Three Doctors Discuss how HyperAldosteronism Causes Hypertension
In service of Adrenal Awareness Month, 2022, Columbia endocrinologist Dr. Hyesoo Lowe hosted a conversation, exploring why some people who have hypertension and high blood pressure may have their adrenal glands to blame.
To help shed light on this topic, two of Columbia’s own adrenal specialists—Dr. Salila Kurra, an endocrinologist and head of Columbia’s Adrenal Center and Dr. Katie McManus, an adrenal surgeon—joined Dr. Lowe on an episode of Columbia Surgery’s podcast Conversations and Curbsides.
The following is a transcription of the discussion, and is loosely edited for context and clarity.
Jump to a Section:
- An Adrenal Gland Overview
- Adrenal Gland & High Blood Pressure
- Too Much Aldosterone
- How Commonly Is the Adrenal Gland the Main Cause Of Hypertension?
- Signs that the Adrenal Gland May Be Causing Hypertension
- Testing For Adrenal Hypertension
- Screening for Surgery
- Adrenal Vein Sampling
- Treatments: Surgical Options
- Laparoscopic Surgery & Robotic Surgery
- Ruling Out Cancerous Tumors
- Non-Surgical Treatments: Medicine
- Recovery After Surgery
- Post Surgical Outcomes
- Non-Surgical Treatments: Medicine
- Summary
Introduction
Dr. Hyesoo Lowe:
So I think the first thing I wanted to mention was that we actually are rescheduled today because of something perfectly appropriate... Why don't you tell us what you were doing, Dr. McManus, that we had to reschedule this interview.
Dr. Katie McManus:
Well, funny you should ask. I was removing an adrenal gland for one of the diseases we're going to be talking about today.
Dr. Hyesoo Lowe:
This is amazing. And that is the absolute perfect segue into our topic for the day, which is adrenals. We're going to talk a little bit about the adrenal gland and how it relates to something that's really, really common around the world, and that is high blood pressure.
An Adrenal Gland Overview
Dr. Hyesoo Lowe:
So, first of all, let's talk about the adrenal gland. What is the adrenal gland? Many people are not aware of where it is, what it does. What is the adrenal gland?
Dr. Salila Kurra:
Well I can take that because, full disclosure, the adrenal gland is my favorite gland. I know Dr. Lowe, yours might be the thyroid?
Dr. Hyesoo Lowe:
It is.
Dr. Salila Kurra:
But mine is the adrenal. And the adrenal glands, they're basically two crowns that sit on top of the kidneys and they make hormones that help regulate your blood pressure, your metabolism, your blood sugar, your immune system and also your response to stress. So they're pretty important with regards to your body functioning normally.
Dr. Hyesoo Lowe:
How many does a person have?
Dr. Salila Kurra:
Everyone has two adrenal glands, or most everyone has two adrenal glands. One sits on the right kidney and the other sits on the left kidney. Interestingly, you really only need part of one adrenal gland to have normal function, so you have a lot of reserve in the sense that you have two that when they function normally, you make hormones that help regulate the things we just talked about.
Dr. Hyesoo Lowe:
Isn't it interesting that the body has certain things in duplicate, just in case. Like two kidneys, two adrenals.
Dr. Salila Kurra:
Yeah. And much like with the kidneys, you don't actually need both adrenals to have normal functions.
Adrenal Gland & High Blood Pressure
Dr. Hyesoo Lowe:
Very good point. So, that's the adrenal gland, it does a whole bunch of things and it regulates a variety of things in your body. Separate to that, a lot of people have high blood pressure, right? It’s possibly the number one type of medication that's prescribed in the US., the number one cause of many things like heart disease and a variety of other things. So how are the adrenal gland and blood pressure related?
Dr. Salila Kurra:
Sure. So the adrenal gland, it makes two hormones that help with blood pressure. Aldosterone is one of those hormones and aldosterone helps you maintain your blood pressure. So when your blood pressure gets lower, your aldosterone level goes up and that's how it sort of directly affects your blood pressure.
