Primary aldosteronism: a new insight into pathogenesis, diagnosis, and treatment in hypertensive patients

Primary aldosteronism (PA) seems to be a pathogenetically heterogenous disease. It is suggested that approximately 30% of all hypertensive patients are affected by this disease. Autonomous hypersecretion of aldosterone, which is observed in this patient group, may be caused by an adrenal adenoma (aldosteronoma), hyperplasia of the zona glomerulosa, mutation of the KCNJ5 potassium channel, or other rare pathogenetic factors. Contrary to what was believed before, PA may be the cause of resistant hypertension rather than mild hypertension, while 70% of the patients have normal serum potassium levels rather than hypokalemia (previously believed to be a classical PA symptom). Hypertensive patients with normal or elevated aldosteronemia (A), suppressed plasma renin activity (PRA) and an elevated A/PRA ratio should undergo further diagnostic work‑up for PA. PA is suspected to be the continuum of low‑renin hypertension. First‑choice therapy of PA should be based on long‑term administration of low‑dose mineralocorticoid receptor antagonists (spironolactone, eplerenone) and, in the nearest future, probably also aldosterone synthase antagonists such as CLI699, regardless of the morphological type of PA. It is still unknown whether pharmacological treatment will totally replace surgical treatment in some types of PA. Long‑term administration of low‑dose aldosterone antagonists is an effective and often underscored antihypertensive treatment, which rarely causes serious hyperkalemia if the kidney function is not impaired.