What are the next steps for a patient with a 2 cm left adrenal adenoma, primary aldosteronism, controlled blood pressure, and potential hypokalemia?

Management of Primary Aldosteronism with 2 cm Left Adrenal Adenoma

For a patient with a 2 cm left adrenal adenoma, elevated aldosterone-to-renin ratio (170), controlled blood pressure, and requiring potassium supplementation, adrenal vein sampling (AVS) should be performed to confirm unilateral aldosterone production, followed by laparoscopic adrenalectomy if lateralization is confirmed. 1

Diagnostic Confirmation

The patient's presentation strongly suggests primary aldosteronism (PA) with:

• 2 cm left adrenal adenoma on imaging
• Elevated aldosterone-to-renin ratio (ARR) of 170 (significantly above the diagnostic threshold of ≥20)
• Hypokalemia requiring supplementation
• Hypertension (currently controlled)

This clinical picture is consistent with an aldosterone-producing adenoma, which requires definitive subtyping before determining final treatment.

Next Steps in Management

1. Adrenal Vein Sampling (AVS)

   • AVS is the gold standard for distinguishing between unilateral and bilateral aldosterone production 1
   • Essential before offering adrenalectomy, particularly since:
     • The adenoma is of intermediate size (2 cm)
     • Need to confirm the visualized adenoma is the source of excess aldosterone

2. If AVS confirms unilateral disease (lateralization to left adrenal)

   • Laparoscopic adrenalectomy is the treatment of choice 1
   • Benefits:
     • Improves blood pressure control in virtually 100% of patients
     • Achieves complete cure of hypertension in approximately 50% of cases
     • Normalizes potassium levels without supplementation
     • Reverses cardiovascular and renal complications

3. If AVS suggests bilateral disease

   • Medical therapy with mineralocorticoid receptor antagonists (MRAs) is indicated 1, 2
   • Spironolactone is the first-line agent:
     • Starting dose: 12.5-25 mg daily
     • Titrate up to 100 mg daily as needed for BP control and potassium normalization
     • Monitor for hyperkalemia, especially with dose increases

Important Considerations

• Preoperative management if surgery is planned:

  • Continue potassium supplementation
  • Optimize blood pressure control
  • Consider short-term spironolactone (25-100 mg daily) to improve potassium levels 2

• Postoperative monitoring if adrenalectomy is performed:

  • Monitor blood pressure and serum potassium levels
  • Assess for resolution of hyperaldosteronism
  • Many patients may still require some antihypertensive therapy, though at reduced doses

• Long-term medical management if surgery is not performed:

  • Spironolactone 100-400 mg daily is indicated for long-term maintenance therapy for patients with aldosterone-producing adenomas who are not surgical candidates 2
  • Eplerenone is an alternative with fewer anti-androgenic side effects

Caution and Pitfalls

• Avoid potassium-wasting diuretics which can worsen hypokalemia
• If using spironolactone, monitor for hyperkalemia, especially in patients with reduced renal function
• The 2 cm adenoma size is below the 3 cm threshold where malignancy becomes more concerning 3, making a benign aldosterone-producing adenoma most likely
• Failure to perform AVS before surgery may lead to inappropriate management if the patient has bilateral disease despite the visible adenoma

The evidence strongly supports proceeding with AVS to confirm unilateral disease, followed by laparoscopic adrenalectomy if confirmed, as this offers the best chance for cure and improved long-term outcomes for this patient.