| BackgroundsAdrenal hyperplasia is one of the important causes of secondary hypertension. In more recent years, with the development of imaging technology and the improvement of the level of diagnosis, the detection rate of adrenal hyperplasia is rising.The secondary hypertension,caused by the adrenal hyperplasia, is characterized by drug-resistant hypertension and the obvious symptoms caused by overproduction of endocrine hormone. Hypertension is not only the main symptom in patients with adrenal hyperplasia, but is also the most important factor for morbidity and reduced quality of life due to a higher rate of cardiovascular complications,target organ damage, and metabolic syndrome than essential hypertension. Therefore, the harm caused by adrenal hyperplasia hypertension can not be ignored. The control of hypertension and symptoms caused by overproduction of endocrine hormone are the most important aim for the treatment of these patients.To remove the tissue of adrenal hyperplasia, the overproduction of endocrine hormone can be reduced. thus,the hypertension and the obvious symptoms caused by overproduction of endocrine hormone can be controlled.The adrenalectomy for the treatment of adrenal hyperplasia hypertension is effective. However, some patients still remain hypertensive after curative surgery. In the influence factors, removing the tissue of adrenal hyperplasia is the decisive factor. The other influence factors of surgical cure or control of hypertension in patients with adrenal hyperplasia hypertension were individual differences,duration of hypertension, preoperative hypertension, preoperative use of antihypertensive medications, and combining with other diseases. Consideration of these factors may help in the evaluation of patients for surgery and for the identification of patients with continued postoperative hypertension that may require more long-term monitoring and treatment.However, adrenalectomy is considered the treatment of choice for patients with adrenal hyperplasia,but there is no unified standard for the the scope of operation. The more the tissue of adrenal hyperplasia is removed, the more it can reduce the amount of adrenal hormone secretion. Thus, the control of hypertension and relieving symptoms are more effective for the treatment of these patients. If the tissue of adrenal hyperplasia is removed too much, it may cause adrenal insufficiency or relative insufficiency. And, even more, it may require long-term hormone replacement therapy in some severe cases. Adrenal insufficiency after surgery is a difficult complication to deal with, and it may occur after surgery of adrenal gland. It is generally considered that even after unilateral adrenalectomy, the remaining contralateral adrenal gland can sufficiently support life because the adrenal gland is critical for survival and may have a large amount of reserve function for maintenance of homeostasis. However, some patients can develop adrenal insufficiency in extreme illness even if they have two healthy adrenal glands and their baseline cortisol and adrenocorticotropin hormone (ACTH) levels are within the normal range. Therefore, patients with one adrenal gland after unilateral adrenalectomy may be more susceptible to relative adrenal insufficiency compared with patients with two healthy adrenal glands in such a situation. Therefore, we closely evaluated adrenal cortisol secretory function before and after unilateral adrenalectomy in patients with unilateral adrenal hyperplasia.It is very important for us to understand adrenal insufficiency occurred after operation and the formulation of adrenal insufficiency prevention scheme.ObjectivesThis study is based on the clinical data to perform comprehensive analysis in the hope of achieving the following goals:1. evaluating the long-term outcomes of patients undergoing unilateral adrenalectomy for adrenal hyperplasia, with particular attention to the control of hypertension, and to determine the preoperative influence factors for recurrent hypertension in patients with adrenal hyperplasia after unilateral adrenalectomy.2. After unilateral adrenalectomy in patients with a unilateral adrenal hyperplasia, the remaining contralateral adrenal gland is generally considered sufficient to support life. However, few studies have compared adrenal reserve function before and after unilateral adrenalectomy. Therefore, we closely evaluated adrenal cortisol secretory function before and after unilateral adrenalectomy in patients with unilateral adrenal hyperplasia.Methods1. From January 2010 to February 2014, a