Zusammenfassung
Der primäre Hyperaldosteronismus (PHA) ist die häufigste sekundäre Hypertonieform mit einer Prävalenz von ca. 5 % bei Patienten mit arteriellem Hypertonus. Die Erkrankung ist charakterisiert durch eine inadäquat hohe Aldosteronsekretion in einer oder beiden Nebennieren. Abklärung und Therapie des PHA sind indiziert, weil Patienten mit PHA im Vergleich zu Patienten mit essentiellem arteriellen Hypertonus, auch bei gleichen Blutdruckwerten, ein signifikant erhöhtes kardiovaskuläres Risiko aufweisen und der PHA sehr gut durch eine spezifische Therapie behandelbar ist.
In den Richtlinien der Endocrine Society wird daher ein weitreichendes Screening auf PHA bei Hypertonikern empfohlen. Als Screeningtest wird die Bestimmung der Aldosteron-zu-Renin-Ratio (ARR) empfohlen, wobei nach einer erhöhten ARR meistens ein Bestätigungstest (z. B. i. v. Kochsalzbelastungstest) angeschlossen werden sollte. Bei biochemischem Nachweis eines PHA wird anschließend evaluiert, ob es sich um eine einseitige (Aldosteron produzierendes Adenom) oder eine beidseitige Aldosteronhypersekretion (bilaterale Nebennierenhyperplasie) handelt, denn die einseitige Erkrankung wird operativ, die beidseitige medikamentös z. B. mit Mineralokortikoidrezeptorblockern behandelt. Die Richtlinien empfehlen zur Unterscheidung neben einem Nebennieren-CT ein so genanntes adrenales Venensampling (AVS), d. h. Blutabnahme und Hormonbestimmungen aus der rechten und linken Nebennierenvene. Neuere Studiendaten legen jedoch nahe, dass eine rein auf dem CT-Befund basierende Subtypenklassifizierung bzw. Therapie dem AVS basierten Vorgehen ebenbürtig ist.
Obwohl die Leitlinien bei in etwa jedem 2. Patienten mit arteriellem Hypertonus eine Abklärung auf PHA empfehlen, wird dies in der allgemeinen Praxis derzeit kaum umgesetzt, weswegen nach wie vor die meisten Patienten mit PHA nicht diagnostiziert und somit auch oft untherapiert sind.
Abstract
Primary aldosteronism (PA) is the most common cause of endocrine hypertension with an estimated prevalence of 5% among patients with arterial hypertension. PA is characterized by inadequately high aldosterone secretion from one or both adrenal glands. Diagnosis and therapy of PA is indicated because patients with PA have, compared to patients with essential arterial hypertension, even at the same blood pressure, a significantly higher cardiovascular risk, that can be effectively treated by specific therapy.
Therefore, the Endocrine Society guidelines recommend broad screening for PA among hypertensive patients. The determination of the aldosterone-to-renin ratio (ARR) is the recommended screening test for PA. In the case of an elevated ARR, a confirmatory test (e. g. i. v. saline infusion test), should be performed. If PA is biochemically confirmed, subtype classification, i. e. differentiation between unilateral (aldosterone producing adenoma) and bilateral aldosterone hypersecretion (bilateral adrenal hyperplasia), is important because unilateral diseases can be treated by adrenal surgery whereas bilateral diseases are treated by drugs, e. g. mineralocorticoid receptor blockers. In addition to an adrenal computed tomography (CT), guidelines recommend adrenal venous sampling (i. e. blood collection for hormone measurement from the right and left adrenal vein) for subtype determination. Recent study results, however, suggest that CT based subtype classification and therapy of PA results in similar outcome when compared to adrenal venous sampling-based procedures.
It is of concern that the recommendations of the guidelines for a wide PA screening in approximately every second patient with arterial hypertension is not implemented in routine clinical practice. Therefore, currently the vast majority of patients suffering from PA remains undiagnosed and untreated.
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S. Pilz, A. Tomaschitz, C. Trummer, A. Bachmann, M. Pandis, V. Schwetz, B. Obermayer-Pietsch und W. März geben an, dass kein Interessenkonflikt besteht.
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Pilz, S., Tomaschitz, A., Trummer, C. et al. Primärer Hyperaldosteronismus: Diagnostik und Therapie. J. Klin. Endokrinol. Stoffw. 10, 82–91 (2017). https://doi.org/10.1007/s41969-017-0010-7
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DOI: https://doi.org/10.1007/s41969-017-0010-7