Adrenalectomy for Primary Aldosteronism: Significant Variability in Work‐Up Strategies and Low Guideline Adherence in Worldwide Daily Clinical Practice

Abstract

Background Various diagnostic tests are available to establish the primary aldosteronism (PA) diagnosis and to determine the disease laterality. Combined with the controversies in the literature, unawareness of guidelines and technical demands and high costs of some of these diagnostics, this could lead to significant differences in work-up strategies worldwide. Therefore, we investigated the work-up before surgery for PA in daily clinical practice within a multicenter study. Methods Patients who underwent unilateral adrenalectomy for PA within 16 centers in Europe, Canada, Australia and the USA between 2010 and 2016 were included. We did not exclude patients based on the performed diagnostic tests during work-up to make our data representative for current clinical practice. Adherence to the Endocrine Society Guideline and variables associated with not performing adrenal venous sampling (AVS) were analyzed. Results In total, 435 patients were eligible. An aldosterone-to-renin ratio, confirmatory test, computed tomography (CT), magnetic resonance imaging and AVS were performed in 82.9%, 32.9%, 86.9%, 17.0% and 65.3% of patients, respectively. A complete work-up, as recommended by the guideline, was performed in 13.1% of patients. Bilateral disease or normal adrenal anatomy on CT (OR 16.19; CI 3.50-74.99), smaller tumor size on CT (OR 0.06; CI 0.04-0.08) and presence of hypokalemia (OR 2.00; CI 1.19-3.32) were independently associated with performing AVS. Conclusions This study is the first to examine the daily clinical practice work-up of PA within a worldwide cohort of surgical patients. The results demonstrate significant variability in work-up strategies and low adherence to The Endocrine Society guideline.

A simplified primary aldosteronism surgical outcome score is a useful prediction model when target organ damage is unknown – Retrospective cohort study

“…The median duration of hypertension was 96 [36–144] months. The median DDD was 3.7 [2.0–5.6] and median nodule size at imaging was 15 [ [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] ] mm. In 7.9% of patients the nodule size was based on MRI, because no CT was performed.…”

“…Therefore, the worldwide increase in primary hypertension over the last decades could also have influenced the lower rates of complete clinical success within our study [ 23 ]. Since our cohort represents daily clinical practice, the preoperative workup within our cohort was less stringent in following current guidelines compared to the preselected PASO cohort [ 17 ]. This is especially seen in the difference in the routine performance of AVS, 100% in the PASO cohort versus 63.4% in our cohort.…”

“…For this validation study, patient data were used from the International CONNsortium Study Group database (NCT04761354, [ 15 ]), which has been previously extensively described [ 11 , 12 , 16 , 17 ]. In brief, patients with APA who were treated with unilateral adrenalectomy between 2010 and 2016 were included from 16 expert medical centers in North America, Europe and Australia ( Supplement 1 ).…”

“…In brief, patients with APA who were treated with unilateral adrenalectomy between 2010 and 2016 were included from 16 expert medical centers in North America, Europe and Australia ( Supplement 1 ). The cohort represents the care delivered in daily clinical practice within the participating medical centers and, therefore, no strict inclusion or exclusion criteria were used regarding the workup to surgery (i.e., screening, case confirmation and subtype testing) [ 17 ]. In general, the elevated aldosterone-to-renin ratio (ARR) was used biochemically to indicate PA and computerized tomography (CT) and/or magnetic resonance imaging (MRI) and/or adrenal venous sampling (AVS) were used to determine disease laterality prior to surgery.…”

Trends in blood pressure-related outcomes after adrenalectomy in patients with primary aldosteronism: A systematic review

“…33,34 Furthermore, the use of AVS in daily clinical practice shows significant variability in expert centers. 35 Moreover, all studies primarily reported data on group level and we did not actively contact authors for individual patient data, which is expected to be favorable with considerable advantages (e.g. subgroup analysis or adjustment for confounding factors), over group level data.…”