Spironolactone-induced inhibition of aldosterone biosynthesis in primary aldosteronism: morphological and functional studies

Severe hyperkalemia following adrenalectomy for aldosteronoma: prediction, pathogenesis and approach to clinical management- a case series

BACKGROUND

As the field of Primary Aldosteronism (PA) becomes ever expanded, diagnosis of PA is increasingly diagnosed by endocrinologists. With increased PA screening, many of the cases are now found in patients with complex co-morbidities in addition to their hypertension. Post adrenalectomy renal impairment with hyperkalemia is now increasingly seen in these complex patients, as evidenced by the numerous reports on this issue that have appeared within the past 3 years. We present a small case series to illustrate the breadth of the problem, along with a discussion about how such CKD/hyperkalemic events may be predicted.

CASE PRESENTATION

We present three cases of primary aldosteronism with long standing hypertension (more than 10 years) hypokalemia (2.0-3.0 mmol/l). Serum aldosterone was high with low renin activity leading to high aldosterone to renin ratio (ARR). They underwent abdominal CT scan revealing adrenal mass and adrenal vein sample confirmed lateralization. None of the patients had evidence of renal disease before surgery (as evident by normal eGFR and serum creatinine). Post adrenalectomy they had reduction in the blood pressure and became eukalemic. Serum aldosterone and renin activity were low leading to a low ARR. Case 1 developed hyperkalemia and increased serum creatinine 6 weeks post operatively which resolved with initiation of fludrocortisone and every attempt to discontinue fludrocortisone resulted in hyperkalemia and rising creatinine. Her hyperkalemia is under control with oral sodium bicarbonate. Case 2 developed hyperkalemia and increasing creatinine 2 months post operatively transiently requiring fludrocortisone and later on managed with furosemide for hyperkalemia. Case 3 developed renal impairment and hyperkalemia 2 weeks post operatively requiring fludrocortisone.

CONCLUSION

Post APA resection severe hyperkalemia may be a common entity and screening should be actively considered in high risk patients. Older age, longer duration of hypertension, impaired pre-op and post-op GFR and higher levels of pre-op aldosterone and are all risk factors which predict the likelihood of developing post-operative hyperkalemia. Fludrocortisone, sodium bicarbonate, loop diuretics and potassium binders can be used for treatment. Treatment choice should be tailored to patient characteristics including fluid status, blood pressure and serum creatinine. Potassium binders should be avoided in patients with history of recent abdominal surgery, opioid use and constipation. Serum electrolytes and creatinine should be monitored every 1-2 weeks after starting treatment to ensure an adequate response. Prolonged management may be necessary in some cases and at-risk patients should be counselled as to the meaning and importance of post-operative changes in measured renal function and potassium.

Relevance of SGK1 in structural, functional and molecular alterations produced by aldosterone in heart

Aldosterone regulates sodium (Na+) and potassium (K+) transports in epithelial cells. Besides, aldosterone participates in cardiac alterations associated with hypertension, heart failure, diabetes, and other pathological alterations. One of the main cardiac alterations induced by aldosterone is cardiac hypertrophy in which different mechanisms are involved such as increased cardiomyocyte, calcium concentration, oxidative stress, and inflammatory and fibrotic mediators stimulation. Many epidemiological studies have demonstrated that left ventricular hypertrophy is associated with significantly increased risk of heart failure and malignant arrhythmias. SGK1 is a member of the serine/threonine kinase gene family that plays an important role in the absorption of Na+ and water through the Na+ channel in the apical membrane of tubular epithelial cells. SGK1 has been related to fibrotic mediator increase such as connective tissue growth factor (CTGF) and transforming growth factor-β (TGF-β) as well as inflammatory [tumor necrosis factor-α (TNF-α) and interleukin (IL)-1β] and oxidative (NADPH oxidase) species. It has been shown that aldosterone induces SGK1 gene expression not only in kidneys but also in the heart. Supporting the central role of SGK1 in cardiac alterations induced by aldosterone, treatment with the mineralocorticoid antagonist spironolactone is able to reduce the gene expression of SGK1 in aldosterone-treated rats. Taken together, data suggest the involvement of SGK1 in a complex intracellular signaling, involving fibrotic, inflammatory, and oxidative pathways, which lead to cardiac hypertrophy and fibrosis induced by aldosterone.

