PDF herunterladen
Exp Clin Endocrinol Diabetes 2019; 127(02/03): 100-108
DOI: 10.1055/a-0662-6081
Review
© Georg Thieme Verlag KG Stuttgart · New York

Treatment of Unilateral PA by Adrenalectomy: Potential Reasons for Incomplete Biochemical Cure

Yuhong Yang
1   Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
,
Martin Reincke
1   Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
,
Tracy Ann Williams
1   Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
2   Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy
› Institutsangaben
Weitere Informationen

Publikationsverlauf

received 23. Mai 2018
revised 11. Juli 2018

accepted 23. Juli 2018

Publikationsdatum:
21. August 2018 (online)

Auch verfügbar auf
   Lizenzen und Reprints

Abstract

The importance of an early diagnosis and appropriate management of patients with primary aldosteronism (PA) has become increasingly clear because of the adverse impact of the disorder on cardiovascular and cerebrovascular events and target organ damage. Adrenalectomy potentially cures patients with unilateral PA resulting in normalisation of blood pressure or significant clinical improvements in the majority of patients. Different criteria have been used to evaluate outcomes of unilateral adrenalectomy. Clinical remission (cure of hypertension) is observed in 6% to 86% of patients and clinical benefits from surgery are seen in the majority. Several factors have been identified that predict clinical success after surgery such as age, sex, anti-hypertensive medication dosage and known duration of hypertension. Biochemical remission of PA after unilateral adrenalectomy, characterised by the resolution of hyperaldosteronism and correction of pre-surgical hypokalaemia, is observed in 67% to 100% of patients with unilateral PA. In only a small proportion of patients, adrenalectomy fails to resolve hyperaldosteronism and inappropriate aldosterone production persists after surgery. In this review we discuss the potential reasons for failing to cure hyperaldosteronism after unilateral adrenalectomy for unilateral primary aldosteronism.

Key words

Primary aldosteronism - adrenalectomy - aldosterone-producing adenoma - bilateral adrenal hyperplasia - persistent hyperaldosteronism
 

