1
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Chung SM. Screening and treatment of endocrine hypertension focusing on adrenal gland disorders: a narrative review. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2024; 41:269-278. [PMID: 39295528 DOI: 10.12701/jyms.2024.00752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 09/03/2024] [Indexed: 09/21/2024]
Abstract
Most cases of high blood pressure have no identifiable cause, termed essential hypertension; however, in approximately 15% of cases, hypertension occurs due to secondary causes. Primary aldosteronism (PA) and pheochromocytoma and paraganglioma (PPGL) are representative endocrine hypertensive diseases. The differentiation of endocrine hypertension provides an opportunity to cure and prevent target organ damage. PA is the most common cause of secondary hypertension, which significantly increases the risk of cardiovascular disease compared to essential hypertension; thus, patients with clinical manifestations suggestive of secondary hypertension should be screened for PA. PPGL are rare but can be fatal when misdiagnosed. PPGL are the most common hereditary endocrine tumors; therefore, genetic testing using next-generation sequencing panels is recommended. Herein, we aimed to summarize the characteristic clinical symptoms of PA and PPGL and when and how diagnostic tests and treatment strategies should be performed.
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Affiliation(s)
- Seung Min Chung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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2
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Lu YC, Liu KL, Wu VC, Wang SM, Lin YH, Chueh SCJ, Wu KD, Su YR, Huang KH. Unilateral adrenalectomy in bilateral adrenal hyperplasia with primary aldosteronism. J Formos Med Assoc 2023; 122:393-399. [PMID: 36813699 DOI: 10.1016/j.jfma.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 10/08/2022] [Accepted: 12/22/2022] [Indexed: 02/22/2023] Open
Abstract
PURPOSE Mineralocorticoid receptor antagonists are the first-line treatment for bilateral adrenal hyperplasia (BAH) with primary aldosteronism (PA), while unilateral adrenalectomy is the standard treatment for aldosterone-producing adenoma (APA). In this study, we investigated the outcomes of patients with BAH after unilateral adrenalectomy and compared them with those of patients with APA. METHODS From January 2010 to November 2018, 102 patients with a diagnosis of PA confirmed by adrenal vein sampling (AVS) and available NP-59 scans were enrolled. All patients underwent unilateral adrenalectomy based on the lateralization test results. We prospectively collected the clinical parameters over 12 months and compared the outcomes of BAH and APA. RESULTS A total of 102 patients were enrolled in this study: 20 (19.6%) had BAH and 82 (80.4%) had APA. Significant improvements in serum aldosterone-renin ratio (ARR), potassium level, and reduction of antihypertensive drugs were observed in both groups at 12 months after surgery (all p < 0.05). Patients with APA showed a significant decrease in blood pressure after surgery (p < 0.001) than those with BAH. Additionally, multivariate logistic regression analysis indicated that APA was associated with biochemical success (odds ratio: 4.32, p = 0.024) compared to BAH. CONCLUSION Patients with BAH had a higher failure rate in clinical outcomes, and APA was associated with biochemical success after unilateral adrenalectomy. However, significant improvements in ARR, hypokalemia, and a decreased use of antihypertensive drugs were noted in patients with BAH after surgery. Unilateral adrenalectomy is feasible and beneficial in selected patients, and could potentially serve as a treatment option.
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Affiliation(s)
- Yu-Cheng Lu
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kao-Lang Liu
- Department of Medical Imagine, National Taiwan University Hospital, Taipei, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuo-Meng Wang
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yann-Rong Su
- Department of Urology, National Taiwan University BioMedical Park Hospital, Hsin-Chu, Taiwan
| | - Kuo-How Huang
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan; Department of Urology, National Taiwan University BioMedical Park Hospital, Hsin-Chu, Taiwan.
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- TAIPAI, Taiwan Primary Aldosteronism Investigator
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3
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Liu Y, Zhu B, Zhu L, Zhao L, Ding D, Liu Z, Fan Z, Zhao Q, Zhang Y, Wang J, Gao C. Clinical outcomes of laparoscopic‐based renal denervation plus adrenalectomy vs adrenalectomy alone for treating resistant hypertension caused by unilateral aldosterone‐producing adenoma. J Clin Hypertens (Greenwich) 2020; 22:1606-1615. [PMID: 32812324 DOI: 10.1111/jch.13963] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/22/2020] [Accepted: 04/28/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Yahui Liu
- Department of Cardiology Henan University People's Hospital Henan Provincial People's Hospital Zhengzhou China
- Henan Provincial Key Lab for Control of Coronary Heart Disease Central China Fuwai Hospital Zhengzhou China
| | - Binbin Zhu
- Henan Provincial Key Lab for Control of Coronary Heart Disease Central China Fuwai Hospital Zhengzhou China
- Department of Cardiology Zhengzhou University People's Hospital Henan Provincial People's Hospital Zhengzhou China
| | - Lijie Zhu
- Henan Provincial Key Lab for Control of Coronary Heart Disease Central China Fuwai Hospital Zhengzhou China
- Department of Cardiology Zhengzhou University People's Hospital Henan Provincial People's Hospital Zhengzhou China
| | - Linwei Zhao
- Henan Provincial Key Lab for Control of Coronary Heart Disease Central China Fuwai Hospital Zhengzhou China
- Department of Cardiology Zhengzhou University People's Hospital Henan Provincial People's Hospital Zhengzhou China
| | - Degang Ding
- Department of Urinary Surgery Zhengzhou University People's Hospital Henan Provincial People's Hospital Zhengzhou China
| | - Zhonghua Liu
- Department of Urinary Surgery Zhengzhou University People's Hospital Henan Provincial People's Hospital Zhengzhou China
| | - Zhiqiang Fan
- Department of Urinary Surgery Zhengzhou University People's Hospital Henan Provincial People's Hospital Zhengzhou China
| | - Qiuping Zhao
- Henan Provincial Key Lab for Control of Coronary Heart Disease Central China Fuwai Hospital Zhengzhou China
- Department of Cardiology Zhengzhou University People's Hospital Henan Provincial People's Hospital Zhengzhou China
| | - You Zhang
- Henan Provincial Key Lab for Control of Coronary Heart Disease Central China Fuwai Hospital Zhengzhou China
- Department of Cardiology Zhengzhou University People's Hospital Henan Provincial People's Hospital Zhengzhou China
- Henan Institute of Cardiovascular Epidemiology Zhengzhou University People's Hospital Henan Provincial People's Hospital Zhengzhou China
| | - Jiguang Wang
- Department of Hypertension Shanghai Jiao Tong University Medical School Affiliated Ruijin Hospital The Shanghai Institute of Hypertension Shanghai China
| | - Chuanyu Gao
- Department of Cardiology Henan University People's Hospital Henan Provincial People's Hospital Zhengzhou China
- Henan Provincial Key Lab for Control of Coronary Heart Disease Central China Fuwai Hospital Zhengzhou China
- Department of Cardiology Zhengzhou University People's Hospital Henan Provincial People's Hospital Zhengzhou China
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4
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Thiesmeyer JW, Ullmann TM, Greenberg J, Williams NT, Limberg J, Stefanova D, Beninato T, Finnerty BM, Vignaud T, Leclerc J, Fahey TJ, Mirallie E, Brunaud L, Zarnegar R. Hypertension resolution after adrenalectomy for primary hyperaldosteronism: Which is the best predictive model? Surgery 2020; 169:133-137. [PMID: 32507297 DOI: 10.1016/j.surg.2020.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND We aimed to compare the predictive performance of three distinct clinical models purported to predict the resolution of aldosteronoma-associated hypertension after adrenalectomy. METHODS A tri-institutional database of aldosteronoma patients who underwent adrenalectomy between 2004 and 2019 was retrospectively reviewed. The three models of interest incorporate various preoperative clinical factors, such as age and sex. The predictive accuracy, as measured by area under the curve of receiver operator characteristic, was estimated. Receiver operator characteristic was evaluated across the whole cohort, then stratified by treatment location. RESULTS A total of 200 patients were included (91 American, 109 French). The clinicodemographic variables between groups were similar; the French cohort had a lower mean body mass index (P = .02). The overall complete clinical resolution of hypertension after adrenalectomy for the entire data set was 45.5% (n = 91). The regression coefficients in the Utsumi et al (2014) Japanese model produced a superior overall area under the curve (0.78, 95% confidence interval [CI] [0.71-0.84]). This model also performed best when the cohort was stratified by treatment location (French area under the curve = 0.74, 95% CI [0.64-0.83], US area under the curve = 0.82, 95% CI [0.72-0.91]). CONCLUSION When comparing three predictive models of aldosteronoma-associated hypertension resolution after adrenalectomy, the Utsumi et al model demonstrated the highest predictive validity across all cohorts. Counseling based on this model regarding probability of cure is recommended.
