Blood pressure and medication changes following adrenalectomy for unilateral primary aldosteronism: a follow-up study

Role of radiologists in the diagnosis and management of adrenal disorders

This study aimed to focus on the role of radiologists in the diagnosis and management of adrenal lesions, particularly primary aldosteronism (PA) and secondary hypertension. As hypertension affects more than one-third of the population in Japan, identifying secondary causes such as PA and adrenal lesions is crucial. Establishing a radiological differential diagnosis of adrenal lesions using advanced imaging techniques, such as computed tomography and magnetic resonance imaging, is crucial. Knowledge of the imaging findings of various benign and malignant adrenal lesions, such as adrenocortical adenomas, cortisol-producing lesions, pheochromocytomas, adrenocortical carcinoma, malignant lymphoma, and metastatic tumors, is necessary. Adrenal venous sampling (AVS) plays a crucial role in accurately localizing aldosterone hypersecretion in PA, especially when imaging fails to provide a clear diagnosis. This paper details the technical aspects of AVS, emphasizing catheterization techniques, anatomical considerations, and the importance of preprocedural imaging for successful sampling. Furthermore, we explore segmental adrenal venous sampling (SAVS), a more refined technique that samples specific adrenal tributary veins, offering enhanced diagnostic accuracy, particularly for microadenomas or challenging cases that may be missed with conventional AVS. The methodology for performing SAVS, along with the interpretation criteria for successful sampling and lateralization, is also outlined. Furthermore, radiologists have initiated treatments for unilateral PA, such as radiofrequency ablation, and play an integral role in the management of adrenal lesions. Collaborative approaches across clinical departments are required to enhance patient management in medical care involving the adrenal gland.

Postoperative outcomes of minimally invasive adrenalectomy: do body mass index and tumor size matter? A single-center experience

Background

Since Gagner performed the first laparoscopic adrenalectomy in 1992, laparoscopy has become the gold-standard procedure in the treatment of adrenal surgical diseases. A review of the literature indicates that the rate of intra- and postoperative complications are not negligible. This study aims to describe the single-center experience of adrenalectomies; and explore the associations between body mass index (BMI) and tumor volume in main postoperative outcomes.

Methods

Retrospective observational study with a prospective database in which we described patients who underwent adrenalectomy between January 2015 and December 2020. Operative time, intraoperative blood loss, conversion rate, complications, length of hospital stay, and comparison of the number of antihypertensive drugs used before and after surgery were analyzed. Analysis of BMI and tumor volume with postoperative outcomes such as anti-hypertensive change (AHC) in drug usage and pre-operative conditions were performed.

Results

Forty-five adrenalectomies were performed, and all of them were carried out laparoscopically. Four were performed as a robot-assisted laparoscopy approach. Nineteen were women and 26 were men. Mean age was 54.9 ± 13.8 years. Mean tumor volume was 95.698 mm³ (3.75–1010.87). Mean operative time was shorter in right tumors (2.64 ± 0.75 h) than in left tumors (3.33 ± 2.73 h). Pearson correlation was performed to assess the relationship between BMI and AHC showing a direct relationship between increased BMI and higher change in anti-hypertensive drug usage at postoperative period r(45) = 0.92, p > 0.05 CI 95%. Higher tumor volume showed a longer operative time, r(45) = 0.6 (p = 0.000 CI 95%).

Conclusions

Obese patients could have an increased impact with surgery with an increased change in postoperative anti-hypertensive management. Tumor volume is associated with increased operative time and blood loss, our data suggest that it could be associated with increased rates of morbidity. However, further prospective studies with larger sample sizes are needed to validate our results.

Accurate Location of Catheter Tip With the Free-to-Total Metanephrine Ratio During Adrenal Vein Sampling

BACKGROUND

The selectivity index (SI) of cortisol is used to document correct catheter placement during adrenal vein sampling (AVS) in patients with primary aldosteronism (PA). We aimed to determine the cutoff values of the SIs based on cortisol, free metanephrine, and the free-to-total metanephrine ratio (FTMR) using an adapted AVS protocol in combination with CT.

METHODS

Adults with PA and referred for AVS were recruited in two hypertension centers. The cortisol and free metanephrine-derived SIs were calculated as the concentration of the analyte in adrenal veins divided by the concentration of the analyte in the distal vena cava. The FTMR-derived SI was calculated as the concentration of free metanephrine in the adrenal vein divided by that of total metanephrine in the ipsilateral adrenal vein. The AVS was classified as an unequivocal radiological success (uAVS) if the tip of the catheter was seen in the adrenal vein. The SI cutoffs of each index marker were established using receiver operating characteristic curve analysis.

