What is the treatment approach for a patient with hyperaldosteronism (excess aldosterone) and chronic kidney disease (CKD)?

Treatment of Hyperaldosteronism in Chronic Kidney Disease

For patients with hyperaldosteronism and CKD, use mineralocorticoid receptor antagonists (MRAs) as the cornerstone of medical therapy, with spironolactone 25-100 mg daily as first-line treatment, while carefully monitoring potassium and renal function. 1, 2, 3

Determine Disease Laterality First

• Adrenal vein sampling is essential to distinguish unilateral from bilateral disease, as approximately 50% of primary aldosteronism cases are unilateral (typically aldosterone-producing adenoma) and 50% are bilateral (idiopathic hyperaldosteronism). 2, 4, 3
• Unilateral disease is potentially curable with laparoscopic adrenalectomy, which improves blood pressure in virtually 100% of patients and achieves complete hypertension cure in approximately 50%. 2, 4, 3
• Bilateral disease requires lifelong medical therapy with MRAs. 2, 4

Medical Management Algorithm for CKD Patients

First-Line Treatment: Spironolactone

• Start spironolactone at 25-50 mg daily in patients with CKD, particularly if eGFR is 30-50 mL/min/1.73 m². 1, 5
• Titrate up to 100-400 mg daily as needed for blood pressure control, though doses above 100 mg/day generally provide minimal additional benefit for hypertension. 1, 2, 5
• For primary hyperaldosteronism specifically, use 100-400 mg daily as the FDA-approved dosing range. 5

Alternative MRA: Eplerenone

• Consider eplerenone 50-100 mg daily (in 1-2 divided doses) if spironolactone causes intolerable side effects like gynecomastia or sexual dysfunction. 1, 3
• Eplerenone often requires twice-daily dosing for adequate blood pressure lowering and is less potent than spironolactone. 1

Critical Monitoring Requirements

• Check serum potassium and creatinine 4 weeks after initiating or changing MRA dose, then regularly during treatment. 1, 6
• Withhold MRA if potassium rises above 5.5 mmol/L, and restart at lower dose (10 mg daily for finerenone protocol, or reduce spironolactone by 50%) when potassium returns to ≤5.0 mmol/L. 1
• Patients with CKD and hyperaldosteronism may develop marked hyperkalemia and creatinine elevation when treated with spironolactone, particularly if they have hypertensive kidney damage. 7

Contraindications and Precautions in CKD

• Avoid MRAs in patients with eGFR <25-30 mL/min/1.73 m² unless carefully monitored, as hyperkalemia risk increases substantially. 1
• Do not combine MRAs with potassium supplements, other potassium-sparing diuretics, or the combination of ACE inhibitor plus ARB due to severe hyperkalemia risk. 1, 3
• Use caution when combining MRAs with ACE inhibitors or ARBs alone in CKD patients, as this increases hyperkalemia risk even without dual RAS blockade. 1, 3

Additional Antihypertensive Therapy

• Add calcium channel blockers or additional diuretics if blood pressure remains uncontrolled on MRA monotherapy. 6
• Loop diuretics (furosemide 20-80 mg twice daily, torsemide 5-10 mg daily) are preferred over thiazides in patients with moderate-to-severe CKD (eGFR <30 mL/min). 1
• Consider newer non-steroidal MRAs like finerenone (10-20 mg daily) for patients with type 2 diabetes, CKD, and albuminuria, as this agent has proven kidney and cardiovascular benefits with lower hyperkalemia risk. 1

Surgical Considerations for CKD Patients

• Laparoscopic adrenalectomy remains the treatment of choice for unilateral disease, even in patients with CKD, as it reduces medication burden and may improve blood pressure control. 3, 8
• Surgical outcomes in CKD patients show similar blood pressure control to medical management but with significantly fewer antihypertensive medications required (mean reduction of 1.7 medications at 5 years). 8
• Both surgical and medical management appear safe in CKD, with no significant differences in kidney or cardiovascular outcomes between approaches. 8

Common Pitfalls to Avoid

• Delayed diagnosis leads to irreversible vascular remodeling that causes persistent hypertension even after appropriate treatment, making early detection critical. 2, 4, 3
• Hypokalemia is absent in the majority of primary aldosteronism cases and should not be used to rule out the diagnosis, particularly in CKD where potassium handling is already impaired. 3
• Renin may not be suppressed in hyperaldosteronism patients with advanced CKD due to hypertensive kidney damage, but an elevated aldosterone-to-renin ratio remains diagnostic. 7
• Starting MRAs at full doses in CKD patients risks severe hyperkalemia and acute kidney injury, necessitating lower starting doses and close monitoring. 1, 7

When to Refer

• Refer complex cases or rare forms of hyperaldosteronism to specialized hypertension centers, particularly when adrenal vein sampling is needed or when standard medical therapy fails. 2, 4