Adrenal gland inclusions in patients treated with aldosterone antagonists (Spironolactone/Eplerenone): incidence, morphology, and ultrastructural findings

Abstract

Background

Spironolactone is often used to treat hypertension caused by hyperaldosteronism, and as a result, can form concentrically laminated electron dense spironolactone body inclusions within the adrenal gland. Spironolactone bodies have not been investigated in a contemporary cohort or in patients treated with the more recently approved aldosterone antagonist, eplerenone.

Methods

Spironolactone bodies were retrospectively investigated in patients treated for hyperaldosteronism (n = 15) from 2012-2013 that underwent a subsequent adrenalectomy.

Results

Inclusions were identified in 33% of patients treated with aldosterone antagonists, far less than previously reported. Remarkably, 50% of patients treated with spironolactone had inclusions while no patients using eplerenone alone had inclusions. Two patients treated with spironolactone had bodies present longer than the duration described in prior studies. Inclusions unexpectedly persisted in 1 patient despite increased duration of discontinued pharmacological treatment. A spectrum of histologic and ultrastructural findings were encountered within an adrenal cortical adenoma from a patient treated with both spironolactone and eplerenone. Ultrastructural examination revealed laminated electron dense bodies with the appearance of classic spironolactone inclusions as well as electron dense bodies without laminations and laminated bodies without electron dense cores.

Conclusions

Our incidence rate of spironolactone bodies was much lower than previously reported, with no inclusions seen in patients treated solely with the newer aldosterone antagonist, eplerenone. Pathologists should be aware of these infrequently encountered inclusions, particularly as the clinical history of hyperaldosteronism and pharmacologic treatment may not be provided.

Virtual Slides

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Cirrhosis and its complications: Evidence based treatment

Cirrhosis results from progressive fibrosis and is the final outcome of all chronic liver disease. It is among the ten leading causes of death in United States. Cirrhosis can result in portal hypertension and/or hepatic dysfunction. Both of these either alone or in combination can lead to many complications, including ascites, varices, hepatic encephalopathy, hepatocellular carcinoma, hepatopulmonary syndrome, and coagulation disorders. Cirrhosis and its complications not only impair quality of life but also decrease survival. Managing patients with cirrhosis can be a challenge and requires an organized and systematic approach. Increasing physicians’ knowledge about prevention and treatment of these potential complications is important to improve patient outcomes. A literature search of the published data was performed to provide a comprehensive review regarding the management of cirrhosis and its complications.

Prolonged zona glomerulosa insufficiency causing hyperkalemia in primary aldosteronism after adrenalectomy

CONTEXT

Unilateral adrenalectomy is the therapy of choice in aldosterone-producing adenoma (APA). Zona glomerulosa (ZG) insufficiency causing hyperkalemia after adrenalectomy has been described in case reports.

OBJECTIVE

Our aim was to analyze the clinical relevance of ZG insufficiency causing hyperkalemia after adrenalectomy in a large series of patients with APA.

DESIGN

This was a retrospective chart review.

SETTING

The study was conducted at two tertiary university referral centers in Germany.

PATIENTS

Data from 110 patients with confirmed APA adrenalectomized at the centers in Munich and Berlin between 2004 and 2012 were analyzed.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of ZG insufficiency causing hyperkalemia after adrenalectomy; the secondary outcome was the identification of risk factors predisposing for hyperkalemia.

