Case 1SB
49 yr old femaleObesityResistant hypertensionNormal K+Aldo 669 (23-415 pmol/L)Renin 8.2 (4-44 mU/L)ARR 81 (1-20)
CT (2011) – small low density lesion R adrenalUnchanged on repeat scan
Put on spironolactone after initial blood test by another physician – good BP response
How would you proceed?
Case 1SB
Medications altered – spiro stoppedDoxazosin added
Repeat bloods...............Aldo 689 (23-415 pmol/L)Renin 12.5 (4-44 mU/L)ARR 55 (1-20)
Is the diagnosis confirmed?
Case 1SB
IV saline suppression test
2 litres 0.9% saline over 4 hrsBloods pre and post
Aldosterone pre-test = 518 post-test = 346 pmol/L
normals should suppress < 50ng/l (140 pmol/L)Abnormal > 100 ng/L
Result confirms PA
How would you proceed?
Case 2BS
53 yr old femaleResistant hypertension for 10 yrs managed by GPLow K+ on several occasions, Na+ 144-148On 3 medications. BP clinic 180/100 (lower at home 140/80)
Aldo 258 (40-310 ng/L) (on meds including lisinopril and amlodipine)Renin 9.7 (4-44 mU/L)ARR 27
After altering meds and normalising K+.............................Aldo 494Renin 3ARR 165
CT Abdo – 2cm low density lesion L adrenal (normal looking R)
How would you proceed?
Case 2BS
AVS (difficult procedure)
cortisol AldoLeft adrenal >1750 1175
Right adrenal 543 194
IVC 468 815
How do you interpret these results?
How would you proceed?
Case 3MJ (Exeter patient)
55 yr old maleResistant hypertensionNormal K+Elevated aldo/renin and confirmed on salt loading
CT adrenals – no lesion identified
How might you proceed?
Case 3MJ (Exeter patient)
AVS results
Time site cortisol Aldosterone1530 L renal vein 321 3441530 Femoral vein 413 3891549 L adrenal vein 1350 9401550 Femoral vein 303 4321600 R adrenal vein 1674 310001602 Femoral vein 253 400
Left adrenal:femoral cortisol ratio 1350/303 = 4.5Right adrenal:femoral cortisol ratio 1674/253 = 6.6
Left adrenal aldosterone:cortisol ratio 940/1350 = 0.7Right adrenal aldosterone:cortisol ratio 31000/1674 = 18.5
Lateralisation ratio is 18.5/0.7 = 26.6