Prognosis of adrenalectomy guided by computed tomography versus adrenal vein sampling in patients with primary aldosteronism: A systematic review and meta‐analysis

Abstract

Adrenal vein sampling (AVS) is recommended to be the gold standard for patients with unilateral subtypes of primary aldosteronism to clinical diagnosis and surgery therapy. However, it is uncertain whether AVS is better for prognosis than computed tomography (CT), which is the most widely used. Pubmed, Embase, and Cochrane Library were searched for articles with no start date restriction. The last search was conducted on Jun 15, 2021. Eligible studies compared the distinct subtypes of primary aldosteronism by AVS with CT (as a control group) and reported the prognosis at follow-up. Evaluation of cohort studies referred to Newcastle -Ottawa Quality Assessment Scale, and randomized controlled trials referred to Updated Cochrane Collaboration tool. A randomeffect model or fixed-effect model was chosen according to the heterogeneity test.All processes were performed following the PRISMA 2020 statement. Eleven studies were identified, including 1325 patients based on AVS and 907 patients based on CT.Compared with patients guided by CT, patients who underwent AVS had an increased possibility of complete biochemical success (odds ratio [OR] 2.78, 95% CI 1.88-4.12) and a decreased chance of absent biochemical success (OR 0.23, 95% CI 0.13-0.40) at follow-up. Nevertheless, the rate of complete clinical success (OR 1.09, 95% CI 0.89-1.35) and absent clinical success (OR 0.96, 95% CI 0.68-1.33) had no significant difference. Therefore, distinguishing subtypes by AVS for early treatment may be crucial since it can promote biochemical improvement.

Assessment of biochemical outcomes in patients with primary aldosteronism after adrenalectomy based on CT scan diagnosis of unilateral adenoma without adrenal vein sampling

“…In our cohort, partial biochemical success was achieved in 14 patients (8.1%) and absent biochemical success in seven patients (4.1%), which is broadly similar to the subgroup of CT-based patients in other studies ( 12 ). Compared with a meta-analysis of the prognosis of patients with primary aldosteronism, partial biochemical successes were similar (8.1% vs. 9.68%) and absent biochemical success rate was less (4.1% vs. 9.59%) ( 26 ); it is possible that the bias is due to the small amount of data, and the results may be close to it as the amount of data grows. Therefore, CT scan is an important method for subtyping of patients with PA in the medical centers where AVS is not routinely available.…”

Unilateral primary aldosteronism considerations about the diagnostic criteria, adrenalectomy, and short and long time biochemical and clinical evaluation

“…These factors and the evaluation of other clinical parameters must be considered to decide on the intervention and to predict its success. Resolution of hypertension occurs in only 30–60% of cases 1 . Chronic therapy with aldosterone receptor blockers alone or with other hypotensive agents is recommended if the patient refuses surgery or if there is a risk of surgery (eg, advanced age or associated diseases) or if the patient has already had surgery.…”

“…Most of the guidelines have focused on biochemical or clinical parameters assessment after surgery, but future studies will need to assess subsequent long‐term cardiovascular risk comparing the long‐term effects of adrenalectomy and those of chronic therapy with aldosterone receptors blockers combined with other hypotensive agents. These studies should consider that about 60% of operated patients are hypertensive after surgery 1 and that sometimes primary aldosteronism can persist even after surgery in cases that were not correctly evaluated.…”

“…The study by Yan and co‐workers 1 sought to review the literature reports on diagnostic criteria and biochemical and clinical success after surgery in patients with unilateral hyperaldosteronism. Primary aldosteronism is a syndrome, that includes various pathologies that have certain signs and symptoms in common.…”

“…Resolution of hypertension occurs in only 30-60% of cases. 1 Chronic therapy with aldosterone receptor blockers alone or with other hypotensive agents is recommended if the patient refuses surgery or if there is a risk of surgery (eg, advanced age or associated diseases) or if the patient has already had surgery. Conversely, medical management with spironolactone or eplerenone is an alternative treatment of cases of primary aldosteronism, so the choice of medical management should always be considered.…”