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Charoensri S, Auchus RJ. Therapeutic management of congenital forms of endocrine hypertension. Eur J Endocrinol 2023; 189:R11-R22. [PMID: 37847213 DOI: 10.1093/ejendo/lvad140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/15/2023] [Accepted: 09/19/2023] [Indexed: 10/18/2023]
Abstract
Congenital forms of endocrine hypertension are rare and potentially life-threatening disorders, primarily caused by genetic defects affecting adrenal steroid synthesis and activation pathways. These conditions exhibit diverse clinical manifestations, which can be distinguished by their unique molecular mechanisms and steroid profiles. Timely diagnosis and customized management approach are crucial to mitigate unfavorable outcomes associated with uncontrolled hypertension and other related conditions. Treatment options for these disorders depend on the distinct underlying pathophysiology, which involves specific pharmacological therapies or surgical adrenalectomy in some instances. This review article summarizes the current state of knowledge on the therapeutic management of congenital forms of endocrine hypertension, focusing on familial hyperaldosteronism (FH), congenital adrenal hyperplasia, apparent mineralocorticoid excess, and Liddle syndrome. We provide an overview of the genetic and molecular pathogenesis underlying each disorder, describe the clinical features, and discuss the various therapeutic approaches available and their risk of adverse effects, aiming to improve outcomes in patients with these rare and complex conditions.
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Affiliation(s)
- Suranut Charoensri
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, United States
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, United States
- Department of Pharmacology, University of Michigan, Ann Arbor, MI 48109, United States
- Endocrinology & Metabolism Section, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI 48104, United States
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Bates MF, Sorensen MJ. Genetic Testing for Adrenal Tumors-What the Contemporary Surgeon Should Know. Surg Oncol Clin N Am 2023; 32:303-313. [PMID: 36925187 DOI: 10.1016/j.soc.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Surgical diseases of the adrenal gland include pheochromocytoma/paraganglioma, primary hyperaldosteronism, Cushing syndrome, and adrenocortical carcinoma. These conditions may be associated with familial syndromes, and genetic testing is available and recommended in most. For adrenal surgeons to be familiar with these syndromes and know when to consider referral for genetic counseling and genetic testing is important. Identification of patients with familial syndromes allows for the detection and screening of associated syndromic neoplasms, guides surgical planning and operative approach, influences recurrence and malignancy risk assessment, aids in the development of a postoperative surveillance plan, and determines the need for screening family members.
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Affiliation(s)
- Maria F Bates
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA; Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA; Section of General Surgery, Division of Endocrine Surgery, One Medical Center Drive, Lebanon, NH 03756, USA. https://twitter.com/mfbates13
| | - Meredith J Sorensen
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA; Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA; Section of General Surgery, Division of Endocrine Surgery, One Medical Center Drive, Lebanon, NH 03756, USA.
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Abstract
PURPOSE OF REVIEW Renin-independent aldosterone production from one or both affected adrenal(s), a condition known as primary aldosteronism (PA), is a common cause of secondary hypertension. In this review, we aimed to summarize recent findings regarding pathophysiology of bilateral forms of PA, including sporadic bilateral hyperaldosteronism (BHA) and rare familial hyperaldosteronism. RECENT FINDINGS The presence of subcapsular aldosterone synthase (CYP11B2)-expressing aldosterone-producing micronodules, also called aldosterone-producing cell clusters, appears to be a common histologic feature of adrenals with sporadic BHA. Aldosterone-producing micronodules frequently harbor aldosterone-driver somatic mutations. Other potential factors leading to sporadic BHA include rare disease-predisposing germline variants, circulating angiotensin II type 1 receptor autoantibodies, and paracrine activation of aldosterone production by adrenal mast cells. The application of whole exome sequencing has also identified new genes that cause inherited familial forms of PA. SUMMARY Research over the past 10 years has significantly improved our understanding of the molecular pathogenesis of bilateral PA. Based on the improved understanding of BHA, future studies should have the ability to develop more personalized treatment options and advanced diagnostic tools for patients with PA.
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Affiliation(s)
- Kazutaka Nanba
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, USA
| | - William E. Rainey
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, USA
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA
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Progress on Genetic Basis of Primary Aldosteronism. Biomedicines 2021; 9:biomedicines9111708. [PMID: 34829937 PMCID: PMC8615950 DOI: 10.3390/biomedicines9111708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 11/23/2022] Open
Abstract
Primary aldosteronism (PA) is a heterogeneous group of disorders caused by the autonomous overproduction of aldosterone with simultaneous suppression of plasma renin activity (PRA). It is considered to be the most common endocrine cause of secondary arterial hypertension (HT) and is associated with a high rate of cardiovascular complications. PA is most often caused by a bilateral adrenal hyperplasia (BAH) or aldosterone-producing adenoma (APA); rarer causes of PA include genetic disorders of steroidogenesis (familial hyperaldosteronism (FA) type I, II, III and IV), aldosterone-producing adrenocortical carcinoma, and ectopic aldosterone-producing tumors. Over the last few years, significant progress has been made towards understanding the genetic basis of PA, classifying it as a channelopathy. Recently, a growing body of clinical evidence suggests that mutations in ion channels appear to be the major cause of aldosterone-producing adenomas, and several mutations within the ion channel encoding genes have been identified. Somatic mutations in four genes (KCNJ5, ATP1A1, ATP2B3 and CACNA1D) have been identified in nearly 60% of the sporadic APAs, while germline mutations in KCNJ5 and CACNA1H have been reported in different subtypes of familial hyperaldosteronism. These new insights into the molecular mechanisms underlying PA may be associated with potential implications for diagnosis and therapy.
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Tevosian SG, Fox SC, Ghayee HK. Molecular Mechanisms of Primary Aldosteronism. Endocrinol Metab (Seoul) 2019; 34:355-366. [PMID: 31884735 PMCID: PMC6935778 DOI: 10.3803/enm.2019.34.4.355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 12/02/2019] [Accepted: 12/09/2019] [Indexed: 01/11/2023] Open
Abstract
Primary aldosteronism (PA) results from excess production of mineralocorticoid hormone aldosterone by the adrenal cortex. It is normally caused either by unilateral aldosterone-producing adenoma (APA) or by bilateral aldosterone excess as a result of bilateral adrenal hyperplasia. PA is the most common cause of secondary hypertension and associated morbidity and mortality. While most cases of PA are sporadic, an important insight into this debilitating disease has been derived through investigating the familial forms of the disease that affect only a minor fraction of PA patients. The advent of gene expression profiling has shed light on the genes and intracellular signaling pathways that may play a role in the pathogenesis of these tumors. The genetic basis for several forms of familial PA has been uncovered in recent years although the list is likely to expand. Recently, the work from several laboratories provided evidence for the involvement of mammalian target of rapamycin pathway and inflammatory cytokines in APAs; however, their mechanism of action in tumor development and pathophysiology remains to be understood.
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Affiliation(s)
- Sergei G Tevosian
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL, USA
| | - Shawna C Fox
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Hans K Ghayee
- Division of Endocrinology, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA.
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Abstract
OBJECTIVES The aim of this study was to present up to date information concerning the diagnosis and treatment of primary aldosteronism (PA). PA is the most common cause of endocrine hypertension. It has been reported up to 24% of selective referred hypertensive patients. METHODS We did a search in Pub-Med and Google Scholar using the terms: PA, hyperaldosteronism, idiopathic adrenal hyperplasia, diagnosis of PA, mineralocorticoid receptor antagonists, adrenalectomy, and surgery. We also did cross-referencing search with the above terms. We had divided our study into five sections: Introduction, Diagnosis, Genetics, Treatment, and Conclusions. We present our results in a question and answer fashion in order to make reading more interesting. RESULTS PA should be searched in all high-risk populations. The gold standard for diagnosis PA is the plasma aldosterone/plasma renin ratio (ARR). If this test is positive, then we proceed with one of the four confirmatory tests. If positive, then we proceed with a localizing technique like adrenal vein sampling (AVS) and CT scan. If the lesion is unilateral, after proper preoperative preparation, we proceed, in adrenalectomy. If the lesion is bilateral or the patient refuses or is not fit for surgery, we treat them with mineralocorticoid receptor antagonists, usually spironolactone. CONCLUSIONS Primary aldosteronism is the most common and a treatable case of secondary hypertension. Only patients with unilateral adrenal diseases are eligible for surgery, while patients with bilateral and non-surgically correctable PA are usually treated by mineralocorticoid receptor antagonist (MRA). Thus, the distinction between unilateral and bilateral aldosterone hypersecretion is crucial.
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Pathogenesis of Familial Hyperaldosteronism Type II: New Concepts Involving Anion Channels. Curr Hypertens Rep 2019; 21:31. [PMID: 30949771 DOI: 10.1007/s11906-019-0934-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW The application of advanced genetic techniques has recently begun to unravel the genetic basis for familial primary aldosteronism type 2 (FH-II). RECENT FINDINGS Whole-exome sequencing in a large family with FH-II revealed a shared rare damaging heterozygous variant in CLCN2 (chr.3: g.184075850C>T, p.Arg172Gln) in three severely affected members. The gene encodes a chloride channel, ClC-2. A cohort of 80 unrelated individuals diagnosed with early-onset primary aldosteronism was also examined for CLCN2 mutations finding three further occurrences of p.Arg172Gln mutations and four single cases of other potentially damaging heterozygous mutations for an overall prevalence of 9.9%. A concurrent report also found a different CLCN2 mutation (p.Gly24Asp) in a single severely affected patient from a cohort of 12 with early-onset PA for a prevalence of 8.3%. Cases of primary aldosteronism associated with CLCN2 mutations appear to be bilateral and respond well to medical treatment. In the adrenal, ClC-2 has been demonstrated to localize predominantly to the zona glomerulosa (ZG), and functional analysis suggests that mutations in ClC-2 predispose ZG cells to depolarization, thus leading to calcium influx via activation of voltage-gated calcium channels and increased aldosterone production. Germline CLCN2 mutations appear to account for a substantial proportion of early-onset primary aldosteronism cases, and genetic testing for mutations in this gene should be considered in appropriate cases.
