Abstract
Primary aldosteronism (PA) with unilateral adrenal disease can be cured or improved by adrenalectomy. Adrenal venous sampling (AVS) is recommended to identify patients for surgical management. However, surgeries based on computed tomography (CT) images are only advocated for PA patients aged <35 with visible unilateral adenoma. Herein, we aimed to compare CT‐based and AVS‐based surgery outcomes for PA patients with visible unilateral adenomas for different age groups. A total of 178 PA patients who underwent unilateral adrenalectomy between June 2018 and January 2021 were included in the study based on CT (n = 54) or AVS (n = 124). Demographics, diagnostics, and follow‐up data were retrospectively collected. Clinical and biochemical outcomes were analyzed according to Primary Aldosteronism Surgical Outcome (PASO) criteria at 1‐year follow‐up. Our results showed that complete clinical success (46.3% vs. 47.6%, p = 0.875) and complete biochemical success (88.8% vs. 91.9%, p = 0.515) were similar between the two groups. Age stratification revealed that patients >55 years old were likely to have worse biochemical outcomes; however, these were still not significantly different (21.4% vs. 8.6%, p = 0.220). Of the 114 AVS‐based patients who achieved complete biochemical success, 37 (32.4%) with bilateral normal or bilateral abnormal CT images changed treatment options according to AVS results, 1 (0.9%) avoided adrenalectomy on the wrong side. Our results indicated that surgery based on CT images might be feasible for highly selected PA patients with visible unilateral adenomas and less limited by age, while for those with normal adrenal or bilateral adrenal lesions, treatment strategy must be decided by AVS.
Keywords: adrenal vein sampling, adrenalectomy, computed tomography, hyperaldosteronism, surgical outcomes
1. INTRODUCTION
Primary aldosteronism (PA) is one of the leading causes of secondary hypertension, accounting for 5%−15% of the hypertensive population. 1 , 2 , 3 Patients with PA have higher cardiovascular morbidity and mortality than blood‐pressure‐matched primary hypertension. 4 , 5 Therefore, early diagnosis and appropriate treatment of PA are crucial for preventing deleterious cardiovascular outcomes. Treatment strategies also have a vital role since bilateral disease mainly relies on a persistent medication of aldosterone antagonist, while unilateral disease can be curable after adrenalectomy. 6 , 7 , 8 Adrenal venous sampling (AVS) is the criterion standard for distinguishing between unilateral and bilateral adrenal disease. It is also recommended to identify patients for surgical management. 9 , 10 However, the AVS technique has some disadvantages, such as higher costs, invasive risks, and high technical requirements. 11 It might also be difficult to promote fully in some regions of developing countries. According to recent guidelines, PA patients aged < 35 years old with visible unilateral adenoma could benefit from surgery based on CT without AVS. 2 However, this suggestion has only been supported by one single center report. 12 , 13 , 14 Additionally, there are limited reports on whether AVS can benefit PA patients with visible unilateral adenoma. Moreover, a randomized prospective study reported that CT‐based and AVS‐based management of patients with PA did not significantly differ in the clinical outcomes. 15
This study aimed to assess surgical outcomes of PA patients with visible unilateral adenoma for different age groups, whose surgical determination was made based on CT or AVS. We evaluated clinical and biochemical outcomes according to Primary Aldosteronism Surgical Outcome (PASO) criteria. 16 PASO was established to evaluate clinical and biochemical outcomes after adrenalectomy for PA. Clinical outcomes referred to postsurgical blood pressure and antihypertensive medication, while biochemical outcomes mainly referred to postsurgical hypokalaemia and ARR ratio. Results were shown as complete, partial, and absent success.
