Management Of Primary Aldosteronism Research Articles

Diagnosis and Management of Primary Aldosteronism

El hiperaldosteronismo primario es un conjunto de patologias que comparten la biosintesis excesiva e hipersecrecion sostenida y autonoma de aldosterona. Clinicamente se manifiesta principalmente por: hipertension arterial sistemica, hipokalemia y alcalosis metabolica. La conducta biologica de la hipertension generalmente es severa y refractaria a los antihipertensivos habituales. Es la causa mas frecuente de hipertension arterial sistemica secundaria. Sus caracteristicas bioquimicas son: PAC > 20 ng/dL, PRA < 0.5 ng/mL/h, concentracion de renina plasmatica indetectable y/o baja e hipokalemia en el 50% de los casos. El diagnostico se establece cuando el cociente PAC/PRA ≥ 50. Los estudios de localizacion son: tomografia computarizada, resonancia magnetica y la concentracion de aldosterona en las venas adrenales derecha e izquierda con gradiente ≥ 4 habiendo confirmado la correcta cateterizacion con la concentracion de cortisol en venas adrenales y en vena cava inferior con proporcion minima de 5:1. Su tratamiento es quirurgico, preferentemente a traves de laparoscopia, aunque otros consideran que, segun las dimensiones del tumor, puede ser mediante laparotomia para una minoria de casos. El tratamiento farmacologico es con antagonistas de los receptores de mineralocorticoides

Diagnosis and Management of Primary Aldosteronism

Primary aldosteronism (PAL) is characterized by excessive production of aldosterone, which leads to hypernatremia, hypertension (HTN), hypokalemia, and alkalosis. Three crucial diagnostic steps include case detection, case confirmation, and subtype classification. Marked improvement or cure of HTN is achieved with appropriate treatment.

Diagnosis and treatment of primary aldosteronism

Primary aldosteronism involves more than 11% of hypertensive patients who are referred to specialized centers for the diagnosis and treatment of hypertension. If not diagnosed early it causes an excess damage to the heart, vessels and kidney, which translates into an cardiovascular events. Since these ominous consequences can be corrected with a timely diagnosis and an appropriate therapy, physicians should exercise a high degree of alert concerning the possibility that primary aldosteronism is present in hypertensive patients. The purpose of this review is to provide up-dated information on the strategy for case detection, the subtype differentiation and the management of primary aldosteronism.

Adrenal Venous Sampling for Primary Aldosteronism and Clinical Outcomes After Unilateral Adrenalectomy: A Single‐Center Experience

Adrenal venous sampling (AVS) remains controversial in the management of primary aldosteronism. Retrospective chart review was conducted at the Hospital of the University of Pennsylvania from July 2001 to September 2007. A total of 113 patients underwent AVS, 16 patients were excluded as records were unavailable. Among 97 remaining patients, 61 had unilateral disease and 57 underwent unilateral adrenalectomy. Blood pressure (BP) improved significantly with less antihypertensive medication requirement. Among those with different BP responses to adrenalectomy (cure, improvement, or no change), a higher number of preoperative antihypertensive medications was associated with persistent hypertension (P = .03). There were no significant differences in age (P = .14), duration of hypertension (P = .60), family history of hypertension (P = .68), or serum creatinine (P = .34). When AVS shows lateralization, age, duration of hypertension, family history, or renal dysfunction did not predict BP response to adrenalectomy. Results suggest that these factors should not preclude AVS and subsequent adrenalectomy. Further studies are indicated to confirm these findings.

Management of Primary Aldosteronism: Its Complications and Their Outcomes After Treatment

Primary aldosteronism is the most common cause of secondary hypertension, accounting for about 10% of all forms of high blood pressure. Life-time pharmacological therapy is the treatment of choice for primary aldosteronism due to idiopathic adrenal hyperplasia (IHA), while adrenalectomy is effective in curing most patients with an aldosterone producing adenoma (APA). Far from being a benign form of hypertension, primary aldosteronism is characterized by the development of cardiovascular renal and metabolic complications, including left ventricular hypertrophy, myocardial infarction, atrial fibrillation and stroke, microalbuminuria, renal cysts as well as metabolic syndrome, glucose impairment and diabetes mellitus. We review recent clinical experience with the above mentioned complications and long-term outcomes of blood pressure normalization and cardiac, renal and gluco-metabolic complications in patients with primary aldosteronism, after medical treatment with mineralocorticoid receptor antagonists and surgical treatment. We conclude that removal of adrenal adenoma results in normalization of the renin-angiotensin-aldosterone system (RAAS) and of kalaemia and improvement of blood pressure levels in all patients. Complete resolution of hypertension is achieved in nearly half of treated patients. Moreover, unilateral adrenalectomy is the best treatment to have the regression of cardiovascular, renal and metabolic complications in patients with APA. On the other hand, targeted medical treatment with aldosterone antagonists improves blood pressure control and appears able to prevent the progression of cardiac and metabolic complications in patients with IHA.

