Updated: 12/21/2019

Primary Hyperaldosteronism

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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
  • Clinical definition
    • excess aldosterone from autonomous secretion from the adrenal gland
  • Epidemiology
    • ~10% of hypertension
    • 2/3 due to adrenal adenoma 
      • more common in women
    • 1/3 due to adrenal hyperplasia
      • more common in African Americans
    • usually between the ages of 30-50 
  • Pathogenesis
    • 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
Studies
  • Diagnostic testing
    • diagnostic approach
      • suspect in patients with hypertension resistant to medical management
      • confirm with laboratory studies and imaging
    • 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
      • chemistries
        • hypokalemia
        • mild hypernatremia
        • metabolic alkalosis
    • imaging
      • computerized tomography scan or magnetic resonance imaging of the adrenal glands
Differential
  • Secondary hyperaldosteronism
    • distinguishing factor
      • elevated renin
  • Adrenal incidentaloma
    • distinguishing factor
      • nonfunctioning adrenal neoplasm
Treatment
  • Management approach
    • treat underlying cause
      • unilateral adenoma adrenalectomy
        • medical therapy, if poor surgical candidate
      • bilateral hyperplasia → medical therapy
    • normalize blood pressure
    • normalize chemistries
  • First-line medical therapy
    • anti-hypertensive therapy
      • spironolactone or eplerenone
        • inhibits the action of aldosterone
        • spironolactone may lead to gynecomastia
        • eplerenone has decreased anti-androgenic effect compared to spironolactone
Complications
  • Hypertensive crisis
  • Hypertensive cardiomyopathy
  • Hypertensive nephropathy
  • Stroke
 

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Questions (8)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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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?
Review Topic | Tested Concept

QID: 108883
1

Increased mineralocorticoid production

56%

(28/50)

2

Vomiting

16%

(8/50)

3

Obesity

4%

(2/50)

4

Increased reabsorption at the collecting duct

10%

(5/50)

5

Decreased renal artery blood flow

12%

(6/50)

L 2 C

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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? Review Topic | Tested Concept

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)

L 2 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? Review Topic | Tested Concept

QID: 104337
1

Metabolic acidosis, hypernatremia, hyperkalemia

0%

(0/20)

2

Metabolic acidosis, hyponatremia, hyperkalemia

5%

(1/20)

3

Metabolic acidosis, hypernatremia, hypokalemia

10%

(2/20)

4

Metabolic alkalosis, hypernatremia, hyperkalemia

5%

(1/20)

5

Metabolic alkalosis, hypernatremia, hypokalemia

75%

(15/20)

L 2 E

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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+: 138 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?
Review Topic | Tested Concept

QID: 104328
1

Aldosterone excess

0%

(0/6)

2

Catecholamine-secreting mass

0%

(0/6)

3

Cortisol excess

17%

(1/6)

4

Impaired kidney perfusion

0%

(0/6)

5

Increased peripheral vascular resistance

67%

(4/6)

L 2 E

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