Treatment Of Primary Aldosteronism Research Articles

Sleep quality in patients with primary aldosteronism.

In subjects at high risk for sleep apnea (SA), aldosterone concentrations correlate with severity of SA and primary aldosteronism (PA) is very often diagnosed. Patients with PA show a high prevalence of SA. Treatment of PA either by adrenalectomy (ADX) or mineralocorticoid receptor (MR) blockade is thought to abolish the increased comorbidities. However, no data are available regarding effectiveness of different PA treatments on quality of sleep. This prospective multi-center study included 15 patients with newly diagnosed PA evaluated before and 0.7 ± 0.2 years after treatment initiation, and a second cohort including 81 patients who were evaluated 5.3 and 6.8 years after treatment initiation. Biochemical parameters, 24h blood pressure and three validated self-assessment questionnaires (Giessen Complaint List (GBB-24), Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality-Index (PSQI)) were analyzed. Z-scores of exhaustion tendency of GBB significantly improved in newly diagnosed PA patients after treatment initiation (1.8 ± 1.4 vs. 1.0 ± 1.2, p=0.034). In the second cohort no differences were found in GBB-24, ESS and PSQI. No differences were found in all three questionnaires independently of type of PA therapy. However, female patients scored significantly higher than males in the PSQI (8.7 ± 3.6 vs 5.7 ± 4.2, p<0.005), indicating lower sleep quality, independently of the type of therapy. For the first time, we analyzed quality of sleep in patients with PA, demonstrating that therapy initiation improves exhaustion tendency. Surprisingly, female PA patients showed significantly more sleep disturbances than male PA patients several years after treatment initiation.

Endocrine diseases: progress in diagnosis and treatments. Topics: V. Adrenal cortex; 2. What can we do for the proper diagnosis and treatment of primary aldosteronism?

Endocrine diseases: progress in diagnosis and treatments. Topics: V. Adrenal cortex; 2. What can we do for the proper diagnosis and treatment of primary aldosteronism?

Management of hypertension in primary aldosteronism.

Hypertension causes significant morbidity and mortality worldwide, owing to its deleterious effects on the cardiovascular and renal systems. Primary hyperaldosteronism (PA) is the most common cause of reversible hypertension, affecting 5%-18% of adults with hypertension. PA is estimated to result from bilateral adrenal hyperplasia in two-thirds of patients, and from unilateral aldosterone-secreting adenoma in approximately one-third. Suspected cases are initially screened by measurement of the plasma aldosterone-renin-ratio, and may be confirmed by additional noninvasive tests. Localization of aldostosterone hypersecretion is then determined by computed tomography imaging, and in selective cases with adrenal vein sampling. Solitary adenomas are managed by laparoscopic or robotic resection, while bilateral hyperplasia is treated with mineralocorticoid antagonists. Biochemical cure following adrenalectomy occurs in 99% of patients, and hemodynamic improvement is seen in over 90%, prompting a reduction in quantity of anti-hypertensive medications in most patients. End-organ damage secondary to hypertension and excess aldosterone is significantly improved by both surgical and medical treatment, as manifested by decreased left ventricular hypertrophy, arterial stiffness, and proteinuria, highlighting the importance of proper diagnosis and treatment of primary hyperaldosteronism. Although numerous independent predictors of resolution of hypertension after adrenalectomy for unilateral adenomas have been described, the Aldosteronoma Resolution Score is a validated multifactorial model convenient for use in daily clinical practice.

