Journal List > Korean J Endocr Surg > v.11(4) > 1060046

M.D., M.D., M.D., M.D., M.D., M.D., M.D., M.D., M.D., M.D., M.D., M.D., and M.D.: Postoperative Outcomes in Patients Undergoing Adrenalectomy for Primary Aldosteronism

Abstract

Purpose:

Primary aldosteronism (PA) is characterized by hypertension (HTN), hypokalemia, suppressed plasma renin activity, and inappropriate aldosterone secretion. The purpose of this study was to analyze postoperative results on blood pressure (BP), and to determine the factors associated with resolution of HTN after adrenalectomy for PA.

Methods:

One hundred eight patients (66 females and 42 males) with a mean age of 46 years underwent adrenalectomy for PA between January 1, 1996 and September 30, 2009. Their clinical characteristics and biochemical parameters were reviewed retrospectively.

Results:

All patients had HTN preoperatively and 20 patients (18.1%) had uncontrolled HTN. Hypokalemia was evident in 89.1% of patients, cardiovascular events in 4.5% and cerebrovascular events in 8.2%. There was a significant decrease in both systolic BP and diastolic BP postoperatively, as compared with that before operation. Median systolic BP decreased from 150 mmHg to 125 mmHg at the last follow-up (P<0.01), and median diastolic BP decreased from 93.5 mmHg to 81.5 mmHg (P<0.01). Sixty two (57.4%) patients were cured of HTN and did not require any hypertensive agent, and 38 (35.1%) patients had an improvement in BP control, whereas 9 (8.3%) patients had no change in BP. Univariate analysis showed that duration of HTN and more than two HTN treatment agents were independent factors predicting sustained hypertension after surgery.

Conclusion:

The duration of HTN and the severity of HTN are factors influencing persistence of HTN after operation for a PA.

REFERENCES

1.Conn JW., Louis LH. Primary aldosteronism, a new clinical entity. Ann Intern Med. 1956. 44:1–15.
crossref
2.Giacchetti G., Ronconi V., Lucarelli G., Boscaro M., Mantero F. Analysis of screening and confirmatory tests in the diagnosis of primary aldosteronism: need for a standardized protocol. J Hypertens. 2006. 24:737–45.
crossref
3.Plouin PF., Amar L., Chatellier G. Trends in the prevalence of primary aldosteronism, aldosterone-producing adenomas, and surgically correctable aldosterone-dependent hypertension. Nephrol Dial Transplant. 2004. 19:774–7.
crossref
4.Mulatero P., Stowasser M., Loh KC., Fardella CE., Gordon RD., Mosso L, et al. Increased diagnosis of primary aldosteronism, including surgically correctable forms, in centers from five continents. J Clin Endocrinol Metab. 2004. 89:1045–50.
crossref
5.Campagnacci R., Crosta F., De Sanctis A., Baldarelli M., Giacchetti G., Paganini AM, et al. Long-term results of laparoscopic adrenalectomy for primary aldosteronism. J Endocrinol Invest. 2009. 32:57–62.
crossref
6.Fowler DL. Laparoscopic adrenalectomy: there can be no doubt. Ann Surg Oncol. 2003. 10:997–8.
crossref
7.Gockel I., Heintz A., Polta M., Junginger T. Long-term results of endoscopic adrenalectomy for Conn's syndrome. Am Surg. 2007. 73:174–80.
crossref
8.Goh BK., Tan YH., Yip SK., Eng PH., Cheng CW. Outcome of patients undergoing laparoscopic adrenalectomy for primary hyperaldosteronism. JSLS. 2004. 8:320–5.
9.Gordon RD. Mineralocorticoid hypertension. Lancet. 1994. 344:240–3.
crossref
10.Rizzoni D., Porteri E., Castellano M., Bettoni G., Muiesan ML., Muiesan P, et al. Vascular hypertrophy and remodeling in secondary hypertension. Hypertension. 1996. 28:785–90.
crossref
11.Strauch B., Petrák O., Zelinka T., Wichterle D., Holaj R., Kasalický M, et al. Adrenalectomy improves arterial stiffness in primary aldosteronism. Am J Hypertens. 2008. 21:1086–92.
crossref
12.Funder JW., Carey RM., Fardella C., Gomez-Sanchez CE., Mantero F., Stowasser M, et al. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2008. 93:3266–81.
crossref
13.Nishizaka MK., Pratt-Ubunama M., Zaman MA., Cofield S., Calhoun DA. Validity of plasma aldosterone-to-renin activity ratio in African American and white subjects with resistant hypertension. Am J Hypertens. 2005. 18:805–12.
crossref
14.Catena C., Colussi G., Nadalini E., Chiuch A., Baroselli S., Lapenna R, et al. Cardiovascular outcomes in patients with primary aldosteronism after treatment. Arch Intern Med. 2008. 168:80–5.
15.Milliez P., Girerd X., Plouin PF., Blacher J., Safar ME., Mourad JJ. Evidence for an increased rate of cardiovascular events in patients with primary aldosteronism. J Am Coll Cardiol. 2005. 45:1243–8.
crossref
16.Rocha R., Stier CT Jr. Pathophysiological effects of aldosterone in cardiovascular tissues. Trends Endocrinol Metab. 2001. 12:308–14.
crossref
17.Sechi LA., Novello M., Lapenna R., Baroselli S., Nadalini E., Colussi GL, et al. Long-term renal outcomes in patients with primary aldosteronism. JAMA. 2006. 295:2638–45.
crossref
18.Blumenfeld JD., Sealey JE., Schlussel Y., Vaughan ED Jr., Sos TA., Atlas SA, et al. Diagnosis and treatment of primary hyperaldosteronism. Ann Intern Med. 1994. 121:877–85.
crossref
19.Obara T., Ito Y., Okamoto T., Kanaji Y., Yamashita T., Aiba M, et al. Risk factors associated with postoperative persistent hypertension in patients with primary aldosteronism. Surgery. 1992. 112:987–93.
20.Sawka AM., Young WF., Thompson GB., Grant CS., Farley DR., Leibson C, et al. Primary aldosteronism: factors associated with normalization of blood pressure after surgery. Ann Intern Med. 2001. 135:258–61.
crossref
21.Giacchetti G., Ronconi V., Rilli S., Guerrieri M., Turchi F., Boscaro M. Small tumor size as favorable prognostic factor after adrenalectomy in Conn's adenoma. Eur J Endocrinol. 2009. 160:639–46.
crossref
22.Meyer A., Brabant G., Behrend M. Long-term follow-up after adrenalectomy for primary aldosteronism. World J Surg. 2005. 29:155–9.
crossref
23.Fukudome Y., Fujii K., Arima H., Ohya Y., Tsuchihashi T., Abe I, et al. Discriminating factors for recurrent hypertension in patients with primary aldosteronism after adrenalectomy. Hypertens Res. 2002. 25:11–8.
crossref
24.TAIPAI Study Group. Wu VC., Chueh SC., Chang HW., Lin LY., Liu KL., Lin YH, et al. Association of kidney function with residual hypertension after treatment of aldosterone -producing adenoma. Am J Kidney Dis. 2009. 54:665–73.
25.Young WF., Stanson AW., Thompson GB., Grant CS., Farley DR., van Heerden JA. Role for adrenal venous sampling in primary aldosteronism. Surgery. 2004. 136:1227–35.
crossref
26.Auchus RJ., Wians FH Jr., Anderson ME., Dolmatch BL., Trimmer CK., Josephs SC, et al. What we still do not know about adrenal vein sampling for primary aldosteronism. Horm Metab Res. 2010. 42:411–5.
crossref
27.Sukor N., Gordon RD., Ku YK., Jones M., Stowasser M. Role of unilateral adrenalectomy in bilateral primary aldosteronism: a 22-year single center experience. J Clin Endocrinol Metab. 2009. 94:2437–45.
crossref

