Updated: 5/15/2019

Secondary Hyperaldosteronism

Review Topic
  • A 32-year-old woman presents to the clinic complaining of a pulsatile headache for the past 2 days. She describes a band-like, 6/10, intermittent pain around her temples. She denies trauma, vision changes, fever, upper respiratory tract infection signs, chest pain, or shortness of breath. Her temperature is 98.6°F (37°C), blood pressure is 164/78 mmHg, pulse is 87/min, and respirations are 12/min. Subsequent laboratory testing reveals a high level of renin (Renal artery stenosis).
  • Clinical definition
    • disorder caused by the overactivity of the renin-angiotensin-aldosterone system (RAAS)
  • Epidemiology
    • demographics
      • most commonly caused by renal artery stenosis
  • Pathogenesis
    • reduced renal blood flow
      • decreased renal blood flow stimulates the RAAS with resultant hypersecretion of aldosterone
      • obstructive renal artery disease
        • most commonly due to atherosclerosis
        • fibromuscular dysplasia (in young females)
        • atheroma
      • edematous disorders
        • heart failure
        • cirrhosis
        • nephrotic syndrome
        • chronic renal failure
    • ectopic secretion
      • juxtaglomerular cell tumor
      • other renin-secreting tumors (e.g., adrenal corticoadenoma)
    • Liddle syndrome 
      • rare autosomal dominant condition when there is a gain-of-function mutation in the collecting tubule sodium channel 
  • Symptoms
    • fatigue
    • headache
    • weakness (secondary to hypokalemia)
    • paresthesia
    • numbness
    • polyuria (secondary to hypokalemic nephropathy)
    • polydipsia
  • Physical exam
    • hypertension
    • peripheral edema (in severe cases)
    • tetany (due to hypokalemia)
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is often based on clinical suspicion, especially in patients with resistant hypertension, and confirmed via laboratory testing
    • imaging
      • computed tomography (CT)
        • best initial imaging test to look for masses 
      • magnetic resonance imaging (MRI)
        • more sensitive test  
    • studies
      • ideally, patients should not take any drugs that affect the RAAS (e.g., thiazide diuretics, ACE inhibitors, or angiotensin antagonists) for 4-6 weeks before tests are done
      • 24-hour urine aldosterone
        • best initial test
        • elevated levels suggest hyperaldosteronism
      • plasma renin concentration
        • best initial test, often ordered in conjunction with aldosterone
        • high renin and aldosterone levels suggest secondary hyperaldosteronism
      • basic metabolic/chemistry panels
        • hypokalemia
        • hypernatremia
        • metabolic alkalosis
  • Primary hyperaldosteronism 
    • distinguishing factor
      • will have low levels of renin due to the negative feedback mechanism
  • Management approach
    • management is focused on treating the underlying cause while treating the hypertension
  • First-line
    • anti-hypertensive therapy
      • spironolactone
        • may lead to gynecomastia
      • epleronone   
        • preferred in men due to its lack of anti-androgenic activity
  • Hypertensive crisis
  • Kidney damage/failure
  • Heart failure

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