The Korean Journal of Medicine

The Korean Association of Internal Medicine (대한내과학회)
권호 표지
DOI QR코드

DOI QR Code

Primary Aldosteronism

일차성 알도스테론증

  • Kim, Sang-Wan (Department of Internal Medicine, Seoul Metropolitan Government Borame Medical Center, Seoul National University College of Medicine)
  • 김상완 (서울대학교 의과대학 내과학교실, 서울특별시 보라매병원 내분비대사내과)
  • Published : 2012.04.01
⟨ Previous Next ⟩

Abstract

Primary aldosteronism (PA) is characterized by inappropriately high production of aldosterone relatively autonomous from the renin-angiotensin system and no suppression by sodium loading. The prevalence of PA is estimated more than 10% among nonseleted hypertensive patients. PA is clinically very important since patients with PA have higher cardiovascular morbidity and mortality than age- and sex-matched patients with essential hypertension and the same degree of blood pressure elevation. The ratio of plasma aldosterone concentration to plasma renin activity (ARR) has been generally accepted as a first-line screening test. ARR might be affected by patient age, anti-hypertensive drugs, posture and menstrual cycles. Once the ARR is measured, confirmative test should be performed. Although a gold standard confirmative test for PA is not yet identified, intravenous saline loading test is widely used. Adrenal venous sampling (AVS) is a gold standard for differentiation of unilateral from bilateral forms of PA. Since adrenal CT imaging has limitations to accurate diagnosis of PA, AVS is recommended for all patients who wish to pursue surgical treatment. Although unilateral laparoscopic adernalectomy is the optimal treatment for patients with aldosterone producing adenoma or unilateral hyperplasia, strong evidence linking adernalectomy with improved quality of life, morbidity or mortality is not available. Mneralocorticoid receptor antagonists, spironolactone or eplerenone, are recommended for pharmacologic therapy of PA.