Medical management of primary aldosteronism

Medical management of primary aldosteronism

Long-term results of laparoscopic adrenalectomy for primary aldosteronism

The management of primary aldosteronism is currently achieved by both medical and surgical treatment. Laparoscopy has in recent years unquestionably become the gold standard in adrenal surgery for benign lesions. This study aims to evaluate our clinical results among patients who underwent laparoscopic adrenalectomy (LA) for primary aldosteronism. From January 1994 to January 2006, amid LA series, 59 primary aldosteronism patients were treated in our institution. Patients were 33 males and 26 females with mean age 49.3 yr (19-78). The mean body mass index was 25.9 kg/m2 (20.5-33.3). The mean size of lesion was 2.9 cm (1-5.5). Clinical symptoms were as follows: hypertension and symptomatic/asymptomatic hypokalemia (54), hypokalemia (5). Thirty-five left and 24 right LA were performed. On the left side, 22 procedures were carried out by anterior approach, 9 by anterior submesocolic route, and 4 by means of flank approach. All right procedures were completed by the anterior supine approach. The mean operative time was 103.5 min for left and 92.8 min for right adrenalectomy. There was one major complication, a colonic post-operative fistula, regarding a left adrenalectomy case. The mean post-operative hospital stay was 3 days (1-9). The cure rate of hypertension and hypokalemia was similar to the current literature results. LA is a safe and effective option in the treatment of primary aldosteronism. Appropriate selection of patients, larger adrenal masses and duration of symptoms are determining factors in the success rate of hypertension management.

The role of radiologic studies in the evaluation and management of primary hyperaldosteronism

Surgical treatment of primary hyperaldosteronism (PHA) requires demonstration of unilateral adrenal hypersecretion. Optimal methods for interpretation of imaging and invasive testing are still in development. A retrospective review from 1996-2007 of 106 patients with PHA was undertaken. Patient demographics, biochemical studies, radiologic imaging, operative reports, and pathology were reviewed and comparisons made. Optimal ratios for adrenal vein sampling were tested with regard to sensitivity and specificity. Preoperative and postoperative medication requirements and blood pressures were compared among different treatment groups. Seventy-eight patients (62 surgically treated) met criteria for inclusion. Median arterial blood pressure at diagnosis was 150/86 mm Hg while taking 3 antihypertensive medications. 69.2% required potassium supplementation. Median aldosterone:renin ratio was 107.0. Forty-two AVS procedures changed the management of 15 patients (35.7%) when compared to CT results. AVS accuracy was 96.6 vs 88.9% for NP-59 scintigraphy. Operative patients remained on fewer antihypertensive medications (1 vs 3), and mean systolic pressure was lower (130 vs 146 mm Hg) compared with medically managed patients. When used together, pre-ACTH aldosterone ratios, normalized A/C:A/C ratios, ratios to define contralateral suppression, and post-ACTH stimulated values allowed for capture of episodically secreting tumors and subtle unilateral or bilateral hyperaldosteronism.

Diagnosis and management of primary aldosteronism

Purpose of review To illustrate the steps for clinical management of primary aldosteronism from screening evaluation to surgical and/or medical treatment. Recent findings It is now widely accepted that primary aldosteronism represents the most common form of endocrine hypertension and its early diagnosis is crucial for hypertensive patients who can be cured by the surgical removal of an aldosterone-secreting adenoma or benefit from a specific medical treatment with mineralocorticoid receptor antagonists. Recent evidence indicates that hyperaldosteronism is indeed associated with detrimental consequences on cardiovascular system, renal function and glucose metabolism. Summary The diagnostic protocol for primary aldosteronism requires multistep evaluation and should begin with a screening test, followed when appropriate, by confirmatory test and functional and anatomical evaluation. Finally, although it is technically difficult and the cut-off levels for acceptance of the success are not standardized, the subtype forms should be identified using a selective adrenal venous sampling.

