Treatment Of Primary Aldosteronism Research Articles

Application value of adrenal venous sampling in the surgical treatment of primary aldosteronism.

The diagnosis of primary aldosteronism (PA) is critical for determining treatment strategies. The aim of the present study was to investigate the clinical value of preoperative adrenal venous sampling (AVS) for determining the benefit of PA surgery. Patients diagnosed with PA at Liaocheng People's Hospital (Liaocheng, China) between January 2015 and December 2020 were selected and divided into two groups: Group A underwent adrenal computed tomography (CT) only, whereas Group B underwent adrenal CT and successful AVS. Subsequently, the improvement rate of adrenal CT and adrenal CT + AVS in the treatment of PA was compared. A total of 164 patients were included, with an average age of 46.69±13.64 years. There were 62 patients in Group A and 102 in Group B. Among the patients diagnosed with unilateral lesions on adrenal CT scan, 82.61% of patients in group A and 87.72% in group B showed improvement; however, the difference was not significant (χ2=0.534, P=0.465). Among the patients diagnosed with bilateral lesions on adrenal CT images, 62.50% of patients in Group A and 91.11% of patients in Group B showed improvement (P=0.019). In conclusion, unilateral adrenal lesions detected by CT did not benefit significantly from surgical decision-making after AVS. AVS should be advised for all patients with bilateral adrenal PA who are willing to undergo adrenal surgery, which is conducive to correct lateral segmentation and improve treatment choices.

Targeted treatment reverses increased left cardiac work in unilateral versus bilateral primary aldosteronism.

The incidence of cardiovascular complications may be higher in unilateral than in bilateral primary aldosteronism (PA). We compared non-invasive hemodynamics before and after targeted therapy of bilateral versus unilateral PA. Adrenal vein sampling was performed, and cardiovascular variables were recorded using radial artery pulse wave analysis and whole-body impedance cardiography (n=114). In a subset of 40 patients (adrenalectomy n=20, spironolactone-based treatment n=20), hemodynamic recordings were again performed after 33 months of targeted PA treatment. In initial cross-sectional analysis, 51 patients had bilateral and 63 had unilateral PA. The mean ages were 50.6 and 54.3 years (p=0.081), and body mass indexes were 30.3 and 30.6kg/m2 (p=0.724), respectively. Aortic blood pressure and cardiac output did not significantly differ between the groups, but evaluated left cardiac work was ~10% higher in unilateral PA (p=0.022). In the followup study, initial and final blood pressure levels in the aorta were not significantly different, while initial cardiac output (+13%, p=0.015) and left cardiac work (+17%, p=0.009) were higher in unilateral than in bilateral PA. After a median treatment time of 33 months, the differences in cardiac load were abolished, and extracellular water volume was reduced by 1.3 and 1.4 liters in bilateral versus unilateral PA, respectively (p=0.814). These results suggest that unilateral PA burdens the heart more than bilateral PA, providing a possible explanation for the higher incidence of cardiac complications in unilateral disease. A similar reduction in aldosterone-induced volume excess was obtained with targeted surgical and medical treatment of PA.

Evaluation of adrenal vein anatomy by adrenal venous sampling in patients with primary aldosteronism in Chinese.

Accurate cannulation of the adrenal vein is challenging during adrenal venous sampling (AVS) because of the variations in adrenal vein anatomy. This study aimed to investigate the adrenal venous morphology in Chinese and improve the success rate of AVS. A total of 221 participants with primary aldosteronism (PA) who underwent AVS were enrolled. Compare the morphology among subgroups divided according to sex, body mass index (BMI), and with or without adenoma. The success rate of right, left, and bilateral AVS was 98.60%, 97.20%, and 96.85%, respectively. The triangular pattern was the most common (39.37%) on the right side, while the glandlike pattern (70.14%) on the left. The proportion of adrenal venous morphology varies among patients with different sexes (χ2=21.335, P<.001), BMI (χ2=10.642 P=.031), and with or without adenoma (χ2=10.637, P=.031) on the right side, and the male, obese and adenoma group showed a higher proportion of glandlike pattern than triangular pattern. If only dependent on computed tomography, 9.05% of patients incorrectly diagnose the dominant side, 14.48% of patients would have inappropriate surgery meanwhile 25.34% of patients would miss the surgical opportunity. In conclusion, the most common types of right and left adrenal venous morphology were triangular pattern and glandlike pattern, respectively. Sex, BMI, and the presence of adenoma affected right adrenal venous morphology. Adequate knowledge of the adrenal venous morphology is critical for improving the success rate of AVS and making an appropriate treatment for PA.

Hip fractures in patients with primary aldosteronism - a Swedish nationwide study.

Previous studies suggest that primary aldosteronism (PA) is associated with dysregulated bone homeostasis. The aim of this study was to evaluate the incidence of hip fractures in patients with PA. We studied a nationwide cohort of 2419 patients with PA (1997-2019) and 24187 age and sex matched controls from the general population. Hip fractures were identified by ICD codes in the Swedish National Patient Register. We estimated hazard ratios (HRs) for incident hip fractures, adjusted for prior fractures, socioeconomic factors, diabetes, osteoporosis, hyperparathyroidism, and cardiovascular disease (CVD). Pairwise subgroup comparisons were performed by age (18-56 and > 56years), sex, CVD at baseline, and treatment for PA. During a mean follow up of 8 ± 5 years, 64 (2.6%) patients had a hip fracture after being diagnosed with PA, compared to 401 (1.7%) controls. After adjustments, PA was associated with a 55% increased risk of hip fracture compared to controls (HR 1.55 [1.18-2.03]). HRs were increased in women (HR 1.76 [95% CI 1.24-2.52]), patients aged > 56 years (HR 1.62 [95% CI 1.21-2.17]), and patients with CVD at diagnosis (HR 2.15 [95% CI 1.37-3.37]). PA patients treated with adrenalectomy did not have higher risk than controls (HR 0.84 [95% CI 0.35-2.0]), while patients treated with mineralocorticoid receptor antagonists (MRA) retained a greater risk (HR 1.84 [95% CI 1.20-2.83]). PA is associated with increased hip fracture risk, especially in women, patients diagnosed after the age of 56 years and patients with established CVD at diagnosis. Also, patients treated with MRA seem to have an increased risk of hip fractures, while adrenalectomy may be protective.

Hiperaldosteronismo primario

Primary hyperaldosteronism (PHA) is the most frequent cause of secondary hypertension (HT). Furthermore, it is associated with greater cardiometabolic and mortality risk than the observed in patients with essential HT. It is recommended to screen for PHA by determining the aldosterone-to-renin ratio in patients with severe and/or resistant HT, HT with hypokalemia, HT and adrenal incidentaloma, HT and a first-degree family history of PHA, and in HT associated with atrial fibrillation that cannot be explained by other causes. If a pathological aldosterone-to-renin ratio is confirmed, dynamic tests should be performed to establish a confirmatory diagnosis; these are usually a saline infusion test or captopril challenge test. These tests can be omitted in patients with overt PHA (plasma aldosterone greater than 20 ng/dl, suppressed renin, and hypokalemia). The last step in the diagnosis is the localization study, being the computed tomography (CT) scan of the adrenal glands the initial test of choice. Nevertheless, in most patients in whom adrenal surgery is considered, adrenal vein sampling (AVS) will be necessary to establish PHA laterality. AVS is not considered necessary in cases of suspected aldosterone-producing adrenocortical carcinoma and/or PHA in patients younger than 35 years with a clear unilateral lesion on a CT/magnetic resonance imaging (MRI) test. The treatment of PHA depends on the results of the localization study: the treatment of choice is a unilateral adrenalectomy in unilateral forms and mineralocorticoid receptor antagonists in bilateral forms.

Efficacy and safety of radiofrequency ablation and laparoscopic adrenalectomy for primary aldosteronism: a meta‑analysis.

To compare the efficacy (including blood pressure, medication reduction, serum potassium, and clinical success) and safety parameters (including operative time, length of hospital stay, blood loss, hypertension crisis rate, and complication rate) of radiofrequency ablation (RFA) and laparoscopic adrenalectomy (LA) in the treatment of primary aldosteronism (PA). Literature search was performed on PubMed, EMBASE, The Cochrane Library (Issue 8, 2023), Web of Science, China National Knowledge Infrastructure, and Wanfang from inception to August 2023. Study selection, data extraction, and risk of bias assessment were performed by two independent reviewers. Quality assessment was conducted using the Newcastle-Ottawa scale. The Stata 12.0 software was used for statistical analyses. Pooled odds ratios (OR) with corresponding 95% confidence interval (CI) were calculated for categorical outcomes, while mean difference (MD) with corresponding 95% CI were calculated for continuous outcomes. A total of 5 studies involving 204 patients (LA, n = 127; and RAF, n = 77) were included. LA had better diastolic blood pressure control than RFA (WMD = 5.19; 95% CI 0.96-9.43); however, the RFA demonstrated better shorter operative time (WMD = - 57.99; 95% CI - 116.54 to 0.57), and shorter length of hospital stay (OR - 1.6; 95% CI - 2.37 to - 0.83) compared to LA. All remaining parameters were comparable between the interventions. While grossly comparable in efficacy as treatment options for PA, RFA may allow for shorter operative time and hospital stay, less intraoperative blood loss, and lower hospitalization costs. However, LA has better diastolic blood pressure control. Even so, we still need larger prospective studies, specifically with comparative hypertension response (short and long term) and number of post-procedural antihypertensive medication requirement.

