Outcomes of Adrenalectomy and the Aldosteronoma Resolution Score in the Black and Hispanic Population

Clinical and biochemical outcomes after adrenalectomy for primary aldosteronism in tertiary and quaternary referral centers: data from SOPRANO study

Hypertension cure following adrenalectomy in unilateral primary aldosteronism (PA) remains uncertain. Previous meta-analyses have shown highly variable surgical outcomes. Our study aimed to determine the unknown proportion of complete clinical and biochemical success in tertiary and quaternary referral centers. We conducted a systematic review and meta-analysis of studies reporting surgical outcomes of unilateral PA patients within the Surgical Outcome of PRimary Aldosteronism progNostic mOdels (SOPRANO) study. From 27 publications we identified 32 eligible studies, of which 22 were judged to be at low risk of bias. Eighteen were single-center studies, while fourteen were multi-center studies, with patients recruited from 132 referral centers worldwide. Adrenalectomy was performed on 5887 patients, with 4861 (83%) included in the final analysis. The pooled estimates of complete clinical and biochemical success for all studies were 39% (95% CI: 34-44%) and 99% (95% CI: 96-99%), respectively, similar to that found for studies at low risk of bias. Multivariate meta-regression analyses for all studies and low-bias risk studies revealed that BMI (P < 0.01), recruitment time period (P < 0.01), and hypertension duration (P < 0.05) inversely correlated with complete clinical success, while BMI (P < 0.05) and the number of enrolled centers (P < 0.05) inversely correlated with complete biochemical success. In summary, our findings offer robust estimates of complete clinical and biochemical success rates following adrenalectomy for unilateral PA in tertiary and quaternary referral centers and identify new potential effect modifiers that can help clinicians to inform and counsel patients about post-surgery expectations, guaranteeing effective treatment and ultimately enhancing outcomes.

The predictors of long-term outcomes after targeted therapy for primary Aldosteronism

Unilateral primary aldosteronism is thought to be a surgically curable disease, and unilateral adrenalectomy is the mainstay treatment. The Primary Aldosteronism Surgical Outcome (PASO) consensus was developed to assess clinical and biochemical outcomes to standardize the classification of surgical outcomes. However, fewer than half of patients are cured of hypertension after adrenalectomy; therefore, preoperative patient counseling and evaluation might be necessary. Moreover, current studies show that genetic mutations and histopathology classification are associated with the treatment outcome. The Task Force of Taiwan PA recommends using a specific scoring system, including the PASO score and nomogram-based preoperative score, to predict the clinical outcome before adrenalectomy. Herein, we discuss the associations of current histopathological classification and specific somatic gene mutations with clinical outcomes after surgery.

Validation of the Aldosteronoma Resolution Score as a Predictive Resolution Score of Hypertension After Unilateral Adrenalectomy for Primary Aldosteronism in a North-African Population

BACKGROUND

Unilateral primary aldosteronism (UPA) is the most frequent surgically curable form of endocrine hypertension. Adrenalectomy is the cornerstone of treatment for UPA, but outcomes after surgery are variable. Aldosteronoma Resolution Score (ARS) is a four-item predictive score for the cure of hypertension after adrenalectomy for UPA and has been demonstrated to be valid in different populations. We aimed in this study to validate the accuracy of this score in a North-African population.

METHODS

Between 2000 and 2021, the charts of 71 Tunisian patients who underwent laparoscopic adrenalectomy for UPA were retrospectively reviewed. Postoperative outcomes were assessed using the primary aldosteronism surgical outcome (PASO) criterion. The accuracy of the ARS was determined retrospectively by receiver operating characteristic curve and area under the curve.

RESULTS

Thirty-four patients (48%) had complete clinical success according to the PASO criteria. Multivariate regression analysis revealed that the main determinants of complete clinical success were the absence of diabetes (OR: 5.205), a BMI <30 (OR: 4.930), a number of antihypertensive medications ≤2 (OR: 8.667), a plasma ARR >332 (OR: 4.554) and an ARS score ≥3 (OR: 2.056). Cure rates were, respectively, 21.1, 51.6, and 66.6% for patients with a score ARS 0-1, 2-3, and 4-5. The AUC of the ARS was 0.837.

CONCLUSION

The ARS is a sufficiently predictive score in our North-African population. It may be used preoperatively to predict the outcome after adrenalectomy in these populations.

[Risk factors of persistent hypertension in primary aldosteronism patients after surgery]

OBJECTIVE

To analyze the risk factors of persistent hypertension in patients who underwent adrenalectomy for primary aldosteronism and to evaluate the predictive value of the aldosteronoma resolution score (ARS) scoring system for surgical outcomes of adrenalectomy for primary aldosteronism.

METHODS

We reviewed the clinical characteristics of patients who underwent adrenalectomy for primary aldosteronism from 2018 to 2021 at Peking University People' s Hospital to recognize risk factors of uncured hypertension after surgery. Based on the patient' s clinical outcomes, the patients were divided into complete success group and partial/absent success group. Risk factors for persistent hypertension were analyzed. The value of the ARS scoring system was assessed by the area under the curve (AUC).

