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Wada N, Baba S, Sugawara H, Miyoshi A, Obara S. Prolonged postoperative hypoaldosteronism related to hyperkalemia in patients with aldosterone-producing adenoma. Endocr J 2023; 70:917-924. [PMID: 37423737 DOI: 10.1507/endocrj.ej23-0174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
Hyperkalemia is developed in a part of patients with aldosterone-producing adenoma (APA) after adrenalectomy, suspected to be due to the insufficiency of aldosterone secretion. The purpose of this study is to determine the frequency and characteristics of prolonged postoperative hypoaldosteronism (PPHA) using chemiluminescent enzyme immunoassay (CLEIA). We studied 58 patients with APA with long time after adrenalectomy and whose PAC was measured using a CLEIA kit. The PAC value measured using CLEIA was significantly lower than that of using RIA between two consecutive visits before and after the shift of measuring method of PAC (median [interquantile range], 123.0 [99.8-164.0] vs. 39.5 [15.8-64.2] pg/mL, p < 0.01). PAC was below the minimum limit of quantification (4.0 pg/mL) of the CLEIA kit at least once in nine patients (15.5%) who had PPHA. The PPHA group were older (mean ± standard deviation, 61.3 ± 8.5 vs. 50.5 ± 10.1 years, p < 0.01) and had lower eGFR (60.3 ± 14.0 vs. 82.3 ± 22.8 mL/min/1.73 m2, p < 0.01) than the non-PPHA group. The frequency of postoperative hyperkalemia (maximum serum potassium >5.5 mEq/L) was higher in the PPHA group than in the non-PPHA group (55.6% vs. 8.2%, p < 0.01). In conclusion, a few patients with APA long time after adrenalectomy had unmeasurable PAC using CLEIA. PPHA is likely to develop in patients with APA after adrenalectomy who are older and have impaired renal function. Additionally, PPHA is related to the occurrence of postoperative hyperkalemia.
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Affiliation(s)
- Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Shuhei Baba
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Hajime Sugawara
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Arina Miyoshi
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Shinji Obara
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
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2
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王 薇, 蔡 林, 高 莹, 郭 晓, 张 俊. [Persistent and serious hyperkalemia after surgery of primary aldosteronism: A case report]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2022; 54:376-380. [PMID: 35435207 PMCID: PMC9069031 DOI: 10.19723/j.issn.1671-167x.2022.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Indexed: 06/14/2023]
Abstract
Hyperkalemia was one of the complications after primary aldosteronism surgery. Hyperkalemia after primary aldosteronism surgery was uncommon in clinical practice, especially persistent and serious hyperkalemia was rare. This complication was not attached great importance in clinical work. A case about persistent and serious hyperkalemia after primary aldosteronism adrenal adenoma surgery was reported and the patient was followed-up for fourteen months in this study. This patient had a laparoscopic adrenalectomy due to primary aldosteronism. Hyperkalemia was detected one month after surgery of this patient, the highest level of plasma potassium was 7.0 mmol/L. The patient felt skin itchy, nausea, palpitation. Plasma aldosterone concentration fell to 2.12 ng/dL post-operation from 35.69 ng/dL pre-operation, zona glomerulosa insufficiency was confirmed by hormonal tests in this patient after surgery. And levels of 24 hours urinary potassium excretion declined. Decrease of aldosterone levels after surgery might be the cause of hyperkalemia. Hyperkalemia lasted for 14 months after surgery and kalemia-lowering drugs were needed. A systemic search with "primary aldosteronism", "hyperkalemia", "surgical treatment" was performed in PubMed and Wanfang Database for articles published between January 2009 and December 2019. Literature review indicated that the incidence of hyperkalemia after primary aldosteronism surgery was 6% to 29%. Most of them was mild to moderator hyperkalemia (plasma potassium 5.5 to 6.0 mmol/L) and transient. 19% to 33% in hyperkalemia patients was persistent hyperkalemia. Previous studies in the levels of plasma potassium reached the level as high as 7 mmol/L in our case were rare. Whether hypoaldosteronemia was the cause of hyperkalemia was not consistent in the published studies. Risk factors of hyperkalemia after primary aldosteronism surgery included kidney dysfunction, old age, long duration of hypertention. This paper aimed to improve doctors' aweareness of hyperkalemia complication after primary aldosteronism surgery. Plasma potassium should be monitored closely after primary aldosteronism surgery, especially in the patients with risk factors. Some patients could have persistent and serious hyperkalemia, and need medicine treatment.