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Affiliation(s)
- Jessica W Thiesmeyer
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Timothy M Ullmann
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Jacques Greenberg
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Nicholas T Williams
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy & Research, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Jessica Limberg
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Dessislava Stefanova
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Toni Beninato
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Timothée Vignaud
- Department of Surgery, Nantes University Hospital, Nantes, France
| | - Julie Leclerc
- Department of Surgery, Nancy University Hospital, Nancy, France
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Eric Mirallie
- Department of Surgery, Nantes University Hospital, Nantes, France
| | - Laurent Brunaud
- Department of Surgery, Nancy University Hospital, Nancy, France
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA.
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5
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Abstract
Primary aldosteronism (PA) is a common cause of secondary hypertension caused by excessive and inappropriate secretion of the hormone aldosterone from one or both adrenal glands. The prevalence of PA ranges from 10% in the general hypertensive population to 20% in resistant hypertension, yet only a small fraction of patients is diagnosed. Disease and symptom recognition, screening in indicated populations, multidisciplinary communication, and appropriate imaging and biochemical workup can identify patients who might benefit from effective and targeted treatment modalities. Effective treatments available include both surgical and medical approaches, usually dependent on the subtype of PA present. Our collective understanding of the pathophysiology of PA is expanded by recent developments in molecular biology and genetics, including understanding the specific somatic and germline mutations involved in pathogenesis. We review the pathophysiology, diagnostic workup, and treatment considerations for this disease process.
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Affiliation(s)
- Sean M Wrenn
- Department of General Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of General Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carrie C Lubitz
- Department of General Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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6
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Hundemer GL, Vaidya A. Primary Aldosteronism Diagnosis and Management: A Clinical Approach. Endocrinol Metab Clin North Am 2019; 48:681-700. [PMID: 31655770 PMCID: PMC6824480 DOI: 10.1016/j.ecl.2019.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Primary aldosteronism used to be considered a rare cause of secondary hypertension. However, accruing evidence indicates that primary aldosteronism is more common than previously recognized. The implications of this increased prevalence are important to public health because autonomous aldosterone production contributes to cardiovascular disease and can be treated in a targeted manner. This article focuses on clinical approaches for diagnosing primary aldosteronism more frequently and earlier in its course, as well as practical treatment objectives to reduce the risk for incident cardiovascular disease.
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Affiliation(s)
- Gregory L Hundemer
- Division of Nephrology, Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Box 511, Ottawa, ON K1H 8L6, Canada
| | - Anand Vaidya
- Center for Adrenal Disorders, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA.
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7
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Long-term blood pressure outcomes of patients with adrenal venous sampling-proven unilateral primary aldosteronism. J Hum Hypertens 2019; 34:440-447. [PMID: 31488861 DOI: 10.1038/s41371-019-0241-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 07/24/2019] [Accepted: 08/09/2019] [Indexed: 11/08/2022]
Abstract
Primary aldosteronism (PA) is mainly treated by mineralocorticoid receptor antagonists or laparoscopic adrenalectomy (LA), but the effectiveness of surgical versus medical treatment in patients with adrenal venous sampling (AVS)-proven unilateral PA is unclear. Fifty-one consecutive patients with AVS-proven PA were enrolled. We compared the therapeutic effects between the surgery group (n = 21) and medication group (n = 30) by evaluating the complete control rate (CCR) of hypertension, blood pressure (BP), and number of antihypertensive drugs after a long-term follow-up (>12 months). The CCR of hypertension was assessed using a multivariate adjusted Cox proportional hazards regression model. After a mean follow-up of 21.18 ± 5.35 months, the CCR was significantly higher in the surgery than medication group (85.7% vs. 13.3%, respectively; p < 0.001). Before adjustment for covariates, the CCR of hypertension in patients who underwent LA was 7.75 times higher than that in patients who underwent medical treatment (95% CI, 2.33-25.78; p = 0.001); significant results were also shown in the adjusted models. Systolic and diastolic BP were also lower in the surgery than medication group (120.3 ± 12.99 vs. 133.54 ± 16.60 and 79.00 ± 7.62 vs. 87.35 ± 12.36 mmHg, respectively; p = 0.01 for both), as was the number of antihypertensive drugs (0.19 ± 0.51 vs. 2.33 ± 0.78, respectively; p < 0.001). The rate of hypokalemia was not significantly different between the two groups (0.0% vs. 13.3%, respectively; p = 0.13). In conclusion, AVS plays an essential role in the subtype diagnosis of PA, and surgical candidates with AVS-proven unilateral PA should be highly suggested to undergo LA.
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8
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Abstract
PURPOSE OF REVIEW Primary aldosteronism (PA) is a common form of hypertension characterized by autonomous aldosterone secretion from one or both adrenal glands. The purpose of this review is to synthesize recent research findings regarding cardiovascular disease risk in PA both pre- and post-targeted therapy. RECENT FINDINGS Previously considered a rare disease, recent prevalence studies demonstrate that PA is actually a very common, yet vastly under-diagnosed, etiology of hypertension. Prior to targeted therapy, PA is associated with substantially higher rates of cardiovascular disease compared with essential hypertension. Surgical adrenalectomy is highly effective in curing or improving hypertension as well as mitigating cardiovascular disease risk in patients with unilateral PA. For the remainder of PA patients, MR antagonists are recommended; however, several recent studies have brought into question their effectiveness in improving cardiovascular outcomes. PA is a common cause of hypertension that leads to disproportionately high rates of cardiovascular disease. Future studies are needed to enhance the clinical approach to both identification and treatment of patients with PA to optimize long-term cardiovascular outcomes.
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Affiliation(s)
- Gregory L Hundemer
- Division of Nephrology, Ottawa Hospital Research Institute, University of Ottawa, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada.
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9
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Abstract
Over six decades since primary aldosteronism was first described, much has been learned about its prevalence and optimal treatment. Estimates of the prevalence of primary aldosteronism have increased considerably over the years, even exceeding 20% in some populations of resistant hypertension. Even in patients with normal blood pressures, the prevalence of overt primary aldosteronism and dysregulated aldosterone production may be more common than appreciated. Emerging data support the concept that primary aldosteronism may be better characterized as a continuum of renin-independent aldosterone production, whose severity influences the clinical presentation and risk for incident cardiovascular disease. Mineralocorticoid receptor antagonists and adrenalectomy are the mainstay treatments for primary aldosteronism and have long been considered equally efficacious. However, recent data suggest that while surgical adrenalectomy can effectively reduce cardiovascular risk, mineralocorticoid receptor antagonist therapy may require a physiologic approach to optimize efficacy.
