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Abstract
In recent years, an increasing number of studies have revealed deleterious effects of aldosterone via the mineralocorticoid receptor (MR). Especially in patients with primary aldosteronism (PA) a significant higher estimated risk of developing cardiovascular comorbidities and comortalities compared to essential hypertensives was reported. As diabetes mellitus and the metabolic syndrome are one of the major contributors to cardiovascular morbidity and mortality their connection to aldosterone excess became a focus of research in PA patients. Several studies assessed the effect of PA on glucose metabolism, the prevalence of diabetes mellitus, and the effect of PA treatment on both revealing different results. Therefore, we performed an extensive literature research. This review focuses on the current knowledge of the connection between aldosterone excess, glucose homeostasis, and diabetes mellitus in patients with PA. We have highlighted this topic from a pro and contra perspective followed by a summarizing concluding remark. Additionally, we have briefly reviewed the data on possible underlying mechanisms and indicated future considerations on the possible impact of cortisol co-secretion in PA.
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Affiliation(s)
- H Remde
- Clinical Endocrinology, Charité Campus Mitte, Berlin, Germany
| | - G Hanslik
- Clinical Endocrinology, Charité Campus Mitte, Berlin, Germany
| | - N Rayes
- Clinic for Surgery, Campus Virchow, Charité University Medicine Berlin, Berlin, Germany
| | - M Quinkler
- Endocrinology in Charlottenburg, Berlin, Germany
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202
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Abstract
Experimental and clinical evidence obtained in the last 2 decades clearly indicates that protracted exposure to inappropriately elevated aldosterone levels causes significant changes in left ventricular structure and function. Animal studies have demonstrated that aldosterone induces myocardial inflammatory changes and fibrosis in the presence of a high salt diet. Moreover, the effects of aldosterone on the heart have been investigated in different clinical conditions. These conditions include systolic and diastolic heart failure, essential hypertension, and primary aldosteronism that offers a unique clinical model to study the cardiac effects of excess aldosterone because these effects are isolated from those of the renin-angiotensin axis. A relatively clear picture is emerging from these studies with regard to aldosterone-related changes in left ventricular mass and geometry. Conversely, no direct effect of aldosterone on left ventricular diastolic function can be demonstrated and improvement of diastolic function obtained in some studies that have employed mineralocorticoid receptor blockers could result from left ventricular mass reduction. Animal experiments demonstrate that effects of aldosterone on the left ventricle require high salt intake to occur, but the evidence of this contribution of salt to aldosterone-induced cardiac changes in humans remains weaker and needs further research. The article reviews the results of clinical studies addressing the role of aldosterone in regulation of LV remodeling and diastolic function, and focuses on the possible relevance of salt intake.
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Affiliation(s)
- C Catena
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medical Science, University of Udine, Udine, Italy
| | - G Colussi
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medical Science, University of Udine, Udine, Italy
| | - G Brosolo
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medical Science, University of Udine, Udine, Italy
| | - M Novello
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medical Science, University of Udine, Udine, Italy
| | - L A Sechi
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medical Science, University of Udine, Udine, Italy
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203
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Sechi LA, Colussi GL, Novello M, Uzzau A, Catena C. Mineralocorticoid Receptor Antagonists and Clinical Outcomes in Primary Aldosteronism: As Good as Surgery? Horm Metab Res 2015; 47:1000-6. [PMID: 26667803 DOI: 10.1055/s-0035-1565128] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Primary aldosteronism (PA) is detected with increasing frequency in hypertensive patients and is associated with excess cardiovascular, renal, and metabolic complications. For these reasons, appropriate choices for treatment of this endocrine condition are mandatory. Adrenalectomy is safely performed in PA patients when adrenal venous sampling (AVS) demonstrates lateralized aldosterone secretion. AVS, however, is a complex procedure and even among worldwide referral centers there are substantial discrepancies for interpretation of results. Also, in the majority of PA patients with lateralized aldosterone secretion, hypertension may persist after adrenalectomy requiring use of additional antihypertensive agents. Treatment with mineralocorticoid receptor antagonists (MRAs) is currently recommended for PA patients with bilateral adrenal disease, but these agents effectively decrease blood pressure also in patients with unilateral disease, although concern remains for possible sex-related side effects. Prospective studies indicate that MRAs have therapeutic values comparable to surgery in the long-term, inasmuch as they effectively correct metabolic abnormalities and subclinical organ damage and reduce the risk of cardiovascular events and renal disease progression. This article overviews the clinical outcomes obtained in patients with PA with use of MRAs.
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Affiliation(s)
- L A Sechi
- Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - G L Colussi
- Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - M Novello
- Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - A Uzzau
- General Surgery, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - C Catena
- Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
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204
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Lubitz CC, Economopoulos KP, Sy S, Johanson C, Kunzel HE, Reincke M, Gazelle GS, Weinstein MC, Gaziano TA. Cost-Effectiveness of Screening for Primary Aldosteronism and Subtype Diagnosis in the Resistant Hypertensive Patients. Circ Cardiovasc Qual Outcomes 2015; 8:621-30. [PMID: 26555126 PMCID: PMC4651757 DOI: 10.1161/circoutcomes.115.002002] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 10/13/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary aldosteronism (PA) is a common and underdiagnosed disease with significant morbidity potentially cured by surgery. We aim to assess if the long-term cardiovascular benefits of identifying and treating surgically correctable PA outweigh the upfront increased costs in patients at the time patients are diagnosed with resistant hypertension (RH). METHODS AND RESULTS A decision-analytic model compares aggregate costs and systolic blood pressure changes of 6 recommended or implemented diagnostic strategies for PA in a simulated population of at-risk RH patients. We also evaluate a 7th "treat all" strategy wherein all patients with RH are treated with a mineralocorticoid-receptor antagonist without further testing at RH diagnosis. Changes in systolic blood pressure are subsequently converted into gains in quality-adjusted life years (QALYs) by applying National Health and Nutrition Examination Survey data on concomitant risk factors to an existing cardiovascular disease simulation model. QALYs and lifetime costs were then used to calculate incremental cost-effectiveness ratios for the competing strategies. The incremental cost-effectiveness ratio for the strategy of computerized tomography (CT) followed by adrenal venous sampling (AVS) was $82,000/QALY compared with treat all. Incremental cost-effectiveness ratios for CT alone and AVS alone were $200,000/QALY and $492,000/QALY; the other strategies were more costly and less effective. Integrating differential patient-reported health-related quality of life adjustments for patients with PA, and incremental cost-effectiveness ratios for screening patients with CT followed by AVS, CT alone, and AVS alone were $52,000/QALY, $114,000/QALY, and $269,000/QALY gained. CONCLUSIONS CT scanning followed by AVS was a cost-effective strategy to screen for PA among patients with RH.
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Affiliation(s)
- Carrie C Lubitz
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.).
| | - Konstantinos P Economopoulos
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - Stephen Sy
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - Colden Johanson
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - Heike E Kunzel
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - Martin Reincke
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - G Scott Gazelle
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - Milton C Weinstein
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - Thomas A Gaziano
- From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.)