RESULTS

Eighteen of 110 patients (16%) developed postoperative hyperkalemia. The majority of these patients (n = 14) had undetectable plasma aldosterone levels after adrenalectomy; four had low aldosterone levels. In 12 of these patients, hyperkalemia was documented only once and resumed spontaneously. Prolonged hypoaldosteronism accompanied by hyperkalemia was observed in six patients (5% of total cohort). These patients needed continuous mineralocorticoid replacement therapy for 11-46 months. Mineralocorticoid antagonist treatment for 4 wk prior to surgery did not prevent hyperkalemia. In multivariate analysis, preoperatively decreased glomerular filtration rate and increased serum creatinine as well as increased postoperative creatinine and microalbuminuria remained significant predictors of hyperkalemia.

CONCLUSION

Persistent postoperative hypoaldosteronism with hyperkalemia occurs in 5% of adrenalectomized PA patients through prolonged ZG insufficiency, requiring long-term fludrocortisone treatment. Potassium levels after adrenalectomy must be monitored to avoid life-threatening hyperkalemia.

Spontaneous remission of idiopathic aldosteronism after long-term treatment with spironolactone: results from the German Conn's Registry

CONTEXT

Primary aldosteronism (PA) is mainly caused by aldosterone-producing adenoma and idiopathic bilateral adrenal hyperplasia (IHA). Recently, spontaneous resolution of IHA has been described.

OBJECTIVE

We aimed to determine the frequency of spontaneous remission of PA during long-term treatment with mineralocorticoid receptor (MR) antagonists.

DESIGN, SETTING AND PATIENTS

Thirty-seven patients of the Munich PA registry with IHA treated by MR antagonists were investigated. The patients were identified retrospectively by chart review and prospectively assessed by clinical and biochemical means.

MAIN OUTCOME MEASURES

Complete remission of IHA was defined as normal aldosterone to renin ratio (ARR), normal suppression test and normalization of hypokalaemia in the presence of normal blood pressure. Partial remission was defined as normalization of normal ARR, normal suppression test and normalization of hypokalaemia in the presence of persistent hypertension.

RESULTS

The mean period of MR antagonist treatment was 5·8 ± 0·7 years in the patients. We identified two of 37 (5·4%) patients with spontaneous remission: one with complete remission and one with partial remission.

CONCLUSION

Remission of IHA in PA may occur in some patients after long-term mineralocorticoid antagonist treatment.

Structural, functional, and molecular alterations produced by aldosterone plus salt in rat heart: association with enhanced serum and glucocorticoid-regulated kinase-1 expression

We aimed to evaluate the structural, functional, inflammatory, and oxidative alterations, as well as serum and glucocorticoid-regulated kinase-1 (SGK-1) expression, produced in rat heart by aldosterone + salt administration. Fibrosis mediators such as connective tissue growth factor, matrix metalloproteinase 2, and tissue inhibitor of metalloproteinases 2 were also evaluated. Treatment with spironolactone was evaluated to prove mineralocorticoid mediation. Male Wistar rats received aldosterone (1 mg[middle dot]kg-1[middle dot]d-1) + 1% NaCl for 3 weeks. Half of the animals were treated with spironolactone (200 mg[middle dot]kg-1[middle dot]d-1). Systolic and diastolic blood pressures, left ventricle (LV) systolic pressure, and LV end-diastolic pressure were elevated (P < 0.05) in aldosterone + salt-treated rats. In aldosterone + salt-treated rats, -dP/dt decreased (P < 0.05), but +dP/dt was similar in all groups. Spironolactone normalized (P < 0.05) systolic blood pressure, diastolic blood pressure, LV systolic pressure, LV end-diastolic pressure, and -dP/dt. Relative heart weight, collagen content, messenger RNA expression of transforming growth factor beta, connective tissue growth factor, matrix metalloproteinase 2, tissue inhibitor of metalloproteinases 2, tumor necrosis factor alpha, interleukin-1[beta], p22phox, endothelial nitric oxide synhtase, and SGK-1 were increased (P < 0.05) in aldosterone + salt-treated rats, being reduced by spironolactone (P < 0.05). SGK-1 might be a key mediator in the structural, functional, and molecular cardiac alterations induced by aldosterone + salt in rats. All the observed changes and mediators are related with the activation of mineralocorticoid receptors.