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Diagnosis of primary aldosteronism in the hypertension specialist centers in Italy: a national survey. J Hum Hypertens 2018; 32:745-751. [DOI: 10.1038/s41371-018-0094-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 07/04/2018] [Accepted: 07/10/2018] [Indexed: 12/13/2022]
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Aristizabal Prada ET, Castellano I, Sušnik E, Yang Y, Meyer LS, Tetti M, Beuschlein F, Reincke M, Williams TA. Comparative Genomics and Transcriptome Profiling in Primary Aldosteronism. Int J Mol Sci 2018; 19:ijms19041124. [PMID: 29642543 PMCID: PMC5979346 DOI: 10.3390/ijms19041124] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 04/04/2018] [Accepted: 04/06/2018] [Indexed: 12/19/2022] Open
Abstract
Primary aldosteronism is the most common form of endocrine hypertension with a prevalence of 6% in the general population with hypertension. The genetic basis of the four familial forms of primary aldosteronism (familial hyperaldosteronism FH types I–IV) and the majority of sporadic unilateral aldosterone-producing adenomas has now been resolved. Familial forms of hyperaldosteronism are, however, rare. The sporadic forms of the disease prevail and these are usually caused by either a unilateral aldosterone-producing adenoma or bilateral adrenal hyperplasia. Aldosterone-producing adenomas frequently carry a causative somatic mutation in either of a number of genes with the KCNJ5 gene, encoding an inwardly rectifying potassium channel, a recurrent target harboring mutations at a prevalence of more than 40% worldwide. Other than genetic variations, gene expression profiling of aldosterone-producing adenomas has shed light on the genes and intracellular signalling pathways that may play a role in the pathogenesis and pathophysiology of these tumors.
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Affiliation(s)
- Elke Tatjana Aristizabal Prada
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany.
| | - Isabella Castellano
- Division of Pathology, Department of Medical Sciences, University of Torino, 10124 Torino, Italy.
| | - Eva Sušnik
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany.
| | - Yuhong Yang
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany.
| | - Lucie S Meyer
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany.
| | - Martina Tetti
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, 10126 Torino, Italy.
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany.
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, CH-8091 Zurich, Switzerland.
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany.
| | - Tracy A Williams
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, 80336 Munich, Germany.
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, 10126 Torino, Italy.
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Regulation of aldosterone production by ion channels: From basal secretion to primary aldosteronism. Biochim Biophys Acta Mol Basis Dis 2018; 1864:871-881. [DOI: 10.1016/j.bbadis.2017.12.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 12/05/2017] [Accepted: 12/23/2017] [Indexed: 01/07/2023]
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Prada ETA, Burrello J, Reincke M, Williams TA. Old and New Concepts in the Molecular Pathogenesis of Primary Aldosteronism. Hypertension 2017; 70:875-881. [PMID: 28974569 DOI: 10.1161/hypertensionaha.117.10111] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Elke Tatjana Aristizabal Prada
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Germany (E.T.A.P., M.R., T.A.W.); and Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Italy (J.B., T.A.W.)
| | - Jacopo Burrello
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Germany (E.T.A.P., M.R., T.A.W.); and Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Italy (J.B., T.A.W.)
| | - Martin Reincke
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Germany (E.T.A.P., M.R., T.A.W.); and Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Italy (J.B., T.A.W.)
| | - Tracy Ann Williams
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Germany (E.T.A.P., M.R., T.A.W.); and Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Italy (J.B., T.A.W.).
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12
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Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140:peds.2017-1904. [PMID: 28827377 DOI: 10.1542/peds.2017-1904] [Citation(s) in RCA: 1912] [Impact Index Per Article: 273.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.
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Affiliation(s)
- Joseph T Flynn
- Dr. Robert O. Hickman Endowed Chair in Pediatric Nephrology, Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - David C Kaelber
- Departments of Pediatrics, Internal Medicine, Population and Quantitative Health Sciences, Center for Clinical Informatics Research and Education, Case Western Reserve University and MetroHealth System, Cleveland, Ohio
| | - Carissa M Baker-Smith
- Division of Pediatric Cardiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Douglas Blowey
- Children's Mercy Hospital, University of Missouri-Kansas City and Children's Mercy Integrated Care Solutions, Kansas City, Missouri
| | - Aaron E Carroll
- Department of Pediatrics, School of Medicine, Indiana University, Bloomington, Indiana
| | - Stephen R Daniels
- Department of Pediatrics, School of Medicine, University of Colorado-Denver and Pediatrician in Chief, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah D de Ferranti
- Director, Preventive Cardiology Clinic, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Bonita Falkner
- Departments of Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan K Flinn
- Consultant, American Academy of Pediatrics, Washington, District of Columbia
| | - Samuel S Gidding
- Cardiology Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Celeste Goodwin
- National Pediatric Blood Pressure Awareness Foundation, Prairieville, Louisiana
| | - Michael G Leu
- Departments of Pediatrics and Biomedical Informatics and Medical Education, University of Washington, University of Washington Medicine and Information Technology Services, and Seattle Children's Hospital, Seattle, Washington
| | - Makia E Powers
- Department of Pediatrics, School of Medicine, Morehouse College, Atlanta, Georgia
| | - Corinna Rea
- Associate Director, General Academic Pediatric Fellowship, Staff Physician, Boston's Children's Hospital Primary Care at Longwood, Instructor, Harvard Medical School, Boston, Massachusetts
| | - Joshua Samuels
- Departments of Pediatrics and Internal Medicine, McGovern Medical School, University of Texas, Houston, Texas
| | - Madeline Simasek
- Pediatric Education, University of Pittsburgh Medical Center Shadyside Family Medicine Residency, Clinical Associate Professor of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vidhu V Thaker
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York; and
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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Wu VC, Hu YH, Er LK, Yen RF, Chang CH, Chang YL, Lu CC, Chang CC, Lin JH, Lin YH, Wang TD, Wang CY, Tu ST, Jeff Chueh SC, Chang CC, Tseng FY, Wu KD. Case detection and diagnosis of primary aldosteronism - The consensus of Taiwan Society of Aldosteronism. J Formos Med Assoc 2017; 116:993-1005. [PMID: 28735660 DOI: 10.1016/j.jfma.2017.06.004] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/17/2017] [Accepted: 06/07/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND/PURPOSE Even though the increasing clinical recognition of primary aldosteronism (PA) as a public health issue, its heightened risk profiles and the availability of targeted surgical/medical treatment being more understood, consensus in its diagnosis and management based on medical evidence, while recognizing the constraints of our real-world clinical practice in Taiwan, has not been reached. METHODS The Taiwan Society of Aldosteronism (TSA) Task Force acknowledges the above-mentioned issues and reached this Taiwan PA consensus at its inaugural meeting, in order to provide updated information of internationally acceptable standards, and also to incorporate our local disease characteristics into the management of PA. RESULTS When there is suspicion of PA, a plasma aldosterone to renin ratio (ARR) should be obtained initially. Patients with abnormal ARR will undergo confirmatory laboratory and image tests. Subtype classification with adrenal venous sampling (AVS) or NP-59 nuclear imaging, if AVS not available, to lateralize PA is recommended when patients are considered for adrenalectomy. The strengths and weaknesses of the currently available identification methods are discussed, focusing especially on result interpretation. CONCLUSION With this consensus we hope to raise more awareness of PA among medical professionals and hypertensive patients in Taiwan, and to facilitate reconciliation of better detection, identification and treatment of patients with PA.
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Affiliation(s)
- Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Hui Hu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Leay Kiaw Er
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Ruoh-Fang Yen
- Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Hui Chang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Ya-Li Chang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Ching-Chu Lu
- Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Chen Chang
- Medical Imagine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jui-Hsiang Lin
- Division of Nephrology, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzung-Dau Wang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Yuan Wang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih Te Tu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Shih-Chieh Jeff Chueh
- Glickman Urological and Kidney Institute, and Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ching-Chung Chang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, 40402, Taiwan
| | - Fen-Yu Tseng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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14
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Fernandes-Rosa FL, Boulkroun S, Zennaro MC. Somatic and inherited mutations in primary aldosteronism. J Mol Endocrinol 2017; 59:R47-R63. [PMID: 28400483 DOI: 10.1530/jme-17-0035] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/11/2017] [Indexed: 01/22/2023]
Abstract
Primary aldosteronism (PA), the most common form of secondary hypertension, is caused in the majority of cases by unilateral aldosterone-producing adenoma (APA) or bilateral adrenal hyperplasia. Over the past few years, somatic mutations in KCNJ5, CACNA1D, ATP1A1 and ATP2B3 have been proven to be associated with APA development, representing more than 50% of sporadic APA. The identification of these mutations has allowed the development of a model for APA involving modification on the intracellular ionic equilibrium and regulation of cell membrane potential, leading to autonomous aldosterone overproduction. Furthermore, somatic CTNNB1 mutations have also been identified in APA, but the link between these mutations and APA development remains unknown. The sequence of events responsible for APA formation is not completely understood, in particular, whether a single hit or a double hit is responsible for both aldosterone overproduction and cell proliferation. Germline mutations identified in patients with early-onset PA have expanded the classification of familial forms (FH) of PA. The description of germline KCNJ5 and CACNA1H mutations has identified FH-III and FH-IV based on genetic findings; germline CACNA1D mutations have been identified in patients with very early-onset PA and severe neurological abnormalities. This review summarizes current knowledge on the genetic basis of PA, the association of driver gene mutations and clinical findings and in the contribution to patient care, plus the current understanding on the mechanisms of APA development.
