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Murai S, Kakeshita K, Imamura T, Koike T, Fujioka H, Yamazaki H, Kinugawa K. Malignant Hypertension and Bilateral Primary Aldosteronism. Intern Med 2023; 62:2675-2680. [PMID: 36725041 PMCID: PMC10569932 DOI: 10.2169/internalmedicine.1098-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/18/2022] [Indexed: 02/03/2023] Open
Abstract
Malignant hypertension triggers incremental renin activity, whereas primary aldosteronism suppresses such activity. We encountered a patient with malignant hypertension refractory to multiple anti-hypertensive agents. Repeated neurohormonal assessments, instead of a single one, eventually uncovered trends in an incremental aldosterone concentration, ranging from 221 up to 468 pg/mL, with a decline in the renin activity from 2.3 to <0.2 ng/mL/h. Adrenal venous sampling confirmed bilateral aldosterone secretion. Following the diagnosis of bilateral primary aldosteronism, we initiated a mineralocorticoid receptor antagonist, which improved his blood pressure. Repeated neurohormonal assessments are encouraged to correctly diagnose underlying primary aldosteronism with malignant hypertension.
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Affiliation(s)
- Sayaka Murai
- The Second Department of Internal Medicine, University of Toyama, Japan
| | - Kota Kakeshita
- The Second Department of Internal Medicine, University of Toyama, Japan
| | - Teruhiko Imamura
- The Second Department of Internal Medicine, University of Toyama, Japan
| | - Tsutomu Koike
- The Second Department of Internal Medicine, University of Toyama, Japan
| | - Hayato Fujioka
- The Second Department of Internal Medicine, University of Toyama, Japan
| | - Hidenori Yamazaki
- The Second Department of Internal Medicine, University of Toyama, Japan
| | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, Japan
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Maruhashi T, Amioka M, Kishimoto S, Ikenaga H, Oki K, Ishida M, Kihara Y, Higashi Y. Elevated Plasma Renin Activity Caused by Accelerated-malignant Hypertension in a Patient with Aldosterone-producing Adenoma Complicated with Renal Insufficiency. Intern Med 2019; 58:3107-3111. [PMID: 31292373 PMCID: PMC6875448 DOI: 10.2169/internalmedicine.2327-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
During the malignant phase of hypertension in patients with primary aldosteronism complicated with severe renal failure, the plasma renin activity may markedly increase with a false negative screening result for primary aldosteronism, thus potentially leading to a missed diagnosis of primary aldosteronism. We herein report the case of 37-year-old man who presented with accelerated-malignant hypertension complicated with severe renal insufficiency. The plasma renin activity was markedly increased in the malignant phase of hypertension, which were atypical results for primary aldosteronism. However, a plain abdominal computed tomography scan revealed a left adrenal nodule, which was diagnosed as aldosterone-producing adenoma by adrenal venous sampling.
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Affiliation(s)
- Tatsuya Maruhashi
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima University, Japan
| | - Michitaka Amioka
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima University, Japan
| | - Shinji Kishimoto
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Japan
| | - Hiroki Ikenaga
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima University, Japan
| | - Kenji Oki
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Mari Ishida
- Department of Cardiovascular Physiology and Medicine, Hiroshima University, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima University, Japan
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Japan
- Division of Regeneration and Medicine, Hiroshima University Hospital, Japan
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Heras Benito M, Fernández-Reyes Luis MJ, Rodríguez Gómez MA. Aldosteronismo con actividad de renina aumentada: ¿primario versus secundario? Importancia del seguimiento en el tiempo para el diagnóstico. Nefrologia 2019; 39:102-103. [DOI: 10.1016/j.nefro.2018.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 06/16/2018] [Indexed: 11/29/2022] Open
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Takahashi F, Goto M, Wada Y, Hasebe N. Successful Treatment with an Antihypertensive Drug Regimen Including Eplerenone in a Patient with Malignant Phase Hypertension with Renal Failure. Intern Med 2015; 54:2467-70. [PMID: 26424305 DOI: 10.2169/internalmedicine.54.4425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 28-year-old man was referred to our hospital for the treatment of congestive heart failure and severe hypertension. The patient was diagnosed with malignant phase hypertension based on the presence of marked hypertension with left ventricular hypertrophy, exudate retinopathy, and renal failure. Intensive therapy for hypertension and heart failure with a combination of antihypertensive drugs including nitroglycerin, nifedipine, eplerenone and candesartan successfully lowered his blood pressure and further improved the renal function. Eplerenone could be one of the choices of antihypertensive drugs in combination therapy in patients with malignant phase hypertension with progressive heart and renal failure.
