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Impact of dedicated multidisciplinary service on patient selection and outcomes for surgical treatment of primary aldosteronism

  • Jinghong Zhang
    Affiliations
    Department of Endocrinology, Monash Health, Victoria, Australia
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  • Jun Yang
    Affiliations
    Department of Endocrinology, Monash Health, Victoria, Australia

    Department of Medicine, Monash University, Victoria, Australia

    Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Victoria, Australia
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  • Renata Libianto
    Affiliations
    Department of Endocrinology, Monash Health, Victoria, Australia

    Department of Medicine, Monash University, Victoria, Australia

    Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Victoria, Australia
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  • Jimmy Shen
    Affiliations
    Department of Endocrinology, Monash Health, Victoria, Australia

    Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Victoria, Australia
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  • Peter J. Fuller
    Affiliations
    Department of Endocrinology, Monash Health, Victoria, Australia

    Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Victoria, Australia
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  • Simon Grodski
    Affiliations
    Monash University Endocrine Surgery Unit, Monash University, Victoria, Australia

    Department of Surgery, Monash Health, Victoria, Australia

    Department of Surgery, Central Clinical School, Monash University, Victoria, Australia
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  • James C. Lee
    Correspondence
    Reprint requests: James C. Lee, MBBS, FRACS, PhD, Monash University Endocrine Surgery Unit, Department of General Surgery, Monash Medical Centre, 246 Clayton Road, Clayton VIC 3168, Australia.
    Affiliations
    Monash University Endocrine Surgery Unit, Monash University, Victoria, Australia

    Department of Surgery, Monash Health, Victoria, Australia

    Department of Surgery, Central Clinical School, Monash University, Victoria, Australia
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Published:September 18, 2022DOI:https://doi.org/10.1016/j.surg.2022.08.010

      Abstract

      Background

      Primary aldosteronism is the most common surgically curable cause of endocrine hypertension. Management of the unilateral subtype of primary aldosteronism with adrenalectomy requires multidisciplinary input. It is unclear if a dedicated endocrine hypertension service confers better outcomes compared to standard care offered by individual clinicians.

      Methods

      In this retrospective study, patients from the Monash University Endocrine Surgery Database were divided into either the endocrine hypertension service group, where patients were managed by a dedicated multidisciplinary team, or the standard group, where patients were managed by individual clinicians. The comparisons included patient selection for surgery, perioperative blood pressure control, and surgical cure rate.

      Results

      Despite similar perioperative blood pressure, patients in the endocrine hypertension service group (n = 41) were on fewer antihypertensive medications (1 vs 2, P = .011) compared to the standard group (n = 55). A larger proportion of patients in the endocrine hypertension service group had either bilateral adrenal nodules or no adrenal lesions on computed tomography (41% vs 18%, P = .013). Patients in the standard group had larger adrenal lesions on computed tomography (median 15 mm vs 10 mm, P = .032). Postoperatively, the biochemical cure rate was higher in the endocrine hypertension service group at 6 to 12 months (97% vs 76%, P = .021).

      Conclusion

      Patients managed by endocrine hypertension service were more likely to be diagnosed with surgically curable primary aldosteronism without a unilateral adrenal adenoma on imaging, required fewer medications for perioperative blood pressure control, and experienced superior postoperative outcomes. Referral to a dedicated endocrine hypertension service is recommended for patients with primary aldosteronism who wish to pursue a surgical cure.
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      References

