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dromlakhani (@dromlakhani) published this skill. Their other Agent Skills are listed on their SkillMD profile.

Esa Pa Interpret 18oxo by dromlakhani

Name: Esa Pa Interpret 18oxo
Rating: 4.666666666666667 (3 reviews)
Author: dromlakhani

Esa Pa Interpret 18oxo

Helps distinguish unilateral from bilateral adrenal disease based on 18-oxocortisol levels, which are typically higher in aldosterone-producing adenoma than idiopathic adrenal hyperplasia. Use when evaluating 18-oxocortisol results during PA workup to guide subtype classification after a positive ARR.

dromlakhani Updated Aug 19, 2026 10 repo stars

File contents

Interpret 18-Oxocortisol Levels for PA Subtyping

STEP 1 — Gather Information

Collect peripheral plasma 18-oxocortisol concentration (ng/dL) in a patient with confirmed primary aldosteronism (positive ARR) and note clinical context (e.g., hypertension, hypokalemia). Also record whether the sample is peripheral or from adrenal venous sampling if available.

STEP 2 — Rule In / Rule Out

If 18-oxocortisol >100 ng/dL (or above the laboratory's upper reference limit for idiopathic hyperplasia), rule in unilateral aldosterone-producing adenoma; otherwise, rule out unilateral source (suggest bilateral idiopathic hyperplasia).

STEP 3 — Classify or Stratify

Stratify as high (>100 ng/dL) favoring unilateral APA, low (≤100 ng/dL) favoring bilateral IHA, noting that up to 40% of patients may have indeterminate levels requiring further testing.

STEP 4 — Decide

For high 18-oxocortisol suggesting unilateral disease, proceed to laparoscopic adrenalectomy if surgical candidate; for low levels suggesting bilateral disease, initiate medical treatment with a mineralocorticoid receptor antagonist (e.g., spironolactone).

Clinical Guardrails / Mimics / Pitfalls

Do not rely solely on 18-oxocortisol for surgical decisions; confirm unilateral disease with adrenal venous sampling. Avoid using 18-oxocortisol in patients with renal insufficiency, as metabolite excretion may be unreliable. Recognize that assay standardization varies and results may not be available in all labs.

Concrete Clinical Example

A 52-year-old man with resistant hypertension and spontaneous hypokalemia has an ARR of 60. Peripheral plasma 18-oxocortisol returns at 135 ng/dL. This elevated level supports a unilateral source, and subsequent AVS confirms left-sided aldosterone excess, leading to laparoscopic left adrenalectomy.

Source: The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2015-4061

---name: esa-pa-interpret-18oxodescription: Helps distinguish unilateral from bilateral adrenal disease based on 18-oxocortisol levels, which are typically higher in aldosterone-producing adenoma than idiopathic adrenal hyperplasia. Use when evaluating 18-oxocortisol results during PA workup to guide subtype classification after a positive ARR.---# Interpret 18-Oxocortisol Levels for PA Subtyping## STEP 1 — Gather InformationCollect peripheral plasma 18-oxocortisol concentration (ng/dL) in a patient with confirmed primary aldosteronism (positive ARR) and note clinical context (e.g., hypertension, hypokalemia). Also record whether the sample is peripheral or from adrenal venous sampling if available.## STEP 2 — Rule In / Rule OutIf 18-oxocortisol >100 ng/dL (or above the laboratory's upper reference limit for idiopathic hyperplasia), rule in unilateral aldosterone-producing adenoma; otherwise, rule out unilateral source (suggest bilateral idiopathic hyperplasia).## STEP 3 — Classify or StratifyStratify as high (>100 ng/dL) favoring unilateral APA, low (≤100 ng/dL) favoring bilateral IHA, noting that up to 40% of patients may have indeterminate levels requiring further testing.## STEP 4 — DecideFor high 18-oxocortisol suggesting unilateral disease, proceed to laparoscopic adrenalectomy if surgical candidate; for low levels suggesting bilateral disease, initiate medical treatment with a mineralocorticoid receptor antagonist (e.g., spironolactone).## Clinical Guardrails / Mimics / PitfallsDo not rely solely on 18-oxocortisol for surgical decisions; confirm unilateral disease with adrenal venous sampling. Avoid using 18-oxocortisol in patients with renal insufficiency, as metabolite excretion may be unreliable. Recognize that assay standardization varies and results may not be available in all labs.## Concrete Clinical ExampleA 52-year-old man with resistant hypertension and spontaneous hypokalemia has an ARR of 60. Peripheral plasma 18-oxocortisol returns at 135 ng/dL. This elevated level supports a unilateral source, and subsequent AVS confirms left-sided aldosterone excess, leading to laparoscopic left adrenalectomy.**Source:** The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2015-4061

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