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Affiliation(s)
- Fabio Luiz Fernandes-Rosa
- INSERMUMRS_970, Paris Cardiovascular Research Center, Paris, France
- University Paris DescartesSorbonne Paris Cité, Paris, France
- Assistance Publique-Hôpitaux de ParisHôpital Européen Georges Pompidou, Service de Génétique, Paris, France
| | - Sheerazed Boulkroun
- INSERMUMRS_970, Paris Cardiovascular Research Center, Paris, France
- University Paris DescartesSorbonne Paris Cité, Paris, France
| | - Maria-Christina Zennaro
- INSERMUMRS_970, Paris Cardiovascular Research Center, Paris, France
- University Paris DescartesSorbonne Paris Cité, Paris, France
- Assistance Publique-Hôpitaux de ParisHôpital Européen Georges Pompidou, Service de Génétique, Paris, France
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15
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Perez-Rivas LG, Rhayem Y, Sabrautzki S, Hantel C, Rathkolb B, Hrabě de Angelis M, Reincke M, Beuschlein F, Spyroglou A. Genetic characterization of a mouse line with primary aldosteronism. J Mol Endocrinol 2017; 58:67-78. [PMID: 27965370 DOI: 10.1530/jme-16-0200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/13/2016] [Indexed: 12/17/2022]
Abstract
In an attempt to define novel genetic loci involved in the pathophysiology of primary aldosteronism, a mutagenesis screen after treatment with the alkylating agent N-ethyl-N-nitrosourea was established for the parameter aldosterone. One of the generated mouse lines with hyperaldosteronism was phenotypically and genetically characterized. This mouse line had high aldosterone levels but normal creatinine and urea values. The steroidogenic enzyme expression levels in the adrenal gland did not differ significantly among phenotypically affected and unaffected mice. Upon exome sequencing, point mutations were identified in seven candidate genes (Sspo, Dguok, Hoxaas2, Clstn3, Atm, Tipin and Mapk6). Subsequently, animals were stratified into wild-type and mutated groups according to their genotype for each of these candidate genes. A correlation of their genotypes with the respective aldosterone, aldosterone-to-renin ratio (ARR), urea and creatinine values as well as steroidogenic enzyme expression levels was performed. Aldosterone values were significantly higher in animals carrying mutations in four different genes (Sspo, Dguok, Hoxaas2 and Clstn3) and associated statistically significant adrenal Cyp11b2 overexpression as well as increased ARR was present only in mice with Sspo mutation. In contrast, mutations of the remaining candidate genes (Atm, Tipin and Mapk6) were associated with lower aldosterone values and lower Hsd3b6 expression levels. In summary, these data demonstrate association between the genes Sspo, Dguok, Hoxaas2 and Clstn3 and hyperaldosteronism. Final proofs for the causative nature of the mutations have to come from knock-out and knock-in experiments.
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Affiliation(s)
- L G Perez-Rivas
- Medizinische Klinik und Poliklinik IVEndocrine Research Unit, Klinikum der Universität München, LMU, Munich, Germany
| | - Y Rhayem
- Medizinische Klinik und Poliklinik IVEndocrine Research Unit, Klinikum der Universität München, LMU, Munich, Germany
| | - S Sabrautzki
- Helmholtz Zentrum MünchenGerman Research Center for Environmental Health (GmbH), Institute of Experimental Genetics and German Mouse Clinic, Neuherberg, Germany
- Helmholtz Zentrum MünchenGerman Research Center for Environmental Health (GmbH), Research Unit Comparative Medicine, Neuherberg, Germany
| | - C Hantel
- Medizinische Klinik und Poliklinik IVEndocrine Research Unit, Klinikum der Universität München, LMU, Munich, Germany
| | - B Rathkolb
- Helmholtz Zentrum MünchenGerman Research Center for Environmental Health (GmbH), Institute of Experimental Genetics and German Mouse Clinic, Neuherberg, Germany
- Member of German Center for Diabetes Research (DZD)Neuherberg, Germany
- Ludwig-Maximilians-Universität MünchenChair for Molecular Animal Breeding and Biotechnology, Gene Center of the München, Germany
| | - M Hrabě de Angelis
- Helmholtz Zentrum MünchenGerman Research Center for Environmental Health (GmbH), Institute of Experimental Genetics and German Mouse Clinic, Neuherberg, Germany
- Member of German Center for Diabetes Research (DZD)Neuherberg, Germany
- Lehrstuhl für Experimentelle GenetikTechnische Universität München, Freising-Weihenstephan, Germany
| | - M Reincke
- Medizinische Klinik und Poliklinik IVEndocrine Research Unit, Klinikum der Universität München, LMU, Munich, Germany
| | - F Beuschlein
- Medizinische Klinik und Poliklinik IVEndocrine Research Unit, Klinikum der Universität München, LMU, Munich, Germany
| | - A Spyroglou
- Medizinische Klinik und Poliklinik IVEndocrine Research Unit, Klinikum der Universität München, LMU, Munich, Germany
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16
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Detecting multiple variants associated with disease based on sequencing data of case-parent trios. J Hum Genet 2016; 61:851-860. [PMID: 27278787 DOI: 10.1038/jhg.2016.63] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/02/2016] [Accepted: 05/03/2016] [Indexed: 01/13/2023]
Abstract
With the advance of next-generation sequencing technology, the rare variants join the common ones in explaining more proportions of heritability. The coexistence of variants of common with rare, causal with neutral and deleterious with protective is a norm and should be appropriately addressed. Some existing methods suffer from low power when one or more forms of coexistence present, impeding their applications in practice. In this paper, for case-parent trios, pseudocontrols are constructed using the nontransmitted alleles of the parents. The Kullback-Leibler divergence is utilized to measure the difference between the distributions of variants in a genetic region for the affected children and pseudocontrols, and two nonparametric test statistics KLTT and cKLTT are proposed. Extensive simulations show that they are robust to the opposite directions of the causal variants and the amount of neutral variants, and have superiority over the existing methods when both rare and common variants are involved. Furthermore, their efficiency is demonstrated in the application to the data from Framingham Heart Study.
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17
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Daniil G, Fernandes-Rosa FL, Chemin J, Blesneac I, Beltrand J, Polak M, Jeunemaitre X, Boulkroun S, Amar L, Strom TM, Lory P, Zennaro MC. CACNA1H Mutations Are Associated With Different Forms of Primary Aldosteronism. EBioMedicine 2016; 13:225-236. [PMID: 27729216 PMCID: PMC5264314 DOI: 10.1016/j.ebiom.2016.10.002] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 09/22/2016] [Accepted: 10/03/2016] [Indexed: 01/10/2023] Open
Abstract
Primary aldosteronism (PA) is the most common form of secondary hypertension. Mutations in KCNJ5, ATP1A1, ATP2B3 and CACNA1D are found in aldosterone producing adenoma (APA) and familial hyperaldosteronism (FH). A recurrent mutation in CACNA1H (coding for Cav3.2) was identified in a familial form of early onset PA. Here we performed whole exome sequencing (WES) in patients with different types of PA to identify new susceptibility genes. Four different heterozygous germline CACNA1H variants were identified. A de novo Cav3.2 p.Met1549Ile variant was found in early onset PA and multiplex developmental disorder. Cav3.2 p.Ser196Leu and p.Pro2083Leu were found in two patients with FH, and p.Val1951Glu was identified in one patient with APA. Electrophysiological analysis of mutant Cav3.2 channels revealed significant changes in the Ca2+ current properties for all mutants, suggesting a gain of function phenotype. Transfections of mutant Cav3.2 in H295R-S2 cells led to increased aldosterone production and/or expression of genes coding for steroidogenic enzymes after K+ stimulation. Identification of CACNA1H mutations associated with early onset PA, FH, and APA suggests that CACNA1H might be a susceptibility gene predisposing to PA with different phenotypic presentations, opening new perspectives for genetic diagnosis and management of patients with PA.
