PERSPECTIVE article
Front. Endocrinol.
Sec. Adrenal Endocrinology
Primary Aldosteronism: Adrenalectomy Could Save More Lives
Provisionally accepted
- 1Carling Adrenal Center, Tampa, United States
- 2HCA Healthcare, Nashville, United States
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Primary aldosteronism (PA), a leading cause of secondary hypertension, remains profoundly underdiagnosed, contributes to vast preventable cardiovascular morbidity and mortality worldwide. Affecting 4.5–20% of patients with high blood pressure, PA drives excess aldosterone production, substantially elevating risks of heart failure, stroke, atrial fibrillation, and renal damage, with untreated cases facing 10–20% higher mortality rates over 5–10 years compared to essential hypertension. Adrenalectomy for unilateral PA driven by somatic mutations (e.g., KCNJ5) offers markedly superior outcomes over medical therapy, yielding an absolute risk reduction in all-cause mortality that rivals or exceeds many major cardiovascular surgeries and greatly improves quality of life by resolving hypertension, hypokalemia, and associated symptoms. Advanced surgical approaches such as mini back scope adrenalectomy (posterior retroperitoneoscopic) minimize risks and enable precise, function-preserving surgery. Yet, current surgical rates, ranging from 1.2 to 8.4 per million across countries like Sweden, Taiwan, France, UK, Germany, and USA, represent less than 4% of the optimal rate of 212 operations/million. Achieving optimal adrenalectomy rates requires increasing surgical capacity 25–170-fold, potentially saving 5,627 lives annually in the USA alone. Disparities arise from diagnostic barriers, including underutilization of aldosterone-to-renin ratio screening, complex confirmatory testing, and limited access to adrenal vein sampling and high-volume adrenal surgeons. This perspective highlights PA's severe burden, compares adrenalectomy's efficacy to major cardiac and vascular operations, examines international caseload variations linked to research infrastructure, PA guidelines, access to high-volume centers, and strongly urges enhanced PA screening, improved case detection and diagnostic workflows, and expanded surgical access to avert this silent epidemic.
Keywords: Adrenalectomy, primary aldosteronism, Aldosterone, Mortality, Underdiagnosis
Received: 01 Nov 2025; Accepted: 25 Nov 2025.
Copyright: © 2025 Carling and Faucz. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Fabio Rueda Faucz
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