Characterization of a Biochemical Mouse Model of Primary Aldosteronism for Thermal Therapies

Introduction

Aldosterone-producing adenoma (APA) is the most common cause of endocrine-related hypertension but surgery is not always feasible. Current medical interventions are associated with significant side effects and poor patient compliance. New APA animal models that replicate basic characteristics of APA and give physical and biochemical feedback are needed to test new non-surgical treatment methods, such as image-guided thermal ablation.

Methods

A model of APA was developed in nude mice using HAC15 cells, a human adrenal carcinoma cell line. Tumor growth, aldosterone production, and sensitivity to angiotensin II were characterized in the model. The utility of the model was validated via treatment with microwave ablation and characterization of the resulting physical and biochemical changes in the tumor.

Results

The APA model showed rapid and relatively homogeneous growth. The tumors produced aldosterone and steroid precursors in response to angiotensin II challenge, and plasma aldosterone levels were significantly higher in tumor bearing mice two hours after challenge verses non-tumor bearing mice. The model was useful for testing microwave ablation therapy, reducing aldosterone production by 80% in treated mice.

Conclusion

The HAC15 model is a useful tumor model to study and develop localized treatment methods for APA.

Is adrenal venous sampling always necessary to differentiate between unilateral and bilateral primary aldosteronism? Lesson from the SPAIN-ALDO register

PURPOSE

To evaluate whether the clinical, biochemical and radiological features of patients with primary aldosteronism (PA) can predict both main subtypes of PA.

METHODS

A retrospective multicenter study of PA patients followed in 27 Spanish tertiary hospitals (SPAIN-ALDO Register). Only patients with confirmed unilateral or bilateral PA based on adrenal venous sampling (AVS) and/or postsurgical biochemical cure after adrenalectomy were included. Supervised regression techniques were used for model development.

RESULTS

328 patients [270 unilateral PA (UPA), 58 bilateral PA (BPA)] were included. The area under the curve (AUC) for aldosterone/potassium ratio and aldosterone responses following saline infusion test were 0.602 [95%CI 0.520 to 0.684] and 0.574 [95% CI 0.446-0.701], respectively, to differentiate UPA from BPA. The AUC was 0.825 [95% 0.764-0.886] when the prediction model with seven parameters - comorbidities (dyslipidemia, cerebrovascular disease, sleep apnea syndrome [SAS]), systolic blood pressure (SBP), plasma aldosterone levels (PAC), hypokalemia and unilateral adrenal nodule >1 cm and normal contralateral adrenal gland on CT/MRI - was used. In patients without comorbidities, hypokalemia, SBP > 160 mmHg, PAC > 40 ng/dL, and unilateral adrenal lesions were associated with a likelihood of having a UPA of 98.5%. The chance of BPA was higher in individuals with comorbidities, SBP < 140 mmHg, normokalemia, low PAC levels, and no adrenal tumors on the CT/MRI (91.5%).

CONCLUSION

A combination of high PAC, SBP > 160 mmHg, low serum potassium, a unilateral adrenal nodule>1 cm and no comorbidities could predict a UPA with a 98.5% accuracy.

Imaging Concordance With Vein Sampling for Primary Aldosteronism: A Cohort Study and Literature Review

INTRODUCTION

Adrenal venous sampling (AVS) is used to distinguish unilateral from bilateral aldosterone hypersecretion as a cause of primary aldosteronism (PA). Unilateral disease is treated with adrenalectomy and bilateral hypersecretion managed medically.

METHODS

We performed a single institution retrospective cohort study of adult patients undergoing adrenalectomy for PA from July 2013 to June 2022. Concordance of imaging findings with AVS was evaluated. Statistical analysis was performed with Mann-Whitney U and chi-squared Fisher's exact. Literature review performed via triple method search strategy.

RESULTS

Twenty-one patients underwent AVS and adrenalectomy for PA. Two patients did not have imaging findings and 19 were localized with an adenoma. For patients with image localization, AVS was concordant in nine, discordant in four, and nondiagnostic in six. For patients with discordant findings, age range was 35.8 to 72.4 y compared with concordant patient age range of 49.8 to 71.7 y. Overall discordance between imaging results and AVS was 40%. The aldosterone level was associated with concordance with a median of 52 ng/dL compared with 26 ng/dL if discordant (P = 0.002). There was a significant reduction in antihypertensive medications for the entire cohort from a median of three medications (interquartile range 2-4) to 1 medication (interquartile range 1-2), P < 0.001.

CONCLUSIONS

In this cohort, 40% of patients with selective AVS had discordant imaging and AVS results. Aldosterone level was associated with concordance. Hypertension was significantly improved with a median decrease of two antihypertensives. Our results support performance of AVS on all candidates for adrenalectomy for PA.

Laparoscopic Adrenalectomy Is Beneficial for the Health-Related Quality of Life of Older Patients with Primary Aldosteronism

OBJECTIVE

Laparoscopic adrenalectomy (LADX) improves hypertension in patients with primary aldosteronism (PA). However, the antihypertensive impact of LADX appears restricted in older patients with PA. In this study, we evaluated the impact of LADX in older patients focusing on the health-related quality of life (HRQoL).

METHODS

A total of 156 patients with PA who underwent LADX in a single institution were enrolled in this prospective cohort study. The patients were divided into 2 groups, with a boundary of 60 years. The HRQoL was evaluated using the Medical Outcomes Study's 36-Item Short-Form Health Survey version 2 (SF-36v2) questionnaire before and after LADX. Demographics, clinical features, antihypertensive drugs before and after surgery, and perioperative evaluation were recorded. We compared all scale scores and summed scores between groups. Multivariate regression models were used to determine the associations between various covariables and the HRQoL.

RESULTS

In the older PA patients, most subscales of HRQoL at baseline were lower than the national standard values. The antihypertensive drug-free rate by LADX was only 21% in older patients, compared to 58% in younger patients. However, a significant improvement in mental HRQoL was observed after LADX (p = 0.002). The much preoperative antihypertensive drugs, lower preoperative potassium level, and smaller degree of comorbidities were predictors of improved mental HRQoL by LADX on multivariate analyses.

CONCLUSION

The older PA patients showed lower mental HRQOL than the national standard populations. Although antihypertensive effects were limited for these patients, LADX was beneficial as PA treatment via improvement of mental HRQoL.

'I can't understand why others don't screen more': a qualitative study exploring why Australian general practitioners screen for primary aldosteronism

OBJECTIVE

We sought to understand the factors that influence a general practitioner's (GP's) experience of screening for primary aldosteronism (PA) in hypertensive patients.

DESIGN

A qualitative study, framed by phenomenology, using semistructured interviews that were audiorecorded, transcribed verbatim, entered into NVivo V.12.0 for coding and analysed for emerging themes.

SETTING

Melbourne, Australia.

PARTICIPANTS

Eligible GPs had received education on PA as part of a previous study. We recruited a purposive sample of 16 GPs (6 females, 10 males) who varied in practice location, clinical experience and the number of patients screened for PA.

