Fast Five Quiz: Adrenal Gland Disorders

Romesh Khardori, MD, PhD

Disclosures

December 11, 2019

Patients with primary aldosteronism do not present with distinctive clinical findings, and a high index of suspicion based on the patient's history is vital in making the diagnosis. Findings may include the following:

  • Hypertension

  • Weakness

  • Abdominal distention

  • Ileus from hypokalemia

  • Findings related to complications of hypertension: cardiac failure, hemiparesis due to stroke, carotid bruits, abdominal bruits, proteinuria, renal insufficiency, hypertensive encephalopathy (confusion, headache, seizures, changes in the level of consciousness), and hypertensive retinal changes

Primary aldosteronism in and of itself is typically not associated with edema, despite the volume-expanded state associated with it. The lack of edema results from spontaneous natriuresis and diuresis (called the "aldosterone escape") that occurs in patients with primary aldosteronism and that appears to be mediated by atrial natriuretic peptide. Hence, the finding of significant edema in patients who are presumed to have aldosteronism suggests either that a wrong diagnosis has been made or that associated complications, such as renal or cardiac failure, are present.

Individuals with primary aldosteronism may present with hypokalemic metabolic alkalosis; however, patients with primary aldosteronism may also be normokalemic at presentation. Routine laboratory studies can show hypernatremia, hypokalemia, and metabolic alkalosis resulting from the action of aldosterone on the renal distal convoluted tubule (ie, enhancing sodium reabsorption and potassium and hydrogen ion excretion).

The initial radiologic investigation in the workup of primary aldosteronism is high-resolution, thin-sliced (2-2.5 mm) adrenal CT with contrast. It is generally accepted that MRI is not superior to contrast-enhanced CT for adrenal visualization. High-resolution CT scans may actually have better adrenal definition.

Among the major goals of therapy for primary aldosteronism are (1) normalization of blood pressure, (2) normalization of levels of serum potassium and other electrolytes, and (3) normalization of serum aldosterone levels. The appropriate treatment for primary aldosteronism depends on its cause. Although hypertension is frequently cured after unilateral adrenalectomy in patients with primary aldosteronism secondary to an adrenal aldosteronoma, the mean hypertension cure rate remains low after unilateral or even bilateral adrenalectomy in patients with idiopathic adrenal hyperplasia. Therefore, medical management is the treatment of choice for the idiopathic adrenal hyperplasia variant of primary aldosteronism.

Read more about primary aldosteronism.

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