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Resistant Hypertension - Primary Aldosteronism 내분비 대사 내과 R3 송 란 Resistant, or refractory, hypertension • Patients with diabetes or renal disease : antihypertensive medications (including a diuretic) : full doses of at least three blood pressure : at least140/90 mm Hg or at least 130/80 mm Hg Secondary causes (including exogenous substances) - Approach to evaluation of resistant hypertension - - N Engl J Med 2006; 355 The effect of age on prevalence of secondary forms of hypertension in 4429 consecutively referred patients - J Hypertens. 1994; 12 • Among 4000 patients with resistant hypertension Secondary causes – 10 % of patients overall – 17 % of patients over the age of 60 years • Chronic renal parenchymal disease : M/C • Atherosclerotic renovascular disease • Primary aldosteronism • Pheochromocytoma • sleep apnea Diagnosis Diagnostic test Chronic kidney disease Estimated GFR Coarctation of aorta CT angiography Cushing syndrome and other glucocorticoid excess states, including chronic steroid therapy History/dexamethasone suppression test Drug-induced/related causes History; drug screening Pheochromocytoma 24-h urinary metanephrine and normetanephrine Primary aldosteronism and other mineralocorticoid excess states Renovascular hypertension Sleep apnea Thyroid/parathyroid disease 24-h urinary aldosterone level or specific measurements of other mineralocorticoids Doppler flow study; magnetic resonance angiography Sleep study with O2 saturation TSH; serum PTH Primary Aldosteronism • 2 % of all hypertensives patients 5 ~ 10 % • Screening test – plasma aldosterone to renin ratio (ARR) test • Diagnosis : missed No hypokalemia • Type of primary aldosteronism Types Relative frequency, % Solitary adrenal adenoma 65 Bilateral adrenal hyperplasia 30 Unilateral adrenal hyperplasia 2 Glucocorticoid-remediable aldosteronism <1 Bilateral solitary adrenal adenomas <1 Adrenal carcinoma <1 Demographic and Clinical Characteristics of Patients with Various Types of Primary Aldosteronism ( Continued ) Continued.. - N Engl J Med, 1998; 339 Screening Spontaneous Hypokalemia + HTN strong indicator of aldosteronism But, 20 % : low normal serum potassium level • Plasma aldosterone(ng/dL) to renin(ng/mL per hour) ratio: ARR – Timing of the tests : morning – The posture before blood sampling : upright – Unit of measurement – Cutt off value > 30 – 경희의료원 : plasma aldo. pg/ml 계산값 X 0.1 • • • • 345 patients of Hypertension Essential hypertension (EH) (n=260) Primary aldosteronism (PA) (n=49) Secondary HTN other than PA (n=36) • ARR – affected by antihypertensive drug use no anti-hypertensive therapy or taking medications least likely to affect it (e.g. calcium-channel blockers or α-blockers) - Nat Clin Pract Endocrinol Metab ,2005;1 Definitive Biochemical Diagnosis • Diet high in sodium chloride (2 to 3 g with each meal for two to three days) high rate of urinary aldosterone excretion < 14 μg in 24 hours : rules out primary aldosteronism • Intravenous infusion of normal saline (1.25 liters over a 2 hours period or 2 liters over a 4 hours period, preferably between 8 a.m. and noon) high plasma aldosterone level < 8.5 ng/dL(240 pmol/L) (performed in the morning) : rules out primary aldosteronism Localizing Test • Adrenal venous blood sampling with adrenocorticotropic hormone infusion unilateral excess of aldosterone secretion : aldosteronoma, unilateral adrenal hyperplasia • Computed tomographic (CT) scanning – Detect most aldosteronomas ( except very small ) – large adrenal tumor (>3 cm in diameter) Possibility adrenal carcinoma : adrenal steroids (androgens, cortisol, estrogen) in the plasma or urine : measured Algorithm for diagnosis and management of primary aldosteronism - Nat Clin Pract Endocrinol Metab ,2005;1