Perirenal fat (PRF), an ectopic fat depot lying adjacent to kidneys, is a risk factor for cardiometabolic and renal dysfunctions in patients with obesity and type 2 diabetes. We aimed to investigate the involvement of PRF in the pathophysiology and treatment of primary aldosteronism (PA). To this end, we measured PRF volume by abdominal CT and evaluated the relationships among PRF volume, cardiometabolic and renin-angiotensin-aldosterone system (RAAS) parameters, and therapeutic response to mineralocorticoid receptor antagonist (MRA) treatment in well-phenotyped PA patients. In addition, we evaluated the effects of MRA treatment on inflammation and fibrosis, potential downstream targets of MR signaling, by analyzing PRF obtained from obese (db/db) mice. PRF volume (PRF%) and visceral fat volume (VFV) were associated with various cardiometabolic and renal risk markers and RAAS parameters, such as body mass index, creatinine, triglyceride, high-density lipoprotein cholesterol, uric acid, fasting glucose, C-reactive protein, 24-h urine aldosterone, and 24-h urine normetanephrine (all P < 0.05). PRF%, but not VFV, positively correlated with changes in systolic and diastolic blood pressure and initial estimated glomerular filtration rate (eGFR) fall following MRA treatment after adjusting for confounders (all P < 0.05). In addition, MRA treatment decreased PRF expression of markers of macrophage infiltration and fibrosis in db/db mice (all P < 0.05). In conclusion, our results suggest that PRF accumulation is involved in the mechanisms linking MR activation to cardiometabolic and renal dysfunctions in PA patients. Moreover, PRF could be not only a prognostic factor but also a new therapeutic target for MRA-resistant hypertension.