ACTA ENDOCRINOLOGICA (BUC)

Primary hyperaldosteronism is the cause of approximately 0.05 to 2.2% of all\r\nunselected cases of hypertension. It was first described in 1955 by Conn in conjunction with\r\naldosterone-producing adrenal adenoma, which is the most frequent aetiology, in 65% of\r\ncases. Clinical features are usually non-specific and result from potassium depletion. We\r\nreport here the case of a 54-year-old woman who was admitted to the emergency department\r\ndue to coma (Glasgow score 6). The presence of severe potassium depletion (1.2 mmol/L)\r\nand metabolic alkalosis (PH=7.76, base excess>30 mmol/L) in a hypertensive patient\r\ndetermined the clinicians to search for a secondary cause of hypertension. This was\r\nconfirmed by localizing on computer tomography a right adrenal adenoma of 31-mm\r\ndiameter and on endocrine measurements that showed mineralocorticoid excess (plasma\r\naldosterone=764 pg/mL;N=14-193). Clinical evolution was slowly favourable after\r\nrestoring the electrolyte balance, with increasing of serum K up to 3.05 mmol/L. The patient\r\nbecame asymptomatic in 3 weeks and underwent laparoscopic right adrenalectomy. The\r\npatient had a good postoperatory evolution. Two weeks after laparoscopic right\r\nadrenalectomy, blood pressure normalized after the discontinuation of the antihypertension\r\ntreatment and the aldosterone measurement was normal (102 pg/mL).

Background. The association between high blood pressure and hypokalemia is usually caused by primary or secondary hyperaldosteronism. Recent studies indicate that\r\nprimary hyperaldosteronism is a much more common cause of hypertension than had been previously demonstrated. Arterial hypertension is often present in hypothyroid patients, but almost never associated with hypokalemia.\r\nCase report. We report the case of a 69 years old male admitted for shortness of breath, inferior limbs edema and fatigue. From his medical history we mention: essential\r\narterial hypertension (for about 25 years), ischaemic coronary artery disease (for 20 years), for which he underwent PTCA (two years ago), atrial fibrillation electrically converted to sinus rhythm (a year a ago). Despite taking four antihypertensive drugs his blood pressure was far from being controlled. Blood analysis revealed an important hypopotasemia (K 2.4mmol/l) and consequently the loop diuretic was replaced with a potassium-sparing diuretic. The measured proved to be unsuccessful and potassium supplements had to be\r\nadded, but with modest results (K 2.94mmol/l). Further specific investigations revealed almost normal levels of aldosteron, low renin, normal cortisol. Associated was a high Thyroid-stimulating hormone (TSH). Computer tomografy (CT) showed bilateral suprarenal glands adenomas.\r\nConsidering the laboratory findings, we interpret the case as a primary hyperaldosteronism and a successful treatment with spironolactone was initiated.

This paper reviews the class of mineralocorticoid receptor (MR) modulators, especially new nonsteroidal antagonists. MR is a nuclear receptor expressed in many tissues and cell types. Aldosterone, the most important mineralocorticoid hormone and MR agonist, has many unfavorable effects, especially on the heart, blood vessels, and kidneys, by promoting fibrosis and tissue remodelling. Classical synthetic MR antagonists (spironolactone, eplerenone) have proven useful in clinical practice through their antihypertensive effects in resistant forms, and through benefits on morbidity and mortality in heart failure with reduced ejection fraction. These benefits are associated with important side effects, hyperkalemia being the main limitation. In the latest years, a new generation of MR modulators with a nonsteroidal structure has emerged. These compounds are more selective than classical MR antagonists, with much higher affinity for the MR than for the glucocorticoid, androgen, or progesterone receptors. Recent clinical and experimental observations suggest that nonsteroidal MR antagonists, especially finerenone, have proven superior renoprotective properties, antiproteinuric efficacy, inhibition of inflammation and heart fibrosis in animal models, without sharing the side effects of steroidal MR antagonists. Nonsteroidal MR modulators represent an interesting new therapeutic approach for the prevention and progression of chronic kidney disease and for patients with heart failure and renal disease. Despite these promising data, there are still many issues to be clarified and it is necessary to accumulate solid evidence from studies on larger numbers of patients and from head-to-head clinical trials.