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邱平, 臧丽, 张丽, 等. 不同剂量促肾上腺皮质激素兴奋试验在原发性醛固酮增多症分型诊断中的比较[J]. 四川大学学报(医学版), 2024, 55(1): 210-216. DOI: 10.12182/20240160105
引用本文: 邱平, 臧丽, 张丽, 等. 不同剂量促肾上腺皮质激素兴奋试验在原发性醛固酮增多症分型诊断中的比较[J]. 四川大学学报(医学版), 2024, 55(1): 210-216. DOI: 10.12182/20240160105
QIU Ping, ZANG Li, ZHANG Li, et al. Comparison of Different Doses of ACTH Used in ACTH Stimulation Test to Determine the Subtypes of Primary Aldosteronism[J]. Journal of Sichuan University (Medical Sciences), 2024, 55(1): 210-216. DOI: 10.12182/20240160105
Citation: QIU Ping, ZANG Li, ZHANG Li, et al. Comparison of Different Doses of ACTH Used in ACTH Stimulation Test to Determine the Subtypes of Primary Aldosteronism[J]. Journal of Sichuan University (Medical Sciences), 2024, 55(1): 210-216. DOI: 10.12182/20240160105

不同剂量促肾上腺皮质激素兴奋试验在原发性醛固酮增多症分型诊断中的比较

Comparison of Different Doses of ACTH Used in ACTH Stimulation Test to Determine the Subtypes of Primary Aldosteronism

  • 摘要:
    目的 比较午夜地塞米松联合不同剂量的促肾上腺皮质激素(adrenocorticotropic hormone, ACTH)兴奋试验对原发性醛固酮增多症(primary hyperaldosteronism, PA)分型的诊断价值。
    方法 本试验为前瞻性试验。对2020年1月1日–2022年9月30日解放军总医院第一医学中心内分泌科确诊为PA的患者进行不同剂量ACTH兴奋试验(所有患者午夜1 mg地塞米松抑制后,按照1∶2随机分为25单位ACTH组和50单位ACTH组);根据肾上静脉取血和/或手术后病理、临床随访分型判断为肾上腺醛固酮瘤(aldosterone-producing adenoma, APA)和特发性醛固酮增多症(idiopathic hyperaldosteronism, IHA)。通过绘制受试者工作特征(receiver operating characteristics, ROC)曲线,研究不同剂量ACTH兴奋试验对鉴别APA和IHA的诊断效能及其差异。
    结果 本研究纳入82例PA患者,包括APA 49例(59.8%)和IHA 33例(40.2%);25单位ACTH组29例(35.4%)和50单位ACTH组53例(64.6%)。两组基线资料在年龄、性别构成比、血压、血钾及生化指标方面差异无统计学意义;两组ACTH刺激后各时间点血醛固酮(plasma aldosterone concentration, PAC)、血皮质醇(cortisol, F)、血醛固酮/同步血皮质醇(PAC/F)无明显差异(P>0.05)。25单位ACTH组PAC值ROC曲线下面积(area under the curve, AUC)较PAC/F更大;其中90 min时AUC最大〔0.948,95%置信区间(confidence interval, CI):0870~1.000〕,最佳切点为38.0 ng/dL,敏感性和特异性分别为92.9%和86.7%。50单位ACTH组PAC值AUC同样较PAC/F更大,AUC最大值仍然为90 min时(0.930,95%CI:0.840~0.994),最佳切点为39.6 ng/dL,敏感性和特异性分别为91.2%和83.3%。25单位ACTH组各点PAC值AUC(0.862~0.948)较50单位ACTH组(0.823~0.930)更大,但差异无统计学意义。
    结论 小剂量地塞米松联合25单位ACTH或50单位ACTH兴奋试验用于PA分型(APA和IHA)鉴别中的最佳PAC切点值接近,分别为38.0 ng/dL和39.6 ng/dL,均在90 min时具有较高的敏感性和特异性。25单位ACTH剂量小、安全性更好,可推荐用于PA分型诊断。

     

    Abstract:
    Objective To compare the diagnostic value of adrenocorticotropic hormone (ACTH) stimulation test (AST) with different doses of ACTH combined with midnight administration of 1 mg dexamethasone for the determination of the subtypes of primary hyperaldosteronism (PA).
    Methods This is a prospective observational study. Patients diagnosed with PA in the Department of Endocrinology, the First Medical Center of of Chinese PLA General Hospital from January 1, 2020 to September 30, 2022 underwent AST with different doses of ACTH. All patients received 1 mg dexamethasone at midnight for inhibition. Then, the patients were randomly assigned to 25-unit and 50-unit ACTH treatment groups by a ratio of 1:2. Subtype classification and diagnosis of aldosterone-producing adenoma (APA) and idiopathic hyperaldosteronism (IHA) was made on the basis of adrenal venous blood samples and/or postoperative pathology and clinical follow-up findings. Receiver operating characteristics (ROC) curves were plotted to examine the diagnostic efficacy and the difference of AST by varying doses of ACTH in distinguishing APA and IHA.
    Results A total of 82 patients, including 49 patients with APA (59.8%) and 33 patients with IHA (40.2%), were enrolled. There were 29 patients in the 25-unit ACTH group (35.4%) and 53 patients in the 50-unit ACTH group (64.6%). There were no significant differences in age, sex, blood pressure, minimum serum potassium, and biochemical parameters between the 25-unit and 50-unit groups. After ACTH stimulation, plasma aldosterone concentration (PAC), cortisol (F), and PAC/F at different points of time showed no statistical difference between the two groups (P>0.05). The area under the curve (AUC) of PAC in the 25-unit group was higher than that of PAC/F. The AUC of PAC reached the maximum at 90 minutes (0.948, 95% confidence interval CI: 0870-1.000) and the optimal cutoff was 38.0 ng/dL, which had a sensitivity of 92.9% and a specificity of 86.7% for differentiating APA and IHA. Similar to the 25-unit group, the maximum AUC of PAC in the 50-unit group was greater than that of PAC/F. The AUC of PAC reached the maximum 90 minutes (0.930, 95% CI: 0.840-0.994) and the optimal cutoff was 39.6 ng/dL, which had a sensitivity of 91.2% and a specificity of 83.3%. The AUC of PAC at different points of time in the 25-unit ACTH group (0.862-0.948) was greater than that of 50-unit ACTH group (0.823-0.930), but the difference was not statistical significance.
    Conclusion AST with 25-unit or 50-unit ACTH combined with small-dose dexamethasone can be used in PA subtype determination, ie, differentiation between APA and IHA. The optimal PAC cut-off values for 25-unit or 50-unit ACTH are similar, being 38.0 ng/dL and 39.6 ng/dL, respectively, and both cutoff values show higher sensitivity and specificity at 90 min. The AST with 25-unit ACTH has the smaller dose and the better safety. Therefore, it is recommended for the diagnosis of PA subtypes.

     

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