Fig. 1
Mean BP measured preoperatively, in the early postoperative period and at last follow up. There was a significant decrease in both systolic BP and diastolic BP at last follow up compared with that before operation and in the early postoperative period.
kjes-11-276f1.tif
Table 1.
Baseline characteristics in patients underwent adrenalectomy with primary aldosteronism
Patients characteristics   %
No. of patients 108  
Mean age at operation (years) 46±9.8  
Sex (M/F) 42/66  
Duration of preoperative 12±6.2  
hypertension (months)    
Uncontrolled HTN, n (%) 20 18.1
Preoperative systolic BP (mmHg) 150±26.0    
Preoperative diastolic BP (mmHg) 94±19.3  
Serum potassium (mmol/l) 2.9±0.6  
Preoperative PAC∗ (pg/ml) 324.3±209.2  
Preoperative PRA (ng/ml/hr) 0.045±0.021  
Preoperative ARR (pg/ml per 73.4±20.9  
ng/ml/hr)    
Hypokalemic at presentation, n (%) 32 89.1
Family history, n (%) 28 25.5
Body mass index (kg/m2) 23.5±7.5    
Response to spirololactone, n (%) 37 33.6
Mean preoperative antihypertensive 1.8  
drugs requirements, n    
Medical history, No. (%)    
Diabetes mellitus 14 12.7
Cerebrovascular disease 9 8.2
Cardiovascular disease 5 4.5
Aortic dissection 1 0.9

PAC = Plasma aldosterone concentration;

PRA = Plasma renin activity;

ARR = Plasma aldosterone to renin ratio.

Table 2.
Assessment of the endocrine adrenal function (n=108)
  Preoperative Postoperative P value
Serum potassium (mmol/L) 2.9±0.6 4.4±0.52 <0.001
Mean PAC (pg/ml) 324.3±209.2 50.9±25.1 <0.001
Mean PRA (ng/ml/hr) 0.045±0.021 0.96±0.21 <0.001
Mean ARR 73.4±20.9 5.36±2.64 <0.001
Table 3.
Antihypertensive drugs requirement (n=108)
Medication requirement (n) Preoperative Postoperative
0 4 64
1 38 24
2 43 14
3∼ 24 8
Table 4.
Factors associated with normalization of blood pressure after surgery
Characteristic Resolution of HTN Univariate analysis Multivariate analysis P value
Yes (n=61) No (n=47) P value 95% CI
Age, y 45 47 0.29 0.952∼1.057 0.9
Women, n (%) 39 23 0.12 0.651∼4.494 0.28
Preoperative systolic BP 153 150 0.78 0.977∼1.030 0.82
Preoperative diastolic BP 94 94 0.89 0.947∼1.022 0.4
Duration of HTN, month 12 12 0.04 0.982∼1.000 0.6
Preoperative treatment with ≤2 antihypertensive agents, n (%) 53 32 0.02 0.136∼1.242 0.11
Family history of HTN, n (%) 45 36 0.74 0.594∼4.891 0.32
Preoperative potassium level, mmol/L 2.9 2.9 0.86 0.564∼2.111 0.79
ARR (pg/ml per ng/ml/hr) 804 561 0.69 1.000∼1.000 0.95
Tumor size, cm 1.5 1.8 0.76 0.492∼1.460 0.55
Response to spirololactone, n (%) 20 12 0.41 0.252∼1.846 0.45
Preoperative Cr. 1 1 0.51 1.092∼14.206 0.91
TOOLS
Similar articles