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Updated: Dec 10 2021

Primary Hyperaldosteronism

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Images
https://upload.medbullets.com/topic/120107/images/adrenal_gland_conn_syndrome4.jpg
https://upload.medbullets.com/topic/120107/images/adrenal_gland_(zona_glomerulosa).jpg
  • Snapshot
    • A 33-year-old woman returns to your clinic for continued management of her hypertension. She reports compliance with lifestyle modifications and prescribed anti-hypertensive medications including lisinopril, metoprolol, and losartan. She reports feeling fatigued and has noted slight abdominal distention. Her blood pressure at this visit is 155/92 mmHg. Serum laboratory tests show potassium 3.1 mEq/L and sodium 144 mEq/L.
  • Introduction
    • Overview
      • primary hyperaldosteronism is a clinical condition caused by excessive and unregulated aldosterone secretion from the adrenal gland, usually from either an adrenal adenoma or adrenal hyperplasia
        • presents with hypertension that is refractory to medical treatments
        • treatment is adrenalectomy if caused from an adrenal adenoma and medical therapy if cause by adrenal hyperplasia
  • Epidemiology
    • Incidence
      • ~10% of patients with hypertension
    • 2/3 due to adrenal adenoma
      • demographics
        • more common in women
    • 1/3 due to adrenal hyperplasia
      • demographics
        • more common in African Americans
    • Usually between the ages of 30-50
  • Etiology
    • Pathophysiology
      • mechanism
        • aldosterone secretion independent of the renin-angiotensin system
          • aldosterone-secreting adenoma of the zona glomerulosa (Conn syndrome)
          • bilateral adrenal hyperplasia
          • adrenal carcinoma
  • Presentation
    • Symptoms
      • headache
      • muscle weakness (due to hypokalemia)
      • palpitations
      • polyuria (due to hypokalemic nephropathy)
      • polydipsia
      • nausea and vomiting
    • Physical exam
      • hypertension
        • refractory to medical treatments
      • arrhythmia
      • abdominal distention
      • no peripheral edema (due to aldosterone escape) but may be present in severe cases
  • Imaging
    • CT
      • indications
        • to evaluate the cuase of primary hyperaldosteronism
        • can differentiate between hyperplasia, adenoma, and carcinoma
  • Studies
      • serum
        • hypokalemia
        • mild hypernatremia
        • metabolic alkalosis
    • Invasive studies
      • plasma aldosterone to plasma renin
        • screening test
        • positive screen shows an inappropriately high ratio ≥ 30
      • saline infusion test
        • definitive diagnosis test
        • persistently elevated aldosterone ≥ 8.5 ng/dL is diagnostic
      • adrenal venous sampling
        • measure aldosterone level
        • unilateral elevation indicates adenoma
        • bilateral elevation indicates bilateral hyperplasia
  • Differential
    • Secondary hyperaldosteronism
      • key distinguishing factor
        • elevated renin
    • Adrenal incidentaloma
      • key distinguishing factor
        • nonfunctioning adrenal neoplasm
  • Treatment
    • Pharmacologic
      • spironolactone or eplerenone
        • indications
          • hypertension
          • bilateral adrenal hyperplasia
    • Operative
      • adrenalectomy
        • indications
          • unilateral adenoma
  • Complications
    • Hypertensive crisis, cardiomyopathy, and nephropathy
    • Stroke
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