ENDO MR

Endocrinology

morning report

Tiffany Gonzales, MD

"M.P."

BP 196/94 HR 60 RR 18 Sats 99% on RA 99.6F

No swelling, pulses full and equal

ROS: no headache, blurring of vision, chest pain, SOB

34yo Hispanic F

HYPERTENSIVE URGENCY

ENDO consulted:

(ratio 58);

No adrenal vein sampling.

24H urine aldosterone 19,

Repeat CT scan:

2012 --> plasma aldosterone 28,

with Na of 180.

Spironolactone + Lisinopril

plasma renin 0.52,

CT scan N.

NEPHRO consulted: treat htn with lisinopril; amlodipine; carvedilol +/- prn clonidine/ hydralazine

Repeat plasma aldosterone/ren ratio, plasma free metanephrine

Amlodipine + Coreg + Lisinorpil + Hydralazine prn BP > 160

CT AP

potassium repleted

Stable adenoma

DAY 1

pregnancy test

repeat lytes

INTERFERING DRUGS:

MINERALOCORTICOID RECEPTOR ANTAGONISTS:

Spironolactone and eplerenone

sodium loss ---> decreased plasma volume ---> elevation in PRA

On review of previous labs...

TSH, PTH, ECHO: N

BP 220/120

ACEI, ARBs, DIRECT RENIN INHIBITORS:

MRA: renal arteries, kidneys & adrenals: N

US retro: normal, no stenosis

CT scans x 2

PRIMARY ALDOSTERONISM:

ADRENAL CT:

TREATMENT:

PRA OR PRC UNDETECTABLE; PAC/PRA > 20

Overall treatment goal is to prevent the morbidity and mortality associated with HTN, hypokalemia, renal toxicity and cardiovascular damage

Initial study to determine subtype (adenoma versus hyperplasia) and exclude adrenal carcinoma

Patients with unilateral disease (APAs or unilateral hyperplasia):

PRA OR PRC ELEVATED; PAC/PRA < 10

• laparoscopic total adrenalectomy (~35-60% curative)

SECONDARY HYPERALDOSTERONISM:

• mineralocorticoid antagonist therapy (spironolactone and eplerenone)

ADRENAL VEIN SAMPLING:

Patients with bilateral idiopathic hyperaldosteronism:

CONFIRMATORY TESTING:

• mineralocorticoid antagonist therapy (spironolactone and eplerenone)

to distinguish between unilateral adenoma or bilateral hyperplasia

• spironolactone 12.5 mg to 25 mg OD (inc q2weeks)
• eplerenone 25mg BID (max 100mg daily)

ORAL SODIUM LOADING X 3 DAYS (5000mg):

INDICATIONS:

• potassium-sparing diuretics (amiloride and triamterene)

• above 35yrs old who wants surgery

24H urine Na excretion > 200mEq (4600mg) to document adequate sodium loading

Patients with persistent HTN:

• + HCTZ or chlorthalidone or an ACEI

• to confirm unilateral disease of the CT is normal, bilateral or unilateral disease

Urine aldosterone excretion > 12mcg/24h

UA: unremarkable

ASU FOLLOW UP:

CONN'S SYNDROME/PRIMARY HYPERALDOSTERONISM

SURGERY REFERRAL: OUTPATIENT LAPAROSCOPIC ADRENALECTOMY

Amlodipine 10mg OD + Carvedilol 6.25mg BID, Lisinopril 10mg BID + Spironolactone 25mg BID

BP well-controlled on BP meds

In general, PRA and PRC are undetectable; PAC > 15ng/dL; PAC/PRA ratio > 20

elevated PAC/PRA ratio and an increased PAC are both required for the diagnosis of primary aldosteronism

• increased (diuretics, renovascular or malignant HTN, renin-secreting tumor)

• typically very low (Conn's)

• collected in the morning from a seated ambulatory pt

Plasma Renin Activity (PRA) or Plasma Renin Concentration (PRC)

Patient to undergo laparoscopic adrenalectomy on February 20, 2017

INITIAL TESTING

Should be suspected in patients with the triad of hypertension, unexplained hypokalemia, and metabolic alkalosis

Case-detection testing w/ PAC/PRA ratio is recommended in HTN pts with:

• hypokalemia, incl patients treated w/ low dose TZD

• severe or resistant HTN

• adrenal adenoma

ENDOCRINE SOCIETY CLINICAL PRACTICE GUIDELINES

• HTN + spontaneous or low-dose diuretic-induced hypokalemia

• severe HTN (SBP >150 or DBP > 100) or drug resistant HTN

• HTN w/ adrenal incidentaloma

• NORMOKALEMIC:

• HTN w/ sleep apnea

• HTN + FHx of early-onset HTN or CVA at a young age (<40yrs)

• all HTN first-degree relatives of pts w/ Conn's

WHO SHOULD BE TESTED?

Primary Hyperaldosteronism

estimated to be responsible for 5 to 13% on HTN

underdiagnosed cause of hypertension

Most frequent causes include:

• 60-70%: bilateral idiopathic hyperaldosteronism

• 30-40%: unilateral Aldosterone-producing adenoma (APA)

January 17, 2017

34 year old Hispanic female

lost to follow-up

HYPERTENSIVE SINCE SHE WAS 29 YRS OLD

PMHx: HTN on labetalol and nifedipine

called ASU for refills

ASU: follow up of hypertension

Severe hypertension on

multiple medications

PSHx: Cesarian section

asking for refills

2011

compliance

no complaints

advised not to get pregnant

220/121

CT A/P

compliance

140-160/80-90

PE: unremarkable

130/90

DIFFERENTIAL DIAGNOSIS?

G3P2

SocHx: never a smoker, no alcohol use, denies illicit drug use, works as a mother

BP 220/120 HR 67 RR 16 BMI 30

SECONDARY HYPERTENSION

PRIMARY (ESSENTIAL) HYPERTENSION

SECONDARY HYPERTENSION

labetalol + nifedipine

LESS COMMON FORMS:

MAJOR CAUSES:

General clinical clues:

High blood pressure with no secondary cause identifiable

Oral conraceptives

Primary kidney disease

• Severe or resistant hypertension

Pheochromocytoma

elevated serum creatinine concentration &/or an abnormal UA

RF: age, obesity, FHx, race, reduced nephron number, high sodium diet, excess alcohol, DM, dyslipidemia, personality traits, depression

• An acute rise in BP developing in a patient with previous stable values

paroxysmal elevations in BP + triad of headache, palpitations, and sweating

Primary aldosteronism

Cushing's syndrome

RESISTANT HYPERTENSION

• Age less than 30 years in non-obese, non-black patients with negative FHx of HTN and no other RF (eg. obesity) for HTN

Coarctation of the aorta

unexplained or easily provoked hypokalemia due to urinary potassium wasting

Blood pressure that remains above goal in spite of concurrent use of THREE anti-HTN agents of different classes

HTN in the upper extremities, diminished or delayed fmeoral pulses, and low arterial BP in the LEs

slight hypernatremia, drug-resistant HTN, &/or HTN with an adrenal incidentaloma

• Malignant or accelerated HTN Severe or resistant hypertension

Other Endocrine disorders (hypothyroidism and primary hyperparathyroidism)

One of the 3 agents should be a diuretic, and all agents should be prescribed at optimal doses

Sleep apnea syndrome

• Proven age of onset before puberty

ED