CLINICAL CASE 5

After several weeks of ACEI or ARB use, the plasma aldosterone levels return to pretreatment levels in 40% of patient. What is this phenomenon called?

Aldosterone Escape 66%

Aldosterone Breakthrough 22%

Aldosterone Resistance 0%

Aldosterone Return 11%

Most of you all said Aldosterone escape and that is incorrect. The correct answer is Aldosterone Breakthrough. There is no such thing as aldosterone resistance or return.

A recent editorial in Nature Nephrology from Feb 2010 issue talks about the difference in these two phenomenon( escape vs Breakthrough).  

Aldosterone escape (AE) is as follows: when you have too much aldesterone in your body, there is an initial decrease in urinary sodium excretion, and renal sodium retention is increased.  However, urinary sodium excretion subsequently increases to balance the sodium intake before detectable edema develops. This phenomenon is called AE and is the reason why edema formation is not a characteristic of primary hyperaldo state.  Multiple mechanisms as described in the above linked editorial are responsible for the AE and prevention of edema.

What is Aldosterone Breaktrough( AB): When we uses ACEI and ARBS medication to inhibit the RAAS system, large increase in renin occurs in administration of these medications. People who treat hypertension with a renin or non renin mediated methods are familiar to this concept that renin will increase with ACEI and ARBs initiation, when you check the level in the plasma, its high.  Interestingly after several weeks of using these medication,

the aldosterone level returns to pre treatment levels in 30-40% of patients. This phenomenon is called AB.  Patients who develop this might have worse outcomes and eventually start not responding to ACEI and ARBS.  This editorial suggests that perhaps direct renin inhibitors or Vitamin D might decrease that renin drive and exert a better profile. 

I think we need to know about this novel concept often confused with the escape.

Please look at the following references as well

Bomback et al. Nature Clinical Pract Nephrol 3, 486-492 ;2007

Doorenbos et al. Nature Clinical Pract Nephrol 5, 691-700;2009

We can't really escape from this new breakthrough.