RESULTS

Although GPs had been educated about PA, they found it challenging to explain the condition to patients and were uncertain about how to screen patients who were already taking antihypertensive medications. Most viewed the screening process to be practical, inexpensive and, by and large, acceptable to their patients. However, they found it inconvenient to alter antihypertensive medications before screening to allow for easier interpretation of the aldosterone-renin ratio. They were also less enthused about screening patients whom they thought fitted a clinical picture of essential hypertension. Knowledge of the screening process, cost and convenience of performing the aldosterone-renin ratio, conceptualisation of risk related to PA, and a desire to improve clinical care were influencing factors that modified the GPs' screening experience.

CONCLUSION

Our findings suggest that knowledge gaps, practical limitations of the aldosterone-renin ratio, and errors in diagnostic reasoning were challenges of routine PA screening. Most of these practical barriers could be addressed by relatively simple educational and practice modifications to increase PA screening rates and optimise detection for the most common cause of secondary hypertension in primary care.

Prognostic value of contralateral suppression for remission after surgery in patients with primary aldosteronism

OBJECTIVE

Primary aldosteronism (PA) is the most common cause of endocrine hypertension and adrenalectomy is the firstline treatment for unilateral PA. Suppression of aldosterone secretion of the nondominant adrenal gland at adrenal venous sampling (AVS), that is, contralateral suppression (CLS) has been suggested as a marker of disease severity. However, whether factors such as CLS, age, gender or comorbidities are associated with remission after surgery is controversial. The objective of this study is to investigate the prognostic value of CLS, age, gender, aldosterone-to-renin ratio, antihypertensives and comorbidities for clinical and biochemical remission following unilateral adrenalectomy in patients with PA.

DESIGN AND PATIENTS

A retrospective study of patients with PA referred for AVS at Rigshospitalet from May 2011 to September 2020, who subsequently underwent adrenalectomy. Clinical remission was defined according to the PA surgical outcome criteria, whereas complete biochemical remission was defined as normalization of hypokalaemia without potassium substitution.

RESULTS

Eighty-four patients were available for analysis of primary outcome. Among patients with CLS, 28/58 (48.3%) obtained complete clinical remission after surgery compared with 10/26 (38.5%) without CLS (p = .40). Complete biochemical remission was obtained in 55/58 (94.8%) of patients with CLS compared with 25/28 (89.3%) without CLS (p = .44). Female gender and lower number of antihypertensives at baseline were associated with higher odds for complete clinical remission, whereas none of the investigated variables were associated with biochemical remission.

CONCLUSION

CLS was not significantly associated with complete clinical or biochemical remission in this cohort. Our results confirmed that female gender and lower number of antihypertensives were predictors of clinical remission.

Hypertension outcomes of adrenalectomy for unilateral primary aldosteronism

PURPOSE

To evaluate laboratory and clinical results after unilateral adrenalectomy in patients with primary aldosteronism (PHA).

METHODS

A cross-sectional analysis was performed using data from patients who underwent transperitoneal laparoscopic adrenalectomy for PHA, between January 2008 and December 2019. Surgical indications were based on adrenal venous sampling without ACTH stimulation. Analyses included patient demographics; preoperative clinical, pharmacological, laboratory, and radiological data; and postoperative results assessed after a median of 4 months. Antihypertensive drug use was quantified by estimating the daily defined dose (DDD) of antihypertensive medication, thus enabling standardized comparison of dosage between the drug classes. Statistical assessments included univariable and multivariable logistic regression analysis.

RESULTS

This study enrolled 87 patients. The patients were taking 5.4 DDD of antihypertensive medication before surgery, and 3.0 DDD after surgery. Complete biochemical success of surgery was reached 67 patients (77%), 19 patients (22%) had partial biochemical success. Complete clinical success with normalization of blood pressure and withdrawal of all antihypertensive drugs was achieved in 19 patients (22%). 57 patients (65%) exhibited a reduction of DDD after surgery and/or improvement of blood pressure-partial clinical success. Thus, in 76 (87%) of all enrolled patients, surgery had an overall positive effect on hypertension control. Multivariable logistic regression showed that complete clinical success was independently associated with female gender and baseline sum of antihypertensive drugs DDD < 4.

CONCLUSION

A majority of patients undergoing unilateral adrenalectomy for PHA achieved markedly improved hypertension control, despite almost halving their antihypertensive medication. Almost a quarter of patients were cured and able to cease using all antihypertensive drugs.

Outcome-Based Decision-Making Algorithm for Treating Patients with Primary Aldosteronism

BACKGROUND

Optimal management of primary aldosteronism (PA) is crucial due to the increased risk of cardiovascular and cerebrovascular diseases. Adrenal venous sampling (AVS) is the gold standard method for determining subtype but is technically challenging and invasive. Some PA patients do not benefit clinically from surgery. We sought to develop an algorithm to improve decision- making before engaging in AVS and surgery in clinical practice.

METHODS

We conducted the ongoing Korean Primary Aldosteronism Study at two tertiary centers. Study A involved PA patients with successful catheterization and a unilateral nodule on computed tomography and aimed to predict unilateral aldosterone-producing adenoma (n=367). Study B involved similar patients who underwent adrenalectomy and aimed to predict postoperative outcome (n=330). In study A, we implemented important feature selection using the least absolute shrinkage and selection operator regression.

RESULTS

We developed a unilateral PA prediction model using logistic regression analysis: lowest serum potassium level ≤3.4 mEq/L, aldosterone-to-renin ratio ≥150, plasma aldosterone concentration ≥30 ng/mL, and body mass index <25 kg/m2 (area under the curve, 0.819; 95% confidence interval, 0.774 to 0.865; sensitivity, 97.6%; specificity, 25.5%). In study B, we identified female, hypertension duration <5 years, anti-hypertension medication <2.5 daily defined dose, and the absence of coronary artery disease as predictors of clinical success, using stepwise logistic regression models (sensitivity, 94.2%; specificity, 49.3%). We validated our algorithm in the independent validation dataset (n=53).

CONCLUSION

We propose this new outcome-driven diagnostic algorithm, simultaneously considering unilateral aldosterone excess and clinical surgical benefits in PA patients.