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Diagnostic value of I-131 NP-59 SPECT/CT scintigraphy in patients with subclinical or atypical features of primary aldosteronism. J Biomed Biotechnol 2011; 2011:209787. [PMID: 21541242 PMCID: PMC3085291 DOI: 10.1155/2011/209787] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 02/15/2011] [Indexed: 11/17/2022] Open
Abstract
Accumulating evidence has shown the adverse effect of long-term hyperaldosteronism on cardiovascular morbidity that is independent of blood pressure. However, the diagnosis of primary aldosteronism (PA) remains a challenge for patients who present with subtle or atypical features or have chronic kidney disease (CKD). SPECT/CT has proven valuable in the diagnosis of a number of conditions. The aim of this study was to determine the usefulness of I-131 NP-59 SPECT/CT in patients with atypical presentations of PA and in those with CKD. The records of 15 patients with PA were retrospectively analyzed. NP-59 SPECT/CT was able to identify adrenal lesion(s) in CKD patients with suspected PA. Patients using NP-59 SPECT/CT imaging, compared with those not performing this procedure, significantly featured nearly normal serum potassium levels, normal aldosterone-renin ratio, and smaller adrenal size on CT and pathological examination and tended to feature stage 1 hypertension and non-suppressed plasma renin activity. These findings show that noninvasive NP-59 SPECT/CT is a useful tool for diagnosis in patients with subclinical or atypical features of PA and those with CKD.
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Ortet Ballesterosa J, Gómez Alamillob C. Crisis hipertensiva como presentación de hiperaldosteronismo primario. Abordaje diagnóstico y terapéutico. HIPERTENSION Y RIESGO VASCULAR 2004. [DOI: 10.1016/s1889-1837(04)71500-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Although they have become less common, hypertensive emergencies occur with an incidence of approximately 1 to 2/100,000 people per year. Our knowledge about this problem, its pathophysiology, risk factors, and appropriate treatment options has expanded during the past decade. A hypertensive emergency can be declared when an elevated blood pressure is associated with acute target-organ damage. Rapid evaluation and treatment (typically with an intravenously administered agent) should be instituted, usually in an intensive care unit setting, and the patient should be observed carefully during acute blood-pressure lowering. When properly treated, the prognosis for these patients is not nearly as dismal as it was more than 60 years ago, and the initial level of function of target organs (brain, heart, kidneys) is more indicative of an emergency than the actual level of blood pressure. Therapeutic options include the time-tested sodium nitroprusside (which has toxic metabolic products and is contraindicated in pregnancy, tobacco amblyopia, and Leber's optic atrophy); fenoldopam mesylate; and nicardipine. When properly treated, "malignant hypertension" need be considered malignant no longer.
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Affiliation(s)
- William J Elliott
- RUSH Medical College of RUSH University at RUSH-Presbyterian-St. Luke's Medical Center, 1700 West Van Buren Street, Suite 470, Chicago, IL 60612, USA.
