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Primary Aldosteronism

DEFINITION

Primary aldosteronism is the overproduction of aldosterone in the adrenal glands. Aldosterone is a mineralocorticoid which is produced to balance the body’s sat content. The adrenal glands are two small glands that sit on top of the kidneys. The adrenal glands are part of the endocrine system, which is the system that regulates hormones in the body. The hormones produced by the adrenal glands are extremely important to regulation and balance (homeostasis) of most of the organ systems in the body. There are two sections to the adrenal gland, the medulla and cortex. The inner section (medulla) produces hormones like adrenaline (also called epinephrine). The outer section (cortex ) is important for production of the corticosteroids. Corticosteroids produced in the cortex include mineralocorticoids (such as aldosterone), glucocorticoids (such as cortisol), and androgens (male sex hormones). The mineralocorticoids, like aldosterone, maintain salt balance and blood pressure in the body through control of sodium and potassium. The glucocorticoids affect the body’s ability to use fuels for energy, allow the body to cause inflammation to help the immune system and regulates the body’s ability to deal with stress. When you have two much aldosterone (primary aldosteronism), your body retains sodium and, as a result, retains fluid and increases blood pressure. There are many causes of primary aldosteronism including an aldosteronoma (a benign growth which secretes aldosterones which is also called Conn’s Syndrome), bilateral adrenal hyperplasia (overgrowth and increased activity of both adrenal glands), cancer of the outside of the adrenal gland (more rare), genetic mutations (also more rare), and a condition called glucocorticoid-remediable aldosteronism that occurs in families (even more rare). The most common complication of primary aldosteronism is hypertension (high blood pressure) but it can also cause low potassium, muscle aches and cramps, heart attacks, heart failure, overgrowth of the left ventricle of the heart (left ventricular hypertrophy), stroke, kidney disease, and death.

SYMPTOMS
Difficult-to-control blood pressure, high blood pressure, low potassium, muscle aches, increased urination

DIAGNOSIS
The diagnosis of primary aldosteronism begins with a history and physical exam. During your physical exam, your doctor will also take your blood pressure. Your doctor will then ask for a blood test to check your aldosterone and renin levels in your blood. If those levels are abnormal, you will have one of several confirmatory tests. One confirmatory test involves eating a high-salt diet followed by checking your urine for aldosterone and sodium levels. A different confirmatory test involves an infusion of saline fluid into your arm through an IV followed by checking the aldosterone level in the blood. A final option for confirmatory test is the fludrocortisones suppression test which involves taking a high salt diet along with fludrocortisone then measuring the aldosterone level in the blood. Once you have the diagnosis of primary alosteronism, your doctor will want to know what is causing your high aldosterone level, so you will need to have additional testing done. You will likely have imaging of your body done with a CT scan which can help show any growths in the adrenal gland. Sometimes your doctor will recommend adrenal vein sampling, where an interventional radiologist will draw blood from each of your adrenal veins to see which adrenal gland is producing the extra aldosterone.

TREATMENT
Many treatment options exist for primary adosteronism and depend on the underlying cause. For bilateral adrenal hyperplasia, both medications and lifestyle modification are used in combination. Medications for bilateral adrenal hyperplasia include mineralocorticoid receptor antagonists (spironolactone) which block aldosterone activity in your body. The side effects of these medications can include gynecomastia (breast enlargement), impotence, decreased libido and changes in the menstrual cycle because these medications also inhibit sex hormones to some degree. A newer medication called eplerenone may not have these side effects but is currently much more expensive than spironolactone. You will probably also need medications for high blood pressure. You will also want to eat a healthy, low salt diet and increase your exercise. If you have an aldosteronoma, you can use the aforementioned medications but you also have the option of surgical removal (adrenalectomy) which can result in resolution of both high blood pressure and low potassium. In general, you should follow recommendations to lower blood pressure including maintaining a healthy body weight, exercising, eating a balanced low salt diet, quitting smoking, and decreasing your caffeine and alcohol intake.

DEFINITION

Primary aldosteronism is a medical condition where the adrenal glands produce too much aldosterone. Adrenal glands are two small glands that sit on top of the kidneys. The adrenal glands are part of the endocrine system which regulates hormones in the body. The hormones produced by the adrenal glands are extremely important to regulation and balance (homeostasis) of most of the organ systems in the body. There are two sections to the adrenal gland, the medulla and cortex. The inner section (medulla) produces hormones like adrenaline (also called epinephrine). The outer section (cortex) is important for production of the corticosteroids. Corticosteroids produced in the cortex include mineralocorticoids (such as aldosterone), glucocorticoids (such as cortisol), and androgens (male sex hormones). The mineralocorticoids maintain salt balance and blood pressure in the body through control of sodium and potassium. The glucocorticoids affect the body’s ability to use fuels for energy, allow the body to cause inflammation to help the immune system and regulates the body’s ability to deal with stress. In primary aldosteronism, the body has too much aldosterone which leads to loss of potassium in the urine and retaining too much sodium. Having too much sodium in the body causes the body to retain too much water leading to elevated blood pressure. Most often, primary aldosteronism is caused by either an aldosteronoma (a small benign growth of the adrenal gland) or bilateral adrenal hyperplasia (increased activity of both of the glands) but can also be caused by cancer, genetic mutations, and a familial type of aldosteronism called glucose-remediable aldosteronism (GRA). If left untreated, primary aldosteronism can lead to heart attack, heart failure, stroke, left ventricular hypertrophy (overgrowth of the muscle of the left side of the heart), kidney disease, and even death.

SYMPTOMS
High blood pressure that is difficult to control with medication, low potassium levels

DIAGNOSIS
Your doctor will begin by talking to you about your symptoms and doing a physical exam. Your doctor will likely recommend some blood tests including the aldosterone-renin test. If that test is positive, several other tests can be done to see if you have primary aldosteronism including an oral salt loading test (where you eat a high-sodium diet for three days before your doctor checks your blood aldosterone levels), saline loading (where saline is injected through a vein for several hours then blood is drawn to check aldosterone levels), or fludrocortisone suppression test (where you eat a high sodium diet and take a medication called fludrocortisone for three days followed by checking blood levels of aldosterone). If your doctor finds that you have primary aldosteronism, he or she may want to check additional tests such as computerized tomography (CT) scan of the abdomen to look at the adrenal glands and determine the cause of the primary aldosteronism. Your doctor or endocrinologist may recommend a procedure called adrenal vein sampling which involves drawing blood from each vein leaving the adrenal glands to determine which one is leading to the high levels of aldosterone.

TREATMENT
Treatment for primary aldosteronism will depend on the cause. If you have bilateral adrenal hyperplasia (overgrowth of both adrenal glands), your doctor will recommend certain medications that block the activity of aldosterone in the body such as spironolactone or eplerenone. Your doctor will also recommend adopting a healthy diet and lifestyle which can make your medications more effective. Stopping smoking and abstaining from alcohol can also be beneficial to improve your condition. If you have aldosteronoma (a single benign tumor that produces aldosterone), you can use the same medications and lifestyle changes as for bilateral adrenal hyperplasia but also have other treatment options. You have the option to have surgery to remove the adrenal gland (adrenalectomy). You should discuss your treatment options with your doctor or endocrinologist.

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