Systematic review of surgery and outcomes in patients with primary aldosteronism

Muth, Andreas; Ragnarsson, Oskar; Johannsson, Gudmundur; Wängberg, Bo

doi:10.1002/bjs.9744

Cited by 109 publications

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“…The differentiation between unilateral and bilateral disease is essential for diagnosis confirmation and proper treatment. Patients with bilateral hyperplasia are treated with a mineralocorticoid receptor antagonist, whereas the subjects with a unilateral adenoma undergo adrenalectomy [8,9]. Because aldosterone-producing microadenomas and multiple bilateral lesions are often undetectable on computed tomography (CT), there is a substantial risk of misdiagnosis when using only CT scanning [10][11][12][13][14][15][16].…”

Section: Introductionmentioning

confidence: 99%

A single-centre experience of the implementation of adrenal vein sampling procedure: the impact on the diagnostic work-up in primary aldosteronism

et al. 2017

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A b s t r a c tBackground: Primary aldosteronism is one of the most common causes of secondary hypertension. Adrenal vein sampling (AVS) remains a "gold standard" procedure in differentiation between unilateral (adenoma) and bilateral (hyperplasia) disease. Aim:The aim of this study was to present our single-centre experience in establishing and implementating the AVS procedure. Methods:All patients had primary aldosteronism confirmed in a salt-infusion test. AVS was performed sequentially during a continuous intravenous infusion of cosyntropin and was preceded by multislice contrast-enhanced computed tomography (CT) examination of adrenal glands performed a few weeks before AVS in the majority of patients. AVS was regarded as successful if the ratio of each adrenal vein cortisol to inferior vena cava cortisol levels (selectivity index [SI]) was higher than 3.0. In the case of failure, a second attempt was considered in a few weeks. Patients were divided into four groups according to the order of the procedure by quartiles.Results: Between 31 May, 2012 and 5 May, 2016, AVS was performed in 124 patients (69% males, aged 55.3 ± 10.3 years) and was successful in 120 (96.8%) patients. All failed cases were due to the failure of cannulation of the right adrenal vein. The first-attempt success rate was 94.3% (117 of 124 patients) and increased from 83.9% in the first 31 patients to 100% in the last 31 patients. Similarly, the overall success rate increased from 93.5% to 100%. The right SI was significantly higher than the left one (26.4 vs. 11.0, p < 0.0001). Both indices did not differ across quartiles of patients. No complications occurred during the procedure. Conclusions:The AVS procedure, preceded by adrenal CT, may be implemented into daily diagnostic practice safely with an excellent success rate.

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Section: Introductionmentioning

confidence: 99%

A single-centre experience of the implementation of adrenal vein sampling procedure: the impact on the diagnostic work-up in primary aldosteronism

et al. 2017

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confidence: 97%

“…This limits the usefulness of the results obtained, since it must be noted that patients with bilateral PA are in general less responsive to monotherapy with MRA than those with unilateral PA [17]. Comparisons between surgically and medically treated patients with PA should, therefore, be interpreted with caution [16].The effects on improvement of BP and hypokalemia were similar in surgically and medically treated patients in six studies, and surgery was reported to be superior in another six studies [16]. Of note, in German Conn's registry, the observed all-cause mortality following adrenalectomy was reduced compared with medical treatment [7].…”

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confidence: 97%

“…Adrenalectomy generally results in the normalization of aldosterone secretion and serum potassium (96-100%); however, patients should be warned that hypertension is not always cured [29]. Based on 2482 patients from 16 studies, BP was normalized in a mean of 42% (range 20-72%) of patients [16]. Of note, older studies with a "cure" rate as high as 56-77% used the cure threshold of BP < 160/95 mm Hg, which is clearly still in the hypertensive range [1].…”

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confidence: 99%

“…However, until these data are reproduced elsewhere, this surrogate may guide the clinician in selecting patients for AVS but should not be used to direct surgical management [1]. High clinical probability of unilateral PA (e.g., severe hypertension, hypokalemia, higher basal, or post-SIT PAC, age < 50 years) [32,42] Patient not suitable for surgery (e.g., older age and/or multiple comorbidities)Positive clinical prediction score for unilateral PA [63,67] Positive clinical prediction criterion for bilateral PA [68] Persistent hypertension less likely [12,16,29,36,37] Persistent hypertension more likely [12,16,29,36,37] Higher peripheral plasma 18-oxocortisol [59] Positive genetic testing for FH-I [1]Note: PAC, plasma aldosterone concentration; SIT, saline infusion test; FH-I, familial hyperaldosteronism type I. …”

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Rational Approach to a Patient with Suspected Primary Aldosteronism

