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Marzano L, Ronco C. Clinical and biochemical outcomes after adrenalectomy for primary aldosteronism in tertiary and quaternary referral centers: data from SOPRANO study. Hypertens Res 2024; 47:721-734. [PMID: 38182902 DOI: 10.1038/s41440-023-01554-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/04/2023] [Accepted: 11/20/2023] [Indexed: 01/07/2024]
Abstract
Hypertension cure following adrenalectomy in unilateral primary aldosteronism (PA) remains uncertain. Previous meta-analyses have shown highly variable surgical outcomes. Our study aimed to determine the unknown proportion of complete clinical and biochemical success in tertiary and quaternary referral centers. We conducted a systematic review and meta-analysis of studies reporting surgical outcomes of unilateral PA patients within the Surgical Outcome of PRimary Aldosteronism progNostic mOdels (SOPRANO) study. From 27 publications we identified 32 eligible studies, of which 22 were judged to be at low risk of bias. Eighteen were single-center studies, while fourteen were multi-center studies, with patients recruited from 132 referral centers worldwide. Adrenalectomy was performed on 5887 patients, with 4861 (83%) included in the final analysis. The pooled estimates of complete clinical and biochemical success for all studies were 39% (95% CI: 34-44%) and 99% (95% CI: 96-99%), respectively, similar to that found for studies at low risk of bias. Multivariate meta-regression analyses for all studies and low-bias risk studies revealed that BMI (P < 0.01), recruitment time period (P < 0.01), and hypertension duration (P < 0.05) inversely correlated with complete clinical success, while BMI (P < 0.05) and the number of enrolled centers (P < 0.05) inversely correlated with complete biochemical success. In summary, our findings offer robust estimates of complete clinical and biochemical success rates following adrenalectomy for unilateral PA in tertiary and quaternary referral centers and identify new potential effect modifiers that can help clinicians to inform and counsel patients about post-surgery expectations, guaranteeing effective treatment and ultimately enhancing outcomes.
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Affiliation(s)
- Luigi Marzano
- Centro per lo Studio e la Cura dell'Ipertensione Arteriosa, Internal Medicine Unit, San Bortolo Hospital, U.L.S.S. 8 Berica, Vicenza, Italy.
- Internal Medicine Unit, San Bortolo Hospital, U.L.S.S. 8 Berica, 36100, Vicenza, Italy.
| | - Claudio Ronco
- Department of Medicine (DIMED), University of Padova, 35128, Padova, Italy
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, 36100, Vicenza, Italy
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2
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Machine learning-based models for predicting clinical outcomes after surgery in unilateral primary aldosteronism. Sci Rep 2022; 12:5781. [PMID: 35388079 PMCID: PMC8986833 DOI: 10.1038/s41598-022-09706-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 03/28/2022] [Indexed: 12/20/2022] Open
Abstract
Unilateral subtype of primary aldosteronism (PA) is a common surgically curable form of endocrine hypertension. However, more than half of the patients with PA who undergo unilateral adrenalectomy suffer from persistent hypertension, which may discourage those with PA from undergoing adrenalectomy even when appropriate. The aim of this retrospective cross-sectional study was to develop machine learning-based models for predicting postoperative hypertensive remission using preoperative predictors that are readily available in routine clinical practice. A total of 107 patients with PA who achieved complete biochemical success after adrenalectomy were included and randomly assigned to the training and test datasets. Predictive models of complete clinical success were developed using supervised machine learning algorithms. Of 107 patients, 40 achieved complete clinical success after adrenalectomy in both datasets. Six clinical features associated with complete clinical success (duration of hypertension, defined daily dose (DDD) of antihypertensive medication, plasma aldosterone concentration (PAC), sex, body mass index (BMI), and age) were selected based on predictive performance in the machine learning-based model. The predictive accuracy and area under the curve (AUC) for the developed model in the test dataset were 77.3% and 0.884 (95% confidence interval: 0.737–1.000), respectively. In an independent external cohort, the performance of the predictive model was found to be comparable with an accuracy of 80.4% and AUC of 0.867 (95% confidence interval: 0.763–0.971). The duration of hypertension, DDD of antihypertensive medication, PAC, and BMI were non-linearly related to the prediction of complete clinical success. The developed predictive model may be useful in assessing the benefit of unilateral adrenalectomy and in selecting surgical treatment and antihypertensive medication for patients with PA in clinical practice.
