Adrenal Vein Sampling Is the Preferred Method to Select Patients With Primary Aldosteronism for AdrenalectomyResponse to Adrenal Vein Sampling Is the Preferred Method to Select Patients With Primary Aldosteronism for Adrenalectomy: Pro Side of the Argument
Pro Side of the Argument
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Hyperaldosteronism, caused by an aldosterone-producing adenoma (APA) or much less commonly unilateral adrenal hyperplasia, can be cured or improved in >95% of patients by unilateral laparoscopic adrenalectomy. Approximately 50% of these patients have a complete clinical remission, with blood pressure returning to normal levels without the need for antihypertensives. In the remaining ≈50%, blood pressure levels commonly fall but not into the normal range, despite biochemical cure: such patients require continuing but usually lower levels of antihypertensive therapy. The persistent hypertension is commonly attributed to vascular damage or underlying primary hypertension.
APA/unilateral adrenal hyperplasia together account for ≈5% of hypertension,1 with the remainder of primary aldosteronism (PA) caused by bilateral adrenal hyperplasia. The prevalence of bilateral adrenal hyperplasia, commonly a less florid form of PA, seems currently to reflect the disparate cutoffs used. Reported levels are equal to or less than those of unilateral disease if strict cutoffs in screening and confirmatory testing are used, and approximately double when more relaxed cutoffs are in place. Such patients are not treated by adrenalectomy, except in a handful of cases of fulminant familial hypertension type III, but with mineralocorticoid receptor antagonists, amiloride, and other antihypertensive agents as required. A large, recent study has shown that a markedly elevated aldosterone-to-renin ratio accurately identified patients with an APA but not its location.2
In most jurisdictions, the advantages of laparoscopic adrenalectomy for unilateral disease are well recognized. These include total cure in half the patients lateralized who are relieved of the burden and cost of lifetime medication and lower levels of medication for blood pressure in the remainder. In addition, patients note a marked improvement in well-being and quality of life. For this reason, adrenal venous sampling (AVS) is recommended3,4 for confirmed PA patients, with some exceptions. Rarely are patients …