        • Baudrand R.
        • Guarda F.J.
        • Fardella C.
        • et al.
        Continuum of renin-independent aldosteronism in normotension.
        Hypertension. 2017; 69: 950-956
        • Käyser S.C.
        • Dekkers T.
        • Groenewoud H.J.
        • et al.
        Study heterogeneity and estimation of prevalence of primary aldosteronism: a systematic review and meta-regression analysis.
        J Clin Endocrinol Metab. 2016; 101: 2826-2835
        • Galasko G.
        Hyperaldosteronism.
        in: Reference Module in Biomedical Sciences. Elsevier, Maryland Heights (MO)2015
        • Funder J.W.
        • Carey R.M.
        • Mantero F.
        • et al.
        The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society Clinical Practice Guideline.
        J Clin Endocrinol Metab. 2016; 101: 1889-1916
        • Young W.F.
        Diagnosis and treatment of primary aldosteronism: practical clinical perspectives.
        J Intern Med. 2019; 285: 126-148
        • Nanba A.T.
        • Nanba K.
        • Byrd J.B.
        • et al.
        Discordance between imaging and immunohistochemistry in unilateral primary aldosteronism.
        Clin Endocrinol (Oxf). 2017; 87: 665-672
        • Young W.F.
        • Stanson A.W.
        • Thompson G.B.
        • Grant C.S.
        • Farley D.R.
        • van Heerden J.A.
        Role for adrenal venous sampling in primary aldosteronism.
        Surgery. 2004; 136: 1227-1235
        • Ng V.W.S.
        Evaluation of Functional and Malignant Adrenal Incidentalomas.
        Arch Intern Med. 2010; 170: 2017-2020
        • Funder J.W.
        • Carey R.M.
        • Fardella C.
        • et al.
        Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline. The.
        J Clin Endocrinol Metab. 2008; 93: 3266-3281
        • Hanna S.
        • El-Kalioubie M.
        • Badawy H.
        • Halim M.
        Optimal diagnosis of adrenal masses.
        Egypt J Radiol Nucl Med. 2015; 46: 511-520
        • Amar L.
        • Plouin P.F.
        • Steichen O.
        Aldosterone-producing adenoma and other surgically correctable forms of primary aldosteronism.
        Orphanet J Rare Dis. 2010; 5: 9
        • Maher D.I.
        • Williams E.
        • Grodski S.
        • Serpell J.W.
        • Lee J.C.
        Adrenal incidentaloma follow-up is influenced by patient, radiologic, and medical provider factors: a review of 804 cases.
        Surgery. 2018; 164: 1360-1365
        • Parksook W.W.
        • Yozamp N.
        • Hundemer G.L.
        • et al.
        Morphologically normal-appearing adrenal glands as a prevalent source of aldosterone production in primary aldosteronism.
        Am J Hypertens. 2022; 35: 561-571
        • Young W.F.
        • Stanson A.W.
        What are the keys to successful adrenal venous sampling (AVS) in patients with primary aldosteronism?.
        Clin Endocrinol (Oxf). 2009; 70: 14-17
        • Williams T.A.
        • Lenders J.W.M.
        • Mulatero P.
        • et al.
        Outcomes after adrenalectomy for unilateral primary aldosteronism: an international consensus on outcome measures and analysis of remission rates in an international cohort.
        Lancet Diab Endocrinol. 2017; 5: 689-699
        • Mathur A.
        • Kemp C.D.
        • Dutta U.
        • et al.
        Consequences of adrenal venous sampling in primary hyperaldosteronism and predictors of unilateral adrenal disease.
        J Am Coll Surg. 2010; 211: 384-390
        • Miller B.S.
        • Turcu A.F.
        • Nanba A.T.
        • et al.
        Refining the definitions of biochemical and clinical cure for primary aldosteronism using the Primary Aldosteronism Surgical Outcome (PASO) Classification system.
        World J Surg. 2018; 42: 454-463
        • Citton M.
        • Viel G.
        • Rossi G.P.
        • Mantero F.
        • Nitti D.
        • Iacobone M.
        Outcome of surgical treatment of primary aldosteronism.
        Langenbecks Arch Surg. 2015; 400: 325-331