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Manosroi W, Atthakomol P, Phinyo P, Inthaphan P. Predictive factors of clinical success after adrenalectomy in primary aldosteronism: A systematic review and meta-analysis. Front Endocrinol (Lausanne) 2022; 13:925591. [PMID: 36060937 PMCID: PMC9434311 DOI: 10.3389/fendo.2022.925591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/03/2022] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Worapaka Manosroi
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- *Correspondence: Worapaka Manosroi,
| | - Pichitchai Atthakomol
- Orthopaedics Department, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Phichayut Phinyo
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Piti Inthaphan
- Department of Internal Medicine, Nakornping Hospital, Chiang Mai, Thailand
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Tang F, Loh LM, Foo RS, Loh WJ, Lim DST, Zhang M, Tan PT, Swee DS, Khoo J, Tay D, Lee L, Tan SY, Zhu L, Soh SB, Tan E, Kek PC, Puar TH. Tolerability and Efficacy of Long-Term Medical Therapy in Primary Aldosteronism. J Endocr Soc 2021; 5:bvab144. [PMID: 34541440 PMCID: PMC8442943 DOI: 10.1210/jendso/bvab144] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Patients with primary aldosteronism (PA) have increased cardiovascular risk, and there are concerns about the efficacy of medical therapy. OBJECTIVE We aimed to assess long-term tolerability and efficacy of medical therapy in PA patients. METHODS We conducted a retrospective study on 201 PA patients treated with medical therapy (spironolactone, eplerenone, or amiloride) from 2000 to 2020 at 2 tertiary centers. Clinical and biochemical control and side effects were assessed. RESULTS Among 155 patients on long-term medications, 57.4% achieved blood pressure (BP) <140/90 mmHg, 90.1% achieved normokalemia (48.0% potassium ≥4.3 mmol/L), and 63.2% achieved renin >1 ng/mL/h. Concordance of biochemical control using potassium and renin levels was 49.1%. Side effects were experienced by 52.3% of patients, with 10.3% switching, 22.6% decreasing dose, and 11.0% stopping medications. Risk factors for side effects were spironolactone use, dose ≥ 50 mg, treatment duration ≥1 year, male gender, and unilateral PA. Patients with unilateral PA used higher spironolactone doses vs bilateral (57 vs 50 mg, P < 0.001) and had more side effects (63.2% vs 41.8%, P = 0.008). Forty-six unilateral PA patients who underwent surgery after initial medical therapy experienced improved BP (systolic from 141 to 135 mmHg, P = 0.045; diastolic from 85 to 79 mmHg, P = 0.002). CONCLUSION Dose-dependent side effects limit efficacy of medical therapy in PA. Future prospective studies should assess the best monitoring strategy for biochemical control during long-term medical therapy. For unilateral PA, surgery remains preferable, yielding better control with less long-term side effects.
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Affiliation(s)
- Fengjie Tang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Lih M Loh
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore 169608, Singapore
| | - Roger S Foo
- Cardiovascular Research Institute, Centre for Translational Medicine, MD6, National University Health System, Singapore 117599, Singapore
- Genome Institute of Singapore, Singapore 138672, Singapore
| | - Wann J Loh
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore 529889, Singapore
| | - Dawn S T Lim
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore 169608, Singapore
| | - Meifen Zhang
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore 529889, Singapore
| | - Pei T Tan
- Department of Clinical Trial Research Unit, Changi General Hospital, SingHealth, Singapore 529889, Singapore
| | - Du S Swee
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore 169608, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore 529889, Singapore
| | - Donovan Tay
- Department of Endocrinology, Sengkang General Hospital, SingHealth, Singapore 544886, Singapore
| | - Lynette Lee
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore 169608, Singapore
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore 529889, Singapore
| | - Sarah Y Tan
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore 169608, Singapore
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore 529889, Singapore
| | - Ling Zhu
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore 169608, Singapore
| | - Shui B Soh
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore 529889, Singapore
| | - Eberta Tan
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore 529889, Singapore
| | - Peng C Kek
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore 169608, Singapore
| | - Troy H Puar
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore 529889, Singapore
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5