Predictors of Decreasing Glomerular Filtration Rate and Prevalence of Chronic Kidney Disease After Treatment of Primary Aldosteronism: Renal Outcome of 213 Cases

In primary aldosteronism (PA), glomerular hyperfiltration due to excessive aldosterone is considered to underestimate actual renal damage. Our objectives were to determine the prevalence of chronic kidney disease (CKD) in PA and identify the predictors of decreasing estimated glomerular filtration rate (eGFR) after treatment. This was a 12-month prospective study of patients with PA treated at Tohoku University Hospital. All patients were treated according to the results of adrenal venous sampling; 102 patients with aldosterone-producing adenoma underwent adrenalectomy, and 111 with bilateral hyperaldosteronism were treated with mineralocorticoid receptor antagonists. Electrolytes, blood pressure, and indicators of renal function were determined at 1 and 12 months after intervention. Blood pressure, urinary albumin excretion (UAE), and eGFR, which significantly decreased at 1 month after treatment of PA, did not further decrease at 12 months. Prevalence of CKD, which was 15.7% in aldosterone-producing adenoma and 8.1% in bilateral hyperaldosteronism at the first visit, increased to 37.1% and 28.3%, respectively, at the end of study (P < .0001). Multivariate regression analysis revealed that higher UAE and lower serum potassium levels were found to be independent predictors of decreasing eGFR after intervention. This large cohort study shows that the prevalence of CKD in PA was increased after treatment and that higher UAE and lower serum potassium levels at the first visit were predictors of decreasing eGFR after treatment of PA. To prevent a large decrease of eGFR after intervention, PA patients should be diagnosed before evolution to severe albuminuria and hypokalemia.

Long-Term Cardio- and Cerebrovascular Events in Patients With Primary Aldosteronism

Aldosterone plays a detrimental role on the cardiovascular system and PA patients display a higher risk of events compared with EH. The objectives of the study were to compare cardio- and cerebrovascular events in patients with primary aldosteronism (PA) and matched essential hypertension (EH). We retrospectively compared the percentage of patients experiencing events at baseline and during a median follow-up of 12 years in 270 PA patients case-control matched 1:3 with EH patients and in PA subtypes [aldosterone-producing adenoma (n = 57); bilateral adrenal hyperplasia (n = 213)] vs matched EH. A significantly higher number of PA patients experienced cardiovascular events over the entire period of the study (22.6% vs 12.7%, P < .001). At the diagnosis of PA, a higher number of patients had experienced total events (14.1% vs 8.4% EH, P = .007); furthermore, during the follow-up period, PA patients had a higher rate of events (8.5% vs 4.3% EH, P = .008). In particular, stroke and arrhythmias were more frequent in PA patients. During the follow-up, a higher percentage of PA patients developed type 2 diabetes. Parameters that were independently associated with the occurrence of all events were age, duration of hypertension, systolic blood pressure, presence of diabetes mellitus, and PA diagnosis. After division into PA subtypes, patients with either aldosterone-producing adenoma or bilateral adrenal hyperplasia displayed a higher rate of events compared with the matched EH patients. This study demonstrates in a large population of patients the pathogenetic role of aldosterone excess in the cardiovascular system and thus the importance of early diagnosis and targeted PA treatment.

Response to Effectiveness of Adrenalectomy and Aldosterone Antagonists for Long-Term Treatment of Primary Aldosteronism

Our data demonstrated the efficacy of mineralocorticoid receptor (MR) blockers for the treatment of primary aldosteronism (PA).1 However, by no means did we interpret our findings to show the superiority of adrenalectomy over MR blocker therapy. The higher rate of cure of hypertension seen with surgery was intrinsic with the definition of cure: 42% of our adrenalectomized versus none of our medically treated patients could withdraw pharmacological treatment at long term. Hence, when guided by results of adrenal vein sampling, adrenalectomy provides long-term cure of hypertension and allows tapering, or withdrawal, of the antihypertensive medications. Comparing adrenalectomy and MR blockade would require randomization of PA patients to either treatment. Neither the study of Reincke et …

Diagnosis and Treatment of Unilateral Forms of Primary Aldosteronism

Primary aldosteronism (PA) is now recognized as the most frequent form of secondary arterial hypertension. The importance of a correct and prompt diagnosis of PA is determined by its relevant prevalence, its increased cardiovascular risk compared to essential hypertension and by the possibility of reversing this increased risk with a targeted therapy. Surgical treatment of unilateral forms of PA (mainly aldosterone-producing adenomas) is at present recommended in well-selected patients because of its cost-effectiveness. Therefore, subtype differentiation of PA forms is of fundamental importance, and available guidelines recommend contrast-enhanced CT-scanning and adrenal venous sampling (AVS) as the main diagnostic tests for this purpose. In this review, we discuss the value of adrenal non-invasive imaging and AVS, the recent advances in complementary tests and, finally, the available data on the outcome of surgical treatment for PA.

