4. Case 1
SB
49 yr old female
Obesity
Resistant hypertension
Normal 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 adrenal
Unchanged on repeat scan
Put on spironolactone after initial blood test by another physician – good BP
response
How would you proceed?
5.
6. Case 1
SB
Medications altered – spiro stopped
Doxazosin added
Repeat bloods...............
Aldo 689 (23-415 pmol/L)
Renin 12.5 (4-44 mU/L)
ARR 55 (1-20)
Is the diagnosis confirmed?
7. Case 1
SB
IV saline suppression test
2 litres 0.9% saline over 4 hrs
Bloods 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?
8. Case 2
BS
53 yr old female
Resistant hypertension for 10 yrs managed by GP
Low K+ on several occasions, Na+ 144-148
On 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 494
Renin 3
ARR 165
CT Abdo – 2cm low density lesion L adrenal (normal looking R)
How would you proceed?
9.
10. Case 2
BS
AVS (difficult procedure)
cortisol Aldo
Left adrenal >1750 1175
Right adrenal 543 194
IVC 468 815
How do you interpret these results?
How would you proceed?
11. Case 3
MJ (Exeter patient)
55 yr old male
Resistant hypertension
Normal K+
Elevated aldo/renin and confirmed on salt loading
CT adrenals – no lesion identified
How might you proceed?
12. Case 3
MJ (Exeter patient)
AVS results
Time site cortisol Aldosterone
1530 L renal vein 321 344
1530 Femoral vein 413 389
1549 L adrenal vein 1350 940
1550 Femoral vein 303 432
1600 R adrenal vein 1674 31000
1602 Femoral vein 253 400
Left adrenal:femoral cortisol ratio 1350/303 = 4.5
Right adrenal:femoral cortisol ratio 1674/253 = 6.6
Left adrenal aldosterone:cortisol ratio 940/1350 = 0.7
Right adrenal aldosterone:cortisol ratio 31000/1674 = 18.5
Lateralisation ratio is 18.5/0.7 = 26.6
Editor's Notes
Levels of cortisol will be affected depending on whether AVS is stimulated with synacthen. Levels in that case higher as likely in this example
