1
|
Hundemer GL, Leung AA, Kline GA, Brown JM, Turcu AF, Vaidya A. Biomarkers to Guide Medical Therapy in Primary Aldosteronism. Endocr Rev 2024; 45:69-94. [PMID: 37439256 PMCID: PMC10765164 DOI: 10.1210/endrev/bnad024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/23/2023] [Accepted: 07/11/2023] [Indexed: 07/14/2023]
Abstract
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.
Collapse
Affiliation(s)
- Gregory L Hundemer
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON K1H 8L6, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada
| | - Alexander A Leung
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Gregory A Kline
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
2
|
Vaidya A, Hundemer GL, Nanba K, Parksook WW, Brown JM. Primary Aldosteronism: State-of-the-Art Review. Am J Hypertens 2022; 35:967-988. [PMID: 35767459 PMCID: PMC9729786 DOI: 10.1093/ajh/hpac079] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Anand Vaidya
- Department of Medicine, Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Kazutaka Nanba
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Wasita W Parksook
- Department of Medicine, Division of Endocrinology and Metabolism, and Division of General Internal Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Gao G, Zhou C, Ao Y, Wang J, Xu Y. Variations in postoperative electrolyte concentrations and influential factors in hip arthroscopy. BMC Musculoskelet Disord 2022; 23:473. [PMID: 35590402 PMCID: PMC9118850 DOI: 10.1186/s12891-022-05451-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Different from arthroscopy in other joints, more perfusion is required for a better access to perform surgical procedures in hip arthroscopic operations. The significant fluid perfused may lead to complications of partial tissue injury and electrolyte imbalance. However, there were few studies on the change of serum electrolyte after hip arthroscopy and the influential factors were still unknown. METHODS We evaluated consecutive patients who underwent hip arthroscopy in our hospital between October 2021 and February 2022. Age, sex, and BMI matched patients who underwent arthroscopic anterior cruciate ligament (ACL) reconstruction at the same time were also included as the control group. Preoperative and postoperative serum electrolyte of sodium (Na +), potassium (K +), chloride (Cl-), magnesium (Mg2 +), and carbon dioxide capacity (CO2CP) were analyzed. The correlations between influential factors like perfusion volume, operating time, BMI and hip circumference, and changes in serum electrolyte were also analyzed. RESULTS A total of 79 patients were involved in this study, including 49 patients who underwent hip arthroscopy and 30 patients who underwent knee arthroscopy. For hip arthroscopy, decrease of potassium levels was observed in 40.8% of the patients, and postoperative hypokalemia was found in 10.2% patients. There were significant variations in postoperative sodium, magnesium, chloride and carbon dioxide capacity in hip arthroscopy (p < 0.05). No correlations were found between each of the electrolyte concentrations and influential factors like perfusion volume, operating time, BMI, sex and hip circumference. The significant variations were found in chloride and carbon dioxide capacity in knee arthroscopy (p < 0.05). CONCLUSIONS Hip arthroscopy would significantly influence postoperative serum electrolyte, and hypokalemia could be a postoperative complication. The correlation between serum electrolyte and fluid perfusion volume is remained to be investigated. We therefor advocate that performing a systematic care of preoperative and postoperative serum electrolyte analysis as perioperative management is necessary.
Collapse
Affiliation(s)
- Guanying Gao
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China
| | - Chang Zhou
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China
| | - Yingfang Ao
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China
| | - Jianquan Wang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China
| | - Yan Xu
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China.
| |
Collapse
|
4
|
Anceschi U, Mormando M, Fiori C, Zappalà O, De Concilio B, Brassetti A, Carrara A, Ferriero MC, Tuderti G, Misuraca L, Bove AM, Mastroianni R, Chiefari A, Appetecchia M, Tirone G, Porpiglia F, Celia A, Gallucci M, Simone G. Surgical Quality, Antihypertensive Therapy, and Electrolyte Balance: A Novel Trifecta to Assess Long-Term Outcomes of Adrenal Surgery for Unilateral Primary Aldosteronism. J Clin Med 2022; 11:794. [PMID: 35160247 PMCID: PMC8836466 DOI: 10.3390/jcm11030794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/05/2022] [Accepted: 01/20/2022] [Indexed: 02/04/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Umberto Anceschi
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (M.C.F.); (G.T.); (L.M.); (A.M.B.); (R.M.); (M.G.); (G.S.)
| | - Marilda Mormando
- Oncologic Endocrinology Unit, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (M.M.); (A.C.); (M.A.)
| | - Cristian Fiori
- Department of Urology, AOU San Luigi Gonzaga, Regione Gonzole, 10, 10043 Orbassano, Italy; (C.F.); (F.P.)
