(CSEMP072) DIAGNOSIS AND MANAGEMENT OF PRIMARY ALDOSTERONISM AT A TERTIARY CARE CENTER: A DESCRIPTIVE AND QUALITY ASSURANCE STUDY

Abstract:

Background:

Primary aldosteronism (PA) is under-diagnosed despite having a global prevalence as high as 12.7% in primary care1 and 11.2% in newly diagnosed hypertensive patients2. Excess aldosterone can lead to increased morbidity and mortality if left untreated, particularly on cardiovascular, cerebrovascular, and renal outcomes, independent of its effect on blood pressure1. Despite international guidelines for the diagnosis and management of PA3, there exists individual provider variability. Many patients go on to receive invasive diagnostic and therapeutic procedures such as adrenal vein sampling (AVS) and adrenalectomies in the absence of a standardized workup algorithm. We aimed to assess the diagnostic workup and management of patients undergoing testing for PA at a tertiary care center and identify gaps in the use of diagnostic tests.

Methods:

A retrospective chart review of patients >18 years who underwent adrenalectomy and/or AVS from 2012-2023 at a tertiary care center was performed. Laboratory data including aldosterone, renin, aldosterone-renin ratio, electrolytes, renal function tests, medications (number and type of antihypertensives and potassium supplementation), confirmatory tests, imaging results, AVS results, surgery details, postoperative laboratory data and outcomes post-adrenalectomy were reviewed.

Results:

We identified 104 patients who underwent laparoscopic adrenalectomies. Of these, 18 had a diagnosis of PA. Twelve did not have relevant investigations for PA despite having a history of hypertension and/or hypokalemia. For those with PA, the average pretreatment potassium and creatinine levels were 3.2 (SD=0.7) and 92 (SD=35) respectively. The average ARR of these patients was 676.6 (SD=773.5), with none in the intermediate range (5-15 ng/dL) yet three had confirmatory testing done, nonetheless. The average number of anti-hypertensives before treatment was 2.94 (range 1-5, SD=1.21) and 14 of them were on potassium supplementation. Three patients did not have AVS prior to their adrenalectomy despite being over 35 years of age. The average post-treatment potassium (off supplementation) and creatinine were 4.4 (SD=0.4) and 105 (SD=35) respectively. Seven of the 18 patients were cured (off hypertension or potassium supplements), while 5 improved with reduction in the anti-hypertensive agents and discontinuation of potassium supplements.

Conclusion:
Most patients diagnosed with PA undergo the appropriate biochemical, imaging and AVS investigations. Some patients undergoing adrenalectomies may not be appropriately screened for PA which may represent an area for improvement given the under recognition of PA. These results will help to improve the consistency of diagnosis and treatment of PA according to evidence-based guidelines at our center.