Unmasked renal impairment and prolonged hyperkalemia after unilateral adrenalectomy for primary aldosteronism coexisting with primary hyperparathyroidism: report of a case

Abstract

We herein report the case of a patient with critical hyperkalemia after unilateral adrenalectomy (ADX) for aldosterone-producing adenomas, which were coexisting with primary hyperparathyroidism. A right adrenal tumor oversecreting mineral corticoid was identified in a 62-year-old female whose kidney function had been impaired due to primary hyperaldosteronism and hyperparathyroidism. The ADX improved her hypertension with normalization of the plasma aldosterone concentration, but without adequately increasing her plasma renin activity. Her eGFR further decreased postoperatively, hyperkalemia appeared and the serum potassium level rose to 6.3 mEq/L at 3 months after ADX. Then, treatment with calcium polystyrene sulfonate jelly was started. Eight months after ADX, a left lower parathyroidectomy was performed, and the serum calcium and intact parathyroid hormone levels decreased to the normal range. The hyperkalemia was difficult to control within 20 months postoperatively without treatment with calcium polystyrene sulfonate jelly or hydrocortisone. This suggests that unmasking the renal impairment and relative hypoaldosteronism after ADX might induce critical hyperkalemia.

Four Cases of Hypovolemic Renin-Aldosterone Axis Deficiency Without Hyperkalemia Following Unilateral Adrenalectomy for Primary Aldosteronism

“…In the context of unilateral adrenalectomy for PA, the discovery of normal to high plasma potassium (4.5 mmol/L) or labile BP could indicate a temporarily insufficient adaptation of the remaining adrenal gland. Such a situation has been reported in previous studies and has been attributed to a transient or prolonged hypoaldosteronism associated with a discrepancy between plasma renin levels and a lack of information concerning volemic status (3)(4)(5)(6)(7)(8).…”

“…The current treatment consists of removing the adrenal gland responsible for aldosterone hypersecretion (2). Numerous studies have reported post-unilateral adrenalectomy complications, which can consist of severe hyperkalemia related to adrenal insufficiency (3)(4)(5)(6)(7)(8)(9).…”

Prolonged postoperative hypoaldosteronism related to hyperkalemia in patients with aldosterone-producing adenoma

“…Hyperkalemia is an important complication of adrenalectomy for PA. It is generally rare and transient and presents shortly after surgery [3][4][5][6][7][8]. Hyperkalemia is thought to be caused by hypoaldosteronism resulting from the removal of APA.…”

“…Adrenalectomy in patients of unilateral APA is expected to be biochemically and clinically curative and to reduce cardiovascular complications [2]. In contrast, some patients with APA develop hyperkalemia after adrenalectomy [3][4][5][6][7][8]. Although postoperative hyperkalemia may have been caused by the insufficiency of aldosterone secretion from the zona glomerulosa of the adrenal cortex, few studies had examined plasma aldosterone concentration (PAC) in patients with postoperative hyperkalemia in detail [8,9].…”