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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Hypertension due to sodium and water retention

  • Hypokalemia and metabolic alkalosis

  • Suppressed renin and angiotensin synthesis

  • Elevated plasma aldosterone levels

  • Imaging results showing adrenal adenoma or bilateral hyperplasia

GENERAL CONSIDERATIONS

  • Increased autonomous production of aldosterone by the adrenal gland

  • This causes sodium retention, plasma volume expansion, and hypertension

  • Renal loss of potassium and bicarbonate causes hypokalemia and alkalosis

    • – Patients usually identified because of hypertension and sometimes hypokalemia

    • – Familial hyperaldosteronism is the cause in 5–10% of cases

    • – Somatic mutations account for about 50% of cases and involve the genes encoding potassium channels, voltage-dependent C-type calcium channels, and sodium/potassium and calcium ATPases

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Usually asymptomatic

PHYSICAL EXAM FINDINGS

  • Hypertension, rarely severe

DIFFERENTIAL DIAGNOSIS

  • Other causes of hypertension (primary aldosteronism accounts for 10–20% of hypertensive patients referred to hypertension clinics)

  • Other causes of hypokalemia

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Serum potassium reduced in about 40%

    • – Reduced plasma renin activity

    • – Elevated plasma aldosterone

    • – Aldosterone to plasma renin ratio (the definition of abnormal varies with the laboratory)

ELECTROCARDIOGRAPHY

  • Occasionally left ventricular hypertrophy or left atrial abnormality is seen

IMAGING STUDIES

  • CT scan distinguishes adrenal hyperplasia from adenoma

DIAGNOSTIC PROCEDURES

  • Aldosterone suppression test

  • Adrenal vein aldosterone levels in selected cases

TREATMENT

CARDIOLOGY REFERRAL

  • Suspected cardiac disease

HOSPITALIZATION CRITERIA

  • Planned surgery

MEDICATIONS

  • Aldosterone antagonists for adrenal hyperplasia: spironolactone 100–200 mg/day PO or eplerenone 25–100 mg/day

  • Calcium channel blockers

  • Amiloride 10–40 mg/day

THERAPEUTIC PROCEDURES

  • CT-guided radiofrequency ablation is a potential alternative to surgery for adenomas

SURGERY

  • Surgical resection of adenoma

DIET AND ACTIVITY

  • Low-sodium diet

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Successful surgery

FOLLOW-UP

  • Depends on situation

COMPLICATIONS

  • Those of systemic hypertension

PROGNOSIS

  • Excellent with early recognition and management

PREVENTION

  • Serum potassium off diuretics should be part of every hypertension evaluation

  • In difficult to manage patients, a plasma aldosterone/renin activity ratio should be measured

RESOURCES

PRACTICE GUIDELINES

  • This diagnosis should be considered:

    • – In patients with hypertension and spontaneous hypokalemia, resistant hypertension, incidental adrenal ...

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