The Evolution of Primary Aldosteronism and the Role of Norrin

The Evolution of Primary Aldosteronism and the Role of Norrin | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search The Evolution of Primary Aldosteronism and the Role of Norrin Stéfanie Parisien-La Salle , Mahyar Heydarpour , Cheng-Hsuan Tsai , Jenifer M Brown , Andrew J Newman , Sanan Mahrokhian , Isabelle Hanna , Brooke Honzel , Laura C Tsai , Sushrut Waikar , Kosuke Inoue , Maria-Christina Zennaro , Richard Auchus , Adina F. Turcu , Jonathan S Williams , Barry Sacks , Marwan Moussa , Anand Vaidya doi: https://doi.org/10.1101/2025.06.05.25329066 Stéfanie Parisien-La Salle 1 Center for Adrenal Disorders, Division of Endocrinology , Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Mahyar Heydarpour 1 Center for Adrenal Disorders, Division of Endocrinology , Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Cheng-Hsuan Tsai 1 Center for Adrenal Disorders, Division of Endocrinology , Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Jenifer M Brown 1 Center for Adrenal Disorders, Division of Endocrinology , Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA 2 Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Andrew J Newman 1 Center for Adrenal Disorders, Division of Endocrinology , Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Sanan Mahrokhian 1 Center for Adrenal Disorders, Division of Endocrinology , Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Isabelle Hanna 1 Center for Adrenal Disorders, Division of Endocrinology , Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Brooke Honzel 1 Center for Adrenal Disorders, Division of Endocrinology , Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Laura C Tsai 1 Center for Adrenal Disorders, Division of Endocrinology , Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Sushrut Waikar 3 Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Kosuke Inoue 4 Department of Social Epidemiology, Graduate School of Medicine, Kyoto University , Kyoto 606-8501, Japan 5 Hakubi Center, Kyoto University , Kyoto 606-8501, Japan Find this author on Google Scholar Find this author on PubMed Search for this author on this site Maria-Christina Zennaro 6 Université Paris Cité , PARCC, Inserm, Paris, France 7 Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique , Paris, France Find this author on Google Scholar Find this author on PubMed Search for this author on this site Richard Auchus 8 Division of Metabolism , Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School , Ann Arbor, MI 48109, USA 9 Department of Pharmacology, University of Michigan Medical School , Ann Arbor, MI 48109, USA 10 Endocrinology & Metabolism Section, Medicine Service, LTC Charles S. Kettles VA Medical Center , Ann Arbor, MI 48105, USA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Adina F. Turcu 10 Endocrinology & Metabolism Section, Medicine Service, LTC Charles S. Kettles VA Medical Center , Ann Arbor, MI 48105, USA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Jonathan S Williams 1 Center for Adrenal Disorders, Division of Endocrinology , Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Barry Sacks 11 Division of Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Marwan Moussa 11 Division of Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Anand Vaidya 1 Center for Adrenal Disorders, Division of Endocrinology , Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA Find this author on Google Scholar Find this author on PubMed Search for this author on this site For correspondence: anandvaidya{at}bwh.harvard.edu Abstract Full Text Info/History Metrics Supplementary material Data/Code Preview PDF Unstructured Abstract Primary aldosteronism (PA) is renin-independent aldosterone production that causes hypertension and cardiovascular disease. We investigated the proteomic evolution of PA from normotensive people with renin-independent aldosteronism to those with overt PA. The PA plasma proteome was characterized by pathways related to cardiovascular disease (inflammation, energy/redox, vascular remodeling). We identified proteins exhibiting dose-dependent trends paralleling the continuum of renin-independent aldosterone production, then using adrenal vein proteomics, identified proteins exhibiting the archetypal pattern of unilateral PA (peak abundance in the dominant vein with suppression in the contralateral vein). Among these, Norrin, a Wnt/β-catenin ligand previously identified as a risk locus for PA by GWAS, was robustly validated using functional testing (ACTH- and angiotensin II-induced interventions, and correlations with 18-hybrid steroids) and genetic testing (dose-dependent associations with NDP SNPs). The evolution of PA originates in normotensive people, is characterized by proteomic signatures of cardiovascular disease, and Norrin is a novel regulator of PA pathophysiology. Primary aldosteronism (PA) was once considered to be a rare hormonal cause of hypertension; however, recent human physiology and epidemiology studies indicate that PA is a common disorder in people with hypertension ( 1 , 2 ). Identification of pathogenic somatic variants that cause PA ( 3 , 4 ), along with the discovery that adrenal glands frequently harbor aldosterone-producing cell clusters and micronodules that are visualized by CYP11B2 immunohistochemistry ( 5 , 6 ), have redefined PA as a multi-factorial syndrome that evolves as a consequence of