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Affiliation(s)
- 薇 王
- 北京大学第一医院内分泌科,北京 100034Department of Endocrinology, Peking University First Hospital, Beijing 100034, China
| | - 林 蔡
- 北京大学第一医院泌尿外科,北京 100034Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - 莹 高
- 北京大学第一医院内分泌科,北京 100034Department of Endocrinology, Peking University First Hospital, Beijing 100034, China
| | - 晓蕙 郭
- 北京大学第一医院内分泌科,北京 100034Department of Endocrinology, Peking University First Hospital, Beijing 100034, China
| | - 俊清 张
- 北京大学第一医院内分泌科,北京 100034Department of Endocrinology, Peking University First Hospital, Beijing 100034, China
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3
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Mermejo LM, Elias PCL, Molina CAF, Tucci S, Muglia VF, Elias J, Antonini SR, de Castro M, Moreira AC. Early Renin Recovery After Adrenalectomy in Aldosterone-Producing Adenomas: A Prospective Study. Horm Metab Res 2022; 54:224-231. [PMID: 35413743 DOI: 10.1055/a-1778-4002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The aim of the study was to clarify the relationship and the time of aldosterone and renin recoveries at immediate and long-term follow-up in aldosterone-producing adenoma (APA) patients who underwent adrenalectomy. Prospective and longitudinal protocol in a cohort of APA patients was followed in a single center. Among 43 patients with primary aldosteronism (PA), thirteen APA patients were enrolled in this study. Blood was collected for aldosterone, renin, potassium, creatinine, cortisol, and ACTH before and 1, 3, 5, 7, 15, 30, 60, 90, 120, 180, 270, 360 days after adrenalectomy. At diagnosis, most patients (84%) had hypokalemia and high median aldosterone levels (54.8; 24.0-103 ng/dl) that decreased to undetectable (<2.2) or very low (<3.0) levels between fifth to seventh days after surgery; then, between 3-12 months, its levels gradually increased to the lower normal range. The suppressed renin (2.3; 2.3-2.3 mU/l) became detectable between the fifteen and thirty days after surgery, remaining normal throughout the study. The aldosterone took longer than renin to recover (60 vs.15 days; p<0.002) and patients with higher aldosterone had later recovery (p=0.03). The cortisol/ACTH levels remained normal despite the presence of a post-operative hypoaldosteronism. Blood pressure and antihypertensive requirement decreased after adrenalectomy. In conclusion, our prospective study shows the borderline persistent post-operative hypoaldosteronism in the presence of early renin recovery indicating incapability of the zona glomerulosa of the remaining adrenal gland to produce aldosterone. These findings contribute to the comprehension of differences in renin and aldosterone regulation in APA patients, although both are part of the same interconnected system.
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Affiliation(s)
- Livia M Mermejo
- Department of Internal Medicine, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Paula C L Elias
- Department of Internal Medicine, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Carlos A F Molina
- Department of Surgery and Anatomy, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Silvio Tucci
- Department of Surgery and Anatomy, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Valdair F Muglia
- Department of Medical Imaging, Hematology and Oncology, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Jorge Elias
- Department of Medical Imaging, Hematology and Oncology, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Sonir R Antonini
- Department of Pediatrics, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Margaret de Castro
- Department of Internal Medicine, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Ayrton C Moreira
- Department of Internal Medicine, University of Sao Paulo, Ribeirao Preto, SP, Brazil
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Preda C, Teodoriu LC, Placinta S, Grigorovici A, Bilha S, Ungureanu CM. Persistent severe hyperkalemia following surgical treatment of aldosterone-producing adenoma. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2020; 25:17. [PMID: 32174989 PMCID: PMC7053163 DOI: 10.4103/jrms.jrms_603_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/30/2019] [Accepted: 12/18/2019] [Indexed: 11/30/2022]
Abstract
Primary aldosteronism is one of the most common causes of secondary hypertension. This condition is characterized by autonomous hypersecretion of aldosterone which produces sodium retention and potassium excretion, resulting in high blood pressure and potential hypokalemia. Transient postoperative hyporeninemic hypoaldosteronism with an increased risk of hyperkalemia may occur in some patients. We report the case of a 63-year-old patient with persistent hypokalemia, periodic paralysis, and refractory hypertension who was diagnosed with primary hyperaldosteronism due to elevated aldosterone, undetectable plasmatic renin concentration, and the presence of a left adrenal mass. One month after the surgery, the patient was admitted with signs of severe hyperkalemia (8 mmol/L) and worsened renal function, thus requiring hemodialysis. Fluid resuscitation, loop diuretic, and sodium bicarbonate treatment decreased his potassium. Zona glomerulosa insufficiency was confirmed by hormonal tests which exposed low aldosterone–renin axis. The fludrocortisone treatment was initiated and maintained, with consequent potassium and creatinine stabilization. Old age, long duration of hypertension, impaired renal function, severe hypokalemia before surgery, and large size of the aldosterone-producing adenoma are important risk factors for serious potassium imbalance after removal of the adenoma. We have to consider monitoring the patients after surgery for primary hyperaldosteronism in order to prevent severe hyperkalemia; therefore, postoperative immediate follow-up (arterial pressure, potassium, and renal function) is mandatory.
