relevant is aldosterone and cortisol co-secretion?
S Bhatt1, Amir H Sam1,2, Victoria Salem1 and
Karim Meeran1,2, 1Imperial College London
School of Medicine, 2Hammersmith Hospital, Imperial College London
Studies suggest that glucocorticoid hypersecretion alongside primary
hyperaldosteronism (PA) is common and may contribute to the adverse metabolic
phenotype. Adrenal crisis post-surgery for PA is rare.
To determine the prevalence of cortisol co-secretion in PA in patients at
Imperial College London NHS Trust, Hammersmith Hospital (a tertiary referral
centre for adrenal tumours).
Amongst patients who had undergone adrenal vein sampling for therapeutic
stratification of PA over the past 5 years, 27 also had formal (overnight
dexamethasone suppression) testing for hypercortisolism with overnight or low
dose dexamethasone suppression test.
Six patients were diagnosed as co-secretors (post dex cortisol range 75 – 435
nM) suggesting a prevalence of 22%. We describe their clinical history. Four
co-secretors underwent unilateral adrenalectomy. Post-operatively, two failed
a synacthen test (peak cortisol range 320-421) and one had a morning cortisol
of 20 nmol/L. They were given glucocorticoid cover post-operatively but it is
not known whether this was of benefit. Previously, no patients were given
glucocorticoid cover, and there was no incidence of severe adrenal crisis post
unilateral adrenalectomy for PA. No improvement in metabolic profile was seen
in follow-up, except for the anticipated improvements in BP control.
It is not clear whether co-secretion in PA is clinically relevant. The
patients described here may not be entirely representative, since we have only
recently prospectively assessed all PA patients for co-secretion. However we
did not find differences in the metabolic profile at presentation between
co-secretors and non-co-secretors. Perhaps co-secreting patients present
earlier, and the burden of cortisol excess has not yet caused a dysmetabolic
profile. In conclusion cortisol co-secretion in PA is more common than
previously thought. Further studies are required to understand exactly what
postoperative monitoring is required in this condition.