ARTICLE IN PRESS

Regulation of Aldosterone
Secretion
Scott M. MacKenzie, Josie C. van Kralingen, Eleanor Davies1
BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular & Medical Sciences, University of
Glasgow, Glasgow, United Kingdom
1
Corresponding author: e-mail address: eleanor.davies@glasgow.ac.uk

Contents
1. Introduction 2
2. Aldosterone Biosynthesis 3
2.1 Cholesterol 3
2.2 Enzymatic Conversion of Cholesterol to Aldosterone 5
3. The Renin–Angiotensin System 7
3.1 AngII-Induced Calcium Effects 8
4. Plasma Potassium 11
5. ACTH 11
6. Other Regulators of Aldosterone Secretion 13
6.1 Leptin 13
6.2 Atrial Natriuretic Peptide 14
6.3 Dopamine 14
6.4 Serotonin 15
7. Common Genetic Polymorphisms Influencing Aldosterone Secretion 15
8. MicroRNAs 17
9. Conclusions 18
Acknowledgments 19
References 19

Abstract
Secretion of the major mineralocorticoid aldosterone from the adrenal cortex is a
tightly-regulated process enabling this hormone to regulate sodium homeostasis
and thereby contribute to blood pressure control. The circulating level of aldosterone
is the result of various regulatory mechanisms, the most significant being those con-
trolled by the renin–angiotensin system and plasma potassium levels. The importance
of maintaining tight control over aldosterone secretion is demonstrated by cases of dys-
regulation, which can result in severe hypertension and significantly increased
cardiovascular risk.

Vitamins and Hormones # 2018 Elsevier Inc. 1

ISSN 0083-6729 All rights reserved.
https://doi.org/10.1016/bs.vh.2018.07.001
 ARTICLE IN PRESS

2 Scott M. MacKenzie et al.

In this article we summarize current knowledge of the major regulatory mecha-

nisms, focusing particularly on the systems operating within the adrenocortical zona
glomerulosa cells; we also describe some of the other factors that influence aldosterone
production to a lesser but still significant extent. Finally, we discuss the influence of com-
mon genetic polymorphisms on aldosterone secretion in large sections of the popula-
tion and also the emerging role of microRNA as significant regulators of this system.

1. INTRODUCTION
The key role of aldosterone in salt and water homeostasis requires tight
regulation of its secretion. The importance of this is apparent under normal
physiological conditions, where multiple stimulatory and inhibitory inputs
must be integrated in order to determine the optimal circulating hormone
level. However, much of our motivation for investigating and understand-
ing how aldosterone is regulated arises from an appreciation of what happens
when such controls break down. Overproduction of aldosterone signifi-
cantly increases cardiovascular risk, resulting in hypertension and its various
comorbidities as well as other harmful consequences that are independent of
blood pressure. The fact that excessive secretion of aldosterone by the adre-
nal cortex, as observed in primary aldosteronism (PA), is such a common and
treatable form of hypertension has spurred much of the ongoing research
into the underlying regulatory mechanisms, prompted by the potential to
discover new targets and therapeutic interventions likely to reduce cardio-
vascular risk in significant sections of the hypertensive population.
In this article we summarize adrenal aldosterone biosynthesis and the
major pathways by which it is regulated, the most important being the ren-
in–angiotensin system (RAS). We then describe some of the factors that
have significant but smaller impact on aldosterone regulation, but which
might be of greater importance in certain pathological states. Finally, we dis-
cuss genetic and epigenetic factors underlying aldosterone production.
Although there have been reports—including our own—of extra-adrenal
aldosterone production and/or steroidogenic enzyme expression in the
mammalian brain and cardiovascular system, in humans these occur at such
a low level (where they can be reproducibly detected at all) that their phys-
iological impact appears questionable (MacKenzie, Connell, & Davies,
2011). For that reason, we focus in this article solely on the regulation of
aldosterone secretion by the adrenal cortex, reasoning that the complex
interplay of multiple pathways this involves is in itself a more than suffi-
ciently broad topic for discussion.
 ARTICLE IN PRESS

Regulation of Aldosterone Secretion 3

2. ALDOSTERONE BIOSYNTHESIS
As the adrenal gland has no capacity to store steroid hormones once
they are produced, the regulation of aldosterone secretion is inextricably
bound up with its synthesis. Before describing the regulatory systems
governing adrenal secretion of aldosterone, it is therefore necessary to sum-
marize the process by which specific cells within the adrenal cortex convert
cholesterol to aldosterone. To perform this task, such cells need firstly to be
supplied with cholesterol and secondly to express the full array of vital ste-
roidogenic enzymes; control of this cholesterol supply and of steroidogenic
enzyme expression are the mechanisms by which all regulatory systems ulti-
mately modulate aldosterone secretion.
The adrenal cortex is arranged into three functionally and structurally
distinct concentric layers. The clustered cells of the zona glomerulosa
(ZG) are outermost, lying just under the fibrous adrenal capsule. Within
is the zona fasciculata and, beneath that, the zona reticularis, which sits adja-
cent to the medulla. Under normal physiological conditions, aldosterone
biosynthesis in humans is confined to the ZG, as these cells alone express
aldosterone synthase, the steroidogenic enzyme that is encoded by the
CYP11B2 gene and performs the final stages of production (Fig. 1). The
other three steroidogenic enzymes required for aldosterone biosynthesis
are the cholesterol side-chain cleavage enzyme (P450scc) encoded by the
CYP11A1 gene, 3β-hydroxysteroid dehydrogenase (3β-HSD) encoded by
the HSD3B2 gene and 21-hydroxylase encoded by the CYP21A2 gene.
Expression of these three enzymes is not confined to the ZG, as they are also
required for cortisol and/or androgen biosynthesis in the zona fasciculata and
zona reticularis, in combination with other enzymes not present in the ZG,
such as 11β-hydroxylase, product of the CYP11B1 gene, and 17α-hydroxylase,
product of the CYP17A1 gene. Zonal control of steroidogenic gene
expression is therefore an important factor in the regulation of aldosterone
biosynthesis, on the one hand confining it to a relatively small area of the
adrenal cortex by restricting CYP11B2 expression while, on the other,
preventing diversion of steroid production within the zona glomerulosa
to cortisol or androgens due to the absence of CYP17A1 and CYP11B1
expression (Miller & Auchus, 2011).

2.1 Cholesterol
The common initial step in all steroidogenesis is the conversion of choles-
terol to pregnenolone by P450scc. Before aldosterone synthesis can
 ARTICLE IN PRESS

4 Scott M. MacKenzie et al.

Fig. 1 Summary of the major steroidogenic pathways in the zona glomerulosa (ZG) and
zona fasciculata (ZF) of the adrenal cortex. The name of the enzyme mediating each
conversion is given together with the name of the gene that encodes it.

commence, cholesterol must first be delivered to P450scc, which is located

on the inner mitochondrial membrane; this is a key rate-limiting step in ste-
roidogenesis. Although adrenocortical cells have the capacity to synthesize
cholesterol de novo from acetate, in humans it is mostly of dietary origin,
circulating in the plasma as low-density lipoprotein (LDL). This is taken
up by receptor-mediated endocytosis via LDL receptors (LDLR) on the sur-
face of steroidogenic cells, transferring cholesterol esters to lysosomes where
they can either be converted into free cholesterol for immediate use in ste-
roidogenesis or stored as lipid droplets in the cytosol, to be released by the
action of hormone-sensitive lipase (HSL) as required. Cytoskeletal
rearrangements then facilitate the movement of cholesterol to the outer
 ARTICLE IN PRESS

Regulation of Aldosterone Secretion 5

mitochondrial membrane and its transport to the side-chain cleavage system

on the inner membrane is performed by the steroidogenic acute regulatory
protein (StAR). Although steroidogenesis can proceed without StAR, its
presence accelerates P450scc conversion approximately sevenfold and it is
clearly vital to normal function; mutation of the StAR gene can result in
lipoid congenital adrenal hyperplasia (CAH) with consequent severe and
potentially lethal steroid hormone deficiency (Bose, Sugawara, Strauss,
Miller, International Congenital Lipoid Adrenal Hyperplasia Consortium,
1996). The activity of StAR is therefore a key factor in determining the
aldosterone-synthesising capacity of ZG cells particularly, as its name
implies, during acute regulatory responses, and this activity is directly
increased by phosphorylating StAR at Ser195 (Arakane et al., 1997).

