Abstract
The past nine years have seen major advances in establishing the etiology of
unilateral primary aldosteronism, and very possibly that of bilateral
hyperaldosteronism, in response to somatic mutations in aldosterone synthase
expressing cells. Though there have been important advances in the management of
primary aldosteronism, in small but convincing studies, they represent minor
changes to current guidelines. What has been totally absent is consideration of
the public health issue that primary aldosterone represents, and the public
policy issues that would be involved in addressing the disorder. In his
introduction to PiPA 6, Martin Reincke calculated that only one in a thousand
patients in Germany with primary aldosteronism were treated appropriately, an
astounding figure for any disease in the 21st century. Towards remedying this
totally unacceptable public health issue, the author proposes a radical
simplification and streamlining of screening for primary aldosteronism, and the
management of most patients by general practitioners. The second bottle-neck in
current management is that of mandatory adrenal venous sampling for all but
1–2% of patients, a costly procedure requiring rare expertise.
Ideally, it should be reserved – on the basis of likelihood, enhanced
imaging, or peripheral steroid profiles – for a small minority of
patients with clear evidence for unilateral disease. Only when costs are
minimized and roadblocks removed will primary aldosteronism be properly treated
as the public health issue that it is.
Key words
somatic mutations - screening - lateralization - public health - health policy