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10
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Lorenz K, Langer P, Niederle B, Alesina P, Holzer K, Nies C, Musholt T, Goretzki PE, Rayes N, Quinkler M, Waldmann J, Simon D, Trupka A, Ladurner R, Hallfeldt K, Zielke A, Saeger D, Pöppel T, Kukuk G, Hötker A, Schabram P, Schopf S, Dotzenrath C, Riss P, Steinmüller T, Kopp I, Vorländer C, Walz MK, Bartsch DK. Surgical therapy of adrenal tumors: guidelines from the German Association of Endocrine Surgeons (CAEK). Langenbecks Arch Surg 2019; 404:385-401. [PMID: 30937523 DOI: 10.1007/s00423-019-01768-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Previous guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime. METHODS A PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting. RESULTS Overall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided. CONCLUSION Effective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.
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Affiliation(s)
- K Lorenz
- Universitätsklinikum Halle, Halle/Saale, Germany.
| | | | - B Niederle
- Ordination Siebenbrunnenstrasse, Wien, Austria
| | - P Alesina
- Kliniken Essen-Mitte, Essen, Germany
| | - K Holzer
- Universitätsklinikum Marburg, Marburg, Germany
| | - Ch Nies
- Marienhospital Osnabrück, Osnabrück, Germany
| | - Th Musholt
- Universitatsklinikum Mainz, Mainz, Germany
| | - P E Goretzki
- Charité Universitätsmedizin Berlin, Berlin, Germany
| | - N Rayes
- Universitätsklinikum Leipzig, Leipzig, Germany
| | - M Quinkler
- Endokrinologiepraxis Berlin, Berlin, Germany
| | - J Waldmann
- MIVENDO Klinik Hamburg, Hamburg, Germany
| | - D Simon
- Evangelisches Krankenhaus BETHESDA Duisburg, Duisburg, Germany
| | - A Trupka
- Klinikum Starnberg, Klinikum Starnberg, Germany
| | - R Ladurner
- Ludwig-Maximilians-Universität München, München, Germany
| | - K Hallfeldt
- Ludwig-Maximilians-Universität München, München, Germany
| | - A Zielke
- Diakonie-Klinikum Stuttgart, Stuttgart, Germany
| | - D Saeger
- Universitätsklinikum Hamburg, Hamburg, Germany
| | - Th Pöppel
- Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - G Kukuk
- Universitätsklinikum Bonn, Bonn, Germany
| | - A Hötker
- Universitätsklinikum Zürich, Zürich, Switzerland
| | - P Schabram
- RAE Ratacjzak und Partner, Sindelfingen, Germany
| | - S Schopf
- Krankenhaus Agatharied, Hausham, Germany
| | - C Dotzenrath
- HELIOS Universitätsklinikum Wuppertal, Wuppertal, Germany
| | - P Riss
- Medizinische Universität Wien, Wien, Austria
| | - Th Steinmüller
- Deutsches Rotes Kreuz Krankenhaus Berlin, Berlin, Germany
| | - I Kopp
- AWMF, Frankfurt am Main, Germany
| | - C Vorländer
- Bürgerhospital Frankfurt, Frankfurt am Main, Germany
| | - M K Walz
- Kliniken Essen-Mitte, Essen, Germany
| | - D K Bartsch
- Universitätsklinikum Marburg, Marburg, Germany
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11
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Vaidya A, Mulatero P, Baudrand R, Adler GK. The Expanding Spectrum of Primary Aldosteronism: Implications for Diagnosis, Pathogenesis, and Treatment. Endocr Rev 2018; 39:1057-1088. [PMID: 30124805 PMCID: PMC6260247 DOI: 10.1210/er.2018-00139] [Citation(s) in RCA: 162] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 08/10/2018] [Indexed: 12/14/2022]
Abstract
Primary aldosteronism is characterized by aldosterone secretion that is independent of renin and angiotensin II and sodium status. The deleterious effects of primary aldosteronism are mediated by excessive activation of the mineralocorticoid receptor that results in the well-known consequences of volume expansion, hypertension, hypokalemia, and metabolic alkalosis, but it also increases the risk for cardiovascular and kidney disease, as well as death. For decades, the approaches to defining, diagnosing, and treating primary aldosteronism have been relatively constant and generally focused on detecting and treating the more severe presentations of the disease. However, emerging evidence suggests that the prevalence of primary aldosteronism is much greater than previously recognized, and that milder and nonclassical forms of renin-independent aldosterone secretion that impart heightened cardiovascular risk may be common. Public health efforts to prevent aldosterone-mediated end-organ disease will require improved capabilities to diagnose all forms of primary aldosteronism while optimizing the treatment approaches such that the excess risk for cardiovascular and kidney disease is adequately mitigated. In this review, we present a physiologic approach to considering the diagnosis, pathogenesis, and treatment of primary aldosteronism. We review evidence suggesting that primary aldosteronism manifests across a wide spectrum of severity, ranging from mild to overt, that correlates with cardiovascular risk. Furthermore, we review emerging evidence from genetic studies that begin to provide a theoretical explanation for the pathogenesis of primary aldosteronism and a link to its phenotypic severity spectrum and prevalence. Finally, we review human studies that provide insights into the optimal approach toward the treatment of primary aldosteronism.
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Affiliation(s)
- Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Rene Baudrand
- Program for Adrenal Disorders and Hypertension, Department of Endocrinology, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Gail K Adler
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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12
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Wachtel H, Bhandari S, Roses RE, Cohen DL, Trerotola SO, Fraker DL. Primary aldosteronism with nonlocalizing imaging. Surgery 2018; 165:211-218. [PMID: 30413318 DOI: 10.1016/j.surg.2018.04.077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/02/2018] [Accepted: 04/09/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Unilateral primary aldosteronism is surgically curable. The goal of this study was to examine outcomes based on preoperative imaging findings. METHODS We performed a retrospective analysis of patients with primary aldosteronism who underwent adrenal vein sampling. Patients were classified by imaging as localized (unilateral adrenal mass) or nonlocalized (no mass/bilateral masses). Outcomes were assessed as complete, partial, or absent clinical success. RESULTS Of 446 patients, 74.9% were localized. There were no significant demographic or biochemical differences between groups; however the imaged tumor size was larger (median 1.3 vs 1.2 cm, P = .038), and rates of lateralizing adrenal vein sampling were higher (79.0% vs 62.2%, P < .001) in the localized group. Of 289 patients who underwent adrenalectomy, adenoma was the most common finding in both groups (79.7% vs 80.3% respectively, P = .447), but median tumor size was larger in localized patients (1.5 vs 1.0 cm, P < .001). Equivalent rates of partial (94.6% vs 91.7%, P = .456) and complete (8.7% vs 9.8%, P = .801) clinical success were observed. At long-term follow-up, nonlocalized patients experienced partial reversal of clinical improvement. CONCLUSION Primary aldosteronism patients with nonlocalizing imaging but lateralizing adrenal vein sampling benefit from adrenalectomy. Regardless of imaging findings, adrenal vein sampling is indicated to determine whether patients may be surgically curable.