2.2 Enzymatic Conversion of Cholesterol to Aldosterone

2.2.1 P450scc
Cholesterol transfer to the inner mitochondrial membrane allows the side-
chain cleavage enzyme, P450scc, to commence aldosterone synthesis. Like
21-hydroxylase and aldosterone synthase, which act later in the process,
P450scc belongs to the cytochrome P450 superfamily of enzymes, which
contain the cofactor haem. Mitochondrial P450s like P450scc and aldoste-
rone synthase use adrenodoxin and adrenodoxin reductase to transfer the
electrons they require as reducing equivalents for hydroxylation from
NADPH. P450scc catalyzes three separate reactions in order to generate
pregnenolone: 20α-hydroxylation, 22-hydroxylation and cleavage of the
bond linking C-20 to C-22. All occur at a single active site. P450scc is
the essential component that renders a cell steroidogenic; loss of P450scc
activity, as observed in rare patients who possess severe mutations at the
CYP11A1 locus on chromosome 15q23–24, prevents all steroidogenesis
and results in a lipoid CAH phenotype largely indistinguishable clinically
from that caused by disruption of the StAR gene (Miller & Auchus, 2011).

2.2.2 3βHSD2
Subsequent conversion of pregnenolone to progesterone is catalyzed by the
type 2 3β-hydroxysteroid dehydrogenase/△5-△4 isomerase enzyme
(3βHSD2) through modification of the 3β-hydroxyl group to a ketone
and isomerization of the C-5 to △4 double bond. In humans, this
enzyme—the only one in the process that is not a cytochrome P450—is
the product of the HSD3B2 gene on chromosome 1p13.1, expressed in
the adrenal gland and gonads, and is closely linked to the gene encoding
 ARTICLE IN PRESS

6 Scott M. MacKenzie et al.

the type 1 isoform, which performs the same function in other tissues
including placenta, brain and liver. Adrenal 3βHSD2 is generally held to
be located in the membrane of the endoplasmic reticulum, requiring preg-
nenolone substrate to pass through the cytosol from the mitochondrion,
although subcellular studies have detected 3βHSD2 in both the microsomal
and mitochondrial fractions of certain other tissues. 3βHSD deficiency due
to rare mutation of HSD3B2 can result in fatal steroid deficiency without
early identification and treatment (Rh
eaume et al., 1992).

2.2.3 21-Hydroxylase
The 21-hydroxylation of progesterone to 11-deoxycorticosterone (DOC) is
catalyzed by 21-hydroxylase, the product of the CYP21A2 gene on human
chromosome 6p21.1. This adrenal cytochrome P450 enzyme is located in
the endoplasmic reticulum and must therefore derive its electrons from
P450 oxidoreductase rather than the adrenodoxin system utilized by the
mitochondrial cytochrome P450 enzymes in this pathway. A pseudogene,
CYP21A1P, lies in tandem with CYP21A2, and recombination of the
two is largely responsible for the high instance of mutation at this locus
and the relatively common occurrence of 21-hydroxylase deficiency.
Indeed, this is the most common form of CAH and, in its most severe forms,
the resulting aldosterone deficiency can lead to death in untreated newborns.

2.2.4 Aldosterone Synthase

The final three steps of biosynthesis from DOC to aldosterone are all cata-
lyzed by the aldosterone synthase enzyme. These are 11β-hydroxylation of
DOC, which forms corticosterone, subsequent 18-hydroxylation to make
18-hydroxycorticosterone and, finally, 18-methyloxidation to produce
aldosterone. Aldosterone synthase is a ZG-expressed mitochondrial cyto-
chrome P450 enzyme and is the product of the CYP11B2 gene located
on human chromosome 8. CYP11B2 lies in tandem with the highly-
homologous CYP11B1 gene, which encodes the 11β-hydroxylase enzyme
essential to cortisol synthesis and is primarily under the regulation of ACTH.
As noted previously, CYP11B1 and CYP11B2 are never normally
coexpressed due to strict zonal control of gene expression within the adrenal
cortex (Fig. 1). Aldosterone deficiency resulting from severe disruption of
CYP11B2 gene function leads to excessive sodium excretion and the
retention of potassium. The characteristic hyponatremia and hyperkalemia
that results is also accompanied by higher plasma renin levels in infants and
young children, although this elevation may not be observed in adults
(White, 2004).
 ARTICLE IN PRESS

Regulation of Aldosterone Secretion 7

3. THE RENIN–ANGIOTENSIN SYSTEM

As a key signalling pathway regulating circulatory homeostasis in
response to the loss of salt and water, the RAS—in concert with plasma
potassium concentration (see below)—is the most important system
governing aldosterone release under normal physiological conditions. It is
initiated in response to either lower sodium concentration, sensed by renal
macula densa cells, or to reduced intravascular pressure or volume, detected
by baroreceptors in the carotid sinus. These result in the release of renin from
juxtaglomerular cells in the kidney by cleavage of its inactive precursor
prorenin (Friis et al., 2013). Renin circulating in the plasma catalyzes the
hydrolysis of angiotensinogen, secreted by the liver, to form the decapeptide
angiotensin I. A further two C-terminal residues are then removed by
angiotensin-converting enzyme (ACE), principally within the lung, to pro-
duce the key active component of the RAS, angiotensin II (AngII). AngII
exerts numerous hypertensive effects (Leenen, Blaustein, & Hamlyn, 2017),
being a powerful vasoconstrictor, for example, while also directly inducing
catecholamine release from the adrenal medulla. Through its stimulation of
aldosterone synthesis AngII also raises blood pressure by increasing salt and
fluid retention. In adult humans this effect is mediated through type I AngII
receptors (AT1R) located on the membrane of adrenocortical zona
glomerulosa cells. Binding of the G-protein coupled AT1R by AngII acti-
vates signal transduction that stimulates aldosterone production through sev-
eral different pathways by means of increasing cholesterol supply to the
mitochondria and upregulating the expression and/or activity of key
enzymes that act at rate-limiting steps in the process.
As is standard for G protein-coupled receptors, AT1R has a seven-
transmembrane domain structure that is coupled to a heterotrimeric
guanine-binding protein consisting of an α, β and γ subunit. Binding of
AngII to AT1R results in conformational change and an exchange of
GDP for GTP by the G protein α subunit that causes its dissociation from
the heterotrimer. Downstream effects of any G protein-coupled receptor are
therefore dictated by the types of α subunit with which it is associated. In the
case of AT1R, its associated heterotrimeric G proteins include Gαq or Gα11
subunits which, upon dissociation, activate phospholipase C (PLC) (Bollag,
2014). PLC then hydrolyses phosphatidylinositol-4,5-bisphosphate (PIP2)
to produce diacylglycerol (DAG) and inositol 1,4,5-trisphosphate (IP3),
which both have downstream signalling roles that elicit a rise in intracellular
calcium. There is also evidence that DAG is generated by phospholipase
 ARTICLE IN PRESS

8 Scott M. MacKenzie et al.

D (PLD) following AngII stimulation (Bollag, Barrett, Isales, Liscovitch, &

Rasmussen, 1990).
It is apparent that sustained AngII signalling results in a downregulation
of its effects through various AT1R-mediated mechanisms. These include
reduced interaction of AT1R with its G protein (Boulay, Chr
etien,
Richard, & Guillemette, 1994), resulting in a less sensitive reaction to AngII
and, over several hours, the number of receptors present at the ZG cell
surface are also found to decrease (Penhoat, Jaillard, Crozat, & Saez,
1988). There is also negative feedback of AngII to the renal juxtaglomerular
cells, which reduces renin release.