There's another hormone called cortisol that also has effects on the blood pressure, and again, when your blood pressure goes down, your cortisol goes up. But aldosterone, which is referred to as a mineralocorticoid hormone, really helps to maintain your normal blood pressure.
Dr. Hyesoo Lowe:
Aldosterone. Okay. So, I'm guessing that if you have some kind of a problem with one of those hormones, you might have a problem with blood pressure. Is that fair to say?
Dr. Salila Kurra:
Definitely. If you have too much of those hormones, your blood pressure can be too high. And if you have too little of those hormones, which is more rare, you can have low blood pressure. What we typically see though is if you make too much, especially aldosterone, your blood pressure can be high and difficult to control or manage.
TOO MUCH ALDOSTERONE
Dr. Hyesoo Lowe:
So why would you make too much aldosterone?
Dr. Katie McManus:
So when we're talking about the adrenal and we're talking about adrenal tumors, which are a common reason that patients come over to surgery, the question is whether that tumor is the focus of the overproduction of any one of these hormones that we're talking about.
So in addition, with aldosterone specifically, it may be coming from a tumor or it may just be coming from the entire adrenal gland or both adrenal glands. And so it's really important in our workup to be able to distinguish between those etiologies so we can provide appropriate treatment.
Dr. Hyesoo Lowe:
Interesting. So this is why I find endocrine and endocrine surgery is so fascinating because you can have a tumor, it can just be a tumor, but you can have a tumor that's actually producing hormones and that could cause problems down the road.
I can see how it can get a little complicated, because a lot of people will get a CAT scan for one reason or another. And what we'll find is something that we call incidentaloma where they say, "Incidentally, you actually have a little something on your adrenal gland and then now it's left up to us to figure out if that is a tumor that is producing a hormone and causing harm, or is it just a tumor?" And there's a lot of evaluation that's got to get done.
How Commonly Is the Adrenal Gland the Main Cause Of Hypertension?
Dr. Hyesoo Lowe:
I'm guessing since so many people have high blood pressure, if you find a tumor on the adrenal gland, we're going to want to know if they're related.
How many people generally with high blood pressure or hypertension actually have an adrenal problem? Is it most people? Is it a small minority? Would you say it's 50/50?
Dr. Salila Kurra:
That's a great question. It's probably not 50/50, it's some people, not most people. So most people have essential or primary hypertension, meaning that their blood pressure is high often because they have family history or they have a diet that's high in salt or they have excess weight that's contributing to blood pressure. Most people who have high blood pressure have it for that reason.
But, there are some people who have it because their adrenal glands are not functioning the way that they should be and they're making too much of a certain hormone, which then can give them high blood pressure. Usually that hormone is aldosterone. So if you make too much aldosterone, your blood pressure will be high and your potassium, which is an electrolyte in your blood, may be low.
So, it's a rare cause of high blood pressure but it's important if you have very high blood pressure that is difficult to control, to think about aldosterone because we may use different medications or even be able to help you have your blood pressure be better controlled by doing surgery.
Dr. Hyesoo Lowe:
That makes sense to distinguish that, right? Because if we're talking about plain old regular high blood pressure, or essential hypertension, we basically think of needing medications lifelong, maybe one or two or three, and that's sort of like a permanent thing. And it seems where the opposite is the case, maybe, if you have something like adrenal hypertension, where you have an aldosterone producing tumor, again, a tumor producing a hormone, if you took care of the tumor, in other words got rid of it or took out that tumor surgically, then you might be cured, potentially, of your high blood pressure. So that seems like something that would be definitely worth looking into.
Signs That The Adrenal Gland May Be The Cause
Dr. Hyesoo Lowe:
What are some signs, you mentioned some already, but what are some possible signs that you might have hyperaldosteronism or adrenal hypertension?