Partial versus total adrenalectomy for the treatment of unilateral aldosterone-producing adenoma: a systematic review and meta-analysis

Adrenalectomy is the first line of treatment in unilateral aldosterone-producing adenoma. Whether adrenalectomy should be performed using a cortex-sparing technique (partial adrenalectomy) or total adrenalectomy remains debatable. Therefore, this meta-analysis aims to evaluate the safety and effectiveness of partial adrenalectomy (PA) to total adrenalectomy (TA) by comparing perioperative and functional outcomes. A systematic search was performed across Pubmed, Embase, Web of Science, Cochrane Library database for RCTs and non-RCTs comparing PA and TA on unilateral aldosterone-producing adenoma. The main outcomes analyzed were the perioperative and postoperative effectiveness. In addition, weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals of continuous and dichotomous variables are presented. Two RCTs and 5 non-RCTs trials, including 834 patients were identified and included in the meta-analysis. PA was associated with statistically significant shorter hospital stay (WMD - 0.51 days, 95% CI - 0.87, - 0.14; p = 0.007), shorter operative time (WMD - 15.54 min, 95% CI - 25.12, - 5.97; p = 0.001) and lower overall complications (OR 0.52, 95% CI 0.32, 0.85; p = 0.009) compared to TA. There was no statistical significance in postoperative effectiveness, including postoperative blood pressure, potassium, hypokalemia, ARR and renin between TA and PA. PA seems to have advantages over TA. The surgical outcomes were comparable in TA and PA. The hospital stay, operative time and overall complications may be reduced. When technically feasible, PA might be considered as a better treatment for unilateral aldosterone-producing adenoma.

Surgical treatment outcome of primary aldosteronism assessed using new modified diagnostic tests

PURPOSE

Primary aldosteronism (PA) is the most frequent type of endocrine hypertension. In our previous studies, we introduced two modified diagnostic tests for PA, the post-dexamethasone saline infusion test (DSIT) and the overnight dexamethasone, captopril, and valsartan test (DCVT). In this study, we aimed to validate both tests in respect to the biochemical and clinical response of a cohort of hypertensive patients in pre- and post-surgical setting.

METHODS

We retrospectively studied 41 hypertensive patients (16 males), with a median (IQR, range) age of 50 (16, 35-74) years and positive histology for adrenal adenoma. Preoperatively, all patients had a single adenoma on CT and a diagnosis of PA with either DSIT or DCVT. The defined daily dose (DDD) of hypertensive drugs was assessed pre- and postoperatively. DSIT or DCVT and basal ARR were reassessed postoperatively.

RESULTS

Two of the 41 patients failed to suppress aldosterone post-surgery, leading to a post-adrenalectomy biochemical cure rate of 95%, while blood pressure was improved in 36 patients, leading to a clinical cure rate of 88% as assessed by the DDD methodology.

CONCLUSIONS

The present study was a proof-of-concept process to validate two modified diagnostic tests for PA in clinical practice. These tests, used to diagnose a group of patients with PA, successfully assessed their biochemical cure post-adrenalectomy at rates similar to those reported in the literature.

Surgical Outcomes Among Primary Aldosteronism Patients Without Visible Adrenal Lesions

CONTEXT

Many patients with unilateral primary aldosteronism (PA) have normal adrenal imaging, but little is known about their outcome following adrenalectomy.

OBJECTIVE

To evaluate biochemical and clinical outcomes after adrenalectomy in patients with unilateral PA and normal-appearing adrenal imaging.

DESIGN

Retrospective cohort study of patients seen between January 2006 and May 2018.

SETTING

A Canadian tertiary care PA referral center.

PATIENTS

Consecutive individuals with PA, normal cross-sectional adrenal imaging, and lateralizing adrenal vein sampling (AVS) who underwent adrenalectomy during the study period.

PRIMARY OUTCOME

Biochemical response to adrenalectomy graded according to the Primary Aldosteronism Surgical Outcome criteria.

RESULTS

A total of 40 patients were included. Biochemical outcomes were available for 33 people (mean age, 54.7 years; 91% male; median follow-up, 2.7 months), with 28 (85%) showing a complete or partial response and 5 (15%) with no response. Clinical outcomes were available for 36 people (mean age, 54.6 years; 86% male; median follow-up, 9.8 months), with 31 (86%) demonstrating a complete or partial response and 5 (14%) with no response.

CONCLUSIONS

The prognosis after adrenalectomy is highly favorable for patients with unilateral PA and normal-appearing adrenal imaging. Patients with lateralizing disease should be considered for surgery despite apparently normal adrenal imaging.

The Primary Aldosteronism Surgical Outcome Score for the Prediction of Clinical Outcomes After Adrenalectomy for Unilateral Primary Aldosteronism

OBJECTIVE

To develop a prediction model for clinical outcomes after unilateral adrenalectomy for unilateral primary aldosteronism.

SUMMARY BACKGROUND DATA

Unilateral primary aldosteronism is the most common surgically curable form of endocrine hypertension. Surgical resection of the dominant overactive adrenal in unilateral primary aldosteronism results in complete clinical success with resolution of hypertension without antihypertensive medication in less than half of patients with a wide between-center variability.

METHODS

A linear discriminant analysis model was built using data of 380 patients treated by adrenalectomy for unilateral primary aldosteronism to classify postsurgical clinical outcomes. The total cohort was then randomly divided into training (280 patients) and test (100 patients) datasets to create and validate a score system to predict clinical outcomes. An online tool (Primary Aldosteronism Surgical Outcome predictor) was developed to facilitate the use of the predictive score.

RESULTS

Six presurgical factors associated with complete clinical success (known duration of hypertension, sex, antihypertensive medication dosage, body mass index, target organ damage, and size of largest nodule at imaging) were selected based on classification performance in the linear discriminant analysis model. A 25-point predictive score was built with an optimal cut-off of greater than 16 points (accuracy of prediction = 79.2%; specificity = 84.4%; sensitivity = 71.3%) with an area under the curve of 0.839.

CONCLUSIONS

The predictive score and the primary aldosteronism surgical outcome predictor can be used in a clinical setting to differentiate patients who are likely to be clinically cured after surgery from those who will need continuous surveillance after surgery due to persistent hypertension.

Taiwan mini-frontier of primary aldosteronism: Updating detection and diagnosis

BACKGROUND

To update information about the internationally accepted standards and clinical recommendations for the detection and diagnosis of primary aldosteronism (PA).

METHODS

The Taiwan Society of Aldosteronism (TSA) Task Force reviewed the latest literature and reached a consensus after group meetings. The nine critical issues were recognized to provide updated information and internationally acceptable protocols.

RESULTS

When screening for PA by using the plasma aldosterone concentration (PAC) to plasma renin activity (PRA) ratio (ARR), withdrawal or adjustment of antihypertensive medication is not always necessary on the first patient visit. Hypokalemia should be corrected before ARR screening. In spontaneous hypokalemia, plasma renin below detection levels, and PAC higher than 20 ng/dL (550 pmol/L), further confirmatory testing is unnecessary for PA diagnosis. Direct renin concentration (DRC) could be used for PA diagnosis if PRA is unavailable. Although additional confirmatory tests are suggested, the result of a single test is still reliable. For patient safety, discontinuation or adjustment of antihypertensive medications is indicated before adrenal venous sampling (AVS). ACTH could be beneficial for successful adrenal vein cannulation but is not necessary for determining lateralization in AVS. Simultaneous technique is preferred for AVS. Adrenal NP-59 scintigraphy integrated with SPECT/CT could guide PA management.

CONCLUSION

With introduction of these new concepts to the clinicians, we expect better identification, management and treatment of PA patients.

