Surgical Approach to Endocrine Hypertension in Patients with Adrenal Disorders

Hypotensive Effects of Arginase Inhibition by L-Norvaline in Genetic Models of Normotensive and Hypertensive Rats

The main effect of arginase inhibition after administration of L-norvaline is a decrease in BP. At the same time, norvaline causes various side effects in normotensive and hypertensive animals. In our experiments, L-norvaline was administered intraperitoneally (30 mg/kg) for 7 days to normotensive WAG rats (Wistar Albino Glaxo) and hypertensive ISIAH rats (Inherited, Stress-Induced Arterial Hypertension). In ISIAH rats, BP decrease was accompanied by an increase in diuresis, while in WAG rats, diuresis remained unchanged or little changed. At the same time, hypertensive rats demonstrated an increase of catecholamine content in the adrenal glands, while in normotensive animals, it was decreased. The differences in the effects of norvaline can be associated with different mechanisms of BP maintenance in normotensive and hypertensive animals. Normally, BP is maintained by the regulatory influences of the nitric oxide system. In hypertension, this system is weakened, and the hypotensive effects are probably achieved via increased diuresis.

Hypertension Resolution after Laparoscopic Adrenal Tumor Resection in Patients of Adrenal Incidentaloma with Normal Hormone Levels

INTRODUCTION

Postoperative hypertension resolution among patients with adrenal incidentalomas and normal hormone levels was unknown. Identifying the predictive factors was beneficial to the management of adrenal incidentalomas.

METHODS

We conducted a retrospective cohort study, recruiting patients undergoing laparoscopic adrenal tumor resection for adrenal incidentaloma with hypertension and normal hormone levels. Demographic, clinical, treatment, and laboratory data were collected and compared. We used univariable and multivariable logistic regression methods to identify the predictive factors of postoperative hypertension resolution.

RESULTS

Of the 171 patients in our study, 130 (76.0%) patients performed a resolution of hypertension, and 57 (33.3%) patients had a significant reduction. Multivariate logistic regression analysis showed that the male sex (odds ratio (OR) 0.305, 95% confidence interval (CI): 0.098-0.948, p = 0.040), body mass index (BMI) (OR 0.973, 95% CI: 0.670-0.938, p = 0.007), aldosterone and plasma renin activity ratio (APR) in erect position (OR 1.206, 95% CI: 1.042-1.397, p = 0.012), and preoperative systolic pressure (OR 1.044, 95% CI: 1.009-1.080, p = 0.014), were significantly associated with the outcomes of hypertension resolution.

DISCUSSION/CONCLUSION

Adrenal incidentalomas patients with hypertension and normal hormone levels would perform hypertension resolution after laparoscopic adrenal tumor resection, especially for females with low BMI, high preoperative systolic blood pressure, and high APR (erect position).

The Entity of Connshing Syndrome: Primary Aldosteronism with Autonomous Cortisol Secretion

Connshing syndrome (CoSh) (adrenal-related synchronous aldosterone (A) and cortisol (C) excess) represents a distinct entity among PA (primary hyperaldosteronisms) named by W. Arlt et al. in 2017, but the condition has been studied for more than 4 decades. Within the last few years, this is one of the most dynamic topics in hormonally active adrenal lesions due to massive advances in steroids metabolomics, molecular genetics from CYP11B1/B2 immunostaining to genes constellations, as well as newly designated pathological categories according to the 2022 WHO classification. In gross, PA causes 4-10% of all high blood pressure (HBP) cases, and 20% of resistant HBP; subclinical Cushing syndrome (SCS) is identified in one-third of adrenal incidentalomas (AI), while CoSh accounts for 20-30% to 77% of PA subjects, depending on the tests used to confirm autonomous C secretion (ACS). The clinical picture overlaps with PA, hypercortisolemia being mild. ACS is suspected in PA if a more severe glucose and cardiovascular profile is identified, or there are larger tumours, ACS being an independent factor risk for kidney damage, and probably also for depression/anxiety and osteoporotic fractures. It seems that one-third of the PA-ACS group harbours mutations of C-related lines like PRKACA and GNAS. A novel approach means we should perform CYP11B2/CYP11B1 immunostaining; sometimes negative aldosteronoma for CYP11B1 is surrounded by micronodules or cell clusters with positive CYP11B1 to sustain the C excess. Pitfalls of hormonal assessments in CoSh include the index of suspicion (check for ACS in PA patients) and the interpretation of A/C ratio during adrenal venous sample. Laparoscopic adrenalectomy is the treatment of choice. Post-operative clinical remission rate is lower in CoSh than PA. The risk of clinically manifested adrenal insufficiency is low, but a synthetic ACTH stimulating testing might help to avoid unnecessary exposure to glucocorticoids therapy. Finally, postponing the choice of surgery may impair the outcome, having noted that long-term therapy with mineralocorticoids receptors antagonists might not act against excessive amounts of C. Awareness of CoSh improves management and overall prognosis.