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205
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Effect of Treatment on Body Fluid in Patients with Unilateral Aldosterone Producing Adenoma: Adrenalectomy versus Spironolactone. Sci Rep 2015; 5:15297. [PMID: 26477337 PMCID: PMC4609981 DOI: 10.1038/srep15297] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 09/22/2015] [Indexed: 11/29/2022] Open
Abstract
Aldosterone affects fluid retention in the body by affecting how much salt and water that the kidney retains or excretes. There is limited information about the effect of prolonged aldosterone excess and treatment on body fluid in primary aldosteronism (PA) patients. In this study, body composition changes of 41 PA patients with unilateral aldosterone producing adenoma (APA) were assessed by a bio-impedance spectroscopy device. Patients with APA receiving adrenalectomy, as compared with those treated with spironolactone, had significantly lower relative overhydration (OH) and urine albumin excretion, and significantly higher urine sodium excretion four weeks after treatment. These differences dissipated 12 weeks after the initial treatment. Independent factors to predict decreased relative OH four weeks after treatment were male patients and patients who experienced adrenalectomy. Patients who underwent adrenaelctomy had significantly decreased TNF-α and increased serum potassium level when compared to patients treated with spironolactone 4 and 12 weeks after treatment. In this pilot study, we found that adrenalectomy leads to an earlier increase in renal sodium excretion and decreases in body fluid content, TNF-α, and urine albumin excretion. Adrenalectomy yields a therapeutic effect more rapidly, which has been shown to ameliorate overhydration in PA patients.
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206
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207
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Circulating tissue inhibitor of matrix metalloproteinase-1 is associated with aldosterone-induced diastolic dysfunction. J Hypertens 2015; 33:1922-30; discussion 1930. [DOI: 10.1097/hjh.0000000000000619] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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208
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Kline GA, Chin A, So B, Harvey A, Pasieka JL. Defining contralateral adrenal suppression in primary aldosteronism: implications for diagnosis and outcome. Clin Endocrinol (Oxf) 2015; 83:20-7. [PMID: 25400021 DOI: 10.1111/cen.12669] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 09/08/2014] [Accepted: 11/10/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Unilateral primary aldosteronism (PA) should have a contralaterally normal and therefore suppressed adrenal zona glomerulosa. However, there is no validated definition of adrenal suppression. We created two biochemical hypotheses of adrenal suppression based upon measurements taken during adrenal vein sampling (AVS) to determine whether either proved useful for interpretation of AVS or prediction of hypertension outcome in operated cases. DESIGN Retrospective database analysis. PATIENTS Ninety-nine cases of PA from a tertiary hypertension unit. MEASUREMENTS Hypothesis 1 was the proportional suppression of the uninvolved/lowest adrenal(aldo/cortisol) to IVC(aldo/cortisol) ratio pre- and post cosyntropin. Hypothesis 2 was the absolute decrease in the uninvolved adrenal(aldo/cortisol) ratio after cortrosyn injection. ROC analysis performed using lateralization and hypertension resolution as the outcomes of interest. RESULTS Hypothesis 1 proved highly predictive of lateralization with a ROC AUC of 0.958, P < 0.0001, giving adrenal(aldo/cortisol):IVC(aldo/cortisol) <1.4 as the optimized criterion (sensitivity 90%, specificity 94%). For blood pressure outcomes in the surgical subgroup (n = 52), hypertension resolution was most commonly seen among subjects with adrenal suppression by both definitions although there was significant overlap with subjects requiring ongoing medication. CONCLUSIONS Post cosyntropin suppression of the uninvolved adrenal-to-IVC ratio is a highly useful definition of adrenal suppression that accurately predicts unilateral PA. This may be particularly useful in a case where AVS fails to catheterize one of the adrenal veins but suppression is seen on the other side. Adrenal suppression may also predict blood pressure outcome, however, a much larger PA database is likely necessary to determine the relative contribution of this predictor.
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Affiliation(s)
- G A Kline
- Division of Endocrinology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - A Chin
- Section of Clinical Biochemistry, Calgary Laboratory Services, Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
| | - B So
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - A Harvey
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - J L Pasieka
- Department of Surgery, University of Calgary, Calgary, AB, Canada
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209
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Abstract
OBJECTIVE To investigate the subclinical cardiac morphological and functional modifications in cirrhotic patients according to the stage of liver disease. PATIENTS AND METHODS One hundred and thirteen cirrhotic patients underwent standard Doppler echocardiography and were compared with healthy individuals. Left ventricular (LV) geometry, systolic/diastolic function, and the main hemodynamic parameters were assessed according to current guidelines. RESULTS Cirrhotic patients showed a reduction in the peripheral vascular resistance (PVR), a compensatory hyperdynamic syndrome, and a significant increase in cardiac index (CI), cardiac output (CO), and cardiac work, with a consequent increase in the prevalence of LV hypertrophy and associated diastolic dysfunction (DD). Age (P=0.005) and LV mass index (P=0.03) were the strongest predictors of DD. Even though all the systolic parameters assessed were similar between patients and controls, in patients with refractory ascites, the reduction of the PVR and mean blood pressure was not balanced by a further increase in cardiac work and therefore the CI and CO were supported only by the increase in heart rate. CONCLUSION In cirrhotic patients, DD is strongly related to the increase in LV mass, not related to the stage of the liver disease, and can be correctly detectable only by the use of tissue Doppler imaging. For systolic dysfunction, along with the development and worsening of ascites, CO and CI do not increase further to compensate the continuous reduction of PVR and mean blood pressure, and their maintenance becomes critically dependent on the heart rate, thus suggesting a possible detrimental effect of β-blockers in these patients.
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210
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Kline GA. Primary Aldosteronism: unnecessary complexity in definition and diagnosis as a barrier to wider clinical care. Clin Endocrinol (Oxf) 2015; 82:779-84. [PMID: 25891981 DOI: 10.1111/cen.12798] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 02/18/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Gregory A Kline
- Department of Medicine, University of Calgary, Calgary, AB, Canada
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211
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Zennaro MC, Fernandes-Rosa F, Boulkroun S. [Genetic alterations in primary aldosteronism]. Med Sci (Paris) 2015; 31:389-96. [PMID: 25958757 DOI: 10.1051/medsci/20153104013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Primary aldostéronism (PA) is the most frequent form of arterial hypertension. It is caused in the majority of cases by an aldosterone producing adenoma (APA) of the adrenal cortex or by bilateral adrenal hyperplasia. Recent advances have allowed to identify a certain number of genetic abnormalities involved in the development of APA or responsible for familial forms of PA. These findings have highlighted the central role of calcium signaling in this process. In this review we will discuss the genetic defects associated with PA and discuss the mechanisms whereby they lead to increased aldosterone production and cell proliferation. The possible consequences that this knowledge will have on the diagnosis and management of PA will be addressed.
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Affiliation(s)
- Maria-Christina Zennaro
- Inserm, UMRS 970, Paris-centre de recherche cardiovasculaire, 56, rue Leblanc, 75015 Paris, France - Université Paris Descartes, Sorbonne Paris Cité, Paris, France - Assistance publique-hôpitaux de Paris, service de génétique, hôpital européen Georges Pompidou, Paris, France
| | - Fabio Fernandes-Rosa
- Inserm, UMRS 970, Paris-centre de recherche cardiovasculaire, 56, rue Leblanc, 75015 Paris, France - Université Paris Descartes, Sorbonne Paris Cité, Paris, France - Assistance publique-hôpitaux de Paris, service de génétique, hôpital européen Georges Pompidou, Paris, France
| | - Sheerazed Boulkroun
- Inserm, UMRS 970, Paris-centre de recherche cardiovasculaire, 56, rue Leblanc, 75015 Paris, France - Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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Steichen O, Lorthioir A, Zinzindohoue F, Plouin PF, Amar L. Outcomes of drug-based and surgical treatments for primary aldosteronism. Adv Chronic Kidney Dis 2015; 22:196-203. [PMID: 25908468 DOI: 10.1053/j.ackd.2014.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 10/08/2014] [Accepted: 10/08/2014] [Indexed: 12/16/2022]
Abstract
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 (BP) 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 BP. 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 BP, serum potassium concentration, or cardiovascular and kidney outcomes, although the benefits of treatment tend to be observed sooner with surgery. Patients with PA display relative glomerular hyperfiltration, which is reversed by specific treatment, revealing CKD in 30% of patients. However, further kidney damage is lessened by the treatment of PA.