3.1 AngII-Induced Calcium Effects

Calcium is the key second messenger regulating aldosterone secretion
within the ZG cell and there are various pathways by which AngII acts
to increase its intracellular levels. The IP3 generated by AngII-stimulated
hydrolysis of PIP2 binds specific receptors (IP3Rs) on the endoplasmic retic-
ulum, causing it to release its intracellular stores of Ca2+ (Barrett, Bollag,
Isales, McCarthy, & Rasmussen, 1989). While this is important to the initial
acute AngII response, persistent aldosterone secretion requires calcium from
an extracellular source, and this is supplied by depolarising the ZG cell and
activating the opening of voltage-dependent calcium channels. At rest ZG
cells maintain a strongly negative potential across the cell membrane due to a
concentration gradient of K+ that is generated by the Na+, K+-ATPase
embedded there. Depolarization can therefore be achieved, as AngII does,
by inhibiting the function of the Na+, K+-ATPase or other potassium chan-
nels (Zennaro, Boulkroun, & Fernandes-Rosa, 2015). This, in turn, causes
voltage-gated Ca2+ channels to open and permit an influx of calcium to
the cytosol through the membrane. Both low voltage-activated transient
(T)-type channels or high voltage-activated long-lasting (L)-type channels
are present in ZG cell membranes. In addition to Gαq and Gα11, AT1R is
also coupled to Gαi-associated G-proteins which, when activated, influ-
ence the activity of T-type (and possibly L-type) calcium channels in the
ZG to increase calcium influx. ZG cells were long regarded as largely elec-
trically inactive, with T-type channels facilitating a low level of calcium
influx which nevertheless was sufficient for aldosterone production, while
the contribution of L-type channels was not significant. However, this view
has been reassessed in light of various strands of evidence demonstrating far
 ARTICLE IN PRESS

Regulation of Aldosterone Secretion 9

greater electrical activity within ZG cells; the fact that functional mutations
of L-type channels (encoded by the CACNA1D gene) are present in a high
proportion of aldosterone-producing adenomas also points to significant
potential impact of such channels on aldosterone secretion (Azizan et al.,
2013). At present it is not clear how, under normal conditions, the ZG cell
membrane becomes sufficiently depolarized to enable the opening of the
low-voltage L-type channels, although the voltage oscillations observed
in these cells may be a factor, as might interaction between the T-type
and L-type channels and the arrangement of ZG cells into “rosette” struc-
tures within cortical tissue. Each is the subject of ongoing study (Barrett
et al., 2016).
Potassium channels are also important. ZG potassium channels activated
by high voltages or Ca2+ levels control repolarization of the cell membrane
following calcium influx; any inhibition of cell repolarization increases the
period of time that calcium channels remain open and therefore extend
the duration of the steroidogenic signal. As an example, mutation of the
G-protein coupled inwardly-rectifying potassium channel encoded by the
KCNJ5 gene results in chronic depolarization of the cell and is the most
common single identified cause underlying aldosterone-producing adeno-
mas, which exhibit uncontrolled secretion of aldosterone (Choi et al.,
2011). Potassium channel activity is also important to the ZG cell at resting
potentials; so-called “leak”channels remain open under these conditions,
permitting K+ conductance that contributes to the maintenance of the
membrane potential. These are TWIK-related acid-sensitive K+ (TASK)
channels, which can be modulated via Gαq- and Gα11-type G-proteins to
control cellular depolarization. DAG (produced by AngII action through
the hydrolyzing action of PLC, as described above) inhibits TASK channel
function in ZG cells. The relative depolarization in resting membrane
potential caused by this will tend to increase calcium influx and therefore
stimulate aldosterone secretion (Wilke et al., 2014).
However, it is achieved, raised cytoplasmic Ca2+ concentration in the
ZG results in the activation of calcium/calmodulin-dependent protein
kinases (CaMK), a process mediated by the calcium-binding protein cal-
modulin. Of the ZG-expressed CaM kinases, CaMKII appears to be key
to the aldosterone response and it is likely to be this that causes the phos-
phorylation of StAR observed at higher cytoplasmic calcium concentra-
tions, resulting in greater cholesterol supply to the mitochondrion and
acceleration of the rate-limiting cholesterol side-chain cleavage step
 ARTICLE IN PRESS

10 Scott M. MacKenzie et al.

(i.e., conversion of cholesterol to pregnenolone), which significantly

increases steroidogenesis (Pezzi, Clark, Ando, Stocco, & Rainey, 1996).
CaMKII also promotes T-type Ca2+ channel activity, further enhancing
Ca2+ influx (Fern et al., 1995). For a more sustained increase in aldosterone
secretion, calcium must be delivered from the cytoplasm to the mitochon-
drion; higher [Ca2+] localized to this organelle stimulates the production of
NADH, thereby generating higher levels of the NADPH cofactor that is
vital to the function of the steroidogenic enzymes P450scc and aldosterone.
This stimulatory effect of Ca2+ on aldosterone secretion can be sustained for
several hours (Sp€at & Hunyady, 2004). In the longer term, transcription of
the steroidogenic machinery can be stimulated in order to boost the
aldosterone-synthesizing capacity of the cell; CaMKI, for example, mediates
an AngII-stimulated rise in CYP11B2 transcription (Condon, Pezzi,
Drummond, Yin, & Rainey, 2002). AngII also stimulates expression of
StAR, apparently through a promoter element that binds the transcription
factor steroidogenic factor 1 (SF1) (Clark & Combs, 1999).
DAG production is sustained in ZG cells following AngII stimulation
(Bollag, Barrett, Isales, & Rasmussen, 1991), exerting downstream effects
mediated via protein kinase C (PKC). There is evidence of aldosterone
secretion being stimulated through PKC-mediated pathways but this is
the subject of some dispute owing to discrepancies between various studies,
which may result from variations in the PKC isoforms under investigation
(Bollag, 2014; Sp€at & Hunyady, 2004). Protein kinase D (PKD) can also be
activated by DAG and by PKC; increases in its activity have been shown to
stimulate aldosterone secretion through greater expression of aldosterone
synthase and StAR (Olala, Choudhary, Johnson, & Bollag, 2014;
Romero et al., 2006), the latter through a CREB-related mechanism
(see below).
In addition to stimulating the expression of steroidogenic enzymes,
mobilizing cholesterol in the ZG cell is also a key mechanism by which aldo-
sterone production is increased. Higher demand for cholesterol requires its
uptake from plasma lipoproteins: LDL and high-density lipoprotein (HDL)
are both exploited for this purpose, with AngII stimulating the use of the lat-
ter by enhancing expression of scavenger receptor class B type 1 (SR-B1)
(Cherradi et al., 2001). Within the cell, AngII also activates HSL to release
cholesterol from the lipid droplets where it is stored in esterified form
(Cherradi, Pardo, Greenberg, Kraemer, & Capponi, 2003); the cytoskele-
ton then transfers the cholesterol to the outer mitochondrial membrane for
transport by StAR.
 ARTICLE IN PRESS

Regulation of Aldosterone Secretion 11

4. PLASMA POTASSIUM
Zona glomerulosa cells are highly sensitive to small increases in extra-
cellular potassium concentration ([K+]e) and, in response, maintain K+
homeostasis by stimulating aldosterone secretion; altering circulating potas-
sium concentration by 5–8% can change serum aldosterone levels by
40–50% (Himathongkam, Dluhy, & Williams, 1975), and variations in
potassium of this magnitude can be induced through dietary intake. This
responsiveness of aldosterone to K+ reflects its major role in potassium
homeostasis, achieved by regulating its excretion. There is a large overlap
between the potassium-mediated regulation of aldosterone production
and the previously-described mechanisms by which AngII influences ZG
cell depolarization. As mentioned previously, TASK K+ channels are impor-
tant to maintaining the resting membrane potential of ZG cells. Rising
extracellular [K+] decreases this electrochemical drive, effectively resulting,
as with AngII stimulation, in a depolarization of the ZG cell membrane,
which increases the T- and L-type Ca2+ channel opening and ultimately
leads to CAMK activation. There is clearly interaction between AngII-
and K+-induced pathways: AngII is a more potent stimulator of aldosterone
secretion at higher potassium levels while, at very low potassium concentra-
tions, the ZG cell membrane is so hyperpolarized that AngII cannot induce
sufficient depolarization to activate calcium influx and steroid biosynthesis
(Chen, Bayliss, Fern, & Barrett, 1999).
Potassium stimulation of aldosterone may differ from that of AngII in
one key respect. Although the subject of some debate, there is evidence that
potassium, unlike AngII, can also activate cAMP production within ZG
cells. As is apparent from the effects of ACTH, cAMP is undoubtedly a
potent second messenger capable of stimulating aldosterone secretion, but
the level of cAMP induction observed with potassium—when it is observed
at all—is of a lower degree leading to some doubt over its physiological sig-
nificance (Tait & Tait, 1999). The various mechanisms by which cAMP reg-
ulates aldosterone secretion are described in more detail in the next section.

