Outcomes after adrenalectomy for unilateral primary aldosteronism: an international consensus on outcome measures and analysis of remission rates in an international cohort.
Ontology highlight
ABSTRACT:
SUBMITTER: Williams TA
PROVIDER: S-EPMC5572673 | biostudies-literature | 2017 Sep
REPOSITORIES: biostudies-literature
Publications
Outcomes after adrenalectomy for unilateral primary aldosteronism: an international consensus on outcome measures and analysis of remission rates in an international cohort.
Williams Tracy A TA Lenders Jacques W M JWM Mulatero Paolo P Burrello Jacopo J Rottenkolber Marietta M Adolf Christian C Satoh Fumitoshi F Amar Laurence L Quinkler Marcus M Deinum Jaap J Beuschlein Felix F Kitamoto Kanako K KK Pham Uyen U Morimoto Ryo R Umakoshi Hironobu H Prejbisz Aleksander A Kocjan Tomaz T Naruse Mitsuhide M Stowasser Michael M Nishikawa Tetsuo T Young William F WF Gomez-Sanchez Celso E CE Funder John W JW Reincke Martin M
The lancet. Diabetes & endocrinology 20170530 9
<h4>Background</h4>Although unilateral primary aldosteronism is the most common surgically correctable cause of hypertension, no standard criteria exist to classify surgical outcomes. We aimed to create consensus criteria for clinical and biochemical outcomes and follow-up of adrenalectomy for unilateral primary aldosteronism and apply these criteria to an international cohort to analyse the frequency of remission and identify preoperative determinants of successful outcome.<h4>Methods</h4>The P ...[more]
Similar Datasets
Project description:ImportanceIn 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.ObjectiveTo 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 participantsA 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 measuresClinical 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.ResultsOn 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 relevanceIn 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 reduction of BP and antihypertensive medications.
| S-EPMC6484800 | biostudies-literature
Project description:Primary aldosteronism (PA) is the most common cause of endocrine hypertension. Unilateral PA can be cured using unilateral adrenalectomy (Adx). PA surgery outcome (PASO) criteria, which include clinical and biochemical outcomes, have been proposed to evaluate PA cure after Adx. However, clinical outcomes are often inconsistent with biochemical outcomes. In addition, although confirmatory tests are included as endpoints of biochemical outcomes in the PASO criteria, their clinical usefulness has not yet been established. We evaluated clinical parameters and confirmatory test results before and after Adx in 16 patients with PA and assessed the usefulness of the confirmatory tests. The following were the clinical outcomes after Adx: 37.5% complete success, 62.5% partial success, and 0% absent success. The ratio of biochemical complete success was as follows: 69% aldosterone/renin ratio and basal plasma aldosterone concentration, 19% as assessed by the captopril challenge test, 47% as assessed by the saline infusion test, 30% as assessed by the furosemide upright test, and 100% urine aldosterone. Of these, biochemical complete success was judged in four cases by aldosterone/renin ratio and basal plasma aldosterone concentration, one case by captopril challenge test, five cases by saline infusion test, and one case by furosemide upright test. Although clinical outcomes and urine aldosterone levels improved after Adx, confirmatory tests failed to improve in some cases. The current criteria are not considered useful for biochemical evaluation after Adx. To determine whether additional treatment with mineralocorticoid receptor antagonists is required, more accurate biochemical criteria should be established after Adx.
| S-EPMC10232090 | biostudies-literature
Project description:The underlying cause of resistant hypertension after adrenalectomy for primary hyperaldosteronism remains controversial. The objective of this study was to identify preoperative factors predictive of resistant hypertension in patients after undergoing retroperitoneoscopic adrenalectomy. Between 2003 and 2009, 124 patients with unilateral aldosterone-producing adenoma or unilateral adrenal hyperplasia underwent retroperitoneoscopic adrenalectomy at our institution. Clinical and biochemical data were reviewed retrospectively at baseline and after a median follow-up time of 59.2 ± 37.2 months. Adrenalectomy cured hypertension in 68 patients (54.8%) and 43 (34.8%) had persistent hypertension that was much easier to control after surgery, whereas 13 patients (10.4%) had continued hypertension and poor blood pressure control. Multivariate regression analysis revealed that the main determinants of postoperative cure were duration of hypertension less than 5 years [odds ratio (OR): 6.515, 95% confidence interval (CI) 2.278-10.293), number of antihypertensive medications ≤2 (OR: 2.939, 95% CI 1.254-5.235), preoperative response to spironolactone (OR: 3.405, 95% CI 1.681-6.985), the TT genotype of the CYP11B2 gene (344 C/T) (OR: 2.765, 95% CI 1.221-4.986), and the presence of adenoma rather than hyperplasia (OR: 5.274, 95% CI 2.150-8.141). The main determinants of surgical cure or control of hypertension in patients with primary hyperaldosteronism were duration of hypertension, number of antihypertensive medications, preoperative response to spironolactone, the presence of adenoma, and CYP11B2 (344 C/T) genotype. Consideration of these factors may help in the evaluation of patients for surgery and for the identification of patients with continued postoperative hypertension that may require more long-term monitoring and treatment.
| S-EPMC3723202 | biostudies-literature
Project description:ContextPrimary aldosteronism (PA) is the most common form of endocrine hypertension. According to the Endocrine Society Practice Guidelines, the diagnosis of PA requires a pathological screening test result and non-suppressible aldosterone levels during confirmatory testing. Sequential testing with more than one confirmatory test may result in discordant test results.Objective and patientsWe investigated the association of discordant results of captopril challenge test (CCT) and saline infusion test (SIT) on patient subtype classification by adrenal vein sampling (AVS) and outcome in 111 consecutive patients from the German Conn's Registry. Concordance was defined as non-suppressible aldosterone levels upon both tests, while discordance was defined as conflicting test results. Patients with unilateral disease were offered adrenalectomy (ADX). Biochemical and clinical outcomes were assessed using the PASO criteria.Results85 of 111 (77%) patients had concordant results of CCT and SIT. Although baseline characteristics were comparable between patients with concordant and discordant tests, the latter had significantly lower aldosterone levels after testing (CCT: 170 vs. 114pg/ml; SIT: 139 vs. 101pg/ml; p=0.004). In 35% of patients with discordant (n=9) and 46% of concordant test results (n=39), AVS suggested lateralized PA. In 36 of 48 cases ADX was performed. 86% of patients with discordant and 72% with concordant results had complete biochemical success.ConclusionThe use of two confirmatory tests in patients with PA results in discordant results in approximately 23% of cases. Patients having discordant confirmatory test results had a comparable rate of lateralized PA and underwent adrenalectomy with similar long-term outcome.
| S-EPMC11637841 | biostudies-literature
Project description:Primary aldosteronism (PA) may induce significant decline of renal function and structural damage of kidney. However, it is difficult to evaluate accurate renal function in patients with PA, because glomerular hyperfiltration and aldosterone escape can conceal renal impairment. In this retrospective cohort study, we compared changes in renal function after unilateral adrenalectomy between patients with PA and patients with other adrenal diseases. Risk factors associated with postoperative renal impairment in patients with PA were analyzed.A total of 558 patients who received unilateral adrenalectomy between January 2002 and June 2013 were included: 136 patients with PA and 422 patients with other adrenal diseases (control). Postoperative serial changes in estimated glomerular filtration rate (eGFR) were analyzed in both groups. Multivariate analyses were performed to identify risk factors of renal impairment after adrenalectomy in all patients and the PA group. Postoperative renal impairment was defined as postoperative eGFR decline of >25% from preoperative eGFR. Chronic kidney disease (CKD) was defined as an eGFR <60 mL/min/1.73 m.There were no differences in preoperative eGFR between groups. The PA group showed a significant decrease in eGFR 3 days, 2 weeks, and 6 months after surgery compared to the control group. The PA group showed significant improvement of hypertension after surgery. In the PA group, 53 (39.0%) patients showed postoperative renal impairment. Multivariate regression analysis identified long-standing hypertension, low body mass index, low serum potassium, and high preoperative eGFR as risk factors for postoperative renal impairment. Among the 89 patients with preoperative eGFR ≥60 mL/min/1.73 m, 29 (32.6%) patients developed CKD postoperatively. Age, low serum potassium, low preoperative eGFR, and high serum cholesterol or uric acid were associated with the postoperative CKD development.Our study demonstrates that patients with PA with old age, low serum potassium, long-standing hypertension, and high serum uric acid or cholesterol are at risk of renal impairment after surgical treatment. High preoperative eGFR was also a risk factor for postoperative renal impairment, whereas low preoperative eGFR was a risk factor for postoperative CKD. Close monitoring of renal function and adequate management are required for patients with these risk factors.
| S-EPMC5058795 | biostudies-literature
Project description:Unilateral primary aldosteronism (PA) is the most common surgically curable form of hypertension that must be accurately differentiated from bilateral PA for therapeutic management (surgical versus medical). Adrenalectomy results in biochemical cure (complete biochemical success) in almost all patients diagnosed with unilateral PA; the remaining patients with partial or absent biochemical success comprise those with persisting aldosteronism who were misdiagnosed as unilateral PA preoperatively. To identify determinants of postsurgical biochemical outcomes, we compared the adrenal histopathology and the peripheral venous steroid profiles of patients with partial and absent or complete biochemical success after adrenalectomy for unilateral PA. A large multicenter cohort of adrenals from patients with absent and partial biochemical success (n=43) displayed a higher prevalence of hyperplasia (49% versus 21%; P=0.004) and a lower prevalence of solitary functional adenoma (44% versus 79%; P<0.001) compared with adrenals from age- and sex-matched patients with PA with complete biochemical success (n=52). We measured the peripheral plasma steroid concentrations in a subgroup of these patients (n=43) and in a group of patients with bilateral PA (n=27). Steroid profiling was associated with histopathologic phenotypes (solitary functional adenoma, hyperplasia, and aldosterone-producing cell clusters) and classified patients according to biochemical outcome or diagnosis of bilateral PA. If validated, peripheral venous steroid profiling may be a useful tool to guide the decision to perform surgery based on expectations of biochemical outcome after the procedure.
| S-EPMC6202235 | biostudies-literature
Project description:BackgroundThe urinary sodium potassium (NaK) ratio is associated with dietary sodium and potassium intake and blood pressure, and it also reflects the activity of aldosterone. Herein we evaluated the value of the urinary NaK ratio in predicting the surgical outcomes of patients with unilateral primary aldosteronism (uPA).MethodsThis non-concurrent prospective cohort study was conducted from 2011 to 2017 and included 241 uPA patients who had undergone adrenalectomy. Predictors of successful clinical outcomes were analyzed using logistic regression.ResultsAmong the 241 uPA patients, 197 (81.7%) achieved clinical complete or partial success. A urinary sodium potassium ratio <3 (odds ratio (OR): 2.5; 95% confidence interval (CI): 1.2-5.4; p = 0.015), body mass index <25 kg/m2 (OR: 2.82; 95% CI: 1.31-6.06; p = 0.008), renin <1 ng/mL/h (OR: 2.51; 95% CI: 1.01-6.21; p = 0.047) and mean preoperative blood pressure >115 mmHg (OR: 5.02; 95% CI: 2.10-11.97; p < 0.001) could predict clinical success after adrenalectomy. Furthermore, higher pre-treatment plasma aldosterone (OR: 1.014; 95% CI 1.005-1.024; p = 0.002) or lower serum potassium (OR: 0.523; 95% CI: 0.328-0.836; p = 0.007) were correlated with lower urinary NaK ratio (<3), and log urinary NaK ratio was positively correlated with serum C-reactive protein (β value 2.326; 95% CI 0.029-4.623; p = 0.047).ConclusionsuPA patients with a lower urinary NaK ratio, due to high plasma aldosterone and low serum potassium concentrations, were more likely to have clinical success after adrenalectomy. uPA patients with a higher urinary NaK ratio were associated with more severe inflammatory status, and possibly more resistant hypertension post-operatively.
| S-EPMC7887682 | biostudies-literature
Project description:BackgroundAdrenal venous sampling (AVS) is performed to distinguish the subtype of primary aldosteronism (PA). The clinical implication of contralateral suppression (CS; aldosterone/cortisolnondominant<aldosterone/cortisolperipheral) at AVS remains unclear. We aimed to investigate the clinical significance of CS and its impact on postoperative outcomes after unilateral adrenalectomy.MethodsIn this retrospective observational multi-center study, we analyzed PA patients who underwent both successful adrenocorticotropin hormone-stimulated AVS and unilateral adrenalectomy. Successful cannulation was defined as the selectivity index (cortisoladrenal/cortisolperipheral) ≥3. Clinical and biochemical outcomes after unilateral adrenalectomy were evaluated based on the international Primary Aldosteronism Surgical Outcome consensus.ResultsAmong 263 patients analyzed, 247 had CS (93.9%). Patients with CS had lower serum potassium levels, higher plasma aldosterone concentration, higher aldosterone-to-renin ratio (ARR), and larger adenoma size than those without CS. Those with CS showed significantly higher lateralization index than those without CS (P<0.001). Although postoperative blood pressure and ARR significantly decreased in those with CS, clinical and biochemical outcomes were comparable in both groups. When the cut-off value of age was determined using receiver operating characteristic (ROC) analysis, patients aged ≥50 years old with contralateral suppression index (CSI; the ratio between aldosterone/cortisolnondominant and aldosterone/cortisolperipheral) ≤0.26 had greater odds ratio (6.43; 95% confidence interval, 1.30 to 31.69) of incident chronic kidney disease than those aged <50 years with CSI >0.26 after adjusting for other factors.ConclusionCS may not predict postoperative clinical and biochemical outcomes in subjects with unilateral aldosterone excess, but it is associated with postsurgical deterioration of renal function in subjects over 50 years with CSI ≤0.26.
| S-EPMC8419620 | biostudies-literature
Project description:This systematic review and metanalysis was conducted to assess differences between perioperative and functional outcomes in patients undergoing minimally-invasive partial (mi-PA) and total adrenalectomy (mi-TA) for unilateral primary aldosteronism (uPHA). Multiple scientific databases (PUBMED, Web of Science, and Cochrane Library) were searched up to November 2021 for surgical series comparing mi-PA vs. mi-TA for uPHA according to the PRISMA statement. Primary outcomes of interest were perioperative and functional outcomes. Overall, a total of 802 patients from six eligible studies were identified, with mi-PA and mi-TA performed in 40.4% (n = 324) and 59.6% (n = 478) of cases, respectively. No differences were recorded between the two groups according to number of transfusions, EBL and Clavien-Dindo complications ≥2. Similarly, no differences in clinical success, persistence of postoperative hypokalemia and improvement in HTN were reported between mi-PA and mi-TA. In a uPHA setting, mi-PA and mi-TA provide comparable perioperative and functional outcomes despite the use of mi-PA remains limited to patients with small adenoma size, or hereditary/bilateral disease. Due to limited use of standardized reporting criteria in most of current series, the quest for a superiority of mi-PA over mi-TA in the treatment of uPHA still remains open.
| S-EPMC8911420 | biostudies-literature
Project description:BackgroundThe prevalence of diabetes mellitus (DM) was higher in primary aldosteronism (PA) patients. We aimed to evaluate the outcome of DM after adrenalectomy and determine the factors associated with that in PA patients.MethodsPA patients with DM (PA + DM patients) who received adrenalectomy were recruited into the study. The patients were classified into 3 groups based on their DM conditions after treatment, including "remission", "improved" and "unchanged" groups. Univariate and multivariate logistic regression analysis was conducted to uncover the preoperative factors affecting the outcome of DM after adrenalectomy.ResultsA total of 54 PA + DM patients received adrenalectomy. After adrenalectomy, 16.7%, 33.3% and 50.0% of patients were classified into the "remission", "improved" and "unchanged" groups, respectively. The factors negatively associated with remission or improvement from DM after adrenalectomy were longer duration of hypertension (P = 0.029). Higher concentration of urinary magnesium (P = 0.031) and higher 24 h urinary potassium (P = 0.049) were factors negatively associated with the "remission" from DM after adrenalectomy.ConclusionsAdrenalectomy was beneficial for the remission and improvement from DM in the half of PA patients with DM. Longer duration of hypertension, higher concentration of urinary magnesium and higher 24 h urinary potassium may prevent the remission and improvement from DM after adrenalectomy in PA patients. Examination of urinary electrolyte could be considered in PA patients with DM for predicting the outcome of DM after adrenalectomy.
| S-EPMC9793683 | biostudies-literature