Appraisal of modified tests for the diagnosis and treatment of primary aldosteronism: A single endocrine center experience

Appraisal of modified tests for the diagnosis and treatment of primary aldosteronism: A single endocrine center experience

THE EFFECT OF TREATMENT ON THE INFLAMMATION PROFILE AMONG PATIENTS WITH PRIMARY ALDOSTERONISM

Objective: Due to direct and indirect effects of aldosterone various pathways of inflammation cascade are activated leading to further end organ damage and higher cardiovascular risk among patients with primary aldosteronism (PA). To what extent the pro-inflammatory effects occur and, more importantly, if they are affected by the PA treatment remain unclear. Therefore, we aimed to analyze the inflammation profile among patients with PA before and after the treatment. Design and method: 46 patients with PA (43% with adrenal adenoma and 57% with bilateral hyperplasia) were included into this study. Patient serum samples were collected at the study entry and 6 months after the treatment of PA was initiated. Demographic, clinical and laboratory data were collected retrospectively. Inflammatory cytokines and proteins were measured in patient’s serum using proximity extension assay (O-link Inflammation panel, Olink Proteomics, Uppsala, Sweden). Results: There were 52% woman and 48% men with a mean age of 50.2±12 years. The median aldosterone-renin-quotient (ARQ) was 96 and the blood pressure values were ranging between 142±17/89±12 mmHg. 6 months following the treatment a significant reduction in blood pressure and ARQ was achieved. Analysis of association between clinical factors and biomarker expression has shown that patients with adrenal adenoma have significantly higher levels of FGF21, whereas female gender was associated with lower expression of pro-inflammatory cytokines such as IL-18, TNFRSF9, CXCL9 and higher expression of protective cytokines such as TWEAK and MCP-4, especially among females with bilateral hyperplasia. According to proteomic analysis at study entry, we have identified 4 patient clusters. Interestingly, young females with adrenal adenoma have composed a separate cluster with significantly higher levels of IL-6, IFN-gamma, MCP-1, MMP1 and FGF21 and robust reduction of these parameters following the treatment. In general, volcano plot analysis of whole study cohort has demonstrated the significant reduction in expression of pro-inflammatory cytokines (EN-RAGE, CCL23, OPG, IL-10, FGF21 etc). Conclusions: The treatment of primary aldosteronism leads to reduced expression of pro-inflammatory proteins. The extent of inflammatory activation as well as response to treatment is highly associated with gender and the cause of aldosterone excess.

Dietary effects on blood pressure control in primary aldosteronism using a cardiorenal model

Primary aldosteronism (PA) is associated with hypertension (HTN), and these patients have significant lowering of blood pressure (BP) and improved hypokalemia when moving to a DASH dietary intervention (≤65 mEq/day Na+ and ≥120 mEq/day K+). However, current guidelines for PA treatment briefly recommend lowering Na+ intake and make no specific mention of supplementing K+ intake or using DASH in PA. Additionally, high levels of aldosterone increase the risk of developing cardiovascular and chronic kidney disease. However, the impact of DASH diet on hyperkalemia risk and the extent of BP reduction in PA patients with renal dysfunction are unknown. Because continuous monitoring of cardiovascular, neural, and hormonal changes during PA and its treatment cannot be achieved experimentally, we used the mathematical model of human physiology, HumMod, to test the responses to a DASH diet during PA. We hypothesized that both low Na+ and high K+ (DASH) have additive benefits on natriuresis and BP control during PA. We added known renal physiological effects of K+ in HumMod using data from David Young’s work in dogs and further validated the model’s response to changes in Na+ intake based off of chronic salt sensitivity experiments in PA patients. Starting from baseline conditions with normal Na+/K+ intake (150 and 40 mmol/day, respectively), we simulated an aldosterone secreting tumor to gradually increase plasma aldosterone to 20 ng/dL over 3 years. Baseline PA was associated with hypertension (149/85 mmHg), very low endogenous renin and aldosterone secretion, hypokalemia (2.6 mmol/L K+), and tumor aldosterone secretion of 360 μg/day. We simulated a chronic change in dietary intake: 1) Low Na+ diet- Na+ intake fixed at 65 mmol/day with normal K+ intake, 2) High K+ diet - 120 mmol/day K+ intake with normal Na+ intake, or 3) DASH diet- Low Na+ intake and high K+ intake. Lowering Na+ intake without or with high K+ intake (DASH) were associated with lower systolic BP over the first 4 weeks and persisted for 2 years despite continued activation of the renin-angiotensin system and increasing tumor aldosterone secretion. Simulating mineralocorticoid blockade (MCB) was associated with reductions in systolic BP (-17 mmHg), decrease in left ventricular mass, and correction of hypokalemia (~4.0 mmol/L), but BP still remained uncontrolled (134/81 mmHg), partly due to the compensatory increase in renin secretion. Adding DASH to MCB therapy completely normalized BP without inducing hyperkalemia (4.8 mmol/L). Simulating chronic kidney disease by reducing nephron number in the model amplified BP sensitivity to changes in both Na+ and K+ but increased plasma K+ near the hyperkalemic range. These current simulations may help better understand the sequence of physiological events in PA and yield new insights into its diagnosis and management in patients with different baseline renal function. The physiological effects of the DASH diet desperately need to be tested in patients with PA with various baseline renal function as our simulations suggest beneficial effects beyond current treatment guidelines. Supported by the National Institute on Minority Health and Health Disparities (R00 MD014738). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

