Renal Function Evolution and Hypoaldosteronism Risk After Unilateral Adrenalectomy for Primary Aldosteronism

Abstract

Few studies demonstrated a percentage decrease in the estimated glomerular filtration rate (eGFR) at a single time and the rate of hypoaldosteronism after adrenalectomy for primary aldosteronism (PA). Our aim was to investigate the evolution of renal function and the hypoaldosteronism risk after adrenalectomy for PA. Aldosterone, renin, eGFR, and electrolyte levels were determined before and at 1 week, 1, 3 and 6 months after unilateral adrenalectomy in 94 PA patients (40 men and 54 women). The main outcome was the postoperative eGFR decline using analysis of covariance with the preoperative eGFR as a covariate. eGFR decreased during first postoperative week compared to 3 months before surgery. During the first 6 months, eGFR remained stable at similar levels to the first week after surgery. Age (p=0.001), aldosterone levels (p=0.021) and eGFR 3 months before surgery (p+<+0.0001) had a significant correlation with eGFR during first postoperative week. High aldosterone levels at diagnosis were correlated with decline in renal function in the univariate model (p=0.033). In the multivariate analysis, aldosterone levels at diagnosis had a tendency to be an independent predictor of renal function after surgery (p=0.059). Postoperative biochemical hypoaldosteronism was diagnosed in 48% of the cases after adrenalectomy, but prolonged hyperkalemia occurred in only 4 cases (4.5%). Our findings showed a decrease of eGFR after unilateral adrenalectomy for PA. Additionally, aldosterone levels at diagnosis correlated with postoperative renal function. Postoperative biochemical hypoaldosteronism occurred in almost half of the patients, but prolonged hyperkalemia with fludrocortisone replacement was less frequent.

