The diagnosis and treatment of primary aldosteronism associated with end-stage renal disease

Presentation Number: SAT-63
Date of Presentation: June 15th, 2013

Akiyo Tanabe* and Atsuhiro Ichihara
Tokyo Women's Medical University, Tokyo, Japan

Abstract

The prevalence of primary aldosteronism (PA) has been reported to be high in the patients with drug-resistant hypertension and/or hypertension with spontaneous or diuretic-induced hypokalemia. In these typical PA cases, renal function could deteriorate because of severe hypertension and hypokalemia, and some patients consequently fell into end-stage renal disease (ESRD). Serum potassium concentration (s-K) level is increased to normal range, and plasma aldosterone concentration (PAC) level and plasma renin activity (PRA) level tend to be increased in patients with PA in ESRD. There are limitations in washing out of interfering antihypertensive medications or in using contrast medium in the imaging study. Therefore the detection and diagnosis of PA in ESRD are often difficult. Herein we describe the clinical characteristics of 4 patients with aldosterone producing adenoma (median of 50 years) in ESRD on hemodialysis (HD). The cause of renal insufficiency were polycystic kidney disease in 1 patient, IgA chronic nephropathy in 1 patient, nephrosclerosis due to hypertension in 2 patients. Hypertension preceded renal insufficiency in all patients. Mean interval between first diagnoses of renal insufficiency to initiation of HD was 7 years and all patients showed drug-resistant hypertension after initiation of HD. S-K levels before each HD treatment were low (4.1±0.7 mEq/L) in spite of renal insufficiency and those were low after each HD treatment (3.1±0.1 mEq/L). PAC levels were 48-2350 ng/dl and they did not change before and after HD. PRA levels were 0.4-6.0 ng/ml/h and they were decreased after HD. PAC levels and PAC responsiveness to ACTH loading in tumor- and contralateral-side adrenal veins were similar to those in non-ESRD patients in selective adrenal sampling (AVS). All patients were performed adrenalectomy and PAC levels after tumor removal were normalized (6-8 ng/dl) in 3 patients, decreased from 2350 to 141 ng/dl in 1 patient. S-K levels after HD (4.7±0.5 mEq/L) were increased in all patients. Blood pressure was slightly improved and the number of antihypertensive medicines was decreased in 2 patients after adrenalectomy. Those findings suggest that AVS is useful in localization of APA with ESRD as well as APA without ESRD. It is important to pay attention on hypokalemia and low PRA level after HD in order to prevent failing to detect typical PA in patients with ESRD.

 

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