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Tan YK, Kwan YH, Teo DCL, Velema M, Deinum J, Tan PT, Zhang M, Khoo JJC, Loh WJ, Gani L, King TFJ, Tan EJH, Soh SB, Au VSC, Tay TL, Dacay LMQ, Ng KS, Wong KM, Wong ASY, Ng FC, Aw TC, Chan YHB, Tong KL, Lee SSG, Chai SC, Puar THK. Improvement in quality of life and psychological symptoms after treatment for primary aldosteronism: Asian Cohort Study. Endocr Connect 2021; 10:834-844. [PMID: 34223820 PMCID: PMC8346187 DOI: 10.1530/ec-21-0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND In addition to increased cardiovascular risk, patients with primary aldosteronism (PA) also suffer from impaired health-related quality of life (HRQoL) and psychological symptoms. We assessed for changes in HRQoL and depressive symptoms in a cohort of Asian patients with PA, after surgical and medical therapy. METHODS Thirty-four patients with PA were prospectively recruited and completed questionnaires from 2017 to 2020. HRQoL was assessed using RAND-36 and EQ-5D-3L, and depressive symptoms were assessed using Beck Depression Inventory (BDI-II) at baseline, 6 months, and 1 year post-treatment. RESULTS At 1 year post-treatment, significant improvement was observed in both physical and mental summative scores of RAND-36, +3.65, P = 0.023, and +3.41, P = 0.033, respectively, as well as four subscale domains (physical functioning, bodily pain, role emotional, and mental health). Significant improvement was also seen in EQ-5D dimension of anxiety/depression at 1 year post-treatment. Patients treated with surgery (n = 21) had significant improvement in EQ-5D index score post-treatment and better EQ-5D outcomes compared to the medical group (n = 13) at 1 year post-treatment. 37.9, 41.6 and 58.6% of patients had symptoms in the cognitive, affective and somatic domains of BDI-II, respectively. There was a significant improvement in the affective domain of BDI-II at 1 year post-treatment. CONCLUSION Both surgical and medical therapy improve HRQoL and psychological symptoms in patients with PA, with surgery providing better outcomes. This highlights the importance of early diagnosis, accurate subtyping and appropriate treatment of PA.
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Affiliation(s)
- Yen Kheng Tan
- Duke-NUS Medical School, SingHealth, Singapore, Singapore
| | - Yu Heng Kwan
- Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Marieke Velema
- Division of Endocrinology, Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jaap Deinum
- Division of Vascular Medicine, Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pei Ting Tan
- Department of Clinical Trials Research Unit, Changi General Hospital, Singapore, Singapore
| | - Meifen Zhang
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | | | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Linsey Gani
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Thomas F J King
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Eberta Jun Hui Tan
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Shui Boon Soh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | | | - Tunn Lin Tay
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | | | - Keng Sin Ng
- Department of Diagnostic Radiology, Changi General Hospital, Singapore, Singapore
| | - Kang Min Wong
- Department of Diagnostic Radiology, Changi General Hospital, Singapore, Singapore
| | | | - Foo Cheong Ng
- Department of Urology, Changi General Hospital, Singapore, Singapore
| | - Tar Choon Aw
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | | | - Khim Leng Tong
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | | | - Siang Chew Chai
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Troy Hai Kiat Puar
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
- Correspondence should be addressed to T H K Puar:
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Chan YHB, Loh LM, Foo RS, Loh WJ, Lim DST, Zhang M, Sultana R, Tan YK, Ng KS, Tay D, Swee DS, Au V, Tay TL, Khoo J, Zhu L, Lee L, Tan SY, Kek PC, Puar TH. Re-evaluating absent clinical success after adrenalectomy in unilateral primary aldosteronism. Surgery 2021; 170:1389-1396. [PMID: 34183182 DOI: 10.1016/j.surg.2021.05.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/03/2021] [Accepted: 05/20/2021] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
| | - Lih Ming Loh
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Roger S Foo
- Cardiovascular Research Institute, Centre for Translational Medicine, MD6, National University Health System, Singapore; Genome Institute of Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Dawn S T Lim
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Meifen Zhang
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | | | | | - Keng Sin Ng
- Department of Radiology, Changi General Hospital, SingHealth, Singapore; Department of Radiology, Mt Alvernia Hospital, Singapore
| | - Donovan Tay
- Department of Endocrinology, Sengkang General Hospital, SingHealth, Singapore
| | - Du Soon Swee
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Vanessa Au
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Tunn Lin Tay
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Ling Zhu
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Lynette Lee
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore; Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Sarah Y Tan
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore; Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Peng Chin Kek
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Troy H Puar
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore.
