Endocrinology, 2022, Vol. 163, No.

1, 1–9
https://doi.org/10.1210/endocr/bqab240
Mini-Review

Mini-Review

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Primary Aldosteronism, Aldosterone, and
Extracellular Vesicles
Cristian  A.  Carvajal,1,2,3,* Alejandra  Tapia-Castillo,1,2,3,* Jorge  A.  Pérez,1,2,3
and Carlos E. Fardella1,2,3
1
Department of Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago,
Chile; 2Millennium Institute of Immunology and Immunotherapy (IMII-ICM), Santiago, Chile; and 3Centro
Traslacional de Endocrinología UC (CETREN-UC), Pontificia Universidad Católica de Chile, Santiago, Chile
ORCiD numbers: 0000-0002-0668-412X (C. A. Carvajal); 0000-0002-6081-1468 (A. Tapia-Castillo); 0000-0002-5500-4434 (C. E.
Fardella).

*Authors with equal contribution.

Received: 14 October 2021; Editorial Decision: 15 November 2021; First Published Online: 22 November 2021; Corrected and
Typeset: 16 December 2021.

Abstract 
Primary aldosteronism (PA) is an endocrine related condition leading to arterial hyperten-
sion due to inappropriately high and unregulated aldosterone concentration. Recently,
a broad spectrum of PA has been recognized, which brings new challenges associated
with early identification of this condition that affect renal epithelial and extrarenal tis-
sues. Reports have shown the potential role of extracellular vesicles (EVs) and EV cargo
as novel and complementary biomarkers in diagnosis and prognosis of PA. In vivo and in
vitro studies have identified specific EV surface antigens, EV-proteins, and EV microRNAs
that can be useful to develop novel diagnostic algorithms to detect, confirm, or follow up
the PA. Moreover, the study of EVs in the field of PA provides further insight in the patho-
physiological mechanism of the PA disease.
Key Words: primary aldosteronism, aldosterone, extracellular vesicles, biomarkers

Arterial hypertension (AHT) is a public health problem Primary Aldosteronism

that affects to 1.39 billion people with a prevalence of
31.1% worldwide (1) and 27.6% in Chile. Primary al-
dosteronism (PA), the most frequent form of secondary
hypertension (2) is characterized by a higher rate of car-
diovascular (CV) events than essential hypertension (EH)
(3-5). In this respect, the aim of this review is to explore re-
cent literature related to PA, aldosterone, and extracellular
vesicles through a search of articles in PubMed MEDLINE
database up to September 2021.
PA is an endocrine disorder characterized by an inappro-
priately high circulating aldosterone independent of known
physiological regulators as renin, angiotensin II, potassium,
and sodium status (eg, high salt intake) (6). The conse-
quences of PA are AHT, hypokalemia, and metabolic alkal-
osis, along with an increase in plasma volume, suppression
of plasma renin, increased potassium excretion (7), and per-
ipheral vascular resistance that results in resistant hyper-
tension (8). The main causes of primary aldosteronism are

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2 Endocrinology, 2022, Vol. 163, No. 1

bilateral PA (~60%) (9) and aldosterone-producing aden- Primary Aldosteronism and the
omas (~30%), which lead to an overproduction of aldos- Aldosterone-to-Renin Ratio
terone (10). Less frequent causes include unilateral adrenal
Currently, the Endocrine Society Guidelines recommend
hyperplasia, aldosterone producing carcinoma, and familial
the screening for PA by determining the aldosterone-
hyperaldosteronism (8,11). Retrospective cohort studies
to-renin ratio (ARR) (24-26) in patients with sustained
have shown that PA patients have a higher CV morbidity
BP > 150/100 mmHg, resistant AHT, AHT with hypokal-
(3-5) and mortality rate (12,13) and increased incidence of
emia, AHT with adrenal incidentaloma AHT with sleep

