Characteristics predicting clinical improvement and cure following laparoscopic adrenalectomy for primary aldosteronism in a large cohort.

Surgical resection is the standard of care for unilateral adrenal adenomas and hyperplasia resulting in primary aldosteronism (PA). Resolution of PA following surgery is variable and some patients continue to require some or all of their antihypertensives. Prior studies have investigated factors contributing to "cure" of PA (defined as no hypertension [HTN] medications required postoperatively). These models are a tool in patient selection, yet fail to consider the benefit of some reduction in medications, resolution of hypokalemia, or reduction in blood pressure which may improve long-term cardiovascular and renal outcomes. We sought to investigate factors contributing to postoperative improvement or complete resolution following surgery. This is a retrospective review of prospectively collected data on 58 adrenalectomies performed for PA from December 1999 to April 2013 at a single center. Patient demographics, PA characteristics, labs, and imaging studies were evaluated, as well as operative characteristics. Mean systolic and diastolic blood pressures were calculated over several visits after discharge, and postoperative antihypertensive regimen was recorded. Patients were stratified by cured vs not cured and then again by improved vs not improved based on differences in pre- and postoperative values. Aldosteronoma Resolution Score was also calculated for each patient. Median age was 52.6 years, with 44.8% women and an average duration of HTN of 13.5 years. Average body mass index (BMI) was 31.5 kg/m(2); 74% of the lesions were adenomas. Patients with complications had higher BMIs than those without (36.9 vs 28.7 kg/m(2), P = .02). In comparing improved (n = 42, 72%) vs not improved (n = 16, 28%) patients, preoperative systolic blood pressure (147.5 vs 159.7 mm Hg, P = .047) and serum creatinine (.94 vs 1.32 mg/dL, P = .016) were higher in the not improved group. Cured (n = 13) vs not cured (n = 45) patients differed in terms of BMI (27.4 vs 32.7, P = .009), duration of HTN (9.1 vs 14.9 years, P = .020), and number of preoperative antihypertensives (2.1 vs 3.7, P = .002). Aldosteronoma Resolution Score was significantly higher in cured patients (3.2 vs 1.0, P < .01). A significant number of patients who are not cured by adrenalectomy for PA will still benefit from surgery. Obesity, duration of HTN, and number of medications may predict cure, yet fail to detect a population of patients with overall improvement. Attention to serum creatinine may help in distinguishing this population of patients.

Worth PJ ，Kunio NR ，Siegfried I ，Sheppard BC ，Gilbert EW ... -  《-》

Persistent hypertension after adrenalectomy for an aldosterone-producing adenoma: weight as a critical prognostic factor for aldosterone's lasting effect on the cardiac and vascular systems.

Primary aldosteronism caused by an aldosterone producing adrenal tumor/aldosteronoma (APA), is a potentially curable form of hypertension, via unilateral adrenalectomy. Resolution of hypertension (HTN) is not as prevalent after tumor resection, as are the normalization of aldosterone secretion, hypokalemia, and other metabolic abnormalities. Here, we review the immediate and long-term medical outcomes of laparoscopic adrenalectomy in patients with an APA, and attempt to identify any distinctive sex differences in the management of resistant HTN. We performed a retrospective review of the prospective adrenal database at the University of Wisconsin between January 2001 and October 2010. Of the 165 adrenalectomies performed, 32 were for the resection of an APA. Patients were grouped according to their postoperative HTN status. Those patients with normal blood pressure (≤120/80 mm Hg) and on no antihypertensive medication (CURE) were compared with those who continued to require medication for blood pressure control (HTN). We evaluated sex, age, body mass index, tumor size, duration of time with high blood pressure, and the differences in systolic and diastolic blood pressure following adrenalectomy. Statistical analysis was performed using Student's t-test. Statistical significance was defined as a P value of <0.05. We identified 32 patients with an APA based on biochemical and radiographic studies, two patients were excluded, due to missing data. There were 19 males (63%) and 11 (37%) females, with a mean age was 48.3 ± 2.1 y, and mean tumor size was 24 ± 3 mm. Postoperatively, patients required significantly fewer antihypertensive medications (1.5 ± 0.2 versus 3.3 ± 0.3, P < 0.001). Nine patients (31%) had complete resolution of their HTN, requiring no postoperative antihypertensive medication. The only significant difference between the sexes, was a lower body mass index in women (27.6 ± 1.7 versus 33.4 ± 2.1 kg/m(2), P = 0.04). Ninety percent of the cohort had at least a 20 mm Hg decline in their systolic blood pressure postoperatively, placing them in the prehypertensive or normal blood pressure categories. Sixty-six percent of the CURE patients required at least 6 mo for resolution of their HTN. All 20 patients who presented with hypokalemia, had immediate resolution postoperatively and did not require continuance of the preoperative spironolactone or potassium supplementation. Laparoscopic adrenalectomy for aldosterone producing adenoma results in the normalization of, or more readily manageable blood pressure in 90% of patients, within 6 mo. Metabolic disturbances are immediately corrected with tumor resection. Weight is an important contributing factor in resolving HTN.

Carter Y ，Roy M ，Sippel RS ，Chen H ... -  《-》

Long-term blood pressure control in patients undergoing adrenalectomy for primary hyperaldosteronism.

Data on long-term blood pressure (BP) control after adrenalectomy for primary hyperaldosteronism are limited. We analyzed long-term outcomes to identify factors predictive of cure. We performed a retrospective cohort study of patients undergoing adrenalectomy for primary hyperaldosteronism (1997-2013). BP and antihypertensive medications were assessed at long-term follow-up (≥ 12 months). Primary outcome was cure, defined as normotension off antihypertensives. Of 85 patients, 15.3% (n = 13) were cured, 54.1% (n = 46) were normotensive while remaining on anti-hypertensives, and 30.6% (n = 26) were hypertensive. Younger age (P = .011), female sex (P < .001), lesser body mass index (P = .018), shorter duration of hypertension (P = .002), lower creatinine (P = .001), and fewer preoperative antihypertensive medications (P < .001) were associated with cure. Female sex, body mass index ≤ 25 kg/m(2), hypertension <5 years, creatinine ≤ 0.8 mg/dL, and <2 antihypertensives were incorporated into a scoring system. For a score of 0-1 (n = 61) the cure rate was 3%; 100% of patients with a score of 4-5 (n = 3) were cured. This scoring system performed comparably to the Aldosterone Resolution Score, which has been used to evaluate short-term postoperative outcomes. This is the largest study to identify factors associated with long-term BP control after adrenalectomy and incorporate these into a scoring system. These data provide a potential tool to guide preoperative patient counseling.

Wachtel H ，Cerullo I ，Bartlett EK ，Kelz RR ，Cohen DL ，Karakousis GC ，Roses RE ，Fraker DL ... -  《-》

Urinary aldosterone-to-active-renin ratio: a useful tool for predicting resolution of hypertension after adrenalectomy in patients with aldosterone-producing adenomas.

Mourad JJ ，Girerd X ，Milliez P ，Lopez-Sublet M ，Lejeune S ，Safar ME ... -  《AMERICAN JOURNAL OF HYPERTENSION》

Development of a novel nomogram to predict hypertension cure after laparoscopic adrenalectomy in patients with primary aldosteronism.

Utsumi T ，Kamiya N ，Endo T ，Yano M ，Kamijima S ，Kawamura K ，Imamoto T ，Naya Y ，Ichikawa T ，Suzuki H ... -  《-》