A Man With Hypokalemia, Sleep Apnea, and Resistant Hypertension

Minh Chung; Eric Warren, DO; Darshan Rola; Brian Zacharias; Jennifer Broyles, MD


July 20, 2022

Primary hyperaldosteronism is often amenable to surgical intervention, which is usually the treatment of choice. Laparoscopic unilateral adrenalectomy for an aldosterone-producing adenoma of the right or left adrenal gland results in complete biochemical resolution of the disease state in about 94% of patients and partial or complete clinical success in approximately 85% of patients.[5] Bilateral hyperaldosteronism is significantly less amenable to unilateral adrenalectomy; the procedure is about half as successful in this setting compared with unilateral disease.

For patients who are unable or unwilling to undergo surgical intervention and for those with bilateral disease, medical therapy with a mineralocorticoid receptor antagonist can be initiated. Spironolactone can be used as a first-line agent. The long-term outcomes of patients with primary hyperaldosteronism who are treated with mineralocorticoid receptor antagonists are not clear, and some evidence suggests that they have a worse prognosis than do patients who are treated surgically.[5]

The patient in this case was referred to an endocrinologist for further workup and management. An MRI revealed a unilateral adrenal adenoma, which makes surgical removal the best option for this patient. Figure 1 shows an example of a section through an adrenal adenoma. If he is not fit for surgery or declines to have the operation, spironolactone can be used for medical management. Both methods will achieve adequate control of the patient's blood pressure. The overall prognosis is good, with minimal complications once the hypertension is well controlled with medical or surgical management.

Figure 1.


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