Diagnostic Considerations

Consider the diagnosis of primary aldosteronism in all persons with hypertension (HTN) and hypokalemia. Making the correct diagnosis may be the only way to achieve adequate blood pressure control and thus, to prevent the sequelae of poorly controlled HTN.

Conditions to consider in the differential diagnosis of primary aldosteronism include the following:

HTN
Malignant HTN
Hypertensive encephalopathy
Hypokalemia
Metabolic alkalosis
Renal artery stenosis
Renovascular HTN
Low-renin essential HTN - Constitutes about 40% of essential HTN
Tobacco chewing
Carbenoxolone intoxication
Apparent mineralocorticoid excess (AME) syndrome
Various causes of secondary aldosteronism - Unlike primary aldosteronism, these causes are associated with elevated renin (plasma renin activity) levels
Chrétien syndrome - This rare syndrome is characterized by mineralocorticoid excess and adrenocortical HTN secondary to a pituitary adenoma producing pro-opiomelanocortin (POMC)^[22]
Deoxycorticosterone (DOC)–secreting adrenal tumors
Renovascular ischemia
Preeclampsia (toxemia of pregnancy)
Renin-secreting tumor - These are rare tumors arising from the juxtaglomerular apparatus
Excessive licorice intake - In this situation, the glycyrrhizinic acid component inhibits 11beta-hydroxysteroid dehydrogenase, impairing conversion of cortisol to cortisone in the kidneys; hence, cortisol binds to mineralocorticoid receptors and acts as a mineralocorticoid

Additional select genetic/familial disorders and syndromes to consider include the following:

Gitelman syndrome - This is due to a defective sodium/chloride cotransporter (NCCT); it is basically a salt-losing tubulopathy with secondary aldosteronism
Barrter syndrome - This is a phenocopy of at least 3 distinct genetic defects (ie, hyperactivition of the sodium-potassium-dichloride cotransporter [NKCC2], the renal outer medullary potassium channel [ROMK1], or the renal epithelial chloride channel [ClCKb],the latter encoded by the barttin gene; this is also a salt-losing tubulopathy with secondary aldosteronism and is pathophysiologically similar to Gitelman syndrome
Gordon syndrome - This is due to inactivating mutations of the serine-threonine kinases WNK1 and WNK4 (“with no lysine [K]” kinases), leading to hypertension, hyperkalemia, mild hyperchloremia, acidosis, and suppressed plasma renin activity
Pseudoaldosteronism (Liddle syndrome) - This is a rare autosomal dominant disorder due to hyperactivating mutations of the renal epithelial sodium channel (ENaC), with excessive sodium reabsorption in the renal distal tubule; levels of renin and aldosterone are low
11beta-hydroxysteroid dehydrogenase deficiency
Glucocorticoid resistance - This is due to inactivating mutations of the glucocorticoid receptor

Differential Diagnoses

Workup

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Media Gallery

Magnetic resonance imaging (MRI) scan in a patient with Conn syndrome showing a left adrenal adenoma.
Scintigram obtained by using iodine-131-beta-iodomethyl-norcholesterol (NP-59) in a 59-year-old man with hypertension shows fairly intense radionuclide uptake in the right adrenal tumor. At surgery, a Conn tumor was confirmed.
Effects of main antihypertensives on the renin-angiotensin system.
Potential causes of primary aldosteronism.
Transitional zone adrenocortical steroids.
Algorithm for screening for potential primary aldosteronism.
Algorithm for confirmation of primary aldosteronism.
Algorithm for distinguishing subtypes of primary aldosteronism.

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Primary Aldosteronism Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

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