Success of Surgery for Primary Aldosteronism Judged by Residual Autonomous Aldosterone Production

Rutherford, John C.; Taylor, Wendy L.; Stowasser, Michael; Gordon, Richard D.

doi:10.1007/s002689900552

Cited by 84 publications

(45 citation statements)

References 5 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…This observation accords with our long-standing experience in a larger cohort of APA patients and with available, 5 albeit not all, 21 previous reports. Thus, cure of hyperaldosteronism can be consistently achieved when the diagnosis of APA is corroborated by the demonstration of a lateralized aldosterone excess.…”

Section: Discussionsupporting

confidence: 80%

Vascular Remodeling and Duration of Hypertension Predict Outcome of Adrenalectomy in Primary Aldosteronism Patients

et al. 2008

View full text Add to dashboard Cite

Abstract-Remodeling of the resistance arteries is a hallmark of arterial hypertension and predicts cardiovascular events, but it was unknown whether it could also predict the blood pressure response to adrenalectomy of patients with an aldosterone-producing adenoma. Therefore, we investigated the outcome of adrenalectomy as a function of vascular remodeling in the context of the preoperative features of aldosterone-producing adenoma patients. At 2 referral centers for hypertension, we prospectively measured the media:lumen ratio of small arteries from fat tissue of 50 consecutive aldosterone-producing adenoma patients treated with adrenalectomy. The blood pressure response to adrenalectomy was assessed by considering the blood pressure values and the number and dosages of antihypertensive medications. Adrenalectomy significantly (PϽ0.001) lowered plasma aldosterone (from 27.3Ϯ4.9 ng/dL to 8.3Ϯ11.2 ng/dL), the aldosterone:renin ratio (from 117Ϯ35 to 11Ϯ2), and blood pressure (from 163Ϯ22/98Ϯ2 mm Hg to 133Ϯ2/ 84Ϯ1 mm Hg), even despite a reduction (from 141Ϯ14 to 100Ϯ15; Pϭ0.02) of the score of antihypertensive treatment.It provided cure of hypertension in 30% of the aldosterone-producing adenoma patients, normotension with less antihypertensive therapy in 52%, and improved blood pressure control in the rest. The media:lumen ratio and the known duration of hypertension significantly predicted the blood pressure response to adrenalectomy at univariate and multivariate analyses. Because a long duration of hypertension and/or the presence of vascular remodeling imply lower chances of blood pressure normalization at long-term follow-up postadrenalectomy, these findings emphasize the importance of an early diagnosis of aldosterone-producing adenoma. Key Words: secondary hypertension Ⅲ aldosterone Ⅲ aldosteronism Ⅲ adrenalectomy Ⅲ outcome Ⅲ vascular remodeling P rimary aldosteronism (PA) is far more common than usually perceived and is attributable to an aldosteroneproducing adenoma (APA) in approximately half of the patients. 1 Thus, it entails the most common endocrine form of secondary arterial hypertension (HT) that is curable by adrenalectomy in many patients. 2 Identification of an APA, or unilateral primary adrenocortical hyperplasia, 3 requires adrenal vein sampling (AVS) that, being minimally risky, should be reserved for patients who are candidates for adrenalectomy and, more importantly, can benefit from it. 4 However, the identification of patients who will benefit more remains a challenging task, because the blood pressure (BP) response to adrenalectomy varies widely across patients. In fact, despite many efforts over the years, only age and lack of family history of HT were suggested to significantly predict the BP response. 5-8 Nevertheless, the large uncertainties in the prediction estimates render them of little, if any, 8 value on an individual basis.The remodeling of resistance arteries is a hallmark of arterial HT and can be implicated in the excess cardiovascular damage associated with HT. Hence, it ...

show abstract

Section: Discussionsupporting

confidence: 80%

Vascular Remodeling and Duration of Hypertension Predict Outcome of Adrenalectomy in Primary Aldosteronism Patients

et al. 2008

View full text Add to dashboard Cite

show abstract

“…6 Others, however, have described patients with apparent adenomas in the absence of elevated plasma aldosterone levels. [22][23][24] Our findings support the need for elevated plasma aldosterone as well as ARR when looking for an anatomically curable cause of PHA. Our estimate of 0.7% prevalence of patients with PHA supports both clinical impression and classical accounts of PHA in which positive scans are uncommon in the absence of hypokalaemia and a plasma aldosterone at least two-fold above normal.…”

Section: Discussionsupporting

confidence: 73%

“…Published reports cite only 50% cure of hypertension in series that include adrenalectomies performed without a positive scan. 22,24,27 In conclusion, we would not advocate further investigation of patients lacking hypokalaemia, elevated aldosterone excess or anatomical abnormalities on a scan.…”

