Abstract Introduction Following resection of unilateral aldosteron producing adenoma, there is a risk of transient but clinically important hyperkalemia due to hypoaldosteronism. It is usually associated with a mild metabolic acidosis with a normal anion gap that is named type 4 renal tubuler acidosis. Here we present a rare but life-threatening condition due to electrolyte imbalance after unilateral adrenalectomy. Clinical Case A 60-year-old female patient was referred to the endocrinology clinic in November 2024 with primary hyperaldosteronism. In August 2024, the patient presented to the internal medicine outpatient clinic with fatigue. Also elevated blood pressure was noted (systolic 150–160 mmHg, diastolic 90–100 mmHg) and hypokalemia observed (3.1 mmol/L). There was no history of hypertensive crises, stress-related fluctuations, or use of additional medications. She was started on Lercanidipine 20 mg once daily. She had surgical treatment of an intracranial aneurysm rupture 15 years before. There was no family history of hypertension. On physical examination, the patient was 155 cm tall and weighed 75 kg, body mass index of 31 kg/m², consistent with obesity. Peripheral pulses were bilaterally palpable. Cardiovascular examination revealed no abnormalities. Laboratory results before surgery showed in Table-1. Adrenal MRI imaging disclosed bilateral adrenal masses: a right adrenal lesion measuring about 28×17 mm situated at the medial crus, and a left adrenal lesion measuring 6×10 mm placed at the junction of the body and medial crus. Pentixafor PET-CT exhibited heightened uptake in the right adrenal lesion. (Figure-1) A right adrenalectomy was conducted on February 2025. Histopathological analysis verified the presence of a cortical adenoma. During the initial postoperative month, the patient experienced hyperkalemia (6.4 mmol/L) and acute renal damage. Dehydration management, along by potassium-binding treatment with calcium polystyrene sulfonate, was started. Potassium levels fell to 4.8 mmol/L. In the third postoperative month, serum potassium levels rose to 7.3 mmol/L, accompanied by metabolic acidosis, necessitating referral to the emergency department. No abnormalities were observed in the electrocardiogram. Due to refractory hyperkalemia, she received urgent hemodialysis for 2 hours, followed by an additional dialysis session the subsequent day. (Table-2) Hydrocortisone 50 mg was administered four times daily. A diagnosis of transient hypoaldosteronism resulting from adrenalectomy for primary hyperaldosteronism was suggested. Aldosterone levels were less than 3.7 ng/dL. Hydrocortisone was terminated, and fludrocortisone 0.1 mg was commenced once daily. Potassium levels normalized. Conclusion hyperkalemia after unilateral adrenalectomy for primary hyperaldosteronism represents a noteworthy observation. Clinicians must consider the risk of postoperative hypotension and hyperkalemia, and ensure diligent follow-up post-surgeryFigure 1:Pentixafor PET-CT increased uptake at right adrenal gland Table 1:Laboratory Results Before Surgery Table 2:Laboratory Results After Surgery
Salva et al. (Thu,) studied this question.