Severity-based stratification and its association with lateralization and treatment outcomes in primary aldosteronism

초록

Objectives: Lateralization is a key determinant of treatment selection in primary aldosteronism. Although adrenal venous sampling is the reference standard, its use is limited by invasiveness and availability. A primary aldosteronism severity classification has been proposed to reflect integrated biochemical and clinical burden. This study aimed to evaluate the association between disease severity, lateralization results, and treatment outcomes in a large multicenter cohort. Methods: We conducted a retrospective multicenter cohort study including patients with confirmed primary aldosteronism who underwent adrenal venous sampling at eight tertiary hospitals. Disease severity was classified as mild, moderate, or severe using the primary aldosteronism severity classification. We assessed the relationships between severity category, adrenal venous sampling results, treatment allocation, and clinical and biochemical outcomes based on international consensus criteria. Logistic regression analyses were performed to identify factors associated with complete treatment response. Results: A total of 848 patients were included, of whom 6.1% were classified as mild, 67.5% as moderate, and 26.4% as severe. Increasing disease severity was associated with a stepwise rise in lateralization indices and a higher prevalence of lateralizing primary aldosteronism on adrenal venous sampling (23.1% in mild, 50.5% in moderate, and 75.9% in severe; P<.001). Complete clinical success was observed in 40.0% of patients with moderate disease and 31.7% of those with severe disease, while partial clinical success predominated in severe disease (55.0%). In contrast, biochemical surgical outcomes were consistent across severity categories (P=.380), with complete biochemical success achieved in 72.5% and 71.7% of patients with moderate and severe disease, respectively. Among patients with bilateral PA treated medically, clinical outcomes varied by disease severity (P=.010), with complete clinical response decreasing from mild to severe disease (35.1%, 26.8%, and 9.1%). Biochemical medical outcomes were comparable across severity groups (P=.996). Conclusions: Disease severity classification demonstrates a strong association with adrenal venous sampling–defined lateralization and treatment selection. Severity-based stratification may provide clinically useful guidance for lateralization assessment and individualized management in primary aldosteronism