Question

Refer to Chapter 10 HYPOKALEMIA AND HYPERTENSION November 25, 20XX CHIEF COMPLAINT: Hypokalemia and hypertension HISTORY OF PRESENT ILLNESS: This is a 53-year-old female who was worked up by Dr. Thomas for primary hypoaldosteronism. She has an aldosterone of 16.9 and a renin of 0.19 with a ratio now of 85 and previously was 170. She has a potassium of 3, and she takes replacement 40 mEq b.i.d. Her hypertension is present for about 10 years and has been getting worse for the past year. Today, her blood pressure is 170/96, and recheck was 168/99. She said that she was taking Aldactone for a while, but she has been off it for many months. She had a CT scan done in 20XX that revealed an adrenal mass measuring 9 mm on the left side. She had a CT scan done recently, which I am asking her to send me the results. We will attempt to get these films. She has also a goiter for which she has been followed. She has some difficulty swallowing mainly solid foods and no history of thyroid cancer in the family. PAST MEDICAL HISTORY: Primary hypoaldosteronism, diabetes type 2, hypertension, hypercholesterolemia, and multinodular goiter. MEDICATIONS: Lisinopril, hydralazine, nifedipine, indapamide, glipizide, metformin, simvastatin, aspirin, Darvocet, potassium, Pepcid, Prevacid, amitriptyline, and iron. SOCIAL HISTORY: She does not smoke or drink or use any drugs. ALLERGIES: She has no known allergies. IMPRESSION AND PLAN: I spent about 45 minutes with this patient discussing the plan of care and the disease itself in most of the appointment. I explained to her that even though her aldosterone ratio is elevated, we need a confirmation test. I will give her the salt-loading test for three days with p.o. intake of 1 g of salt p.o. three times a day. She will collect 24-hour urine the third day and bring it to the lab to be tested for aldosterone, creatinine, and sodium levels. I have also sent her to lab now for aldosterone, renin repeat, a BMP and 18-hydroxycorticoserone levels. If she tolerates the salt loading test and this is positive, she will go to adrenal venous sampling and I explained to her how this is done. I am scheduling her to come back in two weeks to discuss the test results and decide what is the next step. 1) What is occurring with this patient and why are we giving her a salt test when we know salt raises blood pressure when her blood pressure is already high?

Answer 1

Usually salt test is performed to diagnose primary aldosteronism. High salt suppresses the aldosterone secretion ,in turn lowering aldosterone which may indicate presence of primary hypoaldosteronism.

If this salt test is positive , adrenal venous sampling is done to rule out primary adrenal hyperplasia, aldosterone -producing adrenocortical hyperplasia , idiopathic aldosteronism.

So eventhough the patient has has high blood pressure, to rule out the cause of her high aldosterone, high blood pressure , and hypokalemia ,the physician is in position to perform salt test to plan treatment modalities to treat her .