Renal Outcomes in Medically and Surgically Treated Primary Aldosteronism

Abstract

<p class="first" id="P1">Lifelong therapy with mineralocorticoid receptor antagonists (MRAs) or surgical adrenalectomy are the recommended treatments for primary aldosteronism (PA). Whether these treatments mitigate the risk for kidney disease remains unknown. We performed a retrospective cohort study of patients with PA treated with MRAs (N=400) or surgical adrenalectomy (N=120), and age- and estimated glomerular filtration rate (eGFR)-matched patients with essential hypertension (N=15,474) to determine risk for chronic kidney disease and longitudinal eGFR decline. Despite similar blood pressures, patients with PA treated with MRAs had a higher risk for incident chronic kidney disease compared with essential hypertension patients (adjusted HR 1.63 [95% CI 1.33, 1.99]). Correspondingly, the adjusted annual decline in eGFR was greater in PA patients treated with MRAs compared with essential hypertension patients (−1.6 [95% CI −1.4, −1.8] vs. −0.9 [95% CI −0.9, −1.0] mL/min/1.73 m ²/year, p &lt; 0.001). In contrast, patients with unilateral PA treated with surgical adrenalectomy had no significant difference in risk for incident chronic kidney disease or in annual decline in eGFR compared with essential hypertension patients. Among PA patients with diabetes treated with MRAs, there was a higher risk for incident albuminuria compared with essential hypertension (adjusted HR 2.52 [95% CI 1.28, 4.96]). MRA therapy in PA is associated with higher risk for developing chronic kidney disease, when compared with essential hypertension, and surgical adrenalectomy may mitigate this risk. When possible, curative surgical adrenalectomy may be superior to lifelong MRA therapy in preventing kidney disease in PA. </p>