Primary Aldosteronism: Progress in Diagnosis, Therapy, and Genetics

Abstract

Primary aldosteronism (PA) is the most frequent cause of secondary hypertension and its prevalence increases with the severity of hypertension. The importance of PA diagnosis is not just related to offering a targeted treatment, that is, adrenalectomy, for aldosterone-producing adenoma and medical therapy with mineralocorticoid receptor antagonists for bilateral adrenal hyperplasia, but also because it has been demonstrated extensively that patients affected by PA are more susceptible to cardiovascular events and target organ damage compared to essential hypertensives. Herein, we review the pathophysiology of PA and its clinical features and potential complications; the three step approach employed in the diagnosis of PA, established by the Endocrine Society Guidelines, that is, screening, con fi rmation/exclusion, and subtype diagnosis are discussed; the rarer, familial, and sporadic genetic forms of PA are explained and we conclude with a section on targeted PA therapy.

Endocrine Hypertension and Chronic Kidney Disease

“…In patients with resistant HTN, the estimated prevalence of PA is between 17 and 23 % [67]. After applying the aldosterone-to-renin ratio (ARR) not only to hypokalemic but also normokalemic hypertensives, the diagnosis of PA increased up to 15-fold [68]. The ARR, commonly used to screen for PA, has also been viewed as an index for salt sensitivity and recently has been linked to the development of CKD in a longitudinal, observational study of 698 Japanese individuals.…”

“…As there is no general consensus on the ARR cutoff, sensitivity and specificity vary widely. The ARR has good within-patient reproducibility and an accuracy of 80 % for identifying patients with an aldosterone-secreting adenoma [68].Antihypertensive drugs are the most confounding factor affecting the measurement of aldosterone and renin. Especially, MR antagonists, such as spironolactone, eplerenone, and canrenone, should be discontinued 4-6 weeks prior to screening for PA and prior to adrenal vein sampling (AVS), because these agents can lead to an increase in renin secretion and subsequently aldosterone secretion from the unaffected side (if only one adrenal gland was oversecreting aldosterone).…”

“…Amiloride has also antihypertensive effects in patients with PA and can be used in combination with other antihypertensives to achieve BP control. Patients with unilateral aldosteronomas should be offered unilateral laparoscopic adrenalectomy, as their HTN is cured in around 50 % of cases with many others experiencing reduction of BP values and subsequently the number of antihypertensive medications and costs [68]. …”