Endocrine Abstracts

JOINT1011

Introduction: Primary hyperaldosteronism (PHA), or Conn’s syndrome, is a common yet underdiagnosed cause of hypertension, characterized by excessive aldosterone secretion. It is classically associated with hypertension and hypokalemia. PHA can result from unilateral or bilateral adrenal hyperplasia or aldosterone-producing adenomas. This case highlights the diagnostic and therapeutic challenges of PHA complicated by incidental renal cell carcinoma (RCC). The urgency of managing a potentially malignant renal mass may conflict with the need for precise localization of aldosterone hypersecretion through adrenal vein sampling (AVS).

Case Report: A patient with persistently low potassium levels was referred for endocrine evaluation due to uncontrolled hypertension despite being on three antihypertensive agents. Initial investigations revealed a significantly elevated aldosterone-to-renin ratio (ARR), strongly suggestive of primary hyperaldosteronism. Given the high pre-test probability, further confirmatory testing was deemed unnecessary. A CT scan of the adrenal glands identified an 11 mm left adrenal nodule, consistent with an adrenal adenoma, but also incidentally revealed a suspicious left renal mass, concerning renal cell carcinoma (RCC). This finding prompted an urgent referral to the Urology team, and the patient was subsequently reviewed by a specialized Renal Cancer Unit for multidisciplinary discussion. From an endocrine perspective, adrenal vein sampling (AVS) was recommended to confirm the source of aldosterone hypersecretion. However, this required a 6-week washout period from Spironolactone, which posed a significant delay. Given the urgency of addressing the renal mass, the Urology team advised proceeding with kidney surgery without delay for endocrine concerns. The complexities in management arise from the need to balance timely intervention for the renal mass with the diagnostic precision required for PHA. The adrenal gland will be preserved during kidney surgery to allow for future AVS if needed. Post-surgery, the patient will continue medical management of PHA, with the possibility of targeted treatments such as aldosterone synthase inhibitors in the future.

Conclusion: This case highlights the challenges of managing concurrent primary hyperaldosteronism and renal malignancy, particularly when diagnostic and treatment timelines conflict. Multidisciplinary collaboration between Endocrinology, Urology, and Oncology teams is essential to optimize outcomes.

References: 1. Funder, J. W. et. al (2016). The management of primary aldosteronism: Case detection, diagnosis, and treatment: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 101(5), 1889-1916. https://doi.org/10.1210/jc.2015-4061

2. Young, W. F. et. al(2009). What are the keys to successful adrenal venous sampling (AVS) in patients with primary aldosteronism? Clinical Endocrinology, 70(1), 14-17. https://doi.org/10.1111/j.1365-2265.2008.03450.x