2017-08-012024-05-14https://scholars.lib.ntu.edu.tw/handle/123456789/657138摘要：1955 年，Conn 提出了原發性皮質醛酮症(primary aldosteronism, PA)，世人才開始注意這個常合併低血鉀的次發性高血壓(secondary hypertension)，其盛行率目前約占全部高血壓族群的5-10%。PA主要分為兩種亞型：aldosterone-producing adenoma (APA)以及idiopathic adrenal hyperplasia(IAH)，前者可以進行手術以達到治癒次發性高血壓的機會。目前已經知道影像學檢查如電腦斷層(computed tomography)或核磁共振(magnetic resonance imaging)無法確切區分這兩種亞型。腎上腺靜脈取樣adrenal venous sampling (AVS)是一種歷史悠久的技術，傳統用於分辨PA 病人是哪一種亞型，也就是單側或雙側aldosterone 分泌過盛，作為是否可以手術治療的黃金標準。然而腎上腺靜脈取樣受到器材與技術上的限制，仍存在很多臨床上待解的問題。最常見的問題是成功率過低，依德國PA 資料庫(German Conn’s registry)的報告，平均成功率僅有31%左右。在配合研究團隊(Taiwan Primary Aldosteronism Investigation, TAIPAI)下，我們建立起AVS 的標準流程以及累積了相當數量的操作經驗，有效提升了雙側採樣的成功率。結合術中動態電腦斷層(Dyna-CT)，AVS的成功率提升至87%；接著引進了即時皮質醇測量工具(Quick cortisol assay)，成功率更高達97.4%。我們也將這些研究成果發表至國際期刊(Sci Rep. 2016 Jun 23;6:28305; Sci Rep. 2016 Nov23;6:37143)。然而，在這幾年超過200 例的AVS 中，我們發現很多因素會影響分側(lateralization)判讀的結果，我們將進行一系列的研究計畫，其中包含取樣流程的設計、術中鎮靜類藥物或促腎上腺皮質激素(ACTH)的使用，metoclopramide 促進aldosterone 分泌。準確且穩定的AVS 結果，對治療的選擇有決定性的影響，目前臨床上仍存在很多病例游移在藥物治療或手術切除兩種選擇的灰色地帶，我們的研究將會為在這個診斷率不斷上升的疾病中，提供相當重要的發現與參考。除了診斷的提升，我們也開始採用電腦斷層導引的腫瘤消融術來治療PA，這個研究成果將會提供PA 病人除了藥物及手術治療外的另一個選項，加上低侵入性的特性，也給了不願意開刀或有手術高風險的病人另一種治療的機會。<br> Abstract: Hypokalemia and refractory hypertension usually lead to an increased likelihood of primaryaldosteronism (PA), which is the most common cause of secondary hypertension. The main causes ofPA are aldosterone-producing adenoma (APA) and idiopathic adrenal hyperplasia (IAH). Unilaterallaparoscopic adrenalectomy is usually the treatment of choice for patients with APA, whereas patientswith IAH are normally treated with medicines. Adrenal venous sampling (AVS) was introduced in late1960s as a test to distinguish unilateral from bilateral primary aldosteronism. AVS is held to be the‘gold standard’ diagnostic procedure for assessing lateralization of aldosterone secretion and therebyidentifying the surgically curable forms of primary aldosteronism.The successful cannulation of both adrenal veins continues to be challenging clinical issues.Adequate adrenal sampling is based on higher cortisol concentration compared with peripheralsampling. We introduced Dyna-CT into the AVS procedure since 2012 and on-site quick cortisol assay(QCA) since 2015. The successful rate had been improved to 97% in non-stimulated AVS. However,based on our experiences of more than 200 cases, we found multiple factors that influence the resultsof lateralization determined by AVS, such as usage of sedative drugs that stabilize the time-dependentvariation of cortisol concentration, ACTH that markedly improves the cortisol secretion,metoclopramide that increases the aldosterone production. We plan to incorporate these factors intoour designed AVS protocols. The results will be of valuable reference. Furthermore, we develop theCT-guided ablation to treat PA. This treatment has advantages of less invasiveness and safety. Besidesmedical treatment and surgical resection, tumor ablation becomes another choice, especially forpatients with surgical contraindication or unwilling to surgery.This study is relied on cooperation with teammates in Taiwan Primary Aldosteronism Investigation(TAIPAI) study group. We had gradually improved the performance on AVS and alternative treatmentof PA.原發性皮質醛酮症腎上腺靜脈取樣醛酮分泌腺瘤電腦斷層導引腫瘤消融治療primary aldosteronismadrenal venous samplingaldosterone-producing adenomaCT-guided tumor ablation