Primary aldosteronism

Overview

Primary aldosteronism (al-DOS-tuh-ro-niz-um) is a hormonal disorder that leads to high blood pressure. It occurs when your adrenal glands produce too much of a hormone called aldosterone.

Your adrenal glands produce a number of essential hormones, including aldosterone. Usually, aldosterone balances sodium and potassium in your blood. But too much of this hormone can cause you to lose potassium and retain sodium. That imbalance can cause your body to hold too much water, increasing your blood volume and blood pressure.

Treatment options include medications, surgery and lifestyle changes.

Adrenal glands

Perched on top of each of your kidneys, your adrenal glands produce hormones that help regulate your metabolism, immune system, blood pressure and other essential functions. Although small, these glands dictate much of what happens in your body.

Symptoms

Primary aldosteronism often doesn't cause clear symptoms. The first clue that you may have primary aldosteronism is usually high blood pressure, especially hard to control blood pressure.

Sometimes, primary aldosteronism causes low potassium levels. If this happens, you may have:

  • Muscle cramps
  • Weakness
  • Fatigue
  • Headache
  • Excessive thirst
  • A frequent need to urinate

When to see a doctor

Ask your doctor about the possibility of having primary aldosteronism if you have:

  • Moderate to severe high blood pressure, especially if you need many medications to control your blood pressure
  • High blood pressure and a family history of primary aldosteronism
  • High blood pressure and a family history of high blood pressure or stroke at age 40 or younger
  • High blood pressure and a growth on one of your adrenal glands (found in an imaging test done for another reason)
  • High blood pressure and a low potassium level
  • High blood pressure and obstructive sleep apnea

Causes

Common conditions that can cause too much aldosterone include:

  • A benign growth in an adrenal gland
  • Overactivity of both adrenal glands

There are other, much rarer causes of primary aldosteronism, including:

  • A cancerous growth on the outer layer of the adrenal gland
  • An inherited condition that causes high blood pressure in children and young adults

Complications

Primary aldosteronism can lead to high blood pressure and low potassium levels. These complications in turn can lead to other problems.

Problems related to high blood pressure

Persistently elevated blood pressure can lead to problems with your heart and kidneys, including:

  • Heart attack, heart failure and other heart problems
  • Stroke
  • Kidney disease or kidney failure

People with primary aldosteronism have a higher than expected risk of cardiovascular problems compared with people who only have high blood pressure.

Problems related to low potassium levels (hypokalemia)

Primary aldosteronism may cause low potassium levels. If your potassium levels are just slightly low, you may not have any symptoms. Very low levels of potassium can lead to:

  • Weakness
  • Irregular heart rhythm
  • Muscle cramps
  • Excess thirst or urination

Diagnosis

If your doctor suspects primary aldosteronism, you'll likely have a test to measure levels of aldosterone and renin in your blood. Renin is an enzyme released by your kidneys that helps control blood pressure. If your renin level is very low and your aldosterone level is high, you may have primary aldosteronism.

Additional tests

If the aldosterone-renin test suggests primary aldosteronism, you'll need other tests to confirm the diagnosis and look for potential causes. Possible tests include:

  • Salt-loading test. There are a few ways to do this blood or urine test. You may eat a high-sodium diet for a few days or you could have a saline infusion for several hours before your doctor measures your aldosterone levels. You may also be given fludrocortisone — a drug that mimics the action of aldosterone — in addition to the high-sodium diet before the test.
  • Abdominal CT scan. A CT scan may find a tumor on your adrenal gland or show an enlarged adrenal gland that suggests the gland is overactive.
  • Adrenal vein blood test. A radiologist draws blood from both your right and left adrenal veins and compares the two samples. If only one side has elevated aldosterone, your doctor may suspect a growth on that adrenal gland.

    This test involves placing a tube in a vein in your groin and threading it up to the adrenal veins. Though essential for determining the appropriate treatment, this test carries the risk of bleeding or a blood clot in the vein.

Treatment

Treatment for primary aldosteronism depends on the underlying cause. The basic goal is get your aldosterone levels back to normal or to block the effect of high aldosterone to prevent complications.

Treatment for an adrenal gland tumor

An adrenal gland tumor may be treated with surgery or medications and lifestyle changes.

  • Surgical removal of the gland. Surgical removal of the adrenal gland with the tumor (adrenalectomy) is usually recommended. Surgical removal may bring blood pressure, potassium and aldosterone levels back to normal. Your doctor will follow you closely after surgery and progressively adjust or eliminate your high blood pressure medications.

