• Clinical science

Primary hyperaldosteronism (Conn syndrome)

Abstract

Primary hyperaldosteronism, sometimes referred to as Conn syndrome, is an excess of aldosterone caused by autonomous overproduction, usually at the adrenal cortex. It is typically due to adrenal hyperplasia or adrenal adenoma. Primary hyperaldosteronism is one of the common causes of secondary hypertension. High systemic aldosterone levels result in increased sodium reabsorption and potassium secretion in the collecting ducts of the kidney, which leads to the retention of water along with sodium, as well as hypokalemia. Patients are often asymptomatic and found to have hypertension at routine health checks. It will often emerge that the patient's hypertension is resistant to pharmaceutical therapy, and they may have other signs suggestive of secondary hypertension, such as an age of onset below 30 years or above 55 years. If symptoms are present, they typically include headache, muscle weakness, and polyuria. Initial labs in primary hyperaldosteronism classically show a hypertensive patient with hypokalemia and metabolic alkalosis, and high plasma aldosterone concentration (PAC) and low plasma renin activity (PRA) (PAC/PRA ratio increased). Following biochemical confirmation of primary hyperaldosteronism with oral or intravenous sodium loading tests, imaging modalities such as CT and adrenal venous sampling are used to locate the source of autonomous aldosterone secretion. Treatment of primary hyperaldosteronism consists of surgical resection of adrenal adenoma or pharmaceutical therapy with aldosterone antagonists (e.g., spironolactone, eplerenone) in cases of bilateral adrenal hyperplasia.

Epidemiology

References:[1][2][3]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[2][3][4]

Pathophysiology

Autonomous aldosterone secretion and hypertension

Hypokalemia and metabolic alkalosis

  • Increased sodium reabsorption leads to hypokalemia: ↑ Na+ reabsorption → electronegative lumen → K+ follows the electrical gradient through open K+ channels↑ K+ secretionhypokalemia
  • Hypokalemia causes metabolic alkalosis via two mechanisms (both of which decrease extracellular H+, thereby increasing extracellular pH):
    • Efflux of K+ from intracellular to extracellular space in exchange for H+
    • ↑ H+ secretion in the kidney in order to enable ↑ K+ reabsorption
  • Diabetes insipidus: hypokalemiadesensitization of renal tubules to antidiuretic hormone (ADH) → increased water excretion (polyuria) and excessive thirst (polydipsia)

References:[4]

Clinical features

  • Hypertension
    • Sustained systolic blood pressure > 150 mm Hg or diastolic > 100 mm Hg over three measurements on three different days
    • Systolic blood pressure > 140 mm Hg or diastolic > 90 mmHg AND resistant to three-drug therapy with an adrenergic inhibitor, a vasodilator, and a diuretic
    • Controlled blood pressure on four-drug therapy
    • Other evidence of the presence of secondary hypertension
  • Features of hypokalemia
    • Fatigue
    • Muscle weakness, cramping
    • Headaches
    • Polyuria and polydipsia
    • Palpitations
    • Constipation
  • Lack of significant edema (explained by aldosterone escape → see “Pathophysiology” above)
  • Paresthesia in severe cases due to metabolic alkalosis

The classic clinical picture of primary hyperaldosteronism: a young patient with hypokalemia and drug-resistant hypertension!

References:[3][5][6][7][8]

Diagnostics

Screening tests

Confirmatory tests: several alternatives

  • Oral sodium loading test: high-sodium diet (5000 mg) or oral sodium chloride tablets (2 g taken three times daily) for 3 days, followed by 24-hour urine measurements of aldosterone, sodium (to confirm appropriate sodium loading), and creatinine (to assess adequate urine collection)
  • Saline infusion test: Infusion of 2 L of normal saline over 4 hours
    • Healthy individuals: RAAS is physiologically suppressed → inhibition of aldosterone secretion to plasma concentration < 5 ng/dL (139 pmol/L)
    • Primary hyperaldosteronism: failure to suppress aldosterone secretion (PAC > 10 ng/mL, or 277 pmol/L)
  • Fludrocortisone suppression test: Administration of fludrocortisone (0.1 mg every 6 h) for a duration of 4 days (with simultaneous replacement of sodium chloride and potassium)
    • Healthy individuals: RAAS is physiologically suppressed → substantial decrease of aldosterone < 50 ng/mL or ≤ 6 ng/dL (measured in upright position at 10am on day 4)
    • Primary hyperaldosteronism: Failure to suppress the aldosterone secretion (serum levels > 50–60 ng/mL or > 6 ng/dL)
  • Captopril suppression test PRA and PAC are measured at baseline and 2 hours after administration of a single dose of captopril (25–50 mg)
    • Healthy individuals: RAAS is physiologically suppressed → inhibition of aldosterone secretion (less than 30% suppression from baseline)
    • Primary hyperaldosteronism: failure to suppress the aldosterone secretion (more than 30% suppression from baseline)

Subtype identification: imaging

  • Adrenal CT: initial test to identify the cause of primary hyperaldosteronism already confirmed biochemically
    • Allows for carcinoma to be excluded (or detected)
    • Allows bilateral adrenal hyperplasia to be differentiated from unilateral adrenal adenoma
  • Adrenal venous sampling
    • Criterion standard for differentiating between unilateral adenoma and bilateral hyperplasia
    • Administered if surgical treatment of primary hyperaldosteronism is desired
    • Procedure: PAC measured via catheter in blood from right adrenal vein, left adrenal vein, and inferior vena cava
      • Unilateral disease → four-fold increase in PAC compared with the contralateral side
      • Bilateral hyperplasia → small or no difference in PAC between the two sides (i.e. PAC is bilaterally elevated)

The PAC/PRA ratio is used to detect primary hyperaldosteronism.

References:[9][1][2][3][5][10][11]

Differential diagnoses

References:[12][442;323]

The differential diagnoses listed here are not exhaustive.

Treatment

Bilateral adrenal hyperplasia

Unilateral autonomous aldosterone secretion (adenoma, unilateral hyperplasia, carcinoma)

  • Surgery (adrenalectomy)
    • Prior to surgery, hypokalemia should be corrected with spironolactone and potassium supplementation.
    • Following surgery: monitor for hyperkalemia
  • Aldosterone receptor antagonist therapy may be considered in patients who are poor surgical candidates.

References:[1][2][13]