RESULTS

Out of 125 enrolled patients, 65 patients had an uAVS. The SI cutoffs were 2.6 for cortisol, 10.0 for free metanephrine, 0.31 for the FTMR on the left side, and 2.5, 9.9, and 0.25 on the right side. Compared to free metanephrine and the FTMR, cortisol misclassified AVS as unsuccessful in 36.6% and 39.0% of the cases, respectively.

CONCLUSION

This study is the first to calculate the SIs of cortisol, free metanephrine, and the FTMR indices for the AVS procedure. It confirms that free metanephrine-based SIs are better than those based on cortisol.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Trends in blood pressure-related outcomes after adrenalectomy in patients with primary aldosteronism: A systematic review

BACKGROUND

Decrease in blood pressure (BP) is the major goal of adrenalectomy for primary aldosteronism. Nevertheless, the optimal timing to assess these outcomes and the needed duration of follow-up are uncertain. We systematically reviewed the literature regarding trends in BP-related outcomes during follow-up after adrenalectomy.

METHODS

A systematic literature search of medical literature from PubMed, Embase and the Cochrane Library regarding BP-related outcomes (i.e. cure of hypertension rates, BP and antihypertensives) was performed. The Quality In Prognosis Studies risk of bias tool was used.

RESULTS

Of the 2057 identified records, 13 articles met the inclusion criteria. Overall study quality was low. In multiple studies, the biggest decrease in BP was shown within the first month(s) after adrenalectomy and afterwards BP often remained stable during long-term follow-up.

CONCLUSIONS

Based on the available studies one might suggest that long follow-up is unnecessary, since outcomes seem to stabilize within the first months.

Nomogram-Based Preoperative Score for Predicting Clinical Outcome in Unilateral Primary Aldosteronism

CONTEXT

More than half of patients diagnosed with unilateral primary aldosteronism (UPA) suffer from persisting hypertension after unilateral adrenalectomy.

OBJECTIVE

The objective of this work is to develop and validate a nomogram-based preoperative score (NBPS) to predict clinical outcomes after unilateral adrenalectomy for UPA.

DESIGN AND SETTING

The NBPS was developed in an Asian cohort by incorporating predictors independently associated with remission of hypertension after unilateral adrenalectomy for UPA and validated in a Caucasian cohort.

PARTICIPANTS

Participants comprised patients with UPA achieving complete biochemical success after unilateral adrenalectomy.

MAIN OUTCOME MEASURE

Measurements included the predictive performance of the NBPS compared with 2 previously developed outcome prediction scores: aldosteronoma resolution score (ARS) and primary aldosteronism surgical outcome (PASO) score.

RESULTS

Ninety-seven of 150 (64.7%) patients achieved complete clinical success after unilateral adrenalectomy in the training cohort and 57 out of 165 (34.5%) in the validation cohort. A nomogram was established incorporating sex, duration of hypertension, aldosterone-to-renin ratio, and target organ damage. The nomogram showed good C indices and calibration curves both in Asian and Caucasian cohorts. The area under the receiver operating characteristic curve (AUC) of the NBPS for predicting hypertension remission in the training cohort was 0.853 (0.786-0.905), which was superior to the ARS (0.745 [0.667-0.812], P = .019) and PASO score (0.747 [0.670-0.815], P = .012). The AUC of the NBPS in the validation cohort was 0.830 (0.764-0.884), which was higher than the ARS (0.745 [95% CI, 0.672-0.810], P = .045), but not significantly different from the PASO score (0.825 [95% CI, 0.758-0.880], P = .911).

CONCLUSION

The NBPS is useful in predicting clinical outcome for UPA patients, especially in the Asian population.

Adrenalectomy Improves the Long-Term Risk of End-Stage Renal Disease and Mortality of Primary Aldosteronism

OBJECTIVE

Primary aldosteronism (PA) is a common cause of secondary hypertension, and the long-term effect of excess aldosterone on kidney function is unknown.

PATIENTS AND METHODS

We used a longitudinal population database from the Taiwan National Health Insurance system and applied a validated algorithm to identify patients with PA diagnosed between 1997 and 2009.

RESULTS

There were 2699 patients with PA recruited, of whom 761 patients with an aldosterone-producing adenoma (APA) were identified. The incidence rate of end-stage renal disease (ESRD) was 3% in patients with PA after targeted treatments and 5.2 years of follow-up, which was comparable to the rate in controls with essential hypertension (EH). However, after taking mortality as a competing risk, we found a significantly lower incidence of ESRD when comparing patients with PA vs EH [subdistribution hazard ratio (sHR), 0.38; P = 0.007] and patients with APA vs EH (sHR 0.55; P = 0.021) after adrenalectomy; however, we did not see similar results in groups with mineralocorticoid receptor antagonist (MRA)‒treated PA vs EH. There was also a significantly lower incidence of mortality in groups with PA and APA who underwent adrenalectomy than among EH controls (P < 0.001).

