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  • • Hypertension with or without hypokalemia

    • Elevated aldosterone secretion and suppressed plasma renin activity

    • Metabolic alkalosis, relative hypernatremia

    • Weakness, polyuria, paresthesias, tetany, cramps due to hypokalemia

    Common subtypes of primary hyperaldosteronism: aldosteronoma (75%) and bilateral adrenal hyperplasia (25%)

    Rare subtypes of primary hyperaldosteronism: unilateral primary adrenal hyperplasia, aldosterone producing adrenocortical carcinoma, glucocorticoid-remediable hyperaldosteronism (familial hyperaldosteronism type 1)

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Epidemiology

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  • • 1% of patients with hypertension

    • 8% of normokalemic hypertensive patients

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Symptoms and Signs

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  • • Hypertension

    • Headaches

    • Malaise

    • Muscle weakness

    • Polyuria

    • Polydipsia

    • Cramps

    • Paresthesias

    • Hypokalemic paralysis (rare)

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Laboratory Findings

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  • • Hypokalemia

    • Hypernatremia

    • Metabolic alkalosis

    • Elevated plasma aldosterone to renin ratio (> 20)

    • Elevated plasma aldosterone concentration (> 15 ng/dL)

    • Elevated urine/serum aldosterone level with PO or IV sodium challenge

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Imaging Findings

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  • • CT scan with thin sections through adrenals can identify most adenomas

    • Adrenal vein sampling if CT is equivocal

    • MRI can be used as well to identify an adrenal tumor

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  • • Aldosteronoma and rare unilateral primary adrenal hyperplasia are the most amenable types of primary hyperaldosteronism to surgical correction

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Rule Out

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  • • Pheochromocytoma

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  • • Thorough history and physical exam

    • Confirmed hypertension (multiple measurements)

    • Laboratory evaluation (electrolytes, serum aldosterone, and renin levels)

    • Cross sectional imaging (CT, MRI)

    • Possible bilateral adrenal vein sampling

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  • • Goal is to prevent illness associated with hypertension and hypokalemia

    • Surgical therapy for patients with aldosteronoma and unilateral primary adrenal hyperplasia

    • Medical therapy for bilateral adrenal hyperplasia, or poor surgical candidates

    • Preoperative preparation is key, with control of blood pressure and serum potassium

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Surgery

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  • • Nearly always laparoscopic approach

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Indications

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  • • Unilateral aldosteronoma

    • Unilateral primary adrenal hyperplasia

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Contraindications

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  • • Bilateral adrenal hyperplasia

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Medications

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  • Spironolactone: Competitive aldosterone antagonist

    Amiloride:Potassium-sparing diuretic

    • Other antihypertensive agents such as ACE inhibitors and calcium channel blockers

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Treatment Monitoring

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  • • Monitor blood pressure

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Complications

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  • • Uncontrolled hypertension can lead to renal failure, stroke, or myocardial infarction

    • Severe hypokalemia can lead to paralysis; risk of cardiac dysrhythmia increases in combination with digitalis

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Prognosis

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  • • Removal of aldosteronoma normalizes potassium, but hypertension is not always cured

    • 33% of patients have persistent, mild hypertension (easier to control than before operation)

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References

Al Fehaily M, Duh QY: Clinical manifestation of aldosteronoma. Surg Clin North Am 2004;84:887.
Magill SB et al: Comparison of adrenal vein sampling and computed tomography in the differentiation of primary aldosteronism. J Clin Endocrinol ...

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