Complete remission of hypertension in a hemodialysis patient after adrenalectomy for primary aldosteronism and renal transplantation

Abstract

A 64-year-old man was admitted to our hospital for the hormonal evaluation of a right adrenal adenoma. He had been diagnosed with severe proteinuria and hypertension, and antihypertensive treatment was started at the age of 60. His renal function gradually declined, and hemodialysis was begun at the age of 64. Since his blood pressure was uncontrollable and resistant to antihypertensive treatment, an endocrinological examination was performed for an incidental right adrenal mass detected by computed tomography. The results of screening, including captopril challenge and an adrenocorticotropin stimulation test for primary aldosteronism, and adrenal venous sampling suggested excessive aldosterone secretion from the right adrenal gland. Adrenalectomy was performed; his blood pressure decreased and became well-controlled with a reduced antihypertensive regimen. Furthermore, he received renal transplantation which resulted in normalization of his serum potassium level, improvement of renal function and hormonal levels such as plasma renin activity and aldosterone concentration, and satisfactory blood pressure without any antihypertensive medications. This case is extremely important to demonstrate the effects of adrenalectomy for primary aldosteronism in a hemodialysis patient. It is possible that adrenalectomy may be a useful treatment for primary aldosteronism even in patients undergoing hemodialysis. Careful long-term follow-up of our case and investigations of the efficacy of adrenalectomy in similar cases are needed to address this issue.

Keywords: Aldosterone; Blood pressure; End-stage renal disease; Renin; Surgery.

Fig. 1

Abdominal computed tomography. Arrow indicates a low-density tumor on the right adrenal gland

Fig. 2

Pathological examination of the resected right adrenal specimen. a Macroscopic feature of the cut surface showed a bright yellowish solid mass, measuring 1.4 cm × 1.0 cm across. b Adrenal mass was composed mainly of clear cells (hematoxylin and eosin stain, scale bar is 100 µm). c Immunohistochemical staining showed compact cells were positive for CYP11B2 (dilution of 1:20, scale bar is 100 µm)

Fig. 3

Clinical course of the current case. Filled diamond, systolic blood pressure; filled square, diastolic blood pressure. CCB calcium channel blocker, ARB angiotensin II receptor blocker, PAC plasma aldosterone concentration, PRA plasma renin activity, sBP systolic blood pressure, dBP diastolic blood pressure