Kocjan¹

2017

Clinical Management of Adrenal Tumors

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Primary aldosteronism (PA) is the most common form of secondary hypertension that causes higher morbidity and mortality than equally severe essential hypertension. Bilateral PA should be treated medically with spironolactone or eplerenone, the mineralocorticoid receptor antagonists (MRA), while unilateral laparoscopic adrenalectomy is recommended for unilateral disease. Surgery cures hypertension in around 40% of patients with confirmed PA and reliably demonstrated unilateral autonomous aldosterone secretion by adrenal venous sampling (AVS). Regardless of its diagnostic value, AVS has several drawbacks, in particular high cost and invasiveness. Furthermore, only a limited number of referral centers worldwide routinely carry out the procedure. On the other hand, a small number of studies that compared the effects of surgery and MRA on the incidence of cardiovascular and renal outcomes in patients with PA found no difference between the two therapeutic options. In addition, spironolactone has been recently found to be the most effective add-on drug for the treatment of resistant hypertension. Therefore, rational selection of patients with suspected PA for AVS and surgery is of utmost importance.Keywords: adrenalectomy, adrenal venous sampling, hypertension, mineralocorticoid receptor antagonists, primary aldosteronism IntroductionPrimary aldosteronism (PA) is a group of disorders in which aldosterone production is inappropriately high for sodium status, relatively autonomous and nonsuppressible by sodium loading. Such inappropriate production of aldosterone causes hypertension, sodium retention, suppression of plasma renin, and increased potassium excretion [1]. Once thought to be rare, PA is now considered the most common form of secondary hypertension with an © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. estimated prevalence of 4.3% in primary care and of 9.5% among referred hypertensive patients [2]. Accumulated experimental and clinical evidence clearly shows that prolonged exposure to elevated aldosterone levels causes excess cardiovascular and renal damage which is partly independent of blood pressure (BP) levels [3]. Consequently, this endocrine condition is far from being benign, and patients with PA appear to have higher rates of cardiac arrhythmia, coronary heart disease, heart failure, stroke, proteinuria, and renal impairment compared to matched patients with essential hypertension (EH) [4][5][6]. Their cardiovascular mortality might be also increased [7]. Targeted treatment of PA is possible and is of obvious benefit to affected patients.The Endocrine Society now explicitly recognizes PA as a major public health issue and recommends extensive screening for this disorder using the plasma aldosterone/renin ratio (ARR) in high-risk populations, inclu...

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Clinical Outcomes After Unilateral Adrenalectomy for Primary Aldosteronism

et al. 2019

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; for the International CONNsortium study group IMPORTANCE In addition to biochemical cure, clinical benefits after surgery for primary aldosteronism depend on the magnitude of decrease in blood pressure (BP) and use of antihypertensive medications with a subsequent decreased risk of cardiovascular and/or cerebrovascular morbidity and drug-induced adverse effects. OBJECTIVE To evaluate the change in BP and use of antihypertensive medications within an international cohort of patients who recently underwent surgery for primary aldosteronism. DESIGN, SETTING, AND PARTICIPANTS A cohort study was conducted across 16 referral medical centers in Europe, the United States, Canada, and Australia. Patients who underwent unilateral adrenalectomy for primary aldosteronism between January 2010 and December 2016 were included. Data analysis was performed from August 2017 to June 2018. Unilateral disease was confirmed using computed tomography, magnetic resonance imaging, and/or adrenal venous sampling. Patients with missing or incomplete preoperative or follow-up data regarding BP or corresponding number of antihypertensive medications were excluded. MAIN OUTCOMES AND MEASURES Clinical success was defined based on postoperative BP and number of antihypertensive medications. Cure was defined as normotension without antihypertensive medications, and clear improvement as normotension with lower or equal use of antihypertensive medications. In patients with preoperative normotensivity, improvement was defined as postoperative normotension with lower antihypertensive use. All other patients were stratified as no clear success because the benefits of surgery were less obvious, mainly owing to postoperative, persistent hypertension. Clinical outcomes were assessed at follow-up closest to 6 months after surgery. RESULTS On the basis of inclusion and exclusion criteria, a total of 435 patients (84.6%) from a cohort of 514 patients who underwent unilateral adrenalectomy were eligible. Of these patients, 186 (42.3%) were women; mean (SD) age at the time of surgery was 50.7 (11.4) years. Cure was achieved in 118 patients (27.1%), clear improvement in 135 (31.0%), and no clear success in 182 (41.8%). In the subgroup classified as no clear success, 166 patients (91.2%) had postoperative hypertension. However, within this subgroup, the mean (SD) systolic and diastolic BP decreased significantly by 9 (22) mm Hg (P < .001) and 3 (15) mm Hg (P = .04), respectively. Also, the number of antihypertensive medications used decreased from 3 (range, 0-7) to 2 (range, 0-6) (P < .001). Moreover, in 75 of 182 patients (41.2%) within this subgroup, the decrease in systolic BP was 10 mm Hg or greater. CONCLUSIONS AND RELEVANCE In this study, for most patients, adrenalectomy was associated with a postoperative normotensive state and reduction of antihypertensive medications. Furthermore, a significant proportion of patients with postoperative, persistent hypertension may benefit from adrenalectomy given the observed clinically relevant and significant redu...

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Systematic review of surgery and outcomes in patients with primary aldosteronism

Cited by 109 publications

References 68 publications

A single-centre experience of the implementation of adrenal vein sampling procedure: the impact on the diagnostic work-up in primary aldosteronism

A single-centre experience of the implementation of adrenal vein sampling procedure: the impact on the diagnostic work-up in primary aldosteronism

Rational Approach to a Patient with Suspected Primary Aldosteronism

Clinical Outcomes After Unilateral Adrenalectomy for Primary Aldosteronism

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