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Nakai K, Tsurutani Y, Inoue K, Matsui S, Makita K, Yamazaki Y, Sasano H, Makita N, Nangaku M, Saito J, Omura M, Nishikawa T. Steroidogenic Activity in Unresected Adrenals Associated With Surgical Outcomes in Primary Aldosteronism. Hypertension 2021; 77:1638-1646. [PMID: 33775128 DOI: 10.1161/hypertensionaha.120.16335] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Kazuki Nakai
- Endocrinology and Diabetes Center (K.N., Y.T., K.I., J.S., T.N.), Yokohama Rosai Hospital, Japan.,Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Japan (K.N., N.M., M.N.)
| | - Yuya Tsurutani
- Endocrinology and Diabetes Center (K.N., Y.T., K.I., J.S., T.N.), Yokohama Rosai Hospital, Japan
| | - Kosuke Inoue
- Endocrinology and Diabetes Center (K.N., Y.T., K.I., J.S., T.N.), Yokohama Rosai Hospital, Japan.,Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles (K.I.)
| | - Seishi Matsui
- Department of Radiology (S.M.), Yokohama Rosai Hospital, Japan
| | - Kohzoh Makita
- Department of Radiology, Nerima Hikarigaoka Hospital, Tokyo, Japan (K.M.)
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan (Y.Y., H.S.)
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan (Y.Y., H.S.)
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Japan (K.N., N.M., M.N.)
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Japan (K.N., N.M., M.N.)
| | - Jun Saito
- Endocrinology and Diabetes Center (K.N., Y.T., K.I., J.S., T.N.), Yokohama Rosai Hospital, Japan
| | - Masao Omura
- Minato Mirai Medical Square, Yokohama, Japan (M.O.)
| | - Tetsuo Nishikawa
- Endocrinology and Diabetes Center (K.N., Y.T., K.I., J.S., T.N.), Yokohama Rosai Hospital, Japan.,Nishikawa Clinic, Yokohama, Japan (T.N.)
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8
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Puar TH, Loh LM, Loh WJ, Lim DST, Zhang M, Tan PT, Lee L, Swee DS, Khoo J, Tay D, Tan SY, Zhu L, Gani L, King TF, Kek PC, Foo RS. Outcomes in unilateral primary aldosteronism after surgical or medical therapy. Clin Endocrinol (Oxf) 2021; 94:158-167. [PMID: 33058182 DOI: 10.1111/cen.14351] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/12/2020] [Accepted: 10/01/2020] [Indexed: 12/12/2022]
Abstract
CONTEXT Studies find surgery superior to medications in the treatment of primary aldosteronism (PA). It would be ideal to compare surgical and medical therapy in patients with unilateral PA only, who have the option between these treatment modalities. However, this is challenging as most patients with unilateral PA on adrenal vein sampling (AVS) undergo surgery. OBJECTIVE To compare outcomes of surgery and medications in patients with confirmed or likely unilateral PA. DESIGN Retrospective cohort study of 274 patients with PA managed at two referral centres from 2000 to 2019. PATIENTS 154 patients identified with unilateral PA using AVS and a validated clinical prediction model were treated with surgical (n = 86) or medical (n = 68) therapy. MEASUREMENTS Primary outcome was a composite incident cardiovascular event comprising acute myocardial infarction, coronary revascularization, stroke, atrial fibrillation or congestive cardiac failure. Secondary outcomes were clinical and biochemical control. RESULTS Cardiovascular outcomes were comparable, with the surgery group having an adjusted hazard ratio of 0.93 (95% CI: 0.32-2.67), p = .89. Both treatments improved clinical and biochemical control, but surgery resulted in better systolic blood pressure, 133.0 ± 11.7 mmHg versus 137.9 ± 14.6 mmHg, p = .02, and lower defined daily dosages of antihypertensive medications, 1.0 (IQR 0.0-2.0) versus 2.6 (IQR 0.8-4.3), p < .001. In addition, 12 of 86 patients in the surgery group failed medical therapy before opting for surgery. CONCLUSION In patients with unilateral PA who can tolerate medications, medical therapy improves clinical and biochemical control, and may offer similar cardiovascular protection. However, surgery reduces pill burden, may cure hypertension and is recommended for unilateral PA.