Long-Term Control of Arterial Hypertension and Regression of Left Ventricular Hypertrophy With Treatment of Primary Aldosteronism

Primary aldosteronism (PA), a common cause of high blood pressure (BP), induces left ventricular (LV) hypertrophy and an excess rate of cardiovascular events. Whether its treatment provides long-term cure of hypertension and regression of cardiovascular damage remains uncertain. To the aim of assessing the effect of treatment of PA on BP and LV changes, we prospectively recruited 323 patients in a long-term follow-up study entailing serial echocardiography evaluations. Of them, 180 had PA and were assigned to either adrenalectomy (n=110) or medical therapy (n=70) on the basis of the adrenal vein sampling. The remaining 143 were consecutive optimally treated primary hypertensive patients. At baseline, the PA patients had more inappropriate LV mass than PH patients (27.1% versus 16.2%; P=0.020), despite similar BP values. At a median follow-up of 36 months (range, 6-225), BP was lowered (P<0.0001 versus baseline) to similar values in adrenalectomized (135±15/83±9 mm Hg), medically treated PA (133±11/83±7 mm Hg), and PH (139±15/86±9 mm Hg) patients. To this end, the adrenalectomized patients required significantly less drugs than the other groups. In PA patients, the LV mass index and the rate of LV hypertrophy fell through LV inward remodeling to the level of optimally treated PH patients, indicating that the LV work markedly decreased. Findings were similar when long-term (≥5 and ≥10 years) data were examined. Thus, an early diagnosis and a specific treatment of PA warrant normalization of BP and reversal of detrimental LV changes at long term.

Sleep quality in patients with primary aldosteronism

In subjects at high risk for sleep apnea (SA), aldosterone concentrations correlate with severity of SA and primary aldosteronism (PA) is very often diagnosed. Patients with PA show a high prevalence of SA. Treatment of PA either by adrenalectomy (ADX) or mineralocorticoid receptor (MR) blockade is thought to abolish the increased comorbidities. However, no data are available regarding effectiveness of different PA treatments on quality of sleep. This prospective multi-center study included 15 patients with newly diagnosed PA evaluated before and 0.7±0.2 years after treatment initiation, and a second cohort including 81 patients who were evaluated 5.3 and 6.8 years after treatment initiation. Biochemical parameters, 24h blood pressure and three validated self-assessment questionnaires (Giessen complaint List (GBB-24), Epworth sleepiness scale (ESS) and Pittsburgh sleep Quality-Index (PSQI)) were analyzed. Z-scores of exhaustion tendency of GBB significantly improved in newly diagnosed PA patients after treatment initiation (1.8±1.4 vs. 1.0±1.2, p = 0.034). In the second cohort no differences were found in GBB-24, ESS and PSQI. No differences were found in all three questionnaires independently of type of PA therapy. However, female patients scored significantly higher than males in the PSQI (8.7±3.6 vs 5.7±4.2, p<0.005), indicating lower sleep quality, independently of the type of therapy. For the first time, we analyzed quality of sleep in patients with PA, demonstrating that therapy initiation improves exhaustion tendency. surprisingly, female PA patients showed significantly more sleep disturbances than male PA patients several years after treatment initiation.

