Endocrine Abstracts

A 47-year-old lady presented with a long history of resistant hypertension. Her GP referred her for further investigation to a cardiologist who found a smaller right kidney on ultrasound scan and an elevated rennin level. Renal artery MRA revealed right renal artery stenosis. On September 2008, she underwent right renal artery stenting and was advised to stop taking the antihypertensive medications (doxazosin and amlodipine). A week later she was admitted with headache, vomiting and severe hypertension. She was referred to our endocrine department and on review of her notes it was clear that she had very long standing hypokalaemia with potassium ranging between 2.5 and 3.5 mmol/l over the past 5 years. Despite recommencement of her antihypertensive (doxazosin 8 mg b.d) her blood pressure remained difficult to control (220/124). A repeat CT with Doppler flow examination post stent insertion revealed that the proximal segment of the right main renal artery was patent and appeared to show contrast. However, there was no obvious contrast seen within the stent. Distal to the stent the contrast was seen in the vessel and the right kidney showed uniform complete enhancement. The Doppler examination showed forward diastolic flow with patent Doppler signal. Incidentally there was a 10 mm lesion in the left adrenal gland.

Her plasma renin activity remains high and a postural Aldosterone Renin ratios were as follow: 09:19 am renin 10 aldosterone 330, 10:10 am renin 15 aldosterone 1210 and 12:55 pm renin 22 aldosterone 370. UE and LFT were normal as well as the rest of routine blood tests.

She was recently commenced on spironolactone (in addition to doxazosin 8 mg b.d) titrating the dose gradually to 100 mg b.d. This has resulted in improvement in the BP readings. We are contemplating adrenal venous sampling for Conn’s adenoma and possible MRI of the adrenal gland. Also she needs a repeat renal artery MRA to rule out possible blockage of the stent (possible 6 weeks post stent insertion).

This is a case of possible adrenal aldosterone-secreting adenoma with coexisting active renal artery stenosis in a hypertensive middle-aged woman. The concomitance of the two lesions was previously reported in the literature only in five patients. Therefore we would like to present this interesting case to the Third Hammersmith Multidisciplinary Meeting principally to discuss the following points:

1. Is this likely to be Conn’s coexisting with RA stenosis (is hypokalaemia is feature of RA stenosis)

2. Shall we proceed with adrenal venous sampling.

3. The confounding effects on biochemistry when both conditions coexist.