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Original Investigation
February 27, 2019

Clinical Outcomes After Unilateral Adrenalectomy for Primary Aldosteronism

Author Affiliations
  • 1Department of Surgical Oncology and Endocrine Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
  • 2Department of Endocrine and Minimally Invasive Surgery, Weill Cornell Medical College, New York, New York
  • 3Department of Surgery, University of California, San Francisco
  • 4Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
  • 5Department of Graduate Medical Sciences, Boston University School of Medicine, Boston, Massachusetts
  • 6Department of Endocrine Surgery, New York-Presbyterian-Columbia University, New York
  • 7Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
  • 8Department of Endocrine Surgery, Baylor St Luke’s Medical Center, Houston, Texas
  • 9Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
  • 10Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 11Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Québec, Canada
  • 12Department of Surgery, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
  • 13Department of Endocrine Surgery, Royal North Shore Hospital, Sydney, Australia
  • 14Department of Endocrine and Metabolic Surgery, Policlinico Universitario A Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
  • 15Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
  • 16Department of Surgery, VU Medical Center, Amsterdam, the Netherlands
  • 17Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
  • 18Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
  • 19Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
  • 20Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
JAMA Surg. 2019;154(4):e185842. doi:10.1001/jamasurg.2018.5842
Key Points

Question  Is adrenalectomy associated with reduction of blood pressure and need for antihypertensive medications in patients with primary aldosteronism?

Findings  In this international cohort study of 435 surgical patients between 2010 and 2016, 27.1% of patients achieved normotension without requiring antihypertensive medications and 31.0% achieved normotension requiring less than or equal to the number of their preoperative antihypertensive medications. Moreover, patients with postoperative persistent hypertension might have benefitted from surgery given the observed significant reduction of blood pressure and number of medications within this subgroup.

Meaning  Most patients may benefit from adrenalectomy owing to a decrease in blood pressure and need for antihypertensive medications.

Abstract

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 reduction of BP and antihypertensive medications.

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