How do we work up and treat primary hyperaldosteronism?
I actually started here and reminded myself that we should be stopping spironolactone/eplerenone for at least a few weeks before testing these levels. In terms of management, I'm attaching the endocrine clinical practice guidelines I found to be most helpful. They suggest confirmatory testing after finding an elevated ARR, unless the aldo level is above 20 or the renin level is undetectable.
Figure 1. Algorithm for the detection, confirmation, subtype testing, and treatment of PA.
Confirmatory testing can include salt loading, fludricortisone supression, or captopril. Again, this organization explains the various options for confirmatory testing in a simple and clear way. If positive, the next step would be a CT scan and adrenal venous sampling. Unilateral disease is treated with surgical removal; bilateral disease with medication.
I also learned that:
hypokalemia occurs in the minority of these patients
delays in diagnostic testing have been associated with poorer response to treatment
CT is better than MRI for imaging the adrenals
patients with genetic hyperaldosteronism can be normotensive and still have LVH and diastolic dysfunction
some studies estimate the prevalence of primary aldosteronism in a population of patients with hypertension to be as high as 10%
The clinical practice guideline is attached for your review. Please share if you've got more insight into this disease process!
Aldosterone Renin Ratio | Primary Aldosteronism Foundation. Primary Aldosteronism Foundation. Published January 2, 2020. https://primaryaldosteronism.org/step-1-aldosterone-renin-ratio-arr/
Confirmatory Testing | Primary Aldosteronism Foundation. Primary Aldosteronism Foundation. Published January 2, 2020. https://primaryaldosteronism.org/step-2-confirmatory-testing/
Funder JW, Carey RM, Mantero F, et al. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2016;101(5):1889-1916. doi:https://doi.org/10.1210/jc.2015-4061
