ESPE Yearbook of Paediatric Endocrinology

Lancet Diabetes Endocrinol. 2021; 9(12):876-892. PMID: 34798068https://pubmed.ncbi.nlm.nih.gov/34798068/

Brief Summary: This review summarizes the current knowledge on the epidemiology, genetic background, pathophysiology, clinical presentation, diagnosis and treatment of primary aldosteronism.

This review article on primary aldosteronism (PA) describes its clinical characteristics and the diagnostic process of screening, confirmation, and subtyping. Furthermore, the authors highlight the current standards of treatment and discuss controversies and areas of uncertainty.

The importance of awareness of PA owes to the significant comorbidities associated with aldosterone excess on the heart, vessels, brain, and kidney, which are partly independent of elevated blood pressure. These arguments strongly support the early and systematic detection of PA, in order to implement efficient surgical or medical treatment, to prevent or reverse the comorbidities in this specific group of patients with secondary hypertension. Adult patients with moderate to severe hypertension or those with hypertension and spontaneous or diuretic-induced hypokalaemia, adrenal incidentaloma, atrial fibrillation in the absence of structural heart disease, or a family history of early onset hypertension or stroke at a young age (<40 years), as well as all first-degree relatives with hypertension of patients with primary aldosteronism, are candidates for screening. It is important to note that screening prior to commencing antihypertensive therapy has the benefit of avoiding the potentially confounding effects of these agents on renin and aldosterone concentrations, and allows the earlier initiation of specific treatment.

In summary, PA is characterized by the paradox of being a common cause and augmenter of hypertension, with a high incidence, that is underdiagnosed in most health-care systems. Affected patients can potentially develop resistant hypertension associated with a low quality of life and adverse cardiovascular and cerebrovascular outcomes. The authors argue that PA should be regarded as a distinct cardiovascular risk factor, alongside other classic risk factors (e.g., diabetes mellitus, hypercholesterolaemia, and smoking) that aggravate and potentiate adverse outcomes of hypertension. Thus, instead of screening selected at-risk populations, general screening of people with hypertension should be the future strategy to reduce the disease-burden in a cost-effective way. These concepts are of particular importance to Pediatric Endocrinologists because there is higher incidence of PA in hypertensive patients who are routinely screened, and idiopathic hypertension is relatively rare.