Primary hyperaldosteronism

Question 1

What is primary hyperaldosteronism characterised by

Answer 1

an excessive autonomous secretion of aldosterone resulting in a suppression of plasma renin activity

Question 2

What are the 2 main causes of primary hyperaldosteronism

Answer 2

Unilalateral adenoma secreting excess aldosterone (70%)

Bilateral hyperplasia of the adrenal cortex (30%)

Question 3

What is secondary hyperaldosteronism due to

Answer 3

Increased plasma renin activity and may be seen in conditions associated with reduced renal perfusion such as renal artery stenosis, congestive cardiac failure and cirrhosis

Question 4

What sex does aldosterone-producing adenomas occur most commonly in and what age

Answer 4

Females

Younger patients i.e.

Question 5

Bilateral adrenal hyperplasia occurs more commonly in what sex and what age

Answer 5

Men and at an older age

Question 6

Who are more like to get an adrenal carcinoma

Answer 6

Females - between 50 and 70 years

Question 7

What is the function of aldosterone

Answer 7

It stimulates sodium reabsorption and potassium and hydrogen loss by acting on the distal renal tubules

Question 8

What does excessive aldosterone secretion result in

Answer 8

sodium and water retention
hypertension
hypokalaemia
metabolic acidosis

Question 9

What condition typically has aldosterone producing adenomas

Answer 9

Conn’s syndrome

Question 10

Describe the appearance of a aldosterone producing adenoma

Answer 10

Usually 0.5-2cm and have a yellow colour due to their high cholesterol content

Question 11

What is aldosterone production sensitive to in aldosterone producing adenomas

Answer 11

adrenocorticotrophic hormone (ACTH)

Question 12

What is bilateral adrenal hyperplasia also known as

Answer 12

idiopathic hyperaldosteronism

Question 13

Which part of the adrenal gland produces aldosterone

Answer 13

Zona glomerulosa

Question 14

What is the zone glomerulsa very sensitive to in bilateral adrenal hyperplasia

Answer 14

Angiotensin 2

Question 15

What is glucocorticoid-suppressible hyperaldosteronism

Answer 15

a rare autosomal dominant condition

Question 16

What is glucocorticoid-suppressive hyperaldosteronism usually associated with

Answer 16

Bilateral adrenal hyperplasia

Question 17

What are aldosterone-producing carcinomas associated with

Answer 17

hyper secretion of cortisol, androgens and oestrogen, as well as high levels of aldosterone

Question 18

How do patients with primary hyperaldosteronism usually present

Answer 18

hypertension and hypokalaemia

Question 19

What might hypokalaemia cause

Answer 19

fatigue 
muscle weakness
cramps 
polydipsia 
polyuria

Question 20

What is a characteristic presentation of patients with glucocorticoid-suppressible hyperaldosteronism

Answer 20

Early haemorrhagic strokes

Question 21

What is the initial screening test

what would a positive screen test involve?

Answer 21

a measurement of plasma aldosterone concentration and plasma renin activity
Raised plasma aldosterone concentration to renin ratio

Question 22

What must be done prior to measuring the aldosterone to renin ratio

Answer 22

stop antihypertensives as they increase plasma renin activity
Hypokalaemia should be corrected (oral potassium chloride supplementation)

Question 23

In what case might a false negative result of primary hyperaldosteronism be seen

Answer 23

patients with chronic renal failure

Question 24

What is a normal response following a sodium (salt) load

Answer 24

Aldosterone suppression

Question 25

What result would confirm primary hyperaldosteronism with a salt (sodium) loading test

Answer 25

Failure of aldosterone suppression

Question 26

How is a salt loading test carried out

Answer 26

Oral sodium chloride tablets tds. on the 3rd day, a 24 hour urine specimen is collected for measurement of aldosterone, sodium and creatinine

Question 27

What is the treatment for unilateral adenomas

Answer 27

surgery

Question 28

What is the treatment for bilateral adrenal hyperplasia

Answer 28

lifelong pharmacotherapy with aldosterone antagonists

Question 29

In patients with adrenal adenomas, their aldosterone levels are lower at noon. why is this

Answer 29

the circadian secretion of pituitary ACTH releases reaches a nadir during the day

Question 30

What type of imaging is used for suspected primary hyperaldosteronism

Answer 30

CT or MRI

Question 31

What test can confirm the difference between a unilateral aldosterone producing adenoma and bilateral hyperplasia

Answer 31

Adrenal vein sampling by an experienced radiologist

Question 32

Describe the ratio of aldosterone to cortisol in a unilateral aldosterone-producing adenoma

Answer 32

Ratio is 4-5 times greater than that of the opposite side

Question 33

What is the treatment for bilateral adrenal hyperplasia

Answer 33

Spironolactone (200-400mg/ day) is used to treat hypertension and hypokalaemia

Question 34

What are some side effects of spironolactone

Answer 34

gynaecomastia 
impotence 
menstrual irregularities 
muscle cramps 
GI upsets

Question 35

What is an alternative to spironolactone if there are intolerable side effects

Answer 35

eplerenone

Question 36

What is the treatment for an aldosterone producing adenoma

Answer 36

Adrenalectomy (laparoscopic is increasingly being used

Question 37

What drug must be stopped prior to an adrenalectomy and why

Answer 37

Spironolactone - it can cause mineralocorticoid deficiency after this surgery

Question 38

What is the treatment for adrenal carcinoma

Answer 38

Surgery and postoperative mitotane

Question 39

What is the prognosis for adrenal carcinoma

Answer 39

poor

Question 40

What are some other causes of endocrine hypertension

Answer 40

Cushing\s sundrome
Phaeochromocytoma
acromegaly
primary hyperparathyroidism