2. METHODS
2.1. Patient data and outcome assessment
The data of 265 patients with primary aldosteronism who were diagnosed and underwent surgeries in Ruijin Hospital, China, between June 2018 and January 2021 were retrospectively collected. Among them, 17 were lost to follow‐up, and 70 completed follow‐up with insufficient data. Sixty‐two out of the 70 individuals who failed to complete follow‐up due to the COVID‐19 pandemic. Among them, 51 were supposed to be included in AVS group while 11 in CT group. The missing data occupied a relative high proportion which could lead to potential biases. This limitation will be discussed in “Discussion” section. After excluding these cases, 178 patients with complete follow‐ups were included in this study (Figure 1). All these patients were hospitalized for persistent hypertension with or without hypokalemia. Intravenous saline load tests were performed in all patients as a confirmatory test of primary aldosteronism. Patients included in this study were diagnosed in Hypertension Department and underwent surgeries in the Urology Department of the same center. All patients underwent total laparoscopic adrenalectomies since partial adrenalectomy was reported to cause biochemical recurrence due to multifocality. 17 , 18 Preoperative CT scans were completed in all 178 patients, among whom 124 underwent additional AVS confirmatory examinations and were defined as AVS group. Their surgical decisions were made based on AVS suggestions. Surgical decisions of the remaining 54 patients were made based on CT images in the absence of AVS results, and these patients were allocated to the CT group. AVS was not performed for various reasons, mainly including patient rejection of the procedure, unilateral disease based on CT, or younger age. All patients in the CT group had unilateral adrenal lesions of >8 mm in diameter with normal contralateral adrenal. AVS group also included patients with imaging‐based normal adrenal or bilateral adrenal masses besides unilateral adrenal adenoma. In the AVS group, treatment decisions were not determined based on CT results. Postoperative pathologic findings showed no malignant lesions in any of the patients. We retrospectively collected clinical and biochemical data during 3–12 months after the operation, including a complete follow‐up of blood pressure, defined daily doses of antihypertensive drugs (DDD), serum potassium, plasma aldosterone, plasma renin activity (PRA), aldosterone‐renin‐ratio (ARR), and evaluated the clinical and biochemical benefits of patients after surgery according to PASO criteria. Furthermore, patients were divided into subgroups according to different age states. We tried to observe whether elder age affected outcomes in both CT and AVS groups.
FIGURE 1.
Patient allocation. AVS, adrenal venous sampling; CT, computed tomography; MRA, mineralocorticoid receptor antagonist; PA indicates primary aldosteronism.
2.2. CT image assessment criteria
In our center, surgical suggestions were made if CT met the following criteria: (1) confirmatory saline load tests completed before surgeries; (2) adrenal occupying nodules > 8 mm in diameter detected on CT images, and normal contralateral adrenal must be observed; (3) occupying lesions did not include adrenal hyperplasia on images. As a result, the smallest adrenal lesion observed in the CT group was 8 mm in diameter, while the largest one was 28 mm.
2.3. AVS catheterization and lateralization
In our center, we performed AVS by sequential catheterization of adrenal veins without stimulation. All patients included in the AVS group in this study underwent successful AVS cannulation, which was defined as a selectivity index (SI, defined as the ratio of adrenal cortisol to peripheral cortisol) of 3.0 or higher. The unilateral disease was diagnosed by the lateralization index (LI, defined as ratio: dominant adrenal to the nondominant side of estimated aldosterone normalized to cortisol) was 2.0 or higher.
2.4. Data analysis
IBM SPSS22.0 was used for data analyses. Data are presented as absolute numbers and percentages, means with SD, or medians with min‐max. T and Chi‐square tests were used to evaluate the significant differences between groups. A logistic regression equation was established to analyze potential factors potentially influencing the outcomes. P < 0.05 represented statistical significance.
3. RESULTS
3.1. Baseline and follow‐up data
Among a total of 178 patients, 54 underwent surgeries based on CT suggestions, while for the remaining 124, surgical decisions were made according to AVS results. Accordingly, patients were divided into the CT group and the AVS group. Baseline data showed that the proportion of women was higher in the CT group (62.9% vs. 46.7%, p = 0.034), while the average diameter of adrenal lesions was (15.8 mm vs. 12.6 mm, p = 0.011) smaller in the AVS group. A lower preoperative eGFR value (88.3 min/m2vs 99.0 min/m2, p = 0.010) was observed in the CT group. Preoperative systolic blood pressure in the AVS group was higher (163 ± 18 vs. 154 ± 24 mmHg, p = 0.050), while there was no significant difference in diastolic blood pressure and dose of antihypertensive drugs (DDD). As for postoperative data, no significant difference was observed in biochemical results between the two groups, including plasma aldosterone, plasma renin activity, the proportion of persistent high ARR levels, and serum potassium. For postoperative clinical results, no significant difference was found in either systolic blood pressure, diastolic blood pressure, or DDD (Table 1).
TABLE 1.
