Updated: 10/29/2020

Primary Hyperaldosteronism

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Questions
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Evidence
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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 
  • 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
  • Labs   
    • 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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(M2.EC.17.4753) A 27-year-old woman presents to her primary care physician for a follow-up appointment. At her previous visit she had missed her previous two menses and also had a blood pressure of 147/100 mmHg. The patient has a past medical history of anxiety, depression, bulimia nervosa and irritable bowel syndrome. Her physician prescribed her an exercise program as well as started her on hydrochlorothiazide and ordered lab work. The results of the patient's lab work are below:

Serum:
Na+: 145 mEq/L
K+: 2.9 mEq/L
Cl-: 100 mEq/L
HCO3-: 30 mEq/L
BUN: 18 mg/dL
Ca2+: 10.9 mg/dL
Mg2+: 2.0 mEq/L
Creatinine: 1.2 mg/dL
Glucose: 110 mg/dL

The patient's blood pressure at this visit is 145/100 mmHg and she has still not experienced her menses. Her cardiac, abdominal, and pulmonary exams are within normal limits. Inspection of the patient's oropharynx is unremarkable as is inspection of her extremities. The patient is started on furosemide and sent home. Which of the following is the most likely cause of this patient's presentation?

QID: 108883
1

Increased mineralocorticoid production

57%

(33/58)

2

Vomiting

16%

(9/58)

3

Obesity

3%

(2/58)

4

Increased reabsorption at the collecting duct

12%

(7/58)

5

Decreased renal artery blood flow

10%

(6/58)

M 6 C

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(M2.EC.15.12) A 44-year-old female presents to her primary care physician with complaints of headache, fatigue, muscle weakness, and frequent urination. These issues have developed and worsened over the past month. She has no significant prior medical or surgical history other than cholecystitis managed with cholecystectomy 5 years ago. Her vital signs at today's visit are as follows: T 37.1 C, HR 77, BP 158/98, RR 12, and SpO2 99%. Physical examination is significant for tetany, mild abdominal distension, reduced bowel sounds, and hypertensive retinal changes on fundoscopic exam. The physician orders a laboratory and imaging work-up based on his suspected diagnosis. An abdominal CT scan shows an 8 cm unilateral left adrenal mass suggestive of an adrenal adenoma. Which of the following sets of laboratory findings would be most likely in this patient?

QID: 104337
1

Metabolic acidosis, hypernatremia, hyperkalemia

0%

(0/23)

2

Metabolic acidosis, hyponatremia, hyperkalemia

9%

(2/23)

3

Metabolic acidosis, hypernatremia, hypokalemia

13%

(3/23)

4

Metabolic alkalosis, hypernatremia, hyperkalemia

4%

(1/23)

5

Metabolic alkalosis, hypernatremia, hypokalemia

70%

(16/23)

M 6 E

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(M2.EC.15.30) A 44-year-old male presents to his primary care physician with complaints of fatigue, muscle weakness, cramps, and increased urination over the past several weeks. His past medical history is significant only for hypertension, for which he was started on hydrochlorothiazide (HCTZ) 4 weeks ago. Vital signs at today's visit are as follows: T 37.2, HR 88, BP 129/80, RR 14, and SpO2 99%. Physical examination does not reveal any abnormal findings. Serologic studies are significant for a serum potassium level of 2.1 mEq/L (normal range 3.5-5.0 mEq/L). Lab-work from his last visit showed a basic metabolic panel and complete blood count results to all be within normal limits. Which of the following underlying diseases most likely contributed to the development of this patient's presenting condition?

QID: 104355
1

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)

5%

(1/19)

2

Pituitary adenoma

0%

(0/19)

3

Adrenal insufficiency

5%

(1/19)

4

Hyperaldosteronism

74%

(14/19)

5

Cushing's disease

11%

(2/19)

M 6 B

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(M2.EC.13.3) A 56-year-old man with a history of hypertension presents to his physician with progressive fatigue and new onset muscle cramps. He has had no recent changes to his medication regimen, which includes hydrochlorothiazide, lisinopril, and amlodipine. His temperature is 98.0°F (36.7°C), blood pressure is 174/111 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air. The patient's cardiopulmonary and abdominal exams are unremarkable. Laboratory values are ordered as seen below.

Serum:
Na+: 143 mEq/L
Cl-: 100 mEq/L
K+: 3.3 mEq/L
HCO3-: 33 mEq/L
BUN: 20 mg/dL
Glucose: 129 mg/dL

What is the most likely underlying etiology of this patient's hypertension?

QID: 104328
1

Aldosterone excess

10%

(1/10)

2

Catecholamine-secreting mass

10%

(1/10)

3

Cortisol excess

10%

(1/10)

4

Impaired kidney perfusion

10%

(1/10)

5

Increased peripheral vascular resistance

40%

(4/10)

M 6 E

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