Hyperaldosteronism Clinical Presentation
- Author: George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London); Chief Editor: Stephen Kemp, MD, PhD more...
Primary hyperaldosteronism may be asymptomatic, particularly in its early stages. When symptoms are present, they may be related to hypertension (if severe), hypokalemia, or both.
The spectrum of hypertension-related symptoms includes the following:
If hypertension is severe, weakness, visual impairment, impaired consciousness, and seizures (hypertensive encephalopathy)
Hypokalemia can be precipitated by non–potassium-sparing diuretics or sodium loading. Symptoms of hypokalemia include the following:
Polyuria and polydipsia (because of impaired renal concentrating ability)
If the serum potassium is low enough, paralysis and disturbances of cardiac rhythm 
Hyperglycemia or frank diabetes mellitus is possible because insulin secretion is a potassium-dependent process that may be impaired by hypokalemia.
If secondary hyperaldosteronism is suspected as the cause of hypertension, the history should include questions about flushing, diaphoresis, anxiety attacks, and headaches (pheochromocytoma) and about hematuria and abdominal fullness (Wilms tumor or other renal tumor), in addition to the above symptoms.[26, 27]
For patients in whom secondary hyperaldosteronism is suggested, questions should be specifically directed at potential causes (eg, the presence and duration of swelling, the child’s exercise tolerance).
Information should be sought about a family history of essential hypertension and familial syndromes, including the following:
Neurofibromatosis (associated with renal artery stenosis and pheochromocytoma)
Multiple endocrine neoplasia (MEN) type 2 – This includes MEN 2A (parathyroid adenoma, medullary thyroid carcinoma [MTC], and pheochromocytoma) and MEN 2B (mucosal neuromas of eyelids, lips, and tongue with a long thin face, pheochromocytoma, and MTC)
von Hippel-Lindau syndrome - Cerebellar hemangioblastoma; renal and pancreatic cysts and carcinoma; hemangiomas of the retina, liver, and adrenal glands; and pheochromocytomas
In any child or adolescent with significant hypertension, a thorough investigation into the cause is warranted. Hypermineralocorticoidism should be considered in any patient with associated hypokalemia, though it should not be excluded in the absence of hypokalemia. In patients with significant hypertension, blood pressure should be measured several times, preferably with an automated device after a supine rest.
Examination of the hypertensive patient should include the following:
Neck examination – Assess for a thyroid mass (MTC associated with MEN 2)
Cardiovascular examination - Assess left ventricular muscle mass and exclusion of murmurs and pulse differential (eg, coarctation of the aorta); check for abdominal bruits (renal artery stenosis) and peripheral edema (secondary hyperaldosteronism)
Abdominal examination – Look for masses (Wilms tumor), hepatomegaly (cardiac failure or liver disease), splenomegaly, and ascites
Neurologic examination - Examine the eyes, and assess visual acuity (severe hypertension may interfere with vision); examine the eye grounds (looking for retinal angiomas [von Hippel-Lindau syndrome]); be alert for hypertensive retinopathy, which is of prognostic significance, including arterial narrowing, hemorrhages, cotton-wool spots, and papilledema; assess for Lisch nodules of the iris (NF-1)
Strength assessment - Evaluation for weakness, focal neurologic signs, or impaired conscious state in a patient with severe hypertension, which requires urgent treatment and central nervous system (CNS) imaging to exclude infarction or hemorrhage
Skin examination - In patients who have secondary hyperaldosteronism, look for evidence of NF-1
The main complications of primary hyperaldosteronism are hypertension and hypokalemia.
Hypertension due to hyperaldosteronism can damage many organs and organ systems, including the heart (hypertrophy and myocardial fibrosis), the blood vessels (vascular remodeling with medial and intimal hypertrophy and acceleration of atherogenesis), the eyes (arterial narrowing, retinal ischemia, and papilledema), the kidneys (progressive deterioration with nephrosclerosis), and the brain (hemorrhage).
