Primary aldosteronism and long-term outcomes using PAMO definition

Primary aldosteronism is the most common form of endocrine hypertension, traditionally managed with unilateral adrenalectomy for unilateral disease and medical therapy for bilateral forms. However, mineralocorticoid receptor antagonists are often poorly tolerated and less effective in preventing cardiovascular outcomes. In this international retrospective cohort study, we evaluated the clinical and biochemical outcomes of adrenal surgery in 56 patients with bilateral primary aldosteronism from six referral centers across five countries. Patients underwent either unilateral (n = 43) or bilateral (n = 13) adrenal surgery based on adrenal venous sampling and CT findings. At 6-12 months follow-up, a clinical benefit was observed in 81% of patients after unilateral surgery and 92% after bilateral surgery. Biochemical success was achieved in 65% and 85% of these groups, respectively. Similar benefits persisted beyond 12 months. Adrenal insufficiency occurred in 31% of patients after bilateral surgery but was transient in most cases. Histopathological analysis revealed bilaterally symmetric aldosterone-producing lesions in the majority of patients undergoing bilateral adrenalectomy, including adenomas, micronodules, and diffuse hyperplasia. Our findings suggest that adrenal surgery, including in selected bilateral disease, can result in favorable clinical and biochemical outcomes with an acceptable safety profile, challenging the prevailing paradigm of exclusive medical management for bilateral primary aldosteronism.