SODIUM RESTRICTION CONCOMITANT WITH SUFFICIENT ALDOSTERONE SUPPRESSION MAY BE ASSOCIATED WITH RENOPROTECTIVE EFFECTS IN THE PATIENTS WITH PRIMARY ALDOSTERONISM

Objective: Primary aldosteronism (PA) is an independent risk factor for various cardiovascular diseases and chronic kidney disease, which makes it important to treat this condition at an early phase. Currently, the use of mineralocorticoid receptor antagonists (MRAs) is recommended for the treatment of bilateral type, mainly idiopathic hyperaldosteronism. However, recent reports suggest that the benefit of the treatment with MRAs is only obtained in the patients with enough aldosterone suppression, which is indicated as post-treatment plasma renin activity (PRA) &gt;=1.0 ng/mL/h. Since PRA is affected by the amount of sodium intake, PRA elevation after MRAs treatment might partially reflect an adherence to strict sodium restriction, thereby leads to organ protective effects in PA patients. Design and method: A total of 91 patients who received eplerenone or esaxerenone for PA treatment were included. The patients with PRA&gt;=1.0 ng/mL/h at one year after the initiation of MRAs were determined as responders, and others were determined as non-responders. The differences between responders and non-responders were analyzed. In addition, these patients were followed for another two years (total three years), and the transitions of estimated glomerular filtration (eGFR) among responders and non-responders were also compared. Results: The doses of MRAs were equivalent between responders and non-responders. Estimated sodium intake was significantly lower in responders (responders: non-responders; 156.2±42.3 mmol/day: 124.7±41.8 mmol/day P&lt;0.05). Multivariate logistic regression analysis has shown that estimated sodium intake was an independent predictor for responders. During three years’ period, eGFR was significantly decreased in non-responders (pre-treatment: post-treatment; 73.0±14.7 ml/min: 69.5±14.1 ml/min P&lt;0.05), whereas it was comparatively preserved in responders (pre-treatment: post-treatment; 68.3±17.9 ml/min: 68.0±19.0 ml/min P=0.84). Conclusions: The present study have shown that responders in PA patients may partially benefit from an adherence to sodium restriction. Sodium restriction concomitant with sufficient suppression of aldosterone effect may exert renoprotective effects for PA patients.

Adrenalectomy for primary aldosteronism and its related surgical characteristics.

Primary aldosteronism (PA) is a common cause of secondary hypertension. Adrenalectomy is an effective treatment for unilateral PA, particularly aldosterone-producing adenoma (APA), resulting in improvements in biochemical parameters and blood pressure in the vast majority of patients. The article provides a comprehensive overview of PA, focusing on the outcomes of adrenalectomy for PA and the factors that may suggest prognostic implications. Analysis of the outcome of different PA patients undergoing adrenalectomy in terms of preoperative factors, vascular and adipose conditions, type of pathology, and somatic variants. In addition, it is recommended to use the histopathology of primary aldosteronism (HISTALDO) consensus to classify the patient's pathological type, with classical and nonclassical pathological types showing a different prognosis and possibly being associated with an unresected contralateral adrenal gland. The primary aldosteronism surgical outcome (PASO) consensus sets uniform standards for postoperative outcomes in unilateral PA, but its setting of thresholds remains controversial. Partial adrenalectomy shows similar surgical results and fewer postoperative complications than total adrenalectomy, but there is a risk of missing the true source of abnormal aldosterone secretion. Steroid profiling and functional imaging techniques offer alternative options to adrenal vein sampling (AVS) for unilateral and bilateral judgments in patients with PA. A combination of factors is needed to predict the prognosis of PA patients undergoing adrenalectomy in order to manage patient expectations of the outcome of the procedure and to closely monitor blood pressure and biochemical parameters in patients who suggest a poorer prognosis.