Key words

renal function - primary aldosteronism - adrenalectomy - hypoaldosteronism

Publication History

Received: 30 July 2023

Accepted after revision: 01 December 2023

Accepted Manuscript online:
01 December 2023

Article published online:
22 January 2024

• References

• 1 Murray CJL, Lopez AD. Measuring the global burden of disease. N Engl J Med 2013; 369: 448-457
• 2 Funder JW, Carey RM, 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
• 3 Vaidya A, Hundemer GL, Nanba K. et al. Primary aldosteronism: state-of-the-art review. Am J Hypertens 2022; 35: 967-988
• 4 Vilela LAP, Almeida MQ. Diagnosis and management of primary aldosteronism. Arch Endocrinol Metab 2017; 61: 305-312
• 5 Brown JM, Siddiqui M, Calhoun DA. et al. The unrecognized prevalence of primary aldosteronism. Ann Intern Med 2020; 173: 10-20
• 6 Vilela LAP, Rassi-Cruz M, Guimaraes AG. et al. KCNJ5 somatic mutation is a predictor of hypertension remission after adrenalectomy for unilateral primary aldosteronism. J Clin Endocrinol Metab 2019; 104: 4695-4702
• 7 Sukor N, Kogovsek C, Gordon RD. et al. Improved quality of life, blood pressure, and biochemical status following laparoscopic adrenalectomy for unilateral primary aldosteronism. J Clin Endocrinol Metab 2010; 95: 1360-1364
• 8 Rossi GP, Cesari M, Cuspidi C. et al. Long-term control of arterial hypertension and regression of left ventricular hypertrophy with treatment of primary aldosteronism. Hypertens Dallas Tex 1979 2013; 62: 62-69
• 9 Monticone S, D’Ascenzo F, Moretti C. et al. Cardiovascular events and target organ damage in primary aldosteronism compared with essential hypertension: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2018; 6: 41-50
• 10 Ohno Y, Sone M, Inagaki N. et al. Prevalence of cardiovascular disease and its risk factors in primary aldosteronism: a multicenter study in Japan. Hypertens Dallas Tex 1979 2018; 71: 530-537
• 11 Blasi ER, Rocha R, Rudolph AE. et al. Aldosterone/salt induces renal inflammation and fibrosis in hypertensive rats. Kidney Int 2003; 63: 1791-1800
• 12 Reincke M, Rump LC, Quinkler M. et al. Risk factors associated with a low glomerular filtration rate in primary aldosteronism. J Clin Endocrinol Metab 2009; 94: 869-875
• 13 Kawashima A, Sone M, Inagaki N. et al. Renal impairment is closely associated with plasma aldosterone concentration in patients with primary aldosteronism. Eur J Endocrinol 2019; 181: 339-350
• 14 Lu Y-C, Liu K-L, Wu V-C. et al. Factors associated with renal function change after unilateral adrenalectomy in patients with primary aldosteronism. Int J Urol Off J Jpn Urol Assoc 2022; 29: 831-837
• 15 Onohara T, Takagi T, Yoshida K. et al. Assessment of postoperative renal function after adrenalectomy in patients with primary aldosteronism. Int J Urol Off J Jpn Urol Assoc 2019; 26: 229-233
• 16 Kramers BJ, Kramers C, Lenders JWM. et al. Effects of Treating Primary Aldosteronism on Renal Function. J Clin Hypertens Greenwich Conn 2017; 19: 290-295
• 17 Kobayashi H, Abe M, Nakamura Y. et al. Association between acute fall in estimated glomerular filtration rate after treatment for primary aldosteronism and long-term decline in renal function. Hypertens Dallas Tex 1979 2019; 74: 630-638
• 18 Starker LF, Christakis I, Julien JS. et al. Considering postoperative functional hypoaldosteronism after unilateral adrenalectomy. Am Surg 2017; 83: 598-604
• 19 Fischer E, Hanslik G, Pallauf A. et al. Prolonged zona glomerulosa insufficiency causing hyperkalemia in primary aldosteronism after adrenalectomy. J Clin Endocrinol Metab 2012; 97: 3965-3973
• 20 Park KS, Kim JH, Ku EJ. et al. Clinical risk factors of postoperative hyperkalemia after adrenalectomy in patients with aldosterone-producing adenoma. Eur J Endocrinol 2015; 172: 725-731
• 21 Wada N, Baba S, Sugawara H. et al. Prolonged postoperative hypoaldosteronism related to hyperkalemia in patients with aldosterone-producing adenoma. Endocr J 2023; 70: 917-924
• 22 Coresh J, Auguste P. Reliability of GFR formulas based on serum creatinine, with special reference to the MDRD Study equation. Scand J Clin Lab Investig Suppl 2008; 241: 30-38
• 23 Maciel AAW, Freitas TC, Fagundes GFC. et al. Intra-individual variability of serum aldosterone and implications for primary aldosteronism Screening. J Clin Endocrinol Metab 2023; 108: 1143-1153
• 24 Freitas TC, Maciel AAW, Fagundes GFC. et al. Efficacy of oral furosemide test for primary aldosteronism diagnosis. J Endocr Soc 2023; 8: bvad147
• 25 Lim V, Guo Q, Grant CS. et al. Accuracy of adrenal imaging and adrenal venous sampling in predicting surgical cure of primary aldosteronism. J Clin Endocrinol Metab 2014; 99: 2712-2719
• 26 Rassi-Cruz M, Maria AG, Faucz FR. et al. Phosphodiesterase 2A and 3B variants are associated with primary aldosteronism. Endocr Relat Cancer 2021; 28: 1-13
• 27 Williams B, Mancia G, Spiering W. et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J 2018; 39: 3021-3104
• 28 Malachias MVB, Gomes MAM, Nobre F. et al. 7th Brazilian guideline of arterial hypertension: Chapter 2 - diagnosis and classification. Arq Bras Cardiol 2016; 107: 7-13
• 29 Williams TA, Lenders JWM, 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 Diabetes Endocrinol 2017; 5: 689-699
• 30 Vickers AJ. The use of percentage change from baseline as an outcome in a controlled trial is statistically inefficient: a simulation study. BMC Med Res Methodol 2001; 1: 6
• 31 van Buuren S. Flexible imputation of missing data, Second Edition. 2nd ed. New York: Chapman and Hall/CRC,; 2018
• 32 Mermejo LM, Elias PCL, Molina CAF. et al. Early renin recovery after adrenalectomy in aldosterone-producing adenomas: a prospective study. Horm Metab Res 2022; 54: 224-231