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213
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Piaditis G, Markou A, Papanastasiou L, Androulakis II, Kaltsas G. Progress in aldosteronism: a review of the prevalence of primary aldosteronism in pre-hypertension and hypertension. Eur J Endocrinol 2015; 172:R191-203. [PMID: 25538205 DOI: 10.1530/eje-14-0537] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Primary aldosteronism (PA) secondary to excessive and/or autonomous aldosterone secretion from the renin-angiotensin system accounts for ∼10% of cases of hypertension and is primarily caused by bilateral adrenal hyperplasia (BAH) or aldosterone-producing adenomas (APAs). Although the diagnosis has traditionally been supported by low serum potassium levels, normokalaemic and even normotensive forms of PA have been identified expanding further the clinical phenotype. Moreover, recent evidence has shown that serum aldosterone correlates with increased blood pressure (BP) in the general population and even moderately raised aldosterone levels are linked to increased cardiovascular morbidity and mortality. In addition, aldosterone antagonists are effective in BP control even in patients without evidence of dysregulated aldosterone secretion. These findings indicate a higher prevalence of aldosterone excess among hypertensive patients than previously considered that could be attributed to disease heterogeneity, aldosterone level fluctuations related to an ACTH effect or inadequate sensitivity of current diagnostic means to identify apparent aldosterone excess. In addition, functioning aberrant receptors expressed in the adrenal tissue have been found in a subset of PA cases that could also be related to its pathogenesis. Recently a number of specific genetic alterations, mainly involving ion homeostasis across the membrane of zona glomerulosa, have been detected in ∼50% of patients with APAs. Although specific genotype/phenotype correlations have not been clearly identified, differential expression of these genetic alterations could also account for the wide clinical phenotype, variations in disease prevalence and performance of diagnostic tests. In the present review, we critically analyse the current means used to diagnose PA along with the role that ACTH, aberrant receptor expression and genetic alterations may exert, and provide evidence for an increased prevalence of aldosterone dysregulation in patients with essential hypertension and pre-hypertension.
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Affiliation(s)
- George Piaditis
- Department of Endocrinology and Diabetes CenterG. Gennimatas Hospital, 154 Mesogion Avenue, 11527 Holargos, Athens, Greece andDepartment of PathophysiologyNational University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Athina Markou
- Department of Endocrinology and Diabetes CenterG. Gennimatas Hospital, 154 Mesogion Avenue, 11527 Holargos, Athens, Greece andDepartment of PathophysiologyNational University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Labrini Papanastasiou
- Department of Endocrinology and Diabetes CenterG. Gennimatas Hospital, 154 Mesogion Avenue, 11527 Holargos, Athens, Greece andDepartment of PathophysiologyNational University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Ioannis I Androulakis
- Department of Endocrinology and Diabetes CenterG. Gennimatas Hospital, 154 Mesogion Avenue, 11527 Holargos, Athens, Greece andDepartment of PathophysiologyNational University of Athens, Mikras Asias 75, 11527 Athens, Greece Department of Endocrinology and Diabetes CenterG. Gennimatas Hospital, 154 Mesogion Avenue, 11527 Holargos, Athens, Greece andDepartment of PathophysiologyNational University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Gregory Kaltsas
- Department of Endocrinology and Diabetes CenterG. Gennimatas Hospital, 154 Mesogion Avenue, 11527 Holargos, Athens, Greece andDepartment of PathophysiologyNational University of Athens, Mikras Asias 75, 11527 Athens, Greece
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Rao A, Pandya V, Whaley-Connell A. Obesity and insulin resistance in resistant hypertension: implications for the kidney. Adv Chronic Kidney Dis 2015; 22:211-7. [PMID: 25908470 DOI: 10.1053/j.ackd.2014.12.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 12/08/2014] [Accepted: 12/19/2014] [Indexed: 12/12/2022]
Abstract
There is recognition that the obesity epidemic contributes substantially to the increasing incidence of CKD and resistant hypertension (HTN). The mechanisms by which obesity promotes resistance are an area of active interest and intense investigation. It is thought that increases in visceral adiposity lead to a proinflammatory, pro-oxidative milieu that promote resistance to the metabolic actions of insulin. This resistance to insulin at the level of skeletal muscle tissue impairs glucose disposal/utilization through actions on the endothelium that include vascular rarefaction, reductions in vascular relaxation, and vascular remodeling. Insulin resistance derived from increased adipose tissue and obesity has system-wide implications for other tissue beds such as the kidney that affects blood pressure regulation. The additional autocrine and paracrine activities of adipose tissue contribute to inappropriate activation of the renin-angiotensin-aldosterone system and the sympathetic nervous system that promote kidney microvascular remodeling, stiffness, and sodium (Na(+)) retention that in turn promote HTN and in the CKD patient, resistance. In this review, we will summarize the important mechanisms that link obesity to CKD as they relate to resistant HTN.
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Abstract
Endocrine hypertension is an important secondary form of hypertension, identified in between 5% and 10% of general hypertensive population. Primary aldosteronism is the most common cause of endocrine hypertension, accounting for 1%-10% in uncomplicated hypertension and 7%-20% in resistant hypertension. Other less common causes of endocrine hypertension include Cushing syndrome, pheochromocytoma, thyroid disorders, and hyperparathyroidism. Diagnosis requires a high index of suspicion and the use of appropriate screening tests based on clinical presentation. Failure to make proper diagnosis may lead to catastrophic complications or irreversible hypertensive target organ damage. Accordingly, patients who are suspected to have endocrine hypertension should be referred to endocrinologists or hypertension specialists who are familiar with management of the specific endocrine disorders.
