Iacobone Maurizio, Citton Marilisa, Viel Giovanni, Rossi Gian Paolo, Nitti Donato
1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy.
Gland Surg. 2015 Feb;4(1):69-81. doi: 10.3978/j.issn.2227-684X.2015.01.05.
Primary aldosteronism (PA) is the most common cause of endocrine hypertension; it has been reported in more than 11% of referred hypertensive patients. PA may be caused by unilateral adrenal involvement [aldosterone producing adenoma (APA) or unilateral adrenal hyperplasia (UAH)], and bilateral disease (idiopathic adrenal hyperplasia). Only patients with unilateral adrenal hypersecretion may be cured by unilateral adrenalectomy, while patients with bilateral and non-surgically correctable PA are usually treated by mineralocorticoid receptor antagonists; thus the distinction between unilateral and bilateral aldosterone hypersecretion is crucial. Most experts agree that the referral diagnostic test for lateralization of aldosterone hypersecretion should be adrenal venous sampling (AVS) because the interpretation of other imaging techniques [computed tomography (CT), magnetic resonance imaging (MRI) and scintigraphy] may lead to inappropriate treatment. Adrenalectomy represents the elective treatment in unilateral PA variants. Laparoscopic surgery, using transperitoneal or retroperitoneal approaches, is the preferred strategy. Otherwise, the indications to laparoscopic unilateral total or partial adrenalectomy in patients with unilateral PA remain controversial. Adrenalectomy is highly successful in curing the PA, with correction of hypokalemia in virtually all patients, cure of hypertension in about 30-60% of cases, and a marked improvement of blood pressure values in the remaining patients. Interestingly, in several papers the outcomes of surgery focus only on blood pressure changes and the normalization of serum potassium levels is often used as a surrogate of PA recovery. However, the goal of surgery is the normalization of aldosterone, because chronically elevated levels of this hormone can lead to cardiovascular complications, independently from blood pressure levels. Thus, we strongly advocate the need of considering the postoperative normalization of aldosterone-renin ratio (ARR) as the main endpoint for determining outcomes of PA.
原发性醛固酮增多症（PA）是内分泌性高血压最常见的病因；在转诊的高血压患者中，其报告患病率超过11%。PA可能由单侧肾上腺受累[醛固酮分泌腺瘤（APA）或单侧肾上腺增生（UAH）]以及双侧病变（特发性肾上腺增生）引起。只有单侧肾上腺分泌过多的患者可通过单侧肾上腺切除术治愈，而双侧且无法通过手术纠正的PA患者通常采用盐皮质激素受体拮抗剂治疗；因此，区分单侧和双侧醛固酮分泌过多至关重要。大多数专家一致认为，用于醛固酮分泌过多侧别定位的转诊诊断检查应为肾上腺静脉采样（AVS），因为其他成像技术[计算机断层扫描（CT）、磁共振成像（MRI）和闪烁显像]的解读可能导致不恰当的治疗。肾上腺切除术是单侧PA变体的选择性治疗方法。采用经腹或腹膜后入路的腹腔镜手术是首选策略。否则，单侧PA患者行腹腔镜单侧全肾上腺或部分肾上腺切除术的适应证仍存在争议。肾上腺切除术在治愈PA方面非常成功，几乎所有患者的低钾血症均得到纠正，约30 - 60%的病例高血压得以治愈，其余患者的血压值也有显著改善。有趣的是，在几篇论文中，手术结果仅关注血压变化，血清钾水平正常化常被用作PA恢复的替代指标。然而，手术的目标是醛固酮正常化，因为这种激素长期升高会导致心血管并发症，与血压水平无关。因此，我们强烈主张将术后醛固酮 - 肾素比值（ARR）正常化作为确定PA手术结果的主要终点。