Alteration of subcapsular adrenocortical zonation in humans with aging: the progenitor zone predominates over the previously well-developed zona glomerulosa after 40 years of age

Few studies have examined functional adrenal zonation throughout human life. Adrenals from 61 surgical/autopsy patients from 1 day old to 92 years old who had no clinical endocrinological/mineralocorticoid abnormalities were assessed for immunohistochemically defined adrenal zonation. The zona glomerulosa (zG) was well developed in all 11 patients ranging in age from newborn to the 30s. After 40 years of age, however, the zG occupied less than one-quarter of the adrenal circumference, suggestive of zG involution. The other subcapsular areas were occupied by the progenitor zone (zP), which expressed neither cytochrome P450(aldo) nor P450(11β) but 3β-hydroxysteroid dehydrogenase and P450scc, although some autopsy cases had adrenals with zG zonation because of secondary aldosteronism, and others who had experienced severe stresses showed subcapsular zona fasciculata (zF). In conclusion, the adrenal cortex consists of homogeneous zG-topped columns from birth to adolescence. Subsequently, in the fifth decade of life, the cortex is reconstituted by integration of three types of cortical columns: scattered zG-topped columns and zonal zP-topped columns, the latter having the ability for bidirectional differentiation into either zG-topped columns or zF-topped columns, according to secondary aldosteronism or the presence of severe stresses. Such adrenocortical remodeling is ascribed to high-sodium/low-potassium diets.

Effects of adrenal steroids on Na transport in the lower intestine (coprodeum) of the hen

The influence of adrenal steroids on sodium transport in hen coprodeum was investigated by electrophysiological methods. Laying hens were maintained on low-NaCl diet (LS), or on high-NaCl diet (HS). HS hens were pretreated with aldosterone (128 micrograms/kg) or dexamethasone (1 mg/kg) before experiment. A group of LS hens received spironolactone (70 or 160 mg/kg, for three days). The effects of these dietary and hormonal manipulations on the amiloride-sensitive part of the short-circuit current were examined. This part is in excellent agreement with the net Na flux, and therefore a direct electrical measurement for Na transport. After depolarizing the basolateral membrane potential with a high K concentration, the apical Na permeability and the intracellular Na activity were investigated by current-voltage relations for the different experimental conditions. Plasma aldosterone concentrations (PA) were low in HS hens, dexamethasone-treated HS hens and spironolactone-treated LS hens (less than 70 pM). In contrast LS hens and aldosterone-treated HS hens had a PA concentration of 596 +/- 70 and 583 +/- 172 pM, respectively. LS diet (chronic stimulation) had the largest stimulatory effect on Na transport and apical Na permeability. Hormone-treated animals had three- to fourfold lower values. Spironolactone supply in LS hens decreased Na transport and apical Na permeability about 50%. The results provide evidence that both mineralo- and gluco-corticoids stimulate Na transport in this tissue by increasing the apical Na permeability. Quantitative differences between acute and chronic stimulation reveal a secondary slower adaptation in apical membrane properties.

Histopathology of the human adrenal cortex

The morphological features of the adult human adrenal cortex are described with particular respect to changes induced by alterations in function of the hypothalamo-pituitary axis. The occurrence of nodules in the normal and hyperplastic cortex (Cushing's and Conn's syndromes) is discussed in relation to the diagnostic problems that they still pose. Explanations based on the normal mechanisms of functional zonation in the cortex are provided for the different cell types which comprise cortical neoplasms associated with various syndromes of hypercorticalism (Cushing's, adrenogenital and Conn's syndromes), together with morphological and functional criteria to distinguish adenomas from carcinomas.