Keywords

References

  1. Conn JW. Presidential address: I. painting background: II. primary aldosteronism, a new clinical syndrome. J Lab Clin Med 1955;45:3-17.
  2. Funder JW, Carey RM, Fardella C, et al. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2008;93:3266-3281. https://doi.org/10.1210/jc.2008-0104
  3. Fardella CE, Mosso L, Gómez-Sánchez C, et al. Primary hyperaldosteronism in essential hypertensives: prevalence, biochemical profile, and molecular biology. J Clin Endocrinol Metab 2000;85:1863-1867. https://doi.org/10.1210/jc.85.5.1863
  4. Mulatero P, Rabbia F, Milan A, et al. Drug effects on aldosterone/plasma renin activity ratio in primary aldosteronism. Hypertension 2002;40:897-902. https://doi.org/10.1161/01.HYP.0000038478.59760.41
  5. Rossi E, Regolisti G, Negro A, Sani C, Davoli S, Perazzoli F. High prevalence of primary aldosteronism using postcaptopril plasma aldosterone to renin ratio as a screening test among Italian hypertensives. Am J Hypertens 2002;15(10 Pt 1):896-902. https://doi.org/10.1016/S0895-7061(02)02969-2
  6. Brown NJ. Aldosterone and end-organ damage. Curr Opin Nephrol Hypertens 2005;14:235-241. https://doi.org/10.1097/01.mnh.0000165889.60254.98
  7. Milliez P, Girerd X, Plouin PF, Blacher J, Safar ME, Mourad JJ. Evidence for an increased rate of cardiovascular events in patients with primary aldosteronism. J Am Coll Cardiol 2005;45:1243-1248. https://doi.org/10.1016/j.jacc.2005.01.015
  8. Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003; 348:1309-1321. https://doi.org/10.1056/NEJMoa030207
  9. Zannad F, Alla F, Dousset B, Perez A, Pitt B. Limitation of excessive extracellular matrix turnover may contribute to survival benefit of spironolactone therapy in patients with congestive heart failure: insights from the randomized aldactone evaluation study (RALES): Rales Investigators. Circulation 2000;102:2700-2706. https://doi.org/10.1161/01.CIR.102.22.2700
  10. Fallo F, Veglio F, Bertello C, et al. Prevalence and characteristics of the metabolic syndrome in primary aldosteronism. J Clin Endocrinol Metab 2006;91:454-459. https://doi.org/10.1210/jc.2005-1733
  11. Mattsson C, Young WF Jr. Primary aldosteronism: diagnostic and treatment strategies. Nat Clin Pract Nephrol 2006;2:198-208.
  12. Young WF. Primary aldosteronism: renaissance of a syndrome. Clin Endocrinol (Oxf) 2007;66:607-618. https://doi.org/10.1111/j.1365-2265.2007.02775.x
  13. Oelkers WK. Effects of estrogens and progestogens on the renin-aldosterone system and blood pressure. Steroids 1996;61:166-171. https://doi.org/10.1016/0039-128X(96)00007-4
  14. Fommei E, Ghione S, Ripoli A, et al. The ovarian cycle as a factor of variability in the laboratory screening for primary aldosteronism in women. J Hum Hypertens 2009;23:130-135. https://doi.org/10.1038/jhh.2008.109
  15. Ferrari P, Shaw SG, Nicod J, Saner E, Nussberger J. Active renin versus plasma renin activity to define aldosterone-torenin ratio for primary aldosteronism. J Hypertens 2004; 22:377-381. https://doi.org/10.1097/00004872-200402000-00023
  16. Olivieri O, Ciacciarelli A, Signorelli D, et al. Aldosterone to Renin ratio in a primary care setting: the Bussolengo Study. J Clin Endocrinol Metab 2004;89:4221-4226. https://doi.org/10.1210/jc.2003-032179
  17. Unger N, Lopez Schmidt I, Pitt C, et al. Comparison of active renin concentration and plasma renin activity for the diagnosis of primary hyperaldosteronism in patients with an adrenal mass. Eur J Endocrinol 2004;150:517-523. https://doi.org/10.1530/eje.0.1500517
  18. Nishikawa T, Omura M, Satoh F, et al. Guidelines for the diagnosis and treatment of primary aldosteronism: the Japan Endocrine Society 2009. Endocr J 2011;58:711-721. https://doi.org/10.1507/endocrj.EJ11-0133
  19. Cicala MV, Mantero F. Primary aldosteronism: what consensus for the diagnosis. Best Pract Res Clin Endocrinol Metab 2010;24:915-921. https://doi.org/10.1016/j.beem.2010.10.007
  20. Kempers MJ, Lenders JW, van Outheusden L, et al. Systematic review: diagnostic procedures to differentiate unilateral from bilateral adrenal abnormality in primary aldosteronism. Ann Intern Med 2009;151:329-337. https://doi.org/10.7326/0003-4819-151-5-200909010-00007
  21. Stewart PM, Allolio B. Adrenal vein sampling for primary aldosteronism: time for a reality check. Clin Endocrinol (Oxf) 2010;72:146-148. https://doi.org/10.1111/j.1365-2265.2009.03714.x
  22. Lee JS, Kang MY, Kim SW, Shin CS, Kim SY, Chung JW. The clinical implication and problems of adrenal vein sampling in patients with primary aldosteronism. J Korean Endocr Soc 2007;22:428-435. https://doi.org/10.3803/jkes.2007.22.6.428
  23. Young WF, Stanson AW. What are the keys to successful adrenal venous sampling (AVS) in patients with primary aldosteronism? Clin Endocrinol (Oxf) 2009;70:14-17. https://doi.org/10.1111/j.1365-2265.2008.03450.x
  24. Meyer A, Brabant G, Behrend M. Long-term follow-up after adrenalectomy for primary aldosteronism. World J Surg 2005;29:155-159. https://doi.org/10.1007/s00268-004-7496-z
  25. Sawka AM, Young WF, Thompson GB, et al. Primary aldosteronism: factors associated with normalization of blood pressure after surgery. Ann Intern Med 2001;135: 258-261. https://doi.org/10.7326/0003-4819-135-4-200108210-00010
  26. Sywak M, Pasieka JL. Long-term follow-up and cost benefit of adrenalectomy in patients with primary hyperaldosteronism. Br J Surg 2002;89:1587-1593. https://doi.org/10.1046/j.1365-2168.2002.02261.x
  27. Celen O, O'Brien MJ, Melby JC, Beazley RM. Factors influencing outcome of surgery for primary aldosteronism. Arch Surg 1996;131:646-650. https://doi.org/10.1001/archsurg.1996.01430180072015
  28. Proye CA, Mulliez EA, Carnaille BM, et al. Essential hypertension: first reason for persistent hypertension after unilateral adrenalectomy for primary aldosteronism? Surgery 1998;124:1128-1133. https://doi.org/10.1067/msy.1998.93108
  29. Jeunemaitre X, Chatellier G, Kreft-Jais C, et al. Efficacy and tolerance of spironolactone in essential hypertension. Am J Cardiol 1987;60:820-825. https://doi.org/10.1016/0002-9149(87)91030-7
  30. Zannad F, McMurray JJ, Krum H, et al. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med 2011;364:11-21. https://doi.org/10.1056/NEJMoa1009492
  31. Dluhy RG, Lifton RP. Glucocorticoid-remediable aldosteronism. J Clin Endocrinol Metab 1999;84:4341-4344. https://doi.org/10.1210/jc.84.12.4341

Cited by

  1. Changes in the clinical manifestations of primary aldosteronism vol.29, pp.2, 2012, https://doi.org/10.3904/kjim.2014.29.2.217
  2. Bilateral Adrenocortical Masses Producing Aldosterone and Cortisol Independently vol.30, pp.4, 2012, https://doi.org/10.3803/enm.2015.30.4.607