Hyperaldosteronism


Article Author:
Alejandro Dominguez


Article Editor:
Sonu Gupta


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
4/18/2019 12:41:13 PM

Introduction

Hyperaldosteronism occurs due to the excess production of aldosterone from the adrenal gland. Hyperaldosteronism can initially present as essential and refractory hypertension and can often go undiagnosed. This disorder can be of primary or secondary origin, both presenting similarly but differentiated by a set of lab values and diagnostic studies. Treatment is specific to the individual causes of hyperaldosteronism.[1][2][3][4]

Etiology

Its primary or secondary origin can differentiate hyperaldosteronism.[5]

Primary hyperaldosteronism is due to the excess production of the adrenal gland, more specifically the zona glomerulosa. This can present more commonly as a primary tumor in the gland known as Conn syndrome or bilateral hyperplasia. Rarer forms are unilateral adrenal hyperplasia, ectopic aldosterone-secreting tumors, aldosterone-producing adrenocortical carcinomas, and familial hyperaldosteronism type 1.

Secondary hyperaldosteronism occurs due to excess activation of the renin-angiotensin-aldosterone system (RAAS). This activation can take the form of a renin-producing tumor, renal artery stenosis, or edematous disorders like left ventricular heart failure, cor pulmonale, or cirrhosis with ascites.

Epidemiology

Primary hyperaldosteronism is the culprit of less than 1% of hypertensive patients. Although a higher prevalence has been considered, studies have shown an overestimation of cases. Secondary hyperaldosteronism is diagnosed even less often than primary. Both present more frequently in women.

Pathophysiology

Primary hyperaldosteronism occurs due to the excess production of the adrenal gland. The most common cause in two-thirds of the patients occurs due to idiopathic bilateral adrenal hyperplasia. In one-third of patients, a tumor in the zona glomerulosa, known as Conn syndrome, can directly cause an increase in aldosterone. The clinical picture of these patients can range from asymptomatic to hypertension with hypokalemia.

Secondary hyperaldosteronism occurs due to the excess stimulation of the RAAS. Renal artery stenosis (either in the form of atherosclerosis or fibromuscular dysplasia) causes decreased blood flow through the kidneys, stimulating a false sense of hypovolemia and activating aldosterone secretion. In left-sided heart failure and cor pulmonale, a decrease in cardiac output causes aldosterone stimulation. Cirrhosis with ascites patients will produce decreased circulating fluid volume, resulting in less perfusion through the kidneys and causing an increase in aldosterone. Less common is a renin-producing tumor in the juxtaglomerular cells. Like primary, secondary hyperaldosteronism can present with a wide clinical range.

Histopathology

While histopathology is not a common diagnostic tool for hyperaldosteronism, studies have found a correlation between the immunohistochemical staining of CYP-11B2 in aldosterone-producing adenomas. This is primarily used to differentiate the variable types of adenomas such as unilateral micronodules, subtype classifications of adrenal adenomas, multiple aldosterone-producing cell clusters, and aldosterone-producing adenomas.

History and Physical

Patients often can present asymptomatically, but this varies with the severity of hyperaldosteronism. First-occurrence and resistant hypertension are the most common presenting symptoms for these patients, and the sequelae of fatigue, headache, polyuria, and polydipsia commonly occur with it. Metabolic alkalosis is frequently observed in these patients as they are susceptible to the same mechanism that occurs in contraction alkalosis.

Concurrently, hypokalemia historically has been found in a majority of cases, but recent studies have shown a less than 40% correlation. Mild hypernatremia and hypomagnesemia also are found in these patients.

More rarely, muscle weakness and spasms occur due to the hypokalemia of the disorder. Numbness and paroxysmal paralysis also have been reported.

Evaluation

Laboratory findings are typically consistent with hypokalemia, mild hypernatremia, and mild hypomagnesemia.[6][7][8]

Plasma renin concentration (PRC) and plasma renin activity (PRA) are initial laboratory measurements ordered when hyperaldosteronism is suspected. In primary hyperaldosteronism, the PRC and PRA will be decreased (less than 1 ng/mL/hour and undetectable, respectively) as the increased aldosterone originates from the zona glomerulosa itself and not an extrinsic pathway. In secondary hyperaldosteronism, the PRC and PRA will be increased, as renin is the mediator for its hyperaldosteronism effect. These levels are measured in the morning after patients have been out of bed for more than two hours and sitting for at least 5 minutes.