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Affiliation(s)
- Cristina Preda
- Department of Endocrinology, University of Medicine and Pharmacy "Grigore T. Popa", Iaşi, Romania.,Department of Endocrinology, Emergency University Hospital "Sf. Spiridon," Iaşi, Romania
| | - Laura Claudia Teodoriu
- Department of Endocrinology, University of Medicine and Pharmacy "Grigore T. Popa", Iaşi, Romania
| | - Sarolta Placinta
- Department of Endocrinology, Private Medical Practice, Bacău, Romania
| | - Alexandru Grigorovici
- Department of Endocrinology, University of Medicine and Pharmacy "Grigore T. Popa", Iaşi, Romania.,Department of General Surgery, Emergency University Hospital "Sf. Spiridon," Iaşi, Romania
| | - Stefana Bilha
- Department of Endocrinology, University of Medicine and Pharmacy "Grigore T. Popa", Iaşi, Romania
| | - Christina M Ungureanu
- Department of Endocrinology, University of Medicine and Pharmacy "Grigore T. Popa", Iaşi, Romania.,Department of Endocrinology, Emergency University Hospital "Sf. Spiridon," Iaşi, Romania
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5
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Lee DH, Kwon SK, Jeon HJ, Kim HY, Kim SM, Cho H. Life-threatening hyperkalaemia developing after bilateral adrenalectomy in a patient with normal kidney function. Intern Med J 2019; 49:546-547. [PMID: 30957379 DOI: 10.1111/imj.14254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/09/2018] [Accepted: 07/22/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Dong-Hwa Lee
- Division of Endocrinology, Chungbuk National University Hospital, Cheongju, South Korea.,Chungbuk National University Hospital, Cheongju, South Korea
| | - Soon Kil Kwon
- Chungbuk National University Hospital, Cheongju, South Korea.,Division of Nephrology, Chungbuk National University Hospital, Cheongju, South Korea.,Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, South Korea
| | - Hyun Jeong Jeon
- Division of Endocrinology, Chungbuk National University Hospital, Cheongju, South Korea.,Chungbuk National University Hospital, Cheongju, South Korea.,Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, South Korea
| | - Hye-Young Kim
- Chungbuk National University Hospital, Cheongju, South Korea.,Division of Nephrology, Chungbuk National University Hospital, Cheongju, South Korea.,Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, South Korea
| | - Sun Moon Kim
- Chungbuk National University Hospital, Cheongju, South Korea.,Division of Nephrology, Chungbuk National University Hospital, Cheongju, South Korea
| | - Hyunjeong Cho
- Chungbuk National University Hospital, Cheongju, South Korea.,Division of Nephrology, Chungbuk National University Hospital, Cheongju, South Korea
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Kanarek-Kucner J, Stefański A, Barraclough R, Gorycki T, Wolf J, Narkiewicz K, Hoffmann M. Insufficiency of the zona glomerulosa of the adrenal cortex and progressive kidney insufficiency following unilateral adrenalectomy - case report and discussion. Blood Press 2018; 27:304-312. [PMID: 29742971 DOI: 10.1080/08037051.2018.1470460] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Primary aldosteronism (PA) is the most common cause of secondary hypertension and bilateral adrenal hyperplasia (BAH) and aldosterone-producing adenoma (APA) seem to be the most common causes of PA. Unilateral adrenalectomy (UA) is the preferred treatment for APA, although the benefits are still difficult to assess. CASE REPORT We present a case report of a 69-year old man with a 30 year history of hypertension and probably long-standing PA due to APA, with typical organ complications. Since repeated abdominal CT scans were equivocal, not showing radiological changes characteristic for PA, the diagnosis of APA was delayed and was only finally confirmed by adrenal venous sampling which demonstrated unilateral aldosteronism. The patient underwent UA, complicated by mineralocorticoid deficiency syndrome and increased creatinine and potassium levels. At 12 months follow-up the patient still had hyperkalemia and was fludrocortisone dependent. CONCLUSIONS Older patients and patients with long-lasting PA who are treated with UA may demonstrate deterioration of renal function and develop transient or persistent insufficiency of the zona glomerulosa of the remaining adrenal gland necessitating fludrocortisone supplementation. Transient hyperkalemia may be observed following UA as a result of the prolonged effects of aldosterone antagonists and/or transient mineralocorticoid/glucocorticoid insufficiency. Additionally, the level of progression of chronic kidney disease after UA is difficult to predict. There likely exists a group of patients who might paradoxically have higher cardiovascular risk due to significant deterioration in kidney function not only resulting from the removal of the aldosterone induced glomerular hyperfiltration phenomenon. Identification of such a group requires further detailed investigation.
