Outcomes After Surgery for Unilateral Dominant Primary Aldosteronism in Sweden

Hip fractures in patients with primary aldosteronism - a Swedish nationwide study

In this large population-based matched cohort study, patients with primary aldosteronism were at increased risk of hip fracture, particularly subgroups traditionally considered at higher risk of osteoporosis such as women, patients older than 56 years at diagnosis, patients with established cardiovascular disease at diagnosis, and patients treated with MRA.

PURPOSE

Previous studies suggest that primary aldosteronism (PA) is associated with dysregulated bone homeostasis. The aim of this study was to evaluate the incidence of hip fractures in patients with PA.

METHODS

We studied a nationwide cohort of 2419 patients with PA (1997-2019) and 24 187 age and sex matched controls from the general population. Hip fractures were identified by ICD codes in the Swedish National Patient Register. We estimated hazard ratios (HRs) for incident hip fractures, adjusted for prior fractures, socioeconomic factors, diabetes, osteoporosis, hyperparathyroidism, and cardiovascular disease (CVD). Pairwise subgroup comparisons were performed by age (18-56 and > 56 years), sex, CVD at baseline, and treatment for PA.

RESULTS

During a mean follow up of 8 ± 5 years, 64 (2.6%) patients had a hip fracture after being diagnosed with PA, compared to 401 (1.7%) controls. After adjustments, PA was associated with a 55% increased risk of hip fracture compared to controls (HR 1.55 [1.18-2.03]). HRs were increased in women (HR 1.76 [95% CI 1.24-2.52]), patients aged > 56 years (HR 1.62 [95% CI 1.21-2.17]), and patients with CVD at diagnosis (HR 2.15 [95% CI 1.37-3.37]). PA patients treated with adrenalectomy did not have higher risk than controls (HR 0.84 [95% CI 0.35-2.0]), while patients treated with mineralocorticoid receptor antagonists (MRA) retained a greater risk (HR 1.84 [95% CI 1.20-2.83]).

CONCLUSION

PA is associated with increased hip fracture risk, especially in women, patients diagnosed after the age of 56 years and patients with established CVD at diagnosis. Also, patients treated with MRA seem to have an increased risk of hip fractures, while adrenalectomy may be protective.

Unilateral Primary Aldosteronism: Long-Term Disease Recurrence After Adrenalectomy

BACKGROUND

Primary aldosteronism (PA) is frequently caused by a unilateral aldosterone-producing adenoma with a PA-driver mutation. Unilateral adrenalectomy has a high probability of short-term biochemical remission, but long-term postsurgical outcomes are relatively undefined. Our objective was to investigate the incidence of long-term recurrence of PA in individuals with postsurgical short-term biochemical remission.

METHODS

Adrenalectomized patients for unilateral PA were included from a single referral center. Histopathology and outcomes were assessed according to international histopathology of unilateral primary aldosteronism and PASO (Primary Aldosteronism Surgical Outcome) consensuses. Genotyping was performed using CYP11B2 (aldosterone synthase)-guided sequencing.

RESULTS

Classical adrenal histopathology, exemplified by a solitary aldosterone-producing adenoma, was observed in 78% of 90 adrenals, compared with 22% with nonclassical histopathology. The classical group displayed higher aldosterone-to-renin ratios (P=0.013) and lower contralateral ratios (P=0.008). Outcome assessments at both short (12 months [7; 12]) and long (89 months [48; 124]) terms were available for 57 patients. At short-term assessment, 53 (93%) displayed complete biochemical success (43 classical and 10 nonclassical), but long-term assessment demonstrated biochemical PA recurrence in 12 (23%) with an overrepresentation of the nonclassical histopathology (6 [60%] of 10 nonclassical histopathology versus 6 [14%] of 43 classical histopathology; P=0.005). PA-driver mutations were identified in 97% of 64 aldosterone-producing adenomas; there was no association of the aldosterone-producing adenoma genotype with PA recurrence.

CONCLUSIONS

A substantial proportion of individuals display postsurgical biochemical recurrence of PA, which is related to the histopathology of the resected adrenal gland. These findings emphasize the role of histopathology and the requirement for continued outcome assessment in the management of surgically treated patients for PA.

