Snapshot 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). Introduction Clinical definition disorder caused by the overactivity of the renin-angiotensin-aldosterone system (RAAS) Epidemiology Demographics most commonly caused by renal artery stenosis ETIOLOGY 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 Presentation 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) Studies 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 Differential Primary hyperaldosteronism distinguishing factor will have low levels of renin due to the negative feedback mechanism Treatment 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 Complications Hypertensive crisis Kidney damage/failure Heart failure