Iperaldosteronismo
Table of Contents
Definizione
L’ipertensione da iperaldosteronismo costituisce l’1-11% di tutte le forme di ipertensione arteriosa e trova il suo meccanismo eziopatogenetico nell’iperproduzione di aldosterone. La maggior parte dei casi di iperaldosteronismo primitivo è causato da adenoma solitario o da iperplasia della corticale del surrene. L’aldosterone determina incremento dei valori pressori attraverso l’aumento del volume plasmatico, del contenuto di sodio e delle resistenze periferiche. L’eccesso di aldosterone provoca alterazioni vascolari, renali e cardiache caratterizzate da deposito di tessuto fibroso. A livello vascolare ciò determina uno sviluppo accelerato di aterosclerosi, mentre a livello renale e cardiaco provoca una rapida compromissione funzionale.
Eziologia
Ipersecrezione da aldosterone autonoma, che sfugge alla servoregolazione.
- Adenoma benigno della zona glomerulare del cortico-surrene; il tumore è spesso nel surrene sinistro e misura 0,3-3 cm di diametro; è 2-3 volte più frequente nella donna rispetto all’uomo.
- Iperplasia bilaterale della zona glomerulare del cortico-surrene che può essere diffusa o focale, micro o macro nodulare. Il cancro è molto raro.
Sintomi
- L’iperaldosteronismo è caratterizzato da ipertensione secondaria, resistente al trattamento farmacologico.
- Debolezza muscolare, talvolta paralisi intermittente (ipokaliemia).
- Spasmofilia con segni di Chvostek e di Trousseau; talvolta crisi di tetania in rapporto con l’alcalosi. Parestesie.Cefalee frequenti e talvolta intense.
- Polidipsia e poliuria soprattutto notturne, che resistono alla somministrazione di ormone antidiuretico. L’assenza di edema è caratteristica dell’ iperaldosteronismo primitivo.
Esami di laboratorio
L’ipokaliemia (≤ 3,5 mEq/L) spontanea è presente nella maggior parte dei pazienti affetti da iperaldosteronismo. L’attività reninica plasmatica(PRA) di solito è soppressa e non è sensibile al clinostatismo. Il rapporto tra aldosterone plasmatico e attività renina plasmatica (valore normale = 10) spesso è aumentato fino al valore di 20-50. Il test di soppressione con fludrocortisone consiste nella misurazione dei livelli di aldosterone e PRA dopo tre giorni di dieta Ipersodica e fludrocortisone.
Esami strumentali
La TC ad alta definizione può identificare adenomi surrenalici delle dimensioni di pochi millimetri.
La RM è dotata di maggiore sensibilità ma minore specificità.
La scintigrafia con colesterolo marcato con 131I, come il 6β-⌈131⌉- indometil-norcolesterolo (NP-59), con test di soppressione con desametasone consente di distinguere tra adenomi che rimangono visibili e iperplasia che non mostra captazione di radiofarmaco, in quanto inibita.
Terapia
La terapia dell’ipertensione da iperaldosteronismo varia in funzione della sua eziologia: in caso di adenoma sono più indicate le procedure chirurgiche, mentre in caso di iperplasia è da preferire la terapia medica. La tecnica chirurgica maggiormente diffusa è la surrenectomia monolaterale per via laparoscopica. La terapia medica prevede l’uso di antagonisti recettoriali dell’aldosterone come spironolattone o eplerenone in monoterapia o in terapia di combinazione con diuretico tiazidico.
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