SAT-427 - Beyond Hypertension: Pinpointing an Aldosterone-Secreting Adenoma

Introduction:

Primary aldosteronism is associated with increased cardiovascular morbidity and mortality, renal disease, metabolic syndrome, and poor quality of life. The major clinical findings are hypertension and hypokalemia. Despite its high prevalence, primary aldosteronism remains significantly under-diagnosed and inadequately investigated in high-risk individuals. We present a case of primary aldosteronism secondary to adrenal adenoma in a patient with hypertension for greater than 35 years.

Case:

Patient is a 65-year-old male with past medical history of resistant hypertension on four anti-hypertensives and kidney stones who presented to outpatient endocrinology office for work up of secondary hypertension. He was initially diagnosed with hypertension at age 30 and has a family history of hypertension in both parents. His blood pressure was elevated to 146/96 mmHg in office despite being on amlodipine, hydrochlorothiazide, irbesartan and atenolol. Labs were notable for elevated sodium to 144 mmol/L (ref. range 135-145 mmol/L) and hypokalemia with potassium 3.3 mmol/L (ref. range 134-145 mmol/L). Halting the hydrochlorothiazide did not resolve the hypokalemia and he required potassium supplementation. Evaluation of secondary hypertension revealed a significantly elevated aldosterone/renin activity plasma ratio (ARR) to 45.5 (ref. range < 20). CT abdomen/pelvis showed nodular thickening of the left adrenal gland with two nodules measuring 1.2cm and 1.3cm consistent with lipid rich adrenal cortical adenoma with an additional sub-centimeter right adrenal nodule, likely myelolipoma. Subsequent adrenal vein sampling showed laterization to the left adrenal gland. He underwent successful laparoscopic left adrenalectomy with pathology confirming 1.4cm and 1.2cm adrenal cortical adenomas. One week post-operatively, the ARR level improved to 15.2. His blood pressure significantly improved, requiring less medications and hypokalemia resolved.

Conclusions:

This case highlights the necessity of considering primary aldosteronism in the differential diagnosis of refractory hypertension. Early identification and appropriate surgical management of aldosterone-producing adenomas when indicated can lead to significant clinical benefits, including improved blood pressure regulation and resolution of associated electrolyte imbalances. Addressing primary aldosteronism is paramount for improving long-term cardiac, renal, and metabolic outcomes, and for decreasing overall patient morbidity and mortality.

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