  • References

  • 1 Monticone S, Burrello J, Tizzani D. et al. Prevalence and clinical manifestations of primary aldosteronism encountered in primary care practice. J Am Coll Cardiol 2017; 69: 1811-1820
    PubMedGoogle Scholar
  • 2 Mulatero P, Stowasser M, Loh KC. et al. Increased diagnosis of primary aldosteronism, including surgically correctable forms, in centers from five continents. J Clin Endocrinol Metab 2004; 89: 1045-1050
    CrossrefPubMedGoogle Scholar
  • 3 Rossi GP, Bernini G, Caliumi C. et al. A prospective study of the prevalence of primary aldosteronism in 1,125 hypertensive patients. J Am Coll Cardiol 2006; 48: 2293-2300
    CrossrefPubMedGoogle Scholar
  • 4 Douma S, Petidis K, Doumas M. et al. Prevalence of primary hyperaldosteronism in resistant hypertension: a retrospective observational study. Lancet 2008; 371: 1921-1926
    CrossrefPubMedGoogle Scholar
  • 5 Mulatero P, Monticone S, Bertello C. et al. Long-term cardio- and cerebrovascular events in patients with primary aldosteronism. J Clin Endocrinol Metab 2013; 98: 4826-4833
    CrossrefPubMedGoogle Scholar
  • 6 Savard S, Amar L, Plouin PF. et al. Cardiovascular complications associated with primary aldosteronism: a controlled cross-sectional study. Hypertension 2013; 62: 331-336
    CrossrefPubMedGoogle Scholar
  • 7 Fallo F, Veglio F, Bertello C. et al. Prevalence and characteristics of the metabolic syndrome in primary aldosteronism. J Clin Endocrinol Metab 2006; 91: 454-459
    CrossrefPubMedGoogle Scholar
  • 8 Arlt W, Lang K, Sitch AJ et al. Steroid metabolome analysis reveals prevalent glucocorticoid excess in primary aldosteronism. JCI Insight 2017; 2: pii: 93136
    PubMed
  • 9 Catena C, Colussi G, Nadalini E. et al. Cardiovascular outcomes in patients with primary aldosteronism after treatment. Arch Intern Med 2008; 168: 80-85
    CrossrefPubMedGoogle Scholar
  • 10 Monticone S, D'Ascenzo F, Moretti C. et al. Cardiovascular events and target organ damage in primary aldosteronism compared with essential hypertension: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2018; 6: 41-50
    CrossrefPubMedGoogle Scholar
  • 11 Funder JW. Aldosterone, sodium, and hypertension: lessons from torcetrapib?. Hypertension 2010; 55: 221-223
    CrossrefPubMedGoogle Scholar
  • 12 Sonino N, Fallo F, Fava GA. Psychological aspects of primary aldosteronism. Psychother Psychosom 2006; 75: 327-330
    CrossrefPubMedGoogle Scholar
  • 13 Sukor N, Kogovsek C, Gordon RD. et al. Improved quality of life, blood pressure, and biochemical status following laparoscopic adrenalectomy for unilateral primary aldosteronism. J Clin Endocrinol Metab 2010; 95: 1360-1364
    CrossrefPubMedGoogle Scholar
  • 14 Funder JW, Carey RM, Mantero F. et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2016; 101: 1889-1916
    CrossrefPubMedGoogle Scholar
  • 15 Williams TA, Reincke M. MANAGEMENT OF ENDOCRINE DISEASE: Diagnosis and Management of Primary Aldosteronism: the Endocrine Society guideline 2016 revisited. Eur J Endocrinol 2018 pii: EJE-17-0990
    PubMed
  • 16 Muth A, Ragnarsson O, Johannsson G. et al. Systematic review of surgery and outcomes in patients with primary aldosteronism. Br J Surg 2015; 102: 307-317
    CrossrefPubMedGoogle Scholar
  • 17 Young WF, Stanson AW, Thompson GB. et al. Role for adrenal venous sampling in primary aldosteronism. Surgery 2004; 136: 1227-1235
    CrossrefPubMedGoogle Scholar
  • 18 Williams TA, Lenders JWM, Mulatero P. et al. Outcomes after adrenalectomy for unilateral primary aldosteronism: an international consensus on outcome measures and analysis of remission rates in an international cohort. Lancet Diabetes Endocrinol 2017; 5: 689-699
    CrossrefPubMedGoogle Scholar
  • 19 Kanarek-Kucner J, Stefanski A, Barraclough R. et al. Insufficiency of the zona glomerulosa of the adrenal cortex and progressive kidney insufficiency following unilateral adrenalectomy – case report and discussion. Blood Press 2018; 1-9
    PubMedGoogle Scholar
  • 20 Wang W, Hu W, Zhang X. et al. Predictors of successful outcome after adrenalectomy for primary aldosteronism. Int Surg 2012; 97: 104-111
    CrossrefPubMedGoogle Scholar
  • 21 Waldmann J, Maurer L, Holler J. et al. Outcome of surgery for primary hyperaldosteronism. World J Surg 2011; 35: 2422-2427
    CrossrefPubMedGoogle Scholar
  • 22 Lumachi F, Ermani M, Basso SM. et al. Long-term results of adrenalectomy in patients with aldosterone-producing adenomas: multivariate analysis of factors affecting unresolved hypertension and review of the literature. Am Surg 2005; 71: 864-869
    PubMedGoogle Scholar
  • 23 Meyer A, Brabant G, Behrend M. Long-term follow-up after adrenalectomy for primary aldosteronism. World J Surg 2005; 29: 155-159
    CrossrefPubMedGoogle Scholar
  • 24 Proye CA, Mulliez EA, Carnaille BM. et al. Essential hypertension: first reason for persistent hypertension after unilateral adrenalectomy for primary aldosteronism?. Surgery 1998; 124: 1128-1133
    CrossrefPubMedGoogle Scholar
  • 25 Walz MK, Alesina PF, Wenger FA. et al. Posterior retroperitoneoscopic adrenalectomy – results of 560 procedures in 520 patients. Surgery 2006; 140: 943-948 discussion 948-950
    CrossrefPubMedGoogle Scholar
  • 26 Citton M, Viel G, Rossi GP. et al. Outcome of surgical treatment of primary aldosteronism. Langenbecks Arch Surg 2015; 400: 325-331
    CrossrefPubMedGoogle Scholar
  • 27 Lim V, Guo Q, Grant CS. et al. Accuracy of adrenal imaging and adrenal venous sampling in predicting surgical cure of primary aldosteronism. J Clin Endocrinol Metab 2014; 99: 2712-2719
    CrossrefPubMedGoogle Scholar
  • 28 Miller BS, Turcu AF, Nanba AT. et al. Refining the definitions of biochemical and clinical cure for primary aldosteronism using the primary aldosteronism surgical outcome (PASO) elstem. World J Surg 2018; 42: 453-463
    CrossrefPubMedGoogle Scholar
  • 29 Kunzel HE, Apostolopoulou K, Pallauf A. et al. Quality of life in patients with primary aldosteronism: gender differences in untreated and long-term treated patients and associations with treatment and aldosterone. J Psychiatr Res 2012; 46: 1650-1654
    CrossrefPubMedGoogle Scholar
  • 30 Ahmed AH, Gordon RD, Sukor N. et al. Quality of life in patients with bilateral primary aldosteronism before and during treatment with spironolactone and/or amiloride, including a comparison with our previously published results in those with unilateral disease treated surgically. J Clin Endocrinol Metab 2011; 96: 2904-2911
    CrossrefPubMedGoogle Scholar
  • 31 Velema M, Dekkers T, Hermus A. et al. Quality of life in primary aldosteronism: a comparative effectiveness study of adrenalectomy and medical treatment. J Clin Endocrinol Metab 2018; 103: 16-24
    CrossrefPubMedGoogle Scholar
  • 32 Apostolopoulou K, Kunzel HE, Gerum S. et al. Gender differences in anxiety and depressive symptoms in patients with primary hyperaldosteronism: a cross-sectional study. World J Biol Psychiatry 2014; 15: 26-35
    CrossrefPubMedGoogle Scholar
  • 33 Reincke M. Anxiety, depression, and impaired quality of life in primary aldosteronism: why we shouldn't ignore it!. J Clin Endocrinol Metab 2018; 103: 1-4
    CrossrefPubMedGoogle Scholar
  • 34 Hundemer GL, Curhan GC, Yozamp N. et al. Cardiometabolic outcomes and mortality in medically treated primary aldosteronism: a retrospective cohort study. Lancet Diabetes Endocrinol 2018; 6: 51-59
    CrossrefPubMedGoogle Scholar
  • 35 Wu VC, Kuo CC, Wang SM. et al. Primary aldosteronism: changes in cystatin C-based kidney filtration, proteinuria, and renal duplex indices with treatment. J Hypertens 2011; 29: 1778-1786
