Perioperative management of patients with primary aldosteronism: a practical approach for the endocrinologist

Primary aldosteronism (PA) is the most common endocrine cause of secondary hypertension yet remains significantly underdiagnosed. Early recognition is essential, as excess aldosterone leads to substantial cardiovascular and renal morbidity. Approximately one-third of patients have unilateral disease, in whom adrenalectomy is associated with superior long-term clinical outcomes compared with medical therapy. Although current guidelines offer detailed recommendations for diagnosis and subtype classification, guidance on perioperative management remains limited. Preoperative goals should include optimizing blood pressure to <140/90 mmHg and correcting potassium levels, which can be achieved by initiating mineralocorticoid receptor antagonists (MRAs) in all patients. MRA titration ensures effective receptor blockade and supports recovery of contralateral adrenal function. A dedicated preoperative endocrinology consultation is essential to review expected surgical outcomes, address the anticipated postoperative decline in renal function, evaluate cortisol co-secretion, and assess the risk of postoperative adrenal insufficiency. Postoperatively, the primary concern is hyporeninemic hypoaldosteronism. Antihypertensive medications should be down-titrated, MRAs withheld, and a high-sodium diet encouraged. Early biochemical assessment does not establish cure but may still provide clinically relevant information. Follow-up includes weekly assessments during the first month and structured evaluation of clinical and biochemical outcomes at 6-12 months using the PASO criteria. Histological findings help predict recurrence risk and decide long-term follow-up. Patients achieving complete biochemical success, along with a complete or partial clinical response and having classic histopathological features, may transition to long-term follow-up in a primary care setting. This manuscript proposes a structured perioperative management approach for patients with PA undergoing adrenalectomy.