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Affiliation(s)
- Joanna Kanarek-Kucner
- a Department of Hypertension and Diabetology, Faculty of Medicine , Medical University of Gdansk , Gdansk , Poland
| | - Adrian Stefański
- a Department of Hypertension and Diabetology, Faculty of Medicine , Medical University of Gdansk , Gdansk , Poland
| | - Rufus Barraclough
- a Department of Hypertension and Diabetology, Faculty of Medicine , Medical University of Gdansk , Gdansk , Poland
| | - Tomasz Gorycki
- b Department of Radiology, Faculty of Medicine , Medical University of Gdansk , Gdansk , Poland
| | - Jacek Wolf
- a Department of Hypertension and Diabetology, Faculty of Medicine , Medical University of Gdansk , Gdansk , Poland
| | - Krzysztof Narkiewicz
- a Department of Hypertension and Diabetology, Faculty of Medicine , Medical University of Gdansk , Gdansk , Poland
| | - Michał Hoffmann
- a Department of Hypertension and Diabetology, Faculty of Medicine , Medical University of Gdansk , Gdansk , Poland
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7
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Furlanis G, Bernardi S, Cavressi M, Zandonà L, Carretta R, Fabris B, Bardelli M. A case report of hyponatremia after surgery for Conn's adenoma. J Renin Angiotensin Aldosterone Syst 2017; 18:1470320317740240. [PMID: 29141492 PMCID: PMC5843937 DOI: 10.1177/1470320317740240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Primary aldosteronism (PA), also known as Conn's syndrome, is a frequent cause of secondary hypertension. If PA is due to a documented unilateral adrenal adenoma, adrenalectomy is the treatment of choice. Endocrine Society guidelines suggest monitoring potassium after adrenalectomy, while there is no mention of sodium disorders after surgery. Here we report the case of a patient with Conn's syndrome who developed hyponatremia after surgery. This was an unexpected event in the course of the treatment, which sheds light on the fact that low levels of aldosterone strongly influence sodium concentration, and advises clinicians to monitor sodium after adrenalectomy.
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Affiliation(s)
- Giulia Furlanis
- 1 Department of Medical Sciences, University of Trieste, Italy.,2 ASUITS - Azienda Sanitaria Universitaria Integrata di Trieste, Cattinara Teaching Hospital, Italy
| | - Stella Bernardi
- 1 Department of Medical Sciences, University of Trieste, Italy.,2 ASUITS - Azienda Sanitaria Universitaria Integrata di Trieste, Cattinara Teaching Hospital, Italy
| | - Monica Cavressi
- 1 Department of Medical Sciences, University of Trieste, Italy.,2 ASUITS - Azienda Sanitaria Universitaria Integrata di Trieste, Cattinara Teaching Hospital, Italy
| | - Lorenzo Zandonà
- 1 Department of Medical Sciences, University of Trieste, Italy.,2 ASUITS - Azienda Sanitaria Universitaria Integrata di Trieste, Cattinara Teaching Hospital, Italy
| | - Renzo Carretta
- 1 Department of Medical Sciences, University of Trieste, Italy.,2 ASUITS - Azienda Sanitaria Universitaria Integrata di Trieste, Cattinara Teaching Hospital, Italy
| | - Bruno Fabris
- 1 Department of Medical Sciences, University of Trieste, Italy.,2 ASUITS - Azienda Sanitaria Universitaria Integrata di Trieste, Cattinara Teaching Hospital, Italy
| | - Moreno Bardelli
- 1 Department of Medical Sciences, University of Trieste, Italy.,2 ASUITS - Azienda Sanitaria Universitaria Integrata di Trieste, Cattinara Teaching Hospital, Italy
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Tahir A, McLaughlin K, Kline G. Severe hyperkalemia following adrenalectomy for aldosteronoma: prediction, pathogenesis and approach to clinical management- a case series. BMC Endocr Disord 2016; 16:43. [PMID: 27460219 PMCID: PMC4962422 DOI: 10.1186/s12902-016-0121-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 06/20/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND As the field of Primary Aldosteronism (PA) becomes ever expanded, diagnosis of PA is increasingly diagnosed by endocrinologists. With increased PA screening, many of the cases are now found in patients with complex co-morbidities in addition to their hypertension. Post adrenalectomy renal impairment with hyperkalemia is now increasingly seen in these complex patients, as evidenced by the numerous reports on this issue that have appeared within the past 3 years. We present a small case series to illustrate the breadth of the problem, along with a discussion about how such CKD/hyperkalemic events may be predicted. CASE PRESENTATION We present three cases of primary aldosteronism with long standing hypertension (more than 10 years) hypokalemia (2.0-3.0 mmol/l). Serum aldosterone was high with low renin activity leading to high aldosterone to renin ratio (ARR). They underwent abdominal CT scan revealing adrenal mass and adrenal vein sample confirmed lateralization. None of the patients had evidence of renal disease before surgery (as evident by normal eGFR and serum