Symptoms of Hyperaldosteronism
The majority of patients with hyperaldosteronism present with hypertension—often severe or resistant to treatment—while hypokalemia occurs in only approximately 50% of cases, making it an unreliable screening marker. 1, 2
Primary Clinical Manifestations
Hypertension
- Severe, resistant hypertension is the hallmark presentation, defined as blood pressure not controlled on 3 or more medications including a diuretic 3, 1
- Patients may present with accelerated or malignant hypertension, particularly with abrupt onset or loss of previously controlled blood pressure 3
- Hypervolemia or normovolemia despite severe diastolic hypertension is characteristic in the majority of patients 4
Electrolyte Abnormalities
- Hypokalemia is present in only 50% of patients with primary aldosteronism, so normal potassium does not exclude the diagnosis 1, 2
- When present, hypokalemia may be spontaneous or diuretic-induced 2
- Unprovoked or excessive hypokalemia (not taking a diuretic) should raise suspicion 3
- Mild extracellular volume expansion occurs due to aldosterone-induced sodium retention in the distal convoluted tubule 1
Cardiovascular and Renal Manifestations
- Prolonged aldosterone excess causes target organ damage to the heart, kidney, and arterial wall, resulting in increased cardiovascular morbidity and mortality beyond that explained by hypertension alone 5
- Serum creatinine may be elevated, particularly in patients with severe hypertension and secondary kidney damage 1
- In advanced cases, hypertensive kidney damage can cause renin to escape suppression, presenting with normal to high-normal renin levels 6
High-Risk Clinical Scenarios Warranting Screening
The following presentations should trigger screening for hyperaldosteronism 1, 2:
- Resistant hypertension (BP uncontrolled on ≥3 drugs including a diuretic) - prevalence up to 20% 3, 1
- Severe hypertension (BP >180/110 mmHg) 1
- Hypertension with spontaneous or diuretic-induced hypokalemia 2
- Incidentally discovered adrenal mass on imaging 1, 2
- Early-onset hypertension (<30-40 years of age) or family history of early-onset hypertension 3, 1
- Stroke at young age (<40 years) 1
- Abrupt onset or abrupt loss of blood pressure control 3
Treatment Overview
Unilateral Disease
- Laparoscopic unilateral adrenalectomy is the treatment of choice for unilateral aldosterone production, improving blood pressure in virtually 100% of patients and achieving complete cure of hypertension in approximately 50% 1, 2
- Surgery normalizes hypokalemia, lowers blood pressure, reduces antihypertensive medication requirements, and improves cardiac and kidney function 1
- Adrenal venous sampling is mandatory before surgery to distinguish unilateral from bilateral disease, except in patients <40 years with a single affected gland on imaging 1
Bilateral Disease
- Mineralocorticoid receptor antagonists (MRAs) are the cornerstone of medical therapy for bilateral disease 1, 2
- Spironolactone is first-line treatment, starting at 12.5-25 mg/day and titrating up to 100 mg/day as needed 7, 8
- For primary hyperaldosteronism, doses of 100-400 mg daily may be used 7
- Eplerenone (50-100 mg/day) is an alternative with fewer anti-androgenic side effects 1, 8
- Close monitoring of serum potassium and creatinine is essential when initiating MRAs, particularly in patients with renal impairment (eGFR <45 mL/min/1.73 m²) 2, 8
Critical Treatment Considerations
- Avoid combining MRAs with other potassium-sparing medications or potassium supplements due to hyperkalemia risk 2
- In patients with advanced hypertensive kidney damage, spironolactone therapy may cause marked increases in serum creatinine and potassium 6
- Additional antihypertensive agents (potassium-sparing diuretics like amiloride, or calcium channel blockers) may be necessary if blood pressure is not normalized with MRAs alone 8
- The goal of treatment extends beyond blood pressure normalization to include correction of aldosterone excess and prevention of target organ damage 5