CONCLUSION

Regarding incident ESRD, patients with PA were comparable to their EH counterparts after treatment. After adrenalectomy, patients with APA had better long-term outcomes regarding progression to ESRD and mortality than hypertensive controls, but MRA treatments did not significantly affect outcome.

Surgical therapy of adrenal tumors: guidelines from the German Association of Endocrine Surgeons (CAEK)

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.

Hypertension outcomes of adrenalectomy in patients with primary aldosteronism: a systematic review and meta-analysis

BACKGROUND

The hypertension cure rate of unilateral adrenalectomy in primary aldosteronism (PA) patients varies widely in existing studies.

METHODS

We conducted an observational meta-analysis to summarize the pooled hypertension cure rate of unilateral adrenalectomy in PA patients. Comprehensive electronic searches of PubMed, Embase, Cochrane, China National Knowledge Internet (CNKI), WanFang, SinoMed and Chongqing VIP databases were performed from initial state to May 20, 2016. We manually selected eligible studies from references in accordance with the inclusion criteria. The pooled hypertension cure rate of unilateral adrenalectomy in PA patients was calculated using the DerSimonian-Laird method to produce a random-effects model.

RESULTS

Forty-three studies comprising approximately 4000 PA patients were included. The pooled hypertension cure rate was 50.6% (95% CI: 42.9-58.2%) for unilateral adrenalectomy in PA. Subgroup analyses showed that the hypertension cure rate was 61.3% (95% CI: 49.4-73.3%) in Chinese studies and 43.7% (95% CI: 38.0-49.4%) for other countries. Furthermore, the hypertension cure rate at 6-month follow-up was 53.3% (95% CI: 36.0-70.5%) and 49.6% (95% CI: 40.9-58.3%) for follow-up exceeding 6 months. The pooled hypertension cure rate was 50.9% (95% CI: 40.5-61.3%) from 2001 to 2010 and 50.2% (95% CI: 39.0-61.5%) from 2011 to 2016.

CONCLUSIONS

The hypertension cure rate for unilateral adrenalectomy in PA is not optimal. Large clinical trials are required to verify the utility of potential preoperative predictors in developing a novel and effective prediction model.

Suppression of Aldosterone Secretion After Recumbent Saline Infusion Does Not Exclude Lateralized Primary Aldosteronism

Guidelines recommend suppression tests such as the saline infusion test (SIT) to ascertain the diagnosis of primary aldosteronism (PA) in patients with a high aldosterone:renin ratio. However, suppression tests have only been evaluated in small retrospective series, and some experts consider that they are not helpful for the diagnosis of PA. In this study, we evaluated whether low post-SIT aldosterone concentrations do exclude lateralized PA. Between February 2009 and December 2013, 199 patients diagnosed with PA on the basis of 2 elevated aldosterone:renin ratio results and a high basal plasma or urinary aldosterone level or high post-SIT aldosterone level had a selective adrenal venous sampling. We used a selectivity index of 2 and a lateralization index of 4 to interpret the adrenal venous sampling results. Baseline characteristics of the patients were the following (percent or median): men 63%, 48 years old, office blood pressure 142/88 mm Hg, serum potassium 3.4 mmol/L, aldosterone:renin ratio 113 pmol/mU, plasma aldosterone concentration 588 pmol/L. The proportion of patients with lateralized adrenal venous sampling was 12 of 41 (29%) among those with post-SIT aldosterone <139 pmol/L (5 ng/dL) and 38 of 104 (37%) among those with post-SIT aldosterone <277 pmol/L (10 ng/dL). Post-SIT aldosterone levels were not associated with the blood pressure outcome of adrenalectomy. A low post-SIT aldosterone level cannot rule out lateralized PA, even with a low threshold (139 pmol/L). Adrenal venous sampling should be considered for patients who are eligible for surgery with elevated basal aldosterone levels even if they have low aldosterone concentrations after recumbent saline suppression testing.