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Affiliation(s)
- Heather Wachtel
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia.
| | - Sonia Bhandari
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Robert E Roses
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Debbie L Cohen
- Department of Medicine, Division of Renal, Electrolyte and Hypertension, Hospital of the University of Pennsylvania, Philadelphia
| | - Scott O Trerotola
- Department of Radiology, Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Douglas L Fraker
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia
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13
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What factors impact the treatment outcomes of laparoscopic adrenalectomy in patients with functioning adrenal gland tumors? INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2018.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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14
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Lee JM, Kim MK, Ko SH, Koh JM, Kim BY, Kim SW, Kim SK, Kim HJ, Ryu OH, Park J, Lim JS, Kim SY, Shong YK, Yoo SJ. Clinical Guidelines for the Management of Adrenal Incidentaloma. Endocrinol Metab (Seoul) 2017; 32:200-218. [PMID: 28685511 PMCID: PMC5503865 DOI: 10.3803/enm.2017.32.2.200] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/09/2017] [Accepted: 06/01/2017] [Indexed: 12/20/2022] Open
Abstract
An adrenal incidentaloma is an adrenal mass found in an imaging study performed for other reasons unrelated to adrenal disease and often accompanied by obesity, diabetes, or hypertension. The prevalence and incidence of adrenal incidentaloma increase with age and are also expected to rise due to the rapid development of imaging technology and frequent imaging studies. The Korean Endocrine Society is promoting an appropriate practice guideline to meet the rising incidence of adrenal incidentaloma, in cooperation with the Korean Adrenal Gland and Endocrine Hypertension Study Group. In this paper, we discuss important core issues in managing the patients with adrenal incidentaloma. After evaluating core proposition, we propose the most critical 20 recommendations from the initially organized 47 recommendations by Delphi technique.
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Affiliation(s)
- Jung Min Lee
- Department of Internal Medicine, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mee Kyoung Kim
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Hyun Ko
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jung Min Koh
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bo Yeon Kim
- Department of Internal Medicine, Soon Chun Hyang University Bucheon Hospital, Soon Chun Hyang University College of Medicine, Bucheon, Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Soo Kyung Kim
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Hae Jin Kim
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Ohk Hyun Ryu
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Juri Park
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jung Soo Lim
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seong Yeon Kim
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Young Kee Shong
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Soon Jib Yoo
- Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea.
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Funder JW, Carey RM, Mantero F, Murad MH, Reincke M, Shibata H, Stowasser M, Young WF. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101:1889-916. [PMID: 26934393 DOI: 10.1210/jc.2015-4061] [Citation(s) in RCA: 1654] [Impact Index Per Article: 206.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop clinical practice guidelines for the management of patients with primary aldosteronism. PARTICIPANTS The Task Force included a chair, selected by the Clinical Guidelines Subcommittee of the Endocrine Society, six additional experts, a methodologist, and a medical writer. The guideline was cosponsored by American Heart Association, American Association of Endocrine Surgeons, European Society of Endocrinology, European Society of Hypertension, International Association of Endocrine Surgeons, International Society of Endocrinology, International Society of Hypertension, Japan Endocrine Society, and The Japanese Society of Hypertension. The Task Force received no corporate funding or remuneration. EVIDENCE We searched for systematic reviews and primary studies to formulate the key treatment and prevention recommendations. We used the Grading of Recommendations, Assessment, Development, and Evaluation group criteria to describe both the quality of evidence and the strength of recommendations. We used "recommend" for strong recommendations and "suggest" for weak recommendations. CONSENSUS PROCESS We achieved consensus by collecting the best available evidence and conducting one group meeting, several conference calls, and multiple e-mail communications. With the help of a medical writer, the Endocrine Society's Clinical Guidelines Subcommittee, Clinical Affairs Core Committee, and Council successfully reviewed the drafts prepared by the Task Force. We placed the version approved by the Clinical Guidelines Subcommittee and Clinical Affairs Core Committee on the Endocrine Society's website for comments by members. At each stage of review, the Task Force received written comments and incorporated necessary changes. CONCLUSIONS For high-risk groups of hypertensive patients and those with hypokalemia, we recommend case detection of primary aldosteronism by determining the aldosterone-renin ratio under standard conditions and recommend that a commonly used confirmatory test should confirm/exclude the condition. We recommend that all patients with primary aldosteronism undergo adrenal computed tomography as the initial study in subtype testing and to exclude adrenocortical carcinoma. We recommend that an experienced radiologist should establish/exclude unilateral primary aldosteronism using bilateral adrenal venous sampling, and if confirmed, this should optimally be treated by laparoscopic adrenalectomy. We recommend that patients with bilateral adrenal hyperplasia or those unsuitable for surgery should be treated primarily with a mineralocorticoid receptor antagonist.
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Affiliation(s)
- John W Funder
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Robert M Carey
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Franco Mantero
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - M Hassan Murad
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Martin Reincke
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Hirotaka Shibata
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Michael Stowasser
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - William F Young
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
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Rossi GP, Auchus RJ, Brown M, Lenders JWM, Naruse M, Plouin PF, Satoh F, Young WF. An expert consensus statement on use of adrenal vein sampling for the subtyping of primary aldosteronism. Hypertension 2013; 63:151-60. [PMID: 24218436 DOI: 10.1161/hypertensionaha.113.02097] [Citation(s) in RCA: 401] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Adrenal venous sampling is recommended by current guidelines to identify surgically curable causes of hyperaldosteronism but remains markedly underused. Key factors contributing to the poor use of adrenal venous sampling include the prevailing perceptions that it is a technically challenging procedure, difficult to interpret, and can be complicated by adrenal vein rupture. In addition, the lack of uniformly accepted standards for the performance of adrenal venous sampling contributes to its limited use. Hence, an international panel of experts working at major referral centers was assembled to provide updated advice on how to perform and interpret adrenal venous sampling. To this end, they were asked to use the PICO (Patient or Problem, Intervention, Control or comparison, Outcome) strategy to gather relevant information from the literature and to rely on their own experience. The level of evidence/recommendation was provided according to American Heart Association gradings whenever possible. A consensus was reached on several key issues, including the selection and preparation of the patients for adrenal venous sampling, the procedure for its optimal performance, and the interpretation of its results for diagnostic purposes even in the most challenging cases.
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Affiliation(s)
- Gian Paolo Rossi
- Department of Medicine-DIMED-Internal Medicine 4, University Hospital, Via Giustiniani, 2, 35126 Padova, Italy.
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Ip JCY, Lee JC, Sidhu SB. Laparoscopic Adrenalectomy: The Transperitoneal Approach. CURRENT SURGERY REPORTS 2012. [DOI: 10.1007/s40137-012-0002-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Bickenbach KA, Strong VE. Laparoscopic transabdominal lateral adrenalectomy. J Surg Oncol 2012; 106:611-8. [PMID: 22933307 DOI: 10.1002/jso.23250] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 08/07/2012] [Indexed: 01/11/2023]
Abstract
Laparoscopic adrenalectomy is a mainstay of operative options for adrenal tumors and allows surgeons to perform adrenalectomies with less morbidity, less post-operative pain, and shorter hospital stays. The literature has demonstrated its efficacy to be equal to open adrenalectomy in most cases. With regard to malignant primary and metastatic lesions, controversy still remains, however, consideration of a laparoscopic approach for smaller, well circumscribed and non-invasive lesions is reasonable. During any laparoscopic resection, when there is doubt about the ability to safely remove the lesion with an intact capsule, conversion to an open approach should be considered. The primary goal of a safe and complete oncologic resection cannot be compromised. For most benign lesions, laparoscopic approaches are safe and feasible and conversion to an open approach is necessary only for lesions where size limits the ability of a minimally invasive resection.
