Adrenalectomy patients with mixed primary aldosteronism and hypercortisolism: An analysis of outcomes following surgery at a single institution.

Abstract

A subset of patients with primary aldosteronism have clinical and/or biochemical evidence of hypercortisolism, suggesting excess co-secretion of both aldosterone and cortisol (mixed primary aldosteronism/hypercortisolism). This study examined patients with mixed primary aldosteronism/hypercortisolism and compared their outcomes following adrenalectomy to those of patients with primary aldosteronism only. This was a retrospective review of adults who underwent unilateral adrenalectomy at a single institution for primary aldosteronism. Patients were excluded if they did not undergo preoperative testing for hypercortisolism. Demographics, comorbidities, nodule size, adrenal venous sampling, laterality, and perioperative steroid usage were assessed to compare patients with mixed primary aldosteronism/hypercortisolism to those with primary aldosteronism only. The Primary Aldosteronism Surgical Outcome criteria were applied to assess clinical and biochemical success. Of 94 patients who underwent surgery, 28 (29.8%) had mixed primary aldosteronism/hypercortisolism. Patients with mixed primary aldosteronism/hypercortisolism tended to be older than those with primary aldosteronism only. Patients with mixed primary aldosteronism/hypercortisolism had larger adrenal glands on imaging (median 2.4 cm vs 1.3 cm, P = .002) and had higher rates of discharge on glucocorticoid replacement therapy (35.7% vs 3.0%, P < .001). On long-term follow-up, mixed primary aldosteronism/hypercortisolism patients were more likely to remain hypertensive and/or on the same number of antihypertensive medications as before surgery (21.4% vs 3.0%, P = .014). Patients with mixed primary aldosteronism/hypercortisolism were more likely to need postoperative glucocorticoid replacement and less likely to have a partial or complete clinical response to surgery. This highlights the importance of preoperative dexamethasone suppression test in all patients with primary aldosteronism to guide perioperative management, identify those at risk for postoperative adrenal insufficiency, and appropriately frame outcomes.