Worth Patrick J, Kunio Nicholas R, Siegfried Issac, Sheppard Brett C, Gilbert Erin W
Department of Surgery, Division of Gastrointestinal and General Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Pk. Rd., L223A Portland, OR 97239, USA.
Division of General & Vascular Surgery, Department of Surgery, Advocate Medical Group, Elgin, IL, USA.
Am J Surg. 2015 Oct;210(4):702-9. doi: 10.1016/j.amjsurg.2015.05.033. Epub 2015 Aug 17.
Surgical resection is the standard of care for unilateral adrenal adenomas and hyperplasia resulting in primary aldosteronism (PA). Resolution of PA following surgery is variable and some patients continue to require some or all of their antihypertensives. Prior studies have investigated factors contributing to "cure" of PA (defined as no hypertension [HTN] medications required postoperatively). These models are a tool in patient selection, yet fail to consider the benefit of some reduction in medications, resolution of hypokalemia, or reduction in blood pressure which may improve long-term cardiovascular and renal outcomes. We sought to investigate factors contributing to postoperative improvement or complete resolution following surgery.
This is a retrospective review of prospectively collected data on 58 adrenalectomies performed for PA from December 1999 to April 2013 at a single center. Patient demographics, PA characteristics, labs, and imaging studies were evaluated, as well as operative characteristics. Mean systolic and diastolic blood pressures were calculated over several visits after discharge, and postoperative antihypertensive regimen was recorded. Patients were stratified by cured vs not cured and then again by improved vs not improved based on differences in pre- and postoperative values. Aldosteronoma Resolution Score was also calculated for each patient.
Median age was 52.6 years, with 44.8% women and an average duration of HTN of 13.5 years. Average body mass index (BMI) was 31.5 kg/m(2); 74% of the lesions were adenomas. Patients with complications had higher BMIs than those without (36.9 vs 28.7 kg/m(2), P = .02). In comparing improved (n = 42, 72%) vs not improved (n = 16, 28%) patients, preoperative systolic blood pressure (147.5 vs 159.7 mm Hg, P = .047) and serum creatinine (.94 vs 1.32 mg/dL, P = .016) were higher in the not improved group. Cured (n = 13) vs not cured (n = 45) patients differed in terms of BMI (27.4 vs 32.7, P = .009), duration of HTN (9.1 vs 14.9 years, P = .020), and number of preoperative antihypertensives (2.1 vs 3.7, P = .002). Aldosteronoma Resolution Score was significantly higher in cured patients (3.2 vs 1.0, P < .01).
A significant number of patients who are not cured by adrenalectomy for PA will still benefit from surgery. Obesity, duration of HTN, and number of medications may predict cure, yet fail to detect a population of patients with overall improvement. Attention to serum creatinine may help in distinguishing this population of patients.
手术切除是单侧肾上腺腺瘤和增生导致原发性醛固酮增多症（PA）的标准治疗方法。PA手术后的缓解情况各不相同，一些患者仍需要继续服用部分或全部降压药。既往研究调查了促成PA“治愈”（定义为术后无需服用高血压[HTN]药物）的因素。这些模型是患者选择的一种工具，但未考虑到部分减少药物使用、低钾血症的缓解或血压降低可能改善长期心血管和肾脏结局所带来的益处。我们试图调查手术后促成改善或完全缓解的因素。
这是一项对1999年12月至2013年4月在单一中心为PA进行的58例肾上腺切除术的前瞻性收集数据的回顾性研究。评估了患者的人口统计学特征、PA特征、实验室检查和影像学检查以及手术特征。出院后多次就诊时计算平均收缩压和舒张压，并记录术后降压方案。根据治愈与否以及基于术前和术后值的差异改善与否对患者进行分层。还为每位患者计算醛固酮瘤缓解评分。
中位年龄为52.6岁，女性占44.8%，平均高血压病程为13.5年。平均体重指数（BMI）为31.5kg/m²；74%的病变为腺瘤。有并发症的患者BMI高于无并发症的患者（36.9 vs 28.7kg/m²，P = 0.02）。在比较改善组（n = 42，72%）和未改善组（n = 16，28%）的患者时，未改善组的术前收缩压（147.5 vs 159.7mmHg，P = 0.047）和血清肌酐（0.94 vs 1.32mg/dL，P = 0.016）较高。治愈组（n = 13）和未治愈组（n = 45）在BMI（27.4 vs 32.7，P = 0.009）、高血压病程（9.1 vs 14.9年，P = 0.020）和术前降压药数量（2.1 vs 3.7，P = 0.002）方面存在差异。治愈患者的醛固酮瘤缓解评分显著更高（3.2 vs 1.0，P < 0.01）。
大量因PA接受肾上腺切除术未治愈的患者仍将从手术中获益。肥胖、高血压病程和药物数量可能预测治愈情况，但无法检测出总体有改善的患者群体。关注血清肌酐可能有助于区分这类患者群体。