    CrossrefPubMedGoogle Scholar
  • 36 Wu VC, Yang SY, Lin JW. et al. Kidney impairment in primary aldosteronism. Clin Chim Acta 2011; 412: 1319-1325
    CrossrefPubMedGoogle Scholar
  • 37 Rossi GP, Maiolino G, Flego A. et al. Adrenalectomy lowers incident atrial fibrillation in primary aldosteronism patients at long term. Hypertension 2018; 71: 585-591
    CrossrefPubMedGoogle Scholar
  • 38 Steichen O, Zinzindohoue F, Plouin PF. et al. Outcomes of adrenalectomy in patients with unilateral primary aldosteronism: a review. Horm Metab Res 2012; 44: 221-227
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 39 Wachtel H, Cerullo I, Bartlett EK. et al. Long-term blood pressure control in patients undergoing adrenalectomy for primary hyperaldosteronism. Surgery 2014; 156: 1394-1402 discussion1402-1393
    CrossrefPubMedGoogle Scholar
  • 40 Rossi GP, Cesari M, Cuspidi C. et al. Long-term control of arterial hypertension and regression of left ventricular hypertrophy with treatment of primary aldosteronism. Hypertension 2013; 62: 62-69
    CrossrefPubMedGoogle Scholar
  • 41 Sechi LA, Di Fabio A, Bazzocchi M. et al. Intrarenal hemodynamics in primary aldosteronism before and after treatment. J Clin Endocrinol Metab 2009; 94: 1191-1197
    CrossrefPubMedGoogle Scholar
  • 42 Reincke M, Rump LC, Quinkler M. et al. Risk factors associated with a low glomerular filtration rate in primary aldosteronism. J Clin Endocrinol Metab 2009; 94: 869-875
    CrossrefPubMedGoogle Scholar
  • 43 Young Jr WF. Conventional imaging in adrenocortical carcinoma: update and perspectives. Horm Cancer 2011; 2: 341-347
    CrossrefPubMedGoogle Scholar
  • 44 Blake MA, Cronin CG, Boland GW. Adrenal imaging. AJR Am J Roentgenol 2010; 194: 1450-1460
    CrossrefPubMedGoogle Scholar
  • 45 Fassnacht M, Arlt W, Bancos I. et al. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2016; 175: G1-G34
    CrossrefPubMedGoogle Scholar
  • 46 Gordon RD, Stowasser M, Rutherford JC. Primary aldosteronism: are we diagnosing and operating on too few patients?. World J Surg 2001; 25: 941-947
    CrossrefPubMedGoogle Scholar
  • 47 Kempers MJ, Lenders JW, van Outheusden L. et al. Systematic review: diagnostic procedures to differentiate unilateral from bilateral adrenal abnormality in primary aldosteronism. Ann Intern Med 2009; 151: 329-337
    CrossrefPubMedGoogle Scholar
  • 48 Ladurner R, Sommerey S, Buechner S. et al. Accuracy of adrenal imaging and adrenal venous sampling in diagnosing unilateral primary aldosteronism. Eur J Clin Invest 2017; 47: 372-377
    CrossrefPubMedGoogle Scholar
  • 49 Williams TA, Burrello J, Sechi LA et al. Computed Tomography and Adrenal Venous Sampling in the Diagnosis of Unilateral Primary Aldosteronism. Hypertension 2018 pii: HYPERTENSIONAHA. 118.11382
    PubMed
  • 50 Umakoshi H, Ogasawara T, Takeda Y. et al. Accuracy of adrenal computed tomography in predicting the unilateral subtype in young patients with hypokalaemia and elevation of aldosterone in primary aldosteronism. Clin Endocrinol (Oxf) 2018; 88: 645-651
    CrossrefPubMedGoogle Scholar
  • 51 Dekkers T, Prejbisz A, Kool LJS. et al. Adrenal vein sampling versus CT scan to determine treatment in primary aldosteronism: an outcome-based randomised diagnostic trial. Lancet Diabetes Endocrinol 2016; 4: 739-746
    CrossrefPubMedGoogle Scholar
  • 52 Letavernier E, Peyrard S, Amar L. et al. Blood pressure outcome of adrenalectomy in patients with primary hyperaldosteronism with or without unilateral adenoma. J Hypertens 2008; 26: 1816-1823
    CrossrefPubMedGoogle Scholar
  • 53 Rossi GP, Funder JW. Adrenal venous sampling versus computed tomographic scan to determine treatment in primary aldosteronism (The SPARTACUS Trial): A critique. Hypertension 2017; 69: 396-397