The effects of spironolactone on adrenal steroidogenesis in hirsute women

The effect of spironolactone on adrenal androgen and cortisol production was studied in six hirsute women. Hirsute women were evaluated before and 1 month after receiving 200 mg of spironolactone daily. Basal levels of serum androgens, 17-hydroxyprogesterone (17-OHP), cortisol (F), corticosteroid-binding globulin, and plasma adrenocorticotropic hormone (ACTH) were normal and did not change with therapy. The delta maximum (delta max) responses after dexamethasone suppression and ACTH administration of dehydroepiandrosterone (DHEA), androstenedione (delta 4A), 17-hydroxypregnenolone, and 17-OHP were similar in hirsute women and ovulatory control subjects. After spironolactone administration, the delta max DHEA response was unchanged, whereas the delta max delta 4A response was decreased (P less than 0.05). The delta max ratios of DHEA/delta 4A and 17-OHP/delta 4A were significantly increased after spironolactone in hirsute women, which suggested inhibitions of 3 beta-ol-dehydrogenase-isomerase and delta 4 17,20 desmolase activities. A significant reduction in delta max F occurred after spironolactone administration (P less than 0.05). Although baseline 11-desoxycortisol (S) and the plasma S/ACTH ratio were unaltered, the delta max S/F ratio increased after treatment (P less than 0.01), suggesting an inhibition of 11 beta-hydroxylase activity. Inhibition of adrenal androgen production occurs with spironolactone, but only serum levels of delta 4A are decreased, whereas DHEA and its sulfate (DHEA-S) levels remain unchanged.

Relative inhibitory potency of five mineralocorticoid antagonists on aldosterone biosynthesis in vitro

Spirolactones are mineralocorticoid antagonists which bind to aldosterone receptors in the distal nephron. During the last decade, several antimineralocorticoids, which are more potent than spironolactone in competing for mineralocorticoid receptors have been developed. In the present study, we have compared the direct activity of spironolactone and four related compounds: prorénone (SC 23133), SC 19886, SC 26304 and its carboxylic analog SC 27169, on aldosterone biosynthesis. Two of them (SC 26304 and its carboxylic analog SC 27169) had no effect on adrenal steroidogenesis, even at concentrations up to 10(-3)M. Spironolactone and prorenone (SC 23133) induced a marked but reversible inhibition of aldosterone biosynthesis. SC 19886 totally inhibited aldosterone production and the activity of this compound lasted for more than 7 hours. In addition, SC 19886 and prorenone (SC 23133) totally suppressed ACTH and angiotensin II-induced stimulation of aldosterone biosynthesis whereas SC 27169 was unable to block adrenal response to these corticotropic hormones. Our results suggest that compounds such as prorenone (SC 23133), SC 19886 and spironolactone, which are potent inhibitors of aldosterone biosynthesis could be more active in the treatment of primary aldosteronism than those antimineralocorticoids which are devoid of action on aldosterone biosynthesis.

Ultrastructural studies of adrenal adenoma causing primary aldosteronism

Adrenal adenoma tissue was obtained from 7 patients with the diagnosis of primary aldosteronism and was studied electron microscopically. Spironolactone was administered in 6 of these patients, but not in the remaining patient. Most of the mitochondria of the tumour cells possessed tubular cristae, giving an appearance similar to the mitochondria in the cells of the zona glomerulosa. Spironolactone bodies were seen in the tumour cells of 6 patients who were given spironolactone preoperatively, but were not observed in these cells in the patient not given spironolactone. The literature on the developmental mechanism of this spironolactone body was reviewed.