5. ACTH
While ACTH is clearly the major regulator of cortisol secretion
within the adrenal cortex, it is also an extremely potent acute regulator of
aldosterone, capable of eliciting its secretion at doses far lower than those
 ARTICLE IN PRESS

12 Scott M. MacKenzie et al.

required for cortisol (Daidoh et al., 1995). ACTH is secreted from the ante-
rior pituitary as part of the stress-responsive neuroendocrine network that
constitutes the hypothalamic–pituitary–adrenal (HPA) axis. It is formed
by the cleavage of proopiomelanocortin (POMC), secreted by the anterior
pituitary, and acts by binding a membrane-bound G-protein-coupled
receptor, the melanocortin type 2 receptor (MC2R) to generate cAMP.
MC2R is present throughout the adrenal cortex and has exclusive selectivity
for ACTH but also requires the melanocortin-2 receptor accessory protein
(MRAP) to function. MC2R initiates cAMP production via its associated
stimulatory G protein, which releases an αGs subunit capable of activating
adenylate cyclase. The cAMP that this generates then activates protein
kinase A (PKA), which phosphorylates various proteins to induce steroido-
genesis, including StAR (Betancourt-Calle et al., 2001). Gene expression is
also induced through this mechanism; gene promoters possessing a cAMP-
responsive element (CRE) can be recognized and bound by the tran-
scription factors belonging to the CRE-binding protein (CREB) family
following their cAMP-dependent phosphorylation. The promoter of the
CYP11B2 gene encoding aldosterone synthase contains CREs enabling
its transcription to increase in a cAMP-responsive manner (Clyne et al.,
1997). The StAR promoter lacks a canonical CRE but shows similar tran-
scriptional behavior due to the presence of an activator protein-1 (AP1)-like
element in its promoter capable of binding CREB (Clem, Hudson, & Clark,
2005). Increased expression of these two genes acutely stimulates the ste-
roidogenic capacity of ZG cells following ACTH stimulation. PKA may
also phosphorylate L-type calcium channels, stimulating Ca2+ influx that
promotes cell membrane depolarization and, apparently, adenylate cyclase
activity. This implies interaction between the cAMP- and Ca2+-stimulated
pathways that synergistically increases aldosterone secretion (Gallo-Payet
et al., 1996).
Despite its undoubted and significant acute stimulation of steroidogen-
esis, ACTH is generally regarded as having limited long-term effect on
plasma aldosterone levels. This belief arose originally from clinical studies,
which showed that continuous infusion of ACTH causes only a short-lived
rise in aldosterone that falls back to baseline within 72 h. In vitro studies sim-
ilarly found CYP11B2 mRNA to decrease steeply following an initial
ACTH-induced rise due to an as-yet unknown mechanism (Holland &
Carr, 1993). However, later studies showed that administration of ACTH
in a pulsatile manner that more closely models its physiological secretion
avoids this “escape” phenomenon, resulting in sustained increases to circu-
lating aldosterone (Seely, Conlin, Brent, & Dluhy, 1989). This suggests that
 ARTICLE IN PRESS

Regulation of Aldosterone Secretion 13

the influence of ACTH on aldosterone secretion, while undoubtedly less

significant under normal physiological circumstances than AngII and K+,
may be underappreciated. Several lines of evidence support this view:
ACTH and aldosterone levels correlate, for example, with each following
a circadian rhythm that peaks in the morning and falls throughout the
day (Richards et al., 1986). Furthermore, a recent clinical study of essentially
hypertensive patients found a quarter of its subjects to react in a “hyper-
responsive” manner to ultra-low doses of ACTH (0.03 μg), achieving circu-
lating aldosterone levels some four times higher than the other subjects,
although cortisol levels were not markedly different. This led the investiga-
tors to propose that the ZG cells of such individuals have been rendered
more sensitive due to priming by stress-induced ACTH secretion, possibly
as a result of gene mutations that increase ZG responsiveness (Markou et al.,
2015). The underlying cause—genetic or otherwise—of the exaggerated
aldosterone response to ACTH in such a substantial proportion of patients
suffering this common condition warrants further investigation, particularly
given its wider implications for stressful lifestyles and their impact on cardio-
vascular health (MacKenzie, Freel, Connell, Fraser, & Davies, 2017).

6. OTHER REGULATORS OF ALDOSTERONE SECRETION

In addition to the major regulatory systems detailed above, various
other substances have been shown to modulate aldosterone secretion from
the ZG. Although their effects are by no means as pronounced as those of
AngII, potassium or ACTH, they are significant and worthy of note when
considering the complex interplay of factors that determine aldosterone
secretion. The section below briefly summarizes the evidence for the most
significant of these additional regulators, although the list is not exhaustive.

6.1 Leptin
Following initial reports that human adipocytes release a factor capable of
stimulating adrenocortical aldosterone secretion through a mechanism inde-
pendent of AngII (Ehrhart-Bornstein et al., 2003), there is now strong evi-
dence that the factor responsible is the adipocyte-derived hormone leptin.
Expression of leptin receptors and aldosterone synthase colocalize to human
ZG cells, while animal studies demonstrate leptin stimulation of CYP11B2
expression through a Ca2+- and CAMKII-mediated mechanism (Huby
et al., 2015). This effect may underlie the hyperaldosteronism that is often
observed in human obesity and which contributes to its cardiovascular con-
sequences (Calhoun & Sharma, 2010). In support of this, the increased
 ARTICLE IN PRESS

14 Scott M. MacKenzie et al.

endothelial dysfunction and markers of cardiac fibrosis observed following

leptin treatment can be reduced in mice through the blockade of
aldosterone action via mineralocorticoid receptors (Huby et al., 2015).
Intriguingly, subsequent murine studies suggest that these cardiovascular
consequences of leptin-dependent aldosterone secretion are sex-dependent,
with leptin inducing hypertension and endothelial dysfunction in female but
not male mice (Huby, Otvos, & Belin de Chantemèle, 2016). This raises the
prospect of sex-specific therapies for hyperaldosteronism in future clinical
practice.

6.2 Atrial Natriuretic Peptide

Atrial Natriuretic Peptide (ANP) is produced by cardiac muscle in the atria
and is secreted by these cells in response to increased atrial stretch resulting
from higher blood volume. Its main role is to reduce extracellular volume
through stimulation of renal sodium and water excretion. Consistent with
this, ANP also has an inhibitory effect on adrenal aldosterone secretion
and demonstrates an inverse correlation with plasma aldosterone levels
(Shenker, Sider, Ostafin, & Grekin, 1985). In the ZG, ANP acts through
its type A receptor, NPRA, raising cGMP levels and countering the rises
in aldosterone production mediated through various pathways, including
those of AngII and ACTH (Bodart, Rainey, Fournier, Ong, & De L
ean,
1996). Correspondingly, this reduction in steroidogenesis is achieved by
several mechanisms including inhibition of T-type calcium channel activity,
stimulation of potassium channel activity and a downregulation of StAR
phosphorylation and gene expression (Bollag, 2014).