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216
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Cuspidi C, Tadic M, Sala C. Aldosterone and abnormal left ventricular geometry in chronic kidney disease. Hypertens Res 2015; 38:314-6. [PMID: 25787043 DOI: 10.1038/hr.2015.34] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Cesare Cuspidi
- 1] Department of Health Science, University of Milano-Bicocca, Milano, Italy [2] Istituto Auxologico Italiano, Milano, Italy
| | - Marijana Tadic
- University Clinical Hospital Centre "Dragisa Misovic", Belgrade, Serbia
| | - Carla Sala
- 1] Department of Clinical Sciences and Community Health, University of Milano, Milano, Italy [2] Fondazione Policlinico di Milano, Milano, Italy
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217
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Zheng FF, Zhu LM, Nie AF, Li XY, Lin JR, Zhang K, Chen J, Zhou WL, Shen ZJ, Zhu YC, Wang JG, Zhu DL, Gao PJ. Clinical Characteristics of Somatic Mutations in Chinese Patients With Aldosterone-Producing Adenoma. Hypertension 2015; 65:622-8. [DOI: 10.1161/hypertensionaha.114.03346] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Fang-Fang Zheng
- From the State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension and Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (F.-F.Z., L.-M.Z., J.C., J.-G.W., D.-L.Z., P.-J.G.); Laboratory of Vascular Biology and Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China (F.-F.Z., J.-R.L., K.Z., P.-J.G.); Shanghai Institute
| | - Li-Min Zhu
- From the State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension and Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (F.-F.Z., L.-M.Z., J.C., J.-G.W., D.-L.Z., P.-J.G.); Laboratory of Vascular Biology and Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China (F.-F.Z., J.-R.L., K.Z., P.-J.G.); Shanghai Institute
| | - Ai-Fang Nie
- From the State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension and Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (F.-F.Z., L.-M.Z., J.C., J.-G.W., D.-L.Z., P.-J.G.); Laboratory of Vascular Biology and Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China (F.-F.Z., J.-R.L., K.Z., P.-J.G.); Shanghai Institute
| | - Xiao-Ying Li
- From the State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension and Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (F.-F.Z., L.-M.Z., J.C., J.-G.W., D.-L.Z., P.-J.G.); Laboratory of Vascular Biology and Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China (F.-F.Z., J.-R.L., K.Z., P.-J.G.); Shanghai Institute
| | - Jing-Rong Lin
- From the State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension and Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (F.-F.Z., L.-M.Z., J.C., J.-G.W., D.-L.Z., P.-J.G.); Laboratory of Vascular Biology and Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China (F.-F.Z., J.-R.L., K.Z., P.-J.G.); Shanghai Institute
| | - Ke Zhang
- From the State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension and Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (F.-F.Z., L.-M.Z., J.C., J.-G.W., D.-L.Z., P.-J.G.); Laboratory of Vascular Biology and Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China (F.-F.Z., J.-R.L., K.Z., P.-J.G.); Shanghai Institute
| | - Jing Chen
- From the State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension and Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (F.-F.Z., L.-M.Z., J.C., J.-G.W., D.-L.Z., P.-J.G.); Laboratory of Vascular Biology and Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China (F.-F.Z., J.-R.L., K.Z., P.-J.G.); Shanghai Institute
| | - Wen-Long Zhou
- From the State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension and Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (F.-F.Z., L.-M.Z., J.C., J.-G.W., D.-L.Z., P.-J.G.); Laboratory of Vascular Biology and Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China (F.-F.Z., J.-R.L., K.Z., P.-J.G.); Shanghai Institute
| | - Zhou-Jun Shen
- From the State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension and Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (F.-F.Z., L.-M.Z., J.C., J.-G.W., D.-L.Z., P.-J.G.); Laboratory of Vascular Biology and Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China (F.-F.Z., J.-R.L., K.Z., P.-J.G.); Shanghai Institute
| | - Yi-Chun Zhu
- From the State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension and Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (F.-F.Z., L.-M.Z., J.C., J.-G.W., D.-L.Z., P.-J.G.); Laboratory of Vascular Biology and Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China (F.-F.Z., J.-R.L., K.Z., P.-J.G.); Shanghai Institute
| | - Ji-Guang Wang
- From the State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension and Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (F.-F.Z., L.-M.Z., J.C., J.-G.W., D.-L.Z., P.-J.G.); Laboratory of Vascular Biology and Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China (F.-F.Z., J.-R.L., K.Z., P.-J.G.); Shanghai Institute
| | - Ding-Liang Zhu
- From the State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension and Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (F.-F.Z., L.-M.Z., J.C., J.-G.W., D.-L.Z., P.-J.G.); Laboratory of Vascular Biology and Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China (F.-F.Z., J.-R.L., K.Z., P.-J.G.); Shanghai Institute
| | - Ping-Jin Gao
- From the State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension and Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (F.-F.Z., L.-M.Z., J.C., J.-G.W., D.-L.Z., P.-J.G.); Laboratory of Vascular Biology and Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China (F.-F.Z., J.-R.L., K.Z., P.-J.G.); Shanghai Institute
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Marzano L, Colussi G, Sechi LA, Catena C. Adrenalectomy is comparable with medical treatment for reduction of left ventricular mass in primary aldosteronism: meta-analysis of long-term studies. Am J Hypertens 2015; 28:312-8. [PMID: 25336498 DOI: 10.1093/ajh/hpu154] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Primary aldosteronism (PA) is associated with an increase in left ventricular (LV) mass beyond the amount needed to compensate the hypertension-related workload. Available evidence suggests effectiveness of surgical treatment of PA in decreasing LV mass, whereas data on medical treatment are controversial. We have conducted a meta-analysis of long-term follow-up studies on surgical and medical treatment of PA to compare the effects of treatments on LV mass. METHODS Medline and Cochrane searches were performed including the following words: hyperaldosteronism, left ventricular mass, mineralocorticoid receptor antagonists, surgery, adrenalectomy, and follow-up studies. Studies published within 2013 focusing on cardiac effects of treatment and follow-up longer than 6 months were selected. Data extraction was performed independently by 2 authors. RESULTS Of 61 retrieved articles, 4 were included in the analysis. These studies enrolled 355 patients with PA who had an average follow-up of 4.0 years after unilateral adrenalectomy (n = 178) or treatment with mineralocorticoid receptor antagonists (n = 177). Despite greater effect of surgery over medical treatment in reducing blood pressure, meta-analysis of the selected studies demonstrated no significant difference in LV mass change between patients with PA who were treated with mineralocorticoid receptor antagonists or adrenalectomy (standard mean difference = 0.130; 95% confidence interval = -0.085 to 0.345; P = 0.24; I2 = 0%). CONCLUSIONS Available evidence indicates that reduction of LV mass is not different in PA patients treated with adrenalectomy or mineralocorticoid receptor antagonists.
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Affiliation(s)
- Luigi Marzano
- Hypertension Unit, Clinica Medica, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy. luimar-@libero.it
| | - Gianluca Colussi
- Hypertension Unit, Clinica Medica, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - Leonardo A Sechi
- Hypertension Unit, Clinica Medica, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - Cristiana Catena
- Hypertension Unit, Clinica Medica, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
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219
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Iacobone M, Citton M, Viel G, Rossi GP, Nitti D. Approach to the surgical management of primary aldosteronism. Gland Surg 2015; 4:69-81. [PMID: 25713782 DOI: 10.3978/j.issn.2227-684x.2015.01.05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 01/15/2015] [Indexed: 11/14/2022]
Abstract
Primary aldosteronism (PA) is the most common cause of endocrine hypertension; it has been reported in more than 11% of referred hypertensive patients. PA may be caused by unilateral adrenal involvement [aldosterone producing adenoma (APA) or unilateral adrenal hyperplasia (UAH)], and bilateral disease (idiopathic adrenal hyperplasia). Only patients with unilateral adrenal hypersecretion may be cured by unilateral adrenalectomy, while patients with bilateral and non-surgically correctable PA are usually treated by mineralocorticoid receptor antagonists; thus the distinction between unilateral and bilateral aldosterone hypersecretion is crucial. Most experts agree that the referral diagnostic test for lateralization of aldosterone hypersecretion should be adrenal venous sampling (AVS) because the interpretation of other imaging techniques [computed tomography (CT), magnetic resonance imaging (MRI) and scintigraphy] may lead to inappropriate treatment. Adrenalectomy represents the elective treatment in unilateral PA variants. Laparoscopic surgery, using transperitoneal or retroperitoneal approaches, is the preferred strategy. Otherwise, the indications to laparoscopic unilateral total or partial adrenalectomy in patients with unilateral PA remain controversial. Adrenalectomy is highly successful in curing the PA, with correction of hypokalemia in virtually all patients, cure of hypertension in about 30-60% of cases, and a marked improvement of blood pressure values in the remaining patients. Interestingly, in several papers the outcomes of surgery focus only on blood pressure changes and the normalization of serum potassium levels is often used as a surrogate of PA recovery. However, the goal of surgery is the normalization of aldosterone, because chronically elevated levels of this hormone can lead to cardiovascular complications, independently from blood pressure levels. Thus, we strongly advocate the need of considering the postoperative normalization of aldosterone-renin ratio (ARR) as the main endpoint for determining outcomes of PA.