SFE/SFHTA/AFCE consensus on primary aldosteronism, part 6: Adrenal surgery

Treatment of primary aldosteronism (PA) aims at preventing or correcting hypertension, hypokalemia and target organ damage. Patients with lateralized PA and candidates for surgery may be managed by laparoscopic adrenalectomy. Partial adrenalectomy and non-surgical ablation have no proven advantage over total adrenalectomy. Intraoperative morbidity and mortality are low in reference centers, and day-surgery is warranted in selected cases. Spironolactone administered during the weeks preceding surgery controls hypertension and hypokalemia and may prevent postoperative hypoaldosteronism. In most cases, surgery corrects hypokalemia, improves control of hypertension and reduces the burden of pharmacologic treatment; in about 40% of cases, it resolves hypertension. However, success in controlling hypertension and reversing target organ damage is comparable with mineralocorticoid receptor antagonists. Informed patient preference with regard to surgery is thus an important factor in therapeutic decision-making.

Diagnostic criteria for adrenal venous sampling

PURPOSE OF REVIEW

Primary aldosteronism accounts for 3 to 5% of all hypertension cases. Unilateral aldosterone hypersecretion can be treated with adrenalectomy. Guidelines for primary aldosteronism management recommend adrenal vein sampling (AVS) to ascertain unilateral primary aldosteronism before surgery. Many different protocols are used to perform AVS and for the interpretation of its results, but without hard evidence of why one should be given preference. Experts have proposed recommendations to guide clinical practice and the grounds for future research to address this situation.

RECENT FINDINGS

Proper patient preparation is a prerequisite for interpretable results. New trends are emerging to improve adequate cannulation of adrenal veins including: training of a limited number of dedicated radiologists, contrast computed tomography of adrenal veins before or during AVS, and rapid assays to measure cortisol concentrations during AVS. Cosyntropin stimulation is performed in several centers to avoid the variability of cortisol secretion during AVS, but whether this improves diagnostic performance is unknown.

SUMMARY

Better markers of adequate catheter placement are currently under investigation, including other adrenal steroids and metanephrines. Innovative strategies for interpreting partially failed AVS are also being developed. Other approaches to ascertain primary aldosteronism subtype will be necessary because of limited patient access to AVS.

Implication of aortic calcification on persistent hypertension after laparoscopic adrenalectomy in patients with primary aldosteronism

OBJECTIVES

To identify risk factors, including aortic calcification, for persistent hypertension in primary aldosteronism patients undergoing laparoscopic adrenalectomy.

METHODS

Between October 2000 and October 2015, we carried out 101 consecutive laparoscopic adrenalectomies for unilateral primary aldosteronism. Of these, 95 cases with at least 1 year of postoperative follow up were included. These were divided into two study groups based on whether they had normal blood pressure without antihypertensive medications (resolved group) or still required medications (unresolved group) at 1 year after surgery. Variables included age, sex, body mass index, history of hypertension, dosage of antihypertensive medication score, presence of type 2 diabetes, subclinical Cushing syndrome, preoperative renal function, aldosteronoma resolution score and abdominal calcification index. Univariate and multivariate logistic regression analyses were used to assess independent risk factors for persistent hypertension 1 year after surgery.

RESULTS

The complete resolution of hypertension without antihypertensive medication 1 year after adrenalectomy was 36 out of 95 (38%). The preoperative antihypertensive medication score, systolic blood pressure and abdominal calcification index were significantly higher, and the aldosteronoma resolution score were significantly lower in the unresolved group than in the resolved group. Using multivariate logistic regression analysis, independent risk factors significantly correlating with persistent hypertension 1 year after surgery were aldosteronoma resolution score and abdominal calcification index.

CONCLUSIONS

Laparoscopic adrenalectomy for primary aldosteronism is effective in improving blood pressure and reducing the need for antihypertensive medications. Aldosteronoma resolution score and abdominal calcification index represent potential independent risk factors for persistent hypertension 1 year after surgery.

Cardiovascular Risk in Primary Hyperaldosteronism

After the first cases of primary aldosteronism were described and characterized by Conn, a substantial body of experimental and clinical evidence about the long-term effects of excess aldosterone on the cardiovascular system was gathered over the last 5 decades. The prevalence of primary aldosteronism varies considerably between different studies among hypertensive patients, depending on patient selection, the used diagnostic methods, and the severity of hypertension. Prevalence rates vary from 4.6 to 16.6% in those studies in which confirmatory tests to diagnose primary aldosteronism were used. There is also growing evidence indicating that prolonged exposure to elevated aldosterone concentrations is associated with target organ damage in the heart, kidney, and arterial wall, and high cardiovascular risk in patients with primary aldosteronism. Therefore, the aim of treatment should not be confined to BP normalization and hypokalemia correction, but rather should focus on restoring the deleterious effects of excess aldosterone on the cardiovascular system. Current evidence convincingly demonstrates that both surgical and medical treatment strategies beneficially affect cardiovascular outcomes and mortality in the long term. Further studies can be expected to provide better insight into the relationship between cardiovascular risk and complications and the genetic background of primary aldosteronism.