Baseline and follow‐up data of patients.
| Surgical management | |||||
|---|---|---|---|---|---|
| Variable | N | Total | CT (n = 54) | AVS (n = 124) | p value |
| Baseline data | |||||
| Age, y | 178 | 46 ± 13 | 42 ± 13 | 47 ± 12 | 0.021 |
| Gender (female) | 178 | 92(52%) | 34(63%) | 58(47%) | 0.034 |
| BMI, kg/m2 | 178 | 24.9 ± 4.3 | 25.2 ± 4.0 | 24.8 ± 4.6 | 0.687 |
| Aldosterone, pg/mL | 178 | 357 (155–1170) | 332 (213–996) | 388 (155–1170) | 0.614 |
| PRA, ng/mL per h | 178 | 0.16 (0.01–2.23) | 0.13 (0.01–1.94) | 0.17 (0.01–2.23) | 0.345 |
| ARR | 178 | 2240 (299–6300) | 3156 (362–6300) | 2074 (299–5850) | 0.073 |
| Lowest potassium, mmol/L | 178 | 2.71 ± 0.47 | 2.70 ± 0.49 | 2.72 ± 0.47 | 0.819 |
| Lesion size, mm | 178 | 13.5 ± 5.4 | 15.8 ± 6.3 | 12.6 ± 4.7 | 0.011 |
| eGFR, mL/min per m2 | 178 | 95.7 ± 18.0 | 88.3 ± 17.9 | 99.0 ± 17.2 | 0.010 |
| Systolic BP, mm Hg | 178 | 158 ± 19 | 154 ± 24 | 163 ± 18 | 0.050 |
| Diastolic BP, mm Hg | 178 | 94 ± 13 | 93 ± 12 | 94 ± 13 | 0.572 |
| Antihypertension medication (DDD) | 178 | 3.0 (2.0–4.0) | 3.0 (2.0–5.0) | 3.0 (2.0–4.0) | 0.369 |
| Follow‐up data | |||||
| Aldosterone, pg/mL | 178 | 87 (30–367) | 96 (31–367) | 82 (30–330) | 0.111 |
| PRA, ng/mL per h | 178 | 1.11 (0.05–7.90) | 0.88 (0.05–6.23) | 1.23 (0.12–7.90) | 0.199 |
| ARR > 300 | 178 | 16 (9.0%) | 6 (11.1%) | 10 (8.1%) | 0.632 |
| Lowest potassium, mmol/L | 178 | 4.30 ± 0.41 | 4.37 ± 0.47 | 4.27 ± 0.38 | 0.293 |
| Systolic BP, mm Hg | 178 | 134 ± 13 | 132 ± 13 | 134 ± 134 | 0.099 |
| Diastolic BP, mm Hg | 178 | 94 ± 13 | 93 ± 12 | 94 ± 13 | 0.727 |
| Antihypertension medication (DDD) | 178 | 1.0 (0.0–3.0) | 1.0 (0.0–3.0) | 1.0 (0.0–3.0) | 0.645 |
Abbreviations: ARR_PRA, aldosterone‐to‐renin ratio based on PRA; AVS, adrenal venous sampling; BMI indicates body mass index; BP, blood pressure; CT, computed tomography. Data are presented as n (%), mean value ± SD, or median (min–max); DDD, defined daily dose (assumed average maintenance dose per day for a drug used for its main indication in adults); eGFR, estimated glomerular filtration rate; PRA, plasma renin activity.
3.2. Clinical and biochemical outcomes based on PASO criteria
We scored the clinical and biochemical outcomes according to PASO criteria and defined results as a complete success, partial success, or absent success. The clinical complete success rate in the CT group was 46.3% (25 complete success, 27 partial success, two absent success, respectively), while that in the AVS group was 47.6% (59 complete success, 63 partial success, two absent success, respectively); however, the observed differences were not statistically significant (p = 0.875). The biochemical complete success rate in the CT group was 88.9% (48 complete success, four partial success, two absent success), while that in the AVS group was 91.9% (114 complete success, nine partial success, one absent success), with no significant difference (p = 0.515) either. Considering the low incidence of absent success cases, we grouped them with partial success cases for analysis in the following study (Table 2).
TABLE 2.
