Uslar, ThomasSanfuentes, BenjamínOlmos, RobertoBurnier, AlberthBöhm, PaulineGuarda, Francisco J.Huete, ÁlvaroMertens, NicolásBesa, CeciliaAndía, MarceloMajerson, AlejandroCartes, JaimeTapia-Castillo, AlejandraCarvajal, Cristian A.Fardella, Carlos E.Allende, FidelSolari, SandraVaidya, AnandBaudrand, Rene2026-07-212026-07-212026-06-27European Journal of Internal Medicine, (2026), Article 1070420953-6205https://hdl.handle.net/20.500.12254/7674Background: Incidental adrenal adenomas are common, yet renin status is infrequently assessed in hypertensive patients. Emerging evidence supports a spectrum of renin-independent aldosterone excess associated with adverse cardiovascular risk. Objective and methods: To determine the frequency of a low-renin phenotype in a prospective cohort of hypertensive patients with adrenal adenomas and to evaluate the clinical response to aldosterone-targeted therapy across baseline aldosterone categories. Low-renin phenotype was defined as suppressed renin (PRA <1.0 ng/mL/ h or DRC <10 μIU/mL). Among these patients, plasma aldosterone concentration (PAC) was categorized as 5–10 ng/dL (Group 1), 10–15 ng/dL (Group 2), and >15 ng/dL (Group 3). Patients with suppressed renin were treated with MR antagonists or adrenalectomy and followed longitudinally using PAMO/PASO criteria. Results: Low renin was present in 47% (138/290) of hypertensive patients. Increasing aldosterone levels were associated with higher systolic blood pressure (SBP), resistant hypertension, higher antihypertensive treatment burden, lower potassium, and reduced eGFR (p-trend <0.001). After a mean follow-up of 24±18 months (n = 121), aldosterone-targeted therapy (75% medical, 25% surgical) led to significant reductions in SBP (-18, -26, and -30 mmHg across Groups 1–3; all p < 0.001), decreased medication and significant increases in renin (all p < 0.001), irrespective of aldosterone category. Conclusions: Nearly half of hypertensive patients with adrenal incidentalomas exhibit suppressed renin levels associated with greater blood pressure burden and favorable response to aldosterone-targeted therapy, even in lower aldosterone levels categories. These findings support systematic renin assessment in hypertensive patients with incidental adrenal adenomas and provide a rationale for testing aldosterone-targeted therapy in broader hypertensive populations beyond adrenal adenomasenAtribución-NoComercial-CompartirIgual 3.0 Chile (CC BY-NC-SA 3.0 CL)Adrenal adenomasLow renin hypertensionAldosterone dysregulationHypertensionPrimary aldosteronismMineralocorticoid receptorAdrenal incidentalomaArticlehttps://orcid.org/0000-0002-6081-1468https://doi.org/10.1016/j.ejim.2026.107042