1. Prof Emma-Edit Endocrine Hypertension Meet the Experts

7/31/2019 1. Prof Emma-Edit Endocrine Hypertension Meet the Experts

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Emma Sy MoeisDivision of Nephrology & Hypertension

Department of Internal Medicine,

Medical Faculty of Sam Ratulangi University, Manado


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100or> 160Stage 2

90-99or140-159

Stage 1

Hypertension80-89or120-139Prehypertension

18 y.o

Adults on no antihypertensive medications and who arenot acutely ill.


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Hypertension

EssentialSecondary

Causes

Endocrine

Hypertension

Non-Endocrine

Hypertension

Primer (essential) No specific causes that can

be identified

95% of all hypertensioncases

Secondary

Causes can be identified

5% of all hypertensioncases

Kidney disease is the maincause (90%) of all

secondary hypertensioncases


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Renal parenchymal disease:acute nephritis,chronic glomerulonephritis, etc.

Renovascular disease:renal artery stenosis,

atherosclerosis,fibroplasia, etc.

Endocrine causes


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Pheochromocytoma Mineralocorticoid excess (e.g., primary hyperaldosteronism) Glucocorticoid excess (e.g., Cushings syndrome) Acromegaly

Diabetes mellitus

Obesity

Congenital adrenal hyperplasia

Estrogen-induced hypertension Pregnancy-induced hypertension Renin-secreting tumors Hypothyroidism

Hyperthyroidism

Liddle syndrome


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a 47 year old woman referred because ofpoorly controlled hypertension. She has leg

cramps and polyuria, but no episodes ofheadache, sweating or palpitations.There is no family history of hypertension.She is not obese.

HR: 78/min and BP 160/98 mmHg, the examis otherwise normal.

Plasma potassium: 2.5 mM


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1. What symptoms are caused byhypertension? By severe hypokalemia?

2. What are the three major endocrine causesof hypertension (ie, disorder in which themajority of patient has high blood pressure)?How common are they in patient with

hypertension?3. Which endocrine cause of hypertension ismost likely in this patient? What test shouldbe done now?


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Symptoms caused by hypertension:

None

Symptoms caused by severe hypokalemia: Leg cramps

polyuria


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1. What symptoms are caused by hypertension?By severe hypokalemia?

2. What are the three major endocrine causes of

hypertension (ie, disorder in which themajority of patient has high blood pressure)?How common are they in patient withhypertension?

3. Which endocrine cause of hypertension is mostlikely in this patient? What test should be donenow?


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Three major endocrine causes of hypertension: Primary hyperaldosteronism Pheochromocytoma Cushing syndrome

In patient with hypertension, approximately


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1. What symptoms are caused byhypertension? By severe hypokalemia?

2. What are the three major endocrine causesof hypertension (ie, disorder in which themajority of patient has high blood pressure)?How common are they in patient with

hypertension?3. Which endocrine cause of hypertension ismost likely in this patient? What testshould be done now?


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The most likely endocrine causes of hypertension in this

case is Primary Hyperaldosteronism

Test should be done now: Plasma Renin Activity (PRA)

Ratio of Plasma Aldosterone to PRA

Indication for screening for Primary Hyperaldosteronism

1. Hypertension with hypokalemia2. Refractory hypertension (BP >140/90 despite 3 antihypertensives)3. Hypertension with adrenal incidentaloma (incidental adrenal tumor)4. Juvenile patient with hypertension and positive family historyI


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A blood sample is drawn with the patient seatedPlasma Aldosterone: 25 ng/dlPlasma Renin Activity:


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4. Do these result establish a diagnosis? Whywere aldosterone and renin activity

measured simultaneously? Can a diagnosisbe made by measuring either hormonelevel alone?

5. What is the purpose of saline infusion?6. What are the major causes of this syndrome?

Why is it important to distinguish betweenthem, and how can this be done?


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Yes, these result establish diagnosis

of primary hyperaldosteronism

Plasma Aldosterone: 25 ng/dlPlasma Renin Activity:


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Adapted from Young WF Jr, Hogan, MJ. Renin-independent hypermineralocorticoidism. Trends in Endocrinology and Metabolism 1994;5:97106.

Plasma Aldosterone:25 ng/dlPlasma Renin Activity:


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The test should be measured simultaneouslybecause the two hormone may has normal

variation caused by body position, salt intakeand other factor that affected ECF volume, sofor the purpose of having the ratio, it should betaken in the same time

The diagnosis should be performed by both testof hormone level


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4. Do these result establish a diagnosis? Why werealdosterone and renin activity measured

simultaneously? Can a diagnosis be made bymeasuring either hormone level alone?5. What is the purpose of saline infusion?6. What are the major causes of this syndrome?