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Affiliation(s)
- Kai A Bickenbach
- Department of Surgery, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA
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Douma S, Petidis K, Kamparoudis A, Gkaliagkousi E, Anyfanti P, Doumas M, Triantafyllou A, Lazaridis N, Gerasimidis T, Zamboulis C. Surgical Management of Primary Aldosteronism. Not Everything that Shines is Gold. Clin Exp Hypertens 2011; 34:53-6. [DOI: 10.3109/10641963.2011.618204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Sitkin II, Fadeev VV, Bel'tsevich DG, Rogal' EI, Molashenko NV, Kolesnikova GS. Differential diagnostics of primary hyperaldosteronism: The role and significance of comparative selective blood sampling from adrenal veins. ACTA ACUST UNITED AC 2011. [DOI: 10.14341/probl201157252-56] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Primary hyperaldosteronism is known to be one of the commonnest causes of arterial hypertension. The authors propose a diagnostic protocol for primary hyperaldosteronism and a method for comparative selective blood sampling from adrenal veins. This method is described as the sole tool for differential diagnostics of different nosological forms of primary hyperaldosteronism. A clinical case of idiopathic hyperaldosteronism is presented.
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Abstract
Primary aldosteronism (PA) is an important cause of secondary hypertension, is being increasingly diagnosed and may account for more than 10% of hypertensive patients, both in primary care and in referral centers. Aldosterone excess is associated with adverse cardiovascular, renal and metabolic effects that are in part hypertension-independent. Laparoscopic adrenalectomy remains the mainstay of treatment for unilateral forms of PA, whereas medical treatment is recommended for bilateral forms of PA. However, a favourable surgical outcome depends on several factors and many patients are not suitable for this treatment. On the other hand, surgery in patients considered to have bilateral PA may contribute to better blood pressure control. In this review, established and novel strategies for the management of different types of PA are discussed.
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Affiliation(s)
- Asterios Karagiannis
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, 44, Tsimiski str., Thessaloniki, 54623, Greece.
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Abstract
The prevalence of primary hyperaldosteronism approaches 10% of all hypertensive patients, and besides efficient diagnostic procedures, effective treatment is of increasing importance to reverse increased morbidity and mortality. Aldosterone-producing adenoma and unilateral adrenal hyperplasia are amenable to cure by endoscopic adrenalectomy. Bilateral adrenal hyperplasia (micro- or macronodular), which comprises two-thirds of primary hyperaldosteronism, is treated primarily by mineralocorticoid receptor antagonists (starting dose 12.5-25mg/day spironolactone with titration up to 100mg/day, alternatively 50-100mg/day eplerenone). If blood pressure is not normalised by this first-line treatment, additional treatment with potassium-sparing diuretics (amiloride or triamterene) or calcium channel antagonists is necessary. The start of medication should be closely monitored by serum electrolyte and creatinine controls.
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Affiliation(s)
- Marcus Quinkler
- Clinical Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Charitéplatz 1, D 10117 Berlin, Germany.
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Wang B, Zhang G, Ouyang J, Deng X, Shi T, Ma X, Li H, Ju Z, Wang C, Wu Z, Liu S, Zhang X. Association of DNA polymorphisms within the CYP11B2/CYP11B1 locus and postoperative hypertension risk in the patients with aldosterone-producing adenomas. Urology 2010; 76:1018.e1-7. [PMID: 20708777 DOI: 10.1016/j.urology.2010.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Revised: 02/03/2010] [Accepted: 03/01/2010] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Hypertension often persists after adrenalectomy for primary aldosteronism. Traditional factors associated with postoperative hypertension were evaluated, but whether genetic determinants were involved remains poorly understood. The aim of this study was to investigate the association of DNA polymorphisms within steroid synthesis genes (CYP11B2, CYP11B1) and the postoperative resolution of hypertension in Chinese patients undergoing adrenalectomy for aldosterone-producing adenomas (APA). METHODS Ninety-three patients with APA were assessed for postoperative resolution of hypertension. All patients were genotyped for rs1799998 (C-344 T), intron 2 conversion, rs4539 (A2718G) within CYP11B2 and rs6410 (G22 5A), rs6387 (A2803G) within CYP11B1. The associations between CYPB11B2/CYP11B1 polymorphisms and persistent postoperative hypertension were assessed by multivariate analysis. RESULTS CYP11B2-CYP11B1 haplotype was associated with persistent postoperative hypertension in Chinese patients undergoing adrenalectomy with APA (P = .006). Specifically, the rs4539 (AA) polymorphism was associated with persistent postoperative hypertension (P = .002). Multivariate logistic regression revealed the common haplotypes H1 (AGACT), H2 (AGAWT), and H3 (AGAWC) were associated with the persistent postoperative hypertension (P = .01, 0.03, 0.005 after Bonferroni correction). Additional predictors of persistent postoperative hypertension included duration of hypertension (P <.0005), family history of hypertension (P = .001), and elevated systolic blood pressure (P = .015). CONCLUSIONS The rs4539 (AA), H1, H2, and H3 are genetic predictors for postoperative persistence of hypertension for Chinese patients treated by adrenalectomy with APA. DNA polymorphisms at CYP11B2/B1 locus may confer susceptibility to postoperative hypertension of patients with APA.
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Affiliation(s)
- Baojun Wang
- Department of Urology, China PLA General Hospital, Beijing, People's Republic of China
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Diagnosis and surgical management for primary hyperaldosteronism. Curr Urol Rep 2010; 11:51-7. [PMID: 20425638 DOI: 10.1007/s11934-009-0081-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The evaluation of primary hyperaldosteronism presents a challenge to endocrinologists, radiologists, and urologic surgeons. A multidisciplinary approach with biochemical screening and radiologic evaluation is essential in order to assess the nature and function of hypersecreting adrenal glands. Furthermore, it is of great importance to identify individuals that are morbidly affected by aldosterone hypersecretion. Traditionally, open adrenalectomy was the preferred option for these patients. More recently, laparoscopic adrenalectomy has offered a minimally invasive approach, with its resultant advantages of improved perioperative parameters. Herein we describe the evaluation and surgical management for patients with a suspected diagnosis of primary hyperaldosteronism.
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Abstract
It is now widely recognized that primary aldosteronism (PA) is much more common than previously thought, accounting for up to 5-10% of hypertensives, and that aldosterone excess has adverse cardiovascular consequences that go above and beyond hypertension development. These findings have precipitated a marked resurgence of research activity, most of which has supported the concept that PA plays an important role in cardiovascular disease states and should be systematically sought and specifically treated, and the development of an Endocrine Society clinical guideline for the case detection, diagnosis, and management of this common, specifically treatable, and potentially curable condition. Areas of recent, topical research include: 1) the demonstration of excess morbidity in patients with PA compared with other forms of hypertension, confirming the clinical relevance of non-blood pressure-dependent adverse effects of aldosterone excess; 2) the further demonstration that this excess morbidity and mortality are ameliorated with specific (but not nonspecific antihypertensive) therapy directed against aldosterone excess, confirming the importance of detection and diagnosis of PA to enable optimal specific management; 3) the development of new treatment strategies; 4) an ongoing appraisal and refinement of diagnostic approaches including screening, subtype differentiation, and new assay development; and 5) further insights into the importance and nature of genetic factors related to the development of PA.
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Affiliation(s)
- Michael Stowasser
- Hypertension Unit, University of Queensland School of Medicine, Princess Alexandra Hospital, Woolloongabba Brisbane 4102, Australia.