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Affiliation(s)
- Troy H Puar
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Lih M Loh
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Wann J Loh
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Dawn S T Lim
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Meifen Zhang
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Pei T Tan
- Department of Clinical Trial Research Unit, Changi General Hospital, SingHealth, Singapore
| | - Lynette Lee
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Du S Swee
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Donovan Tay
- Department of Endocrinology, Sengkang General Hospital, SingHealth, Singapore
| | - Sarah Y Tan
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Ling Zhu
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Linsey Gani
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Thomas F King
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Peng C Kek
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Roger S Foo
- Cardiovascular Research Institute, Centre for Translational Medicine, MD6, National University Health System, Singapore
- Genome Institute of Singapore, Singapore
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9
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Nakamaru R, Yamamoto K, Akasaka H, Rakugi H, Kurihara I, Yoneda T, Ichijo T, Katabami T, Tsuiki M, Wada N, Yamada T, Kobayashi H, Tamura K, Ogawa Y, Kawashima J, Inagaki N, Fujita M, Oki K, Kamemura K, Tanabe A, Naruse M. Sex Differences in Renal Outcomes After Medical Treatment for Bilateral Primary Aldosteronism. Hypertension 2020; 77:537-545. [PMID: 33356395 DOI: 10.1161/hypertensionaha.120.16449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
A higher incidence of bilateral primary aldosteronism in women is reported. Treatment of bilateral primary aldosteronism usually involves mineralocorticoid receptor antagonists. However, the impact of sex on renal outcomes is unknown. We compared renal outcomes between the sexes after mineralocorticoid receptor antagonist initiation by analyzing data obtained from 415 female and 313 male patients with bilateral primary aldosteronism who were treated with spironolactone or eplerenone in the JPAS (Japan Primary Aldosteronism Study). Over the course of 5 years, the temporal reduction in the estimated glomerular filtration rate was greater in women than in men (P<0.001). Systolic blood pressure levels were equal between the sexes, despite higher doses of antihypertensive drugs in men. The mean of the annual decline in estimated glomerular filtration rate during what we termed the late phase, or 6 to 60 months after mineralocorticoid receptor antagonist initiation, was larger in women than in men after adjusting for patient characteristics (-1.33 mL/min per 1.73 m2 per year versus -1.04 mL/min per 1.73 m2 per year, P<0.01). Female sex was a significant predictor of greater annual decline during the late phase in patients taking spironolactone but not in those taking eplerenone. Spironolactone use and diabetes were independent predictors of a greater annual decline in estimated glomerular filtration rate during the late phase in women. These findings suggest that female sex is associated with poorer renal outcomes in patients receiving mineralocorticoid receptor antagonist for bilateral primary aldosteronism.
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Affiliation(s)
- Ryo Nakamaru
- From the Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Japan (R.N., K.Y., H.A., H.R.)
| | - Koichi Yamamoto
- From the Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Japan (R.N., K.Y., H.A., H.R.)
| | - Hiroshi Akasaka
- From the Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Japan (R.N., K.Y., H.A., H.R.)
| | - Hiromi Rakugi
- From the Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Japan (R.N., K.Y., H.A., H.R.)
| | - Isao Kurihara
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine Keio University, Tokyo, Japan (I.K.)
| | - Takashi Yoneda
- Department of Health Promotion and Medicine of the Future, Graduate School of Medical Science, Kanazawa University, Japan (T. Yoneda)
| | - Takamasa Ichijo
- Department of Diabetes and Endocrinology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan (T.I.)
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Japan (T.K.)
| | - Mika Tsuiki
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Japan (M.T., M.N.)
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Japan (N.W.)
| | - Tetsuya Yamada
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan (T. Yamada)
| | - Hiroki Kobayashi
- Division of Nephrology, Hypertension and Endocrinology, Nihon University School of Medicine, Tokyo, Japan (H.K.)
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Japan (K.T.)
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan (Y.O.)
| | - Junji Kawashima
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Japan (J.K.)
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Japan (N.I.)
| | - Megumi Fujita
- Division of Nephrology and Endocrinology, University of Tokyo, Japan (M.F.)
| | - Kenji Oki
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan (K.O.)
| | - Kohei Kamemura
- Department of Cardiology, Shinko Hospital, Kobe, Japan (K.K.)
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Tokyo, Japan (A.T.)
| | - Mitsuhide Naruse
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Japan (M.T., M.N.)
- Endocrine Center, Ijinkai Takeda General Hospital, Kyoto, Japan (M.N.)
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