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Primary aldosteronism: diagnostic and treatment strategies

Nature Clinical Practice Nephrology volume 2, pages 198–208 (2006)Cite this article

Abstract

Primary aldosteronism is caused by bilateral idiopathic hyperplasia in approximately two-thirds of cases and aldosterone-producing adenoma in one-third. Most patients with primary aldosteronism are normokalemic. In the clinical setting of normokalemic hypertension, patients who have resistant hypertension and hypertensive patients with a family history atypical for polygenic hypertension should be tested for primary aldosteronism. The ratio of plasma aldosterone concentration to plasma renin activity has been generally accepted as a first-line case-finding test. If a patient has an increased ratio, autonomous aldosterone production must be confirmed with an aldosterone suppression test. Once primary aldosteronism is confirmed, the subtype needs to be determined to guide treatment. The initial test in subtype evaluation is CT imaging of the adrenal glands. If surgical treatment is considered, adrenal vein sampling is the most accurate method for distinguishing between unilateral and bilateral adrenal aldosterone production. Optimal treatment for aldosterone-producing adenoma or unilateral hyperplasia is unilateral laparoscopic adrenalectomy. The idiopathic bilateral hyperplasia and glucocorticoid-remediable aldosteronism subtypes should be treated pharmacologically. All patients treated pharmacologically should receive a mineralocorticoid receptor antagonist, a drug type that has been shown to block the toxic effects of aldosterone on nonepithelial tissues.

Key Points

  • Primary aldosteronism is present in 5–13% of people with hypertension

  • Diagnosis of primary aldosteronism is based on an increased ratio of plasma aldosterone concentration to plasma renin activity, and results of a subsequent aldosterone suppression test

  • There are several subtypes of primary aldosteronism—bilateral idiopathic hyperplasia and aldosterone-producing adenoma are the most common

  • Determination of subtype is essential to direct therapy

  • Surgical (e.g. laparoscopic adrenalectomy) and pharmacological (e.g. mineralocorticoid receptor antagonists) interventions are commonly used

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Figure 1: CT of a right adrenal mass in a 35-year-old woman with a 7-year history of hypertension.
Figure 2: Algorithm for using the ratio of plasma aldosterone concentration to plasma renin activity as a case-finding tool, and for subtype evaluation, of primary aldosteronism.
Figure 3: Relationship between maximal diameter of aldosterone-producing adenoma at pathology examination and plasma aldosterone concentration (n = 101).

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  1. Department of Public Health and Clinical Medicine at Umeå University Hospital, Umeå, Sweden

    Cecilia Mattsson

  2. Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic and Professor of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA

    William F Young Jr

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Mattsson, C., Young, W. Primary aldosteronism: diagnostic and treatment strategies. Nat Rev Nephrol 2, 198–208 (2006). https://doi.org/10.1038/ncpneph0151

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