Metabolic effects of high dose amiloride and spironolactone: a comparative study in normal subjects

Amiloride (75 mg daily) and spironolactone (300 mg daily) were given to five normal subjects for 7 days in order to compare metabolic effects at maximal doses. Blood pressure, body weight, Na+ and K+ balance, and plasma concentrations of Na+, K+, active and total renin, angiotensin II, aldosterone, 11-deoxycorticosterone (DOC), 18-hydroxydeoxycorticosterone (18-OH DOC), corticosterone (B), 18-hydroxycorticosterone (18-OH B) and cortisol were measured before and on each day of treatment. Natriuresis and K+ retention were significantly greater with amiloride. Plasma K+ increased from 4.1 +/- 0.2 to 4.9 +/- 0.2 mmol/l (mean +/- s.d.) on amiloride and from 4.0 +/- 0.2 to 4.4 +/- 0.2 mmol/l with spironolactone. Stimulation of renin, angiotensin II, aldosterone and 18-OH B occurred with both drugs but was greater with amiloride in each case. A transient decrease in systolic and diastolic blood pressure was observed after 2 days of spironolactone treatment but not with amiloride. The slope of the regression of aldosterone on angiotensin II during spironolactone treatment was less than that with amiloride, consistent with partial blockade of aldosterone synthesis by spironolactone. These data suggest that the maximum metabolic effects of amiloride exceed those of spironolactone.

ACTH sensitivity of isolated human pathological adrenocortical cells: variability of responses in aldosterone, corticosterone, deoxycorticosterone and cortisol production

In vitro aldosterone, deoxycorticosterone, corticosterone and cortisol production of human adrenocortical cells derived from adenomas (Conn's syndrome, Cushing's syndrome), from hyperplastic adrenals (Cushing's syndrome) and from adrenals surrounding aldosteronoma are described. Cells from adenomas causing either Cushing's syndrome or Conn's syndrome harboured the highest basal and ACTH-stimulated corticosteroid production. Adrenocortical cells derived from micronodular hyperplasia causing Cushing's syndrome and cells from cortisol producing adenoma displayed predominantly cortisol and corticosterone secretion both under basal conditions and following stimulation with ACTH. Aldosteronoma cells showed highly variable aldosterone, deoxycorticosterone, corticosterone and cortisol response to ACTH. However, in aldosteronoma cell suspensions, the basal and ACTH-stimulated ratios of aldosterone to cortisol were increased when compared to ratios of steroids produced by cells from other adrenal tissues. Chronic treatment with spironolactone of patients with Conn's syndrome before surgery was associated with a decreased ratio of aldosterone to corticosterone, revealing that 18-hydroxylase in aldosteronoma cells may be inhibited during long-term therapy. Non-tumorous cells isolated from adrenals surrounding aldosteronoma displayed less aldosterone prior to and after stimulation with ACTH than aldosteronoma cells.

The effects of canrenoate K on corticosteroid biosynthesis in nephrectomized dogs

There is evidence from in vitro experiments that spironolactone not only antagonises the peripheral effects of aldosterone but also inhibits the production of corticosteroids by the adrenals. However relevant data from clinical studies are contradictory probably because spironolactone action on the kidneys also activates other mechanisms, such as renin secretion and potassium retention, which are potent stimulants of the adrenal cortex and thus tend to compensate for the inhibition. To determine the inhibitory effect of spironolactone on the adrenals in isolation, three groups of nephrectomized dogs were studied. Steroidogenesis was stimulated either by angiotensin II, potassium, or ACTH infusion. Potassium canrenoate was administered i.v. bolus at the beginning of the experiment. All the groups showed a similar marked decrease in plasma renin activity (PRA). Plasma aldosterone and cortisol were stimulated by the appropriate stimulus but their increase was blunted after the canrenoate K administration. The altered response between the subgroups was statistically significant (P less than 0.05). Plasma progesterone increased after the administration of canrenoate K. The response difference between the respective subgroups was again statistically significant (P less than 0.05). Canrenoate K was rapidly eliminated from the systemic circulation. These data indicate that canrenoate K causes a partial inhibition of aldosterone and cortisol stimulated secretion but augments the plasma levels of the precursor progesterone, as would be expected following inhibition of specific steps of corticosteroid biosynthesis.