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Affiliation(s)
- Maurizio Iacobone
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Marilisa Citton
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Giovanni Viel
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Gian Paolo Rossi
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Donato Nitti
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
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220
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Magill SB. Pathophysiology, diagnosis, and treatment of mineralocorticoid disorders. Compr Physiol 2015; 4:1083-119. [PMID: 24944031 DOI: 10.1002/cphy.c130042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The renin-angiotensin-aldosterone system (RAAS) is a major regulator of blood pressure control, fluid, and electrolyte balance in humans. Chronic activation of mineralocorticoid production leads to dysregulation of the cardiovascular system and to hypertension. The key mineralocorticoid is aldosterone. Hyperaldosteronism causes sodium and fluid retention in the kidney. Combined with the actions of angiotensin II, chronic elevation in aldosterone leads to detrimental effects in the vasculature, heart, and brain. The adverse effects of excess aldosterone are heavily dependent on increased dietary salt intake as has been demonstrated in animal models and in humans. Hypertension develops due to complex genetic influences combined with environmental factors. In the last two decades, primary aldosteronism has been found to occur in 5% to 13% of subjects with hypertension. In addition, patients with hyperaldosteronism have more end organ manifestations such as left ventricular hypertrophy and have significant cardiovascular complications including higher rates of heart failure and atrial fibrillation compared to similarly matched patients with essential hypertension. The pathophysiology, diagnosis, and treatment of primary aldosteronism will be extensively reviewed. There are many pitfalls in the diagnosis and confirmation of the disorder that will be discussed. Other rare forms of hyper- and hypo-aldosteronism and unusual disorders of hypertension will also be reviewed in this article.
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Affiliation(s)
- Steven B Magill
- Division of Endocrinology, Metabolism, and Clinical Nutrition, Department of Medicine, Medical College of Wisconsin, Menomonee Falls, Wisconsin
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221
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Abstract
Primary aldosteronism (PA) is the most common and curable form of secondary hypertension. It is caused in the majority of cases by either unilateral aldosterone overproduction due to an aldosterone-producing adenoma (APA) or by bilateral adrenal hyperplasia. Recent advances in genome technology have allowed researchers to unravel part of the genetic abnormalities underlying the development of APA and familial hyperaldosteronism. Recurrent somatic mutations in genes coding for ion channels (KCNJ5 and CACNA1D) and ATPases (ATP1A1 and ATP2B3) regulating intracellular ionic homeostasis and cell membrane potential have been identified in APA. Similar germline mutations of KCNJ5 were identified in a severe familial form of PA, familial hyperaldosteronism type 3 (FH3), whereas de novo germline CACNA1D mutations were found in two cases of hyperaldosteronism associated with a complex neurological disorder. These results have allowed a pathophysiological model of APA development to be established. This model involves modifications in intracellular ionic homeostasis and membrane potential, accounting for ∼50% of all tumors, associated with specific gender differences and severity of PA. In this review, we describe the different genetic abnormalities associated with PA and discuss the mechanisms whereby they lead to increased aldosterone production and cell proliferation. We also address some of the foreseeable consequences that genetic knowledge may contribute to improve diagnosis and patient care.
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Affiliation(s)
- Maria-Christina Zennaro
- INSERMUMRS_970, Paris Cardiovascular Research Center - PARCC, 56, rue Leblanc, 75015 Paris, FranceUniversity Paris DescartesSorbonne Paris Cité, Paris, FranceAssistance Publique-Hôpitaux de ParisHôpital Européen Georges Pompidou, Service de Génétique, Paris, France INSERMUMRS_970, Paris Cardiovascular Research Center - PARCC, 56, rue Leblanc, 75015 Paris, FranceUniversity Paris DescartesSorbonne Paris Cité, Paris, FranceAssistance Publique-Hôpitaux de ParisHôpital Européen Georges Pompidou, Service de Génétique, Paris, France INSERMUMRS_970, Paris Cardiovascular Research Center - PARCC, 56, rue Leblanc, 75015 Paris, FranceUniversity Paris DescartesSorbonne Paris Cité, Paris, FranceAssistance Publique-Hôpitaux de ParisHôpital Européen Georges Pompidou, Service de Génétique, Paris, France
| | - Sheerazed Boulkroun
- INSERMUMRS_970, Paris Cardiovascular Research Center - PARCC, 56, rue Leblanc, 75015 Paris, FranceUniversity Paris DescartesSorbonne Paris Cité, Paris, FranceAssistance Publique-Hôpitaux de ParisHôpital Européen Georges Pompidou, Service de Génétique, Paris, France INSERMUMRS_970, Paris Cardiovascular Research Center - PARCC, 56, rue Leblanc, 75015 Paris, FranceUniversity Paris DescartesSorbonne Paris Cité, Paris, FranceAssistance Publique-Hôpitaux de ParisHôpital Européen Georges Pompidou, Service de Génétique, Paris, France
| | - Fabio Fernandes-Rosa
- INSERMUMRS_970, Paris Cardiovascular Research Center - PARCC, 56, rue Leblanc, 75015 Paris, FranceUniversity Paris DescartesSorbonne Paris Cité, Paris, FranceAssistance Publique-Hôpitaux de ParisHôpital Européen Georges Pompidou, Service de Génétique, Paris, France INSERMUMRS_970, Paris Cardiovascular Research Center - PARCC, 56, rue Leblanc, 75015 Paris, FranceUniversity Paris DescartesSorbonne Paris Cité, Paris, FranceAssistance Publique-Hôpitaux de ParisHôpital Européen Georges Pompidou, Service de Génétique, Paris, France INSERMUMRS_970, Paris Cardiovascular Research Center - PARCC, 56, rue Leblanc, 75015 Paris, FranceUniversity Paris DescartesSorbonne Paris Cité, Paris, FranceAssistance Publique-Hôpitaux de ParisHôpital Européen Georges Pompidou, Service de Génétique, Paris, France
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222
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Muth A, Ragnarsson O, Johannsson G, Wängberg B. Systematic review of surgery and outcomes in patients with primary aldosteronism. Br J Surg 2015; 102:307-17. [PMID: 25605481 DOI: 10.1002/bjs.9744] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 11/11/2014] [Accepted: 11/11/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND Primary aldosteronism (PA) is the most common cause of secondary hypertension. The main aims of this paper were to review outcome after surgical versus medical treatment of PA and partial versus total adrenalectomy in patients with PA. METHODS Relevant medical literature from PubMed, the Cochrane Library and Embase OvidSP from 1985 to June 2014 was reviewed. RESULTS Of 2036 records, 43 articles were included in the final analysis. Twenty-one addressed surgical versus medical treatment of PA, four considered partial versus total adrenalectomy for unilateral PA, and 18 series reported on surgical outcomes. Owing to the heterogeneity of protocols and reported outcomes, only a qualitative analysis was performed. In six studies, surgical and medical treatment had comparable outcomes concerning blood pressure, whereas six showed better outcome after surgery. No differences were seen in cardiovascular complications, but surgery was associated with the use of fewer antihypertensive medications after surgery, improved quality of life, and (possibly) lower all-cause mortality compared with medical treatment. Randomized studies indicate a role for partial adrenalectomy in PA, but the high rate of multiple adenomas or adenoma combined with hyperplasia in localized disease is disconcerting. Surgery for unilateral dominant PA normalized BP in a mean of 42 (range 20-72) per cent and the biochemical profile in 96-100 per cent of patients. The mean complication rate in 1056 patients was 4·7 per cent. CONCLUSION Recommendations for treatment of PA are hampered by the lack of randomized trials, but support surgical resection of unilateral disease. Partial adrenalectomy may be an option in selected patients.
