The evaluation and treatment of endocrine forms of hypertension. Curr Cardiol Rep. 2014;16:528. [PMID: 25119722 DOI: 10.1007/s11886-014-0528-x]

Long-term blood pressure outcomes of laparoscopic adrenalectomy in trHTN patients

Background and Objectives

Treatment resistant hypertension (trHTN) is a common clinical problem faced by many clinicians. Laparoscopic adrenalectomy effectively trims blood pressure (BP) elevation secondary to various functional adrenal disorders. However, the impact of adrenalectomy on BP within trHTN patients has never been reported. Our present study aims to investigate the effect of adrenalectomy on BP management within trHTN patients, and to explore clinical predictors for postoperative BP normalization.

Patients and Methods

In our current study, 117 patients diagnosed with trHTN and performed with unilateral adrenalectomy were consecutively enrolled, demographic and medical information were documented for baseline data collection. BP was measured with a standard electronic sphygmomanometer twice a day. Long-term periodical interview was conducted and 109 (93.2%) enrolled patients were successfully followed-up at an averaged 36.2 months.

Results

At follow-up, 27/109 (25%) trHTN patients acquired BP normalization and 68/109 (62%) patients acquired BP improvement. Mean taking anti-hypertensive agents reduced from presurgical 4.24 to present 1.21 (P < 0.01), along with 7.2 mmHg reduction in SBP (P < 0.01). Image macro-adenoma and hypokalemia history were found to be the two strongest predictors for postoperative BP normalization. (χ2= 28.032, P < 0.01). The incidence of adverse postoperative events was quite small.

Conclusions

In summary, this current study implicates that adrenalectomy is an efficacious and safe surgical strategy for BP management in trHTN patients. Patients with both unilateral macro-adenoma and hypokalemia are more prone to acquire postoperative BP normalization.

Long-term blood pressure outcomes of laparoscopic adrenalectomy in trHTN patients

Background and Objectives

Treatment resistant hypertension (trHTN) is a common clinical problem faced by many clinicians. Laparoscopic adrenalectomy effectively trims blood pressure (BP) elevation secondary to various functional adrenal disorders. However, the impact of adrenalectomy on BP within trHTN patients has never been reported. Our present study aims to investigate the effect of adrenalectomy on BP management within trHTN patients, and to explore clinical predictors for postoperative BP normalization.

Patients and Methods

In our current study, 117 patients diagnosed with trHTN and performed with unilateral adrenalectomy were consecutively enrolled, demographic and medical information were documented for baseline data collection. BP was measured with a standard electronic sphygmomanometer twice a day. Long-term periodical interview was conducted and 109 (93.2%) enrolled patients were successfully followed-up at an averaged 36.2 months.

Results

At follow-up, 27/109 (25%) trHTN patients acquired BP normalization and 68/109 (62%) patients acquired BP improvement. Mean taking anti-hypertensive agents reduced from presurgical 4.24 to present 1.21 (P = 0.000), along with 7.2 mmHg reduction in SBP (P = 0.000). Image macro-adenoma and hypokalemia history were found to be the two strongest predictors for postoperative BP normalization. (χ2 = 28.032, P = 0.000). The incidence of adverse postoperative events was quite small.

Conclusions

In summary, this current study implicates that adrenalectomy is an efficacious and safe surgical strategy for BP management in trHTN patients. Patients with both unilateral macro-adenoma and hypokalemia are more prone to acquire postoperative BP normalization.

Glucocorticoid Receptor Antagonist Administration Prevents Adrenal Gland Atrophy in an ACTH-Independent Cushing's Syndrome Rat Model

ACTH-independent Cushing's syndrome (CS) is mainly caused by cortisol-secreting adrenocortical tumours. It is well known that secondary adrenal insufficiency occurs after surgical resection of these tumours. In this regard, impaired adrenocortical function is likely induced by atrophy of the residual adrenal tissue as a result of chronic suppression by the low ACTH levels of the hypercortisolism state. Therefore, we considered the prevention of adrenal atrophy as a method for preventing postoperative adrenal insufficiency. On the basis of these findings, we hypothesized that the use of a glucocorticoid receptor (GR) antagonist before surgery in ACTH-independent CS would rapidly activate the hypothalamic-pituitary-adrenal (HPA) axis and residual adrenal function. We thus examined adrenal function in a dexamethasone- (DEX-) induced CS rat model with or without mifepristone (MIF). In this study, MIF-treated rats had elevated plasma ACTH levels and increased adrenal weights. In addition, we confirmed that there were fewer atrophic changes, as measured by the pathological findings and mRNA expression levels of corticosterone synthase CYP11B1 in the adrenal glands, in MIF-treated rats. These results indicate that MIF treatment prevents the suppression of the HPA axis and the atrophy of the residual adrenal tissue. Therefore, our study suggests that preoperative GR antagonist administration may improve residual adrenal function and prevent postoperative adrenal insufficiency in ACTH-independent CS.