    CrossrefPubMedGoogle Scholar
  • 54 Monticone S, Viola A, Rossato D. et al. Adrenal vein sampling in primary aldosteronism: towards a standardised protocol. Lancet Diabetes Endocrinol 2015; 3: 296-303
    CrossrefPubMedGoogle Scholar
  • 55 Rossi GP, Auchus RJ, Brown M. et al. An expert consensus statement on use of adrenal vein sampling for the subtyping of primary aldosteronism. Hypertension 2014; 63: 151-160
    CrossrefPubMedGoogle Scholar
  • 56 Rossi GP. New concepts in adrenal vein sampling for aldosterone in the diagnosis of primary aldosteronism. Curr Hypertens Rep 2007; 9: 90-97
    CrossrefPubMedGoogle Scholar
  • 57 Stowasser M, Gordon RD. Primary Aldosteronism: Changing definitions and new concepts of physiology and pathophysiology both inside and outside the kidney. Physiol Rev 2016; 96: 1327-1384
    CrossrefPubMedGoogle Scholar
  • 58 Rossi GP, Pitter G, Bernante P. et al. Adrenal vein sampling for primary aldosteronism: the assessment of selectivity and lateralization of aldosterone excess baseline and after adrenocorticotropic hormone (ACTH) stimulation. J Hypertens 2008; 26: 989-997
    CrossrefPubMedGoogle Scholar
  • 59 Monticone S, Satoh F, Giacchetti G. et al. Effect of adrenocorticotropic hormone stimulation during adrenal vein sampling in primary aldosteronism. Hypertension 2012; 59: 840-846
    CrossrefPubMedGoogle Scholar
  • 60 El Ghorayeb N, Mazzuco TL, Bourdeau I. et al. Basal and Post-ACTH aldosterone and its ratios are useful during adrenal vein sampling in primary aldosteronism. J Clin Endocrinol Metab 2016; 101: 1826-1835
    CrossrefPubMedGoogle Scholar
  • 61 Wolley MJ, Ahmed AH, Gordon RD. et al. Does ACTH improve the diagnostic performance of adrenal vein sampling for subtyping primary aldosteronism?. Clin Endocrinol (Oxf) 2016; 85: 703-709
    CrossrefPubMedGoogle Scholar
  • 62 Rossi GP, Barisa M, Allolio B. et al. The adrenal vein sampling international study (AVIS) for identifying the major subtypes of primary aldosteronism. J Clin Endocrinol Metab 2012; 97: 1606-1614
    CrossrefPubMedGoogle Scholar
  • 63 Seccia TM, Miotto D, Battistel M. et al. A stress reaction affects assessment of selectivity of adrenal venous sampling and of lateralization of aldosterone excess in primary aldosteronism. Eur J Endocrinol 2012; 166: 869-875
    CrossrefPubMedGoogle Scholar
  • 64 Almarzooqi MK, Chagnon M, Soulez G. et al. Adrenal vein sampling in primary aldosteronism: concordance of simultaneous vs sequential sampling. Eur J Endocrinol 2017; 176: 159-167
    CrossrefPubMedGoogle Scholar
  • 65 Webb R, Mathur A, Chang R. et al. What is the best criterion for the interpretation of adrenal vein sample results in patients with primary hyperaldosteronism?. Ann Surg Oncol 2012; 19: 1881-1886
    CrossrefPubMedGoogle Scholar
  • 66 Buffolo F, Monticone S, Williams TA. et al. Subtype diagnosis of primary aldosteronism: is adrenal vein sampling always necessary?. Int J Mol Sci 2017; 18: 848
    CrossrefPubMedGoogle Scholar
  • 67 Mulatero P, Bertello C, Sukor N. et al. Impact of different diagnostic criteria during adrenal vein sampling on reproducibility of subtype diagnosis in patients with primary aldosteronism. Hypertension 2010; 55: 667-673
    CrossrefPubMedGoogle Scholar
  • 68 Mailhot JP, Traistaru M, Soulez G. et al. Adrenal vein sampling in primary aldosteronism: Sensitivity and specificity of basal adrenal vein to peripheral vein cortisol and aldosterone ratios to confirm catheterization of the adrenal vein. Radiology 2015; 277: 887-894
    CrossrefPubMedGoogle Scholar
  • 69 Umakoshi H, Naruse M, Wada N. et al. Adrenal venous sampling in patients with positive screening but negative confirmatory testing for primary aldosteronism. Hypertension 2016; 67: 1014-1019
