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Case Detection, Diagnosis, and Treatment of Patients with Primary Aldosteronism: An Endocrine Society Clinical Practice Guideline

Prince Henry’s Institute of Medical Research (J.W.F.), Clayton VIC 3168, Australia; University of Virginia Health System (R.M.C.), Charlottesville, Virginia 22908; Facultad de Medicina Pontificia Universidad Católica de Chile (C.F.), Santiago 1365, Chile; G.V. (Sonny) Montgomery VA Medical Center (C.E.G.-S.), Jackson, Mississippi 39216; University of Padova (F.M.), 35100 Padua, Italy; University of Queensland (M.S.), Brisbane QLD 4000, Australia; and Mayo Clinic (W.F.Y., V.M.M.), Rochester, Minnesota 55902

Address all correspondence and requests for reprints to: The Endocrine Society, 8401 Connecticut Avenue, Suite 900, Chevy Chase, Maryland 20815. E-mail: govt-prof{at}endo.society.org. Telephone: 301-941-0200. Address all reprint requests for orders 101 and more to: Heather Edwards, Reprint Sales Specialist, Cadmus Professional Communications, Telephone: 410-691-6214, Fax: 410-684-2789 or by E-mail: endoreprints{at}cadmus.com. Address all reprint requests for orders 100 or less to Society Services, Telephone: 301-941-0210 or by E-mail: societyservices{at}endo-society.org.

Objective: Our objective was to develop clinical practice guidelines for the diagnosis and treatment of patients with primary aldosteronism.

Participants: The Task Force comprised a chair, selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society, six additional experts, one methodologist, and a medical writer. The Task Force received no corporate funding or remuneration.

Evidence: Systematic reviews of available evidence were used to formulate the key treatment and prevention recommendations. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) group criteria to describe both the quality of evidence and the strength of recommendations. We used "recommend" for strong recommendations and "suggest" for weak recommendations.

Consensus Process: Consensus was guided by systematic reviews of evidence and discussions during one group meeting, several conference calls, and multiple e-mail communications. The drafts prepared by the task force with the help of a medical writer were reviewed successively by The Endocrine Society’s CGS, Clinical Affairs Core Committee (CACC), and Council. The version approved by the CGS and CACC was placed on The Endocrine Society’s Web site for comments by members. At each stage of review, the Task Force received written comments and incorporated needed changes.

Conclusions: We recommend case detection of primary aldosteronism be sought in higher risk groups of hypertensive patients and those with hypokalemia by determining the aldosterone-renin ratio under standard conditions and that the condition be confirmed/excluded by one of four commonly used confirmatory tests. We recommend that all patients with primary aldosteronism undergo adrenal computed tomography as the initial study in subtype testing and to exclude adrenocortical carcinoma. We recommend the presence of a unilateral form of primary aldosteronism should be established/excluded by bilateral adrenal venous sampling by an experienced radiologist and, where present, optimally treated by laparoscopic adrenalectomy. We recommend that patients with bilateral adrenal hyperplasia, or those unsuitable for surgery, optimally be treated medically by mineralocorticoid receptor antagonists.

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