When patients with untreated PA are compared with patients who have essential hypertension, the risk of previous myocardial infarction or acute coronary syndrome is increased approximately 2.5-fold, cerebrovascular event or transient ischemic attack is increased approximately 3–4-fold, sustained cardiac arrhythmia is increased approximately 5-fold, and peripheral arterial disease is increased approximately 3-fold. Renal disease is also increased in patients with PA. The frequency of 24-hour microalbuminuria in patients with PA (both APA and IHA) is twice that of patients with essential hypertension. Renal insufficiency has been reported to occur in 7-29% of patients with PA, and proteinuria has been reported in 8-24%.
Aggressive blood pressure control and early diagnosis and treatment of the underlying hyperaldosteronism minimize the risk.
Hypokalemia initially results in weakness, constipation, and polyuria; when it is more severe, it may cause cardiac arrhythmias. Patients receiving cardiac drugs are at greater risk for this complication. Hypokalemia also impairs insulin secretion and can promote the development of diabetes mellitus. Of note, hypokalemia should not be considered a diagnostic feature of primary hyperaldosteronism. In some studies, only a minority of patients with PA (9-37%) had hypokalemia. Thus, normokalemic hypertension constitutes the most common presentation of the disease; hypokalemia is probably present in only the more severe cases.
Patients with adenomas are more likely to develop this complication, as are patients who have milder disease but receive treatment with diuretics for their hypertension before the hyperaldosteronism is diagnosed.
Weisbrod AB, Webb RC, Mathur A, Barak S, Abraham SB, Nilubol N, et al. Adrenal histologic findings show no difference in clinical presentation and outcome in primary hyperaldosteronism. Ann Surg Oncol. 2013 Mar. 20(3):753-8. [Medline]. [Full Text].
Funder JW. The genetic basis of primary aldosteronism. Curr Hypertens Rep. 2012 Apr. 14(2):120-4. [Medline].
Lifton RP, Dluhy RG, Powers M, Rich GM, Cook S, Ulick S, et al. A chimaeric 11 beta-hydroxylase/aldosterone synthase gene causes glucocorticoid-remediable aldosteronism and human hypertension. Nature. 1992 Jan 16. 355(6357):262-5. [Medline].
Torpy DJ, Gordon RD, Lin JP, Huggard PR, Taymans SE, Stowasser M, et al. Familial hyperaldosteronism type II: description of a large kindred and exclusion of the aldosterone synthase (CYP11B2) gene. J Clin Endocrinol Metab. 1998 Sep. 83(9):3214-8. [Medline].
Lafferty AR, Torpy DJ, Stowasser M, Taymans SE, Lin JP, Huggard P, et al. A novel genetic locus for low renin hypertension: familial hyperaldosteronism type II maps to chromosome 7 (7p22). J Med Genet. 2000 Nov. 37(11):831-5. [Medline]. [Full Text].
Choi M, Scholl UI, Yue P, Björklund P, Zhao B, Nelson-Williams C, et al. K+ channel mutations in adrenal aldosterone-producing adenomas and hereditary hypertension. Science. 2011 Feb 11. 331(6018):768-72. [Medline]. [Full Text].
Scholl UI, Nelson-Williams C, Yue P, Grekin R, Wyatt RJ, Dillon MJ, et al. Hypertension with or without adrenal hyperplasia due to different inherited mutations in the potassium channel KCNJ5. Proc Natl Acad Sci U S A. 2012 Feb 14. 109(7):2533-8. [Medline]. [Full Text].
Charmandari E, Sertedaki A, Kino T, Merakou C, Hoffman DA, Hatch MM, et al. A novel point mutation in the KCNJ5 gene causing primary hyperaldosteronism and early-onset autosomal dominant hypertension. J Clin Endocrinol Metab. 2012 Aug. 97(8):E1532-9. [Medline]. [Full Text].