| | - Orazio Zappalà
- Department of General Surgery, Santa Chiara Regional Hospital, APSS, Largo Medaglie d’Oro 9, 38122 Trento, Italy; (O.Z.); (G.T.)
| | - Bernardino De Concilio
- Department of Urology, San Bassiano Hospital, ULSS 7 Pedemontana, Via dei Lotti, 40, 36061 Bassano del Grappa, Italy; (B.D.C.); (A.C.)
| | - Aldo Brassetti
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (M.C.F.); (G.T.); (L.M.); (A.M.B.); (R.M.); (M.G.); (G.S.)
| | - Alessandro Carrara
- Department of General Surgery, Santa Maria del Carmine Hospital, APSS, Corso Verona 4, 38068 Rovereto, Italy;
| | - Maria Consiglia Ferriero
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (M.C.F.); (G.T.); (L.M.); (A.M.B.); (R.M.); (M.G.); (G.S.)
| | - Gabriele Tuderti
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (M.C.F.); (G.T.); (L.M.); (A.M.B.); (R.M.); (M.G.); (G.S.)
| | - Leonardo Misuraca
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (M.C.F.); (G.T.); (L.M.); (A.M.B.); (R.M.); (M.G.); (G.S.)
| | - Alfredo Maria Bove
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (M.C.F.); (G.T.); (L.M.); (A.M.B.); (R.M.); (M.G.); (G.S.)
| | - Riccardo Mastroianni
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (M.C.F.); (G.T.); (L.M.); (A.M.B.); (R.M.); (M.G.); (G.S.)
| | - Alfonsina Chiefari
- Oncologic Endocrinology Unit, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (M.M.); (A.C.); (M.A.)
| | - Marialuisa Appetecchia
- Oncologic Endocrinology Unit, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (M.M.); (A.C.); (M.A.)
| | - Giuseppe Tirone
- Department of General Surgery, Santa Chiara Regional Hospital, APSS, Largo Medaglie d’Oro 9, 38122 Trento, Italy; (O.Z.); (G.T.)
| | - Francesco Porpiglia
- Department of Urology, AOU San Luigi Gonzaga, Regione Gonzole, 10, 10043 Orbassano, Italy; (C.F.); (F.P.)
| | - Antonio Celia
- Department of Urology, San Bassiano Hospital, ULSS 7 Pedemontana, Via dei Lotti, 40, 36061 Bassano del Grappa, Italy; (B.D.C.); (A.C.)
| | - Michele Gallucci
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (M.C.F.); (G.T.); (L.M.); (A.M.B.); (R.M.); (M.G.); (G.S.)
| | - Giuseppe Simone
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (M.C.F.); (G.T.); (L.M.); (A.M.B.); (R.M.); (M.G.); (G.S.)
| |
Collapse
|
5
|
Ahmed S, Hundemer GL. Benefits of Surgical Over Medical Treatment for Unilateral Primary Aldosteronism. Front Endocrinol (Lausanne) 2022; 13:861581. [PMID: 35557845 PMCID: PMC9086781 DOI: 10.3389/fendo.2022.861581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/28/2022] [Indexed: 11/26/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Sumaiya Ahmed
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Gregory L. Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- *Correspondence: Gregory L. Hundemer,
| |
Collapse
|
6
|
Hundemer GL, Vaidya A. MANAGEMENT OF ENDOCRINE DISEASE: The role of surgical adrenalectomy in primary aldosteronism. Eur J Endocrinol 2020; 183:R185-R196. [PMID: 33077688 PMCID: PMC7853245 DOI: 10.1530/eje-20-0863] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/30/2020] [Indexed: 12/17/2022]
Abstract
Primary aldosteronism is common and contributes to adverse cardiovascular, kidney, and metabolic outcomes. When instituted early and effectively, targeted therapies can mitigate these adverse outcomes. Surgical adrenalectomy is among the most effective treatments because it has the potential to cure, or attenuate the severity of, pathologic aldosterone excess, resulting in a host of biochemical and clinical changes that improve health outcomes. Herein, we review the role of surgical adrenalectomy in primary aldosteronism while emphasizing the physiologic ramifications of surgical intervention, and compare these to other targeted medical therapies for primary aldosteronism. We specifically review the role of curative adrenalectomy for unilateral primary aldosteronism, the role of non-curative adrenalectomy for bilateral primary aldosteronism, and how these interventions influence biochemical and clinical outcomes in relation to medical therapies for primary aldosteronism.
Collapse
Affiliation(s)
- Gregory L. Hundemer
- Division of Nephrology, Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| |
Collapse
|
7
|
Takamatsu K, Takeda T, Hattori S, Tanaka N, Morita S, Matsumoto K, Kosaka T, Mizuno R, Shinojima T, Kikuchi E, Asanuma H, Kurihara I, Itoh H, Oya M. Appropriate timing for a biochemical evaluation after adrenalectomy for unilateral aldosterone-producing adenoma. Clin Endocrinol (Oxf) 2020; 92:503-508. [PMID: 32068902 DOI: 10.1111/cen.14176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/01/2020] [Accepted: 02/04/2020] [Indexed: 11/27/2022]
Abstract
CONTEXT The oversecretion of plasma aldosterone by unilateral aldosterone-producing adenoma (APA) can be cured by adrenalectomy. However, the time needed for the endocrine environment to normalize remains unclear. OBJECTIVE To clarify adequate timing for a biochemical evaluation in unilateral APA patients after adrenalectomy. DESIGN AND PATIENTS A total of 166 unilateral APA patients were retrospectively reviewed. We evaluated the plasma aldosterone concentration (PAC) (pg/mL), active renin concentration (ARC) (pg/mL), aldosterone-renin ratio (ARR; PAC/ARC), serum potassium concentration and estimated glomerular filtration rate (eGFR) at 1, 3 and 6 postoperation months (POM). RESULTS PAC was significantly lower at 1POM than at presurgery (presurgery; 407.2, 1 POM; 90.0 pg/mL, P < .001). ARC did not increase from baseline at 1POM, but significantly increased at 3POM (presurgery; 4.43, 1POM; 4.87, 3POM; 11.3 pg/mL, P < .001). ARR significantly decreased at 1POM (presurgery; 146.9, 1 POM; 26.3, P < .001) although ARC did not increase at 1POM. Among the 34 patients who had hypokalaemia presurgery, it was resolved in 28 (82%) at 1POM and in all (100%) at 3POM. The biochemical outcomes at 1POM were 131 (79%) complete, 20 (12%) partial and 15 (9%) absent successes, while at 3POM, 147 (89%) were complete, 9 (5%) partial and 10 (6%) absent. Twenty-three (14%) patients were reclassified into different biochemical outcomes between 1 and 3POM, whereas only 5 (3%) changed between 3 and 6POM. CONCLUSION The appropriate timing for a biochemical evaluation of unilateral APA patients treated with laparoscopic adrenalectomy appears to be 3 months or more after surgery.
Collapse
Affiliation(s)
| | - Toshikazu Takeda
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Seiya Hattori
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Nobuyuki Tanaka
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Morita
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | | | - Takeo Kosaka
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Ryuichi Mizuno
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | | | - Eiji Kikuchi
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Asanuma
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Isao Kurihara
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Itoh
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
8
|
Shariq OA, Mehta K, Thompson GB, Lyden ML, Farley DR, Bancos I, Dy BM, Young WF, McKenzie TJ. Primary Aldosteronism: Does Underlying Pathology Impact Clinical Presentation and Outcomes Following Unilateral Adrenalectomy? World J Surg 2019; 43:2469-2476. [PMID: 31214831 DOI: 10.1007/s00268-019-05059-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Patients undergoing unilateral adrenalectomy for primary aldosteronism (PA) may have a solitary adenoma, unilateral hyperplasia, or multiple adenomas on final pathology. This study investigated whether the underlying pathological diagnosis was associated with differences in clinical presentation and postoperative outcomes. METHODS A retrospective cohort study of patients undergoing unilateral adrenalectomy for PA from 2004 to 2015 at our institution was performed. Baseline clinical and laboratory parameters, as well as postoperative biochemical and hypertension cure rates, were compared across the three aforementioned pathological groups. RESULTS Of 206 patients who met criteria for inclusion, 152 (73.8%) had a single adenoma, 33 (16%) had unilateral hyperplasia, and 21 (10.2%) had multiple unilateral adenomas. Patients with unilateral hyperplasia were more likely to be male (81.2% vs 57.9%, P = .03), undergo left-sided adrenalectomy (78.8% vs 47.4%, P < .01), and had a lower median adrenal venous sampling lateralization index (9.8 vs 19.8, P = .04) compared to those with solitary, but not multiple unilateral adenomas. No differences were seen in age, duration of hypertension, preoperative plasma aldosterone levels, plasma renin activities, 24-h urinary aldosterone excretion, serum potassium concentrations, and the number of preoperative antihypertensive medications across all three pathological groups. All patients achieved biochemical cure following adrenalectomy, and no significant differences in the rates of hypertension cure or improvement were observed in comparisons across pathological subtype. CONCLUSIONS Clinical presentation and postoperative outcomes are similar regardless of underlying pathology in patients with PA. Because one in four patients may harbor unilateral hyperplasia or multiple adenomas, total unilateral adrenalectomy should be performed as the operation of choice over adrenal-sparing approaches.
Collapse
Affiliation(s)
- Omair A Shariq
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA.
| | - Kabir Mehta
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Geoffrey B Thompson
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Melanie L Lyden
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - David R Farley
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| |
Collapse
|