Mineralocorticoid Receptor Antagonists and Clinical Outcomes in Primary Aldosteronism: As Good as Surgery?

Primary aldosteronism (PA) is detected with increasing frequency in hypertensive patients and is associated with excess cardiovascular, renal, and metabolic complications. For these reasons, appropriate choices for treatment of this endocrine condition are mandatory. Adrenalectomy is safely performed in PA patients when adrenal venous sampling (AVS) demonstrates lateralized aldosterone secretion. AVS, however, is a complex procedure and even among worldwide referral centers there are substantial discrepancies for interpretation of results. Also, in the majority of PA patients with lateralized aldosterone secretion, hypertension may persist after adrenalectomy requiring use of additional antihypertensive agents. Treatment with mineralocorticoid receptor antagonists (MRAs) is currently recommended for PA patients with bilateral adrenal disease, but these agents effectively decrease blood pressure also in patients with unilateral disease, although concern remains for possible sex-related side effects. Prospective studies indicate that MRAs have therapeutic values comparable to surgery in the long-term, inasmuch as they effectively correct metabolic abnormalities and subclinical organ damage and reduce the risk of cardiovascular events and renal disease progression. This article overviews the clinical outcomes obtained in patients with PA with use of MRAs.

Cost-Effectiveness of Screening for Primary Aldosteronism and Subtype Diagnosis in the Resistant Hypertensive Patients

BACKGROUND

Primary aldosteronism (PA) is a common and underdiagnosed disease with significant morbidity potentially cured by surgery. We aim to assess if the long-term cardiovascular benefits of identifying and treating surgically correctable PA outweigh the upfront increased costs in patients at the time patients are diagnosed with resistant hypertension (RH).

METHODS AND RESULTS

A decision-analytic model compares aggregate costs and systolic blood pressure changes of 6 recommended or implemented diagnostic strategies for PA in a simulated population of at-risk RH patients. We also evaluate a 7th "treat all" strategy wherein all patients with RH are treated with a mineralocorticoid-receptor antagonist without further testing at RH diagnosis. Changes in systolic blood pressure are subsequently converted into gains in quality-adjusted life years (QALYs) by applying National Health and Nutrition Examination Survey data on concomitant risk factors to an existing cardiovascular disease simulation model. QALYs and lifetime costs were then used to calculate incremental cost-effectiveness ratios for the competing strategies. The incremental cost-effectiveness ratio for the strategy of computerized tomography (CT) followed by adrenal venous sampling (AVS) was $82,000/QALY compared with treat all. Incremental cost-effectiveness ratios for CT alone and AVS alone were $200,000/QALY and $492,000/QALY; the other strategies were more costly and less effective. Integrating differential patient-reported health-related quality of life adjustments for patients with PA, and incremental cost-effectiveness ratios for screening patients with CT followed by AVS, CT alone, and AVS alone were $52,000/QALY, $114,000/QALY, and $269,000/QALY gained.

CONCLUSIONS

CT scanning followed by AVS was a cost-effective strategy to screen for PA among patients with RH.

Outcomes of drug-based and surgical treatments for primary aldosteronism

Treatments for primary aldosteronism (PA) aim to correct or prevent the deleterious consequences of hyperaldosteronism: hypertension, hypokalemia, and direct target organ damage. Patients with unilateral PA considered fit for surgery can undergo laparoscopic adrenalectomy, which significantly decreases blood pressure (BP) and medications in most cases and cures hypertension in about 40%. Mineralocorticoid receptor antagonists (MRA) are used to treat patients with bilateral PA and those with unilateral PA if surgery is not possible or not desired. Spironolactone is more potent than eplerenone, but high doses are poorly tolerated in men. MRA can be replaced or complemented with epithelial sodium channel blockers, such as amiloride. Thiazide diuretics and calcium channel blockers are used when the first-line drugs are insufficient to control BP. Dietary sodium restriction should be implemented in all cases because the deleterious consequences of hyperaldosteronism are dependent on salt loading. Several studies comparing the results of surgery and MRA have reported no differences in terms of BP, serum potassium concentration, or cardiovascular and kidney outcomes, although the benefits of treatment tend to be observed sooner with surgery. Patients with PA display relative glomerular hyperfiltration, which is reversed by specific treatment, revealing CKD in 30% of patients. However, further kidney damage is lessened by the treatment of PA.