Regression of left ventricular hypertrophy in patients with primary aldosteronism/low-renin hypertension on low-dose spironolactone

The incidence of left ventricular hypertrophy (LVH) in primary aldosteronism (PA) is higher than in essential hypertension. LVH is an independent cardiovascular risk factor. Treatment of PA with mineralocorticoid receptor blockers (MRBs) improves LVH. Previous studies included relatively small groups, low incidence of LVH and used high MRB dose. We tested the hypothesis that long-term regression of LVH in PA/low-renin hypertension may be achieved with low-dose MRB. Forty-eight patients (male/female 28/20, age 61.4 years, range 47-84) had PA (low renin, high aldosterone and high aldosterone/renin ratio, n=24) or low-renin hypertension (low renin, normal aldosterone and high aldosterone/renin ratio, n=24). All had either LVH or concentric remodelling. All had an echocardiogram both at baseline and at 1 year after the initiation of spironolactone. A subgroup of 29 patients had an echocardiogram at baseline, 1 year (range 0.5-1.5) and 3 years (range 1.8-7). At baseline, spironolactone was commenced in all patients. The dose was 33.3±13.7 and 29.0±11.7 mg/day at 1 year and 3 years, respectively. A total of 73% of the patients received ≤37.5 mg/day. Introduction of spironolactone enabled the reduction of other antihypertensive medications (from 2.6±1.2 to 1.5±1.0 at 1 year). At 1 year, systolic and diastolic blood pressure decreased (149.3±14.1 to 126.2±12.0 mmHg, P<0.001, and 88.2±9.8 to 78.3±7.1 mmHg, P<0.001, respectively). At baseline, LVH was present in 39 of the 48 (81%) patients, and concentric remodelling, i.e. increased relative wall thickness (RWT) with a normal left ventricular mass index (LVMI), in 36 (75%). At 1 year, LVMI decreased in 44 of the 48 (92%) patients (142.9±25.4 versus 117.7±20.4 g/m2, P<0.001). LVH normalized in 16 of the 39 (41%) patients. RWT normalized in 36% of the patients. The changes in blood pressure and LVMI did not correlate. At 3 years, LVH decreased further and normalized in 57% of the patients. In patients with PA/low-renin hypertension, long-term regression of LVH may be achieved with low-dose MRB.

Aldosterone receptor antagonists: current perspectives and therapies

Aldosterone is a downstream effector of angiotensin II in the renin–angiotensin–aldosterone system and binds to the mineralocorticoid receptor. The classical view of aldosterone primarily acting at the level of the kidneys to regulate plasma potassium and intravascular volume status is being supplemented by evidence of new “off-target” effects of aldosterone in other organ systems. The genomic effects of aldosterone are well known, but there is also evidence for non-genomic effects and these recently identified effects of aldosterone have required a revision in the traditional view of aldosterone’s role in human health and disease. The aim of this article is to review the biological action of aldosterone and the mineralocorticoid receptor leading to subsequent physiologic and pathophysiologic effects involving the vasculature, central nervous system, heart, and kidneys. Furthermore, we outline current evidence evaluating the use of mineralocorticoid receptor antagonists in the treatment of primary aldosteronism, primary hypertension, resistant hypertension, obstructive sleep apnea, heart failure, and chronic kidney disease.

Effects of Aldosterone Blockade on Metabolic and Renal Factors in Patients with Primary Aldosteronism

