Case capsule Zeeshan
Case capsule
Zeeshan
• Mrs X/34 yrs
• Recurrent episodes of muscle cramps for 1 year
• Polyuria and nocturia for 5 months.
• Dx- Hypertension for 6 years on 4 antihypertensives
• Persistent hypokalemia for 1 year
• Frequent change of antihypertensives once every 3 months for 1 year
Other significant H/O?
On examination
• HR - 80 per minute BP – 170/90 mm Hg.
• General and systemic examination was unremarkable.
Investigations?
Investigation Value
Hb 12.2 gm%
Total counts 10,600 / mm3
Electrolytes Na- 140mmol/l K- 2.5mmol/l
Urine metanephrine/ normetanephrine
105mcg/24hrs (<350ng/24hrs)533 mcg/24 hrs (<600ng/24hrs)
Creatinine 0.62
Renin <0.1 ng/ml/hr (At rest–.05-2.3) (Upright – 1.3-4)
Aldosterone 2.78 nanogm/ml (0.40 – 3.10ng/ml )
Serum Cortisol (8AM) 7mcg/dL (6-23 mcg/dL)
Cortisol post-dexa suppression
0.31 mcg/dl (<1.8mcg/dl)
Differential diagnosis?
DD for Hypertension + Hypokalemia
• Renovascular disease
• Cushing’s syndrome
• Renin secreting tumors
• Congenital adrenal hyperplasia
• Primary aldosteronism
Diagnosis?
Most common subtypes
• Bilateral idiopathic hyperaldosteronism(IHA)
• Aldosterone producing adenomas (APA)
Clinical presentation
• Uncontrolled hypertension
• Unexplained hypokalemia
Who to screen for Hyperaldosteronism
• HTN + Spontaneous/ low dose diuretic induced hypokalemia
• Severe HTN( Systolic> 160mm Hg and Diastolic > 100 mm Hg) / Drug resistant hypertension
J Clin Endocrinol Metab. 2008
• HTN with adrenal incidentaloma
• HTN+ family history of early onset HTN
• All hypertensive first degree relatives of patients with primary hyperaldosteronism.
RAA cascade
Plasma aldosterone conc/Plasma renin activity ratio
• PAC > 15 ng/dl Diagnostic of • Ratio of PAC/PRC > 20 Conn’s
• Test to be performed in the morning 8:00 AM• Paired random sample to be collected• Certain drugs contraindicated prior to test
Drugs interfering with PAC/PRC ratio
• Mineralocorticoid receptor antagonist - Spironolactone - Eplerenone
• ACE inhibitors & ARB - Low PAC/PRC level does not exclude Conn’s
24 hour urine test
• 24 hour urine potassium- Potassium wasting (>30 mEq/day)
• 24 hour urine aldosterone measurement
Why one needs to confirm diagnosis
• Mr. X- Hypertension- Hypokalemia- PAC/PRA – Borderline
Test for confirmation
• Oral Na loading test- Correct hypertension and hypokalemia
- Avoid Spironolactone/ Eplerenone
- Achieve 5000mg Na diet over 3 days/ Two 1 gram Na tablets taken three times daily
Results
- Check 24 hour urine Na for checking adequate loading
- Check urine Aldosterone levels ( > 12 ng/dl diagnostic)
Saline infusion test
• Administer 2 litres of isotonic saline over 4 hours
• Normal individuals – PAC < 5 ng/dl
• Primary hyperaldosteronism – PAC > 10 ng/dl
Diagnostic dillema
Bilateral adrenal hyperplasia
Aldosterone producing adenoma
Incidence 60 % 35%
Aldostn rate
Lower rate of production
Higher rate
Hypokalemia
Mild Profound
Age > 50 yrs < 50 yrs
CT abdomen
Presence of unilateral mass does NOT confirm Adenoma
Presence of bilateral lesion – NOT diagnostic of hyperplasia
Systematic review of 38 studies
• Ann Intern Med. 2009;151(5):329.
If Management was based on CT/MRI
• 139 patients (14.6%) - inappropriately undergone unilateral adrenalectomy
• 181 patient (19.1) - medical management instead of curative adrenalectomy
• 37 patients (3.9%) – adrenalectomy on the wrong side
Adrenal vein sampling
• Measurement of aldosterone sample in adrenal venous blood.
• Unilateral four fold increase of aldosterone diagnostic
Role for adrenal venous sampling in primary aldosteronism.AUYoung WF, Stanson AW, Thompson GB, Grant CS, Farley DR, van Heerden JASOSurgery. 2004;136(6):1227.
APA - Aldosterone producing adenomaIHA – Idiopathic hyperplasia of adrenalsPAH – Unilateral adrenal hyperplasia
Operation
• Retroperitoneoscopic/ Laparoscopic adrenalectomy
Postoperative persistent hypertension
• Long term cure rate – 69%
• 60 % become normotensive• 40% improve markedly but remain
hypertensive
• Normalisation of blood pressure DOES NOT occur immediately after operation – 1 year
Risk factors for persistent HTN
• Age- Older age group associated with lesser
chances of reversal to normotensive• Gender• Duration of HTN preop• Positive family history of HTN