MON-LB062 A Preemptive Strike at Suspected Primary Aldosteronism in a Medically Underserved Patient

Abstract INTRODUCTION: Empiric treatment for primary aldosteronism (PA) and deferring confirmatory biochemical testing may be considered in a medically-underserved patient with high clinical suspicion for PA. CASE: A 29-year-old uninsured male with untreated hypertension, inadequate access to outpatient care, and frequent emergency department (ED) visits presented to the ED with a two-day history of headaches, blurry vision, chest pain, and shortness of breath. He denied muscle cramps, prescription medication use, illicit drug use, or family history of hypertension. His physical exam showed a blood pressure (BP) of 280/140 mmHg, otherwise normal vital signs, and normal cardiopulmonary and neurologic exams. Initial lab studies revealed a low serum potassium (2.2 mEq/L) and elevated serum creatinine (1.4 mg/dL). ECG and serial troponin measurements ruled out acute MI. He was diagnosed with hypertensive emergency with acute kidney injury (AKI) and treated in an ICU setting with potassium repletion and continuous esmolol and nicardipine infusions. With suspicion for PA, morning serum samples for aldosterone and plasma renin activity measurement were collected. The patient was transitioned onto maximum doses of three antihypertensive agents and required continued potassium repletion. Though his AKI resolved his BP remained elevated and, on hospital day #4, he voiced a desire to be discharged at a time his lab evaluation for PA was still pending. With high concern for PA, he was prescribed spironolactone with subsequent improvement in BP and serum potassium. He was discharged with follow up in a local clinic for the uninsured, and his lab evaluation later returned confirming high suspicion for PA. Confirmatory biochemical testing for PA was deferred, CT imaging showed a 2.3 cm right adrenal adenoma, and arrangements were made for right adrenalectomy. CONCLUSIONS: PA is an often underrecognized cause of secondary hypertension that carries significant morbidity. Treatment-resistant hypertension and spontaneous hypokalemia are cardinal features in PA that should prompt a diagnostic evaluation for it. This can be costly, time-consuming, and challenging, however. Medications, hypokalemia, and AKI can result in falsely elevated or suppressed results of biochemical tests used for PA case detection. Further, consensus guidelines indicate confirmatory testing—often to include adrenal venous sampling—should be pursued for many patients for whom PA is suspected based on biochemical case detection results. A patient-centered approach to the evaluation and treatment of PA is essential for medically-underserved patients for whom high clinical suspicion for this diagnosis exists. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.