Case Study: Primary Aldosteronism
By Kathleen Grant MD and Cassie Myers
Published on 05/03/2026
Medical History:
The patient is a 49-year-old female with a history of hypertension, for which she takes atenolol-chlorthalidone, hydralazine, and telmisartan-amlodipine with good control. She was first told in 2005 that she had hypertension when she was delivering her first son. Over the next 20 years, she was prescribed 4 more medications to battle her treatment-resistant hypertension, until she eventually presented to us in 2025 with 5 total medications. She is not currently taking a potassium supplement because her pharmacist was concerned about drug interactions. The patient has no familial history of adrenal issues, but her mother and father had hypertension. She also had a family history of diabetes, obesity, stroke, and heart attack. A CT abdomen scan revealed a 1.6cm left adrenal nodule in 2024. She presented to our clinic in 2025.
Laboratory Findings:
Her basic metabolic panel showed hypokalemia, with a potassium level of 3.3 mEq/L.
An aldosterone-to-direct renin ratio was measured, with aldosterone at 18 ng/dL and renin at 0.359 ng/dL, yielding a ratio of 50.1.
A 24-hour urine collection for aldosterone after a high-salt intake diet was undertaken. The initial 24-hour urine aldosterone level was 7.3 µg/day; however, the collection was suboptimal, as evidenced by a mildly low urine potassium level at the time of collection. The patient was non compliant on collecting the sample and it was disregarded.
On repeat confirmatory testing, her 24-hour urine aldosterone level was elevated at 27.63 µg/day, which was inappropriately high after a high salt intake, where aldosterone would typically be low. This prompted which prompted referral to an endocrine surgeon.
Assessment and Discussion:
We found the clinical picture to be highly suggestive of primary hyperaldosteronism. Primary aldosteronism, also called Conn’s Syndrome, is one of the leading causes of secondary hypertension. It is an endocrine disorder caused by overproduction of aldosterone by the adrenal glands. Defining features of this disorder are high blood pressure, high aldosterone/renin ratio, and low blood potassium levels.
Primary aldosteronism can be caused by either an aldosterone-producing adenoma (small benign tumor) in one adrenal gland, or by the overactivity of both adrenal glands, which is called bilateral adrenal hyperplasia. Bilateral hyperplasia is treated by mineralocorticoid antagonists, while an aldosterone-producing adenoma is most often treated with surgery in the appropriate setting. To help determine which cause of primary aldosteronism is being presented, adrenal venous sampling can be administered. This is a procedure in which aldosterone levels are measured from both adrenal veins via a small puncture in the groin, allowing us to determine if one or both glands is overactive.
Given the patient’s age and medical history, she was recommended for adrenal venous sampling which showed the problem was unilateral and eventually underwent surgical removal of the adrenal nodule contributing to her hypertension. The patient is now stable with 2 medications regulating her blood pressure. Upon following up with her post-procedure, the patient reports that while choosing to undergo surgery was a difficult decision, she is very pleased with the results and only regrets that she did not find her diagnosis sooner.
Many individuals who suffer from hypertension become burdened by the medications they must take to regulate their blood pressure. In this patient’s case, her 5 medications needed to be taken at different times of the day, and amidst her busy life schedule, she often forgot to take them. By the time she presented to us in 2025, she had realized that her current regimen was no longer manageable and was willing to work towards finding a better solution. Screening for primary aldosteronism is an important step in advocating for patients and working to find the deeper causes of hypertension.
It is recommended by the Endocrine Society that all individuals with hypertension should be screened for primary aldosteronism. Unidentified primary aldosteronism can lead to several detrimental effects, including structural damage to the heart muscle and arteries, resulting in numerous cardiovascular dysfunctions. Atrial fibrillation is a common occurrence. Primary aldosteronism is often overlooked due to its apparent similarity to primary hypertension, so timely screening is especially important.
Kathleen Grant is an internal medicine physician who returned to her home state of Athens, Georgia, after completing her training at Wake Forest. She enjoys working in the outpatient setting and is passionate about mentoring pre-medical and medical students affiliated with the University of Georgia and the Medical College of Georgia.
Cassie Myers is a recent graduate from the University of Georgia. She currently works at the Athens Wellness Clinic and plans to attend medical school in the future.
References:
James Brian Byrd, MD, MS, Adina F. Turcu, MD, and Richard J. Auchus, MD, PhD, Primary Aldosteronism: Practical Approach to Diagnosis and Management, 2018
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.118.033597
Brum de Sousa E, do Mar Menezes M, Cordeiro AM. A Case Report of Primary Aldosteronism and Extensive Hypertension-Mediated Organ Damage. Cureus. 2024
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