Chemistry
Adrenal related
Hyperaldosteronism

Author: Renu Virk, M.D. (see Authors page)

Revised: 26 January 2016, last major update February 2010

Copyright: (c) 2002-2016, PathologyOutlines.com, Inc.

PubMed Search: Hyperaldosteronism [title]
Definition / General
Terminology
  • Primary hyperaldosteronism: cause is in the adrenal gland
  • Secondary hyperaldosteronism: cause is extra-adrenal
  • Tertiary hyperaldosteronism: cause is renal juxtaglomerular cells
Diagrams / Tables

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Synthesis pathway

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Renin-angiotensinal-
dosterone axis

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Diagnostic pathways

Etiology
  • Primary hyperaldosteronism causes:
    • Idiopathic adrenal hyperplasia: most common cause
    • Conn syndrome: aldosterone producing adrenal adenoma, rarely adrenal carcinoma

  • Secondary hyperaldosteronism causes:
    • Increased levels of plasma renin from non-adrenal pathology
    • Includes:
      • Congestive heart failure
      • Pregnancy (due to estrogen)
      • Decreased renal perfusion (renal arterial stenosis, nephrosclerosis)
      • Gypoalbuminemia
      • Ovarian tumor
      • Hyperthyroidism

  • Tertiary hyperaldosteronism (Bartter syndrome):
  • Glucocorticoid suppressible hyperaldosteronism:
    • Also called familial hyperaldosteronism type I
    • Rare, familial
      • Due to mutation which causes developmental derangement of cortical zonation, with hybrid cells between glomerulosa and fasciculata that are under the influence of ACTH, but can be suppressed by dexamethasone

  • Familial cases:
    • Early onset hypertension and severe target organ damage
Clinical Features
  • Causes urinary loss of potassium and hypokalemia, sodium retention and hypertension
  • May cause up to 14% of cases of refractory hypertension (Arq Bras Cardiol 2009;92:39)
  • Hypokalemia (present in 63%, Dtsch Arztebl Int 2009;106:305) causes weakness, paresthesias, visual disturbances, tetany
  • Sodium retention causes volume overload which suppresses the renin-angiotensin system and reduces plasma renin activity
    • Volume overload causes polyuria, polydipsia, nocturia, hypertension, alkalosis, hypernatremia
Laboratory
  • High serum sodium, low serum potassium, metabolic alkalosis
Diagnosis
Tests for primary hyperaldosteronism
  • Nonsuppressible aldosterone excretion with normal cortisol excretion, low plasma renin
  • Screening tests:
    • Preferred screening test is Ratio of plasma aldosterone concentration (PAC, in ng/dl) to plasma renin activity (PRA, in ng/ml/hr)
    • Ratio >30 is strongly suggestive of primary hyperaldosteronism
  • Confirmatory test:
    • Serum aldosterone level, urine aldosterone levels, saline suppression test
Case Reports
Treatment
  • Surgery for adenoma
  • Patients with bilateral adrenal hyperplasia need spironolactone or other antihypertensive drugs