Clinical and biochemical outcomes after surgery.
| Surgical management | |||||
|---|---|---|---|---|---|
| Variable | Remission | Total (%) | CT (%) (n = 54) | AVS(%) (n = 124) | p value |
| Clinical outcome (n = 178) | Complete | 84(47.2) | 25(46.3) | 59(47.6) | 0.875 |
| Partial | 90(50.6) | 27(50.0) | 63(50.8) | 0.921 | |
| Absent | 4(2.2) | 2(3.7) | 2(1.6) | 0.388 | |
| Biochemical outcome (n = 178) | Complete | 162(91.0) | 48(88.9) | 114(91.9) | 0.515 |
| Partial | 13(7.3) | 4(7.4) | 9(7.3) | 0.972 | |
| Absent | 3(1.7) | 2(3.7) | 1(0.8) | 0.169 | |
AVS indicates adrenal venous sampling; CT, computed tomography. Data are presented as n (%).
3.3. Clinical and biochemical outcomes of different age groups
Patients were divided into four subgroups based on age (≤35 years, 36−45 years, 46−55 years, and ≥56 years). In each group, clinical and biochemical outcomes were retrospectively analyzed. There were no significant differences in any of the age groups (all P > 0.05) (Table 3).
TABLE 3.
Clinical and biochemical outcomes of different age groups.
| Surgical management | ||||||
|---|---|---|---|---|---|---|
| Age | Variable | Remission | Total (%) | CT (%) | AVS (%) | p Value |
| ≤35 (n = 46) | Clinical outcome | Complete | 39(84.8) | 14(87.5) | 25(83.3) | 0.711 |
| Partial+Absent | 7(15.2) | 2(12.5) | 5(16.7) | |||
| Biochemical outcome | Complete | 45(97.8) | 16(100) | 29(96.7) | 0.465 | |
| Partial+Absent | 1(2.2) | 0(0) | 1(3.3) | |||
| 36–45 (n = 44) | Clinical outcome | Complete | 27(61.4) | 7(58.3) | 20(62.5) | 0.803 |
| Partial+Absent | 17(38.6) | 5(41.7) | 12(37.5) | |||
| Biochemical outcome | Complete | 40(90.9) | 12(92.3) | 28(90.3) | 0.836 | |
| Partial+Absent | 4(9.1) | 1(7.7) | 3(9.7) | |||
| 46‐55 (n = 39) | Clinical outcome | Complete | 8(20.5) | 2(16.7) | 6(22.2) | 0.695 |
| Partial+Absent | 31(79.5) | 10(83.3) | 21(77.8) | |||
| Biochemical outcome | Complete | 34(87.2) | 9(81.8) | 25(89.3) | 0.536 | |
| Partial+Absent | 5(12.8) | 2(18.2) | 3(10.7) | |||
| ≥56 (n = 49) | Clinical outcome | Complete | 10(20.4) | 2(14.3) | 8(22.9) | 0.506 |
| Partial+Absent | 39(79.6) | 12(85.7) | 27(77.1) | |||
| Biochemical outcome | Complete | 43(87.8) | 11(78.6) | 32(91.4) | 0.220 | |
| Partial+Absent | 6(12.2) | 3(21.4) | 3(8.6) | |||
AVS indicates adrenal venous sampling; CT, computed tomography.
3.4. Logistic regression analysis of potential factors affecting surgical outcomes
Factors that might affect the outcomes of different individuals, such as age, minimum serum potassium, BMI index, eGFR, gender, lesion size, postsurgical elevated ARR, and diagnostic basis for surgery decision (CT or AVS), were recorded. Our results showed that elder age, higher BMI index, and elevated ARR were related to worse clinical outcomes (OR 0.949, 95% CI 0.880–0.987; OR 0.835, 95% CI 0.739–0.944; OR 5.184, 95% CI 1.948–13.799, respectively). No significant difference was observed in biochemical outcomes. Surgical decision basis (on CT or AVS) did not independently affect clinical outcomes (complete success vs. partial success + absent success: OR 0.907, 95% CI 0.334–2.469) or biochemical outcomes (complete success vs. partial success + absent success: OR 0.925, 95% CI 0.297–2.887). Other included potential factors did not significantly influence surgical results (Table 4).
TABLE 4.