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stroke (3,4) and atrial fibrillation (14) than patients with
apnea, AHT and a family history of early onset hyperten-
EH (4,8,15).
sion or cerebrovascular accident at a young age (<40 years),
In 2017, Brown et al (16) proposed that a broader spec-
and all hypertensive first-degree relatives of patients with
trum of renin-independent PA should be clinically rele-
PA. However, other factors could influence the precise re-
vant, extending the suspicion of PA even to normotensive
sult of the ARR assay (eg, posture, age, intrasubject vari-
subjects (17), which turns PA into a subclinical and clinical
ation, method variability, medication, salt intake, sex, and
prevalent pathological condition (15,18-20). Around 8%
population used to establish cutoffs), affecting its correct
of randomly selected subjects (21), and 10% of essential
interpretation (15,24,56,57).
hypertensives have PA (22,23) for which an early identifica-
Aldosterone and renin, due to its low concentration, re-
tion and management of both overt PA and subclinical PA
quire a sensitive immunoassay or liquid chromatography-
are relevant to avoid CV risk (24-26).
tandem mass spectrometry technology to be detected and
quantified. Currently, plasma renin activity (PRA) has been
Effects of Aldosterone in Epithelial and replaced by direct renin concentration (DRC) in auto-
Nonepithelial Tissues mated equipment, and their normal values are different
from plasma activity renin, which change the ARR cutoffs.
In PA, the chronic and unregulated aldosterone-
Although the ARR screening has been used worldwide to
mineralocorticoid receptor (MR) activation increases
identify subjects suspected to have PA, the previous men-
the sodium transport and water reabsorption in renal
tioned factors influencing the ARR could affect the PA case
epithelia (24,27), which leads to an excess of intravas-
detection (24,58). Hence, novel biomarkers and develop-
cular volume that will increase the arterial blood pres-
ment of novel diagnostic algorithms to detect, confirm, or
sure (BP) leading to AHT. Aldosterone binds the MR,
follow up the PA or subclinical PA are required (Fig. 1).
which lead to genomic and nongenomic effects (28,29),
which upregulate the expression and abundance of
SCNN1 (epithelial sodium channel alpha-subunit), Biomarkers for Primary Aldosteronism
ATP1A1 (ATPase Na+/K+ transporting subunit alpha
Several efforts have been done in order to advance in the
1), SGK1 (serum and glucocorticoid regulated kinase 1),
identification of novel biomarkers for PA that support its
NEDD4-2, YWHAZ (14-3-3 zeta/delta protein) genes,
early detection and also other reported effects as the in-
leading to water/sodium reabsorption, K + secretion,
flammation, endothelial dysfunction, renal damage, vas-
and further regulation of BP. Nongenomic rapid effects
cular remodeling (40,41) and oxidative stress (47,48).
activate signal transducers as SGK1, Na-K-ATPase, and
Early “surrogate biomarkers,” have been recommended by
sodium-hydrogen exchanger (NHE) activation (30,31),
American Heart Association to assess the CV risk, such as
and membrane receptors as the G-protein-estrogen re-
high sensitive C-reactive protein, plasminogen inhibitor ac-
ceptor 30 (GPER or GPR30) (32).
tivator-1, matrix metallopeptidase 9, and malondialdehyde
Similar to renal epithelial tissues, the aldosterone-MR
(37,38), as well as free Cystatin-C, osteopontin, atrial
complex also has effects on nonepithelial tissues (33) as
natriuretic peptide, and neutrophil gelatinase-associated
endothelial cells, smooth muscle cells (34), cardiomyocytes
lipocalin (NGAL) (59-61). However, none of these bio-
(35), and even immune system cells (eg, dendritic cells) (36),
markers are currently available in clinical diagnoses for
which leads to vasoconstriction, increase of heart rate, vas-
AHT or PA.
cular remodeling, and even an increase of central nervous
system activity control. In PA, high circulating aldosterone
promotes inflammation (37-39), endothelial damage, vas-
cular remodeling (40,41), fibrosis (37,42-46), and oxidative Small Extracellular Vesicles and Primary
stress (47,48) affecting the heart, vessels, kidneys, immune Aldosteronism
system (36,49-54), and adipose tissue (55)—all processes EVs constitute a widespread group of nanoparticles naturally
that worsen the prognosis of PA and increase the CV risk. released or shed from different tissues and cell types. EVs are
Endocrinology, 2022, Vol. 163, No. 1 3