Prevalence of Primary Aldosteronism and Complications in Type 2 Diabetes Mellitus Patients with Resistant Hypertension: A Prospective Observational Single Centre Study Protocol

Primary hyperaldosteronism (PA) has been thought to be an uncommon cause of hypertension, with an estimated prevalence of 2% among the general hypertensive population but is much higher, especially in resistant hypertension (RH) patients. Recent studies, however, have suggested that the prevalence of PA may be as high as 30% in RH populations. PA is associated with higher morbidity rates than matched essential hypertension patients. RH is more common in type 2 diabetes mellitus (T2DM). PA is generally remediable by treatment with an aldosterone antagonist or, in the case of adrenal adenoma, by adrenalectomy, knowing the true prevalence of PA is important for early diagnosis and treatment. Aim: This study aims to evaluate the prevalence of PA and cardiovascular (CVD) and renal complications in T2DM mellitus patients with resistant hypertension . Method: Prospective observational single centre study, in outpatient (OPD) settings in a tertiary care hospital. The primary outcome of the study is to estimate the prevalence of primary aldosteronism in T2DM patients with resistant hypertension. The secondary outcome is to evaluate the difference in prevalence of complications / comorbidities like CVD, left ventricle hypertrophy(LVH) , atrial fibrillation (AF), chronic kidney disease (CKD) in T2DM patients with and without PA hyperaldosteronism . T2DM patients aged more than 18 years with RH will be included in the study. Patients with type 1 diabetes mellitus or secondary causes of diabetes mellitus, acute diabetic complications, severe underlying systemic diseases, chronic kidney disease stage ≥4 , known secondary causes of hypertension, pregnancy and lactation and on medications like oral contraceptives, spironolactone, eplerenone, amiloride, triamterene will be excluded. Study subjects with plasma aldosterone to renin ratio of value ≥ 1.6 ng/dl/μIU/ml and plasma aldosterone concentration (PAC) of value ≥ 10 ng/dl with suppressed renin, will be considered to be positive on a screening test. Patients, those positive on a screening test will undergo seated saline suppression test (SST). Repeat plasma aldosterone concentration (PAC) with value ≥ 6 ng/dl will be confirmatory test for PA. Conclusion: RH specially in T2DM high-risk phenotype, which may be further aggravated by underlying PA . Thus we want to estimate the prevalence of PA in T2DM patients with RH. We also want to highlight any difference in prevalence of CV and renal complications due to in T2DM patients with and without PA, which may support early screening and diagnosis of PA and targeted treatment of PA to prevent its aggravating effects on chronic diabetes complications.

Diagnostic Delay and Disease Burden in Primary Aldosteronism: An International Patient Survey.

Primary aldosteronism (PA) is a common but underdiagnosed cause of hypertension. Many patients experience preventable end-organ injury due to delayed or missed diagnosis but data on the experience of patients are limited. We evaluated the lived experience of PA and determines factors associated with diagnostic delay through an international anonymous online cross-sectional survey, codesigned by researchers and PA consumers. We distributed the survey through academic medical centers, Amazon Mechanical Turk, Twitter, PA patient advocacy groups, and hypertension support groups on Facebook between March 21 and June 5, 2022. Of 684 eligible respondents, 66.5% were women. Diagnostic delay (defined as ≥5 years between the diagnosis of hypertension and PA) was reported in 35.6%. Delay was more likely in women than in men (odds ratio, 1.55 [95% CI, 1.10-2.20]) and respondents with ≥3 comorbidities versus none (odds ratio, 1.77 [95% CI, 1.05-3.02]), ≥10 symptoms versus none (odds ratio, 2.73 [95% CI, 1.74-4.44]), and on ≥4 antihypertensive medications versus none (odds ratio, 18.23 [95% CI, 6.24-77.72]). Three-quarters of patients (74.4%) experienced reduced symptom burden following targeted PA treatment. Quality of life improved in 62.3% of patients, and greater improvement was associated with being a woman (odds ratio, 1.42, [95% CI, 1.02-1.97]), receiving adrenalectomy (odds ratio, 2.36 [95% CI, 1.67-3.35]), and taking fewer antihypertensive medications following diagnosis (odds ratio, 5.28 [95% CI, 3.55-7.90]). One-third of patients with PA experienced prolonged diagnostic delays. Targeted treatment led to reduced symptom burden and improved quality of life. Gender differences in diagnostic delay and symptom burden are prominent. These findings suggest that routine screening for PA at the onset of hypertension may reduce diagnostic delay and facilitate timely diagnosis.

Multiple radiologist review of adrenal CT still frequently misses lateralized surgical primary aldosteronism.

