Outcomes after adrenalectomy for unilateral primary aldosteronism: an international consensus on outcome measures and analysis of remission rates in an international cohort

Williams, Tracy A., Lenders, Jacques W. M., Mulatero, Paolo, Burrello, Jacopo, Rottenkolber, Marietta, Adolf, Christian, Satoh, Fumitoshi, Amar, Laurence, Quinkler, Marcus, Deinum, Jaap, Beuschlein, Felix, Kitamoto, Kanako K., Pham, Uyen, Morimoto, Ryo, Umakoshi, Hironobu, Prejbisz, Aleksander, Kocjan, Tomaz, Naruse, Mitsuhide, Stowasser, Michael, Nishikawa, Tetsuo, Young, William F., Jr., Gomez-Sanchez, Celso E., Funder, John W. and Reincke, Martin (2017) Outcomes after adrenalectomy for unilateral primary aldosteronism: an international consensus on outcome measures and analysis of remission rates in an international cohort. Lancet Diabetes & Endocrinology, 5 9: 689-699. doi:10.1016/S2213-8587(17)30135-3

Author Williams, Tracy A.
Lenders, Jacques W. M.
Mulatero, Paolo
Burrello, Jacopo
Rottenkolber, Marietta
Adolf, Christian
Satoh, Fumitoshi
Amar, Laurence
Quinkler, Marcus
Deinum, Jaap
Beuschlein, Felix
Kitamoto, Kanako K.
Pham, Uyen
Morimoto, Ryo
Umakoshi, Hironobu
Prejbisz, Aleksander
Kocjan, Tomaz
Naruse, Mitsuhide
Stowasser, Michael
Nishikawa, Tetsuo
Young, William F., Jr.
Gomez-Sanchez, Celso E.
Funder, John W.
Reincke, Martin
Title Outcomes after adrenalectomy for unilateral primary aldosteronism: an international consensus on outcome measures and analysis of remission rates in an international cohort
Journal name Lancet Diabetes & Endocrinology   Check publisher's open access policy
ISSN 2213-8595
Publication date 2017-09-01
Sub-type Article (original research)
DOI 10.1016/S2213-8587(17)30135-3
Open Access Status Not yet assessed
Volume 5
Issue 9
Start page 689
End page 699
Total pages 11
Place of publication London, United Kingdom
Publisher Lancet Publishing Group
Language eng
Subject 2724 Internal Medicine
2712 Endocrinology, Diabetes and Metabolism
1310 Endocrinology
Abstract Background Although unilateral primary aldosteronism is the most common surgically correctable cause of hypertension, no standard criteria exist to classify surgical outcomes. We aimed to create consensus criteria for clinical and biochemical outcomes and follow-up of adrenalectomy for unilateral primary aldosteronism and apply these criteria to an international cohort to analyse the frequency of remission and identify preoperative determinants of successful outcome. Methods The Primary Aldosteronism Surgical Outcome (PASO) study was an international project to develop consensus criteria for outcomes and follow-up of adrenalectomy for unilateral primary aldosteronism. An international panel of 31 experts from 28 centres, including six endocrine surgeons, used the Delphi method to reach consensus. We then retrospectively analysed follow-up data from prospective cohorts for outcome assessment of patients diagnosed with unilateral primary aldosteronism by adrenal venous sampling who had undergone a total adrenalectomy, consecutively included from 12 referral centres in nine countries. On the basis of standardised criteria, we determined the proportions of patients achieving complete, partial, or absent clinical and biochemical success in accordance with the consensus. We then used logistic regression analyses to identify preoperative factors associated with clinical and biochemical outcomes. Findings Consensus was reached for criteria for six outcomes (complete, partial, and absent success of clinical and biochemical outcomes) based on blood pressure, use of antihypertensive drugs, plasma potassium and aldosterone concentrations, and plasma renin concentrations or activities. Consensus was also reached for two recommendations for the timing of follow-up assessment. For the international cohort analysis, we analysed clinical data from 705 patients recruited between 1994 and 2015, of whom 699 also had biochemical data. Complete clinical success was achieved in 259 (37%) of 705 patients, with a wide variance (range 17–62), and partial clinical success in an additional 334 (47%, range 35–66); complete biochemical success was seen in 656 (94%, 83–100) of 699 patients. Female patients had a higher likelihood of complete clinical success (odds ratio [OR] 2·25, 95% CI 1·40–3·62; p=0·001) and clinical benefit (complete plus partial clinical success; OR 2·89, 1·49–5·59; p=0·002) than male patients. Younger patients had a higher likelihood of complete clinical success (OR 0·95 per extra year, 0·93–0·98; p<0·001) and clinical benefit (OR 0·95 per extra year, 0·92–0·98; p=0·004). Higher levels of preoperative medication were associated with lower levels of complete clinical success (OR 0·80 per unit increase, 0·70–0·90; p<0·001). Interpretation These standardised outcome criteria are relevant for the assessment of the success of surgical treatment in individual patients and will allow the comparison of outcome data in future studies. The variable baseline clinical characteristics of our international cohort contributed to wide variation in clinical outcomes. Most patients derive clinical benefit from adrenalectomy, with younger patients and female patients more likely to have a favourable surgical outcome. Screening for primary aldosteronism should nonetheless be done in every individual fulfilling US Endocrine Society guideline criteria because biochemical success without clinical success is by itself clinically important and older women and men can also derive post-operative clinical benefit. Funding European Research Council; European Union's Horizon 2020; Else Kröner-Fresenius Stiftung; Netherlands Organisation for Health Research and Development–Medical Sciences; Japanese Ministry of Health, Labour and Welfare; Ministry of Health, Slovenia; US National Institutes of Health; and CONICYT-FONDECYT (Chile).
Q-Index Code C1
Q-Index Status Provisional Code
Grant ID R01 HL027255
R21 DK103183
Institutional Status UQ

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Sub-type: Article (original research)
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