This Article Full Text Full Text (PDF) Submit a related Letter to the Editor Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Copyright Permission Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Oelkers, W. Articles by Bähr, V. Search for Related Content PubMed PubMed Citation Articles by Oelkers, W. Articles by Bähr, V.

Primary Hyperaldosteronism without Suppressed Renin Due to Secondary Hypertensive Kidney Damage

Division of Endocrinology, Department of Medicine, Klinikum Benjamin Franklin, Freie Universität Berlin, 12200 Berlin, Germany

Address all correspondence and requests for reprints to: Prof. W. Oelkers, M.D., Klinikum Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany. E-mail: oelkers{at}medizin.fu-berlin.de

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.

This article has been cited by other articles:

				C. Catena, G. Colussi, E. Nadalini, A. Chiuch, S. Baroselli, R. Lapenna, and L. A. Sechi Relationships of Plasma Renin Levels with Renal Function in Patients with Primary Aldosteronism Clin. J. Am. Soc. Nephrol., July 1, 2007; 2(4): 722 - 731. [Abstract] [Full Text] [PDF]

				J. F. E. Mann What's new in hypertension? Nephrol. Dial. Transplant., January 1, 2007; 22(1): 47 - 52. [Full Text] [PDF]

				L. A. Sechi, M. Novello, R. Lapenna, S. Baroselli, E. Nadalini, G. L. Colussi, and C. Catena Long-term renal outcomes in patients with primary aldosteronism. JAMA, June 14, 2006; 295(22): 2638 - 2645. [Abstract] [Full Text] [PDF]

				J. Ribstein, G. Du Cailar, P. Fesler, and A. Mimran Relative Glomerular Hyperfiltration in Primary Aldosteronism J. Am. Soc. Nephrol., May 1, 2005; 16(5): 1320 - 1325. [Abstract] [Full Text] [PDF]

				F. H. Perschel, R. Schemer, L. Seiler, M. Reincke, J. Deinum, C. Maser-Gluth, D. Mechelhoff, R. Tauber, and S. Diederich Rapid Screening Test for Primary Hyperaldosteronism: Ratio of Plasma Aldosterone to Renin Concentration Determined by Fully Automated Chemiluminescence Immunoassays Clin. Chem., September 1, 2004; 50(9): 1650 - 1655. [Abstract] [Full Text] [PDF]

				D. A. Calhoun, M. K. Nishizaka, M. A. Zaman, R. B. Thakkar, and P. Weissmann Hyperaldosteronism Among Black and White Subjects With Resistant Hypertension Hypertension, December 1, 2002; 40(6): 892 - 896. [Abstract] [Full Text] [PDF]

				M. Brand, B. Dehmel, S. Cristow, and R. Kettritz A strange case of hypokalaemia Nephrol. Dial. Transplant., February 1, 2002; 17(2): 297 - 299. [Full Text] [PDF]