Medical Management of Aldosterone-Producing Adenomas

Ghose, Ranjan P.; Hall, Phillip M.; Bravo, Emmanuel L.

doi:10.7326/0003-4819-131-2-199907200-00005

Cited by 131 publications

(44 citation statements)

References 6 publications

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“…It might be argued that there is a continuous spectrum of aldosterone/renin ratio, with one extreme being the hypokalaemic, classical PHA patient in whom spironolactone would be expected to reduce blood pressure by twice as much as our cut-off of 20 mmHg. 30 However, we identified a practical benefit of separating the normokalaemic, high ARR from the classical PHA patient. This benefit is the ability of plasma renin measurement alone to predict the blood pressure response to spironolactone.…”

Section: Discussionmentioning

confidence: 99%

Prevalence of primary hyperaldosteronism assessed by aldosterone/renin ratio and spironolactone testing

et al. 2005

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-Recent studies have suggested that primary hyperaldosteronism may be present in more than 10% of patients with hypertension. We aimed to estimate the prevalence in unselected patients in primary care, and investigate the influence of current drug treatment upon the aldosterone/renin ratio (ARR) and its prediction of blood pressure response to spironolactone. We measured blood pressure, plasma electrolytes, renin activity and aldosterone in 846 patients with hypertension. Spironolactone 50 mg was prescribed for one month to patients with blood pressure ≥130/85 mmHg and ARR ≥400. The primary outcome measure was to discover the proportion of patients with plasma aldosterone ≥400 pmol/l and ARR ≥800 and either an adrenal adenoma on computed tomography scan or a systolic blood pressure response to spironolactone ≥20 mmHg. Only one patient had an adenoma, and only 16 (1.8%) had both a plasma aldosterone ≥400 pmol/l and ARR ≥800. By contrast, 119 patients (14.1%) had an elevated ARR but normal plasma aldosterone. In 69 patients out of the 119 who received spironolactone, blood pressure fell by 26/11 mmHg. These patients were normokalaemic but had uncontrolled hypertension despite multiple drugs. The response to spironolactone was best predicted by a low plasma renin, ≤0.5 pmol/ml/h (<10 mU/l), despite treatment with an ACE inhibitor. We concluded that adrenal adenomas are an uncommon cause of hypertension. In the absence of hypokalaemia, a low plasma renin is a sufficient and simple way of detecting spironolactoneresponders among patients with resistant hypertension. Only patients with both hypokalaemia and low plasma renin, measured while the patient is off β blockade, require measurement of aldosterone. A plasma aldosterone >400 pmol/l together with renin activity ≤0.5 pmol/ml/h should trigger further investigations for an adrenal adenoma.

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Section: Discussionmentioning

confidence: 99%

Prevalence of primary hyperaldosteronism assessed by aldosterone/renin ratio and spironolactone testing

et al. 2005

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“…However, studies that compared spironolactone with surgery in patients with APAs found no difference between the two options for the control of either BP or serum potassium concentrations (30). As discussed earlier, patients with PA are more likely to have cardiovascular complications than patients with essential hypertension, consistent with aldosterone excess having an etiological role independent of BP (19,20,31).…”

Section: Mras Vs Surgerymentioning

confidence: 84%

PROGRESS IN PRIMARY ALDOSTERONISM: Mineralocorticoid antagonist treatment for aldosterone-producing adenoma

Amar

Lorthioir

Azizi

et al. 2015

European Journal of Endocrinology

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Mineralocorticoid receptor antagonists have been used in patients with aldosterone-producing adenomas (APAs) as a test designed to predict the blood pressure (BP) outcome of surgery. They are commonly used in patients undergoing adrenalectomy to reduce BP and increase plasma potassium levels during the preoperative period. A small number of studies have compared the effects of surgery and mineralocorticoid antagonists either on BP, on serum potassium levels, or on the incidence of cardiovascular and renal outcomes in patients with primary aldosteronism with or without an APA; these studies found no difference between the two therapeutic options. Mineralocorticoid receptor antagonists can be used as a maintenance treatment for patients with APAs, who are judged to be poor operative risks or who do not want to undergo surgery.

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“…However, drug-based treatment in 24 patients with unilateral PA led to normokalemia in all patients and long-lasting BP decreases of a magnitude similar to that observed in surgical series. 83 Moreover, a prospective study showed that the BP-lowering effect of high-dose spironolactone was similar to, or even slightly greater than that of subsequent adrenalectomy in 44 patients. 84 Spironolactone may appear to be less potent than adrenalectomy for improving left ventricular hypertrophy, but studies with long-term follow-up have shown that the same improvement is ultimately achieved, even though the regression of left ventricular mass is slower with spironolactone than with adrenalectomy.…”

Section: Outcomes Of Drug-based Treatmentmentioning

confidence: 99%

Outcomes of Drug-Based and Surgical Treatments for Primary Aldosteronism

Steichen

Lorthioir

Zinzindohoué

et al. 2015

Advances in Chronic Kidney Disease

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Treatments for primary aldosteronism (PA) aim to correct or prevent the deleterious consequences of hyperaldosteronism: hypertension, hypokalemia and direct target organ damage. Patients with unilateral PA considered fit for surgery can undergo laparoscopic adrenalectomy, which significantly decreases blood pressure and medications in most cases, and cures hypertension in about 40%. Mineralocorticoid receptor antagonists (MRA) are used to treat patients with bilateral PA and those with unilateral PA if surgery is not possible or not desired. Spironolactone is more potent than eplerenone, but high doses are poorly tolerated in men. MRA can be replaced or complemented with epithelial sodium channel blockers, such as amiloride. Thiazide diuretics and calcium channel blockers are used when the first-line drugs are insufficient to control blood pressure. Dietary sodium restriction should be implemented in all cases, because the deleterious consequences of hyperaldosteronism are dependent on salt loading. Several studies comparing the results of surgery and MRA have reported no differences in terms of blood pressure, serum potassium concentration or cardiovascular and renal outcomes, although the benefits of treatment tend to be observed sooner with surgery.PA patients display relative glomerular hyperfiltration, which is reversed by specific treatment, revealing chronic kidney disease in 30% of patients. However, further kidney damage is prevented by the treatment of PA. Clinical summary-The goals of treatment are the normalization of serum potassium concentration, blood pressure control and prevention of the direct effects of excess aldosterone on target organs. 3-The non-surgical treatment of PA is based on mineralocorticoid receptor antagonists and dietary sodium restriction.-Epithelial sodium channel blockers are used when mineralocorticoid receptor antagonists are not well tolerated; thiazide diuretics and calcium channel blockers are used when blood pressure control is insufficient with the first-line treatment.-Laparoscopic adrenalectomy is safe and decreases BP and medication requirements in patients with unilateral PA; drug-based treatments are appropriate in cases in which surgery is inappropriate or not desired.

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Medical Management of Aldosterone-Producing Adenomas

Abstract: Medical management of aldosterone-producing adenomas is a viable option for controlling blood pressure and serum potassium concentration.

Cited by 131 publications

References 6 publications

Prevalence of primary hyperaldosteronism assessed by aldosterone/renin ratio and spironolactone testing

Prevalence of primary hyperaldosteronism assessed by aldosterone/renin ratio and spironolactone testing

PROGRESS IN PRIMARY ALDOSTERONISM: Mineralocorticoid antagonist treatment for aldosterone-producing adenoma

Outcomes of Drug-Based and Surgical Treatments for Primary Aldosteronism

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