Objective: The mineralocorticoid Receptor (MR) is expressed not only in the kidneys but also in adipose tissue, and primary aldosteronism (PA) is associated with metabolic syndrome. This study assessed the effects of aldosterone blockade on metabolic factors in patients with PA. Method: Sixty-five patients with PA were treated with one of two MR antagonists; eplerenone (50-100 mg, daily, n=38) or spironolactone (25-50 mg, daily, n=27) for 14 months. Visceral (VAT) and subcutaneous adipose tissue (SAT) were quantified using CT and “Fat Scan” imaging analysis software. Body mass index (BMI), homeostasis model assessment-insulin resistance (HOMA-IR), serum creatinine, potassium and lipids, urinary albumin excretion and plasma aldosterone (PAC) and PRA were measured before and after treatment. Results: Eplerenone and spironolactone decreased blood pressure and increased serum potassium levels similarly. PAC and PRA did not differ among the two groups. Although treatment with the MR antagonists did not change HOMAIR or serum lipids, they significantly decreased urinary albumin excretion and V A T (p<0.05). Conclusion: These results suggest that both eplerenone and spironolactone are effective and safe for treatment of PA. The long-term metabolic effects of these MR antagonists should be further investigated. Sixty-five patients with primary aldosteronism (PA) were treated with eplerenone or spironolactone for 14 months. Visceral (VAT) and subcutaneous adipose tissue (SAT), Body Mass Index (BMI), homeostasis model assessment-insulin resistance (HOMA-IR), serum creatinine, potassium and lipids, and urinary albumin excretion were measured before and after treatment. Eplerenone and spironolactone decreased blood pressure and increased serum potassium levels similarly. Although treatment with the MR antagonists did not change HOMA-IR, they significantly decreased urinary albumin excretion and VAT (p<0.05). These results suggest that both eplerenone and spironolactone are effective for blood pressure and improvement of metabolic factors.

Improving the Success and Reliability of Adrenal Venous Sampling: Focus on Intraprocedural Cortisol Measurement

Primary aldosteronism (PA)2 is much more common than previously thought, possibly accounting for 5%–10% of hypertension cases (1, 2). Importantly, specific treatment of PA not only cures or improves the hypertension but also leads to amelioration of the excess cardiovascular damage and morbidity seen in these patients, compared with other forms of hypertension (1, 3). Consequently, recently published guidelines have recommended wider screening for PA via testing for the plasma aldosterone/renin ratio, in an effort to maximize the detection of patients who may then benefit from optimal, specific management (4). Once diagnosed, it is important to determine the subtype of PA, because the optimal treatment differs for each form. When PA is confined to a single adrenal gland (as in aldosterone-producing adenoma), unilateral adrenalectomy usually cures and virtually always improves the hypertension, with an accompanying improved quality of life. Bilateral forms, however, are more likely to respond to drugs—such as spironolactone, eplerenone, or amiloride—that antagonize aldosterone action. In most current series, unilateral forms make up approximately 30% of patients with PA, and bilateral forms make up the remaining 70% (2, 4). Computed tomography (CT) and other imaging modalities lack adequate sensitivity for identifying unilateral PA, because many aldosterone-producing adenomas are small (<1 cm) or the gland may only be mildly hyperplastic (2). Furthermore, CT may be frankly misleading by demonstrating unilateral nonfunctioning nodules in patients with bilateral PA or by showing nodules that are contralateral to the affected adrenal in unilateral PA (2). Owing to this diagnostic uncertainty, the only reliable way to differentiate unilateral from bilateral PA is by adrenal venous sampling (AVS), which seeks to estimate and evaluate each adrenal's aldosterone production separately (2, 4). The value of AVS is maximized when confounding factors that could complicate the interpretation of results …

Value of Adrenal Venous Sampling for Lesion Localization in Primary Aldosteronism

Distinguishing between unilateral and bilateral adrenal lesions is mandatory for surgical treatment of primary aldosteronism (PA). Adrenal venous sampling (AVS) is considered the gold standard for identification and localization of the lesion or lesions causing PA. The objective of the present study was to determine the usefulness of AVS in PA patients. From January 2001 to October 2011, 86 patients with the biochemical diagnosis of PA were retrospectively analyzed. The study group included 45 males and 41 females with a mean age of 50.7 ± 12.6 years, and all patients underwent adrenal computed tomography (CT) and AVS. The catheterization success rate of AVS was 82.69 % (86/104). In addition, AVS revealed bilateral lesions in 15/75 patients with unilateral abnormalities diagnosed by CT. These patients underwent medical treatment instead of surgery. One patient had an adrenal mass on the right side, but AVS localized the lesion on the left side. This patient underwent left adrenalectomy. Furthermore, AVS revealed a unilateral lesion in 2/5 patients with bilateral abnormalities demonstrated by CT. These patients underwent unilateral adrenalectomy. Finally, AVS demonstrated localization in 1/6 of patients with no CT abnormalities who were subjected to surgery. Fifty-three patients with unilateral lesion and one patient with bilateral hypersecretion underwent surgical removal of the affected gland(s). All patients had resolution of hypokalemia and clinical improvement of hypertension. Many patients (19/86, or 22.09 %) would have been inappropriately managed if decision making had been based solely on CT findings. Therefore, AVS is recommended before determining definitive PA management.

Role of mineralocorticoid receptor in insulin resistance

Recent data suggest that mineralocorticoid receptor activation can affect insulin resistance independent of its effects on blood pressure. This review discusses new evidence linking mineralocorticoid receptor to insulin resistance and the underlying mechanisms of these effects. Observational studies have shown mineralocorticoid activity to be associated with insulin resistance irrespective of race, blood pressure or body weight. Increased mineralocorticoid activity may be the common link between obesity, hypertension, dyslipidemia and insulin resistance, features that make up the metabolic syndrome. Treatment of primary aldosteronism is associated with a decrease in insulin resistance and provides one of the most convincing evidences in favor of the contribution of mineralocorticoid receptor to insulin resistance. Dietary salt restriction, which increases aldosterone levels, is also associated with an increase in insulin resistance. Potential mechanisms by which mineralocorticoid receptor may contribute to insulin resistance include a decreased transcription of the insulin receptor gene, increased degradation of insulin receptor substrates, interference with insulin signaling mechanisms, decreased adiponectin production and increased oxidative stress and inflammation. Advantages of mineralocorticoid receptor antagonists on insulin resistance have been demonstrated in animal models. There may be a benefit of mineralocorticoid receptor antagonists in human insulin resistance states, but more clinical research is needed to explore these possibilities.

A Potential Role for CPY17 as a Parameter in Differentiation Between Aldosterone-producing Adenoma and Nodular Hyperplasia in Patients With Hyperaldosteronism

To investigate CYP17 mRNA and protein expressions in aldosterone-producing adenoma (APA), nodular hyperplasia (NH) and normal adrenal gland (NAG) and if CPY17 might be used as a potential marker to differentiate between APA and NH in patients with hyperaldosteronism. Total RNA and protein were extracted from APA, 12 NH, and 15 NAG tissues. mRNA and protein expressions of CPY17 were examined by real-time polymerase chain reaction (PCR) and Western blot analysis. The relative expression levels of CPY17mRNA to glyceraldehyde 3-phosphate dehydrogenase in the APA, NH, and NAG groups are 0.94 ± 0.09, 2.07 ± 0.10, and 3.94 ± 0.19, respectively, when evaluated by real-time PCR. This result was confirmed by the relative protein expression levels of CPY17 to β-actin, which are 117 ± 13%, 274 ± 19%, and 478 ± 25%, respectively, when evaluated by Western blot analysis. There was a significant difference in mRNA and protein expression level of CYP17 between any two groups (P < .05). Thus, the sequence of the relative expression level of CPY17 is APA < NH < NAG. These results indicate that CPY17 was down-regulated in APA compared with that in NH, suggesting a potential role for CPY17 as a marker in differentiation between APA and NH in patients with hyperaldosteronism. Such a study might be helpful to improve the diagnosis and treatment of primary aldosteronism.

Predictive Factors of Left Ventricular Mass Changes after Treatment of Primary Aldosteronism