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Sukor N, Gordon RD, Ku YK, Jones M, Stowasser M. Role of unilateral adrenalectomy in bilateral primary aldosteronism: a 22-year single center experience. J Clin Endocrinol Metab 2009; 94:2437-45. [PMID: 19401369 DOI: 10.1210/jc.2008-2803] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The aim of the study was to examine blood pressure and biochemical responses to unilateral adrenalectomy in patients with bilateral primary aldosteronism (PA) and identify predictive parameters. CONTEXT PA considered due to bilateral autonomous production of aldosterone is usually treated medically. Unilateral adrenalectomy has been considered ineffective. Because quality outcome data are lacking and medical treatment may cause adverse effects or fail to control hypertension, defining the role for unilateral adrenalectomy in bilateral PA is an important clinical issue. DESIGN AND SETTING Between 1984 and 2004, 51 of 684 patients diagnosed with bilateral PA underwent unilateral adrenalectomy. This report is based on the records of the 40 considered suitable for inclusion, who were followed for at least 12 (median, 56.4) months. RESULTS Hypertension was cured in 15% of patients and improved in 20%, usually within 1 yr of unilateral adrenalectomy. The proportion with controlled hypertension was significantly (P < 0.001) higher after adrenalectomy (65%) than before (25%). Mean systolic (P < 0.001) and diastolic (P < 0.001) blood pressure, left ventricular mass index (P < 0.05), plasma upright aldosterone (P < 0.05), and aldosterone/renin ratio (P < 0.001) fell. Serum creatinine independently predicted hypertension cure. CONCLUSION Although this retrospective analysis of patients from a single center does not permit prediction of response rates among patients diagnosed elsewhere, it suggests that unilateral adrenalectomy can be beneficial in some patients with apparent bilateral PA and should not be dismissed as a treatment option.
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Affiliation(s)
- Norlela Sukor
- Endocrine Hypertension Research Center, University of Queensland School of Medicine, Greenslopes and Princess Alexandra Hospitals, Australia
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27
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Funder JW, Carey RM, Fardella C, Gomez-Sanchez CE, Mantero F, Stowasser M, Young WF, Montori VM. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2008; 93:3266-81. [PMID: 18552288 DOI: 10.1210/jc.2008-0104] [Citation(s) in RCA: 1034] [Impact Index Per Article: 64.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Our objective was to develop clinical practice guidelines for the diagnosis and treatment of patients with primary aldosteronism. PARTICIPANTS The Task Force comprised a chair, selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society, six additional experts, one methodologist, and a medical writer. The Task Force received no corporate funding or remuneration. EVIDENCE Systematic reviews of available evidence were used to formulate the key treatment and prevention recommendations. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) group criteria to describe both the quality of evidence and the strength of recommendations. We used "recommend" for strong recommendations and "suggest" for weak recommendations. CONSENSUS PROCESS Consensus was guided by systematic reviews of evidence and discussions during one group meeting, several conference calls, and multiple e-mail communications. The drafts prepared by the task force with the help of a medical writer were reviewed successively by The Endocrine Society's CGS, Clinical Affairs Core Committee (CACC), and Council. The version approved by the CGS and CACC was placed on The Endocrine Society's Web site for comments by members. At each stage of review, the Task Force received written comments and incorporated needed changes. CONCLUSIONS We recommend case detection of primary aldosteronism be sought in higher risk groups of hypertensive patients and those with hypokalemia by determining the aldosterone-renin ratio under standard conditions and that the condition be confirmed/excluded by one of four commonly used confirmatory tests. We recommend that all patients with primary aldosteronism undergo adrenal computed tomography as the initial study in subtype testing and to exclude adrenocortical carcinoma. We recommend the presence of a unilateral form of primary aldosteronism should be established/excluded by bilateral adrenal venous sampling by an experienced radiologist and, where present, optimally treated by laparoscopic adrenalectomy. We recommend that patients with bilateral adrenal hyperplasia, or those unsuitable for surgery, optimally be treated medically by mineralocorticoid receptor antagonists.
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Affiliation(s)
- John W Funder
- Prince Henry's Institute of Medical Research, Clayton, VIC, Australia
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Adrenal vein sampling may not be a gold-standard diagnostic test in primary aldosteronism: final diagnosis depends upon which interpretation rule is used. Int Urol Nephrol 2008; 40:1035-43. [DOI: 10.1007/s11255-008-9441-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Accepted: 07/09/2008] [Indexed: 10/21/2022]
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Rossi GP, Bolognesi M, Rizzoni D, Seccia TM, Piva A, Porteri E, Tiberio GA, Giulini SM, Agabiti-Rosei E, Pessina AC. Vascular Remodeling and Duration of Hypertension Predict Outcome of Adrenalectomy in Primary Aldosteronism Patients. Hypertension 2008; 51:1366-71. [DOI: 10.1161/hypertensionaha.108.111369] [Citation(s) in RCA: 150] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gian Paolo Rossi
- From the Department of Clinical and Experimental Medicine, University Hospital (G.P.R., M.B., T.M.S., A.P., A.C.P.) and Clinica Medica 4, University Hospital (G.P.R., A.C.P.), University of Padova Medical School, Padova, Italy; and the Clinica Medica (D.R., E.P., E.A-R.) and Clinica Chirurgica, Department of Medical and Surgical Sciences (G.A.M.T., S.M.G.), University of Brescia, Brescia, Italy
| | - Massimo Bolognesi
- From the Department of Clinical and Experimental Medicine, University Hospital (G.P.R., M.B., T.M.S., A.P., A.C.P.) and Clinica Medica 4, University Hospital (G.P.R., A.C.P.), University of Padova Medical School, Padova, Italy; and the Clinica Medica (D.R., E.P., E.A-R.) and Clinica Chirurgica, Department of Medical and Surgical Sciences (G.A.M.T., S.M.G.), University of Brescia, Brescia, Italy
| | - Damiano Rizzoni
- From the Department of Clinical and Experimental Medicine, University Hospital (G.P.R., M.B., T.M.S., A.P., A.C.P.) and Clinica Medica 4, University Hospital (G.P.R., A.C.P.), University of Padova Medical School, Padova, Italy; and the Clinica Medica (D.R., E.P., E.A-R.) and Clinica Chirurgica, Department of Medical and Surgical Sciences (G.A.M.T., S.M.G.), University of Brescia, Brescia, Italy
| | - Teresa M. Seccia
- From the Department of Clinical and Experimental Medicine, University Hospital (G.P.R., M.B., T.M.S., A.P., A.C.P.) and Clinica Medica 4, University Hospital (G.P.R., A.C.P.), University of Padova Medical School, Padova, Italy; and the Clinica Medica (D.R., E.P., E.A-R.) and Clinica Chirurgica, Department of Medical and Surgical Sciences (G.A.M.T., S.M.G.), University of Brescia, Brescia, Italy
| | - Anna Piva
- From the Department of Clinical and Experimental Medicine, University Hospital (G.P.R., M.B., T.M.S., A.P., A.C.P.) and Clinica Medica 4, University Hospital (G.P.R., A.C.P.), University of Padova Medical School, Padova, Italy; and the Clinica Medica (D.R., E.P., E.A-R.) and Clinica Chirurgica, Department of Medical and Surgical Sciences (G.A.M.T., S.M.G.), University of Brescia, Brescia, Italy
| | - Enzo Porteri
- From the Department of Clinical and Experimental Medicine, University Hospital (G.P.R., M.B., T.M.S., A.P., A.C.P.) and Clinica Medica 4, University Hospital (G.P.R., A.C.P.), University of Padova Medical School, Padova, Italy; and the Clinica Medica (D.R., E.P., E.A-R.) and Clinica Chirurgica, Department of Medical and Surgical Sciences (G.A.M.T., S.M.G.), University of Brescia, Brescia, Italy
| | - Guido A.M. Tiberio
