BERKELEY, CA (UroToday Inc.) - Primary aldosteronism (PA), characterized by refractory hypertension and hypokalemia due to renin-independent aldosterone overproduction, is a potentially curable form of hypertension. Adrenalectomy is the treatment of choice in patients with PA due to a unilateral aldosterone secreting adenoma. Interestingly, some of these patients continue to be hypertensive after surgery. Meyer and colleagues from Hannover, Germany performed a study to determine the long-term effects of adrenalectomy for primary PA on blood pressure and subsequent use of antihypertensive medications. Their work was published in the February 2005 edition of the World Journal of Surgery.

They reviewed the charts of 24 patients (15 female and 9 male) who underwent adrenalectomy for PA. PA was defined as refractory hypertension and persistent hypokalemia with suppressed plasma-renin activity (PRA) and elevated plasma-aldosterone concentration (PAC). They specifically looked at time between first symptoms and surgery, pre and postoperative blood pressures, and the number of antihypertensive medications taken.

The mean age of the patients was 48.3 years (± 10.8 years). Refractory hypertension was the major symptom in all cases with a mean maximum systolic blood pressure of 201 mmHg (±32.6 mmHg) and mean maximum diastolic blood pressure of 118 mmHG (±20.6 mmHg). The average time between the recognition of hypertension and surgery was 8.5 years (±5.5 years). 22/24 patients were hypokalemic. Preoperative endocrine studies, done in 20 patients, revealed mean PAC 416.pg/ml (± 240.3 pg/ml) and PRA 0.2 ng/ml/hr (±0.2 ng/ml/hr).

All patients had preoperative imaging studies. Unilateral adrenalectomy was performed in 23 patients, while 1 patient underwent a bilateral adrenalectomy for bilateral adrenal hyperplasia. Pathologic examination revealed adenoma of the adrenal cortex in 23, unilateral nodular hyperplasia in one, and bilateral nodular hyperplasia in one. .

Mean postoperative follow-up was 86 months (±48 months). Mean systolic blood pressure was 142 mmHG (±24.9 mmHg) and mean diastolic pressure was 85 mmHg (±11.8 mmHg). Overall, 12 patients were found to have a normal blood pressure (<140/90 mmHG) while 12 were persistently hypertensive. 8 patients had no signs of hypertension and were off all antihypertensive medications, while 16 took antihypertensives for blood pressure control. Seven of the eight normotensive patients were <50 years old at the time of operation.

23/24 patients had a normal potassium level and 19/20 patients had a PAC that was normal. The abnormal patient was persistently hypertensive despite medication and was found to have a contralateral lesion 44 months after removal of a unilateral aldosterone secreting adenoma.

The authors conclude that a delay in diagnosis and therapy are the main factors for persistent hypertension after adrenalectomy for PA. Patient age at the time of surgery and the duration of hypertension prior to surgery appear to strongly influence outcome after adrenalectomy, with younger patients and earlier surgical intervention having improved outcomes. Despite "curative" surgery and normalization of endocrine adrenal function, long term follow up is important because many of these patients continue to require pharmacologic control of hypertension.

World J Surg 2005; 29(2) 155-9.