How relevant is aldosterone and cortisol co-secretion?


Padmanabh S Bhatt1, Amir H Sam1,2, Victoria Salem1 and Karim Meeran1,2, 1Imperial College London School of Medicine, 2Hammersmith Hospital, Imperial College London NHS Trust


Background: 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.


Aim: 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).

Methods: 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.


Results: 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.


Discussion: 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.