Diagnosis and management of primary hyperaldosteronism in cats

PRIMARY hyperaldosteronism (Conn's syndrome) is characterised by excessive autonomous secretion of aldosterone from one or both adrenal glands, resulting in clinical signs relating to hypertension and/or hypokalaemia. This disease was...

The Role of Adrenal Venous Sampling in the Surgical Management of Primary Aldosteronism

The Role of Adrenal Venous Sampling in the Surgical Management of Primary Aldosteronism

Retroperitoneal laparoscopic management of primary aldosteronism with report of 130 cases

To evaluate retroperitoneal laparoscopic partial or total adrenalectomy for primary aldosteronism. From February 2000 to September 2003, 130 patients (76 women and 54 men) with a confirmed diagnosis of primary aldosteronism underwent retroperitoneal laparoscopic operation. Of the 130 cases, there were 119 cases with Aldosterone-producing Adenoma and 11 cases with Idiopathic Adrenal Hyperplasia (unilateral of 2 cases). Eleven cases with Idiopathic Adrenal Hyperplasia underwent unilateral adrenalectomy. Of the 119 cases with Aldosterone-producing Adenoma, 61 cases underwent total adrenalectomy, and 58 cases underwent partial adrenalectomy. All cases were with preoperatively high plasma aldosterone, low plasma rennin and hypokalemia and arterial hypertension. Operations were successfully performed in all cases. The operative time ranged from 15 to 225 min (mean 52 +/- 40 min, Md = 43 min) and the operative bleeding ranged from 0 to 200 ml (mean 23 +/- 34 ml, Md = 20 ml, zero bleeding means that less than 5 ml) without blood transfusion. The hospital length of stay was ranged from 3 to 9 d (mean 5.1 +/- 1.3 d). No major complication occurred. Kalemia was normalized within one month and aldosterone/PRA ratio was decreased obviously in all cases. Postoperatively blood pressure was normalized within 2 month in 88 cases without using any drug. It is safe and practical to perform retroperitoneal laparoscopic partial on total adrenalectomy on the patients with primary aldosteronism.

Diagnosis and Management of Primary Aldosteronism in Pregnancy: Case Report and Review of the Literature

Primary aldosteronism rarely complicates pregnancy. We present a woman with primary aldosteronism in pregnancy associated with severe preeclampsia. A 33-year-old Japanese woman with hypertension was referred to our hospital at 25 weeks of gestation. Her blood pressure was 180/100 mmHg, and laboratory tests identified a low serum potassium level and moderate proteinuria on urinalysis. The fetus was diagnosed with growth restriction. Plasma renin activity (PRA) value was 2.2 ng/mL/h and plasma aldosterone concentration (PAC) was elevated (260 pg/mL). The patient was treated medically. At 27 weeks of gestation, we noted persistent late fetal heart rate decelerations associated with uterine contractions. Therefore, elective caesarean section was performed and she was delivered of a 698-g female. After delivery, PRA declined and PAC remained elevated. Abdominal computerized tomography scan and I131-iodochoresterol scan revealed a tumor in the left adrenal gland. Laparoscopic adrenalectomy was performed and confirmed the clinical diagnosis.

Review: Diagnosis and management of primary aldosteronism

JRAAS 2001;2:156-69 Introduction Primary aldosteronism (PAL) is characterised by aldosterone production which is excessive to the body’s requirements and relatively autonomous of its normal chronic regulator, angiotensin II (Ang II). Inappropriate aldosterone production results in excessive reabsorption of sodium via the amiloride-sensitive epithelial sodium channels situated within the distal tubule and collecting duct of the kidney (leading to hypertension), and continues in the face of suppression of the reninangiotensin system (RAS). Urinary loss of potassium, which is exchanged for sodium at the distal nephron, may eventually result in hypokalaemia if severe and prolonged enough. Because measurements of plasma aldosterone and plasma renin activity (PRA) have become readily available, it is now feasible to measure their relationship in all hypertensive patients. The wide application of the aldosterone/PRA ratio (ARR) has permitted the diagnosis of PAL in the absence of hypokalaemia,and more commonly, in fact, than in the presence of hypokalaemia. This has led to a new understanding that PAL is not a rare cause of hypertension, to be suspected only when hypokalaemia is present, but is probably the commonest, identifiable, specifically treatable and potentially curable form of hypertension. With most recent studies reporting prevalence rates for PAL that are much higher than those previously described in medical textbooks and reviews on the subject, the diagnosis of PAL is likely to become an increasingly frequent event. The ability to correctly apply diagnostic techniques involved in the workup of PAL and to interpret their results therefore represent skills of increasing importance for physicians who treat hypertension. This review focuses on the rationale and methodology of these diagnostic techniques, and on current approaches to management of patients with PAL.