Boulkroun S, Beuschlein F, Rossi GP, Golib-Dzib JF, Fischer E, Amar L, et al. Prevalence, clinical, and molecular correlates of KCNJ5 mutations in primary aldosteronism. Hypertension. 2012 Mar. 59(3):592-8. [Medline].
Taguchi R, Yamada M, Nakajima Y, Satoh T, Hashimoto K, Shibusawa N, et al. Expression and mutations of KCNJ5 mRNA in Japanese patients with aldosterone-producing adenomas. J Clin Endocrinol Metab. 2012 Apr. 97(4):1311-9. [Medline].
Monticone S, Hattangady NG, Nishimoto K, Mantero F, Rubin B, Cicala MV, et al. Effect of KCNJ5 mutations on gene expression in aldosterone-producing adenomas and adrenocortical cells. J Clin Endocrinol Metab. 2012 Aug. 97(8):E1567-72. [Medline]. [Full Text].
Azizan EA, Lam BY, Newhouse SJ, Zhou J, Kuc RE, Clarke J, et al. Microarray, qPCR, and KCNJ5 sequencing of aldosterone-producing adenomas reveal differences in genotype and phenotype between zona glomerulosa- and zona fasciculata-like tumors. J Clin Endocrinol Metab. 2012 May. 97(5):E819-29. [Medline].
Escher G. Hyperaldosteronism in pregnancy. Ther Adv Cardiovasc Dis. 2009 Apr. 3(2):123-32. [Medline].
Holland OB, Brown H, Kuhnert L, Fairchild C, Risk M, Gomez-Sanchez CE. Further evaluation of saline infusion for the diagnosis of primary aldosteronism. Hypertension. 1984 Sep-Oct. 6(5):717-23. [Medline].
Ignatowska-Switalska H, Chodakowska J, Januszewicz W, Feltynowski T, Adamczyk M, Lewandowski J. Evaluation of plasma aldosterone to plasma renin activity ratio in patients with primary aldosteronism. J Hum Hypertens. 1997 Jun. 11(6):373-8. [Medline].
Galati SJ, Hopkins SM, Cheesman KC, Zhuk RA, Levine AC. Primary aldosteronism: emerging trends. Trends Endocrinol Metab. 2013 Sep. 24(9):421-30. [Medline].
Harvey AM. Hyperaldosteronism: diagnosis, lateralization, and treatment. Surg Clin North Am. 2014 Jun. 94(3):643-56. [Medline].
Rossi GP, Cesari M, Cuspidi C, Maiolino G, Cicala MV, Bisogni V, et al. Long-term control of arterial hypertension and regression of left ventricular hypertrophy with treatment of primary aldosteronism. Hypertension. 2013 Jul. 62(1):62-9. [Medline].
Fourkiotis V, Vonend O, Diederich S, Fischer E, Lang K, Endres S, et al. Effectiveness of eplerenone or spironolactone treatment in preserving renal function in primary aldosteronism. Eur J Endocrinol. 2013 Jan. 168(1):75-81. [Medline].
Kasifoglu T, Akalin A, Cansu DU, Korkmaz C. Hypokalemic paralysis due to primary hyperaldosteronism simulating Gitelman's syndrome. Saudi J Kidney Dis Transpl. 2009 Mar. 20(2):285-7. [Medline].
Künzel HE. Psychopathological symptoms in patients with primary hyperaldosteronism--possible pathways. Horm Metab Res. 2012 Mar. 44(3):202-7. [Medline].
Schmiemann G, Gebhardt K, Hummers-Pradier E, Egidi G. Prevalence of hyperaldosteronism in primary care patients with resistant hypertension. J Am Board Fam Med. 2012 Jan-Feb. 25(1):98-103. [Medline].
Kumar B, Swee M. Aldosterone-renin ratio in the assessment of primary aldosteronism. JAMA. 2014 Jul. 312(2):184-5. [Medline].