Biomarkers to Guide Medical Therapy in Primary Aldosteronism

Primary aldosteronism (PA) is an endocrinopathy characterized by dysregulated aldosterone production that occurs despite suppression of renin and angiotensin II, and that is non-suppressible by volume and sodium loading. The effectiveness of surgical adrenalectomy for patients with lateralizing PA is characterized by the attenuation of excess aldosterone production leading to blood pressure reduction, correction of hypokalemia, and increases in renin-biomarkers that collectively indicate a reversal of PA pathophysiology and restoration of normal physiology. Even though the vast majority of patients with PA will ultimately be treated medically rather than surgically, there is a lack of guidance on how to optimize medical therapy and on key metrics of success. Herein, we review the evidence justifying approaches to medical management of PA and biomarkers that reflect endocrine principles of restoring normal physiology. We review the current arsenal of medical therapies, including dietary sodium restriction, steroidal and nonsteroidal mineralocorticoid receptor antagonists, epithelial sodium channel inhibitors, and aldosterone synthase inhibitors. It is crucial that clinicians recognize that multimodal medical treatment for PA can be highly effective at reducing the risk for adverse cardiovascular and kidney outcomes when titrated with intention. The key biomarkers reflective of optimized medical therapy are unsurprisingly similar to the physiologic expectations following surgical adrenalectomy: control of blood pressure with the fewest number of antihypertensive agents, normalization of serum potassium without supplementation, and a rise in renin. Pragmatic approaches to achieve these objectives while mitigating adverse effects are reviewed.

Predictive model for persistent hypertension after surgical intervention of primary aldosteronism

Primary aldosteronism (PA) is one of the most common causes of secondary hypertension and is potentially curable. However, a large number of patients still undergo persistent hypertension (PHT) after unilateral adrenal surgery. This research retrospectively studied the factors associated with this clinical difficulty and established a prediction model for the postoperative PHT; Methods: 353 patients from 2014 to 2021 with PA undergoing unilateral adrenal surgery were enrolled in this study. Clinical and biochemical characteristics were reviewed and the associating factors were examined using univariate and multivariate analysis. A nomogram-based prediction model was established correspondingly; results: 46.2% (163/190) of patients had post-surgical PHT. Multivariate analysis suggested that BMI ≥ 25, diabetes, duration of hypertension, male gender, and ARR were independent predictors of PHT after surgery. The prediction model based on the nomogram showed good discrimination ability (the C index of the training group and the validation group were 0.783 and 0.769, respectively), and the calibration curves and the Hosmer-Lemeshow test were good as well. Clinical usefulness was quantified using the decision curve analysis; This nomogram is an integration of the clinical and biochemical data of patients before surgery, and is a reliable tool with high accuracy for predicting the postoperative PHT in patients with PA.

Primary Aldosteronism: State-of-the-Art Review

We are witnessing a revolution in our understanding of primary aldosteronism (PA). In the past 2 decades, we have learned that PA is a highly prevalent syndrome that is largely attributable to pathogenic somatic mutations, that contributes to cardiovascular, metabolic, and kidney disease, and that when recognized, can be adequately treated with widely available mineralocorticoid receptor antagonists and/or surgical adrenalectomy. Unfortunately, PA is rarely diagnosed, or adequately treated, mainly because of a lack of awareness and education. Most clinicians still possess an outdated understanding of PA; from primary care physicians to hypertension specialists, there is an urgent need to redefine and reintroduce PA to clinicians with a modern and practical approach. In this state-of-the-art review, we provide readers with the most updated knowledge on the pathogenesis, prevalence, diagnosis, and treatment of PA. In particular, we underscore the public health importance of promptly recognizing and treating PA and provide pragmatic solutions to modify clinical practices to achieve this.

Minimally Invasive Partial vs. Total Adrenalectomy for the Treatment of Unilateral Primary Aldosteronism: A Systematic Review and Meta-Analysis

BACKGROUND

This systematic review and metanalysis was conducted to assess differences between perioperative and functional outcomes in patients undergoing minimally-invasive partial (mi-PA) and total adrenalectomy (mi-TA) for unilateral primary aldosteronism (uPHA).

MATERIAL AND METHODS

Multiple scientific databases (PUBMED, Web of Science, and Cochrane Library) were searched up to November 2021 for surgical series comparing mi-PA vs. mi-TA for uPHA according to the PRISMA statement. Primary outcomes of interest were perioperative and functional outcomes.

RESULTS

Overall, a total of 802 patients from six eligible studies were identified, with mi-PA and mi-TA performed in 40.4% (n = 324) and 59.6% (n = 478) of cases, respectively. No differences were recorded between the two groups according to number of transfusions, EBL and Clavien-Dindo complications ≥2. Similarly, no differences in clinical success, persistence of postoperative hypokalemia and improvement in HTN were reported between mi-PA and mi-TA.