Influence of Diagnostic Criteria on the Interpretation of Adrenal Vein Sampling

Guidelines promote the use of adrenal vein sampling (AVS) to document lateralized aldosterone hypersecretion in primary aldosteronism. However, there are large discrepancies between institutions in the criteria used to interpret its results. This study evaluates the consequences of these differences on the classification and management of patients. The results of all 537 AVS procedures performed between January 2001 and July 2010 in our institution were interpreted with 4 diagnostic criteria used in experienced institutions where AVS is performed without cosyntropin (Brisbane, Padua, Paris, and Turin) and with criteria proposed by a recent consensus statement. AVS procedures were classified as unsuccessful, lateralized, or not lateralized according to each set of criteria. Almost 5× more AVS procedures were classified as unsuccessful with the strictest criteria than with the least strict criteria (18% versus 4%, respectively). Similarly, over 2× more AVS procedures were classified as lateralized with the least stringent criteria than with the most stringent criteria (60% versus 26%, respectively). Multiple samples were available from ≥1 side for 155 AVS procedures. These procedures were classified differently by ≥2 right–left sample pairs in 12% to 20% of cases. Thus, different sets of criteria used to interpret AVS in experienced institutions translate into heterogeneous classifications and hence management decisions, for patients with primary aldosteronism. Defining the most appropriate procedures and diagnostic criteria is needed for AVS to achieve optimal performance and fully justify its status as a gold standard.

Post-saline infusion test aldosterone levels indicate severity and outcome in primary aldosteronism

OBJECTIVE

The saline infusion test (SIT) is widely used as a confirmatory test for primary aldosteronism (PA). SIT results are judged as follows: post-test aldosterone levels <50 ng/l exclude PA, whereas levels >50 ng/l confirm PA. We hypothesized that post-SIT aldosterone concentrations indicate the severity of PA and might predict outcome.

DESIGN

The study includes 256 PA patients of the German Conn's Registry who prospectively underwent SIT. The data of 126 patients with complete follow-up of 1.2±0.3 years after diagnosis were analyzed. The patients were divided into two groups with post-SIT aldosterone levels of 50-100 ng/l (group 1; n=38) and of >100 ng/l (group 2; n=88).

RESULTS

Patients in group 2 had a significantly shorter duration of hypertension (7.5 vs 11.7 years (median), P=0.014), higher systolic blood pressure (BP; 151±16 vs 143±17 mmHg, P=0.036), lower serum potassium (3.3±0.6 vs 3.5±0.4 mmol/l, P=0.006), higher 24-h urine protein excretion (7.4 vs 5.4 mg/dl (median), P=0.012), and were more often female (P=0.038). They showed more often unilateral disease (P<0.005) with larger tumors (14±10 vs 7±10 mm, P=0.021), underwent more often adrenalectomy (75% vs 37%, P<0.005), required a lower number of antihypertensive drugs after adrenalectomy (1.2±1.2 vs 2.5±1.4, P=0.001), had a faster normalization of urinary protein excretion (with medical treatment P=0.049; with Adx P<0.005) at follow-up, and more frequently underlying well-characterized mutation (P=0.047).

CONCLUSIONS

PA patients with post-SIT aldosterone levels of >100 ng/l have a more rapid development of PA caused more frequently by unilateral disease with larger aldosterone-producing adenomas. However, this group of patients may have a significantly better outcome following specific treatment.

Adrenalectomy is comparable with medical treatment for reduction of left ventricular mass in primary aldosteronism: meta-analysis of long-term studies

BACKGROUND

Primary aldosteronism (PA) is associated with an increase in left ventricular (LV) mass beyond the amount needed to compensate the hypertension-related workload. Available evidence suggests effectiveness of surgical treatment of PA in decreasing LV mass, whereas data on medical treatment are controversial. We have conducted a meta-analysis of long-term follow-up studies on surgical and medical treatment of PA to compare the effects of treatments on LV mass.

METHODS

Medline and Cochrane searches were performed including the following words: hyperaldosteronism, left ventricular mass, mineralocorticoid receptor antagonists, surgery, adrenalectomy, and follow-up studies. Studies published within 2013 focusing on cardiac effects of treatment and follow-up longer than 6 months were selected. Data extraction was performed independently by 2 authors.

RESULTS

Of 61 retrieved articles, 4 were included in the analysis. These studies enrolled 355 patients with PA who had an average follow-up of 4.0 years after unilateral adrenalectomy (n = 178) or treatment with mineralocorticoid receptor antagonists (n = 177). Despite greater effect of surgery over medical treatment in reducing blood pressure, meta-analysis of the selected studies demonstrated no significant difference in LV mass change between patients with PA who were treated with mineralocorticoid receptor antagonists or adrenalectomy (standard mean difference = 0.130; 95% confidence interval = -0.085 to 0.345; P = 0.24; I2 = 0%).

