Primary hyperaldosteronism resident survival guide

Template:Primary hyperladosteronism Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Causes

Common Causes

Common causes of Conn's Syndrome may be divided into:

• Adrenal causes:
  • Aldosterone-secreting adrenal adenoma (APA-benign tumor, 50-60%)
  • Idiopathic hyperaldosteronism (IHA-Bilateral hyperplasia of the adrenal gland, 40-50%)
• Extra-adrenal causes
  • Ectopic secretion of aldosterone (Ovaries and Kidneys)

Less Common Causes

• Familial hyperaldosteronism type I (glucocorticoid-remediable aldosteronism [GRA])
• Familial hyperaldosteronism II (the familial occurrence of APA or bilateral idiopathic hyperplasia or both)
• Familial hyperaldosteronism type III (associated with the germline mutation in the KCNJ5 potassium channel)
• Pure aldosterone-producing adrenocortical carcinomas
• Unilateral adrenal hyperplasia

Diagnosis and Treatment

The Management of Primary hyperaldosteronism including case detection, diagnosis, and treatment according to the "Endocrine Society Clinical Practice Guidlines" is as follows:

• Preferred Screening Population:
  • Blood pressure > 160 / 100 particularly (< 50 years)
  • Resistant hypertension or refractory hypertension (use of > 3 anti-hypertensives and poor control of blood pressure)
  • Hypokalemia (provoked by diuretic therapy or unprovoked)
  • Hypertension and incidentally discovered adrenal adenoma
  • Hypertension with a family history of early-onset hypertension (< 20 years) or cerebrovascular accident at age less than 40 years
  • Hypertensive first-degree relatives of patients with PA

Preferred screening population

Plasma Renin Activity/Aldosterone Ratio

Normal or High Renin (Plasma Renin/Aldosterone ratio <10

Suppressed Renin (Plasma Renin/Aldosterone ratio >20

•Renin-secreting tumors •Diuretic use •Renovascular hypertension •Coarctation of aorta •Malignant phase hypertension

Urinary aldosterone

Elevated

Normal

Low

Conn's syndrome (Primary aldosteronism)

Profound K+ depletion

• 17 alpha hydroxylase deficiency • 11 beta hydroxylase deficiency • Liddle's syndrome • Licorice ingestion •Deoxycorticosterone producing tumor

Do confirmatory tests: •Fludrocortisone supression test (Positive test= Aldosterone > 6 ng / dl and simultaneous PRA levels < than 1.0 ng / ml / hour) OR •Intravenous saline load testing (Positive test= Aldosterone more than 10 ng / dl) OR •Oral sodium loading test (Positive test= 24-hour urinary aldosterone excretion > 12 μg / day OR •Captopril challenge test (Positive test= PAC / PRA > 30, measured two hours after the administration of 25 mg or 50 mg of captopril)

Add Mineralocrticoid antagonist for 8 weeks

BP response

No BP response

Subtype classification

• Deoxycorticosterone excess( Tumor, 17 alpha hydroxylase and 11 beta hydroxylase deficiency) • Licorice ingestion •Glucocorticoid resistance

Liddle's syndrome)

Adrenal CT scan

Normal, micornodularity, bilateral masses or unilateral atypical mass

Unilateral hypodense nodule >1cm and <2cm in the setting of marked primary hyperaldosteronism

Surgery not desired

Surgery desired

Surgery desired

Surgery not desired

> 35 years consider

< 35 years consider

Glucocorticoid-remediable aldosteronism (GRA) OR Idiopathic hyperaldosteronism (bilateral hyperplasia): • Preferred regimen-Spironolactone 12.5mg to 25mg QD or Eplerenone 25mg BID • Alternative regimen-Amiloride 5mg BID plus chlorthalidone/hydrochlorothiazide 12.5mg to 25mg QD

No Lateralization with Adrenal Venous Sampling

Lateralization with Adrenal Venous Sampling

Aldosterone Producing Adenoma (APA) OR Primary Adrenal Hyperplasia (PAH): Unilateral laproscopic adrenalectomy

• Preferred regimen-Spironolactone 12.5mg to 25mg QD or Eplerenone 25mg BID • Alternative regimen-Amiloride 5mg BID plus chlorthalidone/hydrochlorothiazide 12.5mg to 25mg QD