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Aldosterone Excess – Causes, Symptoms and Treatment

Aldosterone excess occurs when the adrenal glands produce too much aldosterone, leading to high blood pressure and low potassium levels.

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Things worth knowing about "Aldosterone Excess"

Aldosterone excess occurs when the adrenal glands produce too much aldosterone, leading to high blood pressure and low potassium levels.

What Is Aldosterone Excess?

Aldosterone excess is a condition in which the adrenal glands produce abnormally high levels of the hormone aldosterone. Aldosterone is a mineralocorticoid hormone that plays a key role in regulating the body´s salt and water balance. It promotes the reabsorption of sodium in the kidneys while increasing potassium excretion. When too much aldosterone is produced, this disrupts normal electrolyte balance, most notably causing high blood pressure (hypertension) and a low blood potassium level (hypokalemia).

Causes

Aldosterone excess is broadly classified into two main types:

Primary hyperaldosteronism (Conn syndrome): Caused by autonomous overproduction of aldosterone from the adrenal cortex, independent of the normal regulatory system. The most common causes are a unilateral benign adrenal adenoma (Conn adenoma) or bilateral adrenal hyperplasia.
Secondary hyperaldosteronism: Occurs as a response to increased activity of the renin-angiotensin system, triggered by conditions such as heart failure, liver cirrhosis, renal artery stenosis, or dehydration that stimulate the body to produce more aldosterone.

Symptoms

Many individuals experience no symptoms initially. When symptoms do appear, they may include:

Persistent, difficult-to-control high blood pressure
Muscle weakness and cramps (due to low potassium)
Increased thirst and frequent urination (polydipsia and polyuria)
Headaches and fatigue
Heart palpitations or irregular heartbeat (in severe hypokalemia)
Tingling or numbness in the limbs

Diagnosis

Diagnosis of aldosterone excess typically involves several steps:

Laboratory Testing

The initial screening test is measurement of the aldosterone-to-renin ratio (ARR) in the blood. An elevated ratio with high aldosterone and suppressed renin strongly suggests primary hyperaldosteronism. Blood potassium and other electrolyte levels are also assessed.

Confirmatory Tests

To confirm autonomous aldosterone secretion, physicians may use functional tests such as the saline infusion test or the fludrocortisone suppression test.

Imaging

CT or MRI of the adrenal glands is performed to identify an adenoma or hyperplasia. For precise lateralization, adrenal vein sampling (AVS) may be recommended to determine which gland is responsible for the excess production.

Treatment

Treatment depends on the underlying cause:

Surgical Treatment

For a unilateral adrenal adenoma, surgical removal of the affected adrenal gland (adrenalectomy) is the preferred approach. Blood pressure and potassium levels often normalize permanently after the procedure.

Medical Treatment

When surgery is not possible, or in cases of bilateral adrenal hyperplasia, mineralocorticoid receptor antagonists are the treatment of choice. Spironolactone is the first-line medication, with eplerenone used as an alternative. These drugs block the effects of excess aldosterone, effectively lowering blood pressure and correcting potassium deficiency.

References

Funder JW et al. - The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism, 2016.
Rossi GP et al. - Primary Aldosteronism: An Updated Practical Approach for Diagnosis and Treatment. Journal of the American College of Cardiology, 2019.
Williams B et al. - 2018 ESC/ESH Guidelines for the Management of Arterial Hypertension. European Heart Journal, 2018.

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