- From the Department of Clinical and Experimental Medicine, University Hospital (G.P.R., M.B., T.M.S., A.P., A.C.P.) and Clinica Medica 4, University Hospital (G.P.R., A.C.P.), University of Padova Medical School, Padova, Italy; and the Clinica Medica (D.R., E.P., E.A-R.) and Clinica Chirurgica, Department of Medical and Surgical Sciences (G.A.M.T., S.M.G.), University of Brescia, Brescia, Italy
| | - Stefano M. Giulini
- From the Department of Clinical and Experimental Medicine, University Hospital (G.P.R., M.B., T.M.S., A.P., A.C.P.) and Clinica Medica 4, University Hospital (G.P.R., A.C.P.), University of Padova Medical School, Padova, Italy; and the Clinica Medica (D.R., E.P., E.A-R.) and Clinica Chirurgica, Department of Medical and Surgical Sciences (G.A.M.T., S.M.G.), University of Brescia, Brescia, Italy
| | - Enrico Agabiti-Rosei
- From the Department of Clinical and Experimental Medicine, University Hospital (G.P.R., M.B., T.M.S., A.P., A.C.P.) and Clinica Medica 4, University Hospital (G.P.R., A.C.P.), University of Padova Medical School, Padova, Italy; and the Clinica Medica (D.R., E.P., E.A-R.) and Clinica Chirurgica, Department of Medical and Surgical Sciences (G.A.M.T., S.M.G.), University of Brescia, Brescia, Italy
| | - Achille C. Pessina
- From the Department of Clinical and Experimental Medicine, University Hospital (G.P.R., M.B., T.M.S., A.P., A.C.P.) and Clinica Medica 4, University Hospital (G.P.R., A.C.P.), University of Padova Medical School, Padova, Italy; and the Clinica Medica (D.R., E.P., E.A-R.) and Clinica Chirurgica, Department of Medical and Surgical Sciences (G.A.M.T., S.M.G.), University of Brescia, Brescia, Italy
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Posterior Retroperitoneoscopic Adrenalectomy - Clnical Evaluation of the Method Based on the Four-Year Experience. POLISH JOURNAL OF SURGERY 2008. [DOI: 10.2478/v10035-008-0065-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Pang TC, Bambach C, Monaghan JC, Sidhu SB, Bune A, Delbridge LW, Sywak MS. Outcomes of laparoscopic adrenalectomy for hyperaldosteronism. ANZ J Surg 2007; 77:768-73. [PMID: 17685956 DOI: 10.1111/j.1445-2197.2007.04225.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Primary hyperaldosteronism is a frequent cause of resistant hypertension and is amenable to surgical intervention when caused by a unilateral aldosterone-producing adenoma. The aim of this study was to investigate the long-term results of laparoscopic adrenalectomy in the control of hypertension caused by primary hyperaldosteronism. METHODS A prospective case series of patients undergoing laparoscopic adrenalectomy for hyperaldosteronism was studied. Blood pressure (BP), serum aldosterone levels, plasma renin activity, serum potassium and antihypertensive requirement were measured before and after adrenalectomy. RESULTS Sixty-two patients with hyperaldosteronism underwent laparoscopic adrenalectomy in the period from December 1995 to August 2005. The median follow up was 59 months. There was a significant decrease in both systolic blood pressure and diastolic blood pressure at final follow up compared with that before operation. Systolic blood pressure decreased from 149 mmHg to 129 mmHg at final follow up (P < 0.0001). Diastolic blood pressure decreased from 89 mmHg to 80 mmHg (P < 0.0001). Antihypertensive requirement was decreased from an average of 2.6 separate medications preoperatively to 1.4 medications at final follow up (P < 0.0001). Serum aldosterone levels were significantly lower (698 (confidence interval 534-862) pg/mL vs 181 (confidence interval 139-225) pg/mL, P < 0.0001). Overall, 34% of patients had cure of hypertension and did not require any antihypertensive agent. A further 51% had improvement in BP control, whereas 5% had no change or had worsening hypertension. Multivariate regression analysis showed that age and gland size were independent factors predicting sustained hypertension after surgery. CONCLUSION In appropriately selected patients with primary hyperaldosteronism, laparoscopic adrenalectomy is effective in improving long-term BP control. Larger adrenal gland size and older age at time of surgery are predictors of persisting hypertension.
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Affiliation(s)
- Tony C Pang
- Department of Surgery, University of Sydney Endocrine Surgical Unit, Sydney, Australia
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Patel SM, Lingam RK, Beaconsfield TI, Tran TL, Brown B. Role of radiology in the management of primary aldosteronism. Radiographics 2007; 27:1145-57. [PMID: 17620472 DOI: 10.1148/rg.274065150] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The diagnosis of primary aldosteronism, the most common form of secondary hypertension, is based on clinical and biochemical features. Although radiology plays no role in the initial diagnosis, it has an important role in differentiating between the two main causes of primary aldosteronism: aldosterone-producing adenoma (APA) and bilateral adrenal hyperplasia (BAH). This distinction is important because APAs are generally managed surgically and BAH medically. Adrenal venous sampling is considered the standard of reference for determining the cause of primary aldosteronism but is technically demanding, operator dependent, costly, and time consuming, with a low but significant complication rate. Other imaging modalities, including computed tomography, magnetic resonance imaging, and adrenal scintigraphy, have also been used to determine the cause of primary aldosteronism. Cross-sectional imaging has traditionally focused on establishing the diagnosis of an APA, with that of BAH being one of exclusion. A high specificity for detecting an APA is desirable, since it will avert unnecessary surgery in patients with BAH. However, an overreliance on cross-sectional imaging can lead to the incorrect treatment of affected patients, mainly due to the wide variation in the reported diagnostic performance of these modalities. A combination of modalities is usually required to confidently determine the cause of primary aldosteronism. The quest for optimal radiologic management of primary aldosteronism continues just over a half century since this disease entity was first described.
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Affiliation(s)
- Shilpan M Patel
- Department of Radiology, Central Middlesex and Northwick Park Hospitals, North West London Hospitals Trust, Watford Rd, Harrow HA1 3UJ, England
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Ku JH, Yeo WG, Kwon TG, Kim HH. Laparoscopic adrenalectomy for functioning and non-functioning adrenal tumors: analysis of surgical aspects based on histological types. Int J Urol 2006; 12:1015-21. [PMID: 16409602 DOI: 10.1111/j.1442-2042.2005.01203.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The aim of this study was to evaluate whether hormonal functions of the tumor influence the operative results of laparoscopic adrenalectomy, and to analyse the clinical outcomes in patients with various hormonally active adrenal tumors. METHODS Clinical and pathological records of 68 patients were reviewed. The average age of patients was 40 years (range 20-75); 39 were women and 29 men. For the comparison, patients were divided into the non-functioning tumor group (n = 22) and the functioning tumor group (n = 46). RESULTS All laparoscopic adrenalectomies were finished successfully, and no open surgery was necessary. The median operative time and blood loss in the two groups were similar; however, in subgroup analysis, operative time for pheochromocytoma was significantly longer than that for non-functioning tumor (P = 0.044). No difference was noted in intra- and postoperative data between the groups. Of the 22 patients with aldosteronoma, 18 (81.8%) became normotensive and no longer required postoperative blood pressure medications. Adrenalectomy led to an overall reduction in the median number of antihypertensive medications (P < 0.001). All patients with Cushing adenoma had resolution or improvement of the signs and symptoms during follow-up periods. There was no evidence of biochemical or clinical recurrence in any patient with pheochromocytoma. CONCLUSION The results of this retrospective review document that laparoscopic adrenalectomy is a safe and effective treatment for functioning as well as non-functioning adrenal tumors, although endocrinologic features may play a significant role.
