Hyperaldosteronism occurs in a higher proportion of patients with end-stage kidney disease (ESKD) than in the general population, but adrenal adenomas are infrequently and inappropriately evaluated in ESKD, investigators reported at the 2023 American Transplant Congress in San Diego, California. Underdiagnosis has important clinical consequences.

“Adrenal adenomas may hypersecrete aldosterone hormone, contributing to refractory hypertension and development of heart failure,” Vidyaratna Fleetwood, MD, of Saint Louis University in Missouri, explained in an interview. “Clinicians need to have a low threshold of suspicion for an adrenal adenoma, and order noncontrasted abdominal imaging for any patient with severe or refractory hypertension, especially young patients with hypertension as their ESKD etiology. Patients with an adrenal nodule sized 1 cm or greater should be referred to endocrinology for confirmatory testing.”

Among 612 kidney transplant candidates, adrenal nodules were present in 38 patients (6.2%), Dr Fleetwood’s team found. Of these, 12 had biochemically functional adenomas that produced aldosterone, 7 had nonfunctional adenomas, and 19 were not evaluated at all.

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Overall, 57.9% of nodules that received appropriate biochemical evaluation secreted aldosterone, Dr Fleetwood and her colleagues reported in a presentation.

Common clinical parameters did not distinguish the groups. Demographics, systolic blood pressure (144 vs 126 mm Hg), and serum potassium levels (3.9 vs 4.4) were similar among patients with functional and nonfunctional nodules, respectively. Endocrine Society screening guidelines also did not distinguish groups: 40.0% of patients with functional nodules and 71.4% of patients with nonfunctional nodules met criteria for primary aldosteronism. The aldosterone-renin ratio was similar between groups: 67.0 vs 60.4, respectively.

“Currently, the Endocrine Society guidelines recommend screening with an aldosterone-renin ratio in patients taking 4 or more antihypertensive agents, 3 or more agents with poor blood pressure control, or 1 or more agents with hypokalemia. However, patients with ESKD may not qualify under these guidelines, particularly if their hypokalemia is masked by ESKD or they experience hypotension during dialysis,” Dr Fleetwood said. “The Endocrine Society guidelines should be re-evaluated in the ESKD population.”

The standard of care treatment for unilateral aldosterone-secreting adenoma is surgical adrenalectomy. This offers partial to complete symptom relief in the majority of patients, according to Dr Fleetwood, but it is more effective in younger patients with a shorter hypertension duration. Patients who are poor surgical candidates or who have bilateral disease may benefit from a mineralocorticoid receptor antagonist, she said. MRAs may cause hyperkalemia and should be increased slowly.


Fleetwood V, Ling G, Mosman A, Lentine K. Aldosterone-secreting adrenal adenomas in the kidney transplant population: underdiagnosed and important. Presented at: ATC 2023; June 3-7, San Diego, California. Abstract 386.