    Risks of surgery include bleeding and infection. Adrenal hormone replacement isn't necessary because the other adrenal gland can make enough of all the hormones your body needs.

  • Aldosterone-blocking drugs. If your primary aldosteronism is caused by a benign tumor and you can't have surgery or prefer not to, you can be treated with aldosterone-blocking drugs called mineralocorticoid receptor antagonists (spironolactone and eplerenone) and lifestyle changes. High blood pressure and low potassium will return if you stop taking your medications.

Treatment for overactivity of both adrenal glands

A combination of medications and lifestyle modifications can effectively treat primary aldosteronism caused by overactivity of both adrenal glands.

  • Medications. Mineralocorticoid receptor antagonists block the action of aldosterone in your body. Your doctor may first prescribe spironolactone (Aldactone). This medication helps correct high blood pressure and low potassium, but may cause other problems.

    In addition to blocking aldosterone receptors, spironolactone may inhibit the action of other hormones. Side effects can include male breast enlargement (gynecomastia) and menstrual irregularities in women.

    A newer, more-expensive mineralocorticoid receptor antagonist called eplerenone (Inspra) eliminates the sex hormone side effects associated with spironolactone. Your doctor may recommend eplerenone if you have serious side effects with spironolactone. You may also need other medications for high blood pressure.

  • Lifestyle changes. High blood pressure medications are more effective when combined with a healthy diet and lifestyle. Work with your doctor to create a plan to lower the sodium in your diet and keep a healthy body weight. Getting regular exercise, limiting the amount of alcohol you drink and stopping smoking also may improve your response to medications.

Lifestyle and home remedies

A healthy lifestyle is essential for keeping blood pressure low and keeping long-term heart health. Here are some healthy lifestyle suggestions:

  • Eat a healthy diet. Diets that highlight a healthy variety of foods — including grains, fruits, vegetables and low-fat dairy products — can help with weight loss and help lower blood pressure. Try the Dietary Approaches to Stop Hypertension (DASH) diet — it has proven benefits for your heart. A healthy diet also limits sodium, added sugar, saturated fat and alcohol.
  • Achieve a healthy weight. If your body mass index (BMI) is 25 or more, losing as little as 3% to 5% of your body weight may lower your blood pressure.
  • Exercise. Regular aerobic exercise can help lower blood pressure. You don't have to hit the gym — taking a moderately paced walk for 30 minutes most days of the week can improve your health. Try walking with a friend at lunch instead of dining out.
  • Don't smoke. Quitting smoking improves your overall heart and blood vessel health. Talk to your doctor about medications that can help you stop smoking.

Preparing for an appointment

Since the symptoms of primary aldosteronism aren't always obvious, your doctor may be the one to suggest you get screened for the condition. Your doctor may suspect primary aldosteronism if you have high blood pressure and:

  • Your blood pressure remains persistently high, especially if you're already taking at least three medications for it (resistant hypertension)
  • You have low blood potassium — although many people with primary aldosteronism have normal potassium levels, especially in the early stages of the disease
  • You have a growth on one of your adrenal glands, found on an imaging test taken for another reason
  • You have a personal or family history of high blood pressure or stroke at a young age
  • You also have obstructive sleep apnea

The screening test for primary aldosteronism may need some planning. The test can be performed while you're taking most blood pressure medications, but you may need to stop taking certain drugs, such as spironolactone (Aldactone) and eplerenone (Inspra), up to four weeks before testing. Your doctor may also ask you to avoid real licorice products for a couple of weeks before the test, as these can cause changes that mimic excess aldosterone.

After testing, you'll see your doctor for a follow-up appointment or you may be referred to a doctor who treats hormone disorders (endocrinologist). Here's some information to help you get ready for your appointment.

What you can do

When you make the appointment, make a list of:

  • Your symptoms, including any that seem unrelated to the reason for your appointment
  • Key personal information, including major stresses, recent life changes and family medical history
  • All medications, vitamins or other supplements you take, including the doses
  • Questions to ask your doctor

For primary aldosteronism, some basic questions to ask your doctor include:

  • What do my test results mean?
  • Do I need any additional tests?
  • Is my condition temporary, or will I always have it?
  • What treatments are available? What do you think would be best in my case?
  • I have these other health conditions. How can I best manage them together?
  • Are there any dietary restrictions I need to follow?
  • Are there brochures or other printed material I can have? What websites do you recommend?

What to expect from your doctor

Your doctor is likely to ask you several questions, include:

  • Does anything seem to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?

Last Updated Oct 9, 2019


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