Logistic regression analysis of potential factors affecting surgical outcomes.
| Variables | Clinical outcome | Biochemical outcome | ||
|---|---|---|---|---|
| OR (95% CI) | p Value | OR (95% CI) | p Value | |
| AVS+CT group: complete versus partial+absent (reference: complete) | ||||
| Age, per y | 0.949 (0.880–0.987) | 0.013 | 1.121 (0.901–1.266) | 0.302 |
| Lowest serum potassium, per mmol/L | 0.890 (0.695–1.231) | 0.129 | 1.275 (0.642–2.372) | 0.192 |
| BMI, per 1 kg/m2 | 0.835 (0.739–0.944) | 0.014 | 0.955 (0.944–0.982) | 0.136 |
| eGFR, per mL/min per 1.73 m2 | 1.009 (0.981–1.038) | 0.516 | 0.965 (0.931–1.001) | 0.055 |
| Sex (ref: female) | 1.051 (0.434–2.543) | 0.913 | 0.896 (0.305–2.348) | 0.748 |
| Lesion size, per mm | 1.040 (0.946–1.144) | 0.146 | 1.073 (0.976–1.180) | 0.415 |
| Elevated ARR at FU (ref: not detected) | 5.184 (1.948–13.799) | 0.001 | NA | NA |
| Basis for surgery decision (ref: CT scan) | 0.907 (0.334–2.467) | 0.849 | 0.925 (0.297–2.887) | 0.894 |
Abbreviations: ARR, aldosterone‐to‐renin ratio; AVS, adrenal venous sampling; BMI indicates body mass index; CT, computed tomography; eGFR, estimated glomerular filtration rate; FU, follow‐up; PRA, plasma renin activity. Odds ratio > 1 shows an increased likelihood of clinical or biochemical outcome; odds ratio < 1 shows a decreased likelihood of clinical or biochemical outcome.
3.5. Discordance between CT and AVS results
A total of 124 cases included in the AVS group were retrospectively investigated. Ten patients were recorded as having biochemical remission failure (one absent success; nine partial success), which might indicate that bilateral functional lesions and surgeries based on AVS decisions did not achieve desirable results. The remaining 114 patients in the AVS group achieved complete biochemical success, 38 (33.3%) of whom showed discordant results with CT suggestions. Detailed CT images showed 28 (24.6%) bilateral normal adrenal images and nine (7.9%) had bilateral adrenal lesions or hyperplasia. Only one (0.9%) individual showed a contralateral 8 mm adrenal nodule with a normal ipsilateral adrenal image, thus suggesting that the patient improperly underwent adrenalectomy if the decision was made according to CT suggestion. However, in the CT group, two patients had absent biochemical remission after surgery (persistent hypokalemia and hyperaldosteronism), and they underwent persistent medication of mineralocorticoid receptor antagonist (Figure 1).
4. DISCUSSION
The present study compared surgical outcomes in PA patients lateralized based on CT with AVS. No clinical or biochemical outcomes or meaningful differences were found between AVS‐based and CT‐based surgery at 1‐year follow‐up. PA patients with visible unilateral adenoma generally had excellent surgical responses based on CT. Using PASO criteria, complete biochemical success was 91.0%, and complete clinical improvement was 47.2%, which is consistent with global reports for patients surgically treated for unilateral PA based on AVS. 16 , 19 Although patients aged > 55 years old seemed more likely to have worse biochemical outcomes (21.4% vs. 8.6%), there was still no significant difference between two groups (p = 0.220).
AVS is considered the gold standard for localization diagnosis of PA. 9 , 20 The current Endocrine Society guideline recommends performing AVS in all patients with PA so as to identify those who may benefit from surgery. 2 However, some recent research results have cast uncertainty on the role of AVS. 15 , 21 , 22 The SPARTACUS study found no difference in clinical outcomes between CT‐ and AVS‐based management. 15 Other studies also did not report significant differences in biochemical response and clinical resolution between patients who underwent surgery based on CT and AVS results. 21 , 22 Additionally, not all patients with unilateral adrenal aldosterone hypersecretion diagnosed by AVS can achieve complete biochemical remission after adrenalectomy. 16 , 23 In the present study, among all 124 patients in the AVS group, 114 achieved complete biochemical success and thus should be regarded as proper surgical decisions. The remaining 10 patients achieved incomplete remission (nine partial success; one absent success), which meant that some 8.1% of the patients who underwent surgeries based on AVS did not achieve complete success. These results were consistent with previous studies. 16 , 23 In the present study, the clinical complete success rate was 47.6% in the AVS group and 46.3% in the CT group, while the biochemical complete success rate was 88.9% in the CT group and 91.9% in the AVS group. None of the observed differences were statistically significant. Moreover, logistic regression analysis indicated that surgical decisions based on CT or AVS did not significantly impact surgical outcomes. Meanwhile, elder age and higher BMI index were found to independently affect clinical outcomes. The proportion of CT‐based patients with complete biochemical success was higher in our study than that of Williams et al. 23 (88.9% vs. 80%), which could mainly be due to the different PA populations. In the present study, the CT‐based patients were those with visible unilateral adenoma.