Patients with primary aldosteronism (PA) have increased morbidity and mortality compared to those with essential hypertension. Accurate detection of lateralized PA is important so that affected patients can receive potentially curative adrenalectomy. However, around 40% of patients with lateralized PA have "normal" adrenal glands on computed tomography (CT). Additional independent review of imaging has been shown to improve diagnostic accuracy in many areas of imaging. Therefore, the authors sought to establish if multi-reader re-assessment of previously reported normal CT scans would result in increased detection of surgically remediable disease. The authors found that re-assessment of CT imaging by one, two, or three additional radiologists (or a combination thereof) slightly increased the detection of lateralized disease, but these differences were not statistically significant (p>.05). Readers had low inter-observer agreement (kappa=0.17). If detection of a discrete nodule on CT was made a prerequisite for adrenal vein sampling (AVS), a second read by another reviewer would still result in an excess of missed cases (84.2%, 36.8%, and 65.8%, respectively, for each of the three independent reviewers). Therefore, a "normal" CT does not preclude the possibility of lateralized PA. Adrenal vein sampling should still be strongly considered wherever available and whenever surgery is considered for treatment of PA, irrespective of CT findings.

Increasing rates of referrals for investigation of primary aldosteronism at a tertiary centre.

To describe the frequency and characteristics of patients referred for specialist investigation of primary aldosteronism (PA) in the lower North Island over a 5-year period, and the outcomes of those who received treatment. Patients who underwent confirmatory testing or treatment for PA at Wellington Regional Hospital were retrospectively identified and data were collected from electronic clinical records. There has been a five-fold increase in both referrals and confirmatory testing for PA in 2021 compared to 2015. Compared to patients without PA, those eventually diagnosed with PA had a higher ARR, serum sodium, antihypertensive requirement and cardiovascular disease prevalence, as well as lower serum renin, potassium and GFR (all p <0.05), but similar blood pressure. Complete or partial clinical success was achieved in 96% of surgically treated patients compared with 70% of medically treated patients. Thirty-nine percent of patients experienced minor adverse effects with spironolactone and only one significant adverse event was experienced perioperatively. The rate of referrals and confirmatory testing for PA are increasing in our region. Adrenalectomy and mineralocorticoid antagonist therapy are both safe and effective treatments, although minor adverse effects were common with spironolactone.

Corticotropin Stimulation in Adrenal Venous Sampling for Patients With Primary Aldosteronism

Adrenal venous sampling (AVS) is usually recommended to distinguish between unilateral and bilateral primary aldosteronism (PA) before definitive surgical or medical treatment is offered. Whether a treatment decision based on AVS with or without corticotropin (ACTH) stimulation leads to different biochemical and clinical remission rates in patients with PA remains unclear. To evaluate whether treatment decisions based on AVS with or without ACTH stimulation lead to different biochemical and clinical remission rates in patients with PA. This randomized clinical trial (RCT) was conducted at a tertiary hospital in China from July 8, 2020, to February 20, 2023, among patients with PA aged 18 to 70 years. Patients were followed up for 12 months after the initiation of treatment. An intention-to-diagnose analysis was conducted. Patients were randomly assigned to undergo either ACTH-stimulated or non-ACTH-stimulated AVS. The primary end point was the proportion of patients with complete biochemical remission after 12 months of follow-up. Secondary outcomes included the proportion of patients who achieved complete clinical remission after 12 months of follow-up, dosages of antihypertensive agents, rate of successful bilateral AVS, and adverse events. Of 228 patients with PA, 115 were randomized to the non-ACTH-stimulated group (median age, 50.0 years [IQR, 41.0-57.0 years]; 70 males [60.9%]) and 113 to the ACTH-stimulated group (median age, 50.0 years [IQR, 43.5-56.5 years]; 63 males [55.8%]). A total of 68 patients (59.1%) underwent adrenalectomy in the non-ACTH group and 65 (57.5%) in the ACTH group. There was no significant difference in the proportion of patients with complete biochemical remission who were managed on the basis of AVS with vs without ACTH stimulation (with: 56 of 113 [49.6%]; without: 59 of 115 [51.3%]; P = .79). There also was no significant difference in the proportion of patients who achieved complete clinical remission between the non-ACTH and ACTH groups (26 of 115 [22.6%] and 31 of 113 [27.4%], respectively; P = .40). The intensity of therapy with antihypertensives, successful catheterization of bilateral adrenal veins, and incidence of adverse events did not significantly differ between the non-ACTH and ACTH groups. In this RCT, treatment of PA on the basis of non-ACTH-stimulated or ACTH-stimulated AVS did not lead to significant differences in clinical outcomes for the patients. These results suggest that ACTH stimulation during AVS may not have clinical benefit, at least in the Chinese population. ClinicalTrials.gov Identifier: NCT04461535.

