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# Hyperaldosteronism: primary and secondary

- Lesion

Too much aldosterone from the adrenal causes high blood pressure and low potassium. It is a common, curable cause of hypertension.

Updated Nov 12, 2026

## Key points

- Primary: high aldosterone, low renin; secondary: high aldosterone, high renin (renal artery stenosis, heart failure, cirrhosis, nephrotic syndrome).
- Bilateral idiopathic hyperplasia is the commonest cause; adenoma (Conn) is next.
- Adenomas often carry KCNJ5 mutations (potassium channel), especially in younger patients; also ATP1A1, ATP2B3, CACNA1D, CTNNB1.
- Familial type I (glucocorticoid-remediable): CYP11B1-CYP11B2 chimeric gene puts aldosterone synthase under ACTH control.
- Effects: sodium retention, hypertension, hypokalaemia, metabolic alkalosis; normokalaemia is common.
- Spironolactone bodies: whorled eosinophilic inclusions in adenoma cells after spironolactone therapy.

## What it is

Primary hyperaldosteronism is autonomous aldosterone secretion that suppresses renin. It is one of the commonest causes of secondary hypertension. Bilateral idiopathic hyperplasia and a unilateral aldosterone-producing adenoma (Conn syndrome) cause most cases, and the distinction matters because the adenoma can be removed. Secondary hyperaldosteronism, by contrast, is driven by high renin.

## Structure

- Adenoma: usually small, solitary, bright yellow, well circumscribed; lipid-laden cells resembling fasciculata or glomerulosa.
- Unlike cortisol adenomas, the adjacent and opposite cortex is not atrophic (ACTH is normal).
- Bilateral hyperplasia: diffuse or micronodular expansion of the zona glomerulosa.
- Spironolactone bodies after treatment.

## Step by step

- A mutation (often KCNJ5) depolarises glomerulosa cells.
- Calcium enters and switches on aldosterone synthase (CYP11B2) and cell proliferation.
- Aldosterone acts on the collecting duct: sodium reabsorption, potassium and hydrogen excretion.
- Volume expands and blood pressure rises; renin is suppressed.
- Potassium and hydrogen losses give hypokalaemia and metabolic alkalosis.

## Clinical notes

- Screen hypertensive patients with resistant hypertension, hypokalaemia or an adrenal mass using the aldosterone-to-renin ratio.
- Adrenal vein sampling separates a unilateral adenoma from bilateral hyperplasia.
- Aldosterone excess damages heart and kidney beyond blood pressure itself.

## Memory aid

Primary means the adrenal is the boss (renin silenced); secondary means the kidney is shouting for help (renin loud).

## Test yourself

Think of the answer, then tap the question to see it.

## How do renin levels separate primary from secondary hyperaldosteronism?

Renin is suppressed in primary and raised in secondary hyperaldosteronism.

## What are spironolactone bodies?

Eosinophilic, laminated cytoplasmic inclusions seen in adrenal cortical cells after spironolactone therapy.

## What is the genetic basis of glucocorticoid-remediable aldosteronism?

A chimeric CYP11B1-CYP11B2 gene that places aldosterone synthase under the ACTH-responsive 11-beta-hydroxylase promoter.

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## Elsewhere in DurgiPedia

- [Aldosterone](https://durgical.com/en/biochemistry/molecules/aldosterone/)
- [The adrenal cortex: zones, hormones and androgens](https://durgical.com/en/physiology/the-adrenal-cortex-zones-hormones-and-androgens/)
- [Physiology of hypertension](https://durgical.com/en/physiology/physiology-of-hypertension/)

## Connections

## Related 3

- [Adrenocortical adenoma and carcinoma](https://durgical.com/en/general-pathology/adrenocortical-adenoma-and-carcinoma/)
- [Hypertension: mechanisms](https://durgical.com/en/general-pathology/hypertension-mechanisms/)
- [Hypertensive heart disease and cor pulmonale](https://durgical.com/en/general-pathology/hypertensive-heart-disease-and-cor-pulmonale/)

## Related conditions 4

- [Primary hyperaldosteronism (Conn syndrome)](https://durgical.com/en/conditions/primary-hyperaldosteronism/)
- [Hypokalaemia](https://durgical.com/en/conditions/hypokalaemia/)
- [Adrenal incidentaloma](https://durgical.com/en/conditions/adrenal-incidentaloma/)
- [Metabolic alkalosis](https://durgical.com/en/conditions/metabolic-alkalosis/)

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Educational content on the mechanisms of disease; not a diagnostic or treatment guide and no substitute for a health professional's advice. No doses are given.

Sources: [Familial hyperaldosteronism](https://medlineplus.gov/genetics/condition/familial-hyperaldosteronism/) (MedlinePlus, US National Library of Medicine, 2025).

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Representative model, for educational purposes only.

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/general-pathology/hyperaldosteronism-primary-and-secondary/