Ipertensione e iperaldosteronismo
L’ipertensione è un problema estremamente diffuso e causa la morte di 7,5 milioni di persone.
In Italia colpisce 16 milioni di persone, il 33% uomini e il 31% donne.
Questi dati sono stati forniti dalla SIIA ( Società Italiana dell’Ipertensione Arteriosa)
Che cos’è l’iperaldosteronismo?
L’iperaldosteronismo è una condizione clinica caratterizzata da un eccesso di produzione di aldosterone da parte dei surreni. L’ipertensione da iperaldosteronismo costituisce, a seconda delle casistiche esaminate, 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 causata da adenoma solitario o da iperplasia della corticale del surrene. L’aldosterone determina un incremento dei valori pressori attraverso l’aumento del volume plasmatico, del contenuto di sodio e delle resistenze periferiche.
Cause di iperaldosteronismo primitivo
Origine surrenalica
- Eccesso di aldosterone
- Adenoma secernente aldosterone
- Iperplasia surrenalica
- Carcinoma surrenalico secernente aldosterone
- Tumori extra surrenalici (carcinoma ovarico secernente aldosterone)
- Iperaldosteronismo familiare di tipo 1
Eccesso di desossicorticosterone
- Tumori secernenti desossicorticosterone
- Carenza di 11 β-idrossilasi, 17α-idrossilasi
Origine renale
- Carenza 11 β-idrossilasi ( congenita e acquisita)
- Mutazione del recettore mineralcorticoide
- Pseudoipoaldosteronismo
Quali sono i sintomi dell’iperaldosteronismo?
L’ iperaldosteronismo è caratterizzato da:
- Ipertensione severa, resistente al trattamento farmacologico
La maggior parte dei sintomi riscontrati nell’ iperaldosteronismo è da attribuire all’ ipokaliemia:
- Astenia
- Turbe del batmotropismo ventricolare
- Poliuria
- Polidipsia
- Intolleranza glucidica
Esame obiettivo
All’esame obiettivo possono essere presenti paralisi temporanee o intermittenti e spasmi muscolari.
Esami diagnostici
- La TC ad alta definizione può identificare adenomi surrenalici delle dimensioni di pochi millimetri.
- La Risonanza magnaetica è dotata di maggiore sensibilità ma minore specificità.
- La scintigrafia consente di distinguere tra adenomi che rimangono visibili e iperplasia che non mostra captazione di radiofarmaco, in quanto inibita.
- L’ipokaliemia spontanea è presente nella maggior parte dei pazienti affetti da iperaldosteronismo.
- Nei pazienti con adenoma, ma non in quelli con iperplasia, possono essere riscontrati in circolo precursori o forme ibride di steroidi.
- L’attività reninica plasmatica di solito è soppressa e non è sensibile al clinostatismo.
- Il prelievo selettivo delle vene surrenali rappresenta il miglior test diagnostico per dimostrare la lateralizzazione della produzione di aldosterone.
- La misurazione dell’aldosterone e del cortisolo viene eseguita su campioni di sangue prelevati in vena cava inferiore e allo sbocco delle vene surrenaliche.
Come si cura l’peraldosteronismo?
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 maggiormente diffusa è la surrenectomia monolaterale per via laparoscopica. Tale procedura assicura la guarigione del 33% dei casi, negli altri casi un miglior controllo della pressione arteriosa. La persistenza di valori elevati di pressione arteriosa dopo surrenectomia deve far pensare a:
- Coesistenza di ipertensione essenziale,a come si verifica nel 20% dei casi
- Danno renale indotto da ipertensione secondaria
- Persistenza di tessuto adenomatoso post surrenectomia.
La terapia medica prevede l’uso di antagonisti recettoriali dell’aldosterone come lo spironolattone o eplerenone in monoterapia o in terapia di combinazione con diuretico tiazidico.
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(Bibl. Rugarli, medicina interna sistematica 1, Claudio Rugarli, sett. ediz. Edra s.p.a. Milano, ott. 2017)
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