CONCLUSIONS

In a uPHA setting, mi-PA and mi-TA provide comparable perioperative and functional outcomes despite the use of mi-PA remains limited to patients with small adenoma size, or hereditary/bilateral disease. Due to limited use of standardized reporting criteria in most of current series, the quest for a superiority of mi-PA over mi-TA in the treatment of uPHA still remains open.

Surgical Quality, Antihypertensive Therapy, and Electrolyte Balance: A Novel Trifecta to Assess Long-Term Outcomes of Adrenal Surgery for Unilateral Primary Aldosteronism

Background: To propose a trifecta that summarizes endpoints and predicts their maintenance after adrenalectomy (n = 90) for unilateral primary aldosteronism (UPA). Methods: Trifecta was defined as coexistence of: ≥50% antihypertensive therapeutic intensity score reduction (∆TIS), no hypokalemia at 3 months, and no Clavien grade 2–5. Logistic regression was used to identify predictors of trifecta. Probability of clinical, biochemical, and simultaneous success according to trifecta were assessed by Kaplan–Meier. Cox regression was used to identify predictors of long-term clinical, biochemical, and simultaneous success. For all analyses, a two-sided p < 0.05 was considered significant. Results: Simultaneous success rate was 50%. On multivariable analysis, TIS was an independent predictor of trifecta achievement (HR 3.28; 95% CI 1.07–10.9; p = 0.03). At Kaplan–Meier, trifecta predicted higher success for all endpoints (each p < 0.03). On multivariable Cox analysis, adenoma size (AS) ≥6 cm and trifecta were independent predictors of biochemical (AS: HR 2.87; 95% CI 1.53–5.36; trifecta: HR 2.1; 95% CI 1.13–3.90; each p < 0.02) and simultaneous success (AS: HR 3.81; 95% CI 1.68–8.65; trifecta: HR 4.29; 95% CI 2.08–8.86; each p < 0.01), while trifecta was an independent predictor of complete clinical success (HR 2.84; 95% CI 1.45–5.58; p < 0.01). Conclusions: Trifecta and AS are independent predictors of either long-term complete clinical, biochemical, or combined success after adrenalectomy for UPA.

Pathophysiology and histopathology of primary aldosteronism

Primary aldosteronism (PA) can be sporadic or familial and classified into unilateral and bilateral forms. Sporadic PA predominates with excessive aldosterone production usually arising from a unilateral aldosterone-producing adenoma (APA) or bilateral adrenocortical hyperplasia. Familial PA is rare and caused by germline variants, that partly correspond to somatic alterations in APAs. Classification into unilateral and bilateral PA determines the treatment approach but does not accurately mirror disease pathology. Some evidence indicates a disease continuum ranging from balanced aldosterone production from each adrenal to extreme asymmetrical bilateral aldosterone production. Nonetheless, surgical removal of the overactive adrenal in unilateral PA achieves highly successful outcomes and almost all patients are biochemically cured of their aldosteronism.

Benefits of Surgical Over Medical Treatment for Unilateral Primary Aldosteronism

Primary aldosteronism is the most common and modifiable form of secondary hypertension. Left untreated, primary aldosteronism leads high rates of cardiovascular, metabolic, and kidney disease. Therefore, early diagnosis and targeted therapy are crucial to improve long-term patient outcomes. In the case of unilateral primary aldosteronism, surgical adrenalectomy is the guideline-recommended treatment of choice as compared to alternative medical therapies such as mineralocorticoid receptor antagonist medications. Surgical adrenalectomy is not only highly successful in reversing the biochemical abnormalities inherent to primary aldosteronism, but also in mitigating the long-term risks associated with this disease. Indeed, as opposed to medical treatment alone, surgical adrenalectomy offers the potential for disease cure. Within this review article, we review the existing evidence highlighting the benefits of surgical over medical treatment for unilateral primary aldosteronism.

Predictive factors of clinical success after adrenalectomy in primary aldosteronism: A systematic review and meta-analysis

BACKGROUND

Unilateral adrenalectomy is the mainstay treatment for unilateral primary aldosteronism (PA). This meta-analysis aimed to systematically analyse predictors of clinical success after unilateral adrenalectomy in PA.

METHODS

A search was performed using PubMed/Medline, Scopus, Embase and Web of Science from their inception to February 2022. Observational studies in adult PA patients which reported predictors of clinical success after unilateral adrenalectomy were included. A random-effects model was employed to pool the fully adjusted odds ratio (OR) or standardized mean difference (SMD) with 95% confidence interval (95% CI).