Appropriate timing for a biochemical evaluation after adrenalectomy for unilateral aldosterone-producing adenoma

CONTEXT

The oversecretion of plasma aldosterone by unilateral aldosterone-producing adenoma (APA) can be cured by adrenalectomy. However, the time needed for the endocrine environment to normalize remains unclear.

OBJECTIVE

To clarify adequate timing for a biochemical evaluation in unilateral APA patients after adrenalectomy.

DESIGN AND PATIENTS

A total of 166 unilateral APA patients were retrospectively reviewed. We evaluated the plasma aldosterone concentration (PAC) (pg/mL), active renin concentration (ARC) (pg/mL), aldosterone-renin ratio (ARR; PAC/ARC), serum potassium concentration and estimated glomerular filtration rate (eGFR) at 1, 3 and 6 postoperation months (POM).

RESULTS

PAC was significantly lower at 1POM than at presurgery (presurgery; 407.2, 1 POM; 90.0 pg/mL, P < .001). ARC did not increase from baseline at 1POM, but significantly increased at 3POM (presurgery; 4.43, 1POM; 4.87, 3POM; 11.3 pg/mL, P < .001). ARR significantly decreased at 1POM (presurgery; 146.9, 1 POM; 26.3, P < .001) although ARC did not increase at 1POM. Among the 34 patients who had hypokalaemia presurgery, it was resolved in 28 (82%) at 1POM and in all (100%) at 3POM. The biochemical outcomes at 1POM were 131 (79%) complete, 20 (12%) partial and 15 (9%) absent successes, while at 3POM, 147 (89%) were complete, 9 (5%) partial and 10 (6%) absent. Twenty-three (14%) patients were reclassified into different biochemical outcomes between 1 and 3POM, whereas only 5 (3%) changed between 3 and 6POM.

CONCLUSION

The appropriate timing for a biochemical evaluation of unilateral APA patients treated with laparoscopic adrenalectomy appears to be 3 months or more after surgery.

Steroid Profiling and Immunohistochemistry for Subtyping and Outcome Prediction in Primary Aldosteronism-a Review

PURPOSE OF REVIEW

Steroid profiling and immunohistochemistry are both promising new tools used to improve diagnostic accuracy in the work-up of primary aldosteronism (PA) and to predict treatment outcomes. Herein, we review the recent literature and present an outlook to the future of diagnostics and therapeutic decision-making in patients with PA.

RECENT FINDING

PA is the most common endocrine cause of arterial hypertension and unilateral forms of the disease are potentially curable by surgical resection of the overactive adrenal. Recent studies have shown that adrenal steroid profiling by liquid chromatography-tandem mass spectrometry (LC-MS/MS) can be helpful for subtyping unilateral and bilateral forms of PA, classifying patients with a unilateral aldosterone-producing adenoma (APA) according to the presence of driver mutations of aldosterone production in APAs, and potentially predicting the outcomes of surgical treatment for unilateral PA. Following adrenalectomy, immunohistochemistry of aldosterone synthase (CYP11B2) in resected adrenals is a new tool to analyze "functional" histopathology and may be an indicator of biochemical outcomes after surgery. Biochemical and clinical outcomes of therapy in PA vary widely among patients. Peripheral venous steroid profiling at baseline could improve diagnostic accuracy and help in surgical decision-making in cases of a suspected APA; results of "functional" histopathology could help determine which patients are likely to need close post-surgical follow-up for persistent aldosteronism.

Effectiveness of Thermal Ablation for Aldosterone-Producing Adrenal Adenoma: A Systematic Review and Meta-Analysis of Clinical and Biochemical Parameters

PURPOSE

To assess the effectiveness of thermal ablation for aldosterone-producing adrenal adenoma.

MATERIALS AND METHODS

A systematic search of the PubMed and CINAHL databases was performed to identify studies of thermal ablation for adrenal adenomas. Random effects meta-analysis models were used to compare pre- and post-treatment values of the following outcomes: systolic blood pressure (SBP), diastolic blood pressure (DBP), use of antihypertensive medications, and biochemical parameters (plasma aldosterone levels, aldosterone-to-renin ratio, and potassium levels). The rate of hypertension (HTN) resolution and improvement were also evaluated.

RESULTS

A total of 89 patients from 7 studies were included in the analysis. The mean postablation follow-up duration was 45.8 months. Pooled data analysis revealed a statistically significant decrease in SBP (-29.06 mm Hg; 95% confidence interval [CI], -33.93 to -24.19), DBP (-16.03 mm Hg; 95% CI, -18.33 to -13.73), and the number of antihypertensive medications used (-1.43; 95% CI, -1.97 to -0.89) after ablation. Biochemical parameters had returned to normal ranges after ablation in all studies. The cumulative rate of resolution or improvement in HTN status was 75.3%. On metaregression analysis, there was no statistically significant association between postablation blood pressure changes or serum aldosterone levels and study follow-up duration.

CONCLUSIONS

Thermal ablation for aldosterone-producing adrenal adenoma can be effective in controlling blood pressure, reducing the need for antihypertensive medications, and normalizing hormone secretion. Further higher-quality evidence is needed to confirm these results.

Effect of unilateral adrenalectomy on the quality of life of patients with lateralized primary aldosteronism

Background

Primary aldosteronism (PA) is associated with an increased prevalence of anxiety and depression. Subnormal quality of life (QoL) scores in PA patients may be improved after surgical treatment. The aim of the study was to assess the impact of surgery on health-related QoL and depression status of patients suffering from PA, comparing the results with a control group of patients undergoing surgery for non-secreting adrenal tumors.

Methods

Data on QoL and depression status were prospectively collected, from January 2014 to January 2017, before, early after surgery (at 1 month) and at late follow up (at least 6 months) in patients with unilateral PA and in a control group with non-secreting adrenal tumors submitted to unilateral laparoscopic adrenalectomy. QoL was assessed using the Short Form 36 (SF-36) Health Survey for Physical (PCS) and Mental Component (MCS); the depression status by a 20-item depression scale (DS) questionnaire.

Results

Twenty-six PA patients and 15 controls were recruited. Biochemical cure of the disease was achieved following surgery in all PA patients; hypertension was cured in 31% of cases and improved in the remaining 69% of cases. No morbidity occurred in both groups. There were no significant differences between PA patients and controls concerning demographics, preoperative PCS, MCS and DS values. In patients with PA, MCS values improved at early (42.72 ± 13.68 vs 51.56 ± 9.03, p = 0.0005) and late follow up (42.72 ± 13.68 vs 51.81 ± 7.04, p < 0.0001); also DS values improved at early (15.92 ± 11.98 vs 8.3 ± 8.8, p = 0.0002) and late follow up (15.92 ± 11.98 vs 4.57 ± 6.11, p < 0.0001). In PA patients PCS values significantly improved at late follow up (51.02 ± 8.04 vs 55.85 ± 5.1, p = 0.013). Also in controls an improvement of MCS and DS scores was found at early and late follow up compared to preoperative values, while no significant differences in PCS were found.

