Thread by @AnandVaidya17

1/How does primary aldosteronism present? When should you look for it?

Here are a couple of clinical cases I like to share with audiences when I talk about the severity spectrum of primary aldosteronism, and the many ways autonomous aldosterone secretion can manifest.

2/Here are two patients.

3/
Would you screen for primary aldosteronism?

4/

Case 1 = YES. He has chronic HTN, uncontrolled on 4 drugs, and hypoK.

Case 2 = Prob not? This patient would’ve been “normotensive” in the past, but in 2018, he has HTN. His PCP starts him on chlorthalidone and 2 weeks later his K=2.9.

5/
Would you screen Case 2 for primary aldosteronism now?

6/
YES. Diuretic-induced hypokalemia is an indication to screen for PA
ncbi.nlm.nih.gov/pubmed/28332881

7/
Both patients are screened for PA, see results.

8/ Could these patients have primary aldosteronism?

9/

Case 1: YES/CONFIRMED. HypoK, suppressed renin, very high aldosterone. This is a positive screen and positive confirmation.

Case 2: YES/POSSIBLY. Normal K. suppressed renin. But ?inappropriately elevated? aldosterone?

10/
Case 2 undergoes a confirmatory oral sodium suppression test (4 days of high sodium diet). 24h UNa>200 mmol and 24h aldosterone excretion rate = 16 mcg/24h

11/
Does Case 2 have primary aldosteronism?

12/

YES, they both have PA.

Case 1 was obvious, prob could have been diagnosed years/decades earlier.
Case 2 was diagnosed early and will hopefully avoid years of CV disease.

One diagnostic approach w/flexibility to detect cases of varying severity =>
ncbi.nlm.nih.gov/pubmed/30124805

13/
Final thoughts:
Exact prevalence not completely clear, but primary aldosteronism can be detected in severe/resistant HTN (>10%), mild-mod HTN (~4-10%)…

ncbi.nlm.nih.gov/pubmed/?term=2…
ncbi.nlm.nih.gov/pubmed/?term=1…

14/
As well as among normotensives (who have a higher risk for developing overt HTN).

ncbi.nlm.nih.gov/pubmed/?term=2…
ncbi.nlm.nih.gov/pubmed/?term=2…
ncbi.nlm.nih.gov/pubmed/?term=2…

Much more work needed to determine how to expand screening in an effective way to detect PA early/end

15/ For more on primary aldosteronism => see final version of our comprehensive, contemporary (and colorful!) review. We review the history of aldosteronism, and the latest in diagnosis, pathogenesis, and treatment...

ncbi.nlm.nih.gov/pubmed/30124805

16/ ….approaching the diagnosis of primary aldosteronism…

17/ …current theories on the pathogenesis and severity spectrum of primary aldosteronism…

18/ …recent evidence and opinions on treatment of primary aldosteronism…

19/ Many thanks to #EndocrineReviews @EndoSocJournals @DanielJDrucker for the opportunity, the wordspace, and medical illustration to bring our figures to life!