2. • Mrs X/34 yrs
• Recurrent episodes of muscle cramps for 1
year
• Polyuria and nocturia for 5 months.
3. • Dx- Hypertension for 6 years on 4
antihypertensives
• Persistent hypokalemia for 1 year
• Frequent change of antihypertensives once
every 3 months for 1 year
18. Who to screen for Hyperaldosteronism
• HTN + Spontaneous/ low dose diuretic
induced hypokalemia
• Severe HTN( Systolic> 160mm Hg and Diastolic
> 100 mm Hg) / Drug resistant hypertension
J Clin Endocrinol Metab. 2008
19. • HTN with adrenal incidentaloma
• HTN+ family history of early onset HTN
• All hypertensive first degree relatives of
patients with primary hyperaldosteronism.
21. Plasma aldosterone
conc/Plasma renin activity ratio
• PAC > 15 ng/dl Diagnostic of
• Ratio of PAC/PRC > 20 Conn’s
• Test to be performed in the morning 8:00 AM
• Paired random sample to be collected
• Certain drugs contraindicated prior to test
22. Drugs interfering with PAC/PRC ratio
• Mineralocorticoid receptor antagonist
- Spironolactone
- Eplerenone
• ACE inhibitors & ARB
- Low PAC/PRC level does not exclude Conn’s
25. Why one needs to confirm diagnosis
• Mr. X
- Hypertension
- Hypokalemia
- PAC/PRA – Borderline
26. Test for confirmation
• Oral Na loading test
- Correct hypertension and hypokalemia
- Avoid Spironolactone/ Eplerenone
- Achieve 5000mg Na diet over 3 days/ Two 1
gram Na tablets taken three times daily
33. If Management was based on CT/MRI
• 139 patients (14.6%) - inappropriately
undergone unilateral adrenalectomy
• 181 patient (19.1) - medical management
instead of curative adrenalectomy
• 37 patients (3.9%) – adrenalectomy on the
wrong side
34. Adrenal vein sampling
• Measurement of aldosterone sample in
adrenal venous blood.
• Unilateral four fold increase of aldosterone
diagnostic
35. Role for adrenal venous sampling in primary aldosteronism.
AU
Young WF, Stanson AW, Thompson GB, Grant CS, Farley DR, van Heerden JA
SO
Surgery. 2004;136(6):1227.
APA - Aldosterone producing adenoma
IHA – Idiopathic hyperplasia of adrenals
PAH – Unilateral adrenal hyperplasia
38. Postoperative persistent
hypertension
• Long term cure rate – 69%
• 60 % become normotensive
• 40% improve markedly but remain
hypertensive
• Normalisation of blood pressure DOES NOT
occur immediately after operation – 1 year
39. Risk factors for persistent HTN
• Age
- Older age group associated with lesser
chances of reversal to normotensive
• Gender
• Duration of HTN preop
• Positive family history of HTN