Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Case Study
  • Published:

A case of primary aldosteronism revealed after renal transplantation

Abstract

Background. A 57-year-old woman was referred to a nephrology clinic because of chronic hypokalemia. She had a history of polycystic kidney disease, resistant hypertension, atrial fibrillation, type 2 diabetes, stroke, and end-stage renal disease, and had received a kidney transplant from a deceased donor at the age of 48 years. At presentation, the patient described symptoms of chronic fatigue and muscle aches, but she did not report pareses. Her medications included four antihypertensive agents, glucose-lowering drugs, immunosuppressants, digoxin, a coumarin derivative, and potassium chloride.

Investigations. Full history, physical examination, laboratory testing of blood and urine, including aldosterone-torenin ratio, and a saline infusion test.

Diagnosis. Primary aldosteronism.

Management. Treatment with spironolactone resulted in prompt control of hypertension and hypokalemia, allowing discontinuation of potassium chloride and reduction in antihypertensive medication.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Figure 1: The course of a | serum potassium and b | serum creatinine levels in the main case patient over time.
Figure 2
Figure 3: Factors contributing to renal insufficiency and cardiovascular risk in primary aldosteronism.
Figure 4: Diagnostic and therapeutic approach to primary aldosteronism.

References

  1. Mulatero, P. et al. Increased diagnosis of primary aldosteronism, including surgically correctable forms, in centers from five continents. J. Clin. Endocrinol. Metab. 89, 1045–1050 (2004).

    Article  CAS  Google Scholar 

  2. Rossi, G. P. et al. A prospective study of the prevalence of primary aldosteronism in 1125 hypertensive patients. J. Am. Coll. Cardiol. 48, 2293–2300 (2006).

    Article  CAS  Google Scholar 

  3. Schwartz, G. L. & Turner, S. T. Screening for primary aldosteronism in essential hypertension: diagnostic accuracy of the ratio of plasma aldosterone concentration to plasma renin activity. Clin. Chem. 51, 386–394 (2005).

    Article  CAS  Google Scholar 

  4. Yang, C. W. et al. Primary aldosteronism detected after renal transplantation. Am. J. Nephrol. 14, 220–222 (1994).

    Article  CAS  Google Scholar 

  5. Catena, C. et al. Cardiovascular outcomes in patients with primary aldosteronism after treatment. Arch. Intern. Med. 168, 80–85 (2008).

    Article  CAS  Google Scholar 

  6. Milliez, P. et al. Evidence for an increased rate of cardiovascular events in patients with primary aldosteronism. J. Am. Coll. Cardiol. 45, 1243–1248 (2005).

    Article  CAS  Google Scholar 

  7. Jaffe, I. Z. & Mendelsohn, M. E. Angiotensin II and aldosterone regulate gene transcription via functional mineralocortocoid receptors in human coronary artery smooth muscle cells. Circ. Res. 96, 643–650 (2005).

    Article  CAS  Google Scholar 

  8. Leopold, J. A. et al. Aldosterone impairs vascular reactivity by decreasing glucose-6-phosphate dehydrogenase activity. Nat. Med. 13, 189–197 (2007).

    Article  CAS  Google Scholar 

  9. Sowers, J. R., Whaley-Connell, A. & Epstein, M. Narrative review: the emerging clinical implications of the role of aldosterone in the metabolic syndrome and resistant hypertension. Ann. Intern. Med. 150, 776–783 (2009).

    Article  Google Scholar 

  10. Rucker, D. & Tonelli, M. Cardiovascular risk and management in chronic kidney disease. Nat. Rev. Nephrol. 5, 287–296 (2009).

    Article  Google Scholar 

  11. Funder, J. W. et al. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline. J. Clin. Endocrinol. Metab. 93, 3266–3281 (2008).

    Article  CAS  Google Scholar 

  12. Berl, T., Katz, F. H., Henrich, W. L., de Torrente, A. & Schrier, R. W. Role of aldosterone in the control of sodium excretion in patients with advanced chronic renal failure. Kidney Int. 14, 228–235 (1978).

    Article  CAS  Google Scholar 

  13. Hene, R. J., Boer, P., Koomans, H. A. & Mees, E. J. Plasma aldosterone concentrations in chronic renal disease. Kidney Int. 21, 98–101 (1982).

    Article  CAS  Google Scholar 

  14. Ecder, T. & Schrier, R. W. Hypertension in autosomal-dominant polycystic kidney disease: early occurrence and unique aspects. J. Am. Soc. Nephrol. 12, 194–200 (2001).

    CAS  PubMed  Google Scholar 

  15. Rossi, G. P., Pessina, A. C. & Heagerty, A. M. Primary aldosteronism: an update on screening, diagnosis and treatment. J. Hypertens. 26, 613–621 (2008).

    Article  CAS  Google Scholar 

  16. Ethier, J. H., Kamel, K. S., Magner, P. O., Lemann, J. Jr & Halperin, M. L. The transtubular potassium concentration in patients with hypokalemia and hyperkalemia. Am. J. Kidney Dis. 15, 309–315 (1990).

    Article  CAS  Google Scholar 

  17. Biglieri, E. G. Rare causes of adrenocortical hypertension. Cardiology 72 (Suppl. 1), 70–75 (1985).

    Article  Google Scholar 

  18. Rossi, G. P. et al. Renal damage in primary aldosteronism: results of the PAPY Study. Hypertension 48, 232–238 (2006).

    Article  CAS  Google Scholar 

  19. Corcoran, A. C., Dustan, H. P. & Page, I. H. Renal function in primary aldosteronism. J. Clin. Invest. 35, 1357–1363 (1956).

