Unilateral Primary Aldosteronism as an Independent Risk Factor for Vertebral Fracture

Maki Yokomoto-Umakoshi; Ryuichi Sakamoto; Hironobu Umakoshi; Yayoi Matsuda; Hiromi Nagata; Tazuru Fukumoto; Masatoshi Ogata; Yoshihiro Ogawa


Clin Endocrinol. 2020;92(3):206-213. 

In This Article

Abstract and Introduction


Context: Primary aldosteronism (PA) is known to increase vertebral fracture (VF), although the detailed mechanism remains to be elucidated. We hypothesized that the PA subtype is associated with VF.

Objective: To evaluate whether unilateral PA is associated with the prevalence of VF.

Design: This was a retrospective cross-sectional study in a single referral centre.

Patients: We identified 210 hypertensive patients whose clinical data were available for case-detection results. One hundred and fifty-two patients were diagnosed with PA using captopril challenge tests.

Measurements: We measured the prevalence of VF, according to PA subtype.

Results: One hundred thirteen patients with PA were subtype classified by adrenal vein sampling. Of these, 37 patients had unilateral PA, 76 patients had bilateral PA, 58 patients had non-PA; 39 patients with PA were not subtype-classified. Patients with PA had a higher prevalence of VF (29%, 44/152) than those with non-PA (12%, 7/58; P = .011). Moreover, unilateral PA had a higher prevalence of VF (46%, 17/37) than bilateral PA (20%, 15/76; P = .021). There was no significant difference in the prevalence of VF between bilateral PA and non-PA. Unilateral PA was an independent risk factor for VF after adjusting for age and sex (OR: 3.16, 95% confidence interval: 1.12–8.92; P = .017). Among patients with unilateral PA, serum cortisol concentrations after 1-mg dexamethasone suppression test were higher in those with VF (1.32 ± 0.67 g/dL) than those without (0.96 ± 0.33 g/dL; P = .048).

Conclusions: Unilateral PA is an independent risk factor for VF.


Primary aldosteronism (PA) is the most common form of secondary hypertension, affecting up to 10% of the hypertensive population.[1–3] PA consists of two subtypes: (a) the unilateral subtype (mainly consisting of aldosterone producing adenoma [APA]), which is surgically curable, and (b) the bilateral subtype (mainly consisting of idiopathic hyperaldosteronism [IHA]), which is medically controlled.[4,5]

Primary aldosteronism increases the risk of vertebral fracture (VF),[6–8] which not only considerably decreases quality of life, but also shortens patient survival.[9] PA is also associated with secondary osteoporosis, which may be reversed by optimal management.[10–13] Since PA induces bone fragility even in patients who display a normal bone mineral density (BMD),[7] fracture risk may be underestimated if only BMD values are considered. Thus, identifying risk factors for VF in patients with PA is urgently needed in clinical practice.

There is considerable evidence that PA increases cardio-metabolic complications relative to age- and sex-matched essential hypertension.[14–16] Patients with unilateral PA, who usually have a higher plasma aldosterone concentration (PAC) than those with bilateral PA, exhibit more severe clinical phenotypes in terms of cardiovascular disease (CVD) risk.[2,14,16] Moreover, unilateral PA also increases the risk of secondary hyperparathyroidism, which has well-known effects on bone fragility.[13] We, therefore, hypothesized that PA subtypes affect the prevalence of VF. Accordingly, this study was designed to evaluate whether subtypes of PA alter VF risk factors.