February 2024
Primary aldosteronism in patients with chronic kidney disease

A case series describes treatment outcomes in 239 patients with hypertension, CKD and primary aldosteronism.

Primary aldosteronism is underdiagnosed in patients with chronic kidney disease (CKD), perhaps because clinicians assume that resistant hypertension in these patients is attributable solely to the CKD (J Nephrol 2022; 35: 1667-1677). In this retrospective study, researchers describe outcomes of treatment in 239 hypertensive patients (mean age, 57 years) with CKD who received diagnoses of primary aldosteronism in US academic specialty clinics. At baseline, estimated glomerular filtration rate was between 20 and 60mL/minute/1.73m2 in most patients (mean, 45mL/minute).

On adrenal vein sampling, two-thirds of patients lateralised and underwent adrenalectomy; the others were treated with spironolactone or eplerenone.

During median follow up of 4.5 years, the following outcomes were noted:

  • mean blood pressure decreased from 149/85 mmHg at baseline to 131/78 mmHg, with minimal difference between surgically and medically treated patients
  • average number of antihypertensive medications dropped from about four to about two in surgically treated patients and was relatively unchanged in medically treated patients
  • only 2.5% of medically treated patients developed serum potassium levels greater than 6.0 mmol/L
  • 6% of patients eventually required renal replacement therapy in both the surgically and medically treated groups.

Comment: The take-home message is that primary aldosteronism should be considered in patients with CKD and resistant hypertension. The authors note that treating patients with aldosteronism might have beneficial effects beyond blood pressure reduction: excessive circulating aldosterone is thought to have direct pathogenic effects on kidney and myocardium.

Allan S. Brett, MD, Clinical Professor of Medicine, University of Colorado School of Medicine, Aurora, USA.

Cohen DL, et al. Primary aldosteronism in chronic kidney disease: blood pressure control and kidney and cardiovascular outcomes after surgical versus medical management. Hypertension 2023; 80: 2187-2195.

This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine, Hospital Medicine.