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Affiliation(s)
- Ja H Ku
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
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Abstract
Aldosterone is increasingly considered to have a fundamental role in the pathophysiology of cardiovascular disease. Primary aldosteronism is a much more common cause of secondary hypertension than once suspected, accounting for approximately 10% of cases. Screening for primary aldosteronism should be considered even in the presence of normokalaemia. The non-classical effects of aldosterone, some of which are transcription-independent, may be of similar or greater importance than its traditional effects on the kidney. Treatment of primary aldosteronism should be specific and aim to ameliorate all hormone-related effects of aldosterone, not just the most obvious manifestation of hypertension. Mineralocorticoid antagonism, shown to lead to significant additional survival advantage in heart failure, offers the best prospect for achieving therapeutic goals. For the increasing proportion of patients with primary aldosteronism suitable for long-term medical treatment, mineralocorticoid receptor blockade (better tolerated with eplerenone) should be considered the most appropriate choice of treatment, pending the development of better alternatives.
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Affiliation(s)
- Salim Janmohamed
- Department of Endocrinology, Royal Free Hospital, London, NW3 2QG, UK
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Toniato A, Bernante P, Rossi GP, Pelizzo MR. The Role of Adrenal Venous Sampling in the Surgical Management of Primary Aldosteronism. World J Surg 2006; 30:624-7. [PMID: 16568223 DOI: 10.1007/s00268-005-0482-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Primary aldosteronism is the most common endocrine form of secondary hypertension, but no single test or imaging method always identifies it. Identification of a unilateral overproduction of aldosterone due to Conn's adenoma or unilateral hyperplasia is of utmost importance to the surgeon. MATERIALS AND METHODS We reviewed our experience with primary aldosteronism in 46 consecutive patients who had undergone adrenalectomy at the Surgical Pathology Institute, University of Padua since 1993. All the patients underwent a CT scan. Adrenal venous sampling was performed in those patients with negative or equivocal findings on imaging studies. RESULTS Computed tomography was non-contributory in 12 patients and frankly misleading in 2 patients, demonstrating a probable mass lesion in the contralateral but not in the ipsilateral adrenal. Eighteen patients had selective venous sampling that was successful in altering the management of 14 cases. Eleven patients who biochemically had an adrenal adenoma, had normal/equivocal CT, while the remaining 3 had bilateral or contralateral adrenal masses. Venous sampling localized aldosterone secretion and an adenoma, less than 1 cm in diameter, was removed, curing their hypertension. Eleven patients were treated by open adrenalectomy and 35 by the lateral transperitoneal laparoscopic approach. Histological examination revealed 45 Conn's adenomas, of which 13 had a diameter of less than 1 cm (range 0.3-0.8), and 1 case of nodular hyperplasia. CONCLUSIONS Patients who have equivocal or unexpected CT findings should proceed to hormonal localization. Adrenal venous sampling is essential in patients with equivocal CT scans to avoid unnecessary and inappropriate adrenalectomy.
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Affiliation(s)
- Antonio Toniato
- Department of Medical Surgical Sciences, School of Medicine, University of Padua, Padua 35128, Italy.
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Lumachi F, Ermani M, Basso SM, Armanini D, Iacobone M, Favia G. Long-Term Results of Adrenalectomy in Patients with Aldosterone-Producing Adenomas: Multivariate Analysis of Factors Affecting Unresolved Hypertension and Review of the Literature. Am Surg 2005. [DOI: 10.1177/000313480507101015] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The long-term surgical cure rate of patients with primary aldosteronism varies widely, and causes of persistent hypertension are not completely established. We reviewed retrospectively charts from 98 patients (range, 19–70 years old) with aldosterone-producing adenomas who underwent unilateral adrenalectomy. At a median follow-up of 81 months (range, 18–186 months), the mean blood pressure values improved in 95 out of 98 (96.9%) patients, although hypertension was cured only in 71 out of 98 (72.4%) patients. Multivariate analysis using a logistic regression model adjusted for duration of follow-up showed that only age of the patients and duration of the disease independently correlated with unresolved hypertension. The cumulative odds ratio (OR), obtained using the logistic regression function, was 5.38 (95% CI 1.78–16.22), and the OR of single variables were 1.32 (95% CI 0.36–19.83) and 4.56 (95% CI 1.41–14.78), respectively. By using discriminant analysis to derive a classification function for the prediction of unresolved hypertension, a maximum predictive power of 75 per cent was achieved. In conclusion, in patients with an aldosterone-producing adenoma undergoing surgery, the combination of age and duration of hypertension gave the best predictive power of a linear classification function and represented the main independent risk factors affecting hypertension cure rate.
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Affiliation(s)
- Franco Lumachi
- Endocrine Surgery Unit, Department of Surgical & Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy
| | - Mario Ermani
- Biostatistics Section, Department of Neurosciences, University of Padua, School of Medicine, Padova, Italy
| | - Stefano M.M. Basso
- Endocrine Surgery Unit, Department of Surgical & Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy
| | - Decio Armanini
- Division of Endocrinology, Department of Medical and Surgical Sciences, University of Padua, School of Medicine, Padova, Italy
| | - Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgical & Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy
| | - Gennaro Favia
- Endocrine Surgery Unit, Department of Surgical & Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy
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Dosseh DE, Carnaille BM. [Anatomical substratum of primary hyperaldosteronism: from the difficulties of the diagnosis to the surgical management]. ANNALES DE CHIRURGIE 2005; 130:430-2. [PMID: 15979048 DOI: 10.1016/j.anchir.2005.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Affiliation(s)
- D E Dosseh
- Service de chirurgie générale et endocrinienne, hôpital Claude-Huriez, CHU, 59037 Lille cedex, France
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Abstract
The objective of this study was to assess the long-term effects of adrenalectomy on the blood pressure and antihypertensive medication in patients with primary aldosteronism (PA). Twenty-four patients (15 female and 9 male) with a mean age of 48.3 +/- 10.8 years underwent surgery for PA in our institution between 1988 and 2001. All subjects were re-examined with a complete clinical work-up after a mean follow-up period of 86 +/- 48 months, including blood pressure readings (<140/90 mmHg defined as normal), endocrine adrenal function, and specific medication. All patients suffered from hypertension (onset 8.5 +/- 5.5 years prior to surgery). In 92% of the patients, hypokalemia was present (onset 2.0 +/- 2.6 years prior to surgery). The histopathologic examinations revealed unilateral adenomas in 23 patients and a bilateral hyperplasia in one patient. At follow-up, 33% (8) of the patients were completely cured (normal blood pressure and no antihypertensive treatment), with seven of these eight patients being under 50 years of age at the time of surgery. One patient revealed a contralateral aldosterone-secreting adrenal adenoma during the subsequent endocrine and imaging examination 44 months after the first operation. Despite normalized plasma-aldosterone concentration (PAC), plasma-renin-activity (PRA) and serum potassium levels, a long-lasting insufficiently treated hypertension due to the delayed diagnosis in patients with PA may explain the persistent blood pressure elevation, indicating the necessity of a life-long, regular control of the blood pressure and antihypertensive medication.
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Affiliation(s)
- Andreas Meyer
- Klinik für Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
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Abstract
Formerly, fewer than 1% of patients with hypertension were believed to have primary hyperaldosteronism; however, recent studies have suggested a higher prevalence, in 5% to 10% of patients with hypertension. Hypokalemia is not necessary for the diagnosis and is probably a sign of more advanced disease. The best diagnostic test is the plasma aldosterone concentration to plasma renin activity (PAC/PRA) ratio. Excess aldosterone level has a deleterious effect on the cardiovascular system. Aldosteronomas should be differentiated from idiopathic hyperaldosteronism (IHA),because they are curable by laparoscopic adrenalectomy.
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Affiliation(s)
- Maha Al Fehaily
- Department of Surgery, University of Toronto, 100 College Street, Toronto, ON, M5G 1L5, Canada
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