RESULTS

Thirty-two studies involving 5,601 patients were included. Females had a higher clinical success rate (OR 2.81; 95% CI 2.06-3.83). Older patients, patients with a longer duration of hypertension and those taking a higher number of antihypertensive medications had lower clinical success rates (OR 0.97; 95% CI 0.94-0.99, OR 0.92; 95% CI 0.88-0.96 and OR 0.44; 95% CI 0.29-0.67, respectively). Compared to non-clinical success cases, patients with clinical success had a lower body mass index (SMD -0.49 kg/m²; 95% CI -0.58,-0.39), lower systolic (SMD -0.37 mmHg; 95% CI -0.56,-0.18) and diastolic blood pressure (SMD -0.19 mmHg; 95% CI -0.33,-0.06), lower serum potassium (SMD -0.16 mEq/L; 95% CI -0.28,-0.04), higher eGFR (SMD 0.51 mL/min/1.73m²; 95% CI 0.16,0.87), a lower incidence of dyslipidemia (OR 0.29; 95% CI 0.15-0.58) and a lower incidence of diabetes mellitus (OR 0.36; 95% CI 0.22-0.59).

CONCLUSIONS

Multiple predictors of clinical success after unilateral adrenalectomy in PA were identified which can help improve the quality of care for PA patients. Systematic Review Registration: INPLASY, identifier 202240129.

Re-evaluating absent clinical success after adrenalectomy in unilateral primary aldosteronism

BACKGROUND

Adrenalectomy cures unilateral primary aldosteronism, and it improves or cures hypertension. However, a significant proportion of patients are classified with absent clinical success postsurgery, suggesting that surgery was ineffective.

METHODS

We assessed all patients 6 to 12 months post-surgery for clinical outcomes using Primary Aldosteronism Surgical Outcomes (PASO), AVIS-2, and CONNsortium criteria. We estimated blood pressure changes after adjustment for changes in defined daily dosages of antihypertensive medications. We also reassessed all patients using PASO at their recent clinical visit.

RESULTS

A total of 104 patients with unilateral primary aldosteronism underwent adrenalectomy at 2 tertiary centers from 2000 to 2019; 24 (23%), 31 (30%), and 54 (52%) patients were classified with absent clinical success using PASO, AVIS-2, and CONNsortium criteria, respectively. Among 24 patients with absent clinical success using PASO criteria, 10 had complete biochemical cure, 3 partial, 2 absent, and 9 had resolution of hypokalemia. On multivariable analysis, absent clinical success was associated with presence of hyperlipidemia, diabetes mellitus, and lower defined daily dosages at baseline. After adjustment for changes in defined daily dosages, 7 of 24 patients showed blood pressure improvement ≥20/10 mm Hg post-surgery. After a follow-up of mean 5.6 years, 12 of 24 patients showed partial or complete clinical success when reassessed using PASO criteria. Only 6 of 104 (5.8%) patients failed to show clinical improvement post-surgery using any of the 3 mentioned criteria or using PASO criteria at their recent clinical visit.

CONCLUSION

Although some patients may be classified with absent clinical success post-surgery, the assessment of clinical outcomes remains subject to many variables. In patients with unilateral primary aldosteronism, evidenced by lateralization on AVS, unilateral adrenalectomy should remain the recommended treatment.

Minimally invasive partial versus total adrenalectomy for unilateral primary hyperaldosteronism-a retrospective, multicenter matched-pair analysis using the new international consensus on outcome measures

BACKGROUND

Primary hyperaldosteronism is a recognized risk factor for myocardial infarction, stroke, and atrial fibrillation. Minimally invasive adrenalectomy is the first-line treatment for localized primary hyperaldosteronism. Whether minimally invasive adrenalectomy should be performed using a cortex-sparing technique (partial minimally invasive adrenalectomy) or not (total minimally invasive adrenalectomy) remains a subject of debate. The aim of our study was to evaluate the clinical and biochemical efficacy of both procedures and to examine the morbidity associated with partial minimally invasive adrenalectomy versus total minimally invasive adrenalectomy in a multicenter study.

METHODS

Using a retrospective study design, we determined the efficacy, morbidity, and mortality of partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy. The Primary Aldosteronism Surgical Outcome Study classification was used to explore clinical and biochemical success. Matched-pair analysis was used in order to address possible bias.