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Figure 1.  Proposed flowchart for primary aldosteronism (PA) detection with extracellular vesicles (EVs) and EV cargo as novel and complementary
biomarkers of PA. PA is currently defined a broader and clinical prevalent pathological condition (16). A positive screening for PA is based in both a
suppressed plasma renin activity and a high aldosterone-to-renin ratio (16,25,26). Possible or subclinical PA can be further assayed by confirmatory
test, and/or through novel and complementary biomarkers for PA. Here, EVs and EV cargo (eg, EV proteins and EV miRNA) are being studied and
suggested as renal and extrarenal biomarker associated to PA (eg, inflammation, fibrosis, endothelial damage, among others). Potential connections
are shown in dashed line.

composed of a lipid bilayer containing transmembrane pro-
teins and enclosing cytoplasmatic soluble elements and are
typically classified by their cellular biogenesis where exosomes
or small EV (sEVs; diameter 40-150 nm) are vesicles gener-
ated within the endosomal system and multivesicular bodies,
whereas microvesicles, with a diameter up to 1000 nm, ori-
ginate by an outward budding at the plasma membrane
(62,63). sEVs and microvesicles differ in size, lipid com-
position, content, and cellular origin (62). sEVs formation
is regulated via the endosomal sorting complex required
for transport (ESCRT) (multiprotein complexes that guide
intracellular cargo) and/or by non–endosomal sorting com-
plex required for transport–related mechanisms, including
tetraspanins and membrane lipids. Microvesicle formation
is calcium-dependent and associated with loss of membrane
asymmetry and disruption of the cellular cytoskeleton (62).
Experimental and clinical studies show that sEVs
or exosomes are potential biomarkers of disease (64),
including cancer, metabolic disorders, and CV diseases
(65,66). sEVs have a size of 40 to 150  nm and are bio-
logical signaling vehicles and important regulators of local
and distant cell-cell communication (63) carrying proteins,
lipids, RNA, and microRNAs. All cell types can generate
EVs, which are released from parent cells into the extracel-
lular space and biofluids (as plasma, cerebrovascular fluid,
breast milk, urine, and saliva), and reflect the activation
status and phenotype of the parent cell from which they
were derived (62,63).
Plasma Extracellular Vesicles and Primary
Aldosteronism
A recent paper by Burrello et al (67) reported an increased
concentration of circulating EVs in serum of PA patients
when compared with essential hypertensives and attributed
to an enhanced biological response of the endothelium to
aldosterone levels, which also influenced the EV effects
on the endothelial function. Supporting this observation,
4
aldosterone has been shown to stimulate EV release in
endothelial cells in vitro (68) and to activate endothelial
exocytosis (69). However, how aldosterone modifies the
EV concentration or EV cargo is currently investigated,
and it could be linked to a direct aldosterone action on
the EV shedding or EV biogenesis or an indirect paracrine
action of aldosterone in tissues involved in the course of
the PA pathology (70). Beyond their role as potential vas-
cular biomarkers, EVs directly could regulate endothelial
and vascular smooth muscle cell function by influencing
production of nitric oxide and reactive oxygen species,
proinflammatory signaling, apoptosis, and senescence
(71). These processes have been implicated in various ex-
perimental models of hypertension, including angiotensin
II-infused and spontaneously hypertensive rats and in pa-
tients with EH. (70).
In 2021, Burrello et al (72) also assessed the potential role
of EVs in aldosterone-related vascular damage by evaluating
a panel of 37 EV surface antigens. They showed 19 EV sur-
face antigens differentially expressed in patients with PA
compared with hypertensives or normotensive controls,