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Affiliation(s)
- A Muth
- Section for Endocrine Surgery and Abdominal Sarcoma, Department of Surgery, Institute of Clinical Sciences, Gothenburg, Sweden
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223
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Outcome of surgical treatment of primary aldosteronism. Langenbecks Arch Surg 2015; 400:325-31. [DOI: 10.1007/s00423-014-1269-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 12/22/2014] [Indexed: 10/24/2022]
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224
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Catena C, Colussi G, Sechi LA. Treatment of Primary Aldosteronism and Organ Protection. Int J Endocrinol 2015; 2015:597247. [PMID: 26074961 PMCID: PMC4449945 DOI: 10.1155/2015/597247] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/31/2015] [Indexed: 12/25/2022] Open
Abstract
Primary aldosteronism is a frequent form of secondary hypertension that had long been considered relatively benign. Experimental and clinical evidence collected in the last two decades, however, has clearly demonstrated that this endocrine disorder is associated with excess cardiovascular and renal complications as compared to essential hypertension. These complications reflect the ability of inappropriate elevation of plasma aldosterone to cause tissue damage beyond that induced by high blood pressure itself, thereby setting the stage for major cardiovascular and renal disease. Because of the impact of elevated aldosterone on organ damage, goals of treatment in patients with primary aldosteronism should not be limited to normalization of blood pressure, and prevention or correction of organ complications is mandatory. Treatment with mineralocorticoid receptor antagonists or unilateral adrenalectomy is the respective options for treatment of idiopathic adrenal hyperplasia or aldosterone-producing adenoma. Last years have witnessed a rapid growth in knowledge concerning the effects of these treatments on cardiovascular and renal protection. This paper is an overview of the cardiovascular and renal complications that occur in patients with primary aldosteronism and a summary of the results that have been obtained in the long term on cardiovascular and renal outcomes with either medical or surgical treatment.
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Affiliation(s)
- Cristiana Catena
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, 33100 Udine, Italy
- *Cristiana Catena:
| | - GianLuca Colussi
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, 33100 Udine, Italy
| | - Leonardo A. Sechi
- Hypertension Unit, Internal Medicine, Department of Experimental and Clinical Medical Sciences, University of Udine, 33100 Udine, Italy
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225
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Kitamoto T, Suematsu S, Matsuzawa Y, Saito J, Omura M, Nishikawa T. Comparison of Cardiovascular Complications in Patients with and without KCNJ5 Gene Mutations Harboring Aldosterone-producing Adenomas. J Atheroscler Thromb 2015; 22:191-200. [DOI: 10.5551/jat.24455] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
| | | | - Yoko Matsuzawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital
| | - Jun Saito
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital
| | - Masao Omura
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital
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226
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Indra T, Holaj R, Štrauch B, Rosa J, Petrák O, Šomlóová Z, Widimský J. Long-term effects of adrenalectomy or spironolactone on blood pressure control and regression of left ventricle hypertrophy in patients with primary aldosteronism. J Renin Angiotensin Aldosterone Syst 2014; 16:1109-17. [PMID: 25271250 DOI: 10.1177/1470320314549220] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 07/25/2014] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Primary aldosteronism (PA) represents the most common cause of secondary hypertension. Beyond increased blood pressure, additional harmful effects of aldosterone excess including inappropriate left ventricle (LV) hypertrophy were found. We evaluated the effect of adrenalectomy and spironolactone on blood pressure and myocardial remodelling in a long-term follow-up study. METHODS Thirty-one patients with PA were recruited. Fifteen patients with confirmed aldosterone-producing adenoma underwent adrenalectomy; in the remaining 16 patients, treatment with spironolactone was initiated. Laboratory data, 24-hour ambulatory blood pressure monitoring (ABPM) and echocardiography parameters were evaluated at baseline and at a median follow-up of 64 months. RESULTS Both approaches reduced blood pressure (p = 0.001 vs. baseline). In both groups we observed a decrease in end-diastolic (p = 0.04, p = 0.01) and end-systolic LV cavity diameters (p = 0.03, p = 0.01). Interventricular septum and posterior wall thickness reduction was significant only after adrenalectomy (p = 0.01, p = 0.03) as was reduction of LV mass index (p = 0.004). A trend to lower LV mass on spironolactone was caused predominantly by diminution of the LV cavity, which was reflected in increased relative wall thickness (p = 0.05). CONCLUSIONS Although both surgical and conservative treatment can induce a long-term decrease of blood pressure, adrenalectomy seems to be more effective in reduction of LV mass, as it reverses both wall thickening and enlargement of the LV cavity.
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Affiliation(s)
- Tomáš Indra
- Third Department of Internal Medicine, General University Hospital, Prague, Czech Republic; and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Robert Holaj
- Third Department of Internal Medicine, General University Hospital, Prague, Czech Republic; and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Branislav Štrauch
- Third Department of Internal Medicine, General University Hospital, Prague, Czech Republic; and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ján Rosa
- Third Department of Internal Medicine, General University Hospital, Prague, Czech Republic; and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ondřej Petrák
- Third Department of Internal Medicine, General University Hospital, Prague, Czech Republic; and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Zuzana Šomlóová
- Third Department of Internal Medicine, General University Hospital, Prague, Czech Republic; and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jiří Widimský
- Third Department of Internal Medicine, General University Hospital, Prague, Czech Republic; and First Faculty of Medicine, Charles University, Prague, Czech Republic
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227
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Kao CC, Wu CH, Lin YH, Chang CC, Chen HH, Wu MS, Wu VC, Wu KD. Risk of ischemic stroke in primary aldosteronism patients. Clin Chim Acta 2014; 438:86-9. [PMID: 25124866 DOI: 10.1016/j.cca.2014.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 07/02/2014] [Accepted: 08/04/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND High aldosterone concentrations are associated with the risk of stroke that is independent of blood pressure levels. We investigated the risk of ischemic stroke in primary aldosteronism (PA) patients. METHODS This retrospective case-control study was based on the Taiwan Primary Aldosteronism Investigation (TAIPAI) database from 2004 to 2010. The study group comprised the patients who developed ischemic stroke after the diagnosis of PA. The PA patients who did not develop stroke were matched according to age and sex as the control group. A multivariate logistic regression model was performed to determine the risk factors of ischemic stroke. RESULTS Of 339 patients diagnosed with PA, 22 patients (6.5%) developed de novo ischemic stroke. The PA patients with stroke suffered from a longer hypertensive period (11.0±6.5 vs 7.8±8.3, P=.007) and a higher prevalence of proteinuria than those who did not develop stroke (40.9% vs 12.9%, P=.002). A multivariate logistic regression model showed that PA patients with proteinuria (HR 3.58, P=.02), preexisting coronary artery disease (HR 11.12, P<.001) or left ventricular hypertrophy (HR 3.09, P=.047) were associated with an increased risk of ischemic stroke. CONCLUSIONS Proteinuria, a medical history of coronary artery disease or left ventricular hypertrophy, was associated with an increased risk of ischemic stroke in PA patients. Our results suggest that a public health initiative is necessary to enhance the follow-up of proteinuria and to manage subsequent stroke among patients with aldosteronism.