Conclusions

Both PA and non-secreting adrenal tumors affect health-related QoL, worsening MCS and DS scores. Adrenalectomy is effective in curing PA, and improving MCS and DS scores at early and late follow-up, in patients with PA and non-secreting adrenal tumors. In PA patient surgery also significantly improves PCS at late follow up.

Primary aldosteronism with nonlocalizing imaging

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.

Mineralocorticoid receptor antagonism protects the aorta from vascular smooth muscle cell proliferation and collagen deposition in a rat model of adrenal aldosterone-producing adenoma

The number of patients with adrenal aldosterone-producing adenomas (APAs) has gradually increased. However, even after adenoma resection, some patients still suffer from high systolic blood pressure (SBP), which is possibly due to great arterial remodeling. Moreover, mineralocorticoid receptors (MRs) were found to be expressed in vascular smooth muscle cells (VSMCs). This study aims to determine whether MR antagonism protects the aorta from aldosterone-induced aortic remolding. Male rats were subcutaneously implanted with an osmotic minipumps and randomly divided into four groups: control; aldosterone (1 μg/h); aldosterone plus a specific MR antagonist, eplerenone (100 mg/kg/day); and aldosterone plus a vasodilator, hydralazine (25 mg/kg/day). After 8 weeks of infusion, aortic smooth muscle cell proliferation and collagen deposition, as well as the MDM2 and TGF-β1 expression levels in the aorta, were examined. Model rats with APAs were successfully constructed. Compared with the control rats, the model rats exhibited (1) marked SBP elevation, (2) no significant alteration in aortic morphology, (3) increased VSMC proliferation and MDM2 expression in the aorta, and (4) enhanced total collagen and collagen III depositions in the aorta, accompanied with up-regulated expression of TGF-β1. These effects were significantly inhibited by co-administration with eplerenone but not with hydralazine. These findings suggested that specific MR antagonism protects the aorta from aldosterone-induced VSMC proliferation and collagen deposition.

Body mass index and contralateral ratio predict outcome following unilateral adrenalectomy in primary aldosteronism

The effect of unilateral adrenalectomy on blood pressure (BP) outcome in primary aldosteronism (PA) is diverse. Therefore, we sought to investigate the preoperative factors contributing to postoperative BP outcome. Data for 96 PA patients who underwent unilateral adrenalectomy at our institution from January 2000 to February 2015 were retrospectively collected. Based on postoperative BP after a 12-month follow-up period, the patients were categorized into two groups: cured (C) (<140/90 mm Hg with no antihypertensive drug) and not cured (NC) (if not normotensive). Patient demographics, blood and urine data, data of loading tests and adrenal vein sampling were evaluated. In all, 46 patients were categorized as C and 50 patients as NC. There were significantly more males in the NC group. Age, body mass index (BMI), number of antihypertensive drugs prescribed, serum uric acid concentration and contralateral ratio (CR) after adrenocorticotropic hormone stimulation were significantly higher in the NC group. In the multivariate model, BMI and CR significantly correlated with resolution outcome. The optimal cutoff values were 23.3 kg m^-2 for BMI and 0.5 for CR, and when both parameters were used as predictors, the most optimal cutoff values for BMI and CR were 25.2 kg m^-2 and 0.1, respectively. BMI and CR significantly correlated with BP outcome after adrenalectomy. To our knowledge, this is the first report to show that in addition to BMI, CR is a factor in postoperative BP outcome and to determine the optimal cutoff values of BMI and CR and calculate their sensitivities and specificities.

Endocrine Tumors Causing Arterial Hypertension: Pathophysiological Mechanisms and Clinical Implications

Some tumors are a relatively rare and amendable cause of hypertension, often associated with a higher cardiovascular morbidity and mortality, as compared with that of both general population and patients with essential hypertension. This worse prognosis is not entirely related to blood pressure increase, because the release of substances from the tumor can directly influence blood pressure behavior. Diagnostic approach is challenging and needs a deep knowledge of the different neuro-hormonal and genetic mechanisms determining blood pressure increase. Surgical tumor removal can, but not always, cause blood pressure normalization, depending on how early was tumor detection, since a long-standing history of hypertension is often associated with a much weaker effect on blood pressure. Moreover, target organ damage can be affected by the substances themselves released by the tumors as well as by tumor removal. In this review we consider the phenotype and genetic features of patients with tumor-induced hypertension and focus on their diagnostic work-up.

Development of novel nomograms to predict renal functional outcomes after laparoscopic adrenalectomy in patients with primary aldosteronism

PURPOSE

Most patients with primary aldosteronism (PA) show a significant decrease in kidney function after surgery. Glomerular hyperfiltration peculiar to PA can mask mild renal failure before surgery. The aim of this retrospective study was to investigate postoperative renal functional outcomes in PA patients from different viewpoints and to develop novel nomograms that can predict renal functional outcomes in PA patients after surgery.

METHODS

130 Japanese PA patients treated by unilateral laparoscopic adrenalectomy were retrospectively surveyed. Pre- and postoperative changes of estimated glomerular filtration rates (eGFRs) and the distribution of eGFR classification were compared. Furthermore, predictors of the following renal functional outcomes were investigated: (I) the percentage decrease >25% in eGFR and (II) the presence of new-onset eGFR <45 ml/min/1.73 m². Finally, two nomograms that predicted postoperative renal functional outcomes were developed and internally validated.

RESULTS

At 6 months, the average decrease in eGFR was 16.7 mL/min/1.73 m² (corresponding percent decrease: 19.7%). Upstaging of eGFR classification was observed in 54.6% of patients. Age, potassium, plasma aldosterone concentration, and initial eGFR were incorporated into a nomogram predicting a >25% postoperative decrease in eGFR. Duration of hypertension and initial eGFR were incorporated into a nomogram predicting new-onset eGFR <45 ml/min/1.73 m². The value of the area under the receiver operating characteristics curve for each nomogram was 0.82 and 0.74, respectively.

CONCLUSION

The first nomograms that can predict postoperative renal outcomes in PA patients were developed. They will help clinicians calculate the probability of renal dysfunction in PA patients after laparoscopic adrenalectomy.

The prevalence of CTNNB1 mutations in primary aldosteronism and consequences for clinical outcomes

Constitutive activation of the Wnt pathway/β-catenin signaling may be important in aldosterone-producing adenoma (APA). However, significant gaps remain in our understanding of the prevalence and clinical outcomes after adrenalectomy in APA patients harboring CTNNB1 mutations. The molecular expression of CYP11B2 and gonadal receptors in adenomas were also explored. Adenomas from 219 APA patients (95 men; 44.2%; aged 50.5 ± 11.9 years) showed a high rate of somatic mutations (n = 128, 58.4%). The majority of them harbored KCNJ5 mutations (n = 116, 52.9%); 8 patients (3.7%, 6 women) had CTNNB1 mutations. Patients with APAs harboring CTNNB1 mutations were older and had shorter duration of hypertension. After adrenalectomy, CTNNB1 mutation carriers had a higher possibility (87.5%) of residual hypertension than other APA patients. APAs harboring CTNNB1 mutations have heterogeneous staining of β-catenin and variable expression of gonadal receptors and both CYP11B1 and CYP11B2. This suggests that CTNNB1 mutations may be more related to tumorigenesis rather than excessive aldosterone production.