6.3 Dopamine
Action of the neurotransmitter dopamine has been shown to inhibit aldo-
sterone secretion from ZG via its type 2 (DA2) receptors and is apparently
the result—at least in part—of T-type Ca2+ channel inhibition. This inhi-
bition is apparently of little importance in the basal unstimulated state, but
can blunt aldosterone secretion in response to certain stimulants including
AngII, upright posture or dietary sodium depletion, but not ACTH or
K+ (Stowasser & Gordon, 2016). The inhibition of aldosterone by dopa-
mine is supported by the reduced levels of DA2 expression observed in
APAs, suggesting loss of dopamine action may contribute not only to these
tumors’ uninhibited aldosterone secretion but also to their proliferation
(Chang et al., 2014).
 ARTICLE IN PRESS

Regulation of Aldosterone Secretion 15

6.4 Serotonin
The monoamine neurotransmitter serotonin (5-hydroxytryptamine; 5-HT)
acutely stimulates aldosterone secretion from the ZG in a manner indepen-
dent of ACTH- or AngII-related pathways (Stowasser & Gordon, 2016).
Serotonin binds the 5-HT4 receptor in the human ZG, and the consequent
rise in aldosterone secretion is apparently a consequence of increased cAMP
production and calcium influx (Davies, Edwards, & Williams, 1991; Rocco,
Ambroz, & Aguilera, 1990). The presence of serotonin-containing cells in
the human adrenal cortex implies a paracrine mechanism for this particular
mode of aldosterone regulation (Lefebvre et al., 2001), and it had been
suggested that this could be of importance in the pathogenesis of steroid-
producing adrenocortical hyperplasias and tumors (Lefebvre et al., 2015).

7. COMMON GENETIC POLYMORPHISMS INFLUENCING

ALDOSTERONE SECRETION
When considering the many factors influencing aldosterone secretion,
it is necessary not only to summarize the mechanisms by which certain cir-
culating factors regulate its production, but also to consider inter-individual
genetic variabilities that may confer a greater or lesser response to such fac-
tors. While there is no doubt that rare genetic mutations at steroidogenic loci
can have severe effects on aldosterone secretion, as mentioned above, these
are of little importance in the wider population. However, there is evidence
that far more common polymorphisms exist at relevant loci which, in their
effects, are more subtle yet still significant. Blood pressure itself has a signif-
icant heritable component, estimated to account for approximately 40% of
the phenotype (Vattikuti, Guo, & Chow, 2012). Most of this heritability
derives from common genetic polymorphisms with a minor allele frequency
(MAF) >0.1, which are located in non-coding regions and are likely to be
cis-regulatory (Salfati, Morrison, Boerwinkle, & Chakravarti, 2015).
Genome-wide association studies (GWAS) designed to identify common
polymorphisms influencing blood pressure have to date identified only
50 or so significant loci none of which are directly linked to aldosterone
secretion. This has been interpreted by some as evidence that genetic var-
iation affecting aldosterone secretion is either non-existent or has no signif-
icant impact on blood pressure. However, such an assertion appears
premature given that loci identified by GWAS currently account for under
5% of the heritable component of blood pressure and that studies favoring a
candidate gene approach provide compelling positive data.
 ARTICLE IN PRESS

16 Scott M. MacKenzie et al.

The secretion rate of aldosterone itself and its level within the plasma are
both known to be heritable traits (Inglis et al., 1999; Kathiresan et al., 2005).
Of the studies analyzing the effects of genetic polymorphism on aldosterone
secretion, almost all have focused on CYP11B2. Given its role, it appears an
obvious candidate blood pressure locus. Since the first publication of the
CYP11B2 sequence (Mornet, Dupont, Vitek, & White, 1989) numerous
common polymorphisms have been identified there, the most studied being
a single nucleotide polymorphism (SNP) rs1799998, located 344 bases
upstream of the transcription start site (TSS), and a highly linked gene con-
version event within intron 2. rs1799998 is a very common C/T SNP with a
minor allele frequency (MAF) of
0.43 in Western European populations
and its minor T allele was shown to associate with higher excretion of the
major urinary metabolite of aldosterone, tetrahydroaldosterone (THaldo)
(Paillard et al., 1999). However, numerous investigations of blood pressure
associations with this SNP (or the intron conversion) have failed to achieve a
clear consensus (Davies et al., 1999; Takeuchi et al., 2012; Zhu et al., 2003),
although meta-analysis of 42 such studies has associated rs1799998 with
essential hypertension (Sookoian, Gianotti, González, & Pirola, 2007).
Our subsequent work attributed these inconsistent associations not to any
functional effect of rs1799998 itself but rather to the high degree of linkage
disequilibrium (LD) it shares with the functional polymorphism rs13268025.
This C/T SNP (MAF ¼ 0.47) lies 1651 bases upstream of the CYP11B2 TSS
and, in its C form, disrupts binding of the transcriptional repressor molecule
apurinic/apyrimidinic endodeoxyribonuclease 1 (APEX1), reducing inhibi-
tion of CYP11B2 transcription (McManus et al., 2012). Although the dif-
ferences in transcriptional activity between these two allelic forms of
CYP11B2 are apparent under basal conditions, in vitro analysis shows they
become even more pronounced following stimulation with AngII. In vivo,
a study of 60 normotensive subjects found those homozygous for the
“derepressed” C allele excreted significantly more THaldo than T allele
homozygotes. This polymorphism therefore provides a clear illustration
of a common polymorphism with a significant and predictable impact on
aldosterone secretion. Given the high number of genes that play a role in
the complex regulation of aldosterone production, it is highly likely that
more are to be discovered. Indeed, the aldosterone hyper-response to
ACTH identified by Markou and colleagues in a subgroup of hypertensives
has been attributed to polymorphisms and we have speculated that genetic
variation at the ACTH receptor or its accessory protein might contribute to
this effect (MacKenzie et al., 2017).
 ARTICLE IN PRESS

Regulation of Aldosterone Secretion 17

8. MicroRNAs
MicroRNA (miRNA) is a class of small (
22 nucleotides), endoge-
nous, single-stranded non-coding RNA molecule capable of post-
transcriptionally regulating the expression of specific genes by targeting their
mRNA. This is achieved by incorporating a specific miRNA into the
RNA-induced silencing complex (RISC), enabling the miRNA to bind
complementary 30 UTR sites on target mRNAs. Post-transcriptional regu-
lation is then achieved through both translational repression and mRNA
degradation. The genes targeted by a specific miRNA is determined to a
large degree by the sequence complementarity of the miRNA and the
30 UTR site on the mRNA. While miRNA-mediated regulation is typically
mild in nature (miRNAs are considered to be fine-tuners), it can have a sig-
nificant biological effect due to the fact that any single miRNA has the
potential to regulate the expression of many different mRNAs (Selbach
et al., 2008) and even several components within a single pathway (Kemp
et al., 2014). Furthermore, it is believed that the majority of protein-coding
genes are regulated in some way by miRNAs as >60% of human protein-
coding genes contain a minimum of 1 conserved miRNA-binding site
(Friedman, Farh, Burge, & Bartel, 2009).
To date, few studies have investigated miRNA regulation of cor-
ticosteroidogenic genes. Initially, it was shown that expression of miR-21
is increased in human adrenocortical H295R cells following AngII stimula-
tion and that overexpression of this miRNA results in both increased aldo-
sterone production and cell proliferation, but no mechanism of action was
demonstrated (Romero, Plonczynski, Carvajal, Gomez-Sanchez, &
Gomez-Sanchez, 2008). Subsequent studies have demonstrated that
miRNAs target many different points within the aldosterone biosynthesis
pathway.
Most studies have focused on CYP11B2. We identified miRNA-24 as a
canonical regulator of CYP11B2 expression in H295R cells, observing
changes in aldosterone secretion that correlated with altered levels of
CYP11B2 mRNA; we also observed a regulatory effect of the same miRNA
on CYP11B1 (11β-hydroxylase) expression and cortisol levels (Robertson
et al., 2013). miR-10b also negatively regulates CYP11B1 and CYP11B2
expression in H295R cells, with corresponding effects on aldosterone
and cortisol production (Nusrin et al., 2014). Also using H295R cells,
modulation of CYP11B2 by miR-125a-5p and miR-125b-5p
 ARTICLE IN PRESS