including markers of activated platelets and endothelial
and immune-inflammatory cells. Further in vitro studies in
human endothelial cells incubated with PA-derived EVs in-
creased the expression of AKT1, CALR, CSNK2A1, FN1,
and PIK3R1 genes. These data suggest that EVs are potential
biomarkers of vascular inflammation and endothelial dys-
function in PA, and also that EVs are potential mediators
associated with accelerated organ damage (72).
Urinary Extracellular Vesicles and Primary
Aldosteronism
Urinary EVs (uEVs) have been also recognized as a source
of diagnostic biomarkers for different pathologies, espe-
cially for renal diseases (73). uEVs originate mainly from
epithelial cells in the renal tubules, which carry proteins,
lipids, and RNA, and are protected from RNAses and
proteases proper from the urinary tract (73-75), which
have been associated to physiological and pathophysio-
logical processes in the kidney (76,77) both in vivo and
in vitro (78,79). Renal-derived urinary exosomes have
been shown to be increased in patients with PA and have
been suggested to be markers of aldosterone induced renal
disease (70,73,80,81). We recently performed a prelim-
inary proteomic study in uEVs in a cohort of PA subjects
identifying alpha-1-acid glycoprotein (AGP1), also named
orosomucoid 1, as a differentially expressed protein in PA
(82). AGP1 is mainly synthesized by the liver but can also be
produced extrahepatically, including the kidney and heart
in inflammatory conditions. AGP1 is a protein associated
with the acute phase response with immunomodulatory
Endocrinology, 2022, Vol. 163, No. 1
properties (83) and is a member of the lipocalin family.
It acts as the carrier of basic and neutrally charged lipo-
philic compounds under normal physiological conditions
as well as in tissue injury, inflammation, or infection (84).
AGP1 gene expression is modified by glucocorticoids (85-
87) and mineralocorticoids (88). Moreover, recent prote-
omic studies showed that urinary and serum AGP1 may
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serve as predictors of therapeutic response and diagnostic
and as a prognostic biomarker for inflammatory diseases
(89), such as chronic heart failure (90,91) and some type
of cancer (92). Additionally, in vivo and in vitro studies
in cardiomyocytes showed that aldosterone stimulate the
AGP1 gene expression (88,93), which is inhibited by spir-
onolactone (an MR antagonist) (94), demonstrating a
MR-dependent-regulation of AGP1 expression.
Similar to AGP1, NGAL or lipocalin-2 has been also
found associated with PA (95). NGAL is a glycoprotein
also belonging to the lipocalin family that was originally
isolated from human neutrophils (96) and expressed in
the kidney and heart (97). NGAL plasma levels are associ-
ated with mineralocorticoid effects on cardiac remodeling
(95). NGAL promoter is activated by the Aldo-MR com-
plex, increasing its transcription (95,98,99). Mice deficient
in NGAL blunts the aldosterone/MR-mediated vascular
fibrosis (95). In humans, circulating NGAL conjugated
with matrix metalloproteinase 9 protein (NGAL-MMP9)
are positively correlated with plasma (95) and urine (100)
aldosterone levels. We and others have found NGAL in
human urinary (101) and plasma exosomes; however, the
role of NGAL in exosomes as local and distant mediator of
inflammation and fibrosis in PA is unknown.
In the same way, a recent study by Ochiai-Homma et al
found significant correlation between the ARR and pendrin
levels in uEVs from subjects with PA and a rat model of al-
dosterone excess. These data are consistent with experimental
studies showing the role of pendrin in aldosterone excess and
suggest that pendrin abundance is relevant in PA and is at-
tenuated by therapeutic interventions in human PA (102).
MicroRNAs in Extracellular Vesicles
Associated to Primary Aldosteronism
Recent literature propose to microRNAs (miRNAs) in
EVs (103-107) as potential biomarkers and regulators