creatinine). Post adrenalectomy they had reduction in the blood pressure and became eukalemic. Serum aldosterone and renin activity were low leading to a low ARR. Case 1 developed hyperkalemia and increased serum creatinine 6 weeks post operatively which resolved with initiation of fludrocortisone and every attempt to discontinue fludrocortisone resulted in hyperkalemia and rising creatinine. Her hyperkalemia is under control with oral sodium bicarbonate. Case 2 developed hyperkalemia and increasing creatinine 2 months post operatively transiently requiring fludrocortisone and later on managed with furosemide for hyperkalemia. Case 3 developed renal impairment and hyperkalemia 2 weeks post operatively requiring fludrocortisone. CONCLUSION Post APA resection severe hyperkalemia may be a common entity and screening should be actively considered in high risk patients. Older age, longer duration of hypertension, impaired pre-op and post-op GFR and higher levels of pre-op aldosterone and are all risk factors which predict the likelihood of developing post-operative hyperkalemia. Fludrocortisone, sodium bicarbonate, loop diuretics and potassium binders can be used for treatment. Treatment choice should be tailored to patient characteristics including fluid status, blood pressure and serum creatinine. Potassium binders should be avoided in patients with history of recent abdominal surgery, opioid use and constipation. Serum electrolytes and creatinine should be monitored every 1-2 weeks after starting treatment to ensure an adequate response. Prolonged management may be necessary in some cases and at-risk patients should be counselled as to the meaning and importance of post-operative changes in measured renal function and potassium.
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Affiliation(s)
- A. Tahir
- Department of Internal Medicine, Cummings School of Medicine- University of Calgary, Alberta, Canada
| | - K. McLaughlin
- Department of Nephrology, Cummings School of Medicine- University of Calgary, Alberta, Canada
| | - G. Kline
- Department of Endocrinology, Cummings School of Medicine- University of Calgary, Alberta, Canada
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Vallet M, Martin A, Huyghe E, Amar J, Chamontin B, Kantambadouno J, Tack I, Bouhanick B. Four Cases of Hypovolemic Renin-Aldosterone Axis Deficiency Without Hyperkalemia Following Unilateral Adrenalectomy for Primary Aldosteronism. AACE Clin Case Rep 2016. [DOI: 10.4158/ep15874.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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10
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Hyland KA, Perkins JM. Persistent Hyperkalemia Status Postadrenalectomy for Primary Aldosteronism. AACE Clin Case Rep 2016. [DOI: 10.4158/ep15812.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Park KS, Kim JH, Ku EJ, Hong AR, Moon MK, Choi SH, Shin CS, Kim SW, Kim SY. Clinical risk factors of postoperative hyperkalemia after adrenalectomy in patients with aldosterone-producing adenoma. Eur J Endocrinol 2015; 172:725-31. [PMID: 25766046 DOI: 10.1530/eje-15-0074] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 03/12/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Unilateral adrenalectomy is the first-line treatment for aldosterone-producing adenomas (APA). Hyperkalemia after adrenalectomy because of contralateral zona glomerulosa insufficiency has been reported. We investigated clinical risk factors to predict postoperative hyperkalemia in patients with APA undergoing adrenalectomy. DESIGN AND METHODS This study was conducted by retrospectively reviewing medical records from 2000 to 2012 at Seoul National University Hospital and two other tertiary centers. Data from 124 patients who underwent adrenalectomy were included. Hyperkalemia was defined as serum potassium >5.5 mmol/l. Clinical preoperative risk factors included age, blood pressure, plasma renin activity (PRA), plasma aldosterone concentration (PAC), serum potassium, serum creatinine, glomerular filtration rate (GFR), the mass size on pathology, and mineralocorticoid receptor (MR) antagonist use. RESULTS Out of 124 patients, 13 (10.5%) developed postoperative hyperkalemia. The incidences of transient and persistent hyperkalemia were 3.2 and 7.3% respectively. Preoperative PRA and PAC were not significantly different in postoperative hyperkalemic patients compared with normokalemic patients. Patients with persistent hyperkalemia were older, had a longer duration of hypertension, larger mass size on pathology, and lower GFR (all P<0.05). The incidence of postoperative hyperkalemia was not different between MR antagonist users and non-users. CONCLUSION Older age (≥53 years), longer duration of hypertension (≥9.5 years), larger mass size on pathology (≥1.95 cm), and impaired preoperative renal function (GFR <58.2 ml/min) were associated with prolonged postoperative hyperkalemia in patients with APA. MR antagonist use did not prevent postoperative hyperkalemia.
