Unexpected incidence of low blood pressure 2 years after unilateral adrenalectomy for primary aldosteronism

Aldosterone deficiency after unilateral adrenalectomy for Conn's syndrome: a case report and literature review

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We report a case of postoperative hypotension and hyperkalemia in a unilateral adrenalectomy for Conn’s syndrome.

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We highlight that there are factors that may make certain populations more at risk for developing this complication.

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Increasing awareness about this complication and its consequences highlights the needfor close monitoring in increased risk patients.

Introduction

Approximately 35% of cases of Conn’s syndrome (primary aldosteronism) result from a solitary functioning adrenal adenoma, and these patients are best managed by adrenalectomy. Postoperative hypoaldosteronism after unilateral adrenalectomy is uncommon.

Case presentation

We present a case and literature review of hypoaldosteronism after unilateral adrenalectomy for Conn’s syndrome, which demonstrates the insidious and sometimes delayed presentation.

Discussion

In this clinical case we summarize the previously published cases of post-adrenalectomy hypoaldosteronism based on a PUBMED and EBSCOhost search of all peer-reviewed publications (original articles and reviews) on this topic. A few cases of aldosterone insufficiency post-adrenalectomy for Conn’s syndrome were identified. The etiological factors for prolonged selective suppression of aldosterone secretion after unilateral adrenalectomy remain unclear.

Conclusion

It is important to be aware of the risk of postoperative hypoaldosteronism in this patient population. Close postoperative follow-up is necessary and strongly recommended, especially in patients with certain risk factors. Patients may need mineralocorticoid supplementation during this period.

Removing confounders from the relationship between mortality risk and systolic blood pressure at low and moderately increased systolic blood pressure

OBJECTIVE

To assess the relationship between mortality risk and systolic blood pressure (SBP) at low and moderately increased SBP (less than the 70th percentile) before and after correcting for the regression-dilution bias and J-curve effects.

DESIGN

Cohort study.

SETTING

The First National Health and Nutrition Examination Survey Epidemiologic Follow-Up Study.

PARTICIPANTS

The 6839 individuals who participated in the 1982-1984 survey for whom there were no missing data (age range 34-87 years).

MAIN OUTCOME MEASURE

Cardiovascular disease mortality (n = 678) during a 9-year follow-up.

METHODS

Corrections were made for the regression-dilution bias by using average SBP during the decade before baseline as the mortality predictor, and for J-curve effects by excluding individuals who exhibited high age-stratified mortality rates and a decrease in SBP. Cox's regression was used to analyse the follow-up relationship between mortality risk and SBP.

RESULTS

The corrected relative cardiovascular disease mortality risk was 1.23 (95% confidence interval (CI), 1.16 to 1.31) for a 10 mmHg increase in SBP. The relationship was monotonically positive starting at the lowest SBP category in the analysis (< 115 mmHg), and robustly so above about the 32nd percentile (120 mmHg). The equivalent uncorrected result was 1.08 (95% CI, 1.05 to 1.13), and the relationship was J-shaped and became positive above about the 68th percentile (135 mmHg). Below the 70th percentile of SBP, individuals in the corrected analysis were 89% of all individuals.

CONCLUSION

These two corrections transformed the relationship between mortality risk and SBP at low and moderately increased SBP from no association to a robustly positive association starting at 120 mmHg, for the majority of individuals.

Is routine ipsilateral adrenalectomy during radical nephrectomy harmful for the patient?

To investigate the effects of unilateral adrenalectomy on the postoperative course and laboratory parameters, 40 patients with a renal tumour were randomized either to undergo (n = 20) or not to undergo (n = 20) ipsilateral adrenalectomy. Adrenal hormone (cortisol, epinephrine, norepinephrine and aldosterone), adrenocorticotropic hormone, electrolyte, creatinine, growth hormone, glucose, insulin and free fatty acid concentrations were measured preoperatively and postoperatively. Cortisol and epinephrine concentrations were elevated immediately after the operation but returned to preoperative levels within the first 2 postoperative days. There were no significant differences between the adrenalectomy and non-adrenalectomy groups, except that the cortisol concentration was higher in the latter in the afternoon of the day of surgery. The conclusion is that no long-term shortage of adrenal hormones is caused by unilateral adrenalectomy. Other metabolic and endocrine responses were identical in the groups. Thus ipsilateral adrenalectomy does not seem to be harmful to the patient and the need for it must be resolved on the basis of local tumour factors.