Gouli A, Kaltsas G, Tzonou A, Markou A, Androulakis II, Ragkou D, et al. High prevalence of autonomous aldosterone secretion among patients with essential hypertension. Eur J Clin Invest. 2011 Nov. 41(11):1227-36. [Medline].
Lucatello B, Benso A, Tabaro I, Capello E, Caprino MP, Marafetti L, et al. Long-term re-evaluation of primary aldosteronism after medical treatment reveals high proportion of normal mineralocorticoid secretion. Eur J Endocrinol. 2013 Apr. 168(4):525-32. [Medline].
Wu CH, Yang YW, Hu YH, Tsai YC, Kuo KL, Lin YH, et al. Comparison of 24-h urinary aldosterone level and random urinary aldosterone-to-creatinine ratio in the diagnosis of primary aldosteronism. PLoS One. 2013. 8(6):e67417. [Medline]. [Full Text].
Piaditis GP, Kaltsas GA, Androulakis II, Gouli A, Makras P, Papadogias D, et al. High prevalence of autonomous cortisol and aldosterone secretion from adrenal adenomas. Clin Endocrinol (Oxf). 2009 Dec. 71(6):772-8. [Medline].
Gordon RD. Primary aldosteronism. J Endocrinol Invest. 1995 Jul-Aug. 18(7):495-511. [Medline].
Gordon RD, Stowasser M, Klemm SA, Tunny TJ. Primary aldosteronism--some genetic, morphological, and biochemical aspects of subtypes. Steroids. 1995 Jan. 60(1):35-41. [Medline].
Markou A, Pappa T, Kaltsas G, Gouli A, Mitsakis K, Tsounas P, et al. Evidence of primary aldosteronism in a predominantly female cohort of normotensive individuals: a very high odds ratio for progression into arterial hypertension. J Clin Endocrinol Metab. 2013 Apr. 98(4):1409-16. [Medline].
Papanastasiou L, Markou A, Pappa T, Gouli A, Tsounas P, Fountoulakis S, et al. Primary aldosteronism in hypertensive patients: clinical implications and target therapy. Eur J Clin Invest. 2014 Aug. 44(8):697-706. [Medline].
Mussa A, Camilla R, Monticone S, Porta F, Tessaris D, Verna F, et al. Polyuric-polydipsic syndrome in a pediatric case of non-glucocorticoid remediable familial hyperaldosteronism. Endocr J. 2012 Jun 30. 59(6):497-502. [Medline].
Rossi GP, Auchus RJ, Brown M, Lenders JW, Naruse M, Plouin PF, et al. An expert consensus statement on use of adrenal vein sampling for the subtyping of primary aldosteronism. Hypertension. 2014 Jan. 63(1):151-60. [Medline].
Rossitto G, Regolisti G, Rossi E, Negro A, Nicoli D, Casali B, et al. Elevation of angiotensin-II type-1-receptor autoantibodies titer in primary aldosteronism as a result of aldosterone-producing adenoma. Hypertension. 2013 Feb. 61(2):526-33. [Medline].
Spyridonidis TJ, Apostolopoulos DJ. Is there a role for Nuclear Medicine in diagnosis and management of patients with primary aldosteronism?. Hell J Nucl Med. 2013 May-Aug. 16(2):134-9. [Medline].
Feldman RD. Aldosterone and blood pressure regulation: recent milestones on the long and winding road from electrocortin to KCNJ5, GPER, and beyond. Hypertension. 2014 Jan. 63(1):19-21. [Medline].
Scholl UI, Goh G, Stölting G, de Oliveira RC, Choi M, Overton JD, et al. Somatic and germline CACNA1D calcium channel mutations in aldosterone-producing adenomas and primary aldosteronism. Nat Genet. 2013 Sep. 45(9):1050-4. [Medline]. [Full Text].