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Koshiyama H, Fujisawa T, Kuwamura N, Nakamura Y, Kanamori H, Oida E, Hara A, Suzuki T, Sasano H. A case of normoreninemic aldosterone-producing adenoma associated with chronic renal failure: case report and literature review. Endocrine 2003; 21:221-6. [PMID: 14515005 DOI: 10.1385/endo:21:3:221] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2003] [Revised: 04/21/2003] [Accepted: 04/28/2003] [Indexed: 11/11/2022]
Abstract
The diagnosis of aldosterone-producing adenoma (APA) is challenging for endocrinologists, as APA does not always present with the typical constellation of clinical and laboratory features, such as hypertension, hypokalemia, suppressed plasma renin activity (PRA), and high plasma aldosterone concentration (PAC). Very recently, several studies have indicated that APA can be discovered even in normokalemic subjects with normal PRA more frequently than previously considered. Here we report a case of APA associated with chronic renal failure, which showed normokalemia and normal PRA. The patient was referred to our clinic for evaluation of an incidentally discovered adrenal mass with abnormally high PAC. After 6 yr, it was found that the right adrenal tumor showed a marked increase in size. Endocrinological examinations indicated normal PRA and markedly high PAC. Aldosterone showed a better response to the upright posture test than that to ACTH stimulation test. The diagnosis of APA was made based on the markedly high PAC to PRA ratio and the adrenocortical scintigraphy, which showed unequivocal uptake into the tumor. Right laparoscopic adrenalectomy was performed, revealing a right adrenocortical adenoma with massive hemorrhage. Histopathological examinations revealed the presence of two independent adrenocortical adenomas, one APA with predominant clear tumor cells and few c17 (17alpha-hydroxylase) immunoreactivity and the other, cortisol producing adenoma with compact cytoplasm and abundant C17 immunoreactivity. This case indicates a difficulty of diagnosis of "normoreninemic APA" with renal failure. This case is in line with the recent concept that APA is a continuous condition in which only a minority of patients have the classical clinical picture of primary aldosteronism such as hypokalemia. It is possible that normokalemic APA constitutes the most common presentation of the disease.
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Affiliation(s)
- Hiroyuki Koshiyama
- Division of Diabetes & Endocrinology, Department of Medicine, Tazuke Kofukai Foundation Medical Research Institute Kitano Hospital, 2-4-20 Ohgi-machi, Kita-ku, Osaka 530-8480, Japan.
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Abstract
In summary, patients presenting with a true hypertensive emergency should be diagnosed quickly and promptly started on effective parenteral therapy (typically nitroprusside 0.5 microgram/kg/min or fenoldopam 0.1 microgram/kg/min) in an intensive care unit. Blood pressure should be reduced about 25% gradually over 2 to 3 hours. Oral antihypertensive therapy (often with an immediate-release calcium antagonist) can be instituted after 6 to 12 hours of parenteral therapy, and consideration should be given to secondary causes of hypertension after transfer out of the intensive care unit. Because of advances in antihypertensive therapy and management, "malignant hypertension" should be truly malignant no longer.
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Affiliation(s)
- W J Elliott
- Department of Preventive Medicine, Rush Medical College of Rush University at Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois, USA.
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Oelkers W, Diederich S, Bähr V. Primary hyperaldosteronism without suppressed renin due to secondary hypertensive kidney damage. J Clin Endocrinol Metab 2000; 85:3266-70. [PMID: 10999820 DOI: 10.1210/jcem.85.9.6819] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Primary hyperaldosteronism is characterized by high plasma and urinary aldosterone and suppressed PRA. Renin suppression is due to aldosterone-dependent sodium retention and mild extracellular volume expansion. We observed three patients with primary hyperaldosteronism, severe refractory hypertension, and normal to high normal PRA levels whose aldosterone/renin ratios were still elevated because of disproportionately high aldosterone levels. All available medical data on the patients as well as publications on the aldosterone/renin relationship in primary hyperaldosteronism were reviewed to explain the unusual findings. In one patient, histologically proven renal arteriolosclerosis was the probable cause of the escape of PRA from suppression by an aldosterone-producing adenoma. In the other two patients, hypertensive kidney damage due to primary hyperaldosteronism was the most likely explanation for the inappropriately high PRA, as in patient 1. All patients had high normal or slightly elevated serum creatinine levels and responded to 200 mg spironolactone/day with increased serum creatinine and hyperkalemia. Hyperkalemia was probably due to a decreased filtered load of sodium and a spironolactone-induced decrease in mineralocorticoid function. Two patients were cured of hyperaldosteronism by unilateral adrenalectomy but still need some antihypertensive therapy, whereas one patient has probable bilateral adrenal disease, with normal blood pressure on a low dose of spironolactone. In patients with severe hypertension due to primary hyperaldosteronism, PRA can escape suppression if hypertensive kidney damage supervenes. An increased aldosterone/PRA ratio is still useful in screening for primary hyperaldosteronism. These patients may respond to spironolactone therapy with a strong increase in serum creatinine and potassium. Early specific treatment of primary hyperaldosteronism is therefore indicated, and even a patient with advanced hypertension will profit from adrenalectomy or cautious spironolactone treatment.
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Affiliation(s)
- W Oelkers
- Department of Medicine, Klinikum Benjamin Franklin, Freie Universität Berlin, Germany.
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