Plasma aldosterone concentration (PAC) to PRA ratio is used to confirm a suspicion of primary hyperaldosteronism. Specific criteria vary from institution to institution, but studies support an elevated PAC/PRA (greater than 30) and PAC (greater than 20 ng/dL) levels with a sensitivity and specificity of 90%. However, a PAC/PRA ratio of greater than 20 and PAC greater than 15 ng/dL have been reported to be sufficient. In secondary hyperaldosteronism, both PRA and PRC are increased, but the PAC/PRA is less than 10.

Twenty-four-hour urine collection is controversial in hyperaldosteronism, but it is used to detect inappropriate potassium wasting (greater than 30 mEq/day). This is primarily used to rule out extrarenal losses and diuretic abuse for explanations of hypokalemia with insignificant to mild aldosterone increases.

Aldosterone suppression testing is typically necessary for confirmation and is achieved with sodium loading and consequent aldosterone measurement. This can be performed with oral sodium loading over 3 days (5000 mg total in diet or 90 mEq of sodium as a tablet) and a urine aldosterone excretion measurement of greater than 12 mcg/day to confirm hyperaldosteronism. Another method is a two-liter intravenous isotonic saline infusion over 4 hours. With the saline infusion, PAC levels greater than 10 ng/dL are consistent with hyperaldosteronism; however, saline infusion has a false negative rate of 30%.

Radiological imaging such as CT scan can be used to differentiate adenomas from bilateral hyperplasia, but studies have found that CT cannot differentiate the two reliably.

Adrenal vein sampling is used to differentiate unilateral from bilateral pathology if a CT scan is not diagnostic. An incongruence in levels (usually a four-fold increase on the side of the adenoma) indicates unilateral origin, whereas equivalent levels indicate bilateral origin.

Treatment / Management

Surgery is the treatment of choice in primary hyperaldosteronism cases where a unilateral lesion is the source of disease. A laparoscopic adrenalectomy is preferred over open adrenalectomy due to fewer complications and a shorter hospital stay. Complete adrenalectomy is preferred over partial adrenalectomy due to greater efficacy and resolution of symptoms. For nonsurgical candidates, mineralocorticoid receptor antagonists (MRA) were preferred as a medical therapy.[9][10][11]

For bilateral hyperplasia in primary hyperaldosteronism, MRAs are the treatment of choice. Either spironolactone or eplerenone is used, depending on the adverse effect profile exhibited in the patient. A combination of medical therapy, sodium restriction (less than 100 mEq/day), alcohol avoidance, smoking cessation, aerobic exercise, and maintenance of ideal body weight were shown to produce the best results. According to the 2016 Endocrine Society Guidelines, the spironolactone starting dose is 12.5 to 25 mg daily and titrated upward every 2 weeks. Eplerenone is started at 50 mg daily and titrated upward. The clinical course ultimately dictates increase and frequency in dosage.[12][13]

For secondary hyperaldosteronism, the treatment of the underlying disease will lead to resolution of the symptoms. Salt restriction also is recommended for better efficiency.

Differential Diagnosis

Similar presentations have been observed in essential hypertension, Liddle syndrome, syndrome of apparent mineralocorticoid excess, congenital adrenal hyperplasia, primary glucocorticoid resistance, and ectopic adrenocorticotropic hormone (ACTH) syndrome.

Essential hypertension presents with a normal PAC/PRA ratio. Liddle syndrome will have low aldosterone levels and will normally present in childhood. Syndrome of apparent mineralocorticoid excess will present with low aldosterone levels, high urinary free cortisol levels, hereditary implications, and/or a history of excessive licorice consumption. Congenital adrenal hyperplasia will have a family history of 11-beta-hydroxylase or 17-alpha-hydroxylase deficiency and low aldosterone levels. Primary glucocorticoid resistance will have low aldosterone levels, an elevated ACTH and cortisol, and a family history of this syndrome. Ectopic ACTH syndrome will have elevated ACTH that cannot be suppressed with high-dose dexamethasone, and these patients will have an underlying tumor.

Prognosis

Few studies have been performed on the mortality rates of either form of hyperaldosteronism, but 10-year-survival rates have been reported between 90% to 95% in patients who are treated. The most common morbidity associated with this disorder is cardiovascular. Cardiovascular mortality is increased in these patients, but all-cause mortality is not significantly different.

Complications

The most common complication and comorbidity associated with these patients is the increased risk of cardiovascular mortality. This is associated with excessive aldosterone secretion and can present as atrial fibrillation, left ventricular hypertrophy, myocardial infarction, and stroke.

Postoperative and Rehabilitation Care

Salt restriction (less than 100 mEq/day), alcohol cessation, smoking cessation, maintenance of ideal body weight, and aerobic exercise are all beneficial in the postoperative and posttreatment care.