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The purpose ofNaCl 0.9% iv

infusion is todemonstrating thatplasma aldosteronecannot besuppressed by ECFvolume expansion

Confirmatory test Procedure Interpretation Concerns


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Confirmatory test Procedure Interpretation Concerns

Oral sodium loading test Sodium intake > 200mmol (~6 g) per day,verified by 24-hour

urine sodium. Adequate slow-release

potassium chloridesupplementation.

Urinary aldosterone ismeasured in the 24-

hour urine collectionfrom morning of day 3

to morning day 4.

Unlikely PA :Urinary aldosterone : 12 mcg/24 hr

(>33.3 nmol/d)Cleveland Clinic :

> 14 mcg/24-hr(38.8 noml/d)

Should not be performedin patients with :- Severe uncontrolled

Hpt- renal insufficiency

- cardiac insufficiency- Cardiac arrhytmia

- Severe hypokalemia

Saline infusion test In recumbent positionat least 1 hour before

and during infusion 2 ltrNaCl 0.9% IV over 4

hrs, start at 8:00-

9.30am Blood sample (renin,

aldosterone,cortisol &plasma Kalium) aredrawn at time 0 & after

4 hrs with BP & HRmonitored throughout

the test.

Unlikely PA :aldosterone levels

< 5 ng/dL Very Probably PA :

Aldosterone levels

> 10 ng/dL Indeterminate levels

5 - 10 ng/dL

Should not be performedin patients with :

- Severe uncontrolledHpt

- renal insufficiency

- cardiac insufficiency- Cardiac arrhytmia

- Severe hypokalemia

Confirm Procedure Interpretation Concerns


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Confirmatorytest

Procedure Interpretation Concerns

Fludrocort

isone

suppression test

Fludrocortisone oral : 0.1 mg per

6 hrs for 4 days

Slow-release KCl supplements(per 6 hrs, measured 4 x/d, close

to 4.0 mmol/L)

Slow-release NaCl supplements

(30 mmol 3 x with meals) &

Dietary salt to maintain urinary

sodium excretion rate at least 3

mmol/kgBW Day 4: measured

- plasma aldosterone & PRA at

10 am, in seated posture

- plasma cortisol: measured at 7

am & 10 am

Confirms PA :

- upright plasma

aldosterone > 6 ng/dL(day 4 at 10 am)

- PRA < 1 ng/ml/h

- plasma cortisol : lower

than the value

obtained at 7 am (to

exclude confounding

ACTH effect)

FST is the most sensitive

for confirming PA:

- less likey to provoke non-renin-dependent

alteration of aldosterone

levels

- allows for the potentially

confounding effects of

potassium to be

controlled, for ACTH(viacortisol) to be monitored &

detected

- Safe when performed by

experienced hands

CaptoprilChallenge

test

Captopril 25-50 mg oral aftersitting/standing at least 1 hr.

Measured PRA, plasma

aldosterone, cortisol at time 0, 1

or 2 hrs after challenge with

remaining seated.

PA :- Plasma aldosterone

remain elevated

- PRA remains

suppressed

Difference APA & IHA:

- Some decrease of

aldosterone levels isoccasionall seen in

Reports of substantialnumber of false negative or

equivocal results.


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4. Do these result establish a diagnosis? Whywere aldosterone and renin activity measured

simultaneously? Can a diagnosis be made bymeasuring either hormone level alone?5. What is the purpose of saline infusion?6. What are the major causes of this syndrome?



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The major causing of this syndrome are:

Aldosterone-secreting adrenal adenomas

(2/3 of cases)

Bilateral adrenal hyperplasia

The importance to distinguish between them is due todifferent management. In aldosterone-secretingadrenal adenomas, surgery is an option while in bilateraladrenal hyperplasia medical management is needed

This can be done by CT scan examination


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Abdominal CT scan shows a 2 cm mass in theright adrenal

This finding confirm the diagnosis of Aldosterone-secreting adenomas on right adrenal as the cause of

primary hyperaldosteronism

Answer


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Adapted from Young WF Jr, Hogan, MJ. Renin-independent hypermineralocorticoidism. Trendsin Endocrinology and Metabolism 1994;5:97106.


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DiganosisandTreatment

Algorithmfor PrimaryHyperaldosteronism


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1. Prof Emma-Edit Endocrine Hypertension Meet the Experts

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