RE: adrenalectomy

September 20, 2011

DASH is will help a lot.CE Grim MD Has anyone had unilateral adrenalectomy with bilateral disease? My aldosterone is very high. (Latest numbers from 23 August 2011—Aldo: 252 ngdl, Renin:2.7ng/mL/h, ARR: 93) I take 200mg Inspra daily, 50mg of Metoprolol daily, and 20 meq of KlorCon daily. Potassium ranges 3.0-4.3 typically but will often go below normal range even with supplements and potassium sparing meds. CT was normal as well as renal ultrasound and renal arteriogram. I have no other health problems except medullary sponge kidney and kidney stones. My kidney function is normal for my age. I dash and workout 4-5 days a week. Inspra is managing my hypertension very well but I have had to increase the dose every 2-3 months for the last 15 months as my blood pressure rises. AVS showed both adrenal glands overproduce, but the numbers from the left are much higher than in the right: Site Aldosterone ng/dl Cortisol mcg/dl A/C ratio IVC before stim 26 22.4 1.2 Left adrenal after stim 35000 895 39.1 Right adrenal after stim 960 48.9 19.6 High IVC after stim 280 38.5 7.3 Low IVC after stim 160 31.6 5.1 The Docs were not real pleased with numbers from the right, as they show dilution, but it was my third AVS so we rolled with it. We have come to the point where we are considering a leap of faith and removing the left adrenal attempting to decrease circulating aldosterone, lower ARR and achieve better BP control. I have no secondary cause for HTN. Everyone is puzzled as to why Aldo is so high and renin is still normal.

September 20, 2011

I have done 24 hour urine for Na, K, creatinine and aldo. Doc could tell I do very well at DASHing. What would radio active scan prove ? I've been setting records everywhere I go, my docs said they have not seen aldo this high.(:

To: hyperaldosteronism From: lowerbp2@...Date: Mon, 19 Sep 2011 09:56:02 -0500Subject: Re: adrenalectomy

You have Primary Aldo which is mostly due to bilateral lumps and bumps which produce aldo but may not be seen by CT or other imaging tests.

You could reqeust a radioactie scan.

However here is what I recommend to your team now.

1. Do a 24 hr urine for Na, K and creatinine and aldo. These will tell us and them if you are DASHing to the max. If not doing so will likely help all of your problems.

The Right adrenal sample appears to not be from an adrenal vein.

A 3rd failed AVS now sets our record here I think.

I am available to work with you and your team to get you back to health as a consultant. You can email me at lowerbp2@...

Just in case you did not get our welcome it is below. Please add thumbnail at end of messages.

Welcome to the exciting world of Hyperaldosteronism

You are in the right place!

I am Dr. CE Grim a retired Professor of Medicine and Endocrinology.

I have had a long standing interest is Primary Aldosteronism since medical school days when I saw my first patient with Primary Aldosteronism in 1963 as a 4th year medical student. I did a Nephrology Fellowship at Duke and an Endocrinology and Metabolism Fellowship with Dr. Conn (1969-70). I have been on the faculty of the University of MO, Indiana Univ, UCLA/ R. Drew, and the Medical College of Wisconsin in Divisions of Nephrology, Endocrinology, Hypertension, Cardiology and Epidemiology.

I have published over 240 papers and book chapters in most areas of the broad discipline of High Blood Pressure. My CV is in our files for details.

The GOAL of our group is to teach you and your health care team about the ins and outs of the causes, diagnosis and control of the many forms of hyperaldosteronism.

The steps below will introduce you into the fascinating world of high blood pressure, salt and potassium and the role of the adrenal hormone aldosterone in health and disease. Doing these in sequence will save you time and effort in getting up to speed in taking control of you health and educating your own health care team.

While we can’t make you a doctor we will make you into a pretty good BP doctor-a skill that you will have for life.

1. Overview: Read my article in our files on the evolution of PA (Evolution_of_PA-Grim.pdf ) and take to all members of health care team. Tell us what stage you believe you are in. This is a brief review of most causes of hyperaldosteronism, high blood pressure, low potassium (K).