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Affiliation(s)
- Chih-Chin Kao
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Che-Hsiung Wu
- Division of Nephrology, Taipei Tzu Chi General Hospital, Taiwan
| | - Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Chen Chang
- Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsi-Hsien Chen
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Kwan-Dun Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Rossi GP, Cesari M, Letizia C, Seccia TM, Cicala MV, Zinnamosca L, Kuppusamy M, Mareso S, Sciomer S, Iacobone M, Mantero F, Pessina AC. KCNJ5 gene somatic mutations affect cardiac remodelling but do not preclude cure of high blood pressure and regression of left ventricular hypertrophy in primary aldosteronism. J Hypertens 2014; 32:1514-21; discussion 1522. [DOI: 10.1097/hjh.0000000000000186] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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229
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Combination of LC–MS/MS aldosterone and automated direct renin in screening for primary aldosteronism. Clin Chim Acta 2014; 433:209-15. [DOI: 10.1016/j.cca.2014.03.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 02/24/2014] [Accepted: 03/15/2014] [Indexed: 01/14/2023]
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230
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Aronova A, III TJF, Zarnegar R. Management of hypertension in primary aldosteronism. World J Cardiol 2014; 6:227-233. [PMID: 24944753 PMCID: PMC4062125 DOI: 10.4330/wjc.v6.i5.227] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 04/16/2014] [Indexed: 02/06/2023] Open
Abstract
Hypertension causes significant morbidity and mortality worldwide, owing to its deleterious effects on the cardiovascular and renal systems. Primary hyperaldosteronism (PA) is the most common cause of reversible hypertension, affecting 5%-18% of adults with hypertension. PA is estimated to result from bilateral adrenal hyperplasia in two-thirds of patients, and from unilateral aldosterone-secreting adenoma in approximately one-third. Suspected cases are initially screened by measurement of the plasma aldosterone-renin-ratio, and may be confirmed by additional noninvasive tests. Localization of aldostosterone hypersecretion is then determined by computed tomography imaging, and in selective cases with adrenal vein sampling. Solitary adenomas are managed by laparoscopic or robotic resection, while bilateral hyperplasia is treated with mineralocorticoid antagonists. Biochemical cure following adrenalectomy occurs in 99% of patients, and hemodynamic improvement is seen in over 90%, prompting a reduction in quantity of anti-hypertensive medications in most patients. End-organ damage secondary to hypertension and excess aldosterone is significantly improved by both surgical and medical treatment, as manifested by decreased left ventricular hypertrophy, arterial stiffness, and proteinuria, highlighting the importance of proper diagnosis and treatment of primary hyperaldosteronism. Although numerous independent predictors of resolution of hypertension after adrenalectomy for unilateral adenomas have been described, the Aldosteronoma Resolution Score is a validated multifactorial model convenient for use in daily clinical practice.
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231
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Turchi F, Ronconi V, di Tizio V, Ceccoli L, Boscaro M, Giacchetti G. Primary aldosteronism and essential hypertension: assessment of cardiovascular risk at diagnosis and after treatment. Nutr Metab Cardiovasc Dis 2014; 24:476-482. [PMID: 24630976 DOI: 10.1016/j.numecd.2013.09.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 08/26/2013] [Accepted: 09/23/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND AIMS Primary aldosteronism (PA), the most frequent form of secondary hypertension, is characterized by a higher rate of cardiovascular (CV) events than essential hypertension (EH). Aim of the study was to evaluate the cardiovascular risk according to the ESH/ESC 2007 guidelines, in patients with PA and with EH, at diagnosis and after treatment. METHODS AND RESULTS We prospectively studied 102 PA patients (40 with aldosterone producing adenoma-APA and 62 with idiopathic hyperaldosteronism-IHA) and 132 essential hypertensives at basal and after surgical or medical treatment (mean follow-up period 44 months for PA and 42 months for EH). At baseline evaluation the stratification of CV risk was significantly different: the predominant risk category was the high CV risk (50% in total PA, 53% in PA matched for blood pressure values and 55% in EH), but the very high risk category was twice in PA than in EH patients (36% in total PA and 33% in matched PA vs. 17% in EH, p < 0.05). The worse risk profile of PA was due to a higher prevalence of glycemic alterations, metabolic syndrome and left ventricular hypertrophy (LVH) (p < 0.05). After adequate treatment, the CV risk was significantly reduced becoming comparable in PA and in EH patient due to a reduction of hypertension grading, prevalence of metabolic syndrome, hypertension persistence and LVH (p < 0.05). CONCLUSION Patients with PA present a high CV risk, which is in part reversible after specific treatment, due both to the reduced blood pressure values and to the improvement of end-organ damage.
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Affiliation(s)
- F Turchi
- Division of Endocrinology, Università Politecnica delle Marche, Ospedali Riuniti "Umberto I-G.M. Lancisi-G.Salesi", Via Conca 71, Ancona 60126, Italy; Department of Diabetology and Endocrinology, Asur Marche Area Vasta 1, S. Maria della Misericordia Hospital, Urbino, Italy
| | - V Ronconi
- Division of Endocrinology, Università Politecnica delle Marche, Ospedali Riuniti "Umberto I-G.M. Lancisi-G.Salesi", Via Conca 71, Ancona 60126, Italy
| | - V di Tizio
- Division of Endocrinology, Università Politecnica delle Marche, Ospedali Riuniti "Umberto I-G.M. Lancisi-G.Salesi", Via Conca 71, Ancona 60126, Italy
| | - L Ceccoli
- Division of Endocrinology, Università Politecnica delle Marche, Ospedali Riuniti "Umberto I-G.M. Lancisi-G.Salesi", Via Conca 71, Ancona 60126, Italy
| | - M Boscaro
- Division of Endocrinology, Università Politecnica delle Marche, Ospedali Riuniti "Umberto I-G.M. Lancisi-G.Salesi", Via Conca 71, Ancona 60126, Italy
| | - G Giacchetti
- Division of Endocrinology, Università Politecnica delle Marche, Ospedali Riuniti "Umberto I-G.M. Lancisi-G.Salesi", Via Conca 71, Ancona 60126, Italy.
