Adrenal Excess - Aldosterone

Question 1

Which layer of the adrenal gland produces aldosterone?

Answer 1

Zona glomerulosa

Question 2

Aldosterone’s main goal

Answer 2

increase intravascular volume

kidneys reabsorb Na+ and secretion of K+ and H+
Regulated by K+ and RAAS
System is triggered by stress, hypovolemia, and hyperkalemia

Question 3

Do tumors usually result in hypersecretion or suppression of endocrine system?

Answer 3

Hypersecretion

Question 4

Primary Aldosteronism Causes

Answer 4

• Aldosterone-producing adenoma 90%
• Bilateral Idiopathic Hyperplasia or Primary Adrenal Hyperplasia (60%)

Other: Aldosterone-producing renin-responsive adenomas, ovarian or nephritic neoplastic ectopic secretion of aldosterone (rare)

Question 5

Primary symp of hyperaldosteronism

Answer 5

• SS related to HTN & Hypokalemia

Question 6

When to screen HTN pts for Hyperaldosteronism

Answer 6

if they have HTN + Hypokalemia

Hyperaldosteronism is a secondary cause of HTN

Question 7

Hyperaldosteronism WU

Answer 7

aldosterone-to-renin ratio

Ratio of aldosterone to plasma renin activity (PRA)
As aldosterone incr, PRA should decr
Aldosterone producing adenomas are unresponsive to a rise in renin, so aldosterone falls
In IHA, the rise in renin causes a rise in aldosterone

Question 8

Primary Aldosteronism

Which will have higher BP: Adenoma or Hyperplasia?

Answer 8

tumors have higher BP than hyperplasia

Question 9

Imaging order for Aldosteronism

Answer 9

Abd CT to r/o cancer

Question 10

aldosterone-producing adenoma (APA) Trmnt

Answer 10

Tumors should be removed laparoscopically. After removal of an adenoma, serum potassium normalizes and blood pressure decreases in all patients; complete normalization of the blood pressure without the need forantihypertensive treatment occurs in 50 to 70% of patients.

Question 11

Who gets it? Patho? Trmnt?

Bilateral Idiopathic Hyperplasia or Primary Adrenal Hyperplasia

Answer 11

• More common in older men
• Bilateral adrenal cortex hyperplasia results in elevations of aldosterone
• HTN and low potassium
• Tx: spironolactone (potassium sparing diuretic/androgen receptor blocker) to retain potassium and reduce water/Na
• Eplerenone-aldosterone antagonist* long term management for men due to no gynecomastia/ED like spironolactone
• Most will require additional HTN meds for control

Question 12

What is it? causes?

Aldosterone Insufficiency/Hypoaldosteronism

Answer 12

component of Addison
Drug induced –NSAIDs, heparin
Diabetes
Kidney failure (GFR<15)

Question 13

Addison Disease (Adrenocortical insufficiency) typically affects which parts of the adrenal gland?

Answer 13

Candy shell (zona glomerulosa and fasiculata)

So it affects Glucocorticoids and Mineralocorticoid function. Usu affects both but can be just one layer

Question 14

Hypoaldosteronism is due to a decreased _____ secretion

Answer 14

Renin

Note: Diseased kidneys fail to detect decreased ECF volume, decreased NaCl, and decreased arterial BP so RENIN is not secreted adequately.
There is no increased angiotensin and no increase in aldosterone

Question 15

Will Hypoaldosteronism cause hyper or hypo K+?

Answer 15

Hyperkalemia

Also metabolic acidosis due to kidneys not producing enough bicarb

Question 16

Hypoaldosteronism Trmnt

Answer 16

• Maximize medical management of cause
• Kidney failure – remove all medication that affect kidneys
• Dialysis if needed
• Hyperkalemia – loop diuretic if volume can tolerate being dropped
• Emergently, can give .9NS bolus and loop diuretic
• may need to address bicarb, depending on kidney function
• DM – better control
• Addison – add Fludrocortisone/Florinef if not already being replaced

Question 17

what? ET?

Pheochromocytoma

Answer 17

• Catecholamine-secreting tumor (chromaffin cells of adrenal gland)
• 30% due to hereditary syndromes

von Hippel-Lindau (VHL) syndrome
multiple endocrine neoplasia type 2(MEN 2)
neurofibromatosis type 1(NF1)

Question 18

Pheochromocytomas secrete what?

Answer 18

Catecholamines: norepi, epi, +/- dopamine

MOST pheochromocytomas secrete norepi predominantly

Question 19

What do Catecholamines do?

Answer 19

• Stimulate alpha-adrenergic receptors resulting in vasoconstriction -> Incr BP
• increased cardiac contractility ->Incr Pulse
• glycogenolysis, gluconeogenesis -> Incr Blood Sugar
• GI tract stimulation -> increased mucus, motility and relaxed sphincter tone
• Stimulation of beta-adrenergic receptors results in incr in HR and contractility

Question 20

which endocrine disorder causes H/A, Diaphoresis, and Palpitations + Severe HTN?

Answer 20

Pheochromocytoma

The spells may vary from monthly to several times per day, and the duration may vary from seconds to hours. Typically, they worsen with time, occurring more frequently and becoming more severe as the tumor grows.

Question 21

Pheochromocytoma WU

Answer 21

• Biochemical Testing -> plasma free metanephrines or urinary fractionated metanephrines
• CMP for gluc, high Ca+
• CBC for erythrocytosis

Biochemical Tests
- if (+) -> order CT
- plasma free metanephrine level may be measured in a standard venipuncture sample, drawn about 15-20 minutes after intravenous catheter insertion.
- a 24-hour urine collection for creatinine, total catecholamines, vanillylmandelic acid, and metanephrines.
- Cannot be on beta blockers, TCAs, amphetamines, buspirone, Dopamine agonists, alcohol (all inc metanephrines)

Question 22

If pheochromocytoma biochemical test is (+) -> order ______

Biochemical tests -> plasma free metanephrines or urinary fractionated metanephrines

Answer 22

CT

Question 23

Pheochromocytoma Trmt

Answer 23

• Endo referral
• Laparoscopic Adrenalectomy

Prior to Sx
- Alpha-adrenergic antagonist (BP control to prevent HTN crisis. High catecholamines stim alpha receptors on blood vessels -> vasoconstriction)
- BBs (if signficant tachycardia occurs after alpha antagonist. Don’t start until alpha antagonist is stable)

Sx resection cures HTN