CONCLUSIONS

Available evidence indicates that reduction of LV mass is not different in PA patients treated with adrenalectomy or mineralocorticoid receptor antagonists.

Systematic review of surgery and outcomes in patients with primary aldosteronism

BACKGROUND

Primary aldosteronism (PA) is the most common cause of secondary hypertension. The main aims of this paper were to review outcome after surgical versus medical treatment of PA and partial versus total adrenalectomy in patients with PA.

METHODS

Relevant medical literature from PubMed, the Cochrane Library and Embase OvidSP from 1985 to June 2014 was reviewed.

RESULTS

Of 2036 records, 43 articles were included in the final analysis. Twenty-one addressed surgical versus medical treatment of PA, four considered partial versus total adrenalectomy for unilateral PA, and 18 series reported on surgical outcomes. Owing to the heterogeneity of protocols and reported outcomes, only a qualitative analysis was performed. In six studies, surgical and medical treatment had comparable outcomes concerning blood pressure, whereas six showed better outcome after surgery. No differences were seen in cardiovascular complications, but surgery was associated with the use of fewer antihypertensive medications after surgery, improved quality of life, and (possibly) lower all-cause mortality compared with medical treatment. Randomized studies indicate a role for partial adrenalectomy in PA, but the high rate of multiple adenomas or adenoma combined with hyperplasia in localized disease is disconcerting. Surgery for unilateral dominant PA normalized BP in a mean of 42 (range 20-72) per cent and the biochemical profile in 96-100 per cent of patients. The mean complication rate in 1056 patients was 4·7 per cent.

CONCLUSION

Recommendations for treatment of PA are hampered by the lack of randomized trials, but support surgical resection of unilateral disease. Partial adrenalectomy may be an option in selected patients.

Management of hypertension in primary aldosteronism

Hypertension causes significant morbidity and mortality worldwide, owing to its deleterious effects on the cardiovascular and renal systems. Primary hyperaldosteronism (PA) is the most common cause of reversible hypertension, affecting 5%-18% of adults with hypertension. PA is estimated to result from bilateral adrenal hyperplasia in two-thirds of patients, and from unilateral aldosterone-secreting adenoma in approximately one-third. Suspected cases are initially screened by measurement of the plasma aldosterone-renin-ratio, and may be confirmed by additional noninvasive tests. Localization of aldostosterone hypersecretion is then determined by computed tomography imaging, and in selective cases with adrenal vein sampling. Solitary adenomas are managed by laparoscopic or robotic resection, while bilateral hyperplasia is treated with mineralocorticoid antagonists. Biochemical cure following adrenalectomy occurs in 99% of patients, and hemodynamic improvement is seen in over 90%, prompting a reduction in quantity of anti-hypertensive medications in most patients. End-organ damage secondary to hypertension and excess aldosterone is significantly improved by both surgical and medical treatment, as manifested by decreased left ventricular hypertrophy, arterial stiffness, and proteinuria, highlighting the importance of proper diagnosis and treatment of primary hyperaldosteronism. Although numerous independent predictors of resolution of hypertension after adrenalectomy for unilateral adenomas have been described, the Aldosteronoma Resolution Score is a validated multifactorial model convenient for use in daily clinical practice.

An expert consensus statement on use of adrenal vein sampling for the subtyping of primary aldosteronism

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.

Cardiovascular complications associated with primary aldosteronism: a controlled cross-sectional study

A higher risk of cardiovascular events has been reported in patients with primary aldosteronism (PA) than in otherwise similar patients with essential hypertension (EH). However, the evidence is limited by small sample size and potential confounding factors. We, therefore, compared the prevalence of cardiovascular events in 459 patients with PA diagnosed in our hypertension unit from 2001 to 2006 and 1290 controls with EH. PA cases and EH controls were individually matched for sex, age (± 2 years), and office systolic blood pressure (± 10 mm Hg). Patients with PA and EH differed significantly in duration of hypertension, serum potassium, plasma aldosterone and plasma renin concentrations, aldosterone-to-renin ratio, and urinary aldosterone concentration (P<0.001 for all comparisons). The prevalence of electrocardiographic and echocardiographic left ventricular hypertrophy was about twice higher in patients with PA even after adjustment for hypertension duration. PA patients also had a significantly higher prevalence of coronary artery disease (adjusted odds ratio, 1.9), nonfatal myocardial infarction (adjusted odds ratio, 2.6), heart failure (adjusted odds ratio, 2.9), and atrial fibrillation (adjusted odds ratio, 5.0). The risks associated with PA were similar across levels of serum potassium and plasma aldosterone. To conclude, patients with PA are more likely to have had a cardiovascular complication at diagnosis than otherwise similar patients with EH. Target organ damage and complications disproportionate to blood pressure should be considered as an additional argument for suspecting PA in a given individual and possibly for broadening the scope of screening at the population level.

