Home

Search

Pathway AI

Account ⋅ Sign Out

Table of contents

Primary aldosteronism

Definition
Primary hyperaldosteronism is an endocrine disorder characterized by excessive secretion of aldosterone from the adrenal glands.
1
Pathophysiology
Hypersecretion of aldosterone may be due to neoplasia of the adrenal glands (adrenal adenoma or adrenocortical carcinoma), adrenal hyperplasia (typically bilateral), mutations in genes coding for enzymes involved in aldosterone synthesis (familial hyperaldosteronism), or may be idiopathic. Ectopic aldosterone-producing adenoma or carcinoma accounts for < 0.1% of cases.
1
Epidemiology
In patients with secondary hypertension, the prevalence of primary hyperaldosteronism is estimated at 5-20%.
2
Disease course
Increased plasma aldosterone leads to the clinical manifestations of resistant hypertension and hypokalemia. Untreated disease may result in early cardiovascular complications and CKD.
1
Prognosis and risk of recurrence
Patients with PA have an increased risk of cardiovascular morbidity (including myocardial infarction, stroke, and AF) as compared with patients with matched controls with essential hypertension. The 10-year survival of patients with hyperaldosteronism is similar to that of matched hypertensive controls.
3
4
Key sources
The following summarized guidelines for the evaluation and management of primary aldosteronism are prepared by our editorial team based on guidelines from the Canadian Urological Association (CUA 2023), the American Academy of Family Physicians (AAFP 2023), the Japan Endocrine Society (JES 2022), the American Association of Endocrine Surgeons (AAES 2022), the Hypertension Canada (HC 2020), the Italian Society of Arterial Hypertension (SIIA 2020), the Endocrine Society (ES 2016), and the European Society of Endocrinology (ESE/ENSAT 2016).
1
2
3
4
5
6
7
8
9
10
11
12

Guidelines

1.Screening and diagnosis

Indications for testing, hypertension, AAFP
Obtain screening for PA in patients with resistant hypertension and in patients having well-controlled hypertension with any of the following:
hypokalemia
AF
obstructive sleep apnea,
adrenal incidentaloma
first-degree relative with PA
family history of early stroke (< 40 years)
B
Measure plasma aldosterone concentration and plasma renin levels simultaneously in the initial case detection for PA, recognizing that aldosterone elevation with suppressed renin levels identifies patients with potential PA.
B
Create free account

More topics in this section

  • Indications for testing (tumor)

2.Diagnostic investigations

Plasma aldosterone-to-renin ratio: as per CUA 2023 guidelines, obtain aldosterone-to-renin ratio to evaluate for PA in patients with an adrenal incidentaloma and hypertension and/or hypokalemia.
B

More topics in this section

  • Confirmatory testing

  • Adrenal imaging

  • Genetic testing

3.Diagnostic procedures

Adrenal venous sampling: as per AAFP 2023 guidelines, perform adrenal vein sampling to determine if aldosterone production is unilateral or bilateral once PA has been diagnosed.
B

4.Medical management

Mineralocorticoid receptor antagonists: as per JES 2022 guidelines, consider initiating pharmacotherapy taking into consideration other clinical features (gender, age, BMI, plasma aldosterone concentrations, aldosterone to renin ratio and results of confirmatory test) and bypassing adrenal venous sampling (after obtaining informed consent) in patients with normokalemia and no adrenal tumors on CT, as these patients are more likely to have bilateral disease.
C
Show 5 more

More topics in this section

  • Conventional antihypertensives

  • Corticosteroids

5.Perioperative care

Preoperative medical therapy
As per JES 2022 guidelines:
Initiate appropriate treatment for the complications before unilateral adrenalectomy to reduce the risks during general anesthesia and adrenalectomy, as the prevalence of resistant hypertension, hypokalemia and cardiovascular complications is higher in patients with unilateral PA than in patients with bilateral PA and essential hypertension.
B
Initiate mineralocorticoid receptor antagonists as first-line therapy to control hypertension and hypokalemia before adrenalectomy.
B

More topics in this section

  • Postoperative monitoring

  • Postoperative corticosteroid replacement therapy

6.Surgical interventions

Indications for adrenalectomy: as per CUA 2023 guidelines, perform adrenalectomy, with a minimally invasive technique when feasible, in patients with a unilateral aldosterone-secreting adrenal mass.
E

7.Specific circumstances

Pregnant patients: as per JES 2022 guidelines, initiate antihypertensives approved for pregnancy (alpha-methyldopa, hydralazine, labetalol, and nifedipine only after 20 weeks of pregnancy) for the treatment of hypertension in pregnant patients.
B
Show 2 more

8.Follow-up and surveillance

Follow-up: as per JES 2022 guidelines, recognize that the cure rate of hypertension by adrenalectomy in patients with unilateral PA is affected by the following factors:
number of antihypertensive medications before surgery
duration of hypertension
gender
BMI
age
renal function.
B
Show 3 more