A variety of abnormalities that occur in patients with primary aldosteronism indicate the capability of elevated aldosterone to induce cardiac damage over that induced by hypertension itself. This study investigates factors that can predict structural and functional changes of the heart after treatment of primary aldosteronism in a post-hoc analysis of 54 patients who were enrolled in a long-term follow-up study that was conducted after either adrenalectomy or treatment with spironolactone. Cardiac ultrasound assessment was performed before treatment and after with an average follow-up of 6.4 years. During follow-up, blood pressure decreased significantly and comparably in both treatment groups. In both treatment groups, left ventricular mass decreased significantly with a trend to improved diastolic filling profile and no changes in ventricular geometry. At univariate analysis, changes in left ventricular mass induced by treatment of primary aldosteronism were directly related with changes in systolic blood pressure and pretreatment plasma aldosterone levels measured both at baseline and after an intravenous saline load. This relationship was maintained when patients treated with adrenalectomy and spironolactone were analyzed separately. Multivariate regression analysis showed that changes in systolic blood pressure and pretreatment aldosterone levels were independent predictors of left ventricular mass changes after treatment. This study strongly supports a role of aldosterone in promoting left ventricular hypertrophy that is independent of the hypertension-related hemodynamic load and suggests a practical way to predict left ventricular mass changes following surgical and medical treatment of primary aldosteronism.

Primary Aldosteronism: Who Should be Screened?

Primary aldosteronism (PA) has a prevalence in the general hypertensive population from 5 to 10%, and is widely recognized as the most frequent form of secondary hypertension. The 2 main PA subtypes are aldosterone producing adenoma (APA) and bilateral adrenal hyperplasia (BAH) that account for 95% of all PA cases. The diagnosis of PA is a 3-step process that comprises screening, confirmatory testing, and subtype differentiation. The different categories of patients at an increased risk of PA who should thus undergo a screening test were described in the first Endocrine Society (ES) Practice Guidelines for diagnosis and treatment of PA published in 2008. These categories include patients with Joint National Committee Stage 2, Stage 3, or drug-resistant hypertension; hypertension, and spontaneous or diuretic-induced hypokalemia; hypertension with adrenal incidentaloma; hypertension and a family history of early-onset hypertension or cerebrovascular accident at a young age and all hypertensive first degree relatives of patients with PA. Recently, a growing number of studies have linked PA with the metabolic syndrome, diabetes, and obstructive sleep apnea that may be partly responsible for the higher rate of cardio and cerobrovascular accidents in PA patients. The aim of this review is to discuss, which patients should be screened for PA, focusing not only on the well-established categories of the ES Guidelines, but also on additional other group of patients with a potentially high prevalence of PA that has emerged from recent research.

Hyperparathyroidism in Patients with Primary Aldosteronism: Cross-Sectional and Interventional Data from the GECOH Study

Experimental studies suggest that aldosterone induces hypercalciuria and might contribute to hyperparathyroidism. We aimed to test for differences in PTH levels and parameters of calcium and vitamin D metabolism in patients with primary aldosteronism (PA) compared with patients with essential hypertension (EH) and to evaluate the impact of PA treatment on these laboratory values. The Graz Endocrine Causes of Hypertension study includes hypertensive patients referred for screening for endocrine hypertension at a tertiary care center in Graz, Austria. Differences in PTH levels between patients with PA and EH. Among 192 patients, we identified 10 patients with PA and 182 with EH. PTH levels (mean ± sd in picograms per milliliter) were significantly higher in PA patients compared with EH (67.8 ± 26.9 vs. 46.5 ± 20.9; P = 0.002). After treatment of PA with either adrenal surgery (n = 5) or mineralocorticoid receptor antagonists (n = 5), PTH concentrations decreased to 43.9 ± 14.9 (P = 0.023). Serum 25-hydroxyvitamin D concentrations were similar in both groups. Compared with EH, serum calcium concentrations were significantly lower (2.35 ± 0.10 vs. 2.26 ± 0.10 mmol/liter; P = 0.013), and there was a nonsignificant trend toward an increased spot urine calcium to creatinine ratio in PA [median (interquartile range) 0.19 (0.11-0.31) vs. 0.33 (0.12-0.53); P = 0.094]. Our results suggest that PA contributes to secondary hyperparathyroidism. Further studies are warranted to evaluate whether PTH has implications for PA diagnostics and whether mineralocorticoid receptor antagonists have a general impact on PTH and calcium metabolism.

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.