Current guidelines indicate that patients aged < 35 years old are recommended for adrenalectomy based on CT if severe hyperaldosteronism exists. 2 Nonetheless, these data are from only one report in the literature. 12 It has been reported that AVS can be avoided when the patients are <40 years old. 13 In the cohort of the AVIS‐2 Young Study, the cut‐off age was recommended as <45 years. 14 In the present study, we divided patients into different age subgroups to observe the cut‐off age. Nevertheless, there was no difference in either subgroup. Although for patients > 55 years old, the biochemical success rate seemed to be lower in the CT group, the difference was not significantly different. It seemed that patients aged > 55 years old had better biochemical outcomes in the AVS group than in the CT group. However, the sample size of this study was too small, which may affect the statistical power. Accordingly, future studies with larger sample sizes are needed to further confirm reported findings.
The importance of AVS is indisputable. Our results do not negate the importance of AVS, especially in patients with bilateral adrenal disease. Of 114 AVS‐based patients who achieved complete biochemical success, there were 33.3% of patients (38 of 114) whose CT results did not agree with AVS results. Also, 37 (32.4%) patients with bilateral normal or bilateral lesions CT images changed treatment options according to the AVS results, while 1 (0.9%) patient avoided adrenalectomy on the wrong side. This means that if only CT results were used to determine lateralization, inappropriate exclusion from adrenalectomy would have occurred in 32.4%, and adrenalectomy on the wrong side would have occurred in 0.9%. AVS is recommended for patients with potential surgical options in most situations, especially when bilaterally normal or abnormal CT images are detected. When inconsistent results between AVS and CT images are observed, treatment management should be established according to AVS results. However, AVS is technically challenging, expensive, invasive, unavailable at all medical institutions, and associated with a 0.2%–2% risk of complications. 24 , 25 In the AVS study, only 77% of patients at 20 referral centers were systematically sent for AVS. 25 Additionally, the successful cannulation rates of both adrenal veins are widely variable in different studies, ranging from 20% to 99%. 22 , 25 , 26 CT might be reliable for PA patients with visible unilateral adenoma when AVS cannot be obtained for technical reasons.
There are some limitations in the present study. The first limitation is the retrospective design and relative small sample, especially after grouping. Secondly, CT images were viewed before surgery in all cases. Although surgical decisions were made only by AVS results in the AVS group, selection bias should still be taken into consideration. Thirdly, as was mentioned before, 87 out of 256 patients (31.6%) lost follow‐up mainly because COVID‐19 pandemic. The relative high proportion of data missing might lead to potential biases. As shown in baseline data, there were significant differences in age, systolic blood pressure, and preoperative eGFR between the CT and AVS groups, potentially affecting the results. We used 24‐h blood pressure monitoring for presurgical estimation, but only office blood pressure measurement was available in most stages after the operation. The follow‐up was within one year, and long‐term blood pressure changes and cardiovascular events should be observed.
5. CONCLUSION
Surgery based on CT images might be feasible for highly selected patients with unilateral aldosterone‐producing adenoma younger than 45 years old, while for PA patients with normal adrenal or bilateral adrenal lesions, the role of AVS in the selection of the proper treatment is irreplaceable.
CONFLICT OF INTEREST STATEMENT
The authors have no conflict of interest to declare.
FUNDING INFORMATION
This study was supported by the Scientific Research Project of Shanghai Health Committee (Grant/Award Number: 202040018) and the National Natural Science Foundation of China (Grant/Award Number: U21A20354)
Fang C, Dai J, Zhao J, et al. Surgery based on computed tomography images might be feasible for primary aldosteronism patients with visible unilateral adenoma. J Clin Hypertens. 2023;25:1001–1008. 10.1111/jch.14725
Chen Fang and Jun Dai contributed equally to this work and should be considered as equal first coauthors.
Contributor Information
Jianzhong Xu, Email: jianzhongxv@outlook.com.
Fukang Sun, Email: sfkang66@163.com.
DATA AVAILABILITY STATEMENT
The datasets generated and analyzed during the current study are not publicly available due to confidentiality requirements but are available from the corresponding author on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed during the current study are not publicly available due to confidentiality requirements but are available from the corresponding author on reasonable request.