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

Abstract

Background Although unilateral primary aldosteronism is the most common surgically correctable cause of hypertension there are no standard criteria to classify surgical outcomes. Methods The Primary Aldosteronism Surgical Outcome study reached consensus by an international panel of 31 experts, including 6 endocrine surgeons, using the Delphi method. On the basis of standardised criteria, remission (complete, partial, absent) rates for clinical and biochemical outcomes were determined in retrospective cohorts (n=30-99) of consecutive patients unilaterally adrenalectomized based on adrenal venous sampling from 12 tertiary centres in 9 countries over 4 continents. Findings Consensus was reached for 6 criteria of clinical and biochemical outcome and 2 recommendations for follow-up. Complete clinical success was achieved in 37% of patients, with a wide variance (17-62%), and partial clinical success in an additional 47% (35-66%); complete biochemical success was seen in 94% (83-100%). Female patients had a higher likelihood of complete clinical success (OR=2.25; 95% CI, 1.40-3.62) and clinical benefit (complete + partial clinical success) (OR=2.89; 95% CI, 1.49-5.59). Younger patients had a higher likelihood of complete clinical success (OR=0.95 per extra year; 95% CI, 0.93-0.98) and clinical benefit (OR=0.95 per extra year; 95% CI, 0.92-0.98). Higher levels of pre-operative medication were associated with lower levels of complete clinical success. Interpretation Standardised outcome criteria are relevant for evaluating the quality of surgical treatment in individual patients and will allow the comparison of outcome data in clinical and scientific studies. The baseline clinical characteristics of a cohort contribute to the wide variation in clinical outcome rates. A majority of patients derive clinical benefit from adrenalectomy with younger patients and female patients likely to particularly benefit from a favourable surgical outcome. Screening for primary aldosteronism should nonetheless be performed in every individual fulfilling the Guideline criteria, since biochemical cure is by itself clinically important and older women and men may also derive post-operative clinical benefit.