2023 Korean Endocrine Society Consensus Guidelines for the Diagnosis and Management of Primary Aldosteronism.

Primary aldosteronism (PA) is a common, yet underdiagnosed cause of secondary hypertension. It is characterized by an overproduction of aldosterone, leading to hypertension and/or hypokalemia. Despite affecting between 5.9% and 34% of patients with hypertension, PA is frequently missed due to a lack of clinical awareness and systematic screening, which can result in significant cardiovascular complications. To address this, medical societies have developed clinical practice guidelines to improve the management of hypertension and PA. The Korean Endocrine Society, drawing on a wealth of research, has formulated new guidelines for PA. A task force has been established to prepare PA guidelines, which encompass epidemiology, pathophysiology, clinical presentation, diagnosis, treatment, and follow-up care. The Korean clinical guidelines for PA aim to deliver an evidence-based protocol for PA diagnosis, treatment, and patient monitoring. These guidelines are anticipated to ease the burden of this potentially curable condition.

FRI125 Recurrence Of Primary Aldosteronism Long-Term After Adrenalectomy For Aldosterone-Producing Adenoma With KCNJ5 Gene Mutation: A Two-Cases Report

Abstract Disclosure: K. Aiga: None. M. Kometani: None. D. Aono: None. S. Karashima: None. T. Yoneda: None. Primary aldosteronism (PA) is a major cause of secondary hypertension. PA is known to have higher prevalence of cerebral or cardiovascular complications, indicating the importance of early detection and treatment for PA. PA is caused by autonomous secretion of aldosterone in the adrenal glands. PA is characterized by high plasma aldosterone concentration, low plasma renin activity and hypokalemia. PA is classified into unilateral PA (aldosterone-producing adenoma [APA] or unilateral hyperplasia) and bilateral PA (bilateral adrenal hyperplasia). PA with aldosterone excess in bilateral adrenal glands is defined as bilateral PA. On the other hand, PA with aldosterone excess in unilateral adrenal gland is defined as unilateral PA. Strategies for PA treatment depends on the subtype of PA. Medication by mineralocorticoid receptor antagonists is a common treatment for bilateral PA. Adrenalectomy is the most efficient treatment for unilateral PA. In general, patients tend to maintain normal serum potassium level and blood pressure after adrenalectomy, and recurrence of PA is extremely rare. Recently, mutation in the gene named KCNJ5 was found to derive APA. Herein, we report two cases of PA recurrence more than 10 years after surgical treatment for APA. Somatic mutation in KCNJ5 was detected in the first occurrence of PA in both cases. First case, a 52-year-old woman was examined for hypertension 22 years after total adrenalectomy of the right adrenal gland. Recurrent PA was diagnosed based on high aldosterone-renin-ratio (ARR), identification of left adrenal gland tumor by computed tomography (CT), and a confirmatory test. Second case, a 65-year-old man was examined for hypertension 17 years after total adrenalectomy of the left adrenal gland. He had maintained his blood pressure using medication since the onset of hypertension 4 years after the surgery. A year later, a high ARR was observed. PA recurrence was determined by a right adrenal gland tumor noted on CT and a confirmatory test. Tissues of the adrenal gland were obtained from adrenalectomy in both cases. Histopathological analysis revealed presence of one adenoma in the first case, while two adenomas were confirmed in the second case. Somatic mutation in KCNJ5 gene was detected in both cases. To date, there are no specific guidelines established for the management of recurrent PA. Early detection is crucial for the prevention of severe cardiovascular diseases. Long-term follow-up is recommended after the treatment of PA. Presentation: Friday, June 16, 2023

THU474 Primary Hyperaldosteronism As A Cause Of PTH Elevation After Parathyroid Surgery