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Affiliation(s)
- Georgios Daniil
- INSERM, UMRS_970, Paris Cardiovascular Research Center, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Fabio L Fernandes-Rosa
- INSERM, UMRS_970, Paris Cardiovascular Research Center, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France.
| | - Jean Chemin
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS UMR 5203, INSERM U 1191, Montpellier F-34094, France; LabEx Ion Channel Science and Therapeutics, Montpellier F-34094, France
| | - Iulia Blesneac
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS UMR 5203, INSERM U 1191, Montpellier F-34094, France; LabEx Ion Channel Science and Therapeutics, Montpellier F-34094, France
| | - Jacques Beltrand
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants Malades, Service d'Endocrinologie, Paris, France; Inserm UMR_1016, Institut Cochin, Paris, France; Institut Imagine, Paris Descartes - Université Sorbonne Paris Cité, Paris, France
| | - Michel Polak
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants Malades, Service d'Endocrinologie, Paris, France; Inserm UMR_1016, Institut Cochin, Paris, France; Institut Imagine, Paris Descartes - Université Sorbonne Paris Cité, Paris, France
| | - Xavier Jeunemaitre
- INSERM, UMRS_970, Paris Cardiovascular Research Center, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France
| | - Sheerazed Boulkroun
- INSERM, UMRS_970, Paris Cardiovascular Research Center, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Laurence Amar
- INSERM, UMRS_970, Paris Cardiovascular Research Center, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Unité Hypertension artérielle, Paris, France
| | - Tim M Strom
- Institute of Human Genetics, Helmholtz Zentrum München, Neuherberg, Germany; Institute of Human Genetics, Technische Universität München, Munich, Germany
| | - Philippe Lory
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS UMR 5203, INSERM U 1191, Montpellier F-34094, France; LabEx Ion Channel Science and Therapeutics, Montpellier F-34094, France
| | - Maria-Christina Zennaro
- INSERM, UMRS_970, Paris Cardiovascular Research Center, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France.
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18
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Stowasser M, Gordon RD. Primary Aldosteronism: Changing Definitions and New Concepts of Physiology and Pathophysiology Both Inside and Outside the Kidney. Physiol Rev 2016; 96:1327-84. [DOI: 10.1152/physrev.00026.2015] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In the 60 years that have passed since the discovery of the mineralocorticoid hormone aldosterone, much has been learned about its synthesis (both adrenal and extra-adrenal), regulation (by renin-angiotensin II, potassium, adrenocorticotrophin, and other factors), and effects (on both epithelial and nonepithelial tissues). Once thought to be rare, primary aldosteronism (PA, in which aldosterone secretion by the adrenal is excessive and autonomous of its principal regulator, angiotensin II) is now known to be the most common specifically treatable and potentially curable form of hypertension, with most patients lacking the clinical feature of hypokalemia, the presence of which was previously considered to be necessary to warrant further efforts towards confirming a diagnosis of PA. This, and the appreciation that aldosterone excess leads to adverse cardiovascular, renal, central nervous, and psychological effects, that are at least partly independent of its effects on blood pressure, have had a profound influence on raising clinical and research interest in PA. Such research on patients with PA has, in turn, furthered knowledge regarding aldosterone synthesis, regulation, and effects. This review summarizes current progress in our understanding of the physiology of aldosterone, and towards defining the causes (including genetic bases), epidemiology, outcomes, and clinical approaches to diagnostic workup (including screening, diagnostic confirmation, and subtype differentiation) and treatment of PA.
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Affiliation(s)
- Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland School of Medicine, Greenslopes and Princess Alexandra Hospitals, Brisbane, Queensland, Australia
| | - Richard D. Gordon
- Endocrine Hypertension Research Centre, University of Queensland School of Medicine, Greenslopes and Princess Alexandra Hospitals, Brisbane, Queensland, Australia
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19
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Dutta RK, Söderkvist P, Gimm O. Genetics of primary hyperaldosteronism. Endocr Relat Cancer 2016; 23:R437-54. [PMID: 27485459 DOI: 10.1530/erc-16-0055] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 08/01/2016] [Indexed: 01/19/2023]
Abstract
Hypertension is a common medical condition and affects approximately 20% of the population in developed countries. Primary aldosteronism is the most common form of secondary hypertension and affects 8-13% of patients with hypertension. The two most common causes of primary aldosteronism are aldosterone-producing adenoma and bilateral adrenal hyperplasia. Familial hyperaldosteronism types I, II and III are the known genetic syndromes, in which both adrenal glands produce excessive amounts of aldosterone. However, only a minority of patients with primary aldosteronism have one of these syndromes. Several novel susceptibility genes have been found to be mutated in aldosterone-producing adenomas: KCNJ5, ATP1A1, ATP2B3, CTNNB1, CACNA1D, CACNA1H and ARMC5 This review describes the genes currently known to be responsible for primary aldosteronism, discusses the origin of aldosterone-producing adenomas and considers the future clinical implications based on these novel insights.
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Affiliation(s)
- Ravi Kumar Dutta
- Department of Clinical and Experimental MedicineMedical Faculty, Linköping University, Linköping, Sweden
| | - Peter Söderkvist
- Department of Clinical and Experimental MedicineMedical Faculty, Linköping University, Linköping, Sweden
| | - Oliver Gimm
- Department of SurgeryCounty Council of Östergötland, Department of Clinical and Experimental Medicine, Medical Faculty, Linköping University, Linköping, Sweden
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20
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Primary Aldosteronism: Diagnosis and Management. Am J Med Sci 2016; 352:391-398. [PMID: 27776721 DOI: 10.1016/j.amjms.2016.06.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/14/2016] [Accepted: 06/24/2016] [Indexed: 11/21/2022]
Abstract
Primary aldosteronism (PA) is an important and commonly unrecognized cause of secondary hypertension. Idiopathic hyperaldosteronism and aldosterone-producing adenomas account for more than 95% of PA and are characterized, respectively, by bilateral or unilateral involvement of the adrenal glands. When there is suspicion for the presence of PA, a plasma aldosterone to renin ratio should be obtained initially. Localization to determine adrenal gland involvement is done by imaging, with computerized tomography or magnetic resonance imaging. After imaging, adrenal vein sampling is done to establish treatment options. Patients with unilateral disease, who are good surgical candidates, are most appropriately managed with adrenalectomy. A biochemical cure is almost certain following adrenalectomy; however, only 30-50% of patients would show adequate blood pressure improvement. Patients with bilateral adrenal disease and those believed not to be surgical candidates are managed with mineralocorticoid antagonists.
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21
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Zennaro MC, Jeunemaitre X. SFE/SFHTA/AFCE consensus on primary aldosteronism, part 5: Genetic diagnosis of primary aldosteronism. ANNALES D'ENDOCRINOLOGIE 2016; 77:214-9. [PMID: 27315758 DOI: 10.1016/j.ando.2016.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/05/2016] [Indexed: 11/15/2022]
Abstract
While the majority of cases of primary aldosteronism (PA) are sporadic, four forms of autosomal-dominant inheritance have been described: familial hyperaldosteronism (FH) types I to IV. FH-I, also called glucocorticoid-remediable aldosteronism, is characterized by early and severe hypertension, usually before the age of 20 years. It is due to the formation of a chimeric gene between the adjacent CYP11B2 and CYP11B1 genes (coding for aldosterone synthase and 11β-hydroxylase, respectively). FH-I is often associated with family history of stroke before 40years of age. FH-II is clinically and biochemically indistinguishable from sporadic forms of PA and is only diagnosed on the basis of two or more affected family members. No causal genes have been identified so far and no genetic test is available. FH-III is characterized by severe and early-onset hypertension in children and young adults, resistant to treatment and associated with severe hypokalemia. Mild forms, resembling FH-II, have been described. FH-III is due to gain-of-function mutations in the KCNJ5 gene. Recently, a new autosomal-dominant form of familial PA, FH-IV, associated with mutations in the CACNA1H gene, was described in patients with hypertension and PA before the age of 10years. In rare cases, PA may be associated with complex neurologic disorder involving epileptic seizures and cerebral palsy (Primary Aldosteronism, Seizures, and Neurologic Abnormalities [PASNA]) due to de novo germline CACNA1D mutations.
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Affiliation(s)
- Maria-Christina Zennaro
- INSERM, U970, Paris Cardiovascular Research Center-PARCC, 56, rue Leblanc, 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Service de génétique, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, Paris, France.
| | - Xavier Jeunemaitre
- INSERM, U970, Paris Cardiovascular Research Center-PARCC, 56, rue Leblanc, 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Service de génétique, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, Paris, France
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22
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Funder JW, Carey RM, Mantero F, Murad MH, Reincke M, Shibata H, Stowasser M, Young WF. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101:1889-916. [PMID: 26934393 DOI: 10.1210/jc.2015-4061] [Citation(s) in RCA: 1610] [Impact Index Per Article: 201.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop clinical practice guidelines for the management of patients with primary aldosteronism. PARTICIPANTS The Task Force included a chair, selected by the Clinical Guidelines Subcommittee of the Endocrine Society, six additional experts, a methodologist, and a medical writer. The guideline was cosponsored by American Heart Association, American Association of Endocrine Surgeons, European Society of Endocrinology, European Society of Hypertension, International Association of Endocrine Surgeons, International Society of Endocrinology, International Society of Hypertension, Japan Endocrine Society, and The Japanese Society of Hypertension. The Task Force received no corporate funding or remuneration. EVIDENCE We searched for systematic reviews and primary studies to formulate the key treatment and prevention recommendations. We used the Grading of Recommendations, Assessment, Development, and Evaluation group criteria to describe both the quality of evidence and the strength of recommendations. We used "recommend" for strong recommendations and "suggest" for weak recommendations. CONSENSUS PROCESS We achieved consensus by collecting the best available evidence and conducting one group meeting, several conference calls, and multiple e-mail communications. With the help of a medical writer, the Endocrine Society's Clinical Guidelines Subcommittee, Clinical Affairs Core Committee, and Council successfully reviewed the drafts prepared by the Task Force. We placed the version approved by the Clinical Guidelines Subcommittee and Clinical Affairs Core Committee on the Endocrine Society's website for comments by members. At each stage of review, the Task Force received written comments and incorporated necessary changes. CONCLUSIONS For high-risk groups of hypertensive patients and those with hypokalemia, we recommend case detection of primary aldosteronism by determining the aldosterone-renin ratio under standard conditions and recommend that a commonly used confirmatory test should confirm/exclude the condition. We recommend that all patients with primary aldosteronism undergo adrenal computed tomography as the initial study in subtype testing and to exclude adrenocortical carcinoma. We recommend that an experienced radiologist should establish/exclude unilateral primary aldosteronism using bilateral adrenal venous sampling, and if confirmed, this should optimally be treated by laparoscopic adrenalectomy. We recommend that patients with bilateral adrenal hyperplasia or those unsuitable for surgery should be treated primarily with a mineralocorticoid receptor antagonist.
