Vascular Remodeling and Duration of Hypertension Predict Outcome of Adrenalectomy in Primary Aldosteronism Patients

Abstract

Abstract-Remodeling of the resistance arteries is a hallmark of arterial hypertension and predicts cardiovascular events, but it was unknown whether it could also predict the blood pressure response to adrenalectomy of patients with an aldosterone-producing adenoma. Therefore, we investigated the outcome of adrenalectomy as a function of vascular remodeling in the context of the preoperative features of aldosterone-producing adenoma patients. At 2 referral centers for hypertension, we prospectively measured the media:lumen ratio of small arteries from fat tissue of 50 consecutive aldosterone-producing adenoma patients treated with adrenalectomy. The blood pressure response to adrenalectomy was assessed by considering the blood pressure values and the number and dosages of antihypertensive medications. Adrenalectomy significantly (PϽ0.001) lowered plasma aldosterone (from 27.3Ϯ4.9 ng/dL to 8.3Ϯ11.2 ng/dL), the aldosterone:renin ratio (from 117Ϯ35 to 11Ϯ2), and blood pressure (from 163Ϯ22/98Ϯ2 mm Hg to 133Ϯ2/ 84Ϯ1 mm Hg), even despite a reduction (from 141Ϯ14 to 100Ϯ15; Pϭ0.02) of the score of antihypertensive treatment.It provided cure of hypertension in 30% of the aldosterone-producing adenoma patients, normotension with less antihypertensive therapy in 52%, and improved blood pressure control in the rest. The media:lumen ratio and the known duration of hypertension significantly predicted the blood pressure response to adrenalectomy at univariate and multivariate analyses. Because a long duration of hypertension and/or the presence of vascular remodeling imply lower chances of blood pressure normalization at long-term follow-up postadrenalectomy, these findings emphasize the importance of an early diagnosis of aldosterone-producing adenoma. Key Words: secondary hypertension Ⅲ aldosterone Ⅲ aldosteronism Ⅲ adrenalectomy Ⅲ outcome Ⅲ vascular remodeling P rimary aldosteronism (PA) is far more common than usually perceived and is attributable to an aldosteroneproducing adenoma (APA) in approximately half of the patients. 1 Thus, it entails the most common endocrine form of secondary arterial hypertension (HT) that is curable by adrenalectomy in many patients. 2 Identification of an APA, or unilateral primary adrenocortical hyperplasia, 3 requires adrenal vein sampling (AVS) that, being minimally risky, should be reserved for patients who are candidates for adrenalectomy and, more importantly, can benefit from it. 4 However, the identification of patients who will benefit more remains a challenging task, because the blood pressure (BP) response to adrenalectomy varies widely across patients. In fact, despite many efforts over the years, only age and lack of family history of HT were suggested to significantly predict the BP response. 5-8 Nevertheless, the large uncertainties in the prediction estimates render them of little, if any, 8 value on an individual basis.The remodeling of resistance arteries is a hallmark of arterial HT and can be implicated in the excess cardiovascular damage associated with HT. Hence, it ...

Small tumor size as favorable prognostic factor after adrenalectomy in Conn's adenoma

“…In agreement with the previous studies (18,19,24), in our group of patients, duration of hypertension can be considered as a prognostic factor; shorter hypertension duration gives a higher recovery percentage. In particular, the ROC curve analysis showed that the best predictor of hypertension recovery after surgery is the duration of hypertension equal to or shorter than 6 years, in accordance with a recent study by Zarnegar et al (18).…”

“…Moreover, 63% of our APA patients were cured of hypertension (blood pressure below 140/90 mmHg, without the aid of antihypertensive medications), while blood pressure levels improved in the remaining patients. Such results are in line with the literature data reporting a rate of blood pressure normalization ranging between 30 and 70% (19,24). This broad range comes from studies performed with different data collection methods and with different definition of cure/improvement of hypertension (18,19,21,28).…”

“…Numerous factors have been proposed as predictive factors for hypertension recovering, including age at surgery, response to spironolactone, blood pressure levels on discharge (20), duration of hypertension, family history for hypertension, preoperative ratio of plasma aldosterone to PRA (21), renal damage (22), serum potassium levels, sex (23) and vascular remodeling (24).…”

Progrès récents dans la génétique de l’hyperaldostéronisme primaire

“…L'existence d'une corrélation stricte entre le génotype et le phénotype a été récem-ment nuancée par la description d'un patient porteur d'une mutation hétérozygote germinale p.Gly151Arg, qui avait développé une polyurie à l'âge de 18 mois et une hypertension avec hypokaliémie à 4 ans. Par la suite, son hyper aldostéronisme a été traité avec succès durant sept ans avec de la spironolactone 6 sans que soit observé un élargissement de la surrénale [31]. Dans tous les cas, la recherche de mutations dans le gène KCNJ5 doit être considérée même dans les formes familiales modérées d'HAP.…”

“…À long terme, le traitement de l'hyperaldostéronisme primaire permet une réversibilité de l'hypertrophie ventriculaire gauche [5]. Le remodelage vasculaire dû à l'excès d'aldostérone ainsi que la durée de l'hypertension constituent des indicateurs de la réponse de la pression artérielle à la surrénalectomie, soulignant ainsi l'importance d'un diagnostic précoce de la maladie [6]. La production d'aldostérone par la zone glomérulée du cortex surréna-lien est finement régulée afin d'assurer le maintien de l'homéostasie hydrosodée au niveau rénal (Figure 1).…”