Persistent adrenal insufficiency may follow adrenalectomy to treat primary aldosteronism
Unilateral adrenalectomy to treat primary aldosteronism can lead to both transient and persistent adrenal insufficiency, and clinicians should perform postoperative adrenocorticotropic hormone stimulation testing to avoid potential adrenal crisis in patients, according to an analysis of registry data.
“In this study, we prospectively investigated [primary aldosteronism] patients who underwent unilateral adrenalectomy and identified a surprisingly high number of cases with postoperative adrenal insufficiency,” Daniel A. Heinrich, MD, a clinician scientist at LMU Munich, and colleagues wrote. “Even though, at average, the biochemical presentation was less severe and of shorter duration than in other entities of endogenous hypercortisolism, clinicians treating [primary aldosteronism] patients should to be aware of the risk of development of postoperative adrenal insufficiency as a potentially life-threatening condition.”
Heinrich and colleagues analyzed data from 100 consecutive patients (51 men) who underwent unilateral adrenalectomy between 2014 and 2018 to treat primary aldosteronism as well as postoperative adrenocorticotropic hormone (ACTH) stimulation testing at discharge to identify adrenal insufficiency; 67 patients also underwent preoperative ACTH stimulation testing. Moderate adrenal insufficiency was defined as a serum cortisol level between 13.5 µg/dL and 17 µg/dL; severe adrenal insufficiency was defined as a serum cortisol level of less than 13.5 µg/dL.
Within the cohort, 13 patients (six men) had postoperative ACTH stimulation cortisol levels of less than 13.5 µg/dL, and 14 patients (four men) had stimulation serum cortisol values between 13.5 µg/dL and 17 µg/dL. There were no between-group differences in baseline characteristics in patients with moderate, severe or no adrenal insufficiency, according to researchers.
Among the 67 patients who underwent a preoperative ACTH stimulation test, none had abnormal results, the researchers wrote (mean stimulated serum cortisol, 23 µg/dL). The researchers noted that 1 mg overnight dexamethasone suppression testing, salivary cortisol and urinary cortisol excretion before surgery failed to predict which patients developed adrenal insufficiency.
Among patients who developed severe or moderate adrenal insufficiency, 17 underwent repeat ACTH stimulation testing at least once after diagnosis (median follow-up, 293 days). Hydrocortisone therapy was continued for a median of 340 days. During follow-up, one patient with severe adrenal insufficiency was hospitalized for an acute adrenal crisis.
“Based on our findings we suggest performing postoperative ACTH stimulation tests in all [primary aldosteronism] patients undergoing adrenalectomy,” the researchers wrote. “Further analysis is required to identify markers that would predict the development of clinically relevant postoperative adrenal insufficiency.” – by Regina Schaffer
Disclosures: The authors report no relevant financial disclosures.