        • Lim Y.Y.
        • Shen J.
        • Fuller P.J.
        • Yang J.
        Current pattern of primary aldosteronism diagnosis: Delayed and complicated.
        Aust J Gen Pract. 2018; 47: 712-718
        • Lim Y.Y.
        • Libianto R.
        • Shen J.
        • Young M.J.
        • Fuller P.J.
        • Yang J.
        Impact of Victoria’s first dedicated endocrine hypertension service on the pattern of primary aldosteronism diagnoses.
        Inern J Med. 2021; 51: 1255-1261
        • Chee N.Y.N.
        • Abdul-Wahab A.
        • Libianto R.
        • et al.
        Utility of adrenocorticotropic hormone in adrenal vein sampling despite the occurrence of discordant lateralization.
        Clin Endocrinol (Oxf). 2020; 93: 394-403
        • Kozłowski T.
        • Choromanska B.
        • Wojskowicz P.
        • et al.
        Laparoscopic adrenalectomy: lateral transperitoneal versus posterior retroperitoneal approach – prospective randomized trial.
        Wideochir Inne Tech Maloinwazyjne. 2019; 14: 160-169
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications.
        Ann Surg. 2004; 240 (215–213)
        • Sander K.
        • Gendron T.
        • Cybulska K.A.
        • et al.
        Development of [18F] AldoView as the first highly selective aldosterone synthase PET tracer for imaging of primary hyperaldosteronism.
        J Med Chem. 2021; 64: 9321-9329
        • Powlson A.S.
        • Gurnell M.
        • Brown M.J.
        Nuclear imaging in the diagnosis of primary aldosteronism.
        Curr Opin Endocrinol Diabetes Obes. 2015; 22: 150-156
        • Teng J.
        • Hutchinson M.E.
        • Doery J.C.G.
        • et al.
        Role of adrenal vein sampling in primary aldosteronism: the Monash Health experience.
        Intern Med J. 2015; 45: 1141-1146
        • Zhang J.
        • Libianto R.
        • Lee J.C.
        • et al.
        Preoperative mineralocorticoid receptor antagonist reduces postoperative hyperkalaemia in patients with Conn syndrome.
        Clin Endocrinol (Oxf). 2022; 96: 40-46
        • Zarnegar R.
        • Young W.F.
        • Lee J.
        • et al.
        The Aldosteronoma Resolution Score: predicting complete resolution of hypertension after adrenalectomy for aldosteronoma.
        Ann Surg. 2008; 247: 511-518
        • Utsumi T.
        • Kawamura K.
        • Imamoto T.
        • et al.
        High predictive accuracy of Aldosteronoma Resolution Score in Japanese patients with aldosterone-producing adenoma.
        Surgery. 2012; 151: 437-443
        • Ruhle B.C.
        • White M.G.
        • Alsafran S.
        • Kaplan E.L.
        • Angelos P.
        • Grogan R.H.
        Keeping primary aldosteronism in mind: deficiencies in screening at-risk hypertensives.
        Surgery. 2019; 165: 221-227
        • Burrello J.
        • Monticone S.
        • Losano I.
        • et al.
        Prevalence of hypokalemia and primary aldosteronism in 5100 patients referred to a tertiary hypertension unit.
        Hypertension. 2020; 75: 1025-1033
        • Liu Y yuan
        • King J.
        • Kline G.A.
        • et al.
        Outcomes of a specialized clinic on rates of investigation and treatment of primary aldosteronism.
        JAMA Surg. 2021; 156: 541
        • Kocjan T.
        • Jensterle M.
        • Vidmar G.
        • Vrckovnik R.
        • Berden P.
        • Stankovic M.
        Adrenal vein sampling for primary aldosteronism: a 15-year national referral center experience.
        Radiol Oncol. 2020; 54: 409-418
        • Cohen J.B.
        • Cohen D.L.
        • Herman D.S.
        • Leppert J.T.
        • Byrd J.B.
        • Bhalla V.
        Testing for primary aldosteronism and mineralocorticoid receptor antagonist use among U.S. veterans.
        Ann Intern Med. 2021; 174: 289-297
        • Williams T.A.
        • Reincke M.
        Pathophysiology and histopathology of primary aldosteronism.
        Trends Endocrinol Metab. 2022; 33: 36-49