Hyperaldosteronism Follow-up

Frequency and requirement for follow-up depends on the cause of the hyperaldosteronism.

Patients who are treated medically need regular follow-up to ensure adequacy of blood pressure control and treatment of hypokalemia.

In children, doses must be adjusted as patients grow.

In cases with familial hyperaldosteronism, genetic counseling is also important at an age-appropriate level.

Severe hypokalemia may require intravenous correction if the potassium is less than 2.5 mmol/L or the patient is clinically symptomatic. Once stable, sodium restriction and oral potassium supplements may be used as effectively as or in addition to potassium-sparing diuretics.

Spironolactone is the most effective drug for controlling the effects of hyperaldosteronism, although it may interfere with the progression of puberty. Newer drugs with greater specificity for the mineralocorticoid receptor than spironolactone are becoming available.

Alternative medications for patients in whom aldosterone antagonists are contraindicated include amiloride and triamterene as well as calcium channel antagonists (see Medication), alpha-adrenergic antagonists (especially alpha1-specific agents, eg, prazosin, doxazosin); in patients with angiotensin II–responsive disease, angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists are indicated.

Patients receiving medical treatment for hyperaldosteronism must be transferred to a physician with experience managing such cases. This may be an endocrinologist, a cardiologist, or a nephrologist.

Complications of primary hyperaldosteronism can be divided into those due to the primary disease, such as hypertension and hypokalemia, and those arising from treatment.

Hypertension

Hypertension due to hyperaldosteronism can cause damage to 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).

Aggressive blood pressure control and early diagnosis and treatment of the underlying hyperaldosteronism minimize the risk of these complications.

Hypokalemia

Hypokalemia initially results in weakness, constipation, polyuria, and, if more severe, may cause cardiac arrhythmias.

Patients on cardiac drugs are at greater risk of this complication.

Adrenal venous sampling

Adrenal venous sampling should be performed in centers with appropriate expertise. Adrenal veins are often small, and the right vein is difficult to cannulate.

Performance of adrenal venography is not recommended because this may cause bleeding into the gland.

Specific treatment-related complications

The use of laparoscopic adrenalectomy considerably reduces postoperative recovery time and complication risk. The risk of operative complications is related directly to the experience of the surgeon.

In addition to these complications, following surgical removal of aldosteronoma, a period of hypoadrenalism can occur. If not recognized, this can result in clinically significant hyponatremia and hyperkalemia.

The age of the patient and the duration of disease before diagnosis are the 2 most important prognostic factors.

Adult studies have shown that hypertension is improved significantly in approximately 70% of cases (see Treatment). This figure is likely to be higher in children because disease duration is shorter and the prevalence of other causes of hypertension is lower.

Patients with mild hyperaldosteronism must learn how to avoid foods that are high in sodium because this exacerbates their hypertension and increases their tendency to develop hypokalemia.

Patients also need to know that medication can lead to hyperkalemia and hypotension, particularly in the presence of intercurrent illness, and they should be advised to see their pediatrician in these circumstances.