Dr. Salila Kurra:
I think it's important if somebody is young—and although the word “young” sadly means something different to me nowadays than it did 20 years ago!—if you are below the age of 30, with high blood pressure, then you should be screened for hyperaldosteronism.
If you have what we call resistant hypertension, meaning that you're on multiple medications and your blood pressure is still high; if you have “very high” blood pressure, meaning that your blood pressure is greater than or equal to 180 over 120; or if you have high blood pressure that, all of the sudden, doesn't respond to the medications that you are on—in other words, if your blood pressure was well controlled for years, and then all of a sudden causes to you need more medications or if it's higher than it used to be—then you should think about being screened for hyperaldosteronism.
The other thing which a patient may not know on their own, but their physician would know, is if their potassium is low. So if your potassium is consistently low and you need potassium supplementation, that's another meaning that you have to actually take potassium or eat lots of bananas or do whatever it is to keep your potassium high, then you should also be screened for hyperaldosteronism.
Dr. Hyesoo Lowe:
Great. That's actually really helpful. And I think it's becoming more on patient's radar screens, as well as doctor radar screens, to know that screening for these, what we call, secondary sources of hypertension are really important and potentially quite curable.
Testing For Adrenal Hypertension
Dr. Hyesoo Lowe:
Okay. So let's say we've kind of gotten that on our radar screen. What kind of tests would have to be done to see if you've got adrenal hypertension?
Dr. Salila Kurra:
We usually check aldosterone levels and renin. Renin is an enzyme that's involved in the production of aldosterone. So typically we will check for both renin and aldosterone levels and if the aldosterone is high and the renin is low, then we are concerned that the person may have hyperaldosteronism.
There are some guidelines that suggest that we should also give the person salt, and see if they make aldosterone in their urine but that test is hard to do because if you have high blood pressure, as you know, we tell you to always avoid salt. So we often don't like to give people salt on purpose just for this testing, because it might make their blood pressure high and their potassium low.
Dr. Hyesoo Lowe:
Excellent. And so we feel like, okay, we're pretty sure that this person is making too much aldosterone. Now what are we going to do? And when would they come and see you, Katie?
Screening for Surgery
Dr. Katie McManus:
Well, the first thing beyond getting the blood work is to see if this may be coming from one adrenal or both adrenals. And when it's coming from one adrenal, it could be coming from, again, that entire adrenal or a tumor on that adrenal. But in any case, the main differentiating point is whether it's coming from one side or if it's coming from both sides, and that really impacts the treatment options for the patient.
So, many times patients will get an imaging study, such as a CAT scan or an MRI of the abdomen to see if there are any tumors. The tricky thing is that with this particular disease, we're always wary when we see a tumor because we don't 100% know that this tumor is the source of the high amount of aldosterone in the patient's blood. Because, as Dr. Lowe mentioned, adrenal incidentalomas, which are little masses on the adrenal that you find incidentally, can be nonfunctional.
So it may be that somebody has a lump on their adrenal that isn't making too much aldosterone on its own and that it's actually their other adrenal gland, the one that looks normal, that's making too much aldosterone.
Adrenal Vein Sampling
Dr. Katie McManus:
So this sounds confusing, right? Because it is. Fortunately, there is a special procedure that we can do called adrenal vein sampling. And we at Columbia have an excellent team who do this very, very well. And essentially in that procedure, they collect blood from each adrenal gland and they compare the two sides to see if we can tell which side this overproduction is coming from, or if it's from both.
Dr. Hyesoo Lowe:
So if you have high blood pressure, this does automatically mean that you should go out and get a CAT scan and see if you have something on your adrenal gland, because you may find something that has nothing to do with your high blood pressure.
What you should first do is get properly screened with the correct type of lab testing. And if that indicates something more that's abnormal with the adrenal then there is, of course, confirmatory testing with adrenal vein sampling that can give us a little bit more clarity. Thank you for that, that's very helpful.