Abstract Disclosure: W. Thi: None. A. Rao: None. Background: Primary hyperaldosteronism can cause hypercalciuria, parathyroid hormone (PTH) elevation due to secondary hyperparathyroidism, and reduce bone mineral density. Screening for primary hyperaldosteronism can be done with serum aldosterone-renin ratio (ARR). We report a case of recurrent hyperparathyroidism after parathyroid surgery. Workup identified primary hyperaldosteronism as the cause of recurrent hyperparathyroidism. Treatment with spironolactone normalized PTH levels. Case Presentation: A 59-year-old African-American female in the Columbia VA Health Care System presented with hypertension, hypokalemia, bone density loss, and elevated PTH with normal calcium, one year after resection of a right inferior parathyroid adenoma to treat primary hyperparathyroidism. The patient had uncontrolled hypertension with hypokalemia while on losartan and amlodipine. Serum calcium was 9.4mg/dl(8.4-10.2mg/dl), PTH 89.4 pg/ml(29.2-79.9pg/ml), albumin 3.8g/dl(3.5-5G/dl), vitamin D 34 ng/ml(&amp;gt;28.9ng/ml), aldosterone 9ng/dl(&amp;lt;/=28ng/dl), plasma renin activity 0.28ng/ml/h(0.25-5.82ng/ml/h), ARR 32. Treatment of the patient with potassium supplements corrected the hypokalemia to 3.7mmol/L (5-5.1mm/l), and ARR was 94 with aldosterone 17 ng/dl and PRA 0.18 ng/ml/h and 24-hour urine calcium 304mg/24h(35-250mg/24h). Based on the laboratory values, and the absence of adrenal nodules during a CT scan, a diagnosis of primary hyperaldosteronism due to idiopathic hyperplasia of the adrenal was made. Spironolactone was started and PTH levels dropped down to 64.8pg/ml and serum calcium remained normal 5 months after treatment was initiated. Discussion: Primary Hyperaldosteronism causes extravascular fluid volume expansion with a reduction in proximal tubular sodium and calcium reabsorption. Increased calcium and sodium delivery to distal segments of the nephron leads to sodium reabsorption by mineralocorticoids without reabsorbing calcium, resulting in hypocalcemia with concomitant secondary hyperparathyroidism. Bone loss results from direct mineralocorticoid receptor-mediated effects of aldosterone on osteoblasts and osteoclasts and indirectly from high PTH levels to promote bone resorption. Treatment of primary hyperaldosteronism can reverse bone loss and reduce fracture risk rate within 18-36 months. This case suggests that primary hyperaldosteronism be considered a cause of secondary hyperparathyroidism and successfully treated with mineralocorticoid receptor antagonists. Presentation: Thursday, June 15, 2023

FRI123 Development And Impact Of A Best Practice Alert For Primary Aldosteronism Screening

Abstract Disclosure: S. Charoensri: None. L. Bashaw: None. C. Dehmlow: None. T. Ellies: None. A.F. Turcu: None. Background: Primary aldosteronism (PA) is a common cause of secondary hypertension, affecting up to 25% of patients with treatment-resistant hypertension. PA amplifies the risk of cardiovascular morbidity and mortality above that of equivalent primary hypertension. Despite this, &amp;lt;3% of candidates for PA screening are ever evaluated, including in academic centers with facile access to all required resources for PA subtyping and treatment. Clinical decision support tools, such as best practice alerts (BPA), can leverage electronic medical records technology to support health care delivery improvement efforts. Intervention and Measurements: In collaboration with institutional Informational Technology services, we developed an algorithm that identifies PA screening candidates as adult patients with hypertension and one of the following criteria: ≥ 4 current antihypertensive medications; age &amp;lt; 35 years; hypokalemia (defined by potassium supplements or low serum potassium in the past year); or adrenal mass on problem list. The algorithm excluded patients who had both plasma aldosterone and renin measurements within the past 5 years. A non-disruptive BPA to suggest PA screening was constructed and set to trigger in patients meeting inclusion and exclusion criteria when evaluated in outpatient setting by clinicians who treat hypertension, including Internists, Family Practitioners, Cardiologists, Nephrologists, and Endocrinologists. An order set for PA screening and a link to results interpretation guidance were also embedded within the BPA. The BPA was first piloted between Aug-Sept 2021, and then launched on October 1st, 2021. We assessed the number of unique patients identified by the BPA between Oct 1st, 2021- Dec 14th, 2022, stratified by PA screening indications; attitude towards the BPA; and number of patients who received PA screening orders. Results: In total, the BPA identified 14,443 unique candidates for PA screening, including: 6944 patients with treatment-resistant hypertension; 6583 patients with hypertension and hypokalemia; 1527 patients with hypertension &amp;lt;35 years; and 444 with hypertension and an adrenal mass. During the same time frame, 3614 (25%) patients received orders for plasma aldosterone and renin. Patients tested were on average 57 +/-17 years old, 2000 (55.3%) were women, 2573 (71.2%) were White, 712 (19.7%) Black, and 105 (2.9%) Asian. Of new orders, 1364 (37.7%) were placed by Internists, 685 (18.9%) by Family Medicine physicians, 559 (15.5%) by Endocrinologists, 235 (6.5%) by Cardiologists, and 50 (1.4%) by Nephrologists. Family Practitioners and Internists placed most orders via the embedded BPA order set (66.6% and 46.3%, respectively), while Endocrinologists placed 98.6% of the orders outside of the BPA order set. Conclusions: Non-disruptive BPAs enhance the rates of PA screening, particularly among Internists and Family Practitioners. Presentation: Friday, June 16, 2023