The Endocrine Society's New Guidelines on Primary Aldosteronism (PA) - Comments and Critique by the Carling Adrenal Center

The Endocrine Society has recently released its updated clinical practice guidelines for Primary Aldosteronism (PA) in 2025, marking a significant revision nearly a decade after the previous iteration. Published in The Journal of Clinical Endocrinology & Metabolism, these guidelines aim to provide a framework for diagnosing and managing PA, a common endocrine cause of hypertension characterized by excessive aldosterone production. At the Carling Adrenal Center, we applaud the progress made in these guidelines but believe there are areas where simplification and innovation could further enhance patient outcomes. Below, we outline our key observations and critiques, emphasizing practical improvements and the importance of individualized care.

Universal Screening for PA: A Long-Overdue Endorsement

For decades, Dr. Tobias Carling and the Carling Adrenal Center have advocated for universal screening of all patients with hypertension for PA. The 2025 Endocrine Society guidelines finally align with this stance, recommending screening for PA in all individuals with hypertension. This is a monumental step forward. PA affects 5% to 14% of individuals with hypertension in primary care settings and up to 30% in referred hypertensive patients, making it the most common endocrine cause of high blood pressure. Early detection can prevent severe complications such as renal injury, stroke, and cardiovascular diseases, which are significantly elevated in PA patients due to aldosterone excess.

Screening for PA is simple, cost-effective, and can be performed using the aldosterone-to-renin ratio (ARR), a test with high sensitivity (97%) and specificity (94%) when properly conducted. By identifying PA early, we can initiate targeted treatments like mineralocorticoid receptor antagonists (MRAs) or curative surgery, potentially saving thousands of lives and reducing the burden of chronic hypertension-related morbidity. The Carling Adrenal Center has long championed this approach, and we are gratified to see the Endocrine Society catch up to this critical public health strategy.

Overly Cumbersome Diagnostic Workup: A Barrier to Care

While the guidelines’ endorsement of universal screening is a victory, the recommended diagnostic workup remains overly complex, potentially delaying or denying curative treatment for many patients. The guidelines advocate for confirmatory testing and adrenal vein sampling (AVS) in most cases to distinguish between unilateral and bilateral PA. This process, while thorough, is resource-intensive, requires specialized expertise, and is not universally accessible, particularly in rural or underserved regions.

At the Carling Adrenal Center, we propose a more streamlined approach. If two sets of laboratory tests demonstrate a normal to high aldosterone level combined with a low renin level (indicative of PA with an ARR ≥ 20 for plasma renin activity or ≥ 70 for direct renin concentration when measured by immunoassay), the next step should be a computed tomography (CT) scan of the adrenals. This simplifies the diagnostic pathway, reducing the need for confirmatory tests like aldosterone suppression tests, which can be logistically challenging and less necessary in clear-cut cases. For patients with a unilateral adrenal adenoma on CT, particularly those under 60 years and/or female with marked PA and hypokalemia, the guidelines themselves note that AVS may be unnecessary. We believe this exception should be expanded to expedite surgical intervention, particularly minimally invasive adrenalectomy, which offers a potential cure.

By prioritizing efficiency, we can reduce diagnostic delays and ensure more patients have access to potentially curative surgery without the burden of excessive testing. The current guidelines’ reliance on AVS for most patients risks excluding those in regions without access to specialized centers, perpetuating inequities in care. An individualized approach to AVS and confirmatory testing is warranted.

Function-Preserving Adrenalectomy: A Missed Opportunity

One significant oversight in the 2025 guidelines is the lack of discussion on function-preserving adrenalectomy, a major surgical advancement for PA patients. Recent studies, such as the one recently published (Carling T, LaRue M. Improved and individualized approach to adrenal surgery. Endocr Relat Cancer. 2025), highlight the benefits of partial adrenalectomy, which preserves healthy adrenal tissue while removing aldosterone-producing adenomas. This approach minimizes the risk of adrenal insufficiency and reduces the need for lifelong glucocorticoid replacement, improving patients’ quality of life.