Treatments: Surgical Options
Dr. Hyesoo Lowe:
Let's talk about treatments. We talked about how hyperaldosterone is potentially very curable, if it indeed is coming from a tumor producing that aldosterone. So, are there different kinds of operations? What kind of operation is done to get rid of this type of tumor?
Dr. Katie McManus:
Yes. Excellent question. So if through our adrenal vein sampling we are able to determine that only one of the adrenal glands is responsible for the high level of aldosterone, surgery is an option. And we actually know that the majority of patients have improvement in their blood pressure after removing that adrenal gland as well as curing their low potassium level. And so in terms of surgery, there are a few different options and it really depends on the individual patient.
Dr. Katie McManus:
Here at Columbia, we, as the endocrine surgeons, are all trained in the various options including an open operation, which is the traditional larger incision to remove the adrenal gland, though that is probably the least frequently used approach.
And then there's the minimally invasive approach where we make small incisions and go in with a camera and long instruments to take out the adrenal gland in a minimally invasive way. And there are even a variety of approaches for that as well.
We can go through the front, the belly. We can go through the back, which is a technique, an approach, that was described first in Germany and popularized in the early 2000's. And we can even use a robot, the robotic approach, to remove these adrenal glands as well.
We have found that patients have a much better response to surgery and much faster recovery when we're able to remove the adrenal in a laparoscopic way.
Dr. Hyesoo Lowe:
So is laparoscopic, I'm sorry for my ignorance about these surgical techniques, but this is why we're here! Is laparoscopic and robotic putting much used interchangeably here?
Laparoscopic Surgery & Robotic Surgery
Dr. Katie McManus:
Not interchangeably. The robot is essentially a machine that has the instruments attached to it and those instruments are controlled by the surgeon who's actually sitting at a separate machine, where they have the screen there and they are using their hands and fingers to manipulate the instruments which are being held by the robot.
Dr. Hyesoo Lowe:
Okay, interesting. And when you do that approach, is that through the front or through the back?
Dr. Katie McManus:
Typically, that's through the front, however, we are exploring the possibility of doing it also through the back as the robotic technology is advancing.
Dr. Hyesoo Lowe:
Interesting. I'm just wondering, is it easier to access the adrenal from one approach versus the other? I know that it's obviously posterior, but is it an easier way to get to that area?
Dr. Katie McManus:
Absolutely. And that's why the posterior approach was initially invented because the adrenal glands, the crowns that sit on top of the kidney, sit toward your back. And so that's the most direct approach to make incisions actually, through the back, to get to the adrenal gland and that way you don't have to encounter the other organs that are in your belly that get in the way of taking out the adrenal. So that's why patients have a much faster recovery, when we're able to approach it from the back.
Dr. Hyesoo Lowe:
Terrific. Now back to the robot, because it's just so fascinating to me. So the patient has the operation with the surgeon inserting the instruments in the appropriate places and then sits at a separate console, which is connected to the robot, I guess, the robotic arms? And the idea is that the robot kind of takes specific guided, measured incisions and cuts and things like that. Is that the whole idea?
Dr. Katie McManus:
Yeah, absolutely. So the surgeon themselves, we are the ones who make the incisions and put the instruments inside and hook them up to the arms of the robot. And the robot can't move without the surgeon moving the robot at the separate console, so when they move, it's like a video game. When they move, the robot will respond but the robot does not, yet!, have a mind of its own.
Dr. Hyesoo Lowe:
Hahah. Interesting. So it's sort of like an extension of the surgeon's hand?
Dr. Katie McManus:
Absolutely.
Dr. Hyesoo Lowe:
Fascinating! Technology. All right, so. Talking about these tumors a little bit more, are they ever cancer?
Ruling Out Cancerous Tumors
Dr. Salila Kurra:
So very rarely are they cancer, especially the ones that are making too much aldosterone. So the things that make us worry about cancer are if the tumor is large when you find it. By “large” I mean greater than four centimeters. That is when we might start worrying about cancer.