Non-stimulated adrenal venous sampling using Dyna computed tomography in patients with primary aldosteronism

In this retrospective study, we aimed to examine the effect of applying Dyna computed tomography (CT) on the success rate of adrenal venous sampling (AVS) without adrenocorticotropic hormone stimulation. A total of 100 consecutive patients with primary aldosteronism who underwent AVS between May 2012 and July 2015 were enrolled. In all the cases, Dyna CT was used in AVS to validate catheter position in the right adrenal vein. A selectivity index (cortisol_{adrenal vein} /cortisol_{inferior vena cava}) of ≥2.0 of both adrenal veins were required for successful AVS. Dyna CT indicated misplaced catheters in 16 patients; of these patients, 75% (12/16) eventually had successful right AVS after catheter repositioning. The success rate of initial sampling at the right adrenal vein was 76% (76/100), which increased to 88% (88/100) after Dyna CT was applied (p < 0.001). The most common inadvertently catheterised vessels detected using Dyna CT were the accessory hepatic veins (56.3%, 9/16), followed by the renal capsular veins (37.5%, 6/16). The overall success rate of non-stimulated AVS using Dyna CT was 87% (87/100). Thus, the application of Dyna CT further increased the success rate of non-stimulated AVS.

Is Laparoendoscopic Single-Site Adrenalectomy a Feasible Alternative in Treating Aldosterone-Producing Adenoma?

Objective. To compare laparoendoscopic single-site (LESS) and conventional multiport adrenalectomy in patients with aldosterone-producing adenoma (APA). Material and Methods. We retrospectively reviewed patients who had been clinically confirmed with unilateral APA and who underwent LESS or multiport adrenalectomy between 2009 and 2014. Perioperative data were obtained for all patients. Blood pressure and the levels of serum aldosterone, renin, and potassium were checked periodically. Results. We identified 45 APA patients in the LESS group and 71 in the multiport group. The baseline characteristics were matched between two groups. All adrenalectomies were completed successfully, except one with laparoscopic conversion in the single-port group and one open conversion in the multiport group. After a mean follow-up around one year, there were no significant group differences in the improvement of hypertension, number of types of medication taken, and cure of hypokalemia after operation. Conclusions. Our study confirm that LESS adrenalectomy achieved similar clinical and functional outcomes as conventional multiport adrenalectomy for management of unilateral APA.

Primary Aldosteronism: Changing Definitions and New Concepts of Physiology and Pathophysiology Both Inside and Outside the Kidney

In the 60 years that have passed since the discovery of the mineralocorticoid hormone aldosterone, much has been learned about its synthesis (both adrenal and extra-adrenal), regulation (by renin-angiotensin II, potassium, adrenocorticotrophin, and other factors), and effects (on both epithelial and nonepithelial tissues). Once thought to be rare, primary aldosteronism (PA, in which aldosterone secretion by the adrenal is excessive and autonomous of its principal regulator, angiotensin II) is now known to be the most common specifically treatable and potentially curable form of hypertension, with most patients lacking the clinical feature of hypokalemia, the presence of which was previously considered to be necessary to warrant further efforts towards confirming a diagnosis of PA. This, and the appreciation that aldosterone excess leads to adverse cardiovascular, renal, central nervous, and psychological effects, that are at least partly independent of its effects on blood pressure, have had a profound influence on raising clinical and research interest in PA. Such research on patients with PA has, in turn, furthered knowledge regarding aldosterone synthesis, regulation, and effects. This review summarizes current progress in our understanding of the physiology of aldosterone, and towards defining the causes (including genetic bases), epidemiology, outcomes, and clinical approaches to diagnostic workup (including screening, diagnostic confirmation, and subtype differentiation) and treatment of PA.

Radiofrequency ablation compared with laparoscopic adrenalectomy for aldosterone-producing adenoma

BACKGROUND

Radiofrequency ablation (RFA) is an emerging treatment for primary aldosteronism owing to aldosterone-producing adenoma. Whether RFA could be an alternative treatment to laparoscopic adrenalectomy is unknown.

METHODS

This was a retrospective comparative study in patients with aldosterone-producing adenoma undergoing either laparoscopic adrenalectomy or CT-guided percutaneous RFA between 2004 and 2012. Short-term outcomes and long-term resolution rates of primary aldosteronism (normalized aldosterone to renin ratio), hypokalaemia and hypertension (BP lower than 140/90 mmHg without antihypertensive medical therapy) were evaluated.

RESULTS

Some 63 patients were included, 27 in the laparoscopic adrenalectomy group and 36 in the RFA group. RFA was associated with shorter duration of operation (median 12 versus 124 min; P < 0·001), shorter hospital stay (2 versus 4 days; P < 0·001), lower analgesic requirements (13 of 36 versus 23 of 27 patients; P < 0·001) and earlier resumption of work (median 4 versus 14 days; P = 0·006). Morbidity rates were similar in the two groups. With median follow-up of 5·7 (range 1·9-10·6) years, resolution of primary aldosteronism was seen in 33 of 36 patients treated with RFA and all 27 patients who had laparoscopic adrenalectomy (P = 0·180). Hypertension was resolved less frequently after treatment with RFA compared with laparoscopic adrenalectomy (13 of 36 versus 19 of 27 patients; P = 0·007). Hypokalaemia was resolved in all patients.

CONCLUSION

For patients with aldosterone-producing adenoma the efficacy of resolution of primary aldosteronism and hypertension was inferior after treatment with RFA compared with laparoscopic adrenalectomy.

Risk factors for renal impairment revealed after unilateral adrenalectomy in patients with primary aldosteronism

Primary aldosteronism (PA) may induce significant decline of renal function and structural damage of kidney. However, it is difficult to evaluate accurate renal function in patients with PA, because glomerular hyperfiltration and aldosterone escape can conceal renal impairment. In this retrospective cohort study, we compared changes in renal function after unilateral adrenalectomy between patients with PA and patients with other adrenal diseases. Risk factors associated with postoperative renal impairment in patients with PA were analyzed.A total of 558 patients who received unilateral adrenalectomy between January 2002 and June 2013 were included: 136 patients with PA and 422 patients with other adrenal diseases (control). Postoperative serial changes in estimated glomerular filtration rate (eGFR) were analyzed in both groups. Multivariate analyses were performed to identify risk factors of renal impairment after adrenalectomy in all patients and the PA group. Postoperative renal impairment was defined as postoperative eGFR decline of >25% from preoperative eGFR. Chronic kidney disease (CKD) was defined as an eGFR <60 mL/min/1.73 m.There were no differences in preoperative eGFR between groups. The PA group showed a significant decrease in eGFR 3 days, 2 weeks, and 6 months after surgery compared to the control group. The PA group showed significant improvement of hypertension after surgery. In the PA group, 53 (39.0%) patients showed postoperative renal impairment. Multivariate regression analysis identified long-standing hypertension, low body mass index, low serum potassium, and high preoperative eGFR as risk factors for postoperative renal impairment. Among the 89 patients with preoperative eGFR ≥60 mL/min/1.73 m, 29 (32.6%) patients developed CKD postoperatively. Age, low serum potassium, low preoperative eGFR, and high serum cholesterol or uric acid were associated with the postoperative CKD development.Our study demonstrates that patients with PA with old age, low serum potassium, long-standing hypertension, and high serum uric acid or cholesterol are at risk of renal impairment after surgical treatment. High preoperative eGFR was also a risk factor for postoperative renal impairment, whereas low preoperative eGFR was a risk factor for postoperative CKD. Close monitoring of renal function and adequate management are required for patients with these risk factors.