Medical management of primary hyperaldosteronism.

Most forms of primary aldosteronism are surgically correctable. However, when surgery is not appropriate, medical management is just as effective in correcting the pathophysiologic abnormalities due to aldosterone excess. A prerequisite for the rational medical management of primary aldosteronism is an understanding of the mechanisms that sustain hypertension. Primary aldosteronism can be associated with severe and resistant hypertension, and persistent hypervolemia is the primary reason for resistance to therapy. Patients with overriding comorbidities or strong preferences have been medically treated over the intermediate term of 5 to 7 years without evidence of escape or evidence of malignant transformation of adrenal adenomas.

Rapid intraoperative cortisol assay: design and utility for localizing adrenal tumors by venous sampling

Primary aldosteronism is the most common cause of secondary hypertension. Adrenal vein sampling plays a critical role in the management of primary aldosteronism, serving as the final determinant between surgery and medical management. In this chapter, we discuss the diagnosis of primary aldosteronism, patient selection for adrenal vein sampling, actual sampling technique, result interpretation, and means for improving the success rate of the procedure.

How common is adrenal-based mineralocorticoid hypertension?

Adrenal-based mineralocorticoid excess that is not secondary to excessive angiotensin II or adrenocorticotrophic hormone (ACTH) exists primarily as primary aldosteronism (PAL) and rarely as deoxycorticosterone- secreting adrenal tumor. The availability and wide application of the plasma aldosterone-plasma renin activity (PRA) ratio as a screening test for PAL has led to the recent recognition that PAL is common, possibly accounting for 5 to 10% of patients with hypertension, with most normokalemic. Detection and appropriate management of PAL relies on (1) screening of all patients with hypertension and not just those with hypokalemia or resistant hypertension; (2) confirmation of PAL using a reliable diagnostic approach such as fludrocortisone suppression testing (saline infusion testing may lack sensitivity); and (3) careful further assessment to differentiate the subtype, including genetic testing for the hybrid gene that causes glucocorticoid-remediable aldosteronism, and adrenal venous sampling to differentiate unilateral from bilateral aldosterone overproduction. The establishment of other underlying genetic mutations and new genetic tests should also aid in the detection of PAL and potentially curable hypertension. (C) 2000 Lippincott Williams and Wilkins. Inc.

Pitfalls in the Diagnosis and Management of Primary Hyperaldosteronism

Pitfalls in the Diagnosis and Management of Primary Hyperaldosteronism

Primary aldosteronism. Results of surgical treatment.

Management of primary hyperaldosteronism has undergone dramatic changes in the past 40 years. This retrospective study was carried out to review our recent surgical experience and to identify potential factors associated with postoperative persistent hypertension. Forty-six patients who had adrenal surgery for primary hyperaldosteronism from 1983 to 1994 were included in the study. Periodic paralysis occurred in 12 (26%) patients. Hypertension and hypokalemia (mean serum potassium, 2.2 + 0.5 [+ standard deviation (SD) mmol/L) were present in all patients. Postural study was diagnostic in 85% (23 of 27). Computed tomography scan correctly localized the tumor in all except 1 patient, and venous sampling was performed in 11 patients. There was no operative mortality, and complications developed in six patients (13%), including one patient requiring re-exploration for hemostasis. All patients had a histologically documented adenoma. During a mean follow-up of 51 months, 34 (77%) of the 44 patients required no further antihypertensive treatment. Two patients were lost to follow-up. Age, response to spironolactone treatment, and blood pressure on discharge were risk factors identified for persistent hypertension. Primary hyperaldosteronism due to aldosterone-producing adenoma can be diagnosed and localized expeditiously, whereas surgical treatment can be performed safely. Hypokalemia may be cured by surgical treatment, although persistent hypertension, usually of a mild degree, still occurs in selected patients.

The diagnosis and management of primary hyperaldosteronism

The diagnosis and management of primary hyperaldosteronism