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суббота, 6 сентября 2008 г.

Диагностика и лечение первичного альдостеронизма

В сентябрьском номере Journal of Clinical Endocrinology & Metabolism опубликованы новые клинические рекомендации по диагностике и лечению первичного альдостеронизма.
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. 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).
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.
* Use of the lowest dose of glucocorticoid that can normalize blood pressure and serum potassium levels is recommended in patients with GRA, rather than first-line treatment with a mineralocorticoid receptor antagonist.
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