Abstract Body: Case presentation
We present a case of a 48-year-old female with past medical history of long-standing hypertension for more than 20 years managed with two antihypertensive medications (losartan 100 mg and amlodipine 10 mg), who was referred to emergency room for hypokalemia of 2.5 mmol/l, however, she did not have any complaints. Vital signs were: BP 125/76 mmHg, HR 72 bpm. Physical exam was unremarkable. EKG showed normal sinus rhythm and U-waves. Additional work-up revealed aldosterone of 26 ng/dL (N: 7 - 30 ng/dL) and suppressed plasma renin level <0.04 (N: 0.25-5.82 ng/ml/h). Aldosterone-to-renin ratio was more than 30 (N: < 30) suggesting primary hyperaldosteronism (PA) which was confirmed with salt loading. CTAP revealed left adrenal adenoma. Adrenal vein sampling confirmed unilateral secretion of aldosterone.
Differential diagnosis
Secondary hypertension causes were included in differential diagnosis, such as PA, Cushing syndrome, pheochromocytoma, thyroid dysfunction, renal artery stenosis, renal parenchymal disease and substance-abuse related hypertension. However, additional work-up was done showing normal levels of TSH, free T4, 24-hour urine cortisol, metanephrines and normetanephrines. Drug screen was negative. Renal structure was normal on CTAP. Renal Doppler study excluded renal artery stenosis.
Treatment and Management
Patient underwent robotic left adrenalectomy. Levels of aldoserone and potassium normalized shortly after surgery.
Outcome and Follow-Up
In 6 weeks after surgery, her BP regimen has decreased to one medication at the lower dose (losartan 50 mg) with subsequent resolution of long-standing hypertension and no need in antihypertensive therapy in 8 months. Patient remained off medications two years after surgery.
Teaching points
PA is associated with higher risk of cardiovascular events and renal damage compared to primary hypertension (HTN) and occurs in up to 20 % of patients with HTN. Patients with mild hypertension are usually excluded from the screening for PA, thus, high index of clinical suspicion for PA is mandatory for these patients. More than 60 % of patients with PA do not have hypokalemia and some of them have normal BP. Appropriate surgical treatment of unilateral PA leads to normalization of serum aldosterone in 97.6% of patients with subsequent decrease in the number and dosing of antihypertensive therapy and reduction of cardiovascular risks as well as eliminates the risk of side effects from antihypertensive therapy.