A patient with primary hyperaldosteronism has a unilateral adrenal adenoma confirmed on adrenal vein sampling. Her aldosterone-to-renin ratio is 50 (ng/dL per ng/mL/hr). Adrenal vein sampling shows a lateralization ratio of 6:1. What is the MOST appropriate definitive management?
- A Unilateral laparoscopic adrenalectomy ✓
- B Bilateral adrenalectomy
- C Long-term spironolactone monotherapy
- D Eplerenone plus dexamethasone suppression
Explanation
Adrenal vein sampling (AVS) is the gold standard to distinguish unilateral from bilateral disease in primary hyperaldosteronism. A lateralization ratio ≥2:1 (post-ACTH) confirms unilateral source. Laparoscopic unilateral adrenalectomy is indicated for confirmed unilateral adenoma (Conn's adenoma); it cures hypokalemia in virtually all patients and normalises blood pressure in approximately 50–80%. Bilateral disease is managed medically with mineralocorticoid receptor antagonists, not bilateral adrenalectomy. Dexamethasone is used only for glucocorticoid-remediable aldosteronism (GRA/FH-I).
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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