Section: Discussionmentioning

confidence: 99%

Prevalence of primary hyperaldosteronism assessed by aldosterone/renin ratio and spironolactone testing

et al. 2005

View full text Add to dashboard Cite

-Recent studies have suggested that primary hyperaldosteronism may be present in more than 10% of patients with hypertension. We aimed to estimate the prevalence in unselected patients in primary care, and investigate the influence of current drug treatment upon the aldosterone/renin ratio (ARR) and its prediction of blood pressure response to spironolactone. We measured blood pressure, plasma electrolytes, renin activity and aldosterone in 846 patients with hypertension. Spironolactone 50 mg was prescribed for one month to patients with blood pressure ≥130/85 mmHg and ARR ≥400. The primary outcome measure was to discover the proportion of patients with plasma aldosterone ≥400 pmol/l and ARR ≥800 and either an adrenal adenoma on computed tomography scan or a systolic blood pressure response to spironolactone ≥20 mmHg. Only one patient had an adenoma, and only 16 (1.8%) had both a plasma aldosterone ≥400 pmol/l and ARR ≥800. By contrast, 119 patients (14.1%) had an elevated ARR but normal plasma aldosterone. In 69 patients out of the 119 who received spironolactone, blood pressure fell by 26/11 mmHg. These patients were normokalaemic but had uncontrolled hypertension despite multiple drugs. The response to spironolactone was best predicted by a low plasma renin, ≤0.5 pmol/ml/h (<10 mU/l), despite treatment with an ACE inhibitor. We concluded that adrenal adenomas are an uncommon cause of hypertension. In the absence of hypokalaemia, a low plasma renin is a sufficient and simple way of detecting spironolactoneresponders among patients with resistant hypertension. Only patients with both hypokalaemia and low plasma renin, measured while the patient is off β blockade, require measurement of aldosterone. A plasma aldosterone >400 pmol/l together with renin activity ≤0.5 pmol/ml/h should trigger further investigations for an adrenal adenoma.

show abstract

“…However, 5 to 10% of patients display residual autonomous aldosterone production after surgery, even if hypertension is cured 26 and adrenal venous sampling (AVS) is used in the diagnostic process. Hypokalemia, when present, resolves in more than 95% of cases, in all series.…”

Section: Outcomes Of Adrenalectomy In Unilateral Pamentioning

confidence: 99%

Outcomes of Drug-Based and Surgical Treatments for Primary Aldosteronism

Steichen

Lorthioir

Zinzindohoué

et al. 2015

Advances in Chronic Kidney Disease

View full text Add to dashboard Cite

Treatments for primary aldosteronism (PA) aim to correct or prevent the deleterious consequences of hyperaldosteronism: hypertension, hypokalemia and direct target organ damage. Patients with unilateral PA considered fit for surgery can undergo laparoscopic adrenalectomy, which significantly decreases blood pressure and medications in most cases, and cures hypertension in about 40%. Mineralocorticoid receptor antagonists (MRA) are used to treat patients with bilateral PA and those with unilateral PA if surgery is not possible or not desired. Spironolactone is more potent than eplerenone, but high doses are poorly tolerated in men. MRA can be replaced or complemented with epithelial sodium channel blockers, such as amiloride. Thiazide diuretics and calcium channel blockers are used when the first-line drugs are insufficient to control blood pressure. Dietary sodium restriction should be implemented in all cases, because the deleterious consequences of hyperaldosteronism are dependent on salt loading. Several studies comparing the results of surgery and MRA have reported no differences in terms of blood pressure, serum potassium concentration or cardiovascular and renal outcomes, although the benefits of treatment tend to be observed sooner with surgery.PA patients display relative glomerular hyperfiltration, which is reversed by specific treatment, revealing chronic kidney disease in 30% of patients. However, further kidney damage is prevented by the treatment of PA. Clinical summary-The goals of treatment are the normalization of serum potassium concentration, blood pressure control and prevention of the direct effects of excess aldosterone on target organs. 3-The non-surgical treatment of PA is based on mineralocorticoid receptor antagonists and dietary sodium restriction.-Epithelial sodium channel blockers are used when mineralocorticoid receptor antagonists are not well tolerated; thiazide diuretics and calcium channel blockers are used when blood pressure control is insufficient with the first-line treatment.-Laparoscopic adrenalectomy is safe and decreases BP and medication requirements in patients with unilateral PA; drug-based treatments are appropriate in cases in which surgery is inappropriate or not desired.

show abstract

Success of Surgery for Primary Aldosteronism Judged by Residual Autonomous Aldosterone Production

Cited by 84 publications

References 5 publications

Vascular Remodeling and Duration of Hypertension Predict Outcome of Adrenalectomy in Primary Aldosteronism Patients

Vascular Remodeling and Duration of Hypertension Predict Outcome of Adrenalectomy in Primary Aldosteronism Patients

Prevalence of primary hyperaldosteronism assessed by aldosterone/renin ratio and spironolactone testing

Outcomes of Drug-Based and Surgical Treatments for Primary Aldosteronism

Contact Info

Product

Resources

About