Tactic of diagnostic and treatment of patients with bilateral adrenal gland’s lesions associated with primary aldosteronism

Abstract

Introduction. The problem of primary aldosteronism (PA) different forms diagnosis and treatment is absolutely interesting in the 21 st century as over the last 15 years it has been proved that PA syndrome had been distributed much more than previously thought. It accounts for 10-15% of all cases of hypertension. Aim: to analyze the diagnostic and treatment of patients with bilateral lesions of adrenal glands (AG) with PA. Materials and Methods. During the period from 2014 to March 2017 year 14 patients with bilateral lesions of AG with PA have been examined and treated at the clinic. 8 (57.1%) were women and 6 (42.9%) were men. The average age of patients was 55,6±11,9 years. Adenomas of AG were diagnosed in 6 (42.9%) of cases, hyperplasia of AG in 8 (57.1%). We measured the concentration of aldosterone, renin, adrenocorticotropic hormone, cortisol in plasma, levels of potassium and sodium, loading tastes, night dexamethasone suppression test, computer tomography and adrenal vein sampling (AVS). Surgical treatment was performed in 7 (50%) of patients - in 3 cases (21.4%) it was the laparoscopic adrenalectomy (LAE) and in 1 case (7.2%) – the laparoscopic resection of the adrenal gland (LRAG), for 3 (21.4%) patients endovascular destruction of the AG (EVD) was performed. Conservative therapy including aldosterone antagonists was prescribed for 7 (50%) patients. Results and Discussion. Indication for the surgical treatment or REVD was a gradient of lateralization rated 3:1 and more. If the gradient was below a specified value, the result was regarded as idiopathic aldosteronism (IA) and aldosterone antagonists (verospiron, eplerenonum) with control of K+ concentration level were used. We believe that in case with bilateral adenomas of AG, if there are no conditions for the AG resection, it is necessary to perform LAE of functionally more active gland. It helps to stabilize the level of blood pressure without antihypertensive drugs prescription or with reducing of their dosage and to achieve the hormonal status normalization. REVD is used in cases of unilateral hyperplasia of AG with hypersecretion. In case of IA using of this treatment method is inappropriate, as the therapy has temporary effect, which is demonstrated by relapse of aldosterone and blood pressure level increasing. We use EVD in IA treatment to reduce the dosages of aldosterone antagonists. Conclusions. AVS with calculation of aldosterone-cortisol ratio with a negative dexamethasone suppression test is the crucial point for diagnosis. Preference should be given to LRAG with saving adrenal central vein as surgical treatment. In case of IA the therapy starts from aldosterone antagonists prescription with dosage titration. EVD should be used for reduction of drugs large doses.