Preoperative masked renal damage in Japanese patients with primary aldosteronism: Identification of predictors for chronic kidney disease manifested after adrenalectomy

Abstract

Abbreviations & Acronyms APA = aldosterone-producing adenoma BMI = body mass index BP = blood pressure CKD = chronic kidney disease eGFR = estimated glomerular filtration rate EH = essential hypertension FBGL = fasting blood glucose level GFR = glomerular filtration rate IHA = idiopathic hyperaldosteronism mo = months PA = primary aldosteronism PAC = plasma aldosterone concentration PRA = plasma renin activity Postop. = postoperative Preop. = preoperative SD = standard deviation TC = total cholesterol TG = triglycerides Objective: Correct interpretation of renal function in patients with primary aldosteronism is difficult before adrenalectomy, because subtle kidney impairment is often masked by glomerular hyperfiltration peculiar to primary aldosteronism. The aim of this study was to investigate postoperative changes in renal function for patients with primary aldosteronism and to identify clinical predictors of chronic kidney disease manifested postoperatively in the patients without pre-existing chronic kidney disease. Methods: Records of 78 Japanese patients who underwent unilateral adrenalectomy for primary aldosteronism were retrospectively surveyed. Patients who had been followed up for <6 months were excluded. Preoperative and postoperative estimated glomerular filtration rate were compared. Furthermore, uni-and multivariate analyses were carried out to identify clinical predictors for chronic kidney disease manifested postoperatively. Results: Patients with preoperative estimated glomerular filtration rate Ն60 mL/min/ 1.73 m 2 showed a significant decrease after surgery. Of the 66 patients without preexisting chronic kidney disease, 24 developed chronic kidney disease postoperatively. Multivariate logistic regression analysis identified a medical history of dyslipidemia as an independent predictor for chronic kidney disease manifested postoperatively. According to univariate analyses, additional factors associated with postoperative manifestation of chronic kidney disease included older age, lower diastolic blood pressure and lower estimated glomerular filtration rate. Conclusions: The interpretation of normal or abnormal renal functions by examining estimated glomerular filtration rate heightened by hyperfiltration alone can mislead clinicians before adrenalectomy. Clinicians should pay attention to patients at greater risk of a significant decline in postoperative renal function.

Kidney dysfunction following adrenalectomy in autosomal dominant polycystic kidney disease complicated with primary aldosteronism: A case report

“…Adrenalectomies were performed in 8 patients (6,7,23-26) and anti-aldosterone drugs were administered to the other 4 cases (22,23,27). Worsening of kidney function following adrenalectomy for PA has been reported (23); the cause may be the correction of glomerular hyperfiltration once aldosterone levels have been stabilized (3)(4)(5). Therefore, overestimated kidney function due to glomerular hyperfiltration was canceled out, which led to an accurate kidney function.…”

“…Among cases of hypertension, Utsumi et al (3) reported that 6-11% are secondary to PA, although prevalence varies worldwide. The pathogenesis of PA is excess secretion of aldosterone from bilateral or unilateral adrenal gland or tumors (3). The early discovery and treatment of PA is a crucial clinical issue to prevent progression of atherosclerosis.…”

“…The classical symptoms of PA are refractory hypertension and hypokalemia. However, those symptoms do not always occur, which makes early discovery difficult (3). Adrenalectomy is widely performed to treat adrenal tumors; however, there is increasing focus on attenuating the progression of renal dysfunction following adrenalectomy to treat PA (3)(4)(5), the mechanism of which has not been fully elucidated.…”

Outcomes of Drug-Based and Surgical Treatments for Primary Aldosteronism

“…40 They are most marked in patients with unilateral PA 41,42 and are reversed within one month of adrenalectomy (Figure 1). 40,[43][44][45][46][47][48][49][50][51][52][53][54][55] Hemodynamic stress and hyperaldosteronism per se lead to chronic structural damage in the long run. 45,56 PA patients have been reported to display a certain level of insulin resistance, which may improve after adrenalectomy.…”

“…Mineralocorticoid receptor antagonist treatment and potassium supplements should be discontinued immediately after surgery and serum potassium concentrations should be monitored closely. 25  Adrenalectomy also unmasks postoperative eGFR below 60 ml/min/1.73m² in 30% to 40% of patients with unilateral PA. 52,54,55 It is more likely in patients who have a preoperative eGFR that is already close to this threshold. 54 Drug-based treatment  The pharmacokinetics of spironolactone and eplerenone are unaffected in patients with CKD.…”