RESULTS

In this study, 112 patients were included. Most of the patients benefited from the surgery for 94.6% were a complete or partial clinical success after follow-up for at least 6 months. According to postoperative hypertension status, the patients were divided into complete success group (51 cases) and partial/absent success group (61 cases). There were statistical differences between the two groups in age, body mass index (BMI), waist circumference, duration of hypertension, number of preoperative antihypertension medications, preoperative systolic blood pressure, history of diabetes, history of cardiovascular and cerebrovascular diseases, serum creatinine, estimated glomerular filtration rate(eGFR), high-density lipoprotein cholesterol and triglyceride. Logistic regression analysis showed that age (OR=1.111, 95%CI: 1.029-1.199), waist circumference (OR=1.073, 95%CI: 1.013-1.137), pre-operative systolic blood pressure (OR=1.033, 95%CI: 1.008-1.060) and history of cardiovascular and cerebrovascular diseases (OR=16.061, 95%CI: 1.312-196.612) were the risk factors for uncured hypertension in primary aldosteronism patients after surgery, but female gender not. The median ARS in the complete success group was 4 and in the partial/absent success group, it was 2. Among the patients with ARS of 4-5, the cure rate of hypertension was 76.5%. The area under the curve of ARS was 0.743.

CONCLUSION

The history of cardiovascular and cerebrovascular diseases is a significant risk factor for persistent hypertension after surgery in primary aldosteronism patients. ARS scoring system has a certain value in predicting the postoperative hypertension status of primary aldosteronism patients. However, further research is still needed on a prediction model for surgical outcomes of primary aldosteronism which is more suitable for the Chinese population is still needed.

Assessment of performance of stratum-specific likelihood ratios of the aldosteronoma resolution score for predicting hypertension cure after adrenalectomy for primary aldosteronism: a systematic review and meta-analysis

The Aldosteronoma Resolution Score (ARS) is the most studied scoring system for predicting the high likelihood of hypertension cure after adrenalectomy for unilateral primary aldosteronism (PA). However, the ARS's accuracy in PA patients worldwide is uncertain. We aimed to perform a meta-analysis of the accuracy, discrimination, and calibration of the ARS using stratum-specific likelihood ratios (SSLR) by organizing available data from cohort studies. We searched PubMed, Embase (Ovid), the Cochrane CENTRAL, Web of Science to November 2021 according to PRISMA statement. The quality assessment used adapted TRIPOD and PROBAST criteria. Thirteen studies comprising 2158 PA patients from North America (43%), Europe (32%), Asia (22%), and other continents, were included. The pooled estimate of the area under the receiver operating characteristic curve for all studies was 0.77 (95% CI: 0.73-0.81), and the ratio of the observed to expected complete resolution of hypertension (CRH) for all studies was 0.9 (95% CI: 0.8-1.0). The summary estimates of the SSLR for all studies were 0.31, 0.89, and 3.1, for the low (ARS 0-1), medium (ARS 2-3), and high-likelihood group (ARS 4-5) of CRH, respectively. However, substantial heterogeneity existed among studies. Follow-up period, and adrenalectomy AVS (adrenal vein sampling)-guided served as potential sources of heterogeneity for quantitative studies, which were measurement and reference standard for qualitative studies selection. In conclusion, in patients with unilateral PA, the ARS is currently an accurate prediction tool, the easiest and cheapest, for identifying long-term high likelihood of CRH after adrenalectomy, particularly when the adrenalectomy is AVS-guided.

Predictive factors of clinical success after adrenalectomy in primary aldosteronism: A systematic review and meta-analysis

BACKGROUND

Unilateral adrenalectomy is the mainstay treatment for unilateral primary aldosteronism (PA). This meta-analysis aimed to systematically analyse predictors of clinical success after unilateral adrenalectomy in PA.

METHODS

A search was performed using PubMed/Medline, Scopus, Embase and Web of Science from their inception to February 2022. Observational studies in adult PA patients which reported predictors of clinical success after unilateral adrenalectomy were included. A random-effects model was employed to pool the fully adjusted odds ratio (OR) or standardized mean difference (SMD) with 95% confidence interval (95% CI).

RESULTS

Thirty-two studies involving 5,601 patients were included. Females had a higher clinical success rate (OR 2.81; 95% CI 2.06-3.83). Older patients, patients with a longer duration of hypertension and those taking a higher number of antihypertensive medications had lower clinical success rates (OR 0.97; 95% CI 0.94-0.99, OR 0.92; 95% CI 0.88-0.96 and OR 0.44; 95% CI 0.29-0.67, respectively). Compared to non-clinical success cases, patients with clinical success had a lower body mass index (SMD -0.49 kg/m²; 95% CI -0.58,-0.39), lower systolic (SMD -0.37 mmHg; 95% CI -0.56,-0.18) and diastolic blood pressure (SMD -0.19 mmHg; 95% CI -0.33,-0.06), lower serum potassium (SMD -0.16 mEq/L; 95% CI -0.28,-0.04), higher eGFR (SMD 0.51 mL/min/1.73m²; 95% CI 0.16,0.87), a lower incidence of dyslipidemia (OR 0.29; 95% CI 0.15-0.58) and a lower incidence of diabetes mellitus (OR 0.36; 95% CI 0.22-0.59).

CONCLUSIONS

Multiple predictors of clinical success after unilateral adrenalectomy in PA were identified which can help improve the quality of care for PA patients. Systematic Review Registration: INPLASY, identifier 202240129.