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Affiliation(s)
- John W Funder
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Robert M Carey
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Franco Mantero
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - M Hassan Murad
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Martin Reincke
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Hirotaka Shibata
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - Michael Stowasser
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
| | - William F Young
- Hudson Institute of Medical Research (J.W.F.), Clayton, VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; University of Padova (F.M.), 35122 Padua, Italy; Mayo Clinic, Evidence-based Practice Center (M.H.M.), Rochester, Minnesota 55905; Klinikum of the Ludwig-Maximilians-University of Munich (M.R.), 80366 München, Bavaria, Germany; Oita University (H.S.), Oita 870-1124, Japan; University of Queensland (M.S.), Brisbane, Australia; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
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23
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Abstract
Familial forms of primary aldosteronism have been suggested to account for up to 6% of cases in referral centers. For many years, the genetics of familial hyperaldosteronism remained unknown, with the notable exception of glucocorticoid-remediable aldosteronism, due to unequal crossing over and formation of a chimeric 11β-hydroxylase/aldosterone synthase gene. Over the past 5 years, mutations in 3 additional genes have been shown to cause familial forms of primary aldosteronism. Gain-of-function heterozygous germline mutations in KCNJ5, which encodes an inward rectifier potassium channel, cause autosomal dominant syndromes of PA and hypertension with or without adrenal hyperplasia. Germline mutations in CACNA1D, which codes for an L-type calcium channel, have so far only been found in 2 cases with a syndrome of primary aldosteronism, seizures, and neurologic abnormalities. Both KCNJ5 and CACNA1D mutations in familial hyperaldosteronism were only discovered following identification of similar or identical somatic mutations in aldosterone-producing adenomas. In contrast, a recent exome sequencing study identified germline mutations in CACNA1H (a T-type calcium channel), previously undescribed in adenomas, in 5 unrelated families with early-onset primary aldosteronism and hypertension, without any additional shared symptoms. Future exome or genome sequencing studies are expected to shed light on the genetic basis of many cases of familial hyperaldosteronism that remain unexplained.
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Affiliation(s)
- H E Korah
- Department of Nephrology, Medical School, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - U I Scholl
- Department of Nephrology, Medical School, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
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24
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Abstract
Aldosterone plays an essential role in the maintenance of fluid and electrolyte homeostasis in the distal nephron. Monogenic forms of mineralocorticoid hypertension result from genetic defects leading to excessive production of aldosterone (or other mineralocorticoids) from the adrenal cortex or to illegitimate mineralocorticoid effects in the kidney. They are characterized in the majority of cases by early onset, severe or resistant hypertension and associated with suppressed renin levels. Depending on their causes, these diseases are distinguished at the clinical and biochemical level and differently affect aldosterone levels and kalemia. The diagnosis is confirmed by genetic testing, which allows in many cases targeted treatment to prevent severe cardiovascular consequences of high blood pressure or aldosterone excess. In this review we describe the different forms of inherited mineralocorticoid hypertension, providing an overview of their clinical and biochemical features, their underlying genetic defects and specific therapeutic options.
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Affiliation(s)
- Maria-Christina Zennaro
- INSERM, UMRS_970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes, Sorbonne Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France.
| | - Sheerazed Boulkroun
- INSERM, UMRS_970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Fabio Fernandes-Rosa
- INSERM, UMRS_970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes, Sorbonne Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France
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Williams TA, Mulatero P, Bidlingmaier M, Beuschlein F, Reincke M. Genetic and potential autoimmune triggers of primary aldosteronism. Hypertension 2015; 66:248-53. [PMID: 26056334 DOI: 10.1161/hypertensionaha.115.05643] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 05/14/2015] [Indexed: 01/15/2023]
Affiliation(s)
- Tracy Ann Williams
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany (T.A.W., M.B., F.B., M.R.); and Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy (T.A.W., P.M.).
| | - Paolo Mulatero
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany (T.A.W., M.B., F.B., M.R.); and Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy (T.A.W., P.M.)
| | - Martin Bidlingmaier
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany (T.A.W., M.B., F.B., M.R.); and Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy (T.A.W., P.M.)
| | - Felix Beuschlein
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany (T.A.W., M.B., F.B., M.R.); and Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy (T.A.W., P.M.)
| | - Martin Reincke
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany (T.A.W., M.B., F.B., M.R.); and Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy (T.A.W., P.M.).
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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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Monticone S, Else T, Mulatero P, Williams TA, Rainey WE. Understanding primary aldosteronism: impact of next generation sequencing and expression profiling. Mol Cell Endocrinol 2015; 399:311-20. [PMID: 25240470 PMCID: PMC4285708 DOI: 10.1016/j.mce.2014.09.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 09/11/2014] [Accepted: 09/15/2014] [Indexed: 10/24/2022]
Abstract
Primary aldosteronism (PA) encompasses a broad, heterogeneous group of disorders including both sporadic and familial forms (familial hyperaldosteronism type I, II and III). PA is the most common form of secondary hypertension and associated with a higher rate of cardiovascular complications, compared with essential hypertension. Despite significant progress in the diagnosis and management of PA, until recently the molecular mechanisms leading to inappropriate aldosterone production were largely unknown. The introduction of next-generation sequencing has had a profound impact on the field of human genetics and has given new insight in the molecular determinants that lead to both sporadic and familial forms of PA. Here we review the recent progress toward understanding of the genetic and molecular mechanisms leading to autonomous aldosterone production in PA.
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Affiliation(s)
- Silvia Monticone
- Department of Medical Sciences, Division of Internal Medicine and Hypertension, University of Torino, Torino, Italy.
| | - Tobias Else
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Paolo Mulatero
- Department of Medical Sciences, Division of Internal Medicine and Hypertension, University of Torino, Torino, Italy
| | - Tracy A Williams
- Department of Medical Sciences, Division of Internal Medicine and Hypertension, University of Torino, Torino, Italy
| | - William E Rainey
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA
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28
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Abstract
Aldosterone plays a major role in the regulation of sodium and potassium homeostasis and blood pressure. More recently, aldosterone has emerged as a key hormone mediating end organ damage. In extreme cases, dysregulated aldosterone production leads to primary aldosteronism (PA), the most common form of secondary hypertension. However, even within the physiological range, high levels of aldosterone are associated with an increased risk of developing hypertension over time. PA represents the most common and curable form of hypertension, with a prevalence that increases with the severity of hypertension. Although genetic causes underlying glucocorticoid-remediable aldosteronism, one of the three Mendelian forms of PA, were established some time ago, somatic and inherited mutations in the potassium channel GIRK4 have only recently been implicated in the formation of aldosterone-producing adenoma (APA) and in familial hyperaldosteronism type 3. Moreover, recent findings have shown somatic mutations in two additional genes, involved in maintaining intracellular ionic homeostasis and cell membrane potential, in a subset of APAs. This review summarizes our current knowledge on the genetic determinants that contribute to variations in plasma aldosterone and renin levels in the general population and the genetics of familial and sporadic PA. Various animal models that have significantly improved our understanding of the pathophysiology of excess aldosterone production are also discussed. Finally, we outline the cardiovascular, renal, and metabolic consequences of mineralocorticoid excess beyond blood pressure regulation.
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Chao CT, Wu VC, Kuo CC, Lin YH, Chang CC, Chueh SJ, Wu KD, Pimenta E, Stowasser M. Diagnosis and management of primary aldosteronism: an updated review. Ann Med 2013; 45:375-83. [PMID: 23701121 DOI: 10.3109/07853890.2013.785234] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Primary aldosteronism (PA) is the most common secondary form of arterial hypertension, with a particularly high prevalence among patients with resistant hypertension. Aldosterone has been found to be associated with cardiovascular toxicity. Prolonged aldosteronism leads to higher incidence of cardiac events, glomerular hyperfiltration, and potentially bone/metabolic sequels. The wider application of aldosterone/renin ratio as screening test has substantially contributed to increasing diagnosis of PA. Diagnosis of PA consists of two phases: screening and confirmatory testing. Adrenal imaging is often inaccurate for differentiation between an adenoma and hyperplasia, and adrenal venous sampling is essential for selecting the appropriate treatment modality. The etiologies of PA have two main subtypes: unilateral (aldosterone-producing adenoma) and bilateral (micro- or macronodular hyperplasia). Aldosterone-producing adenoma is typically managed with unilateral adrenalectomy, while bilateral adrenal hyperplasia is amenable to pharmacological approaches using mineralocorticoid antagonists. Short-term treatment outcome following surgery is determined by factors such as preoperative blood pressure level and hypertension duration, but evidence regarding long-term treatment outcome is still lacking. However, directed treatments comprising of unilateral adrenalectomy or mineralocorticoid antagonists still potentially reduce the toxicities of aldosterone. Utilizing a physician-centered approach, we intend to provide up-dated information on the etiology, diagnosis, and the management of PA.