of the cell-cell communication involved in physiological
and pathophysiological processes associated to AHT
(73,108-110), PA (73), and response to sodium intake
(111). miRNAs are short, noncoding RNA molecules that
are approximately 22 nucleotides in length and modu-
late downstream gene expression by posttranscriptional
mechanisms, specifically by binding to the 3′ untrans-
lated region of a target messenger RNA, leading to target
Endocrinology, 2022, Vol. 163, No. 1
messenger RNA degradation or translation repression
(109,112,113). In this respect, human studies and animal
models highlight some miRNAs present in EVs associated
with AHT (73,114), PA, or aldosterone metabolism. For
example, the EV-associated miR-196b-5p has been linked
to the aldosterone-induced renal fibrosis in mice with
diabetes. EVs rich in miR-196b-5p mediate the crosstalk
between proximal tubule epithelial cells and fibroblasts
during the development of renal fibrosis, which might
be associated with STAT3/SOCO2 signaling pathway
(115). Other miRNA, the uEV-hsa-miR-4516 is involved
in signaling pathways that regulate renal sodium trans-
porters involved in PA pathophysiology, such as thiazide-
sensitive sodium chloride cotransporter and epithelial
sodium channel (110,116,117). Most interesting, Let-7i
and miR-21 have been found in urine (118) and plasma
exosomes (106) associated with the renin-angiotensin-
aldosterone system and mediating renal inflammation, fi-
brosis (119,120), and CV diseases (119,121,122). Let-7i
also would regulate downstream targets genes related
to inflammation and fibrosis (119,120), such as IL6,
COL1A1, COL3A1, ELN, MMP1, VIM, FN1, ACTIN,
TGFBR1, TIMP1, and MMP2 (120,123,124). Similarly,
miR-21 is an aldosterone-regulated miRNA mediating
renin-angiotensin-aldosterone system effects in the ad-
renal gland (108), heart (121,122), inflammation (125),
and fibrosis (103,126). miR-21 would affect downstream
targets genes as IL-1B, TIAM1, NEDD4, MMP2, MMP9,
TLR4, STAT3, and CCR1, among others. Further re-
search is needed to clarify the role of these EV-miRNA
in the pathophysiology of PA and its potential as novel
or complementary biomarker of PA.
Conclusion
PA is an endocrine disorder associated to high circulating
aldosterone, which increase the arterial BP, inflammation,
and fibrosis, all effects that are mainly addressed by high
aldosterone-MR activity. Recently, a broad spectrum of
PA has been recognized, which brings new challenges as-
sociated with early identification of this condition that
affects renal epithelia and extrarenal tissues. Recent re-
ports have shown the potential role of EVs and EV cargo
as novel and complementary biomarkers in the diagnosis
and prognosis of PA, supported by in vivo and in vitro
studies that have identified specific EV surface antigens,
EV proteins (eg, AGP1, Pendrin), and EV-miRNAs that
can be useful to develop novel diagnostic algorithms to
detect, confirm, or follow-up the PA and subclinical PA.
Moreover, the study of EVs in the field of PA provides
further insight in the pathophysiological mechanism of
the PA disease.
5
Acknowledgments
Financial Support: This study was supported partially by grants
ANID-FONDECYT 1212006 ( to C.A.C.) and 3200646 (to A.T.C.);
CONICYT-FONDEQUIP EQM150023 (to C.A.C.); ANID–Millen-
nium Science Initiative Program-IMII P09/016-F, ICN09_016 (to
C.E.F.); SOCHED 2019-09 (to C.A.C.).
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Additional Information
Correspondence: Cristian A.  Carvajal, PhD, Associate Professor,
Departamento de Endocrinología, Escuela de Medicina, Pontificia
Universidad Católica de Chile, Diagonal Paraguay 362, Piso 4, San-
tiago 8330077, Chile. Email: ccarvajm@uc.cl.
Disclosure Statement: The authors have nothing to disclose.
Data Availability: Data sharing is not applicable to this article as
no data sets were generated or analyzed during the current study.
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