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Affiliation(s)
- Kyeong Seon Park
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of Internal MedicineSeoul Metropolitan Government Borame Medical Center, Seoul 156-707, South KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam-city, Gyeonggi-do, South Korea
| | - Jung Hee Kim
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of Internal MedicineSeoul Metropolitan Government Borame Medical Center, Seoul 156-707, South KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam-city, Gyeonggi-do, South Korea
| | - Eu Jeong Ku
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of Internal MedicineSeoul Metropolitan Government Borame Medical Center, Seoul 156-707, South KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam-city, Gyeonggi-do, South Korea
| | - A Ram Hong
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of Internal MedicineSeoul Metropolitan Government Borame Medical Center, Seoul 156-707, South KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam-city, Gyeonggi-do, South Korea
| | - Min Kyong Moon
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of Internal MedicineSeoul Metropolitan Government Borame Medical Center, Seoul 156-707, South KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam-city, Gyeonggi-do, South Korea Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of Internal MedicineSeoul Metropolitan Government Borame Medical Center, Seoul 156-707, South KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam-city, Gyeonggi-do, South Korea
| | - Sung Hee Choi
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of Internal MedicineSeoul Metropolitan Government Borame Medical Center, Seoul 156-707, South KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam-city, Gyeonggi-do, South Korea Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of Internal MedicineSeoul Metropolitan Government Borame Medical Center, Seoul 156-707, South KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam-city, Gyeonggi-do, South Korea
| | - Chan Soo Shin
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of Internal MedicineSeoul Metropolitan Government Borame Medical Center, Seoul 156-707, South KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam-city, Gyeonggi-do, South Korea
| | - Sang Wan Kim
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of Internal MedicineSeoul Metropolitan Government Borame Medical Center, Seoul 156-707, South KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam-city, Gyeonggi-do, South Korea Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of Internal MedicineSeoul Metropolitan Government Borame Medical Center, Seoul 156-707, South KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam-city, Gyeonggi-do, South Korea
| | - Seong Yeon Kim
- Department of Internal MedicineSeoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, KoreaDepartment of Internal MedicineSeoul Metropolitan Government Borame Medical Center, Seoul 156-707, South KoreaDepartment of Internal MedicineSeoul National University Bundang Hospital, Seongnam-city, Gyeonggi-do, South Korea
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12
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Chau K, Holmes D, Melck A, Chan-Yan C. Secondary hypertension due to concomitant aldosterone-producing adenoma and parathyroid adenoma. Am J Hypertens 2015; 28:280-2. [PMID: 24951725 DOI: 10.1093/ajh/hpu102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
There is a growing body of evidence supporting a bidirectional relationship between parathyroid hormone (PTH) and aldosterone (Aldo). We report a case of secondary hypertension due to concomitant Aldo-producing adenoma (APA) and parathyroid adenoma (PA) requiring both unilateral adrenalectomy and parathyroidectomy.
