Primary aldosteronism

Patients who have undergone unilateral adrenalectomy for unilateral primary aldosteronism (PA)

• BP, plasma electrolytes, and aldosterone and renin levels should be monitored every 6 to 12 months for clinical and biochemical evidence of recurrence (if cured postoperatively) or worsening (if improved but not cured) of PA. Patients should have an adrenal CT scan performed at 1 year postoperatively, and at 1- to 3-year intervals thereafter. This is because it has become apparent from careful postoperative follow-up of patients that some have a natural history of the disease in which the remaining adrenal slowly increases in size and becomes nodular, and which may turn out to be in a different class genetically. Occasionally, a new adenoma that may or may not be secreting aldosterone requires removal on size criteria alone (e.g., ≥2.5 cm, although some centres use higher cutoffs of 3.0 cm or even 4.0 cm), with preservation of an apparently normal limb of the adrenal if possible.

Patients receiving aldosterone medications

• Electrolytes and renal function should be monitored regularly (e.g., every 3 to 6 months), watching for development of hyperkalaemia (more likely in patients who have renal dysfunction or are taking other potassium-retaining agents such as angiotensin-converting enzyme [ACE] inhibitors, angiotensin-II receptor antagonists, or non-steroidal anti-inflammatory drugs [NSAIDs]), hyponatraemia, and uraemia. Renin levels can be used to guide doses of treatment, provided that the method is sound and results are not confounded by the use of other medicines. In all patients with PA treated medically, CT of the adrenals should be performed annually at first and, if no nodular growth is seen, every 3 to 4 years, indefinitely.

Patients with familial hyperaldosteronism type I (FH-I)

• Hypertension is readily controlled by administering glucocorticoids in low doses. Control can be assessed by clinic, home, and ambulatory BP monitoring, and by periodic (e.g., yearly) echocardiographic assessments of left ventricular mass index and diastolic function. Patients should also be monitored for the development of glucocorticoid-induced osteoporosis by dual-energy x-ray absorptiometry (DXA) performed every 2 to 3 years.