The effect of the antimineralocorticoid RU 28318 on aldosterone biosynthesis in vitro

The effect of RU 28318, a specific and highly potent aldosterone antagonist on mineralocorticoid biosynthesis has been studied using a new in vitro model which combined three original features: (1) a very specific radioimmunoassay for aldosterone (2) a simplified perifusion system and (3) frog interrenal tissue which spontaneously produces high amounts of aldosterone. A dose-related inhibition of aldosterone production was observed for doses ranging from 10(-5) to 10(-3) M of RU 28318. The intermediate dose of 10(-4) M caused 71% inhibition of aldosterone production. Long term infusion of RU 28318 for 8 h led to a significant, stable and reversible inhibition of aldosterone production. In addition, we provide evidence that RU 28318 is capable of blocking the stimulation of aldosterone secretion induced by synthetic ACTH or by angiotensin II analogue. The present results demonstrate that RU 28318 is responsible for a significant and reversible inhibition of spontaneous, ACTH-induced and angiotensin II-induced aldosterone biosynthesis in vitro.

Primary tumorous aldosteronism due to a black adrenal adenoma: a light and electron microscopic study

A case of primary tumorous aldosteronism due to a black adrenal adenoma in a 37-year-old man is reported. Light microscopy showed the tumour to consist predominantly of compact cells containing intracytoplasmic lipofuscin, accompanied by zona fasciculata and intermediate type cells. Electron microscopy identified compact and interface (inner zona fasciculata) type cells, and also demonstrated spironolactone bodies in a compact cell. The morphological appearance of the tumour and adjacent adrenal gland, combined with the clinical and biochemical findings, supports both its secretory function and its classification as a rare variant of the more common non-pigmented aldosteronoma.

Studies of impaired aldosterone response to spironolactone-induced renin and potassium elevations in adenomatous but not hyperplastic primary aldosteronism

Spironolactone (SPL) corrects hypertension, hypokalemia, and hyporeninemia in patients with primary hyperaldosteronism (PHA) by blocking mineralocorticoid (MCH) receptors. We evaluated the effect of continuous SPL treatment (100 to 300 mg/day for 7 days to 9 years) on plasma renin (PRC), potassium, aldosterone (PA), 18-hydroxycorticosterone (18-OHB), deoxycorticosterone (DOC), and corticosterone (B) concentrations and 24-hour urinary excretion of aldosterone (UA) in 24 patients with PHA (15 with an aldosterone-producing adenoma [APA] and nine with idiopathic PHA [IHA]). Despite the normalization of PRC and K in both APA and IHA patients by SPL, UA and PA failed to increase in APA (55.8 +/- 8.8 to 51.4 +/- 7.3 micrograms/24 hr and 54.0 +/- 9.4 to 44.6 +/- 6.2 ng/dl, respectively) in contrast to rises in IHA patients (22.3 +/- 2.5 to 69.3 +/- 10.3 micrograms/24 hr and 16.0 +/- 1.0 to 49.9 +/- 9.9 ng/dl). Similar corrections with amiloride (20-40 mg/day for 2 months) in one patient with APA produced a three- to fourfold increase in UA and PA. In addition, while on SPL the characteristic fall or no change in PA and 18-OHB during upright posture persisted in all APA patients despite further increases in PRC (4.48 +/- 1.15 to 7.86 +/- 1.89) and K (4.0 +/- 0.1 to 4.3 +/- 0.1). The patterns of the aldosterone precursors, DOC, B, and 18-OHB, and their ratios to acute stimulation with cosyntropin were not altered by SPL. Thus, SPL treatment causes a sustained impairment of the aldosterone secretory response to normalized PRC and K, but not to ACTH stimulation, only in patients with APA.

Factors affecting the frequency of occurrence of spironolactone bodies in aldosteronomas and non-tumorous cortex

Histological sections taken from aldosterone-producing-adenomas and from non-tumorous adrenal cortex of 18 patients treated for primary aldosteronism by unilateral adrenalectomy were examined for spironolactone inclusion bodies. Typical inclusions were found in 10 of the 13 patients who received spironolactone up to within 24 h of surgery. They were present in the tumours of 7 patients, and their frequency correlated positively with the percentage of glomerulosa type cells in the tumours. In tumours containing 50% or more glomerulosa-type cells, their frequency correlated negatively with duration of treatment. They were present in the non-tumorous cortex of 4 of these 7 patients, and in the cortex of 3 others whose tumours did not contain them. In the cortex, they were found only in glomerulosa cells, and their presence appeared unrelated to dosage or duration of treatment. No spironolactone inclusion bodies were seen in either the tumour of the non-tumorous cortex of 3 patients who had discontinued spironolactone 19 to 97 d before surgery, or of 2 patients who had never received spironolactone.

Long term spironolactone and the adrenal cortex in essential hypertension

In view of recent evidence that spironolactone may inhibit synthesis of corticosteroids by a direct effect on the adrenal cortex, adrenocortical function was studied in eight patients with essential hypertension who had been treated with spironolactone from 3 months to 14 years. Their 24 h renal excretion of adrenocorticoid metabolites and the responses of cortisol, aldosterone and 18-hydroxy-11 -deoxycorticosterone (18-OH-DOC) to an incremental infusion of tetracosactrin (1-24 ACTH) were compared with those in eight patients with recently diagnosed essential hypertension who had received no spironolactone. The spironolactone-treated group had a significantly higher excretion of aldosterone, whilst the excretion of other adrenocorticoid metabolites did not differ. The same group also required less tetracosactrin to stimulate a detectable rise of plasma cortisol and 18-OH-DOC, they had greater plasma 18-OH-DOC responses at all infusion rates and, at the lowest infusion rates, had greater aldosterone responses. These results indicate that long-term spironolactone therapy does not inhibit adrenocortical function and may have some stimulatory effects.

Primary aldosteronism with bilateral adrenal adenomas

An unusual case of primary aldosteronism with bilateral single adenomas is reported. The two tumors were revealed by computerized axial tomography and subsequently confirmed by surgical exploration. Spironolactone therapy prior to the operation induced the formation of spironolactone bodies in only one of the two adenomas. As it has been postulated that these cytoplasmic inclusions may reflect the activity of the adenomatous cells, the presence of the bodies in a single adenoma would indicate a unilateral source of the hyperaldosteronism. Thus, the existence of spironolactone bodies could corroborate the data of functional localizing tests more closely than the morphological findings of computerized tomography.

Mineralocorticoid replacement in Addison's disease

Eight patients with treated Addison's disease were studied whilst receiving different doses of fludrocortisone together with a constant intake of glucocorticoid. Plasma renin activity (PRA), blood pressure, pulse rate and plasma potassium and urea concentrations were measured after 2-week periods on each dose. In two patients, PRA measurements indicated that mineralocorticoid replacement therapy had been inadequate. In four others, PRA remained normal throughout the study, even after fludrocortisone had been discontinued, suggesting that the drug was unnecessary for the maintenance of normal sodium balance in these patients. Asymptomatic fludrocortisone overdosage was indicated by a low plasma potassium concentration, but not by PRA measurements which failed in this study to distinguish between adequate and excessive mineralocorticoid replacement.

Adrenal adenomata causing primary aldosteronism. An ultrastructural study of twenty five cases

Adenomata taken from 25 patients with primary aldosteronism were observed by electron microscopy. The cells in the adenoma had a well developed agranular endoplasmic reticulum but granular endoplasmic reticulum was not prominent. Most of the mitochondria resembled those in the cells of the zona glomerulosa, suggesting that the adenomata which caused primary aldosteronism are derived from this zone. Spironolactone bodies were found in the cells of the adenoma from a patient who received spironolactone. Their appearance was identical to that described in previous reports.