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Affiliation(s)
- Katrina Chau
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
| | - Daniel Holmes
- Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Adrienne Melck
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Clifford Chan-Yan
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada;
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13
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Hibi Y, Hayakawa N, Hasegawa M, Ogawa K, Shimizu Y, Shibata M, Kagawa C, Mizuno Y, Yuzawa Y, Itoh M, Iwase K. Unmasked renal impairment and prolonged hyperkalemia after unilateral adrenalectomy for primary aldosteronism coexisting with primary hyperparathyroidism: report of a case. Surg Today 2013; 45:241-6. [PMID: 24343173 PMCID: PMC4293497 DOI: 10.1007/s00595-013-0813-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 10/28/2013] [Indexed: 01/26/2023]
Abstract
We herein report the case of a patient with critical hyperkalemia after unilateral adrenalectomy (ADX) for aldosterone-producing adenomas, which were coexisting with primary hyperparathyroidism. A right adrenal tumor oversecreting mineral corticoid was identified in a 62-year-old female whose kidney function had been impaired due to primary hyperaldosteronism and hyperparathyroidism. The ADX improved her hypertension with normalization of the plasma aldosterone concentration, but without adequately increasing her plasma renin activity. Her eGFR further decreased postoperatively, hyperkalemia appeared and the serum potassium level rose to 6.3 mEq/L at 3 months after ADX. Then, treatment with calcium polystyrene sulfonate jelly was started. Eight months after ADX, a left lower parathyroidectomy was performed, and the serum calcium and intact parathyroid hormone levels decreased to the normal range. The hyperkalemia was difficult to control within 20 months postoperatively without treatment with calcium polystyrene sulfonate jelly or hydrocortisone. This suggests that unmasking the renal impairment and relative hypoaldosteronism after ADX might induce critical hyperkalemia.
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Affiliation(s)
- Yatsuka Hibi
- Department of Endocrine Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan,
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14
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Chiang WF, Cheng CJ, Wu ST, Sun GH, Lin MY, Sung CC, Lin SH. Incidence and factors of post-adrenalectomy hyperkalemia in patients with aldosterone producing adenoma. Clin Chim Acta 2013; 424:114-8. [DOI: 10.1016/j.cca.2013.05.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 04/23/2013] [Accepted: 05/15/2013] [Indexed: 10/26/2022]
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15
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Fischer E, Hanslik G, Pallauf A, Degenhart C, Linsenmaier U, Beuschlein F, Bidlingmaier M, Mussack T, Ladurner R, Hallfeldt K, Quinkler M, Reincke M. Prolonged zona glomerulosa insufficiency causing hyperkalemia in primary aldosteronism after adrenalectomy. J Clin Endocrinol Metab 2012; 97:3965-73. [PMID: 22893716 DOI: 10.1210/jc.2012-2234] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
CONTEXT Unilateral adrenalectomy is the therapy of choice in aldosterone-producing adenoma (APA). Zona glomerulosa (ZG) insufficiency causing hyperkalemia after adrenalectomy has been described in case reports. OBJECTIVE Our aim was to analyze the clinical relevance of ZG insufficiency causing hyperkalemia after adrenalectomy in a large series of patients with APA. DESIGN This was a retrospective chart review. SETTING The study was conducted at two tertiary university referral centers in Germany. PATIENTS Data from 110 patients with confirmed APA adrenalectomized at the centers in Munich and Berlin between 2004 and 2012 were analyzed. MAIN OUTCOME MEASURES The primary outcome was the incidence of ZG insufficiency causing hyperkalemia after adrenalectomy; the secondary outcome was the identification of risk factors predisposing for hyperkalemia. RESULTS Eighteen of 110 patients (16%) developed postoperative hyperkalemia. The majority of these patients (n = 14) had undetectable plasma aldosterone levels after adrenalectomy; four had low aldosterone levels. In 12 of these patients, hyperkalemia was documented only once and resumed spontaneously. Prolonged hypoaldosteronism accompanied by hyperkalemia was observed in six patients (5% of total cohort). These patients needed continuous mineralocorticoid replacement therapy for 11-46 months. Mineralocorticoid antagonist treatment for 4 wk prior to surgery did not prevent hyperkalemia. In multivariate analysis, preoperatively decreased glomerular filtration rate and increased serum creatinine as well as increased postoperative creatinine and microalbuminuria remained significant predictors of hyperkalemia. CONCLUSION Persistent postoperative hypoaldosteronism with hyperkalemia occurs in 5% of adrenalectomized PA patients through prolonged ZG insufficiency, requiring long-term fludrocortisone treatment. Potassium levels after adrenalectomy must be monitored to avoid life-threatening hyperkalemia.