[Hypertension associated with paraparesis of the lower limbs revealing an adrenal adenoma]

Cushing's syndrome is a rare cause of high blood pressure. The originally adrenal cause is found in 15% of cases. We describe the case of a patient with hypertension associated with paraparesis of the lower limbs revealing a Cushing syndrome due to a left adrenal adenoma. A 23-year-old man consults for a paraparesis of the lower limbs. The highlighting of an arterial high blood pressure led to the realization of complementary examinations. Computed tomography of the abdomen shows a left adrenal mass. Chirurgical excision of the mass was performed and histological examination concluded with adrenal adenoma. After intervention, the patient normalized his blood pressure with 3 years of follow up. This case illustrates a form of endocrine hypertension of adrenal origin and the need for a careful clinical examination during the discovery of hypertension in the young subject in order to carry out adequate balance sheets to search for a curable cause of secondary hypertension.

Ophthalmic clues to the endocrine disorders

PURPOSE

Eye is a vital sense organ and reflects the physical and mental wellbeing of a person. Detailed examination of the eye is an essential part in the clinical evaluation of patients with any systemic disorder. The interaction between ophthalmologists and endocrinologists is often limited to Graves' ophthalmopathy and diabetic retinopathy. However, there are many ophthalmic manifestations, which are characteristically seen in endocrine disorders. In this review, we shall discuss the ocular manifestations of the endocrine syndromes excluding the Graves' ophthalmopathy and diabetic retinopathy.

METHODS

We performed a PubMed search of articles published in English showing the ophthalmic features in the endocrine disorders. Relevant cited articles were also retrieved.

RESULTS

Most of the publications included in the review were case reports and review articles. Many endocrine disorders have characteristic manifestations pertaining to the various structures of the eye. The involvement is seen from the external structures of the eye to the inner most layers of the retina. Many ocular-endocrine syndromes also exist with characteristic clues to the clinical diagnosis.

CONCLUSION

The endocrinologists need to be aware of these ocular signs that help in the early diagnosis of the underlying disorder. A syndromic approach is essential in the diagnosis of endocrinopathy in patients presenting with ophthalmic features.

Endocrine Hypertension: A Practical Approach

Elevated blood pressure resulting from few endocrine disorders (endocrine hypertension) accounts for a high proportion of cases of secondary hypertension. Although some features may be suggestive, many cases of endocrine hypertension remain silent until worked up for the disease. A majority of cases result from primary aldosteronism. Other conditions that can cause endocrine hypertension are: congenital adrenal hyperplasia, Liddle syndrome, pheochromocytomas, Cushing's syndrome, acromegaly, thyroid diseases, primary hyperparathyroidism and iatrogenic hormone manipulation. Early identification and treatment of the cause of endocrine hypertension may help to reduce morbidity and mortality related to these disorders. This article gives a comprehensive and practical approach to the diagnosis and management of endocrine hypertension.

Endocrine hypertension: An overview on the current etiopathogenesis and management options

Endocrine causes of secondary hypertension include primary aldosteronism, pheochromocytoma, cushing’s syndrome, hyperparathyroidism and hypo- and hyperthyroidism. They comprise 5%-10% of the causes of secondary hypertension. Primary hyperaldosteronism, the most common of the endocrine cause of hypertension often presents with resistant or difficult to control hypertension associated with either normo-or hypokalemia. Pheochromocytoma, a great mimicker of many conditions, is associated with high morbidity and mortality if left untreated. A complete history including pertinent family history, physical examination along with a high index of suspicion with focused biochemical and radiological evaluation is important to diagnose and effectively treat these conditions. The cost effective targeted genetic screening for current known mutations associated with pheochromocytoma are important for early diagnosis and management in family members. The current review focuses on the most recent evidence regarding causes, clinical features, methods of diagnosis, and management of these conditions. A multidisciplinary approach involving internists, endocrinologists and surgeons is recommended in optimal management of these conditions.