RESULTS

We evaluated 234 matched patients with unilateral primary hyperaldosteronism: 78 (33.3%) underwent partial minimally invasive adrenalectomy, and 156 (66.7%) were treated with total minimally invasive adrenalectomy. Complete clinical success was achieved in 40.6%, and partial clinical success in an additional 52.6% of patients in the entire cohort. Complete biochemical success was seen in 94.0% of patients. Success rates and the incidence of perioperative complications were comparable between groups. Both postoperative hypocortisolism (11.5% vs 25.0% after partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy, respectively; P < .001) and postoperative hypoglycemia (2.6% vs 7.1% after partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy; P = .039) occurred more frequently after total minimally invasive adrenalectomy.

CONCLUSION

Our study provides evidence that patients with unilateral primary hyperaldosteronism are good surgical candidates for partial minimally invasive adrenalectomy. Not only is the surgical outcome comparable to that of total minimally invasive adrenalectomy, but also postsurgical morbidity, particularly in terms of hypocortisolism and hypoglycemia, may be reduced.

Treatment of primary hyperaldosteronism

Primary aldosteronism is associated with higher cardiovascular and renal morbidity and mortality than essential hypertension in age- and sex-matched patients with the same degree of blood pressure elevation. Therefore, it is essential to establish a specific treatment to avoid the deleterious effects of aldosterone excess. Although adrenalectomy is generally considered the treatment of choice in cases of primary aldosteronism due to unilateral disease, several aspects and circumstances should be taken into account that may make medical treatment more appropriate. Among them, in this review we mention the limited experience and efficacy, and the potential risks of adrenal vein sampling; the risks and low efficacy of adrenalectomy; the high safety and efficacy of medical treatment and some special situations such as primary aldosteronism during pregnancy, in patients of advanced age or hereditary forms of primary aldosteronism, in which medical treatment is considered especially indicated as the first line therapy. The main studies comparing medical and surgical treatment in primary aldosteronism are also discussed.

Minimally Invasive Partial Versus Total Adrenalectomy for the Treatment of Primary Aldosteronism: Results of a Multicenter Series According to the PASO Criteria

BACKGROUND

Determination of success after adrenal-sparing surgery for primary aldosteronism (PA) is limited by the lack of standardized definitions of outcomes.

OBJECTIVE

To evaluate the safety and effectiveness of minimally invasive partial adrenalectomy (MIPA) for PA by comparing perioperative and functional outcomes with minimally invasive total adrenalectomy (MITA) according to the Primary Aldosteronism Surgical Outcome (PASO) criteria.

DESIGN, SETTING, AND PARTICIPANTS

Between March 2011 and April 2020, a multicenter adrenalectomy dataset was queried for "unilateral adrenal mass, PA, MIPA (n = 29), or MITA (n = 61)"at four participating Institutions.

INTERVENTION

MITA and MIPA for PA.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Differences between continuous variables were assessed with the Wilcoxon rank sum test, while Pearson's χ² test was used for categorical data. Complete, partial, and absent clinical success rates were assessed for the overall cohort and compared between groups.

RESULTS AND LIMITATIONS

The median tumor size was significantly higher in the MITA group (4.2 vs 2.7 cm; p = 0.001), while preoperative hypertension rate was significantly higher in the MIPA series (82.8% vs 57.4%, p = 0.01). The median length of hospital stay was increased in the MITA cohort (4 vs 3 d; p = 0.038). Overall, at a median follow-up of 42 mo (interquartile range 27-54 mo), complete, partial, and absent clinical success was observed in 60%, 17.7%, and 22.3% of cases, respectively. The complete clinical success rate was higher in the MIPA group (72.4% vs 54.1%), while a partial clinical success was higher in the MITA series (23% vs 6.8%). The absence of clinical success was comparable between groups (MITA 23% vs MIPA 20.7%).

CONCLUSIONS

MIPA showed excellent perioperative results with a complete clinical success rate of 72.4%. Owing to the heterogeneity of the PASO criteria in the assessment of partial or absent success, the quest for a univocal definition of satisfactory clinical outcomes in the treatment of PA remains open.

PATIENT SUMMARY

We compared minimally invasive partial adrenalectomy (MIPA) and minimally invasive total adrenalectomy for the treatment of unilateral primary aldosteronism, assessing the outcomes with the Primary Aldosteronism Surgical Outcome (PASO) criteria. MIPA seems to provide comparable perioperative outcomes and midterm clinical success rates.