Cerny MA. Progress towards clinically useful aldosterone synthase inhibitors. Curr Top Med Chem. 2013. 13(12):1385-401. [Medline].
Uppot RN, Gervais DA. Imaging-guided adrenal tumor ablation. AJR Am J Roentgenol. 2013 Jun. 200(6):1226-33. [Medline].
Spence JD. Diagnosis of primary aldosteronism: for medical management, not just surgery. J Hypertens. 2009 Jan. 27(1):204-5; author reply 205. [Medline].
Hu YH, Wu CH, Er LK, Lin CD, Liu YB, Chueh SC, et al. Laparoendoscopic single-site adrenalectomy in patients with primary hyperaldosteronism: A prospective study with long-term follow up. Asian J Surg. 2015 Nov 25. [Medline].
Prejbisz A, Warchoł-Celińska E, Lenders J, Januszewicz A. Cardiovascular Risk in Primary Hyperaldosteronism. Horm Metab Res. 2015 Nov 17. [Medline].
Korah HE, Scholl UI. An Update on Familial Hyperaldosteronism. Horm Metab Res. 2015 Oct 7. [Medline].
|False Negative Results|
|K-wasting diuretics (Non-K-sparing diuretics, such as thiazides, induce renal potassium losses and reduce plasma potassium concentrations, leading to decreased aldosterone secretion.)||→↑||↑↑||↓|
|Angiotensin receptor blockers||↓||↑↑||↓|
|DHPs (It is a shared opinion that dihydropyridinic calcium channel blockers do not significantly affect aldosterone secretion, mainly causing an increase in PRA, which rarely gives false negatives.)||→↓||↑||↓|
|False Positive Results|
|Central alpha-2 agonists (eg, clonidine, alpha-methyldopa)||↓||↓↓||↑|
|Luteal phase of menstrual cycle||↑||PRA: Unchanged||↑|
|Antihypertensive Medications With Minimal Effect on the ARR|
|Prazosin, doxazosin, terazosin||←→|
|Renin inhibitors (Renin inhibitors raise the ARR if renin is measured as PRA [false positive] and lower it if measured as DAR concentration [false negative.])||↓||↑↓||↑↓|
|OCPs (OCPs have little effect on ARR when renin is measured as PRA. Use of immunometric measurements of DAR rather than PRA may give false positive results. Subdermal etonogestrel has no effect on ARR.)||↑||↓DAR||↑|
ARR, aldosterone-renin ratio; NSAIDs, non-steroidal anti-inflammatory drugs; K, potassium; ACE, angiotensin converting enzyme; ARBs, angiotensin II type 1 receptor blockers; DHPs, dihydropyridines; PHA-2, pseudohypoaldosteronism type 2; PRA, plasma renin activity; DAR, direct active renin; OCPs, oral contraceptive agents; SSRIs, selective serotonin reuptake inhibitors
|Spironolactone||Aldosterone antagonist||0-10 kg: 6.25 mg/dose PO q12h
11-20 kg: 12.5 mg/dose PO q12h
21-40 kg: 25 mg/dose PO q12h
>40 kg: 25 mg PO q8h
|Potassium canrenoate||Aldosterone antagonist||3-8 mg/kg IV qd; not to exceed 400 mg|
|Amiloride||Potassium-sparing diuretic||0.2 mg/kg q12h|
|Triamterene||Potassium-sparing diuretic||2 mg/kg/dose q8-24h|
|Nifedipine||Dihydropyridine calcium channel antagonist||0.25-0.5 mg/kg PO q6-8h|
|Amlodipine||Calcium channel antagonist||0.05-0.2 mg/ day PO|
|Doxazosin||Alpha1 -specific adrenergic antagonist||0.02-0.1 mg/day; not to exceed 4 mg|
|Prazosin||Alpha1 -specific adrenergic antagonist||0.005 mg/kg test dose, then 0.025-0.1 mg/kg/dose q6h; not to exceed 0.5 mg/dose|