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232
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McManus F, Alvarez-Madrazo S, Connell JM. Progress in the identification of responsible genes and molecular mechanisms in primary aldosteronism. Expert Rev Endocrinol Metab 2014; 9:163-174. [PMID: 30743758 DOI: 10.1586/17446651.2014.883276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Aldosterone, the mineralocorticoid hormone, plays an important role in blood regulation. Autonomous secretion of aldosterone is known as primary aldosteronism (PA), the most common cause of secondary hypertension. PA comprises a group of heterogenous disorders which makes their classification and management challenging. With the advent of the genomic era several germline and somatic mutations have been identified that are involved in the pathogenesis of primary aldosteronism. This article will review our current knowledge of the genetic mechanisms of familial hyperaldosterism, somatic mutations in genes encoding electrolyte channels and other potential genetic mechanisms implicated in the dysregulation of aldosterone production from in vitro and animal models. There is potential for novel targeted therapies and diagnosis for subsets of patient. The challenges to achieve them are highlighted in this review.
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Affiliation(s)
- Frances McManus
- a Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | - Samantha Alvarez-Madrazo
- a Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | - John M Connell
- b Medical Research Institute, College of Medicine, Dentistry and Nursing, University of Dundee, Dundee DD1 9SY, UK
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233
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Rossi GP, Dalla Cà A. Clinical management of primary aldosteronism: 2013 Practical Recommendations of the Italian Society of Hypertension (SIIA). High Blood Press Cardiovasc Prev 2014; 21:71-5. [PMID: 24464387 DOI: 10.1007/s40292-014-0039-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 12/18/2013] [Indexed: 01/19/2023] Open
Abstract
Primary aldosteronism is the most common form of endocrine hypertension and is highly prevalent among patients with difficult to control high blood pressure. In the presence of a high sodium intake primary aldosteronism carries has detrimental effects on the cardiovascular system, which translate into an excess rate of cardiovascular events. Therefore, to prevent these ominous consequences primary aldosteronism should be detected as early as possible and should be accurately diagnosed. Institution of the most appropriate treatment can lead to long-term cure of hypertension and to regression of the cardiovascular changes with a great benefit for the patients. We herein summarize the current evidence-based practical recommendations that will help physicians to diagnose and treat primary aldosteronism properly.
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Affiliation(s)
- Gian Paolo Rossi
- Department of Medicine-DIMED, Internal Medicine 4, University Hospital, University of Padua, Via Giustiniani 2, 35126, Padua, Italy,
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234
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Catena C, Colussi G, Nait F, Martinis F, Pezzutto F, Sechi LA. Aldosterone and the heart: still an unresolved issue? Front Endocrinol (Lausanne) 2014; 5:168. [PMID: 25352832 PMCID: PMC4196571 DOI: 10.3389/fendo.2014.00168] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 09/26/2014] [Indexed: 11/21/2022] Open
Abstract
Receptors for mineralocorticoid hormones are expressed in myocardial cells and evidence obtained in animal studies suggests that activation of these receptors causes cardiac damage independent from blood pressure levels. In the last years, many of the issues related to the effects of aldosterone on the heart have received convincing answers and clinical investigation has focused on a variety of conditions including systolic and diastolic heart failure, arrhythmia, primary hypertension, and primary aldosteronism. Some issues, however, await clarification in order to obtain better understanding of what could be the role of aldosterone blockade in prevention and treatment of cardiovascular diseases. In this article, we overview the most recent findings of animal studies that have examined the contribution of aldosterone to cardiac function and clinical studies that have investigated the influence of aldosterone on left ventricular structure and function in the setting of primary hypertension and primary aldosteronism.
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Affiliation(s)
- Cristiana Catena
- Hypertension Unit, Department of Experimental and Clinical Medical Sciences, Clinica Medica, University Hospital, University of Udine, Udine, Italy
| | - GianLuca Colussi
- Hypertension Unit, Department of Experimental and Clinical Medical Sciences, Clinica Medica, University Hospital, University of Udine, Udine, Italy
| | - Francesca Nait
- Hypertension Unit, Department of Experimental and Clinical Medical Sciences, Clinica Medica, University Hospital, University of Udine, Udine, Italy
| | - Flavia Martinis
- Hypertension Unit, Department of Experimental and Clinical Medical Sciences, Clinica Medica, University Hospital, University of Udine, Udine, Italy
| | - Francesca Pezzutto
- Hypertension Unit, Department of Experimental and Clinical Medical Sciences, Clinica Medica, University Hospital, University of Udine, Udine, Italy
| | - Leonardo A. Sechi
- Hypertension Unit, Department of Experimental and Clinical Medical Sciences, Clinica Medica, University Hospital, University of Udine, Udine, Italy
- *Correspondence: Leonardo A. Sechi, Hypertension Unit, Department of Experimental and Clinical Medical Sciences, Clinica Medica, University Hospital, University of Udine, Building 8, Udine 33100, Italy e-mail:
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235
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Rossi GP, Auchus RJ, Brown M, Lenders JWM, Naruse M, Plouin PF, Satoh F, Young WF. An expert consensus statement on use of adrenal vein sampling for the subtyping of primary aldosteronism. Hypertension 2013; 63:151-60. [PMID: 24218436 DOI: 10.1161/hypertensionaha.113.02097] [Citation(s) in RCA: 390] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Adrenal venous sampling is recommended by current guidelines to identify surgically curable causes of hyperaldosteronism but remains markedly underused. Key factors contributing to the poor use of adrenal venous sampling include the prevailing perceptions that it is a technically challenging procedure, difficult to interpret, and can be complicated by adrenal vein rupture. In addition, the lack of uniformly accepted standards for the performance of adrenal venous sampling contributes to its limited use. Hence, an international panel of experts working at major referral centers was assembled to provide updated advice on how to perform and interpret adrenal venous sampling. To this end, they were asked to use the PICO (Patient or Problem, Intervention, Control or comparison, Outcome) strategy to gather relevant information from the literature and to rely on their own experience. The level of evidence/recommendation was provided according to American Heart Association gradings whenever possible. A consensus was reached on several key issues, including the selection and preparation of the patients for adrenal venous sampling, the procedure for its optimal performance, and the interpretation of its results for diagnostic purposes even in the most challenging cases.
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Affiliation(s)
- Gian Paolo Rossi
- Department of Medicine-DIMED-Internal Medicine 4, University Hospital, Via Giustiniani, 2, 35126 Padova, Italy.
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Rossi GP, Cesari M, Cuspidi C, Maiolino G, Cicala MV, Bisogni V, Mantero F, Pessina AC. Response to Effectiveness of Adrenalectomy and Aldosterone Antagonists for Long-Term Treatment of Primary Aldosteronism. Hypertension 2013; 62:e14. [DOI: 10.1161/hypertensionaha.113.01755] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gian Paolo Rossi
- Department of Medicine-DIMED, University of Padova, Padua, Italy
| | - Maurizio Cesari
- Department of Medicine-DIMED, University of Padova, Padua, Italy
| | - Cesare Cuspidi
- Department of Health Science, University of Milano-Bicocca, andIstituto Auxologico Italiano IRCCS Milan, Italy
| | | | | | - Valeria Bisogni
- Department of Medicine-DIMED, University of Padova, Padua, Italy
| | - Franco Mantero
- Department of Medicine-DIMED, University of Padova, Padua, Italy
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237
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Kaplan N. Effectiveness of adrenalectomy and aldosterone antagonists for long-term treatment of primary aldosteronism. Hypertension 2013; 62:e13. [PMID: 23918755 DOI: 10.1161/hypertensionaha.113.01754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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