May 20, 2025
Once thought rare, primary aldosteronism (PA) is now known to be a common cause of hypertension. According to a 2022 study published in the World Journal of Surgery, estimated rates of PA are 5% to 10% in people with newly diagnosed hypertension and up to 20% in people with resistant hypertension.
Primary aldosteronism can involve one or both adrenal glands, with bilateral disease (idiopathic hyperaldosteronism) accounting for about 60% of cases. Historically, lifelong blood pressure management with multiple medications has been the main treatment for PA due to bilateral adrenal disease. Even with optimal blood pressure management, elevated aldosterone can result in increased risk to the heart and kidneys. Research at Mayo Clinic is finding that minimally invasive unilateral adrenalectomy may be a better treatment option than medication alone.
"This is a new application of a well-established procedure," says Travis J. McKenzie, M.D., an endocrine surgeon at Mayo Clinic in Rochester, Minnesota. "By removing one adrenal gland, we can preserve adrenal function while reducing aldosterone levels, which can result in disease improvement."
Minimally invasive options for adrenalectomy
Mayo Clinic surgeons most commonly perform adrenalectomy using advanced minimally invasive techniques. "In primary aldosteronism from bilateral adrenal disease, the adrenal glands are usually nearly normal in size or have very small benign nodules," says Dr. McKenzie. "That means we're almost always able to use a minimally invasive laparoscopic, robotic or posterior retroperitoneoscopic approach. We utilize the most advanced approaches and technology to enhance efficacy and outcomes."
When deciding which adrenal gland to remove, Dr. McKenzie uses adrenal venous sampling (AVS) to select the gland with the higher aldosterone production.
AVS is the gold standard for determining if primary aldosteronism is bilateral or unilateral. An interventional radiologist performs AVS by sampling blood from the right and left adrenal veins and inferior vena cava (IVC) for comparative laboratory analysis.
With minimally invasive adrenalectomy, patients are typically discharged the same day or stay one night in the hospital. Out-of-town patients usually can receive all their care in a short, single trip. First, they meet with the endocrinologist and surgeon and have preoperative lab work. Next, they undergo AVS. The following day, they have surgery. Patients then return to the care of their referring healthcare professional, who can consult with the Mayo Clinic team if necessary.
Benefits of unilateral adrenalectomy for bilateral primary aldosteronism
People with primary aldosteronism have a significantly higher risk of cardiovascular and metabolic disease. These effects are due to hypertension, hypokalemia and excess aldosterone. One review in The Lancet Diabetes & Endocrinology compared published outcomes of people with PA and people with essential hypertension. Primary aldosteronism was associated with an increased risk of:
- Atrial fibrillation (3.5 times).
- Stroke (2.6 times).
- Left ventricular hypertrophy (2.3 times).
- Heart failure (2.1 times).
- Coronary artery disease (1.8 times).
- Metabolic syndrome (1.5 times).
- Diabetes (1.3 times).
Historically, PA due to bilateral adrenal disease has been considered a noncurable disease and treated with medication alone. Medication therapy for PA typically includes mineralocorticoid receptor antagonists (MRAs) plus antihypertensive medications. While medications can control blood pressure, patients need to take them for life. Furthermore, even with adequate blood pressure control, aldosterone levels remain elevated, which can have negative health consequences.
However, surgical intervention with unilateral adrenalectomy can decrease hormone levels, resulting in better blood pressure control with fewer medications. It also can normalize potassium levels and may result in improved long-term heart and kidney health.
Dr. McKenzie authored a Mayo Clinic study of 24 patients who underwent unilateral adrenalectomy for primary aldosteronism due to bilateral adrenal disease. None of the patients experienced postoperative complications, and the team found several key benefits:
- At the last follow-up, 65% of patients had improvements in hypertension, and 11% had discontinued antihypertensive medications.
- The percentage of patients with hypokalemia declined from 92% preoperatively to 12% postoperatively.
- The median number of antihypertension medications decreased from three before surgery to one after surgery.
- Two-thirds of patients taking an MRA before surgery did not require an MRA after surgery.
"The duration of follow-up ranged from 6 to 33 months, so we were unable to measure long-term outcomes," says Dr. McKenzie. "Additional studies are needed to determine whether unilateral adrenalectomy reduces the risk of cardiovascular and metabolic outcomes compared to medication therapy alone."
Improving primary aldosteronism diagnosis
Primary aldosteronism is an underdiagnosed condition. Some estimates suggest that only 1% of people with the condition receive a diagnosis, according to a 2023 article published in the Polish Archives of Internal Medicine. One challenge in diagnosing primary aldosteronism is a lack of specific clinical features.
"In general, people with primary aldosteronism tend to be younger at diagnosis, typically between ages 20 and 60," says Dr. McKenzie. "Their hypertension is usually more severe, requiring multiple medications."
The Endocrine Society recommends screening people with hypertension for primary aldosteronism if they have:
- Sustained blood pressure above 150/100 mm Hg.
- Controlled blood pressure on four or more medications.
- Resistant hypertension despite treatment with three or more antihypertensive medications.
- Hypertension and adrenal incidentaloma.
- Hypertension and hypokalemia.
- Hypertension and sleep apnea.
- Hypertension and a family history of early-onset hypertension or stroke before age 40.
- Hypertension and a first-degree relative with primary aldosteronism.
Given the prevalence of hypertension, some experts recommend screening all people with newly diagnosed hypertension or even all patients with hypertension. The costs and benefits of universal screening in the U.S. have not yet been evaluated.
For more information
Szabo Yamashita T, et al. Unilateral adrenalectomy for primary aldosteronism due to bilateral adrenal disease can result in resolution of hypokalemia and amelioration of hypertension. World Journal of Surgery. 2023;47:314.
Monticone S, et al. Cardiovascular events and target organ damage in primary aldosteronism compared with essential hypertension: A systematic review and meta-analysis. The Lancet Diabetes & Endocrinology. 2018;6:41.
Pilz S, et al. Primary aldosteronism 2.0: An update for clinicians on diagnosis and treatment. Polish Archives of Internal Medicine. 2023;133:16585.
Refer a patient to Mayo Clinic.