The vast majority of adrenal incidentalomas that we see are smaller than four centimeters, so they are rarely cancerous. Unfortunately, sometimes, we do find adrenal cancer, but it's a rare disease.
Recovery after Surgery
Dr. Hyesoo Lowe:
Got it, got it. How major is this operation? Are we talking about a long recovery time? How long is the operation itself?
Dr. Katie McManus:
So with the laparoscopic approaches, patients are usually in the hospital for one night, and go home the next day. They're able to eat and drink right away. We tell them to take it easy in terms of physical activity, just while the incisions are healing. But overall pain control and everything is much, much better and faster for patients when we are able to do the minimally invasive techniques.
Dr. Hyesoo Lowe:
Got it. Seems to be a pretty good return on the investment if it means that the blood pressure's going to be a lot easier to manage, or even if you can graduate from some of your pills or all of your pills. So what happens after the operation? Do people indeed graduate from all their blood pressure pills?
Post-Surgical Outcomes
Dr. Salila Kurra:
It's a great question and it really depends on how long someone's had hypertension and low potassium. So if you were recently diagnosed and we find that you have an adrenal nodule that can be removed, then your likelihood of never having to worry about that again is much higher than someone who's had high blood pressure for 20, 30 years. And because they may have had a little bit of aldosterone secretion that's affected their body, then it's really hard to reverse that completely. But to Dr. McManus' earlier point, the potassium almost always seems to get better when we remove the adrenal gland, which for many people, it really improves their quality of life because they don't have to take potassium multiple times a day.
Non-Surgical Treatments: Medicine
Dr. Hyesoo Lowe:
Got it. And I guess one last question is, is there adrenal-related high blood pressure that is not from one removable adrenal tumor? Let's say it's coming from both sides. Is there any value to knowing about that?
Dr. Salila Kurra:
Yes. In fact, more people have it from both sides than from one side. And when you have it from both sides, there are medications that we can use that help with that.
Spironolactone and Eplerenone are the two medications that are used, and they antagonize, or take up the receptor, that aldosterone would bind to so that aldosterone can't bind there. The ain is to help decrease the blood pressure. And since the problem is with the aldosterone, the treatment is directed against the aldosterone, which really can help people get their blood pressure and their potassium under control.
Dr. Hyesoo Lowe:
Got it. So if you have one side causing the whole problem, you can remove the tumor on that one side. If it's both sides, you can't take out both adrenals because that would not be healthy for a person, so you can give medications that specifically block aldosterone. And we know that those are very, very effective and probably reduce the need for other blood pressure medicines, because those are so very specific.
Dr. Salila Kurra:
Exactly.
Summary
Dr. Hyesoo Lowe:
Got it. Any final comments to make about the adrenal? What should everybody know about adrenals and high blood pressure?
Dr. Salila Kurra:
I think if your blood pressure is all of a sudden not well controlled or if your potassium is all of a sudden very low, then you should talk to your doctor about being evaluated for extra aldosterone production.
Dr. Hyesoo Lowe:
Fantastic. Dr. McManus is any parting words about surgery for hyperaldosteronism, adrenal surgery in general, that we might not have otherwise known?
Dr. Katie McManus:
The fact that we are able to offer all of the approaches to removing the adrenal gland makes it much better for the patient because, depending on their clinical history, we can decide the most appropriate operation for them. And we, here at Columbia, have the appropriate equipment for offering all of the approaches out there. So I think that overall it is very good for providing good patient care.
Dr. Hyesoo Lowe:
Terrific. I think in summary, the adrenal gland can sometimes be a bit of a black box when interpreting some of the blood testing and there are a lot of different values that you have to sort out in order to really decide if something is a real issue or whether it's not.
I think, as always, teamwork makes the dream work and we have a great adrenal team here at Columbia. And so thanks for talking about all of this, guys. I really appreciate it.
Dr. Katie McManus:
Thanks for having us!