Be certain that you and your health care team understand the key role of excess diet salt in HTN and especially in PA.

Go to: http://www.worldactiononsalt.com/evidence/treatment_trials.htm

For a state of the art and science discussion of salt and health.

2. Other patients with hyperaldosteronism (Conn’s syndrome). Read our Conn's stories in our files and then give us your own in as much detail as you can. Dr. Conn was the first to describe this disease process and the syndrome is named after him. To see others' stories, on the Hyperaldosteronism home page, go to Files/Conn’s Stories. You'll find instructions in "A - How to put your story here.doc "

Then send us your story in an email and then we will likely ask more questions and make suggestions before you upload it to our files.

3. Hyperaldosteronism and Salt: The deadly Duo.

Eating Plan to control high blood pressure due to hyperaldosteronism and most others with high blood pressure. This will reduce your need for medications and in many will get your BP and K to goal without meds.. Get the DASH diet book by T. et al, read it and use it: $8 in paperback at your local bookstore. If they don’t have it ask them to order it for you. Learning to eat the DASH way will play a major role in your road to good BP and K control and, in many of our folks here, will revolutionize your life.

Go to chapter 9 and do the 14 day challenge. Tell your Dr you are doing this as your BP may plummet if you are on other meds in only 2-3 days.

or

go to http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

download this 64 page booklet free and do the Week on the DASH Diet for 2 weeks. If you are on BP meds be prepared for a large fall in BP and let your Dr. know you are doing this.

Or go to (but costs money)

DASH Diet for Health Program

The DASH Diet for Health Program is designed to help you improve your eating and exercise habits. Twice each week we will provide you with information on our website about food, food preparation, eating out, losing weight, getting fit and much more. In addition to providing new information each week on our website, we create a web page specially for you where you can track progress in areas such as your weight, blood pressure, and exercise.

http://www.dashforhealth.com/

I strongly recommend you get the book and read it now!

4. Measure your BP: Measure your BP daily so you can see if it is getting better. If you are taking meds be sure to tell your health care team you are doing this as your BP may plummet to normal quickly. We recommend you use a device you listen to and will help you learn how to do this. If this is not something you want to do we can teach a significant other how to do it. See sharedcareinc.com or email to sharedcare@... to order a video on how to do this. If you already have one we will teach you how to teach your health care team how to validate your device. Your life and health depends on accurate BP measurements.

Go to the amricanheart.org and download the Guidelines for Human Blood Pressure Measurement. Insist the your health care team do BP the AHA way. Your life is in the hands of those who measure your BP. Never trust your life to an automatic BP machine unless you know it is accurate on YOU.

5. Genetics and your BP: Go to familyhistory.hhs.gov and do your detailed family medical history so we can review with you to help Dx familial causes of high blood pressure and heart disease. If BP runs in your family you may save lives in your family by checking their BP yourself. There is a brief discussion of this in my Evolution Article.

6. How to DX and treat PA: Go to our file

/Conn's Articles of Note/Medications/Bravo spir 1973.pdf and read this article and take to your health care team. It is old but still one of the best in the medical management of PA.

Also see our file from the Endocrine Society Guidelines on PA.

Dr. Grim's Perfect Primary Aldosteronism Blood and Urine Testing to diagnose PA in one day.

1. Eat a high salt diet for 2 weeks-at least 4000 mg of Na a day.

2. No BP meds in last 4-12 weeks depending on meds and Drs advice.

3. Collect 24 hr urine for Na, K and creatinine and aldosterone. Do not lose a drop of this liquid gold. It is impossible to interpret the renin and aldo without this.

4. The morning you finish the 24 hr urine have fasting blood drawn for renin, aldo and K using our guidelines to get an accurate K. Try to get this done about 1-4 hours after you have been out of bed.

5. Send us the results with the normal values for your lab.

6. If you ever have a salt (saline) infusion test for PA be certain to ask them to measure how much you pee during the 4 hours of the infusion. If it is 1-1.5 liter of urine it strongly suggests that you may have PA. If more tha 1.5 L you almost certainly have PA. I call this Dr. Grim’s “Quick Pee Test” for PA.

Our PA Registry: If you have been Dxed with PA already and are on Rx or have had surgery please go

to http://www.kwiksurveys.com/online-survey.php?surveyID=HIJIO_f2685379

and complete our survey with as much information as you know. If there is some information you don't know ask us and we will help. If you need to update this as you journey thru the diagnostic/treatment process you can add another entry but label it as Nameyymmdd. For example today 4/20/11 for me would be Grim110420. This way of writing the date is an ever increasing number and will allow us and you to sort your multiple entries into a dated order. We are working on a more extensive database.

8. Learn the language: If you are new to medical lingo then download the acroyms from

http://health.groups.yahoo.com/group/bloodpressureline/message/29186

9. Salt and high blood pressure: To learn the state of the science of salt and blood pressure please spend some time looking at

http://www.worldactiononsalt.com/evidence/treatment_trials.htm

10. Become a HBP expert consumer: Expect that it will take at least several weeks to get all this digested and to learn the new language of high blood pressure health care. As most doctors and nurses in practice have had very little training in high blood pressure you must become an expert yourself. For example most have never had anyone listen with them with a double stethoscope to verify that they can hear BP sounds.

We cannot make you a doctor but we will make you a pretty good BP doctor.

11. How High Blood Pressure should be managed:

Go to nih.gov and download and read the Joint National Commission (JNC) Report 7 to get an overview on current guidelines. I ask all my secretaries to read this so they can communicate the importance of high blood pressure to my patients. JNC 8 will be out soon.

Then: get (and study) the Hypertension Primer from americanheart.org. This is the most up-to-date compendium of what is known about high blood pressure and what every Dr. should know when they graduate from Medical School. Every chapter is only 2-3 pages. Read one chapter every week-night and you will finish it in about a year. I am working on a reading guide for lay people for the Primer. Stay tuned.

12. Ask us questions: Ask any questions about high blood pressure you want answered. That is what we are here for.

13. One-on-one Consulting: I can provide individual consulting if you do not want to go public. If you want individual one-on-one consulting for you and your Doctor contract me directly at lowerbp2@....

May your pressure be low!

Clarence E. Grim BS, MS, MD, FACP, FACC

Board Certified in Internal Medicine, Geriatrics, and High Blood Pressure

Specializing in Primary Aldosteronism and Difficult to Control High Blood Pressure.

Has anyone had unilateral adrenalectomy with bilateral disease? My aldosterone is very high. (Latest numbers from 23 August 2011—Aldo: 252 ngdl, Renin:2.7ng/mL/h, ARR: 93) I take 200mg Inspra daily, 50mg of Metoprolol daily, and 20 meq of KlorCon daily. Potassium ranges 3.0-4.3 typically but will often go below normal range even with supplements and potassium sparing meds. CT was normal as well as renal ultrasound and renal arteriogram. I have no other health problems except medullary sponge kidney and kidney stones. My kidney function is normal for my age. I dash and workout 4-5 days a week. Inspra is managing my hypertension very well but I have had to increase the dose every 2-3 months for the last 15 months as my blood pressure rises. AVS showed both adrenal glands overproduce, but the numbers from the left are much higher than in the right:Site Aldosterone ng/dl Cortisol mcg/dl A/C ratioIVC before stim 26 22.4 1.2Left adrenal after stim 35000 895 39.1Right adrenal after stim 960 48.9 19.6High IVC after stim 280 38.5 7.3Low IVC after stim 160 31.6 5.1The Docs were not real pleased with numbers from the right, as they show dilution, but it was my third AVS so we rolled with it. We have come to the point where we are considering a leap of faith and removing the left adrenal attempting to decrease circulating aldosterone, lower ARR and achieve better BP control. I have no secondary cause for HTN. Everyone is puzzled as to why Aldo is so high and renin is still normal.

September 21, 2011

Scan may be able to tell if problemis on one or both sides. Give us you 24 hr urine numbers and we can tell if u were DASHING at the time.Tiped sad Send form miiPhone ;-)May your pressure be low!CE Grim MDSpecializing in DifficultHypertension

I have done 24 hour urine for Na, K, creatinine and aldo. Doc could tell I do very well at DASHing. What would radio active scan prove ? I've been setting records everywhere I go, my docs said they have not seen aldo this high.(:

To: hyperaldosteronism From: lowerbp2@...Date: Mon, 19 Sep 2011 09:56:02 -0500Subject: Re: adrenalectomy

You have Primary Aldo which is mostly due to bilateral lumps and bumps which produce aldo but may not be seen by CT or other imaging tests.

You could reqeust a radioactie scan.

However here is what I recommend to your team now.

1. Do a 24 hr urine for Na, K and creatinine and aldo. These will tell us and them if you are DASHing to the max. If not doing so will likely help all of your problems.

The Right adrenal sample appears to not be from an adrenal vein.

A 3rd failed AVS now sets our record here I think.

I am available to work with you and your team to get you back to health as a consultant. You can email me at lowerbp2@...

Just in case you did not get our welcome it is below. Please add thumbnail at end of messages.

Welcome to the exciting world of Hyperaldosteronism

You are in the right place!

I am Dr. CE Grim a retired Professor of Medicine and Endocrinology.

I have had a long standing interest is Primary Aldosteronism since medical school days when I saw my first patient with Primary Aldosteronism in 1963 as a 4th year medical student. I did a Nephrology Fellowship at Duke and an Endocrinology and Metabolism Fellowship with Dr. Conn (1969-70). I have been on the faculty of the University of MO, Indiana Univ, UCLA/ R. Drew, and the Medical College of Wisconsin in Divisions of Nephrology, Endocrinology, Hypertension, Cardiology and Epidemiology.

I have published over 240 papers and book chapters in most areas of the broad discipline of High Blood Pressure. My CV is in our files for details.

The GOAL of our group is to teach you and your health care team about the ins and outs of the causes, diagnosis and control of the many forms of hyperaldosteronism.

The steps below will introduce you into the fascinating world of high blood pressure, salt and potassium and the role of the adrenal hormone aldosterone in health and disease. Doing these in sequence will save you time and effort in getting up to speed in taking control of you health and educating your own health care team.

While we canâ€™t make you a doctor we will make you into a pretty good BP doctor-a skill that you will have for life.

1. Overview: Read my article in our files on the evolution of PA (Evolution_of_PA-Grim.pdf ) and take to all members of health care team. Tell us what stage you believe you are in. This is a brief review of most causes of hyperaldosteronism, high blood pressure, low potassium (K).

Be certain that you and your health care team understand the key role of excess diet salt in HTN and especially in PA.

Go to: http://www.worldactiononsalt.com/evidence/treatment_trials.htm

For a state of the art and science discussion of salt and health.

2. Other patients with hyperaldosteronism (Connâ€™s syndrome). Read our Conn's stories in our files and then give us your own in as much detail as you can. Dr. Conn was the first to describe this disease process and the syndrome is named after him. To see others' stories, on the Hyperaldosteronism home page, go to Files/Connâ€™s Stories. You'll find instructions in "A - How to put your story here.doc "

Then send us your story in an email and then we will likely ask more questions and make suggestions before you upload it to our files.

3. Hyperaldosteronism and Salt: The deadly Duo.

Eating Plan to control high blood pressure due to hyperaldosteronism and most others with high blood pressure. This will reduce your need for medications and in many will get your BP and K to goal without meds.. Get the DASH diet book by T. et al, read it and use it: $8 in paperback at your local bookstore. If they donâ€™t have it ask them to order it for you. Learning to eat the DASH way will play a major role in your road to good BP and K control and, in many of our folks here, will revolutionize your life.

Go to chapter 9 and do the 14 day challenge. Tell your Dr you are doing this as your BP may plummet if you are on other meds in only 2-3 days.

or

go to http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

download this 64 page booklet free and do the Week on the DASH Diet for 2 weeks. If you are on BP meds be prepared for a large fall in BP and let your Dr. know you are doing this.

Or go to (but costs money)

DASH Diet for Health Program

The DASH Diet for Health Program is designed to help you improve your eating and exercise habits. Twice each week we will provide you with information on our website about food, food preparation, eating out, losing weight, getting fit and much more. In addition to providing new information each week on our website, we create a web page specially for you where you can track progress in areas such as your weight, blood pressure, and exercise.

http://www.dashforhealth.com/

I strongly recommend you get the book and read it now!

4. Measure your BP: Measure your BP daily so you can see if it is getting better. If you are taking meds be sure to tell your health care team you are doing this as your BP may plummet to normal quickly. We recommend you use a device you listen to and will help you learn how to do this. If this is not something you want to do we can teach a significant other how to do it. See sharedcareinc.com or email to sharedcare@... to order a video on how to do this. If you already have one we will teach you how to teach your health care team how to validate your device. Your life and health depends on accurate BP measurements.

Go to the amricanheart.org and download the Guidelines for Human Blood Pressure Measurement. Insist the your health care team do BP the AHA way. Your life is in the hands of those who measure your BP. Never trust your life to an automatic BP machine unless you know it is accurate on YOU.

5. Genetics and your BP: Go to familyhistory.hhs.gov and do your detailed family medical history so we can review with you to help Dx familial causes of high blood pressure and heart disease. If BP runs in your family you may save lives in your family by checking their BP yourself. There is a brief discussion of this in my Evolution Article.

6. How to DX and treat PA: Go to our file

/Conn's Articles of Note/Medications/Bravo spir 1973.pdf and read this article and take to your health care team. It is old but still one of the best in the medical management of PA.

Also see our file from the Endocrine Society Guidelines on PA.

Dr. Grim's Perfect Primary Aldosteronism Blood and Urine Testing to diagnose PA in one day.

1. Eat a high salt diet for 2 weeks-at least 4000 mg of Na a day.

2. No BP meds in last 4-12 weeks depending on meds and Drs advice.

3. Collect 24 hr urine for Na, K and creatinine and aldosterone. Do not lose a drop of this liquid gold. It is impossible to interpret the renin and aldo without this.

4. The morning you finish the 24 hr urine have fasting blood drawn for renin, aldo and K using our guidelines to get an accurate K. Try to get this done about 1-4 hours after you have been out of bed.

5. Send us the results with the normal values for your lab.

6. If you ever have a salt (saline) infusion test for PA be certain to ask them to measure how much you pee during the 4 hours of the infusion. If it is 1-1.5 liter of urine it strongly suggests that you may have PA. If more tha 1.5 L you almost certainly have PA. I call this Dr. Grimâ€™s â€œQuick Pee Testâ€ for PA.

Our PA Registry: If you have been Dxed with PA already and are on Rx or have had surgery please go

to http://www.kwiksurveys.com/online-survey.php?surveyID=HIJIO_f2685379

and complete our survey with as much information as you know. If there is some information you don't know ask us and we will help. If you need to update this as you journey thru the diagnostic/treatment process you can add another entry but label it as Nameyymmdd. For example today 4/20/11 for me would be Grim110420. This way of writing the date is an ever increasing number and will allow us and you to sort your multiple entries into a dated order. We are working on a more extensive database.

8. Learn the language: If you are new to medical lingo then download the acroyms from

http://health.groups.yahoo.com/group/bloodpressureline/message/29186

9. Salt and high blood pressure: To learn the state of the science of salt and blood pressure please spend some time looking at

http://www.worldactiononsalt.com/evidence/treatment_trials.htm

10. Become a HBP expert consumer: Expect that it will take at least several weeks to get all this digested and to learn the new language of high blood pressure health care. As most doctors and nurses in practice have had very little training in high blood pressure you must become an expert yourself. For example most have never had anyone listen with them with a double stethoscope to verify that they can hear BP sounds.

We cannot make you a doctor but we will make you a pretty good BP doctor.

11. How High Blood Pressure should be managed:

Go to nih.gov and download and read the Joint National Commission (JNC) Report 7 to get an overview on current guidelines. I ask all my secretaries to read this so they can communicate the importance of high blood pressure to my patients. JNC 8 will be out soon.

Then: get (and study) the Hypertension Primer from americanheart.org. This is the most up-to-date compendium of what is known about high blood pressure and what every Dr. should know when they graduate from Medical School. Every chapter is only 2-3 pages. Read one chapter every week-night and you will finish it in about a year. I am working on a reading guide for lay people for the Primer. Stay tuned.

12. Ask us questions: Ask any questions about high blood pressure you want answered. That is what we are here for.

13. One-on-one Consulting: I can provide individual consulting if you do not want to go public. If you want individual one-on-one consulting for you and your Doctor contract me directly at lowerbp2@....

May your pressure be low!

Clarence E. Grim BS, MS, MD, FACP, FACC

Board Certified in Internal Medicine, Geriatrics, and High Blood Pressure

Specializing in Primary Aldosteronism and Difficult to Control High Blood Pressure.

Has anyone had unilateral adrenalectomy with bilateral disease? My aldosterone is very high. (Latest numbers from 23 August 2011â€”Aldo: 252 ngdl, Renin:2.7ng/mL/h, ARR: 93) I take 200mg Inspra daily, 50mg of Metoprolol daily, and 20 meq of KlorCon daily. Potassium ranges 3.0-4.3 typically but will often go below normal range even with supplements and potassium sparing meds. CT was normal as well as renal ultrasound and renal arteriogram. I have no other health problems except medullary sponge kidney and kidney stones. My kidney function is normal for my age. I dash and workout 4-5 days a week. Inspra is managing my hypertension very well but I have had to increase the dose every 2-3 months for the last 15 months as my blood pressure rises. AVS showed both adrenal glands overproduce, but the numbers from the left are much higher than in the right:Site Aldosterone ng/dl Cortisol mcg/dl A/C ratioIVC before stim 26 22.4 1.2Left adrenal after stim 35000 895 39.1Right adrenal after stim 960 48.9 19.6High IVC after stim 280 38.5 7.3Low IVC after stim 160 31.6 5.1The Docs were not real pleased with numbers from the right, as they show dilution, but it was my third AVS so we rolled with it. We have come to the point where we are considering a leap of faith and removing the left adrenal attempting to decrease circulating aldosterone, lower ARR and achieve better BP control. I have no secondary cause for HTN. Everyone is puzzled as to why Aldo is so high and renin is still normal.

November 26, 2011

Had left adrenalectomy on Nov. 7th.Aug. 23rd blood work before surgery aldo 252 ng/dl , renin 2.7ng/mL, ARR 93. Nov. 16th blood work after surgery aldo 21 ng/dL ref. range 0-31, renin 7.0 ref. range 0.8-5.2, ARR 3, k 4.0. Meds I'm off of 20mEq Potassium, 200mg Inspra. Doc left me on 25mg b.i.d. of Metoprolol out of caution because of renin being a little high. Blood pressure is 117/76 and I feel amazing . Doc says we'll repeat blood work in 1 month and if numbers are still good he'll be excited. Just a little unsure if the renin might kick up the aldo. Pathology report said gland appeared completely normal. I'm not much of a writer so haven't posted much but I have really appreciated this sight , I 've learned alot and felt like I wasn't alone.Not sure how to make a thumb nail but I'm 49 yr old female , 5' 6", 150 lbs , HTN for 3 years, Dx hyperaldo in Nov. 2009 after v-tac from low k, adrenals normal on CT, AVS 3 times, left always very high never a good reading on the right. Only other health issue is medullary sponge kidney with stones.To: hyperaldosteronism From: debbie5a2@...Date: Tue, 20 Sep 2011 22:09:55 -0700Subject: RE: adrenalectomy