Integrating Genetics and Genomics in Primary Aldosteronism

Abstract

Primary aldosteronism (PA) is the most common form of secondary hypertension, with an estimated prevalence of ≈10% in referred patients and 4% in primary care1,2 but as high as 20% in patients with resistant hypertension.3,4 It is characterized by hypertension with low plasma renin and elevated aldosterone that is often seen with hypokalemia. PA occurs as a result of a dysregulation of the normal mechanisms controlling adrenal aldosterone production. The 2 major causes are aldosterone-producing adenomas (APAs) and bilateral adrenal hyperplasia (BAH), also called idiopathic hyperaldosteronism. The early detection of PA has an enormous impact on clinical outcome and survival, given the major cardiovascular adverse effects of aldosterone excess, which are independent of blood pressure,5,6 and predict outcome after surgical treatment.7,8 Patients with PA have a significantly higher risk of nonfatal myocardial infarction, atrial fibrillation, and stroke compared with age-, sex-, and blood pressure–matched essential hypertensives.5 Furthermore, changes in cardiac structure and function9 and partially reversible renal dysfunction10 have been described, whereas the increased occurrence of metabolic abnormalities in patients with PA is still a matter of debate.11,12 Although the 2008 guidelines for the management of PA have been pivotal for homogenizing screening procedures and treatment among specialized centers,13 there remain a few critical issues related to diagnosis, subtype differentiation, and treatment of nonsurgically correctable forms. Reliable diagnostic and prognostic biomarkers are lacking for more sensitive and specific screening, as well as new therapeutic avenues, because medical and/or surgical treatment of PA leads to normotension in only a minority of patients. This may come from a better understanding of the pathogenic mechanisms of the disease, in particular, identification of the genetic and molecular determinants leading to the development of APA and …