At least 5% of individuals with hypertension have adrenal aldosterone-producing adenomas (APAs). Gain-of-function mutations in KCNJ5 and apparent loss-of-function mutations in ATP1A1 and ATP2A3 were reported to occur in APAs. We find that KCNJ5 mutations are common in APAs resembling cortisol-secreting cells of the adrenal zona fasciculata but are absent in a subset of APAs resembling the aldosterone-secreting cells of the adrenal zona glomerulosa. We performed exome sequencing of ten zona glomerulosa-like APAs and identified nine with somatic mutations in either ATP1A1, encoding the Na(+)/K(+) ATPase α1 subunit, or CACNA1D, encoding Cav1.3. The ATP1A1 mutations all caused inward leak currents under physiological conditions, and the CACNA1D mutations induced a shift of voltage-dependent gating to more negative voltages, suppressed inactivation or increased currents. Many APAs with these mutations were <1 cm in diameter and had been overlooked on conventional adrenal imaging. Recognition of the distinct genotype and phenotype for this subset of APAs could facilitate diagnosis.

This study demonstrates that it is pointless to claim low or high prevalence of primary aldosteronism based on published reports. Because of the significant impact of a diagnosis of primary aldosteronism on health care resources and the necessary facilities, our findings urge for a prevalence study whose design takes into account the factors identified in the meta-regression analysis.

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BACKGROUND. Adrenal aldosterone excess is the most common cause of secondary hypertension and is associated with increased cardiovascular morbidity. However, adverse metabolic risk in primary aldosteronism extends beyond hypertension, with increased rates of insulin resistance, type 2 diabetes, and osteoporosis, which cannot be easily explained by aldosterone excess.METHODS. We performed mass spectrometry–based analysis of a 24-hour urine steroid metabolome in 174 newly diagnosed patients with primary aldosteronism (103 unilateral adenomas, 71 bilateral adrenal hyperplasias) in comparison to 162 healthy controls, 56 patients with endocrine inactive adrenal adenoma, 104 patients with mild subclinical, and 47 with clinically overt adrenal cortisol excess. We also analyzed the expression of cortisol-producing CYP11B1 and aldosterone-producing CYP11B2 enzymes in adenoma tissue from 57 patients with aldosterone-producing adenoma, employing immunohistochemistry with digital image analysis.RESULTS. Primary aldosteronism patients had significantly increased cortisol and total glucocorticoid metabolite excretion (all P < 0.001), only exceeded by glucocorticoid output in patients with clinically overt adrenal Cushing syndrome. Several surrogate parameters of metabolic risk correlated significantly with glucocorticoid but not mineralocorticoid output. Intratumoral CYP11B1 expression was significantly associated with the corresponding in vivo glucocorticoid excretion. Unilateral adrenalectomy resolved both mineralocorticoid and glucocorticoid excess. Postoperative evidence of adrenal insufficiency was found in 13 (29%) of 45 consecutively tested patients.CONCLUSION. Our data indicate that glucocorticoid cosecretion is frequently found in primary aldosteronism and contributes to associated metabolic risk. Mineralocorticoid receptor antagonist therapy alone may not be sufficient to counteract adverse metabolic risk in medically treated patients with primary aldosteronism.FUNDING. Medical Research Council UK, Wellcome Trust, European Commission.

Somatic mutations in KCNJ5, ATP1A1, or CACNA1D genes are not limited to APAs but are also found in the more frequent multinodular adrenals. In multinodular glands, only one nodule harbors a mutation. This suggests that the occurrence of a mutation and nodule formation are independent processes. The implications for clinical management remain to be determined.

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P rimary aldosteronism (PA) is the leading cause of secondary hypertension with a prevalence of 4.3% in the general hypertensive population and 9.5% of patients referred to hypertension units. 1 The diagnosis of PA is fundamental because these patients are at an increased risk of cardiovascular and cerebrovascular complications and metabolic syndrome compared with patients with primary hypertension and similar cardiovascular risk profiles. [2][3][4][5] The underlying cause of PA in the majority of patients is either bilateral adrenal hyperplasia (BAH, also called idiopathic hyperaldosteronism) or unilateral aldosterone-producing adenoma (APA). These subtypes must be differentiated to permit a targeted therapeutic strategy: surgical removal of APA or pharmacological treatment of BAH with mineralocorticoid receptor antagonists. Adrenal venous sampling (AVS) is the gold standard to localize the source of aldosterone excess and to discriminate between unilateral and bilateral forms of the disease. However, AVS is a technically demanding and invasive procedure requiring a dedicated radiologist. The reliable differentiation of APA and BAH by an alternative technique could potentially circumvent the requirement of AVS in patients with BAH that account for around two thirds of all cases of PA. 6 Subsequently, for the APA subtype, both clinician and patient would be highly motivated to perform/undergo AVS to confirm unilateral PA and define the side of aldosterone excess before adrenalectomy.Somatic mutations have been identified in APA in 4 genes (KCNJ5, ATP1A1, ATP2B3, and CACNA1D) to date that all lead to an increase in constitutive aldosterone production. 7 In a large European study, the combined prevalence of APA mutations in these 4 genes was found to be 54% with 38% Abstract-Primary aldosteronism comprises 2 main subtypes: unilateral aldosterone-producing adenoma (APA) and bilateral adrenal hyperplasia. Somatic KCNJ5 mutations are found in APA at a prevalence of around 40% that drive and sustain aldosterone excess. Somatic APA mutations have been described in other genes (CACNA1D, ATP1A1, and ATP2B3) albeit at a lower frequency. Our objective was to identify genotype-specific steroid profiles in adrenal venous (AV) and peripheral venous (PV) plasma in patients with APAs. We measured the concentrations of 15 steroids in AV and PV plasma samples by liquid chromatography-tandem mass spectrometry from 79 patients with confirmed unilateral primary aldosteronism. AV sampling lateralization ratios of steroids normalized either to cortisol or to DHEA+androstenedione were also calculated. 9 Intriguingly, mutations in ATP1A1, ATP2B3, and CACNA1D that stimulate aldosterone production have been identified recently in aldosterone-producing cell clusters of normal adrenal glands from kidney donors; in contrast, mutations in KCNJ5 were not detected. 10In this study, we used liquid chromatography-tandem mass spectrometry (LC-MS/MS) to determine the steroid profiles in adrenal venous (AV) and peripheral venous (PV) plasma samples ...

BACKGROUND:Differentiating patients with primary aldosteronism caused by aldosterone-producing adenomas (APAs) from those with bilateral adrenal hyperplasia (BAH), which is essential for choice of therapeutic intervention, relies on adrenal venous sampling (AVS)-based measurements of aldosterone and cortisol. We assessed the utility of LC-MS/MS-based steroid profiling to stratify patients with primary aldosteronism.