Volume 2, Number 3, September 2001

Diagnosis and management of primary aldosteronism
Michael Stowasser, Richard D Gordon, John C Rutherford, Nik Z Nikwan, Nicholas Daunt, Gregory J Slater

Availability and wider application of the plasma aldosterone/renin activity (PRA) ratio as a screening test for primary aldosteronism (PAL) has led to the recent recognition that PAL is a common specifically treatable and potentially curable cause of hypertension. Screening of all (and not just hypokalaemic) hypertensives at the Greenslopes Hospital Hypertension Unit led to a ten-fold increase in detection rate (confirmed in all by fludrocortisone suppression testing [FST]), only 22% of whom were hypokalaemic, and a four-fold increase in the rate of removal of aldosterone-producing adenomas (APAs). Reliable detection and appropriate management requires that (1) the diagnosis is considered in all hypertensives, (2) samples are collected under standardised conditions of diet, posture and time of day, (3) medications known to alter aldosterone and PRA levels are avoided or their effects taken into account, (4) reliable methods (such as FST) are used to confirm PAL, (5) careful further diagnostic workup (including genetic testing for the glucocorticoid-remediable variety, and adrenal venous sampling to differentiate APA from bilateral adrenal hyperplasia) is undertaken to determine the subtype and (6) each stage of the workup is carefully explained and discussed with the patient. The availability of laparoscopic adrenalectomy and a new aldosterone antagonist (eplerenone), which promises fewer side effects, represent important advances in management. Elucidation of the genetic mutation responsible for glucocorticoid-remediable PAL (familial hyperaldosteronism type I, FH-I) has greatly facilitated detection of that subtype. The identification of genetic mutations causing another, more common, non-glucocorticoid-remediable familial variety (FH-II) should be of similar value.

JRAAS 2001;2:156-169.

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