**5. Conclusion**

130 Novel Insights on Chronic Kidney Disease, Acute Kidney Injury and Polycystic Kidney Disease

hypokalemia and end-organ damage.29 Management strategies should take patient characteristics and desires into consideration. Surgical treatment may not be appropriate for all patients with unilateral hypersecreting adrenal mass but may be reasonable for those

Medical management with a mineralocorticoid receptor (MR) antagonist is recommended for patients who do not undergo surgery. Medical treatment is recommended for patients with bilateral hypersecreting adrenal lesions or for those with unilateral lesion who are not optimal for or who do not want surgical treatment (see Pharmacotherapy for hyperaldosteronism). Medications that block aldosterone action are effective for the treatment of hypokalemia and HTN and these include nonselective (spironolactone) and selective aldosterone receptor antagonists (eplerenone). Amiloride is not an aldosterone receptor antagonist and is not effective in controlling HTN in PAL but may be used for its

Prior studies on the efficacy of spironolactone in treating resistant HTN have used 25 to 50 mg daily dosing, whereas true PAL may require larger daily doses up to 100 to 400 mg. The onset of action on BP may be slow. Measurements of PRA are not necessary but may be an indication that an optimal dose of the medication has been prescribed when it is no longer

Spironolactone is a nonselective MR antagonist with significant antiandrogenic and progestational activities responsible for its most common side effects (gynecomastia, erectile dysfunction and abnormal menstrual cycles) 2. Eplerenone is a selective MR antagonist without antiandrogen or progesterone agonist activity: it has 60% of the potency of spironolactone in vivo and should be administered twice daily given its short half-life. Combined therapy with a small dose of spironolactone and amiloride may alleviate these undesirable consequences.29 Eplerenone, a more selective mineralocorticoid receptor blocker, also effectively reduces BP in patients with resistant hypertension Eplerenone has a beter adverse reaction profile because it has substantially less binding affinity to androgen

Laparoscopic adrenalectomy is currently the best treatment, and can be performed during a short hospital stay at a very low operative risk.38-39 This surgery has cured primary aldosteronism in 33–72% of patients and resulted in marked improvements in 40–50% of patients.40,41 Approximately one-third of all PAL patients has clear lateralization of aldosterone production and will benefit from unilateral adrenalectomy. Laparoscopic adrenectomy is the most suitable therapy for APA or unilateral adrenal hyperplasia. After adrenalectomy hypertension is cured in around 50% of patients with APA (range 33–70%) [3] with the remaining patients showing a significant reductions in blood pressure and number of antihypertensive drugs. Chronic suppression of the renin-angiotensin axis may cause transient postoperative hypoaldosteronism and a liberal sodium diet should be allowed to prevent hyperkalemia after the surgery. An I.V. infusion of 0.9% sodium chloride

with bilateral hypersecretion.

potassium sparing property.

**4.2 Surgical treatment** 

and progesterone receptors than spironolactone.

suppressed.

**4.1 Medical treatment** 

Until recently, aldosterone excess was thought to play a minor role in the development of hypertension. Beginning in the early 1990s, however, reports from investigators worldwide have found that primary aldosteronism is common in patients with hypertension, with prevalence rates of 10 to 15%. In patients with severe or resistant hypertension, the prevalence of primary aldosteronism is even higher, with a prevalence of approximately 20%. Approximately 30% to 60% of APA patients are improved or have resolution of HTN and hypokalemia with normal SA and PRA after unilateral adrenectomy. HTN is normally resolved within 1 to 6 months and patients with persistent HTN are more likely to be older, require more than two antihypertensive drugs preoperatively, or have a longer duration of HTN or underlying renal dysfunction. The postoperative BP in those with persistent HTN is usually easier to control with fewer medications. The cardiovascular complications of patients who achieve optimal BP control with or without medications eventually decrease to the levels of those with essential HTN. Partial reversal of renal dysfunction, regression of LVM and improved diastolic left ventricular function have been demonstrated after successful treatment of PAL. It has been reported that adrenalectomy for APA is more costeffective than long-term medical therapy.