The guidelines’ failure to address this option is a missed opportunity to promote innovative surgical techniques that align with the goal of personalized medicine. At the Carling Adrenal Center, we have successfully implemented function-preserving adrenalectomy for select patients, tailoring the procedure to the individual’s anatomy and disease characteristics. Including this approach in the guidelines would have encouraged its adoption, potentially transforming the surgical management of PA.

Surgery for Bilateral PA: An Underemphasized Option

Another critical gap in the guidelines is the lack of discussion on surgical options for bilateral PA. The document focuses heavily on medical management with MRAs, such as spironolactone, for bilateral disease. While MRAs are effective, studies cited in the guidelines demonstrate that surgical management, such as unilateral or function-preserving bilateral adrenalectomy in select cases of bilateral PA, can achieve better blood pressure control and lower cardiovascular risk compared to medical therapy alone.

Research indicates that even in bilateral PA, one adrenal gland may contribute disproportionately to aldosterone excess. Targeted surgical intervention, guided by advanced imaging or AVS, can offer superior outcomes compared to lifelong pharmacotherapy. The guidelines’ omission of this option limits the consideration of surgery for patients who might benefit from it, particularly those with refractory hypertension or intolerance to MRAs. At the Carling Adrenal Center, we evaluate each patient with bilateral PA individually, considering surgical intervention when appropriate to optimize outcomes.

The Carling Adrenal Center: A Leader in Individualized PA Care

At the Carling Adrenal Center, we pride ourselves on being the world’s highest-volume center for adrenal surgery and AVS, offering unparalleled expertise in the diagnosis and treatment of PA. Our approach is rooted in viewing each patient as an individual, tailoring diagnostic and therapeutic strategies to their unique clinical profile. Whether it’s streamlining the diagnostic process, performing function-preserving adrenalectomy, or considering surgical options for bilateral PA, our goal is to provide the most effective and efficient care possible.

Our center’s extensive experience allows us to navigate the complexities of PA with precision, ensuring that patients receive timely diagnoses and access to cutting-edge treatments. We advocate for simplifying the diagnostic pathway to make PA screening and management more accessible, particularly for underserved populations. By combining advanced surgical techniques, such as minimally invasive and function-preserving adrenalectomy, with a patient-centered philosophy, we strive to set the standard for PA care globally.

When performed by Dr. Carling, a mini back scope adrenalectomy (MBSA) for PA (Conn's Syndrome) typically takes less than 20minutes.  Without a doubt, the best operation for removing the adrenal tumor that is causing PA and Conn's syndrome is the MBSA. The MBSA is the preferred technique in over 95% of adrenal surgery cases, and close to 100% (since it is rare with tumors > 8cm in PA) in patients with PA.

Conclusion

The Endocrine Society’s 2025 guidelines on Primary Aldosteronism represent a significant step forward, particularly in endorsing universal screening for PA among hypertensive patients—a position the Carling Adrenal Center has championed for decades. However, the guidelines fall short in addressing critical advancements like function-preserving adrenalectomy and surgical options for bilateral PA, while the recommended diagnostic workup remains overly complex for many clinical settings. At the Carling Adrenal Center, we believe that simplifying the diagnostic process and embracing innovative surgical techniques can improve outcomes and reduce disparities in PA care. As the world’s leading center for adrenal surgery, we remain committed to providing individualized, high-quality care that pushes the boundaries of what is possible for patients with PA.

Reference

• Adler GK, Stowasser M, Correa RR, Khan N, Kline G, McGowan MJ, Mulatero P, Murad MH, Touyz RM, Vaidya A, Williams TA, Yang J, Young WF, Zennaro MC, Brito JP. Primary Aldosteronism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2025 Jul 14:dgaf284. doi: 10.1210/clinem/dgaf284. Epub ahead of print. PMID: 40658480.

Dr. Tobias Carling, of the Carling Adrenal Center, is one of the world's leading experts in adrenal gland surgery. Dr. Carling performs more adrenal operations than any other surgeon in America. Dr. Carling left Yale University in 2020 to open the Carling Adrenal Center in Tampa, Florida.

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Additional Resources: 

• Learn more about the Carling Adrenal Center
• Learn more about Dr. Tobias Carling
• Learn more about our sister surgeons at the Norman Parathyroid Center, and Clayman Thyroid Center.
• Learn more about the Hospital for Endocrine Surgery