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Stowasser M, Gordon RD. The Renaissance of Primary Aldosteronism: What Has it Taught Us? Heart Lung Circ 2013; 22:412-20. [DOI: 10.1016/j.hlc.2013.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 01/05/2013] [Indexed: 10/27/2022]
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Mulatero P, Monticone S, Rainey WE, Veglio F, Williams TA. Role of KCNJ5 in familial and sporadic primary aldosteronism. Nat Rev Endocrinol 2013; 9:104-12. [PMID: 23229280 DOI: 10.1038/nrendo.2012.230] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Primary aldosteronism is characterised by the dysregulation of aldosterone production and comprises both sporadic forms, caused by an aldosterone-producing adenoma or bilateral adrenal hyperplasia, and familial forms (familial hyperaldosteronism types I, II and III). The two principal physiological regulators of aldosterone synthesis are angiotensin II and serum K(+), which reverse the high resting K(+) conductance and hyperpolarized membrane potential of adrenal glomerulosa cells. The resulting membrane depolarization causes the opening of voltage-gated Ca(2+) channels and an increase in intracellular Ca(2+) that stimulates aldosterone biosynthesis. Point mutations in the KCNJ5 gene, which encodes the G-protein-activated inward rectifier K(+) channel 4 (GIRK4), have been implicated in the pathogenesis of both sporadic and familial forms of primary aldosteronism. These mutations interfere with the selectivity filter of GIRK4 causing Na(+) entry, cell depolarization and Ca(2+) channel opening, resulting in constitutive aldosterone production. Seven families with familial hyperaldosteronism caused by KCNJ5 germline mutations have so far been described, and multicentre studies have reported KCNJ5 mutations in approximately 40% of sporadic aldosterone-producing adenomas. Herein, we review the role of GIRK4 in adrenal pathophysiology and provide an overview of the clinical and biochemical phenotypes resulting from KCNJ5 mutations in patients with sporadic and familial primary aldosteronism.
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Affiliation(s)
- Paolo Mulatero
- University of Torino, Department of Medical Sciences, Division of Internal Medicine and Hypertension, Italy. paolo.mulatero@ unito.it
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Abstract
High blood pressure (BP) is a complex trait determined by genetic and environmental factors, as well as their interactions. Over the past few decades, there has been substantial progress elucidating the genetic determinants underlying BP response to sodium intake, or BP salt sensitivity. Research of monogenic BP disorders has highlighted the importance of renal salt handling in BP regulation, implicating genes and biological pathways subsequently identified in candidate gene studies of salt sensitivity. Despite these advancements, certain candidate gene findings await replication evidence, and some biological pathways warrant further investigation. Furthermore, results from genome-wide association studies (GWASs) and sequencing work have yet to be reported. GWAS will be valuable for uncovering novel mechanisms underlying salt sensitivity, whereas future sequencing efforts promise the discovery of functional variants related to this complex trait. Delineating the genetic architecture of salt sensitivity will be critical to understanding how genes and dietary sodium interact to influence BP.
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Mulatero P, Tauber P, Zennaro MC, Monticone S, Lang K, Beuschlein F, Fischer E, Tizzani D, Pallauf A, Viola A, Amar L, Williams TA, Strom TM, Graf E, Bandulik S, Penton D, Plouin PF, Warth R, Allolio B, Jeunemaitre X, Veglio F, Reincke M. KCNJ5
Mutations in European Families With Nonglucocorticoid Remediable Familial Hyperaldosteronism. Hypertension 2012; 59:235-40. [DOI: 10.1161/hypertensionaha.111.183996] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Paolo Mulatero
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Philipp Tauber
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Maria-Christina Zennaro
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Silvia Monticone
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Katharina Lang
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Felix Beuschlein
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Evelyn Fischer
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Davide Tizzani
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Anna Pallauf
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Andrea Viola
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Laurence Amar
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Tracy Ann Williams
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Tim M. Strom
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Elisabeth Graf
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Sascha Bandulik
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - David Penton
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Pierre-François Plouin
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Richard Warth
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Bruno Allolio
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Xavier Jeunemaitre
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Franco Veglio
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
| | - Martin Reincke
- From the Division of Internal Medicine and Hypertension (P.M., S.M., D.T., A.V., T.A.W., F.V.), University of Torino, Torino, Italy; Medical Cell Biology (P.T., S.B., D.P., R.W.), University Regensburg, Regensburg, Germany; Institut National de la Santé et de la Recherche Médicale (M.C.Z., L.A., P.F.P., X.J.), U970, Paris Cardiovascular Research Center, Paris, France; University Paris Descartes (M.C.Z., L.A., P.F.P., X.J.), Paris, France; Assistance Publique-Hôpitaux de Paris (M.C.Z., L.A., P.F.P.,
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Gene-sodium interaction and blood pressure: findings from genomics research of blood pressure salt sensitivity. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2012; 108:237-60. [PMID: 22656380 DOI: 10.1016/b978-0-12-398397-8.00010-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
High blood pressure (BP) is a complex trait determined by both genetic and environmental factors, as well as the interactions between these factors. Over the past few decades, there has been substantial progress in elucidating the genetic determinants underlying the BP response to sodium intake, or BP salt sensitivity. Research of monogenic BP disorders has highlighted the importance of renal salt handling in BP regulation, implicating genes and biological pathways related to salt sensitivity. Candidate gene studies have contributed important information toward understanding the genomic mechanisms underlying the BP response to salt intake, identifying genes in the renin-angiotensin-aldosterone system, renal sodium channels/transporters, and the endothelial system related to this phenotype. Despite these advancements, genome-wide association studies are still needed to uncover novel mechanisms underlying salt sensitivity, while future sequencing efforts promise the discovery of functional variants related to this complex trait. Delineating the genetic architecture of salt sensitivity will be critical to understanding how genes and dietary sodium interact to influence BP.
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Mulatero P, Tizzani D, Viola A, Bertello C, Monticone S, Mengozzi G, Schiavone D, Williams TA, Einaudi S, La Grotta A, Rabbia F, Veglio F. Prevalence and Characteristics of Familial Hyperaldosteronism. Hypertension 2011; 58:797-803. [DOI: 10.1161/hypertensionaha.111.175083] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Primary aldosteronism (PA) is the most frequent cause of secondary hypertension, and patients display an increased prevalence of cardiovascular events compared with essential hypertensives. To date, 3 familial forms of PA have been described and termed familial hyperaldosteronism types I, II, and III (FH-I to -III). The aim of this study was to investigate the prevalence and clinical characteristics of the 3 forms of FH in a large population of PA patients. Three-hundred consecutive PA patients diagnosed in our unit were tested by long-PCR of the
CYP11B1/CYP11B2
hybrid gene that causes FH-I, and all of the available relatives of PA patients were screened to confirm or exclude PA and, thus, FH-II. Urinary 18-hydroxycortisol and 18-oxocortisol were measured in all of the familial PA patients. Two patients were diagnosed with FH-I (prevalence: 0.66%), as well as 21 of their relatives, and clinical phenotypes of the 2 affected families varied markedly. After exclusion of families who refused testing and those who were not informative, 199 families were investigated, of which 12 were diagnosed with FH-II (6%) and an additional 15 individuals had confirmed PA; clinical and biochemical phenotypes of FH-II families were not significantly different from sporadic PA patients. None of the families displayed a phenotype compatible with FH-III diagnosis. Our study demonstrates that familial forms of hyperaldosteronism are more frequent than previously expected and reinforces the recommendation of the Endocrine Society Guidelines to screen all first-degree hypertensive relatives of PA patients.
