PONE-D-22-08400

Illness perspectives in patients with primary aldosteronism

PLOS ONE

Dear Dr. Ragnarsson,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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The reviewer was overall positive about your manuscript, but had feedback about reporting in the Methods, Results, and Discussion sections. Among their concerns, the reviewer expressed that the article should discuss how results for different groups of participants compared with one another, i.e. differences between treatment groups, and differences between participants who showed complete, partial, or no clinical success following adrenalectomy. Please address all of the reviewer's comments in manuscript revisions and your Response to Reviewer letter.

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

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Reviewer #1: No

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Reviewer #1: Yes

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5. Review Comments to the Author

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Reviewer #1: The study of Ragnarsson O. and colleagues qualitatively describes the quality of life of patients with primary aldosteronism before, during and after treatment in both, unilateral and bilateral disease. This is the first study to adopt a qualitative approach to this topic and therefore is of particular interest.

The study is well designed and described; however, some issues are presents and are listed below:

Methods:

• I suggest to provide more information for screening test, confirmatory test and respective cut-offs for PA diagnosis.

• More details on AVS methods (stimulated or unstimulated? simultaneous or sequential?) criteria should be provided

Results:

• How many medically treated patients were treated with spironolactone? How many with eplerenone? Did the authors notice any difference between the two groups?

• There was any difference between patients that showed complete clinical success after adrenalectomy (defined according to PASO criteria, Williams TA, Lancet DE 2017 doi: 10.1016/

S2213-8587(17)30135-3) and those that showed partial or absent clinical success? Did biochemical success influence the satisfaction after adrenalectomy?

Discussion:

• Many studies reported that QOL is reduced in patients with PA, compared to the general population. However, patients with PA show similar QOL compared to patients with EH matched for hypertension severity (Buffolo F, EJCI 2021, DOI: 10.1111/eci.13419). This finding may suggest that hypertension and antihypertensive drug treatment may be the most important factors affecting QOL in PA patients, more than the effect of aldosterone per se. I suggest to briefly discuss this aspect in Discussion.

• Some authors reported that patients with PA showed reduced well-being and higher levels of stress and psychological distress (Sonino N, JCEM 2011; doi: 10.1210/jc.2010-2723). Moerover, depressive symptoms improve at FU after adrenalectomy (Citton, BMC surgery 2019, doi:10.1186/s12893-018-0432-1). I would discuss this themes in Discussion describing whether some of this aspects emerged from the interviews of this study

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Reviewer #1: No

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Illness perspectives in patients with primary aldosteronism

PONE-D-22-08400R1

Dear Dr. Ragnarsson,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Esmat Mehrabi

Academic Editor

PLOS ONE

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