Risk of sepsis in patients with primary aldosteronism

Abstract

Background: The interaction between hyperaldosteronism and immune dysfunction has been reported and glucocorticoid co-secretion is frequently found in primary aldosteronism (PA). The aforementioned conditions raise the possibility of the infection risk; however, clinical episodes of sepsis have not been reported in PA.

Methods: Using Taiwan's National Health Insurance Research Database between 1997 and 2009, we identified PA and aldosterone-producing adenoma (APA) matched with essential hypertension (EH) at a 1:1 ratio by propensity scores. The incidences of sepsis and mortality after the index date were evaluated, and the risk factors of outcomes were identified using adjusted Cox proportional hazards models and taking mortality as a competing risk.

Results: We enrolled 2448 patients with PA (male, 46.08%; mean age, 48.4 years). There were 875 patients who could be ascertained as APA. Taking mortality as the competing risk, APA patients had a lower incidence of sepsis than their matched EH patients (hazard ratio (HR) 0.29; P < 0.001) after target treatments. Patients receiving adrenalectomy showed a benefit of decreasing the risk of sepsis (PA vs EH, HR 0.14, P = 0.001; APA vs EH, HR 0.16, P = 0.003), but mineralocorticoid receptor antagonist treatment may differ. Compared with matched control cohorts, patients with APA had a lower risk of all-cause mortality (PA, adjusted HR 0.84, P = 0.050; APA, adjusted HR 0.31, P < 0.001) after target treatments.

Conclusions: Our study demonstrated that patients with PA/APA who underwent adrenalectomy could attenuate the risk of sepsis compared with their matched EH patients. We further found that APA patients with target treatments could decrease all-cause mortality compared with EH patients.

Keywords: Chronic inflammation; Glucocorticoid; Hypertension; Oxidative stress; Primary aldosteronism; Sepsis; Taiwan Primary Aldosteronism Investigation.

Fig. 1

Flowchart of participants. *Patients who did not use MRA during the year before or 2 years after the first PA coding. APA aldosterone-producing adenoma, EH essential hypertension, ICD International Classification of Diseases, MRA mineralocorticoid receptor antagonist, PA primary aldosteronism

Fig. 2

Risk of sepsis between PA (a) and APA (b) patients with adrenalectomy and their EH controls by participant characteristics. ACEI angiotensin-converting enzyme inhibitor, APA aldosterone-producing adenoma, ARB angiotensin receptor blocker, CI confidence interval, EH essential hypertension, NSAID nonsteroidal antiinflammatory drug, OP operation, PA primary aldosteronism

Fig. 3

Proportional curve (adjusted with age, gender, and Charlson score) for sepsis in patients with adrenalectomy (OP), mineralocorticoid receptor antagonist (MRA) treatment, and essential hypertension (EH) during follow-up period by Cox regression model. Cumulative proportions to sepsis of PA (a) and APA (b) patients after target treatments (adrenalectomy or MRA treatment) and their EH controls by Cox proportional plot, taking mortality as a competing risk. Cox regression: (a) P < 0.001 (OP/MRA) and P = 0.001 (OP/EH); (b) P = 0.030 (OP/MRA) and P = 0.003 (OP/EH)