Adrenal Ablation Versus Mineralocorticoid Receptor Antagonism For The Treatment Of Primary Aldosteronism

Research background:Hypertension is one of the largest contributors to the global disease burden,one of the chronic non communicable diseases with the largest number of patients,and the most important risk factor for the death of cardiovascular and cerebrovascular diseases among urban and rural residents.Primary aldosteronism(PA)is one of the most common causes of secondary hypertension.At present,with the improvement of doctors’ awareness level and testing technology,the detection rate has greatly increased,5-10 times higher than that in 1990,accounting for 5%-10% of all hypertension patients,and even up to 20% of patients with refractory hypertension.Compared with primary hypertension,the incidence of cardiovascular disease is higher,the damage of target organs such as heart,brain and kidney is earlier and more serious,which seriously affects people’s health and socio-economic development.Therefore,the treatment of PA is urgent.Previous guidelines recommended that surgery should be the first choice for unilateral primary aldosteronism(including aldosterone tumor and unilateral adrenal hyperplasia);For bilateral primary aldehyde disease,the first choice is conservative medical treatment(aldosterone receptor antagonists: spironolactone,eplerenone,etc.).However,these two treatment methods have inevitable shortcomings,so clinicians have been exploring more safe and effective treatment methods.Super selective adrenal artery embolization(SAAE)is a kind of operation based on catheter,which can selectively inject absolute ethanol into adrenal artery through percutaneous cavity to cause necrosis of adrenal tissue.In recent years,SAAE has been used as a replacement therapy for patients with unilateral aldosterone producing adenoma and idiopathic aldosteronism without obvious adenoma.However,previous studies were mostly case reports or single center clinical studies without control.At present,there is no report on whether SAAE is superior to mineralocorticoid receptor antagonist(MRA)in the treatment of PA(either unilateral or bilateral).Purpose:This single-center prospective cohort study aimed to compare the efficacy of SAAE with mineralocorticoid receptor antagonists(MRA)in treating primary aldosteronism patients who refused unilateral adrenalectomy.Methods:This study is an observational study.From April 2019 to April 2021,2212 patients with hypertension who were hospitalized in the Chengdu Medical of the First Affiliated Hospital of Chengdu Medical College were screened for primary aldosteronism,of whom 188(8.4%)were diagnosed with PA.Among these 188 patients,the main treatment methods for PA were described in detail,including drug therapy(spironolactone,epridone,fenisolone,etc.),surgical treatment(open adrenalectomy,laparoscopic adrenalectomy),and interventional treatment(superselective adrenal arterial embolization is provided by the research center).A total of 149 patients(79.2%)met the inclusion criteria and chose to participate in this study.According to the wishes of patients,they were divided into two groups: superselective adrenal artery embolization group(80 patients in the embolization group)and spironolactone group(69 patients in the drug group).Finally,a one-year follow-up observation was conducted between the two groups of patients(74 patients in the embolization group and 66 patients in the drug group).By comparing the changes in blood pressure,types of antihypertensive drugs used,biochemical indicators(serum K+,plasma aldosterone to renin ratio,and serum cortisol)of the two groups of patients,meanwhile,observe whether there are complications and adverse events after the surgery,the final evaluation of the surgical outcome of superselective adrenal artery embolization was conducted with reference to the " Primary Aldosteronism Surgery Outcome(PASO)".Results:1.Baseline clinical and biochemical characteristics of the patients were similar between groups.2.Comparison of antihypertensive efficacy: office,home,and ambulatory blood pressure reduction at 1 month after discharge was more pronounced in SAAE group than MRA group(all P<0.05)while the blood pressure reduction was comparable between the two groups at 6 and 12 months.Patients who underwent SAAE took less anti-hypertensive medications than MRA group during 12-month follow-up(P<0.01).3.Comparison of changes in biochemical indicators: both SAAE and MRA treatment improved renin suppression,aldosterone-to-renin ratio elevation,and hypokalemia at 6 and 12 months,whereas only SAAE but not MRA reduced plasma aldosterone levels.4.Final efficacy determination(clinical evaluation and biochemical evaluation):moreover,SAAE achieved higher rates of complete clinical and biochemical success than MRA(both P<0.01).5.Multivariate Logistic regression analysis related to efficacy: Logistic regression found that complete clinical and biochemical success was only directly associated with diagnosis of unilateral PA in contrast to bilateral PA(P<0.01).6.Adverse events: A total of 81 adverse events occurred in the SAAE group,and11 adverse events occurred in the MRA group.There were no surgical or drug related deaths.Conclusion:The present study provides evidence that SAAE is a reasonable choice of treatment in the patients with either unilateral or bilateral primary aldosteronism in terms of clinical and biochemical outcome.