18 Scott M. MacKenzie et al.

(Robertson et al., 2017) as well as miR-766 (Maharjan, Mopidevi, Kaw,

Puri, & Kumar, 2014) have been demonstrated, although effects on aldoste-
rone production were not investigated. In addition to direct targeting of
CYP11B2, miRNAs may affect its expression by other means. miR-34
and miR-23 have been shown to decrease levels of TASK channel mRNA
by binding to its 30 UTR. The resulting decrease in TASK-2 expression is
associated with increased expression of CYP11B2 and StAR and with higher
aldosterone levels (Lenzini et al., 2013).
Other enzymes regulating aldosterone secretion can also be regulated by
miRNA; we have demonstrated a direct regulatory effect of miR-320a-3p
on CYP11A1 mRNA (Robertson et al., 2017), while Hu and colleagues
reported that miR-132 regulates steroidogenesis by inhibiting StAR expres-
sion in Y1 mouse adrenocortical cells, while also indirectly influencing
expression of 3β-HSD (Hu, Shen, Kraemer, & Azhar, 2017). The same
group has reported negative regulation of HDL cholesteryl ester uptake
and HDL-stimulated progesterone production by miR-125a and miR-
455, acting via scavenger receptor class B type I (SR-B1), although this work
was primarily carried out in Leydig testicular cells (Hu, Shen, Kraemer, &
Azhar, 2012).
It is therefore clear that numerous miRNAs mentioned here (and likely
many more, as yet undiscovered) regulate the adrenal steroidogenic pathway
at numerous points. The combined impact of these individual regulatory
miRNAs acting concurrently across the entirety of the corticosteroid path-
way has yet to be assessed. Furthermore, if miRNA-mediated regulation of
aldosterone synthesis is to be fully understood, regulation of miRNA pro-
duction itself requires further investigation, particularly the response to
known regulators of aldosterone secretion such as AngII and ACTH, where
only limited information is currently available (Hu et al., 2017; Romero
et al., 2008).

9. CONCLUSIONS
Circulating aldosterone levels are the result of a complex interplay of
regulatory systems. Although the major factors governing aldosterone secre-
tion are known and understood to a large extent, it is apparent that many of
the mechanistic details underlying these are still to be fully dissected. Given
the consequences for the individual when such regulatory systems break
down, full understanding of these mechanisms is clearly a desirable aim
and, as we look more closely, the number of individuals suffering from
 ARTICLE IN PRESS

Regulation of Aldosterone Secretion 19

aldosterone excess seems set to rise ever higher (Piaditis, Markou,

Papanastasiou, Androulakis, & Kaltsas, 2015). The tendency of certain indi-
viduals to react to a greater or lesser extent to the various regulatory factors
may also become more prominent as our ability to identify genetic polymor-
phisms predisposing to higher aldosterone levels and target treatment
accordingly becomes increasingly viable. Finally, while the effect of micro-
RNAs upon aldosterone secretion is now beyond doubt, the full significance
of its impact in health and disease is yet to be determined.

ACKNOWLEDGMENTS
S.M.M., J.C.v.K. and E.D. are members of the ENS@T-HT EU-funded Horizon 2020
research and innovation project into hypertension and personalised treatments (http://
www.ensat-ht.eu).

REFERENCES
Arakane, F., King, S. R., Du, Y., Kallen, C. B., Walsh, L. P., Watari, H., et al. (1997). Phos-
phorylation of steroidogenic acute regulatory protein (StAR) modulates its steroidogenic
activity. The Journal of Biological Chemistry, 272(51), 32656–32662.
Azizan, E. A. B., Poulsen, H., Tuluc, P., Zhou, J., Clausen, M. V., Lieb, A., et al. (2013).
Somatic mutations in ATP1A1 and CACNA1D underlie a common subtype of adrenal
hypertension. Nature Genetics, 45, 1055–1060.
Barrett, P. Q., Bollag, W. B., Isales, C. M., McCarthy, R. T., & Rasmussen, H. (1989). Role
of calcium in angiotensin II-mediated aldosterone secretion. Endocrine Reviews, 10(4),
496–518.
Barrett, P. Q., Guagliardo, N. A., Klein, P. M., Hu, C., Breault, D. T., & Beenhakker, M. P.
(2016). Role of voltage-gated calcium channels in the regulation of aldosterone produc-
tion from zona glomerulosa cells of the adrenal cortex. The Journal of Physiology, 594(20),
5851–5860.
Betancourt-Calle, S., Calle, R. A., Isales, C. M., White, S., Rasmussen, H., & Bollag, W. B.
(2001). Differential effects of agonists of aldosterone secretion on steroidogenic acute
regulatory phosphorylation. Molecular and Cellular Endocrinology, 173(1–2), 87–94.
Bodart, V., Rainey, W. E., Fournier, A., Ong, H., & De L
ean, A. (1996). The H295R
human adrenocortical cell line contains functional atrial natriuretic peptide receptors that
inhibit aldosterone biosynthesis. Molecular and Cellular Endocrinology, 118(1–2), 137–144.
Bollag, W. B. (2014). Regulation of aldosterone synthesis and secretion. Comprehensive Phys-
iology, 4(3), 1017–1055. Hoboken, NJ: John Wiley & Sons, Inc.
Bollag, W. B., Barrett, P. Q., Isales, C. M., Liscovitch, M., & Rasmussen, H. (1990).
A potential role for phospholipase-D in the angiotensin-II-induced stimulation of aldo-
sterone secretion from bovine adrenal glomerulosa cells. Endocrinology, 127(3),
1436–1443.
Bollag, W. B., Barrett, P. Q., Isales, C. M., & Rasmussen, H. (1991). Angiotensin-II-
induced changes in diacylglycerol levels and their potential role in modulating the ste-
roidogenic response. Endocrinology, 128(1), 231–241.
Bose, H. S., Sugawara, T., Strauss, J. F., Miller, W. L., & International Congenital Lipoid
Adrenal Hyperplasia Consortium. (1996). The pathophysiology and genetics of congen-
ital lipoid adrenal hyperplasia. The New England Journal of Medicine, 335(25), 1870–1878.
 ARTICLE IN PRESS

20 Scott M. MacKenzie et al.

Boulay, G., Chr
etien, L., Richard, D. E., & Guillemette, G. (1994). Short-term desensiti-
zation of the angiotensin II receptor of bovine adrenal glomerulosa cells corresponds to a
shift from a high to a low affinity state. Endocrinology, 135(5), 2130–2136.
Calhoun, D. A., & Sharma, K. (2010). The role of aldosteronism in causing obesity-related
cardiovascular risk. Cardiology Clinics, 28(3), 517–527.
Chang, H.-W., Huang, C.-Y., Yang, S.-Y., Wu, V.-C., Chu, T.-S., Chen, Y.-M., et al.
(2014). Role of D2 dopamine receptor in adrenal cortical cell proliferation and
aldosterone-producing adenoma tumorigenesis. Journal of Molecular Endocrinology,
52(2), 87–96.
Chen, X. L., Bayliss, D. A., Fern, R. J., & Barrett, P. Q. (1999). A role for T-type Ca2 +
channels in the synergistic control of aldosterone production by ANG II and K+.
The American Journal of Physiology, 276(5 Pt. 2), F674–F683.
Cherradi, N., Bideau, M., Arnaudeau, S., Demaurex, N., James, R. W., Azhar, S., et al.
(2001). Angiotensin II promotes selective uptake of high density lipoprotein cholesterol
esters in bovine adrenal glomerulosa and human adrenocortical carcinoma cells through
induction of scavenger receptor class B type I. Endocrinology, 142(10), 4540–4549.
Cherradi, N., Pardo, B., Greenberg, A. S., Kraemer, F. B., & Capponi, A. M. (2003). Angio-
tensin II activates cholesterol ester hydrolase in bovine adrenal glomerulosa cells through
phosphorylation mediated by p42/p44 mitogen-activated protein kinase. Endocrinology,
144(11), 4905–4915.
Choi, M., Scholl, U. I., Yue, P., Bj€ orklund, P., Zhao, B., Nelson-Williams, C., et al. (2011).
K+ channel mutations in adrenal aldosterone-producing adenomas and hereditary
hypertension. Science (New York, N.Y.), 331(6018), 768–772.
Clark, B. J., & Combs, R. (1999). Angiotensin II and cyclic adenosine 300 ,5-00 monophosphate
induce human steroidogenic acute regulatory protein transcription through a common
steroidogenic factor-1 element. Endocrinology, 140(10), 4390–4398.
Clem, B. F., Hudson, E. A., & Clark, B. J. (2005). Cyclic adenosine 300 ,500 -monophosphate
(cAMP) enhances cAMP-responsive element binding (CREB) protein phosphorylation
and phospho-CREB interaction with the mouse steroidogenic acute regulatory protein
gene promoter. Endocrinology, 146(3), 1348–1356.
Clyne, C. D., Zhang, Y., Slutsker, L., Mathis, J. M., White, P. C., & Rainey, W. E. (1997).
Angiotensin II and potassium regulate human CYP11B2 transcription through common
cis-elements. Molecular Endocrinology (Baltimore, Md.), 11(5), 638–649.
Condon, J. C., Pezzi, V., Drummond, B. M., Yin, S., & Rainey, W. E. (2002). Calmodulin-
dependent kinase I regulates adrenal cell expression of aldosterone synthase.
Endocrinology, 143(9), 3651–3657.
Daidoh, H., Morita, H., Mune, T., Murayama, M., Hanafusa, J., Ni, H., et al. (1995).
Responses of plasma adrenocortical steroids to low dose ACTH in normal subjects. Clin-
ical Endocrinology, 43(3), 311–315.
Davies, E., Edwards, C. R., & Williams, B. C. (1991). Serotonin stimulates calcium influx in
isolated rat adrenal zona glomerulosa cells. Biochemical and Biophysical Research Communi-
cations, 179(2), 979–984.
Davies, E., Holloway, C. D., Ingram, M. C., Inglis, G. C., Friel, E. C., Morrison, C., et al.
(1999). Aldosterone excretion rate and blood pressure in essential hypertension are
related to polymorphic differences in the aldosterone synthase gene CYP11B2.
Hypertension, 33(2), 703–707.
Ehrhart-Bornstein, M., Lamounier-Zepter, V., Schraven, A., Langenbach, J.,
Willenberg, H. S., Barthel, A., et al. (2003). Human adipocytes secrete
mineralocorticoid-releasing factors. Proceedings of the National Academy of Sciences of the
United States of America, 100(24), 14211–14216.
Fern, R. J., Hahm, M. S., Lu, H. K., Liu, L. P., Gorelick, F. S., & Barrett, P. Q. (1995). Ca2
+/calmodulin-dependent protein kinase II activation and regulation of adrenal
glomerulosa Ca2 + signaling. The American Journal of Physiology, 269(6 Pt. 2), F751–F760.
 ARTICLE IN PRESS