    Article  CAS  Google Scholar 

  20. Sechi, L. A. et al. Long-term renal outcomes in patients with primary aldosteronism. JAMA 295, 2638–2645 (2006).

    Article  CAS  Google Scholar 

  21. Sechi, L. A., Di Fabio, A., Bazzocchi, M., Uzzau, A. & Catena, C. Intrarenal hemodynamics in primary aldosteronism before and after treatment. J. Clin. Endocrinol. Metab. 94, 1191–1197 (2009).

    Article  CAS  Google Scholar 

  22. Catena, C. et al. Relationships of plasma renin levels with renal function in patients with primary aldosteronism. Clin. J. Am. Soc. Nephrol. 2, 722–731 (2007).

    Article  CAS  Google Scholar 

  23. Linas, S. L. & Dickmann, D. Mechanism of the decreased renal blood flow in the potassium-depleted conscious rat. Kidney Int. 21, 757–764 (1982).

    Article  CAS  Google Scholar 

  24. Reungjui, S. et al. Hypokalemic nephropathy is associated with impaired angiogenesis. J. Am. Soc. Nephrol. 19, 125–134 (2008).

    Article  CAS  Google Scholar 

  25. Tolins, J. P., Hostetter, M. K. & Hostetter, T. H. Hypokalemic nephropathy in the rat. Role of ammonia in chronic tubular injury. J. Clin. Invest. 79, 1447–1458 (1987).

    Article  CAS  Google Scholar 

  26. Tsao, T. et al. Expression of insulin-like growth factor-I and transforming growth factor-beta in hypokalemic nephropathy in the rat. Kidney Int. 59, 96–105 (2001).

    Article  CAS  Google Scholar 

  27. Cremer, W. & Bock, K. D. Symptoms and course of chronic hypokalemic nephropathy in man. Clin. Nephrol. 7, 112–119 (1977).

    CAS  PubMed  Google Scholar 

  28. Sontia, B., Montezano, A. C., Paravicini, T., Tabet, F. & Touyz, R. M. Downregulation of renal TRPM7 and increased inflammation and fibrosis in aldosterone-infused mice: effects of magnesium. Hypertension 51, 915–921 (2008).

    Article  CAS  Google Scholar 

  29. Winter, C., Schulz, N., Giebisch, G., Geibel, J. P. & Wagner, C. A. Nongenomic stimulation of vacuolar H+-ATPases in intercalated renal tubule cells by aldosterone. Proc. Natl Acad. Sci. USA 101, 2636–2641 (2004).

    Article  CAS  Google Scholar 

  30. Gregoire, J. R. Adjustment of the osmostat in primary aldosteronism. Mayo Clin. Proc. 69, 1108–1110 (1994).

    Article  CAS  Google Scholar 

  31. Bobrie, G. et al. Autosomal dominant polycystic kidney disease with primary hyperaldosteronism. Nephrol. Dial. Transplant. 7, 647–650 (1992).

    Article  CAS  Google Scholar 

  32. Gejyo, F., Ishida, K. & Arakawa, M. Autosomal dominant polycystic kidney disease complicated by primary aldosteronism. Case report and review of the literature. Am. J. Nephrol. 14, 236–238 (1994).

    Article  CAS  Google Scholar 

  33. Rajasoorya, Chee, T. S. & Ng, B. K. Hypertension in disguise—a trap for the unwary. Eur. J. Endocrinol. 133, 93–96 (1995).

    Article  CAS  Google Scholar 

  34. Torres, V. E., Young, W. F. Jr, Offord, K. P. & Hattery, R. R. Association of hypokalemia, aldosteronism, and renal cysts. N. Engl. J. Med. 322, 345–351 (1990).

    Article  CAS  Google Scholar 

  35. Novello, M. et al. Renal cysts and hypokalemia in primary aldosteronism: results of long-term follow-up after treatment. J. Hypertens. 25, 1443–1450 (2007).

    Article  CAS  Google Scholar 

  36. Perey, D. Y., Herdman, R. C. & Good, R. A. Polycystic renal disease: a new experimental model. Science 158, 494–496 (1967).

    Article  CAS  Google Scholar 

  37. Brown, J. J. et al. Comparison of surgery and prolonged spironolactone therapy in patients with hypertension, aldosterone excess, and low plasma renin. Br. Med. J. 2, 729–734 (1972).

    Article  CAS  Google Scholar 

  38. Ghose, R. P., Hall, P. M. & Bravo, E. L. Medical management of aldosterone-producing adenomas. Ann. Intern. Med. 131, 105–108 (1999).

    Article  CAS  Google Scholar 

  39. Stowasser, M. & Gordon, R. D. Primary aldosteronism: learning from the study of familial varieties. J. Hypertens. 18, 1165–1176 (2000).

    Article  CAS  Google Scholar 

Download references

Acknowledgements

Written consent for publication was obtained from the patient.

Author information

Authors and Affiliations

Authors

Contributions

E. J. Hoorn wrote the initial first draft; all of the authors researched data for the article and contributed to the discussion of content, and reviewed/edited the manuscript before submission.

Corresponding author

Correspondence to Ewout J. Hoorn.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hoorn, E., Hesselink, D., Kho, M. et al. A case of primary aldosteronism revealed after renal transplantation. Nat Rev Nephrol 7, 55–60 (2011). https://doi.org/10.1038/nrneph.2010.158

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrneph.2010.158

This article is cited by

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing