Abstract: TH-PO239
Primary Hyperaldosteronism Secondary to Right Adrenal Hyperplasia with Nonfunctioning Left Adrenal Adenoma Elucidated by Adrenal Vein Sampling
Session Information
- Hypertension and CVD: Clinical - I
November 02, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Hypertension and CVD
- 1602 Hypertension and CVD: Clinical
Authors
- Tuchinsky, Adam, UPMC Pinnacle Lititz, Lititz, Pennsylvania, United States
- Sardar, Sundus, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, United States
- Akkari, Abdel-Rauof M., Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, United States
- Farooq, Umar, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, United States
- Ghahramani, Nasrollah, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, United States
Introduction
Primary hyperaldosteronism includes two main subtypes namely idiopathic hyperaldosteronism(also termed bilateral adrenal hyperplasia) and unilateral aldosterone-producing adenoma, managed with aldosterone antagonists or adrenalectomy, respectively. Aldosterone renin ratio (ARR) has emerged as a significant parameter as compared to plasma aldosterone concentration (PAC), thus identifying need for adrenal vein sampling (AVS) or further exclusionary tests including imaging, the solitary utility of which without AVS may result in unwarranted adrenalectomy. Our case demonstrates the importance of AVS and elaborates the context that needs to be applied to plasma renin and aldosterone levels.
Case Description
A 68-year-old male with history of type 2 diabetes, coronary artery disease status post stenting 15 years ago, hyperlipidemia, and GERD, was referred for refractory hypertension, requiring carvedilol 25mg twice a day, doxazosin 2mg twice a day, hydrochlorothiazide 50mg daily, isosorbide mononitrate 30mg daily, losartan 100mg daily and spironolactone 50mg daily. Workup revealed microalbuminuria, normal serum potassium, bicarbonate, free metanephrines, renin, elevated aldosterone level of 40.1ng/dL, and elevated ARR of 44.6. Renal duplex ultrasound negative for renal artery stenosis. Noncontrast CT revealed 13x11mm left adrenal adenoma and bilateral adrenal gland thickening likely secondary to hyperplasia; adrenal vein sampling confirmed right adrenal vein aldosterone of 4880ng/dL, cortisol of 1158nmol/L(ratio 4.2), with left aldosterone 146ng/dL, cortisol 495nmol/L(ratio 0.3), and cortisol-corrected PAC laterization ratio of 14. He underwent laparoscopic right adrenalectomy with pathology confirming adrenocortical adenoma. Postoperative followup showed significant improvement in hypertension on fewer agents, decreased aldosterone of 7.8ng/dL, and ARR of 15.6.
Discussion
PAC may be challenging to interpret due to many influencing factors, hence, ARR is emerging as a beneficial parameter to delineate the initial diagnosis of primary hyperaldosteronism. Our case also emphasizes the utility of cortisol corrected PAC laterization ratio in these cases. While adrenal vein sampling may appear counterintuitive, it is prudent to consider AVS for confirmation prior to adrenalectomy.