Regulation of Aldosterone Secretion 21

Friedman, R. C., Farh, K. K.-H., Burge, C. B., & Bartel, D. P. (2009). Most mammalian
mRNAs are conserved targets of microRNAs. Genome Research, 19(1), 92–105.
Friis, U. G., Madsen, K., Stubbe, J., Hansen, P. B. L., Svenningsen, P., Bie, P., et al. (2013).
Regulation of renin secretion by renal juxtaglomerular cells. Pflugers Archiv: European
Journal of Physiology, 465(1), 25–37.
Gallo-Payet, N., Grazzini, E., C^ ot
e, M., Chouinard, L., Chorvátová, A., Bilodeau, L., et al.
(1996). Role of Ca2 + in the action of adrenocorticotropin in cultured human adrenal
glomerulosa cells. The Journal of Clinical Investigation, 98(2), 460–466.
Himathongkam, T., Dluhy, R. G., & Williams, G. H. (1975). Potassium-aldosterone-renin
interrelationships. The Journal of Clinical Endocrinology and Metabolism, 41(1), 153–159.
Holland, O. B., & Carr, B. (1993). Modulation of aldosterone synthase messenger
ribonucleic acid levels by dietary sodium and potassium and by adrenocorticotropin.
Endocrinology, 132(6), 2666–2673.
Hu, Z., Shen, W.-J., Kraemer, F. B., & Azhar, S. (2012). MicroRNAs 125a and 455 repress
lipoprotein-supported steroidogenesis by targeting scavenger receptor class B type I in
steroidogenic cells. Molecular and Cellular Biology, 32(24), 5035–5045.
Hu, Z., Shen, W.-J., Kraemer, F. B., & Azhar, S. (2017). Regulation of adrenal and ovarian
steroidogenesis by miR-132. Journal of Molecular Endocrinology, 59(3), 269–283.
Huby, A.-C., Antonova, G., Groenendyk, J., Gomez-Sanchez, C. E., Bollag, W. B.,
Filosa, J. A., et al. (2015). Adipocyte-derived hormone leptin is a direct regulator of aldo-
sterone secretion, which promotes endothelial dysfunction and cardiac fibrosis.
Circulation, 132(22), 2134–2145. Lippincott Williams & Wilkins.
Huby, A.-C., Otvos, L., & Belin de Chantemèle, E. J. (2016). Leptin induces hypertension
and endothelial dysfunction via aldosterone-dependent mechanisms in obese female
mice. Hypertension, 67(5), 1020–1028.
Inglis, G. C., Ingram, M. C., Holloway, C. D., Swan, L., Birnie, D., Hillis, W. S., et al.
(1999). Familial pattern of corticosteroids and their metabolism in adult human
subjects—the Scottish Adult Twin Study. The Journal of Clinical Endocrinology and Metab-
olism, 84(11), 4132–4137.
Kathiresan, S., Larson, M. G., Benjamin, E. J., Corey, D., Murabito, J. M., Fox, C. S., et al.
(2005). Clinical and genetic correlates of serum aldosterone in the community: the
Framingham Heart Study. American Journal of Hypertension, 18(5 Pt 1), 657–665.
Kemp, J. R., Unal, H., Desnoyer, R., Yue, H., Bhatnagar, A., & Karnik, S. S. (2014). Angio-
tensin II-regulated microRNA 483-3p directly targets multiple components of the
renin-angiotensin system. Journal of Molecular and Cellular Cardiology, 75, 25–39.
Leenen, F. H. H., Blaustein, M. P., & Hamlyn, J. M. (2017). Update on angiotensin II: New
endocrine connections between the brain, adrenal glands and the cardiovascular system.
Endocrine Connections, 6(7), R131–R145.
Lefebvre, H., Compagnon, P., Contesse, V., Delarue, C., Thuillez, C., Vaudry, H., et al.
(2001). Production and metabolism of serotonin (5-HT) by the human adrenal cortex:
Paracrine stimulation of aldosterone secretion by 5-HT. The Journal of Clinical Endocrinol-
ogy and Metabolism, 86(10), 5001–5007.
Lefebvre, H., Duparc, C., Pr
evost, G., Zennaro, M. C., Bertherat, J., & Louiset, E. (2015).
Paracrine control of steroidogenesis by serotonin in adrenocortical neoplasms. Molecular
and Cellular Endocrinology, 408, 198–204.
Lenzini, L., Caroccia, B., Campos, A. G., Fassina, A., Belloni, A. S., Seccia, T. M., et al.
(2013). Lower expression of the twik-related acid-sensitive K+ channel 2 (TASK-2) gene
is a hallmark of aldosterone producing adenoma causing human primary aldosteronism.
The Journal of Clinical Endocrinology and Metabolism.
MacKenzie, S. M., Connell, J. M. C., & Davies, E. (2011). Non-adrenal synthesis of aldo-
sterone: A reality check. Molecular and Cellular Endocrinology, 350(2), 163–167.
MacKenzie, S. M., Freel, E. M., Connell, J. M., Fraser, R., & Davies, E. (2017). ACTH and
polymorphisms at steroidogenic loci as determinants of aldosterone secretion and blood
 ARTICLE IN PRESS

22 Scott M. MacKenzie et al.

pressure. International Journal of Molecular Sciences, 18(3), 579. Multidisciplinary Digital