Evaluation of right adrenal vein anatomy by Dyna computed tomography in patients with primary aldosteronism

Primary aldosteronism (PA) is the most common cause of secondary hypertension and consists up to 11% of patients with hypertension. Adrenal venous sampling (AVS) is the recommended procedure for diagnosis of PA, but the technique is difficult and the right adrenal vein is especially hard to catheterize. We retrospectively examined the clinically relevant anatomy of the right adrenal vein in a sample of 66 PA patients with technically successful AVS and distinctly-opacified right adrenal veins in Dyna computed tomography (CT). In the majority of cases: the right adrenal veins were catheterized when the catheter tilted posterior and rightward (57/66, 86.4%), the transverse direction of the right adrenal vein from the inferior vena cava (IVC) was posterior and rightward (55/66, 83.3%), and the vertical direction of the right adrenal vein from the IVC was caudal (52/66, 78.8%). This study shows that Dyna CT is able to provide detailed anatomical information to the course and direction of the right adrenal vein.

Gene Expression Profile of Persistent Postoperative Hypertension Patients with Aldosterone-producing Adenomas

Background:

Hypertension often persists after adrenalectomy for primary aldosteronism (PA). Many studies have analyzed the outcomes of adrenalectomy for aldosterone-producing adenomas (APA) to identify predictive factors for persistent hypertension. However, differentially expressed genes in persistent postoperative hypertension remain unknown. Our aim was to describe gene expression profile of persistent postoperative hypertension patients with APA.

Methods:

In this study, we described and compared gene expression profiles in persistent postoperative hypertension and postoperative normotension in Chinese patients with APA using microarray analysis. Confirmation was performed with quantitative real time-polymerase chain reaction analysis. Bioinformatic analysis (gene ontology analysis, pathway analysis and network analysis) was used for further research.

Results:

Microarray analysis identified a total of 99 differentially expressed genes, including 18 up-regulated and 81 down-regulated genes. Among the dysregulated genes were fat atypical cadherin 1 as well as fatty acid binding protein 4 and other genes that have not been previously studied in persistent postoperative hypertension with APA. Bioinformatics analysis indicated that differentially expressed genes were associated with lipid metabolic process, metal ion binding, and cell differentiation. Pathway analysis determined that five pathways corresponded to the dysregulated transcripts. The mRNAs-ncRNAs co-expression network was composed of 49 network nodes and 72 connections between 18 coding genes and 31 noncoding genes.

Conclusions:

This study revealed differentially expressed genes in persistent postoperative hypertension with APA and provided a resource of candidate genes for exploration of possible drug targets and prognostic markers.

Laparoendoscopic single-site adrenalectomy in patients with primary hyperaldosteronism: A prospective study with long-term follow up

OBJECTIVE

Laparoendoscopic single-site (LESS) adrenalectomy is a promising minimally invasive technique, however, the current evidence has not confirmed its long-term effectiveness in primary aldosteronism (PA). We conducted a study to analyze the long-term efficacy of LESS adrenalectomy in patients with PA.

METHODS

A total of 49 patients who had been clinically confirmed with PA who had an indication for unilateral adrenalectomy were included in this study. Perioperative data were obtained for all patients. Blood pressure and the levels of serum aldosterone, renin, and potassium were checked periodically. The median follow-up was 16.5 months.

RESULTS

No intra- or early post-operative complication occurred. All LESS adrenalectomies were completed successfully, except one with laparoscopic conversion. Hypokalemia was resolved in all cases and no patient required potassium supplements after surgery. Post-operative cure of hypertension was achieved in 63% of our patients. Overall, 84% of our PA patients had clinical improvement in blood pressure control after surgery.

CONCLUSIONS

Our long-term experience revealed that LESS adrenalectomy is a safe and effective approach, which demonstrated comparable long-term cure and improvement of hypertension to a conventional laparoscopic series in treating PA.

Resistant hypertension with adrenal nodule: are we removing the right gland?

Resistant hypertension is often difficult to treat and may be associated with underlying primary aldosteronism (PA). We describe the case of an elderly gentleman who presented with severe and resistant hypertension and was found to have a left adrenal incidentaloma during evaluation but had aldosterone excess secondary to unilateral adrenal hyperplasia (UAH) of the contralateral gland, which needed surgical intervention. A 65-year-old gentleman was evaluated for uncontrolled high blood pressure (BP) in spite of taking four antihypertensive medications. The high BP was confirmed on a 24-h ambulatory reading, and further biochemical evaluation showed an elevated serum aldosterone renin ratio (ARR) (1577 pmol/l per ng per ml per h). Radiological evaluation showed an adrenal nodule (15 mm) in the left adrenal gland but an adrenal vein sampling demonstrated a lateralization towards the opposite site favouring the right adrenal to be the source of excess aldosterone. A laparoscopic right adrenalectomy was performed and the histology of the gland confirmed nodular hyperplasia. Following surgery, the patient's BP improved remarkably although he remained on antihypertensives and under regular endocrine follow-up. PA remains the most common form of secondary and difficult-to-treat hypertension. Investigations may reveal incidental adrenal lesions, which may not be the actual source of excess aldosterone, but UAH may be a contributor and may coexist and amenable to surgical treatment. An adrenal vein sampling should be undertaken for correct lateralization of the source, otherwise a correctable diagnosis may be missed and the incorrect adrenal gland may be removed.

Development of a novel nomogram to predict hypertension cure after laparoscopic adrenalectomy in patients with primary aldosteronism

BACKGROUND

Primary aldosteronism is the most common curable cause of secondary hypertension. Despite resection, however, many patients with primary aldosteronism continue to require antihypertensive drugs to control their blood pressure. Although many patients with primary aldosteronism want to know the postoperative probability of hypertension cure before surgery, there are no predictive models calculating its probability. We therefore developed a nomogram to predict hypertension cure in patients with primary aldosteronism after laparoscopic adrenalectomy.

