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Updated: Dec 10 2021

Secondary Hyperaldosteronism

  • 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
    • 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
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