Publishing Institute.
Maharjan, S., Mopidevi, B., Kaw, M. K., Puri, N., & Kumar, A. (2014). Human aldosterone
synthase gene polymorphism promotes miRNA binding and regulates gene expression.
Physiological Genomics, 46(24), 860–865. https://doi.org/10.1152/physiolgenomics.
00084.2014.
Markou, A., Sertedaki, A., Kaltsas, G., Androulakis, I. I., Marakaki, C., Pappa, T., et al.
(2015). Stress-induced aldosterone hyper-secretion in a substantial subset of patients with
essential hypertension. The Journal of Clinical Endocrinology and Metabolism, 100(8),
2857–2864.
McManus, F., Sands, W., Diver, L., MacKenzie, S. M., Fraser, R., Davies, E., et al. (2012).
APEX1 regulation of aldosterone synthase gene transcription is disrupted by a common
polymorphism in humans. Circulation Research, 111(2), 212–219.
Miller, W. L., & Auchus, R. J. (2011). The molecular biology, biochemistry, and physiology
of human steroidogenesis and its disorders. Endocrine Reviews, 32(1), 81–151.
Mornet, E., Dupont, J., Vitek, A., & White, P. C. (1989). Characterization of two genes
encoding human steroid 11 beta-hydroxylase (P-450(11) beta). The Journal of Biological
Chemistry, 264(35), 20961–20967.
Nusrin, S., Tong, S. K. H., Chaturvedi, G., Wu, R. S. S., Giesy, J. P., & Kong, R. Y. C.
(2014). Regulation of CYP11B1 and CYP11B2 steroidogenic genes by hypoxia-
inducible miR-10b in H295R cells. Marine Pollution Bulletin, 85, 344–351.
Olala, L. O., Choudhary, V., Johnson, M. H., & Bollag, W. B. (2014). Angiotensin
II-induced protein kinase D activates the ATF/CREB family of transcription factors
and promotes StAR mRNA expression. Endocrinology, 155(7), 2524–2533.
Paillard, F., Chansel, D., Brand, E., Benetos, A., Thomas, F., Czekalski, S., et al. (1999).
Genotype-phenotype relationships for the renin-angiotensin-aldosterone system in a
normal population. Hypertension, 34(3), 423–429.
Penhoat, A., Jaillard, C., Crozat, A., & Saez, J. M. (1988). Regulation of angiotensin II recep-
tors and steroidogenic responsiveness in cultured bovine fasciculata and glomerulosa
adrenal cells. European Journal of Biochemistry, 172(1), 247–254.
Pezzi, V., Clark, B. J., Ando, S., Stocco, D. M., & Rainey, W. E. (1996). Role of
calmodulin-dependent protein kinase II in the acute stimulation of aldosterone produc-
tion. The Journal of Steroid Biochemistry and Molecular Biology, 58(4), 417–424.
Piaditis, G., Markou, A., Papanastasiou, L., Androulakis, I. I., & Kaltsas, G. (2015). Progress
in aldosteronism: A review of the prevalence of primary aldosteronism in pre-
hypertension and hypertension. European Journal of Endocrinology/European Federation of
Endocrine Societies, 172(5), R191–R203.
Rh
eaume, E., Simard, J., Morel, Y., Mebarki, F., Zachmann, M., Forest, M. G., et al. (1992).
Congenital adrenal hyperplasia due to point mutations in the type II 3 beta-
hydroxysteroid dehydrogenase gene. Nature Genetics, 1(4), 239–245.
Richards, A. M., Nicholls, M. G., Espiner, E. A., Ikram, H., Cullens, M., & Hinton, D.
(1986). Diurnal patterns of blood pressure, heart rate and vasoactive hormones in normal
man. Clinical and Experimental Hypertension. Part A, Theory and Practice, 8(2), 153–166.
Robertson, S., Diver, L. A., Alvarez-Madrazo, S., Livie, C., Ejaz, A., Fraser, R., et al. (2017).
Regulation of corticosteroidogenic genes by MicroRNAs. International Journal of Endo-
crinology, 2017(6), 2021903–2021911.
Robertson, S., MacKenzie, S. M., Alvarez-Madrazo, S., Diver, L. A., Lin, J., Stewart, P. M.,
et al. (2013). MicroRNA-24 is a novel regulator of aldosterone and cortisol production
in the human adrenal cortex. Hypertension, 62(3), 572–578.
Rocco, S., Ambroz, C., & Aguilera, G. (1990). Interaction between serotonin and other reg-
ulators of aldosterone secretion in rat adrenal glomerulosa cells. Endocrinology, 127(6),
3103–3110.
 ARTICLE IN PRESS

Regulation of Aldosterone Secretion 23

Romero, D. G., Plonczynski, M. W., Carvajal, C. A., Gomez-Sanchez, E. P., & Gomez-
Sanchez, C. E. (2008). Microribonucleic acid-21 increases aldosterone secretion and
proliferation in H295R human adrenocortical cells. Endocrinology, 149(5), 2477–2483.
Romero, D. G., Welsh, B. L., Gomez-Sanchez, E. P., Yanes, L. L., Rilli, S., & Gomez-
Sanchez, C. E. (2006). Angiotensin II-mediated protein kinase D activation stimulates
aldosterone and cortisol secretion in H295R human adrenocortical cells.
Endocrinology, 147(12), 6046–6055.
Salfati, E., Morrison, A. C., Boerwinkle, E., & Chakravarti, A. (2015). Direct estimates of the
genomic contributions to blood pressure heritability within a population-based cohort
(ARIC) [T. Zeller & T. Zeller, Eds.]. PloS one, 10(7), e0133031.
Seely, E. W., Conlin, P. R., Brent, G. A., & Dluhy, R. G. (1989). Adrenocorticotropin stim-
ulation of aldosterone: Prolonged continuous versus pulsatile infusion. The Journal of
Clinical Endocrinology and Metabolism, 69(5), 1028–1032.
Selbach, M., Schwanh€ausser, B., Thierfelder, N., Fang, Z., Khanin, R., & Rajewsky, N.
(2008). Widespread changes in protein synthesis induced by microRNAs. Nature,
455(7209), 58–63.
Shenker, Y., Sider, R. S., Ostafin, E. A., & Grekin, R. J. (1985). Plasma levels of immuno-
reactive atrial natriuretic factor in healthy subjects and in patients with edema. The Journal
of Clinical Investigation, 76(4), 1684–1687.
Sookoian, S., Gianotti, T. F., González, C. D., & Pirola, C. J. (2007). Association of the
C-344T aldosterone synthase gene variant with essential hypertension: A meta-analysis.
Journal of Hypertension, 25(1), 5–13.
Sp€at, A., & Hunyady, L. (2004). Control of aldosterone secretion: A model for convergence
in cellular signaling pathways. Physiological Reviews, 84(2), 489–539.
Stowasser, M., & Gordon, R. D. (2016). Primary aldosteronism: Changing definitions and
new concepts of physiology and pathophysiology both inside and outside the kidney.
Physiological Reviews, 96(4), 1327–1384.
Tait, J. F., & Tait, S. A. (1999). Role of cAMP in the effects of K+ on the steroidogenesis of
zona glomerulosa cells. Clinical and Experimental Pharmacology & Physiology, 26(12),
947–955.
Takeuchi, F., Yamamoto, K., Katsuya, T., Sugiyama, T., Nabika, T., Ohnaka, K., et al.
(2012). Reevaluation of the association of seven candidate genes with blood pressure
and hypertension: A replication study and meta-analysis with a larger sample size. Hyper-
tension Research: Official Journal of the Japanese Society of Hypertension, 35(8), 825–831.
Vattikuti, S., Guo, J., & Chow, C. C. (2012). Heritability and genetic correlations explained
by common SNPs for metabolic syndrome traits [P. M. Visscher, Ed.]. PLoS Genetics,
8(3), e1002637.
White, P. C. (2004). Aldosterone synthase deficiency and related disorders. Molecular and
Cellular Endocrinology, 217(1–2), 81–87.
Wilke, B. U., Lindner, M., Greifenberg, L., Albus, A., Kronimus, Y., B€ unemann, M., et al.
(2014). Diacylglycerol mediates regulation of TASK potassium channels by Gq-coupled
receptors. Nature Communications, 5, 5540.
Zennaro, M.-C., Boulkroun, S., & Fernandes-Rosa, F. (2015). An update on novel mech-
anisms of primary aldosteronism. The Journal of Endocrinology, 224(2), R63–R77.
Zhu, H., Sagnella, G. A., Dong, Y., Miller, M. A., Onipinla, A., Markandu, N. D., et al.
(2003). Contrasting associations between aldosterone synthase gene polymorphisms
and essential hypertension in blacks and in whites. Journal of Hypertension, 21(1), 87–95.