METHODS

We retrospectively surveyed 132 Japanese patients with primary aldosteronism who were treated by unilateral laparoscopic adrenalectomy. Hypertension cure was defined as normal blood pressure (<140/90 mmHg) without antihypertensive drugs 6 months postoperatively. We developed a novel nomogram that postoperatively predicted cured hypertension in 105 (80 %) randomly selected patients and validated it with the remaining 27 (20 %).

RESULTS

At 6 months, blood pressure had normalized in 42 % of patients without antihypertensive drugs. Duration of hypertension, preoperative number of antihypertensive drug classes, age, and sex were incorporated into a novel nomogram as independent predictors of hypertension cure. The value of the area under the receiver operating characteristics curve for this nomogram was 0.83-which was significantly higher than that of the Aldosteronoma Resolution Score-on internal validation.

CONCLUSIONS

We developed the first nomogram that can accurately predict postoperative hypertension cure in patients with primary aldosteronism. This nomogram can help clinicians calculate the probability of postoperative hypertension cure in patients with primary aldosteronism and objectively inform them of their hypertension outcome before laparoscopic adrenalectomy.

Contralateral adrenal abnormalities in Conn's syndrome

BACKGROUND

During the course of evaluation for primary hyperaldosteronism, cross-sectional imaging is obtained in efforts to identify patients with an aldosterone producing adenoma (APA). A subset of these patients will have a synchronous, contralateral adrenal abnormality. Adrenal vein sampling (AVS) further guides clinical decision making by identifying unilateral (APA) versus bilateral hypersecretion. In the subset of patients with contralateral adrenal abnormalities, it is unclear how this affects the durability of an adrenalectomy for APA. This study characterizes this group of patients to assess the efficacy of surgical intervention.

METHODS

A retrospective review of patients undergoing adrenalectomy for APA based on AVS at a university practice. Preoperative and postoperative patient characteristics, laboratory evaluations, imaging results, and final pathology were noted.

RESULTS

From 2000 to 2011, 103 patients with APA underwent unilateral adrenalectomy. Eighteen patients (17%) had discordant results between AVS and imaging. Most of these patients were male (78%), and the mean age was 57 ± 13 y. Median duration of follow-up was 3.5 y [1 y, 6 y]. All patients with initial hypokalemia were rendered normokalemic after the operation. Four patients increased their antihypertensive regimen during the follow-up period. These patients all had nodular hyperplasia on final pathology.

CONCLUSIONS

In patients with bilateral adrenal abnormalities who have undergone unilateral adrenalectomy for primary hyperaldosteronism, patients with clear APAs on final pathology appear to have durable outcomes after resection. Conversely, nodular hyperplasia on final pathology may be a risk factor for ongoing aldosterone hypersecretion. An algorithm for biochemical surveillance in this subset of patients should be considered.

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.

Aldosteronoma resolution score predicts long-term resolution of hypertension

BACKGROUND

The Aldosteronoma Resolution Score (ARS) takes into consideration four, readily available, preoperative clinical parameters in predicting the likelihood of resolution of hypertension in patients 6 months after undergoing unilateral adrenalectomy for aldosterone-producing adenoma (APA). We sought to determine the durability of this predictive model after 1 year.

METHODS

Sixty patients who underwent unilateral adrenalectomy for APA at a single institution between 2004 and 2013 were reviewed retrospectively. Patients who were normotensive without any antihypertensive medication requirement at greater than 1-year follow-up were considered to have complete resolution of hypertension.

RESULTS

Forty-seven patients had data available for analysis. Median follow-up was 1,135 days (371-3,202). Forty-five percent of patients had complete resolution, 45% had improvement, and 10% had no improvement in hypertension. Applying the ARS, we found there was complete resolution of hypertension in 73% of patients with ARS 4-5, 53% of patients with ARS 2-3, and 24% of patients with ARS 0-1 compared with 75% (P = .9), 46% (P = .66), and 28% (P = .76), respectively, in the original cohort used to create the ARS.

CONCLUSION

Most patients (90%) have long-term improvement or complete resolution of hypertension after unilateral adrenalectomy for APA. The ARS predicts accurately a patient's likelihood of complete resolution of hypertension beyond 1 year.

Long-term blood pressure control in patients undergoing adrenalectomy for primary hyperaldosteronism

BACKGROUND

Data on long-term blood pressure (BP) control after adrenalectomy for primary hyperaldosteronism are limited. We analyzed long-term outcomes to identify factors predictive of cure.

METHODS

We performed a retrospective cohort study of patients undergoing adrenalectomy for primary hyperaldosteronism (1997-2013). BP and antihypertensive medications were assessed at long-term follow-up (≥ 12 months). Primary outcome was cure, defined as normotension off antihypertensives.

RESULTS

Of 85 patients, 15.3% (n = 13) were cured, 54.1% (n = 46) were normotensive while remaining on anti-hypertensives, and 30.6% (n = 26) were hypertensive. Younger age (P = .011), female sex (P < .001), lesser body mass index (P = .018), shorter duration of hypertension (P = .002), lower creatinine (P = .001), and fewer preoperative antihypertensive medications (P < .001) were associated with cure. Female sex, body mass index ≤ 25 kg/m(2), hypertension <5 years, creatinine ≤ 0.8 mg/dL, and <2 antihypertensives were incorporated into a scoring system. For a score of 0-1 (n = 61) the cure rate was 3%; 100% of patients with a score of 4-5 (n = 3) were cured. This scoring system performed comparably to the Aldosterone Resolution Score, which has been used to evaluate short-term postoperative outcomes.

CONCLUSION

This is the largest study to identify factors associated with long-term BP control after adrenalectomy and incorporate these into a scoring system. These data provide a potential tool to guide preoperative patient counseling.

The value of losartan suppression test in the confirmatory diagnosis of primary aldosteronism in patients over 50 years old

OBJECTIVE

The diagnosis of primary aldosteronism (PA) among the older-aged population has posed a crucial challenge. Among patients over 50 years old, this trial assessed comparability of the performance of two PA diagnostic tests: losartan and captopril suppression tests.

METHODS

A post-hoc subgroup analysis from a prospective cohort was conducted by the TAIPAI (Taiwan Primary Aldosteronism Investigation) group between July 2003 and July 2006. Of the 160 patients in the cohort, 60 patients over 50 years old received captopril and losartan tests to confirm PA.

RESULTS

Among the 60 patients over 50 years old, 31 patients had PA confirmed by standardized protocol. The area under the receiver-operating characteristic (ROC) curve for post-captopril aldosterone was significantly less than that for post-losartan plasma aldosterone concentration (PAC) (0.87 vs 0.94, p=0.02). Using the aldosterone-renin ratio (ARR)>35 with PAC>10 ng/dl, the specificity was 82.76% vs 93.1% and the sensitivity was 77.42% vs 87.10% for the captopril and losartan tests, respectively. The equivalence between the two tests were confirmed by the exact McNemar's test (p=1.0).

CONCLUSION

The losartan test showed comparable accuracy to confirm PA. Verification of this "elderly-friendly" confirmatory test will be the first step to prepare a specific diagnostic model of PA for the older-aged population.