    CrossrefPubMedGoogle Scholar
  • 70 Stowasser M, Gordon RD, Gunasekera TG. et al. High rate of detection of primary aldosteronism, including surgically treatable forms, after 'non-selective' screening of hypertensive patients. J Hypertens 2003; 21: 2149-2157
    CrossrefPubMedGoogle Scholar
  • 71 Monticone S, Satoh F, Viola A. et al. Aldosterone suppression on contralateral adrenal during adrenal vein sampling does not predict blood pressure response after adrenalectomy. J Clin Endocrinol Metab 2014; 99: 4158-4166
    CrossrefPubMedGoogle Scholar
  • 72 Umakoshi H, Tanase-Nakao K, Wada N. et al. Importance of contralateral aldosterone suppression during adrenal vein sampling in the subtype evaluation of primary aldosteronism. Clin Endocrinol (Oxf) 2015; 83: 462-467
    CrossrefPubMedGoogle Scholar
  • 73 Nishikawa T, Omura M, Satoh F. et al. Guidelines for the diagnosis and treatment of primary aldosteronism--the Japan Endocrine Society 2009. Endocr J 2011; 58: 711-721
    CrossrefPubMedGoogle Scholar
  • 74 Burrello J, Monticone S, Tetti M. et al. Subtype Diagnosis of Primary Aldosteronism: Approach to Different Clinical Scenarios. Horm Metab Res 2015; 47: 959-966
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 75 Heinze B, Fuss CT, Mulatero P. et al. Targeting CXCR4 (CXC Chemokine Receptor Type 4) for Molecular Imaging of Aldosterone-Producing Adenoma. Hypertension 2018; 71: 317-325
    CrossrefPubMedGoogle Scholar
  • 76 Eisenhofer G, Dekkers T, Peitzsch M. et al. Mass Spectrometry-Based Adrenal and Peripheral Venous Steroid Profiling for Subtyping Primary Aldosteronism. Clin Chem 2016; 62: 514-524
    CrossrefPubMedGoogle Scholar
  • 77 Williams TA, Peitzsch M, Dietz AS. et al. Genotype-Specific Steroid Profiles Associated With Aldosterone-Producing Adenomas. Hypertension 2016; 67: 139-145
    CrossrefPubMedGoogle Scholar
  • 78 Scholl UI, Abriola L, Zhang C. et al. Macrolides selectively inhibit mutant KCNJ5 potassium channels that cause aldosterone-producing adenoma. J Clin Invest 2017; 127: 2739-2750
    CrossrefPubMedGoogle Scholar
  • 79 Caroccia B, Prisco S, Seccia TM. et al. Macrolides blunt aldosterone biosynthesis: A proof-of-concept study in kcnj5 mutated adenoma cells ex vivo. Hypertension 2017; 70: 1238-1242
    CrossrefPubMedGoogle Scholar
  • 80 Maiolino G, Ceolotto G, Battistel M. et al. Macrolides for KCNJ5-mutated aldosterone-producing adenoma (MAPA): design of a study for personalized diagnosis of primary aldosteronism. Blood Press 2018; 1-6
    PubMedGoogle Scholar
  • 81 Takeda R, Matsubara T, Miyamori I. et al. Vascular complications in patients with aldosterone producing adenoma in Japan: comparative study with essential hypertension. The Research Committee of Disorders of Adrenal Hormones in Japan. J Endocrinol Invest 1995; 18: 370-373
    CrossrefPubMedGoogle Scholar
  • 82 Catena C, Colussi G, Lapenna R. et al. Long-term cardiac effects of adrenalectomy or mineralocorticoid antagonists in patients with primary aldosteronism. Hypertension 2007; 50: 911-918
    CrossrefPubMedGoogle Scholar
  • 83 Iacobellis G, Petramala L, Cotesta D. et al. Adipokines and cardiometabolic profile in primary hyperaldosteronism. J Clin Endocrinol Metab 2010; 95: 2391-2398
    CrossrefPubMedGoogle Scholar
  • 84 Fischer E, Adolf C, Pallauf A. et al. Aldosterone excess impairs first phase insulin secretion in primary aldosteronism. J Clin Endocrinol Metab 2013; 98: 2513-2520
    CrossrefPubMedGoogle Scholar
  • 85 Somloova Z, Widimsky Jr. J, Rosa J. et al. The prevalence of metabolic syndrome and its components in two main types of primary aldosteronism. J Hum Hypertens 2010; 24: 625-630
    CrossrefPubMedGoogle Scholar