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Residents Clinical Vignette
Primary Hyperaldosteronism: Reassessing a "Negative" Work
Author: Jessica Schwartz, MD
Although previously thought to be a relatively rare cause of
secondary hypertension, hyperaldosteronism is now believed to be
present in 5-13% of cases making it the most common endocrine cause
of uncontrolled blood pressure.
A 59 year-old male with 10 years of worsening resistant
hypertension was seen at a specialist's office and noted to have a
blood pressure of 219/122 mmHg. His hypertension had remained
uncontrolled despite three medications, including a diuretic, which
was discontinued due to persistent hypokalemia. Even off of the
diuretic, the patient required potassium supplementation to
maintain normokalemia. History included no tobacco use and good
medication compliance. Workup to date had included a normal serum
cortisol, 24-hour urine for catecholamines, renal duplex
ultrasound, and an undetectable serum renin level (<0.06 ng/mL)
leading to an EMR entry documenting "negative secondary
hypertension workup". Upon discovery of this incomplete evaluation,
a repeat renin with serum aldosterone found renin <0.06 ng/mL
and aldosterone 26 ng/dL (normal: 8-20 ng/dL), aldosterone to renin
ratio > 25 which led to an adrenal CT which discovered a 7mm
nodule on the left adrenal gland. The patient was referred for
definitive adrenal vein sampling and consideration for surgery.
As only 9-37% of patients demonstrate hypokalemia, a higher
index of suspicion to test for aldosteronism should be uncontrolled
hypertension. Correct identification of a secondary hypertension
cause can lead to definitive therapy that can result in long-term
hypertension control. Physicians caring for patients with resistant
hypertension should review the previous 'workup' to re-consider
whether hyperaldosteronism could have been overlooked as it was