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Affiliation(s)
- Evelyn Fischer
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ziemssenstr. 1, 80336 München, Germany
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16
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Koshiyama H, Fujisawa T, Kuwamura N, Nakamura Y, Kanamori H, Oida E, Hara A, Suzuki T, Sasano H. A case of normoreninemic aldosterone-producing adenoma associated with chronic renal failure: case report and literature review. Endocrine 2003; 21:221-6. [PMID: 14515005 DOI: 10.1385/endo:21:3:221] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2003] [Revised: 04/21/2003] [Accepted: 04/28/2003] [Indexed: 11/11/2022]
Abstract
The diagnosis of aldosterone-producing adenoma (APA) is challenging for endocrinologists, as APA does not always present with the typical constellation of clinical and laboratory features, such as hypertension, hypokalemia, suppressed plasma renin activity (PRA), and high plasma aldosterone concentration (PAC). Very recently, several studies have indicated that APA can be discovered even in normokalemic subjects with normal PRA more frequently than previously considered. Here we report a case of APA associated with chronic renal failure, which showed normokalemia and normal PRA. The patient was referred to our clinic for evaluation of an incidentally discovered adrenal mass with abnormally high PAC. After 6 yr, it was found that the right adrenal tumor showed a marked increase in size. Endocrinological examinations indicated normal PRA and markedly high PAC. Aldosterone showed a better response to the upright posture test than that to ACTH stimulation test. The diagnosis of APA was made based on the markedly high PAC to PRA ratio and the adrenocortical scintigraphy, which showed unequivocal uptake into the tumor. Right laparoscopic adrenalectomy was performed, revealing a right adrenocortical adenoma with massive hemorrhage. Histopathological examinations revealed the presence of two independent adrenocortical adenomas, one APA with predominant clear tumor cells and few c17 (17alpha-hydroxylase) immunoreactivity and the other, cortisol producing adenoma with compact cytoplasm and abundant C17 immunoreactivity. This case indicates a difficulty of diagnosis of "normoreninemic APA" with renal failure. This case is in line with the recent concept that APA is a continuous condition in which only a minority of patients have the classical clinical picture of primary aldosteronism such as hypokalemia. It is possible that normokalemic APA constitutes the most common presentation of the disease.
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Affiliation(s)
- Hiroyuki Koshiyama
- Division of Diabetes & Endocrinology, Department of Medicine, Tazuke Kofukai Foundation Medical Research Institute Kitano Hospital, 2-4-20 Ohgi-machi, Kita-ku, Osaka 530-8480, Japan.
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Sugawara A, Takeuchi K, Suzuki T, Itoi K, Sasano H, Ito S. A Case of Aldosterone-Producing Adrenocortical Adenoma Associated with a Probable Post-Operative Adrenal Crisis: Histopathological Analyses of the Adrenal Gland. Hypertens Res 2003; 26:663-8. [PMID: 14567506 DOI: 10.1291/hypres.26.663] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We describe a case of aldosterone-producing adrenocortical adenoma (APA) associated with a probable post-operative adrenal crisis possibly due to subtle autonomous cortisol secretion. The patient was a 46-year-old female who suffered from severe hypertension and hypokalemia. CT and MRI scans revealed a 2-cm diameter adrenal mass. The patient's plasma aldosterone level was increased, and her plasma renin activity was suppressed, both of which findings were consistent with APA. Cushingoid appearance was not observed. Morning and midnight serum cortisol and plasma adrenocorticotropic hormone (ACTH) levels were all within the normal range. Her serum cortisol level was suppressed to 1.9 microg/dl as measured by an overnight 1-mg dexamethasone suppression test, but was incompletely suppressed (2.7 microg/dl) by an overnight 8-mg dexamethasone suppression test. In addition, adrenocortical scintigraphy showed a strong uptake at the tumor region and a complete suppression of the contra-lateral adrenal uptake. After unilateral adrenalectomy, she had an episode of adrenal crisis, and a transient glucocorticoid replacement improved the symptoms. Histopathological studies demonstrated that the tumor was basically compatible with APA. The clear cells in the tumor were admixed with small numbers of compact cells that expressed 17alpha-hydroxylase, suggesting that the tumor was able to produce and secrete cortisol. In addition, the adjacent non-neoplastic adrenal cortex showed cortical atrophy, and dehydroepiandrosterone sulfotransferase immunoreactivity in the zonae fasciculata and reticularis was markedly diminished, suggesting that the hypothalamo-pituitary-adrenal (HPA) axis of the patient was suppressed due to neoplastic production and secretion of cortisol. Together, these findings suggested that autonomous secretion of cortisol from the tumor suppressed the HPA axis of the patient, thereby triggering the probable post-operative adrenal crisis. Post-operative adrenocortical insufficiency should be considered in clinical management of patients with relatively large APA, even when physical signs of autonomous cortisol overproduction are not apparent.
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Affiliation(s)
- Akira Sugawara
- Division of Nephrology, Endocrinology, and Vascular Medicine, Department of Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
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