total of 66 patients with adrenal hyperplasia underwent unilateral adrenalectomy were included. All cases are from department of urology in Guangzhou General Hospital of Guangzhou Command and department of urology in Jiangmen Hospital Affiliated to Southern Medical University. Clinical and biochemical data were reviewed retrospectively, including age, gender, body mass index, duration of hypertension, blood pressure, side of adrenal hyperplasia, preoperative biochemical test results correlated with adrenal (blood potassium, blood cortisol rhythm, aldosterone/renin ratio,24-hour urine catechu amine metabolites, operation time and pathological type.) We follow up all the patients to collect the recovery of blood pressure and the improvement of clinical symptoms data after adrenalectomy, after a median follow-up time of 47.2±5.9 months. We analyzed the influence factors for recurrent hypertension in patients with adrenal hyperplasia after adrenalectomy.2. From January 2010 to February 2014, a total of 40 patients with were diagnosed with adrenal hyperplasia and underwent unilateral adrenalectomy for unilateral adrenal hyperplasia were initially included in this study. All cases are from department of urology in Guangzhou General Hospital of Guangzhou Command and department of urology in Jiangmen Hospital Affiliated to Southern Medical University. Patients with subclinical Cushing’s syndrome (SCS) or Cushing’s syndrome(CS) were excluded on suspicion of autonomous cortisol secretion. Morning basal serum cortisol and plasma adrenocorticotropin hormone (ACTH) levels were measured, and ACTH stimulation tests under 1-mg dexamethasone suppression (dex-ACTH test) were performed before and after unilateral adrenalectomy. Before,2 weeks after and 1 year after unilateral adrenalectomy, blood samples were collected between 08:00 and 09:00 am after the patients had maintained a supine position for 30min to measure the basal serum cortisol and plasma ACTH levels. The dex-ACTH test was also performed before and 2 weeks after unilateral adrenalectomy. Serum cortisol levels were measured at each time point.This test was repeated 1 year after unilateral adrenalectomy in 40 patients who requested reassessment of their adrenocortical reserve function after unilateral adrenalectomy for a longer duration.Results1. The blood pressure was normalized in 66 patients. After a averge follow-up time of 47.2±5.9 months,24 of 66 patients had recurrent hypertension. In the univariate analysis of outcome, Age at adrenalectomy, postoperative systolic blood pressure, duration of hypertension, pathological types were significantly differences in patients with recurrent hypertension and in those without it (P< 0.05). multivariate regression analysis revealed that the main determinants of recurrent hypertension after unilateral adrenalectomy were age at adrenalectomy more than 50 years old (OR:16.083, 95% CI:1.975-130.981), duration of hypertension more than 5 years(OR:18.013, 95%CI:1.359-238.702), the presence of adrenal cortical and medullary hyperplasia(l) (OR:0.012,95%CI:0.001-0.235) and the presence of adrenal cortical and medullary hyperplasia(2) (OR:0.012,95%CI:0.000-0.998).2. No patient developed clinical adrenal insufficiency. Basal cortisol levels were not significantly different before and after unilateral adrenalectomy. However, basal ACTH levels were significantly elevated after unilateral adrenalectomy. In addition, peak cortisol levels on the dex-ACTH test decreased in all patients after unilateral adrenalectomy. The peak cortisol level 2 weeks after unilateral adrenalectomy was 83.5±15.6% of the level before unilateral adrenalectomy. And the peak cortisol level 1 year after unilateral adrenalectomy was 85.5±16.2% of the level before unilateral adrenalectomy.Conclusions1. Adrenalectomy for the treatment of unilateral adrenal hyperplasia hypertension is safe and effective.2. Age at adrenalectomy more than 50 years old, duration of hypertension more than 5 years, and the presence of adrenal cortical and medullary hyperplasia are the influence factors for recurrent hypertension in patients with adrenal hyperplasia after adrenalectomy, which can provide the basis for adrenal hyperplasia hypertension operation prognosis.3. The basal cortisol level is sustained by elevated ACTH after unilateral adrenalectomy. Nevertheless, more than 80% of the reserve capacity is preserved after unilateral adrenalectomy, which is compatible with the fact that patients generally exhibit no problems in daily life after unilateral adrenalectomy. |
PDF Full Text Request