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Primary aldosteronism

What's new

The Endocrine Society (ES) has released an updated guideline for the diagnosis and management of primary aldosteronism (PA). Screening for PA is now suggested for all patients with hypertension, removing the previous requirement for additional comorbidities or conditions to prompt testing. The choice between medical and surgical therapy should be guided by the lateralization of aldosterone hypersecretion and the patient's surgical candidacy. Spironolactone is preferred over other mineralocorticoid receptor antagonists (MRAs) due to its low cost and broad availability. MRAs are also preferred over epithelial sodium channel (ENaC) inhibitors such as amiloride and triamterene. .

Background

Overview

Definition
Primary hyperaldosteronism is an endocrine disorder characterized by excessive secretion of aldosterone from the adrenal glands.
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Pathophysiology
Hypersecretion of aldosterone may be due to neoplasia of the adrenal glands (adrenal adenoma or adrenocortical carcinoma), adrenal hyperplasia (typically bilateral), mutations in genes coding for enzymes involved in aldosterone synthesis (familial hyperaldosteronism), or may be idiopathic. Ectopic aldosterone-producing adenoma or carcinoma accounts for < 0.1% of cases.
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Epidemiology
In patients with secondary hypertension, the prevalence of primary hyperaldosteronism is estimated at 5-20%.
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Disease course
Increased plasma aldosterone leads to the clinical manifestations of resistant hypertension and hypokalemia. Untreated disease may result in early cardiovascular complications and CKD.
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Prognosis and risk of recurrence
Patients with PA have an increased risk of cardiovascular morbidity (including myocardial infarction, stroke, and AF) as compared with patients with matched controls with essential hypertension. The 10-year survival of patients with hyperaldosteronism is similar to that of matched hypertensive controls.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of primary aldosteronism are prepared by our editorial team based on guidelines from the Endocrine Society (ES 2025,2016), the European Reference Network on Rare Endocrine Conditions (Endo-ERN 2024), the European Society of Cardiology (ESC 2024), the American Academy of Family Physicians (AAFP 2023), the Canadian Urological Association (CUA 2023), the American ...
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Screening and diagnosis

Indications for testing, hypertension: as per ES 2025 guidelines, consider obtaining screening for PA in patients with hypertension.
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  • Indications for testing (tumor)

Diagnostic investigations

Plasma aldosterone-to-renin ratio, initial testing: as per ES 2025 guidelines, consider obtaining serum/plasma aldosterone concentration and plasma renin (concentration or activity), with determination of the aldosterone-to-renin ratio, to screen for PA in patients with hypertension.
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  • Plasma aldosterone-to-renin ratio (technical considerations)

  • Confirmatory testing

  • Adrenal imaging

  • Genetic testing

  • Cardiac evaluation

  • Renal evaluation

  • Evaluation for Cushing's syndrome

Diagnostic procedures

Adrenal venous sampling: as per ES 2025 guidelines, consider obtaining CT and adrenal venous sampling for adrenal lateralization in patients with PA who are being considered for surgery before deciding on a medical or surgical treatment approach.
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Medical management

General principles: as per ES 2025 guidelines, consider offering PA-specific therapy, either medical or surgical, to patients with hypertension and PA:
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consider preferring medical treatment with mineralocorticoid receptor antagonists over nonspecific antihypertensive therapy in patients with lateralizing PA who are not surgical candidates or do not desire surgery, and in patients with bilateral PA
consider preferring unilateral adrenalectomy over nonspecific antihypertensive therapy in patients with lateralizing PA who are surgical candidates and desire surgery
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  • Mineralocorticoid receptor antagonists

  • Conventional antihypertensives

  • Potassium-sparing diuretics

  • Corticosteroids

Nonpharmacologic interventions

Sodium restriction: as per Endo-ERN 2024 guidelines, advise reducing sodium intake in all patients with familial hyperaldosteronism and hypertension.
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Perioperative care

Preoperative medical therapy
As per JES 2022 guidelines:
Initiate appropriate treatment for the complications before unilateral adrenalectomy to reduce the risks during general anesthesia and adrenalectomy, as the prevalence of resistant hypertension, hypokalemia and cardiovascular complications is higher in patients with unilateral PA than in patients with bilateral PA and essential hypertension.
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Initiate mineralocorticoid receptor antagonists as first-line therapy to control hypertension and hypokalemia before adrenalectomy.
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  • Postoperative monitoring

  • Postoperative corticosteroid replacement therapy

Surgical interventions

Indications for adrenalectomy: as per Endo-ERN 2024 guidelines, do not perform surgery in patients with familial hyperaldosteronism, as it is a bilateral disease. Consider performing surgery only in patients with familial hyperaldosteronism type III if BP is not normalized after optimal therapy.
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Specific circumstances

Pregnant patients: as per Endo-ERN 2024 guidelines, normalize BP levels in female patients with familial hyperaldosteronism planning for pregnancy and obtain strict monitoring of potassium and BP levels during pregnancy.
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Follow-up and surveillance

Follow-up: as per Endo-ERN 2024 guidelines, obtain clinical and biochemical follow-up every 3-6 months.
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