Primary aldosteronism

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 3 Apr 2025

Last updated: 03 Apr 2024

Primary aldosteronism (PA) is the most common specifically treatable and potentially curable form of hypertension. It accounts for at least 5% of hypertensive patients, with most patients normokalemic.

Approximately 30% have unilateral forms correctable by unilateral laparoscopic adrenalectomy, and 70% have bilateral forms in which hypertension responds well to aldosterone antagonist medications.

Optimal detection involves screening all hypertensive patients using the plasma aldosterone/renin ratio, after controlling for factors (including medications) that may confound results.

In patients with repeatedly elevated aldosterone/renin ratios, definitive confirmation or exclusion of diagnosis involves careful suppression testing with measurement of aldosterone response to fludrocortisone or to salt loading.

Subtype differentiation for optimal treatment involves genetic testing for familial forms where suspected. If genetic testing is not performed or negative, adrenal CT and adrenal venous sampling should be performed to differentiate unilateral from bilateral forms.

Definition

In PA, aldosterone production exceeds the body's requirements and is relatively autonomous with regard to its normal chronic regulator, the renin-angiotensin II system.[1][2] This results in excessive sodium reabsorption via amiloride-sensitive epithelial sodium channels within the distal nephron, leading to hypertension and suppression of renin-angiotensin II. Urinary loss of potassium and hydrogen ions, exchanged for sodium at the distal nephron, may result in hypokalemia and metabolic alkalosis if severe and prolonged.[1][2]

History and exam

Key diagnostic factors

hypertension

Full details

Other diagnostic factors

age 20 to 70 years
nocturia, polyuria
lethargy
mood disturbance (irritability, anxiety, depression)
difficulty concentrating
paresthesias, muscle cramps
muscle weakness
palpitations

Full details

Risk factors

family history of PA
family history of early onset of hypertension and/or stroke

Full details

Diagnostic tests

1st tests to order

plasma potassium
aldosterone/renin ratio

Full details

Tests to consider

fludrocortisone suppression test
saline infusion testing
oral salt loading
genetic testing
adrenal CT
adrenal venous sampling
adrenal MRI
posture stimulation testing
angiotensin II infusion testing
24-hour urinary hybrid steroids (18-hydroxy- and 18-oxo-cortisol)
dexamethasone suppression testing

Full details

Emerging tests

¹¹ C-Metomidate PET/CT

Treatment algorithm

ONGOING

unilateral PA

bilateral PA (excluding familial hyperaldosteronism type I)

familial hyperaldosteronism type I

Contributors

Authors

Michael Stowasser, MBBS, FRACP, PhD

Professor

Endocrine Hypertension Research Centre

University of Queensland Frazer Institute

Greenslopes and Princess Alexandra Hospitals

Brisbane

Queensland

Australia

Disclosures

MS is an author of several references cited in this topic.

Acknowledgements

Professor Michael Stowasser would like to gratefully acknowledge Professor Richard D. Gordon, a previous contributor to this topic.

Peer reviewers

Paolo Mulatero, MD

Department of Medicine and Experimental Oncology

Division of Medicine and Hypertension

San Giovanni Battista Hospital

Torino

Italy

Disclosures

PM declares that he has no competing interests.

Wail Malaty, MD

Clinical Professor

Department of Family Medicine

University of North Carolina

Chapel Hill

Assistant Program Director

MAHEC Rural Family Medicine Residency

Hendersonville

Disclosures

WM declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Mulatero P, Sechi LA, Williams TA, et al. Subtype diagnosis, treatment, complications and outcomes of primary aldosteronism and future direction of research: a position statement and consensus of the Working Group on Endocrine Hypertension of the European Society of Hypertension. J Hypertens. 2020 Oct;38(10):1929-36. Abstract

Reincke M, Bancos I, Mulatero P, et al. Diagnosis and treatment of primary aldosteronism. Lancet Diabetes Endocrinol. 2021 Dec;9(12):876-92. Abstract

Funder JW, Carey RM, Mantero F, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment. J Clin Endocrinol Metab. 2016 May;101(5):1889-916.Full text Abstract

Young WF Jr. Diagnosis and treatment of primary aldosteronism: practical clinical perspectives. J Intern Med. 2019 Feb;285(2):126-48.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Essential hypertension (HTN)
- Thiazide-induced hypokalemia in patient with essential HTN
- Renal artery stenosis
More Differentials
Guidelines
- NCCN clinical practice guidelines in oncology: neuroendocrine and adrenal tumors
- Japan Endocrine Society clinical practice guideline for the diagnosis and management of primary aldosteronism 2021
More Guidelines
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Primary aldosteronism

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Emerging tests

Treatment algorithm

unilateral PA

bilateral PA (excluding familial hyperaldosteronism type I)

familial hyperaldosteronism type I

Contributors

Authors

Michael Stowasser, MBBS, FRACP, PhD

Disclosures

Acknowledgements

Peer reviewers

Paolo Mulatero, MD

Disclosures

Wail Malaty, MD

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice