Long-standing high-renin hypertension and hypokalemia.

A 43-year-old white woman was evaluated for uncontrolled hypertension, progressive weakness, and fatigue. High blood pressure (BP) was diagnosed at the age of 28 years during the first trimester of pregnancy. A caesarean section was performed at week 37 for intrauterine growth retardation and preeclampsia. From 1993 through 2007, her BP was poorly controlled, first on atenolol and indapamide therapy, and then on candesartan and nebivolol therapy. Canrenoate was not tolerated because of nausea and abdominal pain. Her course also has been notable for persistent hypokalemia, with potassium values ranging from 2.8 to 3.2 mEq/L (2.8 to 3.2 mmol/L). On physical examination, the patient’s BP was 150/105 mm Hg and pulse rate was 88 beats/min. Grade II retinopathy was present. Serum laboratory data included the following values: potassium ion, 2.9 mEq/L (2.9 mmol/L); bicarbonate, 33 mEq/L (33 mmol/L); serum creatinine, 0.7 mg/dL (61.9 mol/L); estimated glomerular filtration rate, 97 mL/min/1.73 m2 (1.62 mL/s/1.73 m2); and magnesium ion, 1.64 mEq/L (0.82 mmol/L). Urinalysis showed pH 6.0; specific gravity, 1,019; negative glucose, ketone, and nitrite; and 2 protein; urinary sediment was unremarkable. Twentyfour– hour urinary protein excretion ranged between 518 and 1,409 mg. Echocardiography showed mild concentric left ventricular hypertrophy. Twenty-four–hour urinary excretion of free cortisol and metanephrines was normal. After felodipine and doxazosin were substituted for nebivolol and candesartan, plasma renin activity (PRA) was increased at 39.94 ng/ mL/h (reference range, 1.50 to 5.70 ng/mL/h [11.09 ng/L/s; reference range, 0.42 to 1.58 ng/L/s]) and aldosterone level in the upright position was very high at 92.9 ng/dL (reference range, 3.8 to 31.3 ng/dL [2.58 nmol/L; reference range, 0.11 to 0.87 nmol/L]). Abdominal computed tomography (CT) with contrast injection was performed (Fig 1A and B). FINAL DIAGNOSIS Renin-secreting tumor of the juxtaglomerular apparatus