Primary Aldosteronism and the Kidneys

Primary aldosteronism (PA) is the most common and modifiable form of secondary hypertension, being responsible for 5-10% of all cases of hypertension and over 20% of cases of resistant hypertension. PA is characterized by autonomous aldosterone secretion from 1 or both adrenal glands, independent of regulation by renin and angiotensin II. Although the adverse cardiovascular consequences garner the majority of attention in regard to its clinical impact, PA leads to important detrimental effects on kidney health also. This includes early glomerular hyperfiltration followed by albuminuria, steeper longitudinal estimated glomerular filtration rate decline, and a higher risk for CKD. Importantly, early diagnosis and initiation of targeted therapies, namely surgical adrenalectomy and mineralocorticoid receptor antagonist medications, effectively mitigate these kidney disease risks. Although these aldosterone-targeted therapies provide long-term kidney protection, they often "unmask" previously unrecognized CKD due to reversal of the longstanding glomerular hyperfiltration inherent to the pathophysiology of PA. Herein, a teaching case is discussed which highlights the diagnostic and treatment approaches to PA along with commonly encountered kidney manifestations which arise from PA and its treatments.