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Affiliation(s)
- Paolo Mulatero
- From the Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension (P.M., D.T., A.V., C.B., S.M., D.S., T.A.W., F.R., F.V.), and Department of Endocrinology and Diabetology, Regina Margherita Pediatric Hospital (S.E.), University of Torino, Torino, Italy; Clinical Chemistry Laboratory (G.M.), San Giovanni Battista University Hospital, Torino, Italy; Division of Internal Medicine (A.L.G.), Service of Endocrinology and Hypertension, Cardinal Massaia Hospital,
| | - Davide Tizzani
- From the Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension (P.M., D.T., A.V., C.B., S.M., D.S., T.A.W., F.R., F.V.), and Department of Endocrinology and Diabetology, Regina Margherita Pediatric Hospital (S.E.), University of Torino, Torino, Italy; Clinical Chemistry Laboratory (G.M.), San Giovanni Battista University Hospital, Torino, Italy; Division of Internal Medicine (A.L.G.), Service of Endocrinology and Hypertension, Cardinal Massaia Hospital,
| | - Andrea Viola
- From the Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension (P.M., D.T., A.V., C.B., S.M., D.S., T.A.W., F.R., F.V.), and Department of Endocrinology and Diabetology, Regina Margherita Pediatric Hospital (S.E.), University of Torino, Torino, Italy; Clinical Chemistry Laboratory (G.M.), San Giovanni Battista University Hospital, Torino, Italy; Division of Internal Medicine (A.L.G.), Service of Endocrinology and Hypertension, Cardinal Massaia Hospital,
| | - Chiara Bertello
- From the Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension (P.M., D.T., A.V., C.B., S.M., D.S., T.A.W., F.R., F.V.), and Department of Endocrinology and Diabetology, Regina Margherita Pediatric Hospital (S.E.), University of Torino, Torino, Italy; Clinical Chemistry Laboratory (G.M.), San Giovanni Battista University Hospital, Torino, Italy; Division of Internal Medicine (A.L.G.), Service of Endocrinology and Hypertension, Cardinal Massaia Hospital,
| | - Silvia Monticone
- From the Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension (P.M., D.T., A.V., C.B., S.M., D.S., T.A.W., F.R., F.V.), and Department of Endocrinology and Diabetology, Regina Margherita Pediatric Hospital (S.E.), University of Torino, Torino, Italy; Clinical Chemistry Laboratory (G.M.), San Giovanni Battista University Hospital, Torino, Italy; Division of Internal Medicine (A.L.G.), Service of Endocrinology and Hypertension, Cardinal Massaia Hospital,
| | - Giulio Mengozzi
- From the Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension (P.M., D.T., A.V., C.B., S.M., D.S., T.A.W., F.R., F.V.), and Department of Endocrinology and Diabetology, Regina Margherita Pediatric Hospital (S.E.), University of Torino, Torino, Italy; Clinical Chemistry Laboratory (G.M.), San Giovanni Battista University Hospital, Torino, Italy; Division of Internal Medicine (A.L.G.), Service of Endocrinology and Hypertension, Cardinal Massaia Hospital,
| | - Domenica Schiavone
- From the Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension (P.M., D.T., A.V., C.B., S.M., D.S., T.A.W., F.R., F.V.), and Department of Endocrinology and Diabetology, Regina Margherita Pediatric Hospital (S.E.), University of Torino, Torino, Italy; Clinical Chemistry Laboratory (G.M.), San Giovanni Battista University Hospital, Torino, Italy; Division of Internal Medicine (A.L.G.), Service of Endocrinology and Hypertension, Cardinal Massaia Hospital,
| | - Tracy Ann Williams
- From the Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension (P.M., D.T., A.V., C.B., S.M., D.S., T.A.W., F.R., F.V.), and Department of Endocrinology and Diabetology, Regina Margherita Pediatric Hospital (S.E.), University of Torino, Torino, Italy; Clinical Chemistry Laboratory (G.M.), San Giovanni Battista University Hospital, Torino, Italy; Division of Internal Medicine (A.L.G.), Service of Endocrinology and Hypertension, Cardinal Massaia Hospital,
| | - Silvia Einaudi
- From the Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension (P.M., D.T., A.V., C.B., S.M., D.S., T.A.W., F.R., F.V.), and Department of Endocrinology and Diabetology, Regina Margherita Pediatric Hospital (S.E.), University of Torino, Torino, Italy; Clinical Chemistry Laboratory (G.M.), San Giovanni Battista University Hospital, Torino, Italy; Division of Internal Medicine (A.L.G.), Service of Endocrinology and Hypertension, Cardinal Massaia Hospital,
| | - Antonio La Grotta
- From the Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension (P.M., D.T., A.V., C.B., S.M., D.S., T.A.W., F.R., F.V.), and Department of Endocrinology and Diabetology, Regina Margherita Pediatric Hospital (S.E.), University of Torino, Torino, Italy; Clinical Chemistry Laboratory (G.M.), San Giovanni Battista University Hospital, Torino, Italy; Division of Internal Medicine (A.L.G.), Service of Endocrinology and Hypertension, Cardinal Massaia Hospital,
| | - Franco Rabbia
- From the Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension (P.M., D.T., A.V., C.B., S.M., D.S., T.A.W., F.R., F.V.), and Department of Endocrinology and Diabetology, Regina Margherita Pediatric Hospital (S.E.), University of Torino, Torino, Italy; Clinical Chemistry Laboratory (G.M.), San Giovanni Battista University Hospital, Torino, Italy; Division of Internal Medicine (A.L.G.), Service of Endocrinology and Hypertension, Cardinal Massaia Hospital,
| | - Franco Veglio
- From the Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension (P.M., D.T., A.V., C.B., S.M., D.S., T.A.W., F.R., F.V.), and Department of Endocrinology and Diabetology, Regina Margherita Pediatric Hospital (S.E.), University of Torino, Torino, Italy; Clinical Chemistry Laboratory (G.M.), San Giovanni Battista University Hospital, Torino, Italy; Division of Internal Medicine (A.L.G.), Service of Endocrinology and Hypertension, Cardinal Massaia Hospital,
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Abstract
OBJECTIVE To review the first reported cases of successfully treated pheochromocytoma and primary aldosteronism and to document the diagnostic and therapeutic advances that have occurred since the initial descriptions. METHODS The original case descriptions and the subsequent pertinent literature were reviewed. RESULTS The successful management of the initial cases of pheochromocytoma in 1926 and primary aldosteronism in 1954 was highlighted by keen clinical observation, clinical intuition, and application of scientific principles. Since those prismatic case descriptions, the technological advances in laboratory-based diagnosis, radiology-based tumor localization, and surgical approaches to the adrenal glands have been truly remarkable. CONCLUSIONS The evolution in the diagnosis and treatment of pheochromocytoma will continue to progress as we identify more genetic causes, develop biochemical markers for "preclinical" pheochromocytoma, identify better markers for malignant disease, and develop more effective treatment options for malignant pheochromocytoma. Over the next decade, we hope to determine the pathophysiology for bilateral idiopathic hyperaldosteronism, develop less invasive and less technically demanding tests to distinguish between unilateral aldosterone-producing adenoma and bilateral idiopathic hyperaldosteronism, determine where low renin hypertension stops and primary aldosteronism starts, and determine the impact of genetic and environmental factors on aldosterone secretion in patients with and without primary aldosteronism.
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Affiliation(s)
- William F Young
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Stowasser M, Pimenta E, Gordon RD. Familial or genetic primary aldosteronism and Gordon syndrome. Endocrinol Metab Clin North Am 2011; 40:343-68, viii. [PMID: 21565671 DOI: 10.1016/j.ecl.2011.01.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Salt-sensitive forms of hypertension have received considerable renewed attention in recent years. This article focuses on 2 main forms of salt-sensitive hypertension (familial or genetic primary aldosteronism [PA] and Gordon syndrome) and the current state of knowledge regarding their genetic bases. The glucocorticoid-remediable form of familial PA (familial hyperaldosteronism type I) is dealt with only briefly because it is covered in depth elsewhere.
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Affiliation(s)
- Michael Stowasser
- Endocrine Hypertension Research Center, University of Queensland School of Medicine, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane 4102, Australia.
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Abstract
PURPOSE OF REVIEW Inherited forms of mineralocorticoid hypertension are a group of monogenic disorders that, although rare, have enlightened our understanding of normal physiology, and subsequent processes implicated in the pathogenesis of 'essential' hypertension. They often present in early life and can be a cause of major morbidity and mortality that can be effectively treated with simple but targeted pharmacological therapy. Interestingly, all the conditions centre on the regulation of sodium transport through its epithelial channel, either directly or through mediators that act via the mineralocorticoid receptor. RECENT FINDINGS In recent years, molecular mechanisms of these conditions and their functional consequences have been elucidated. Diagnosis has been facilitated by plasma and urinary biomarkers. SUMMARY We provide an overview and diagnostic approach to apparent mineralocorticoid excess, glucocorticoid remediable aldosteronism, familial hyperaldosteronism type 2, Liddle's syndrome, Gordon's syndrome, activating mutations of the mineralocorticoid receptor, generalized glucocorticoid resistance and hypertensive forms of congenital adrenal hyperplasia.
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Affiliation(s)
- Zaki Hassan-Smith
- Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
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Abstract
Primary aldosteronism (PAL) is characterized by excessive production of aldosterone, which leads to hypernatremia, hypertension (HTN), hypokalemia, and alkalosis. Three crucial diagnostic steps include case detection, case confirmation, and subtype classification. Marked improvement or cure of HTN is achieved with appropriate treatment.
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40
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Moraitis A, Stratakis C. Adrenocortical causes of hypertension. Int J Hypertens 2011; 2011:624691. [PMID: 21423682 PMCID: PMC3057029 DOI: 10.4061/2011/624691] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 01/09/2011] [Accepted: 01/13/2011] [Indexed: 01/11/2023] Open
Abstract
Primary aldosteronism is the most common cause of secondary hypertension. In the past, screening for primary aldosteronism was offered only in patients with hypertension associated with hypokalemia. Recent studies showed that hypokalemia is seen in only 25% of the patients with primary aldosteronism, which has increased the prevalence of primary aldosteronism to 10–15% of all cases with new onset hypertension.
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Affiliation(s)
- Andreas Moraitis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Program on Developmental Endocrinology and Genetics, Bethesda, MD 20892, USA
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41
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Abstract
Primary aldosteronism (PA) is an important cause of secondary hypertension, is being increasingly diagnosed and may account for more than 10% of hypertensive patients, both in primary care and in referral centers. Aldosterone excess is associated with adverse cardiovascular, renal and metabolic effects that are in part hypertension-independent. Laparoscopic adrenalectomy remains the mainstay of treatment for unilateral forms of PA, whereas medical treatment is recommended for bilateral forms of PA. However, a favourable surgical outcome depends on several factors and many patients are not suitable for this treatment. On the other hand, surgery in patients considered to have bilateral PA may contribute to better blood pressure control. In this review, established and novel strategies for the management of different types of PA are discussed.
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Affiliation(s)
- Asterios Karagiannis
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, 44, Tsimiski str., Thessaloniki, 54623, Greece.
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Carss KJ, Stowasser M, Gordon RD, O'Shaughnessy KM. Further study of chromosome 7p22 to identify the molecular basis of familial hyperaldosteronism type II. J Hum Hypertens 2010; 25:560-4. [PMID: 20927129 DOI: 10.1038/jhh.2010.93] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Familial hyperaldosteronism type II (FH-II) is an inherited form of hyperaldosteronism associated with hypertension in most patients. The mutations that cause FH-II are unknown, but linkage analysis has mapped them to chromosome 7p22. As FH-II is clinically indistinguishable from sporadic primary aldosteronism, a common and treatable condition, unravelling the cause of FH-II has important implications for these sporadic cases. To investigate whether FH-II is caused by large deletions or insertions, we examined the virtual karyotype of four pairs of affected and unaffected individuals using high-density bead chips. We also sequenced the coding regions of five 7p22 candidate genes that were prioritized because of their putative role in cell growth. We found no evidence of single-nucleotide polymorphism (SNP) copy number variation between pairs, and from the widest gap on the chip, chromosome 7p22 deletions or insertions exceeding ∼50 kb in these pedigrees can be excluded. We found 15 SNPs (two of which were novel), but none of them were non-synonymous and segregated with the disease in the FH-II pedigrees. We have been able to exclude large genomic deletions or insertions at 7p22 and refine the candidate gene list for this locus, but the mutations causing FH-II remain elusive.
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Affiliation(s)
- K J Carss
- Clinical Pharmacology Unit, Department of Medicine, University of Cambridge, Cambridge, UK
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43
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Somekh NN, Finkielstein D. A mother/daughter case of familial hyperaldosteronism. Clin Cardiol 2010; 33:E68-9. [PMID: 20865750 DOI: 10.1002/clc.20654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 06/18/2009] [Indexed: 11/06/2022] Open
Affiliation(s)
- Nir N Somekh
- Department of Internal Medicine, Beth Israel Medical Center, New York, New York 10003, USA.
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Abstract
It is now widely recognized that primary aldosteronism (PA) is much more common than previously thought, accounting for up to 5-10% of hypertensives, and that aldosterone excess has adverse cardiovascular consequences that go above and beyond hypertension development. These findings have precipitated a marked resurgence of research activity, most of which has supported the concept that PA plays an important role in cardiovascular disease states and should be systematically sought and specifically treated, and the development of an Endocrine Society clinical guideline for the case detection, diagnosis, and management of this common, specifically treatable, and potentially curable condition. Areas of recent, topical research include: 1) the demonstration of excess morbidity in patients with PA compared with other forms of hypertension, confirming the clinical relevance of non-blood pressure-dependent adverse effects of aldosterone excess; 2) the further demonstration that this excess morbidity and mortality are ameliorated with specific (but not nonspecific antihypertensive) therapy directed against aldosterone excess, confirming the importance of detection and diagnosis of PA to enable optimal specific management; 3) the development of new treatment strategies; 4) an ongoing appraisal and refinement of diagnostic approaches including screening, subtype differentiation, and new assay development; and 5) further insights into the importance and nature of genetic factors related to the development of PA.
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Affiliation(s)
- Michael Stowasser
- Hypertension Unit, University of Queensland School of Medicine, Princess Alexandra Hospital, Woolloongabba Brisbane 4102, Australia.
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46
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Abstract
Aldosterone is a key regulator of electrolyte and water homeostasis and plays a central role in blood pressure regulation. Hormonal changes during pregnancy, among them increased progesterone and aldosterone production, lead to the required plasma volume expansion of the maternal body as an accommodation mechanism for fetus growth. This review discusses the regulation of aldosterone production by aldosterone synthase (CYP11B2); the impact on aldosterone secretion due to the presence of a chimeric gene originating from a crossover between CYP11B1 and CYP11B2 in glucocorticoid remediable aldosteronism (GRA) — the inherited form of hypertension; enhanced aldosterone production in aldosterone-producing adenoma (APA); and idiopathic hyperaldosteronism (IHA). Features of hyperaldosteronism are also found in patients with apparent mineralocorticoid excess (AME), in which glucocorticoids exacerbate activation of the mineralocorticoid receptor (MR) because of a defect in the 11β-hydroxysteroid dehydrogenase type 2 enzyme. Regulation of aldosterone production and tissue-specific activation of the mineralocorticoid receptor are prerequisites for optimal control of body fluids and blood pressure during pregnancy and contribute largely to the wellbeing of the mother-to-be.
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Affiliation(s)
- Geneviève Escher
- University Hospital of Berne, Division of Nephrology and Hypertension, Berne, Switzerland,
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Funder JW, Carey RM, Fardella C, Gomez-Sanchez CE, Mantero F, Stowasser M, Young WF, Montori VM. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2008; 93:3266-81. [PMID: 18552288 DOI: 10.1210/jc.2008-0104] [Citation(s) in RCA: 1034] [Impact Index Per Article: 64.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Our objective was to develop clinical practice guidelines for the diagnosis and treatment of patients with primary aldosteronism. PARTICIPANTS The Task Force comprised a chair, selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society, six additional experts, one methodologist, and a medical writer. The Task Force received no corporate funding or remuneration. EVIDENCE Systematic reviews of available evidence were used to formulate the key treatment and prevention recommendations. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) group criteria to describe both the quality of evidence and the strength of recommendations. We used "recommend" for strong recommendations and "suggest" for weak recommendations. CONSENSUS PROCESS Consensus was guided by systematic reviews of evidence and discussions during one group meeting, several conference calls, and multiple e-mail communications. The drafts prepared by the task force with the help of a medical writer were reviewed successively by The Endocrine Society's CGS, Clinical Affairs Core Committee (CACC), and Council. The version approved by the CGS and CACC was placed on The Endocrine Society's Web site for comments by members. At each stage of review, the Task Force received written comments and incorporated needed changes. CONCLUSIONS We recommend case detection of primary aldosteronism be sought in higher risk groups of hypertensive patients and those with hypokalemia by determining the aldosterone-renin ratio under standard conditions and that the condition be confirmed/excluded by one of four commonly used confirmatory tests. We recommend that all patients with primary aldosteronism undergo adrenal computed tomography as the initial study in subtype testing and to exclude adrenocortical carcinoma. We recommend the presence of a unilateral form of primary aldosteronism should be established/excluded by bilateral adrenal venous sampling by an experienced radiologist and, where present, optimally treated by laparoscopic adrenalectomy. We recommend that patients with bilateral adrenal hyperplasia, or those unsuitable for surgery, optimally be treated medically by mineralocorticoid receptor antagonists.
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Affiliation(s)
- John W Funder
- Prince Henry's Institute of Medical Research, Clayton, VIC, Australia
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Geller DS, Zhang J, Wisgerhof MV, Shackleton C, Kashgarian M, Lifton RP. A novel form of human mendelian hypertension featuring nonglucocorticoid-remediable aldosteronism. J Clin Endocrinol Metab 2008; 93:3117-23. [PMID: 18505761 PMCID: PMC2515083 DOI: 10.1210/jc.2008-0594] [Citation(s) in RCA: 174] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Primary aldosteronism is a leading cause of secondary hypertension (HTN), but the mechanisms underlying the characteristic renin-independent secretion of aldosterone remain unknown in most patients. OBJECTIVES We report a new familial form of aldosteronism in a father and two daughters. All were diagnosed with severe HTN refractory to medical treatment by age 7 yr. We performed a variety of clinical, biochemical, and genetic studies to attempt to clarify the underlying molecular defect. RESULTS Biochemical studies revealed hyporeninemia, hyperaldosteronism, and very high levels of 18-oxocortisol and 18-hydroxycortisol, steroids that reflect oxidation by both steroid 17-alpha hydroxylase and aldosterone synthase. These enzymes are normally compartmentalized in the adrenal fasciculata and glomerulosa, respectively. Administration of dexamethasone failed to suppress either aldosterone or cortisol secretion; these findings distinguish this clinical syndrome from glucocorticoid-remediable aldosteronism, another autosomal dominant form of HTN, and suggest a global defect in the regulation of adrenal steroid production. Genetic studies excluded mutation at the aldosterone synthase locus, further distinguishing this disorder from glucocorticoid-remediable aldosteronism. Because of unrelenting HTN, all three subjects underwent bilateral adrenalectomy, which in each case corrected the HTN. Adrenal glands showed dramatic enlargement, with paired adrenal weights as high as 82 g. Histology revealed massive hyperplasia and cellular hypertrophy of a single cortical compartment that had features of adrenal fasciculata or a transitional zone, with an atrophic glomerulosa. CONCLUSION These findings define a new inherited form of aldosteronism and suggest that identification of the underlying defect will provide insight into normal mechanisms regulating adrenal steroid biosynthesis.
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Affiliation(s)
- David S Geller
- Section of Nephrology, Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, Connecticut 06520-8029, USA.
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49
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Further evidence for linkage of familial hyperaldosteronism type II at chromosome 7p22 in Italian as well as Australian and South American families. J Hypertens 2008; 26:1577-82. [DOI: 10.1097/hjh.0b013e3283028352] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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50
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Mulatero P. A new form of hereditary primary aldosteronism: familial hyperaldosteronism type III. J Clin Endocrinol Metab 2008; 93:2972-4. [PMID: 18685118 DOI: 10.1210/jc.2008-1241] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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