Primary aldosteronism: evidence against a second epidemic

Primary aldosteronism is widely held to be the most common cause of identifiable (secondary) hypertension, reported to be present in 6-10% of all hypertensive patients. This belief reflects the widespread use of the aldosterone-to-renin ratio (ARR) as a screening test. Unfortunately, the ARR is often wrong, leading to even more expensive testing that is also often misleading but that may then lead to potentially harmful additional measures. This review provides evidence that referral bias has markedly inflated the estimates of this condition and recommends a much less aggressive approach to the diagnosis of this condition based on more limited testing and the use of mineralocorticoid receptor antagonists in the treatment of most hypertensive patients.

Aldosterone-to-renin ratio for diagnosing aldosterone-producing adenoma: a multicentre study

BACKGROUND

Biological diagnostic criteria for diagnosing aldosterone-producing adenoma (APA) are not well-established.

AIM

The aim of the study was to establish the best biological predictors of APA.

METHODS

A prospective register was implemented in 17 secondary or tertiary hypertension centres. The inclusion criterion was one of the following: onset of hypertension before 40 years of age; history of hypokalaemia; drug-resistant hypertension (resistant to three drugs); or spironolactone efficiency on BP.

RESULTS

Among the 338 collected cases, 192 patients had two aldosterone-to-renin ratio (ARR) determinations (after 1 hour supine and at least 1 hour upright) on the same occasion. Twenty-five patients (8.2%) had biological hyperaldosteronism and an adrenal adenoma identified by computed tomography. APA was histologically confirmed in all 12 patients who underwent surgery. Histologically proven APAs were used as the 'gold standard' in receiver operating characteristic (ROC) curve analysis. ARRs were computed with a minimum renin value set at 5 ng/L to avoid misclassification of so-called 'low-renin hypertension'. To predict an APA, the ARR area under the ROC curve was 0.93. A supine ARR cut-off value of 32ng/ng provided the highest sum of sensitivity (92%) plus specificity (92%). On the basis of an ARR≥32 ng/ng in the supine and/or upright position, sensitivity reached 100%.

CONCLUSION

The proposed cut-off value of 32 ng/ng for ARR (minimum renin value set at 5 ng/L) in one of two determinations had 100% sensitivity and 72% specificity with 20% positive and 100% negative predictive values for diagnosing APA.

A clinical prediction score to diagnose unilateral primary aldosteronism

CONTEXT

Adrenal venous sampling is recommended to assess whether aldosterone hypersecretion is lateralized in patients with primary aldosteronism. However, this procedure is invasive, poorly standardized, and not widely available.

OBJECTIVE

Our goal was to identify patients' characteristics that can predict unilateral aldosterone hypersecretion in some patients who could hence bypass adrenal venous sampling before surgery.

DESIGN AND SETTING

A cross-sectional diagnostic study was performed from February 2009 to July 2010 at a single center specialized in hypertension care.

PATIENTS

A total of 101 consecutive patients with primary aldosteronism who underwent adrenal venous sampling participated in the study. The autonomy of aldosterone hypersecretion was assessed with the saline infusion test.

INTERVENTION

Adrenal venous sampling was performed without ACTH infusion but with simultaneous bilateral sampling.

MAIN OUTCOME MEASURES

Variables independently associated with a lateralized adrenal venous sampling in multivariate logistic regression were used to derive a clinical prediction rule.

RESULTS

Adrenal venous sampling was successful in 87 patients and lateralized in 49. All 26 patients with a typical Conn's adenoma plus serum potassium of less than 3.5 mmol/liter or estimated glomerular filtration rate of at least 100 ml/min/1.73 m2 (or both) had unilateral primary aldosteronism; this rule had 100% specificity (95% confidence interval, 91-100) and 53% sensitivity (95% confidence interval, 38-68).

CONCLUSIONS

If our results are validated on an independent sample, adrenal venous sampling could be omitted before surgery in patients with a typical Conn's adenoma if they meet at least one of two supplementary biochemical characteristics (serum potassium<3.5 mmol/liter or estimated glomerular filtration rate ≥100 ml/min/1.73 m2).