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Adrenalectomy for Primary Aldosteronism
- William F. Young, Jr, MD;
- Anna M. Sawka, MD; and
- Jon A. van Heerden, MD
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IN RESPONSE:
Dr. Martinez makes an important point regarding the key role of adrenal venous sampling in the subtype evaluation of primary aldosteronism. In many patients with primary aldosteronism, CT imaging may reveal normal-appearing adrenals, minimal unilateral adrenal limb thickening, a unilateral microadenoma (≤ 1 cm), or bilateral macroadenomas. A small aldosterone-producing adenoma may be labeled incorrectly as bilateral idiopathic hyperplasia on the basis of CT findings of bilateral nodularity or normal-appearing adrenals (1). Also, apparent adrenal microadenomas and macroadenomas may represent areas of hyperplasia or nonfunctioning cortical adenomas, and unilateral adrenalectomy would be inappropriate.
Patients with aldosterone-producing adenomas have more severe hypertension, more frequent hypokalemia, and higher plasma and urinary levels of aldosterone and are generally younger than those with bilateral idiopathic hyperaldosteronism (2). Such patients have a high probability of aldosterone-producing adenomas (Figure). However, these factors are not absolute predictors of unilateral versus bilateral adrenal disease. In our experience, unilateral aldosterone-producing adenomas were found in 36% of patients with clinically high-probability scenarios who had normal findings or unilateral adrenal limb thickening on CT (4). Therefore, adrenal venous sampling is essential to direct therapy in patients with primary aldosteronism who have a high probability of aldosterone-producing adenomas. However, adrenal venous sampling is an invasive, difficult procedure, and the success rate is dependent on the angiographer's proficiency (4). When a solitary hypodense unilateral macroadenoma (>1 cm) and normal contralateral adrenal are found on CT in a young patient with primary aldosteronism, unilateral adrenalectomy is reasonable. However, because of the age-dependent risk that a solitary unilateral adrenal macroadenoma may be a nonfunctioning cortical adenoma (5), adrenal venous sampling should be considered in patients older than 40 years of age (Figure).
We reported that hypertension improved (decrease of more than one stage using Joint National Commission VI classification or fewer antihypertensive agents taken at follow-up) in 92 of 93 patients (99%) and resolved in 31 of 93 patients (33%) after adrenalectomy for primary aldosteronism. Adrenal venous sampling was performed in 44 of 93 patients (Figure). Hypertension resolved after adrenalectomy in 15 of 49 patients (31%) who did not undergo adrenal venous sampling and 16 of 44 patients (36%) who did (P > 0.2, Fisher exact test). Given that the rates of resolution of hypertension were not different between the two groups, it is unlikely that lack of adrenal venous sampling accounted for the lack of resolution of hypertension in most patients.
William F. Young Jr. MD
Anna M. Sawka, MD
Jon A. van Heerden, MD
Mayo Clinic; Rochester, MN 55905
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
