eplerenone and Adrenal-Cortex-Neoplasms

The identification of primary aldosteronism as a common cause of resistant hypertension is a significant advance in our ability to care for patients with hypertension. Primary aldosteronism is common, and when unrecognized is associated with an increased incidence of adverse cardiovascular outcomes. Identification of primary aldosteronism is based on use of the plasma aldosterone level, plasma renin activity, and the aldosterone:renin ratio. Differentiation between unilateral and bilateral autonomous adrenal aldosterone production then guides further therapy, with use of mineralocorticoid-receptor blockers for patients with bilateral autonomous adrenal aldosterone production and laparoscopic adrenalectomy for patients with unilateral autonomous aldosterone production. In this review, we discuss in detail the pathogenesis of primary aldosteronism-induced hypertension and potassium disorders, the evaluation of the patient with suspected primary aldosteronism, and the management of primary aldosteronism, both through medications and surgery.

Topics: Adrenal Cortex Neoplasms; Adrenalectomy; Adrenocortical Adenoma; Aldosterone; Eplerenone; Humans; Hyperaldosteronism; Hypertension; Hypokalemia; Mineralocorticoid Receptor Antagonists; Renin; Spironolactone

Primary hyperaldosteronism (PHA) is characterized by an increased Aldosterone synthesis which is independent of the Renin-Angiotensin-Aldosterone-System (RAAS). The prevalence of PHA in patients who present in specialized hypertension centers is approx. 10 %. Besides patients with the classical symptoms known as "Conn-Trias" (hypertension, hypokalemia, metabolic alkalosis), the more frequent normokalemic patients with PHA also show a worse outcome compared to patients with essential hypertension. Identifying these patients is an important task in the evaluation of hypertension since targeted treatment options are available. Screening for PHA using the Aldosterone-Renin-Ratio (ARR) should be performed in patients with hypokalemic, severe or resistant hypertension. In addition, young patients with early onset of severe hypertension and/or positive family history should be screened. A positive screening result should be followed by a confirmatory test. The saline infusion test is the preferred clinical test for confirming a suspected PHA since it is accessible and time efficient. Other confirmatory tests are not used on a regular basis. After any confirmatory test, CT- or MRI-imaging and adrenal vein sampling (AVS) is used in order to differentiate between a unilateral adenoma, a bilateral hyperplasia or another cause of PHA. CT or MRI usually cannot discriminate smaller tumors form hyperplasia. Therefore AVS is used to detect lateralization of autonomous aldosterone production. Lateralization of aldosterone production indicates a unilateral adenoma. In these cases, laparoscopic adrenalectomy is the therapeutic option of choice with a hypertension cure rate of up to 60 %. If no lateralization is detectable, bilateral hyperplasia as the underlying cause of PHA is likely. Pharmacological inhibition of the mineralocorticoid receptor is the preferred treatment option in these cases. If Spironolactone is not well tolerated, Eplerenone and potassium-sparing diuretics should be prescribed. Often, however, in order to fully control hypertension, additional antihypertensive therapy is necessary.

Topics: Adrenal Cortex Neoplasms; Adrenal Glands; Adrenal Hyperplasia, Congenital; Adrenocortical Adenoma; Aldosterone; Antihypertensive Agents; Diagnosis, Differential; Eplerenone; Hyperaldosteronism; Hypertension; Hypokalemia; Magnetic Resonance Imaging; Mass Screening; Renin; Spironolactone; Tomography, X-Ray Computed

It remains unclear whether adrenalectomy has more beneficial effects than treatment with a mineralocorticoid receptor antagonist on vascular function in patients with aldosterone-producing adenoma (APA).. The aim of this study was to compare the effects of adrenalectomy and treatment with eplerenone on vascular function in patients with APA.. Flow-mediated vasodilation (FMD), as an index of endothelium-dependent vasodilation, and nitroglycerine-induced vasodilation (NID), as an index of endothelium-independent vasodilation, were measured to assess vascular function before and after a 3-month treatment with eplerenone and at 3 months after adrenalectomy in 23 patients with APA.. Flow-mediated vasodilation and NID after adrenalectomy were significantly higher than those before treatment with eplerenone (5.4 ± 2.6% vs 2.7 ± 1.9% and 14.8 ± 4.7% vs 9.6 ± 4.6%, P < 0.01, respectively) and those after treatment with eplerenone (5.4 ± 2.6% vs 3.1 ± 2.3% and 14.8 ± 4.7% vs 11.0 ± 5.3%, P < 0.01 and P = 0.03, respectively), while treatment with eplerenone did not alter FMD and NID compared with those before treatment with eplerenone. After adrenalectomy, the increase in FMD and NID were significantly correlated with a decrease in plasma aldosterone concentration and a decrease in the aldosterone-renin ratio. There were no significant relationships between FMD and changes in other parameters or between NID and changes in other parameters.. Adrenalectomy, but not treatment with eplerenone, improved vascular function in patients with APA. Adrenalectomy may be more effective than treatment with eplerenone for reducing the incidence of future cardiovascular events in patients with APA. Clinical Trial Information: URL for the clinical trial: http://UMIN; Registration Number for the clinical trial: UMIN000003409.

Topics: Adrenal Cortex Neoplasms; Adrenalectomy; Adrenocortical Adenoma; Adult; Aldosterone; Blood Pressure; Endothelium, Vascular; Eplerenone; Female; Humans; Hyperaldosteronism; Male; Middle Aged; Mineralocorticoid Receptor Antagonists; Nitroglycerin; Vasodilation

Topics: Adrenal Cortex Neoplasms; Adrenalectomy; Adrenocortical Adenoma; Adult; Aldosterone; Blood Pressure; Cytokines; Eplerenone; Female; Humans; Lymphocytes; Mineralocorticoid Receptor Antagonists; Monocytes; Spironolactone

Topics: Adrenal Cortex Neoplasms; Adrenalectomy; Adrenocortical Adenoma; Adult; Eplerenone; Female; Follow-Up Studies; Humans; Hyperaldosteronism; Mineralocorticoid Receptor Antagonists; Pregnancy; Pregnancy Complications; Spironolactone; Treatment Outcome