) can easily performed in outpatient clinics, but the accuracy of it is still PA in 64 subjects with suspected PA who had hypertension and ARR > 20. We suggested that subjects with PAC post-CCT at 90 min <13 ng/dL are less likely to have PA, and those with PAC post-CCT at

In PA, adrenal vein sampling (AVS) is recognized as a golden standard method of distinguishing in several hospitals in Korea. Thus, we developed the clinical prediction parameters as a lateralization marker. Our new clinical prediction parameters included serum potassium, PAC after saline infusion test and unilateral nodule on CT (AUC = 0.779). Patients aged under 35 years with unilateral nodule on CT and hypokalemia may skip the AVS, which was suggested by the Guideline.

In aldosterone-producing adenomas, hyperkalemia after adrenalectomy has been reported due to contralateral zona glomerulosa insufficiency. In SNUH, 13 of 124 patients (10.5%) developed postoperative hyperkalemia. Older age ( > 53 years), longer duration of hypertension ( > 9.5 years), larger mass size on CT ( > 1.95 cm), and impaired preoperative renal function (GFR < 58.2 ml/min) were associated with prolonged postoperative hyperkalemia in patients with APA. The mineralocorticoid receptor (MR) antagonist use did not prevent postoperative hyperkalemia.

Patients with aldosterone-producing adenomas are treated using surgery, and patients with idiopathic hyperaldosteronism receive medical treatment using MR antagonists. However, the outcomes of surgical and medical treatment for PA remain unclear. Therefore, we compared the outcomes of surgical and medical treatment in 269 patients who were treated for PA. Among patients who were > 60 years old or had impaired renal function, surgical and medical treatment provided similar amelioration of hypokalemia and hypertension. Surgical treatment provided better hypertension and hypokalemia outcomes among patients with PA, compared to medical treatment.

In the future, we may design the Korean nationwide registry for PA, and elucidate the genetic background and prognosis of PA in Korean. Furthermore, the optimal cut-off values for diagnostic testing and noninvasive lateralization markers can be developed.

SS-2

DIAGNOSIS AND PROGNOSIS OF PRIMARY ALDOSTERONISM, TAIWAN-TAIPAI EXPERIENCE

VIN-CENT WU, MD, PHD

National Taiwan University Hospital,

Given the increasing clinical recognition of primary aldosteronism as public health issue, its heightened risk profile and the availability of targeted surgical/medical treatment. The nationwide were 25% in men and 18% in women, and that rate increased to 47% among individuals with age > 60 years. The prevalence of primary aldosteronism (PA) is from 5.5% in normotensive to 16.4% in stage resources and even certain special equipment/tests, it is very helpful to have a consensus for patient care. Recently, the Endocrine Society updated its clinical guidelines entitled ‘the management of PA’ in 2016. The Japan Endocrine Society (JES) also developed guidelines because of the high prevalence of cardiovascular disease and the current low case-detection rate of PA in Japan. From a Taiwan Primary Aldosteronism Investigation (TAIPAI) cohort(4), there is a higher prevalence of somatic mutationcarriers among Taiwanese APA patients and there was no gender differences, which are different from other western reports(5, 6). Adrenalectomy decreases long-term all-cause mortality independently for PA patients, while minerocorticoid receptor antagonist treatment may alleviate risk of death only in a U-shape dose. However, an European study showed no difference between surgically and medical treated patients with PA in terms of incidence of cardiovascular accident. The Taiwan Society of Aldosteronism (TSA) task force acknowledges such various nuances and force to accomplish this Taiwan PA consensus at its inauguration meeting, in order to provide update information of internationally acceptable standards, and also to incorporate our local disease characteristics in the management of PA. The consensus is based on evidence medicine and also recognizes the constraints of our real-world clinical practice in managing PA in Asian countries.

It is our hope that the algorithm proposed in this article could further arouse substantial awareness of PA among the medical professionals and the patients, and reconcile its fundamental diagnosis and prognosis.