Consultations

Endocrinologists and nutritionists can better manage these patients long-term. Surgery is indicated for a subset of this disorder.

Enhancing Healthcare Team Outcomes

The diagnosis and management of hyperaldosteronism is complex and best done by a multidisciplinary team that includes a radiologist, pathologist, internist, endocrinologist, nurse practitioner and a surgeon. Surgery is the treatment of choice in primary hyperaldosteronism cases where a unilateral lesion is the source of disease. A laparoscopic adrenalectomy is preferred over open adrenalectomy due to fewer complications and a shorter hospital stay. Complete adrenalectomy is preferred over partial adrenalectomy due to greater efficacy and resolution of symptoms. For nonsurgical candidates, mineralocorticoid receptor antagonists (MRA) were preferred as a medical therapy. 

The primary care providers should educate the patient on the importance of salt restriction, alcohol cessation, smoking cessation, maintenance of ideal body weight, and aerobic exercise. Follow up is necessary as the risk of adverse cardiac events is high in these patients.[13]


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Hyperaldosteronism - Questions

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A 43-year-old man has hypertension, confirmed by 5 readings above 160/99. He refuses medications but quits smoking, starts a low sodium diet, and enters an exercise program. What aspect of the adrenal gland is expected to increase secondary to his diet?



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What is usually seen in a patient with excess aldosterone?



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A 28-year-old woman has a blood pressure of 180/115 and a potassium of 2.8. Which of the following tests should be ordered?



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Which one of the following features is not likely to be observed in patients with primary aldosteronism?



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A 60-year-old male has uncontrolled hypertension resistant to multiple antihypertensives. Abdominal CT shows the presence of bilateral adrenal hyperplasia. Which one of the following is consistent with a diagnosis of primary hyperaldosteronism?



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Hyperaldosteronism - References

References

Stowasser M,Wolley M,Wu A,Gordon RD,Schewe J,Stölting G,Scholl UI, Pathogenesis of Familial Hyperaldosteronism Type II: New Concepts Involving Anion Channels. Current hypertension reports. 2019 Apr 4;     [PubMed]
Corssmit EPM,Dekkers OM, Screening in adrenal tumors. Current opinion in oncology. 2019 May;     [PubMed]
Chikladze NM,Favorova OO,Chazova IE, Family hyperaldosteronism type I: a clinical case and review of literature. Terapevticheskii arkhiv. 2018 Sep 20;     [PubMed]
Pons Fernández N,Moreno F,Morata J,Moriano A,León S,De Mingo C,Zuñiga Á,Calvo F, Familial hyperaldosteronism type III a novel case and review of literature. Reviews in endocrine     [PubMed]
Morera J,Reznik Y, MANAGEMENT OF ENDOCRINE DISEASE: The role of confirmatory tests in the diagnosis of primary aldosteronism. European journal of endocrinology. 2019 Feb 1;     [PubMed]
Grasso M,Boscaro M,Scaroni C,Ceccato F, Secondary Arterial Hypertension: From Routine Clinical Practice to Evidence in Patients with Adrenal Tumor. High blood pressure     [PubMed]
Vaidya A,Mulatero P,Baudrand R,Adler GK, The Expanding Spectrum of Primary Aldosteronism: Implications for Diagnosis, Pathogenesis, and Treatment. Endocrine reviews. 2018 Dec 1;     [PubMed]
Seccia TM,Caroccia B,Gomez-Sanchez EP,Gomez-Sanchez CE,Rossi GP, The Biology of Normal Zona Glomerulosa and Aldosterone-Producing Adenoma: Pathological Implications. Endocrine reviews. 2018 Dec 1;     [PubMed]
Veselý J, Spironolactone in the treatment of hypertension: a neglected molecule. Vnitrni lekarstvi. Fall 2018;     [PubMed]
Rossi GP,Mulatero P,Satoh F, 10 good reasons why adrenal vein sampling is the preferred method for referring primary aldosteronism patients for adrenalectomy. Journal of hypertension. 2019 Mar;     [PubMed]
Williams TA,Reincke M, MANAGEMENT OF ENDOCRINE DISEASE: Diagnosis and management of primary aldosteronism: the Endocrine Society guideline 2016 revisited. European journal of endocrinology. 2018 Jul;     [PubMed]
Funder JW, Primary Aldosteronism: The Next Five Years. Hormone and metabolic research = Hormon- und Stoffwechselforschung = Hormones et metabolisme. 2017 Dec;     [PubMed]
Kline GA,Prebtani APH,Leung AA,Schiffrin EL, Primary aldosteronism: a common cause of resistant hypertension. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2017 Jun 5;     [PubMed]

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