Hyperaldosteronism resident survival guide
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Hyperaldosteronism Main page |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mehrian Jafarizade, M.D [2]
Overview
Causes
Common Causes
Less Common Causes
Diagnosis and Treatment
Focused Initial Rapid Evaluation
Preparation:
1. Attempt to correct hypokalemia. Measure plasma potassium in blood collected slowly with a syringe and needle [preferably not a Vacutainer to minimize the risk of spuriously raising potassium]. During collection, avoid fist clenching, wait at least 5 seconds after tourniquet release (if used) to achieve insertion of needle, and ensure separation of plasma from cells within 30 minutes of collection. A plasma [K+] of 4.0 mmol/L is the aim of supplementation.
2. Encourage patient to liberalize (rather than restrict) sodium intake.
3. Withdraw agents that markedly affect the plasma aldosterone to renin ratio (ARR) for at least 4 weeks:
- Spironolactone, eplerenone, amiloride, and triamterene
- Potassium-wasting diuretics
- Products derived from licorice root (eg, confectionary licorice, chewing tobacco)
4. If the results of ARR after discontinuation of the above agents are not diagnostic, and if hypertension can be controlled with relatively noninterfering medications, withdraw other medications that may affect the ARR for at least 2 weeks, such as:
- β-Adrenergic blockers
- Central α-2 agonists (eg, clonidine, α-methyldopa)
- Nonsteroidal anti-inflammatory drugs
- Angiotensin-converting enzyme inhibitors
- Angiotensin receptor blockers
- Renin inhibitors
- Dihydropyridine calcium channel antagonists
5. If necessary to maintain hypertension control, commence other antihypertensive medications that have lesser effects on the ARR (e.g. verapamil slow-release, hydralazine with verapamil slow-release, to avoid reflex tachycardia), prazosin, doxazosin, terazosin.
B. Blood collection
1. Collect blood mid morning, after the patient has been up (sitting, standing, or walking) for at least 2 hours and seated for 5–15 minutes.
2. Collect blood carefully, avoiding stasis and hemolysis.
3. Maintain sample at room temperature (and not on ice, as this will promote conversion of inactive to active renin) during delivery to laboratory and prior to centrifugation and rapid freezing of plasma component pending assay.
C. Factors affecting interpretation of results
1. Age: in patients aged >65 years, renin can be lowered more than aldosterone by age alone, leading to raised ARR.
2. Gender: premenstrual, ovulating females have higher ARR levels than age-matched men, especially during the luteal phase of the menstrual cycle, during which false positives can occur, but only if renin is measured as DRC and not as PRA (220).
3. Time of day, recent diet, posture, and length of time in that posture
4. Medications
5. Method of blood collection
6. Level of potassium
7. Level of creatinine (renal failure can lead to false-positive ARR)
| 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 | 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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||