multiple molecular abnormalities ( 7 ). In support of this evolution, aldosterone-producing micronodules harboring pathogenic somatic mutations can be detected in morphologically normal adrenal glands from normotensive people ( 5 , 6 , 8 ) and in a process that parallels aging ( 8 – 10 ), implying that the origins of PA precede the development of hypertension, and that the pathophysiology of PA may be an important contributor to age-related hypertension. Using deep phenotyping maneuvers, human physiology studies have revealed that features known to be operative in overt PA, such as renin- and angiotensin II-independent and ACTH-mediated aldosterone production, enhanced aldosterone synthase expression, increased mineralocorticoid receptor activity, and natriuretic hormone deficiency, can also be identified in normotensive individuals ( 1 , 11 – 13 ). In parallel, prospective studies have consistently identified a continuum of PA pathophysiology (non-suppressible and renin-independent aldosterone production) that ranges from subclinical in normotensive individuals (SubPA) to overt in individuals with severe hypertension and heightened cardiovascular risk (overt PA) ( 1 , 11 – 19 ). Hypertension is the leading cause of morbidity and mortality, affecting 1.3 billion people worldwide ( 20 ). A better understanding of the pathogenesis of PA is essential since it is a prevalent mechanism of hypertension and adverse cardiovascular outcomes. To gain these insights, we combined detailed physiologic phenotyping of aldosterone production with large-scale proteomic profiling across the spectrum of PA, from SubPA in normotensive people to overt PA in hypertensive people, to identify proteomic signatures and pathways that characterize the evolution of PA. We leveraged dose-dependent aldosterone production trends to identify proteins implicated in PA pathophysiology, then adrenal vein proteomics to further refine putative proteins implicated in PA, and finally, in vivo functional and genetic validation studies to replicate and confirm our findings. Results Study Population The overall study design ( Figure 1 ) included participants with normal blood pressure who exhibited a spectrum of renin-independent aldosterone production (SubPA) following an oral sodium loading test (OSLT) (n=61) and those with overt PA (n=50) ( Table 1 ). As expected, participants with overt PA were older, had higher BMI and blood pressure, used antihypertensive medications, had lower serum potassium and kidney function, and were predominantly male, when compared to normotensive participants. The median seated plasma aldosterone concentration (PAC) trended from 7.1 to 23.0 ng/dL from SubPA to overt PA. Download figure Open in new tab Figure 1: Overarching Study Design Proteomic profiling was performed in normotensive participants who completed and oral sodium loading test to quantify renin-independent aldosterone production and in patients with overt PA. Subsequently, trend analyses were conducted to identify proteins that paralleled the magnitude of PA pathophysiology from subclinical PA (SubPA), defined as renin-independent aldosterone production despite supine posture during an oral sodium loading test in normotensive people, to overt PA. Adrenal vein sampling proteomics were used to identify adrenal-sourced proteins. Candidate proteins underwent separate physiological (ACTH modulated and angiotensin II-dependent) proteomic profiles for replication, hybrid steroid association, and candidate gene association studies. View this table: View inline View popup Download powerpoint The Proteomic Signature of Overt PA Of the 1500 measured proteins ( Supplemental Table 1 ), a total of 903 exhibited statistically significant differences in categorical analyses between overt PA and normotensive participants with SubPA ( Figure 2A , Supplemental Table 2 ). There were no statistically significant differences between the circulating proteomic signatures of participants with overt PA who had unilateral versus bilateral disease ( Supplemental Figure 1 ); consequently, participants with overt PA were analyzed together. The most statistically significant proteins that were more abundant in overt PA were primarily involved in glycolysis and glycation (PKLR, GLO1), coagulation and inflammation (F11, CD14), iron and hemoglobin metabolism (BPGM, CYBRD1), and calcium signaling (S100A6). In contrast, proteins that were significantly less abundant in overt PA were associated with mitochondrial function and energy production (ATP5PF, NAMPT, ECHS1, DECR1, IVD) as well as immune signaling and cell–matrix interactions (PTPN6, CCL20, ITGB1/ITGA2). Download figure Open in new tab Figure 2: The Proteomic Signature of Primary Aldosteronism A) Volcano plot showing 903 proteins differentially abundant between normotensive individuals (blue) and those with Overt PA (red). B) Volcano plot of the 82 proteins that exhibited consistent trends across the continuum of PA, from tertiles of SubPA to Overt PA. Proteins were required to exhibit consistently upward (red) or downward (blue) patterns and are ordered by slope magnitude. C) Heatmap of 82 proteins that exhibited consistent upward or downward trends across the PA continuum, ordered by trend direction and adjusted p-value. D) Table of the top 20 proteins most significantly abundant in overt PA (left column) and the top trending proteins across the SubPA to overt PA continuum (right column), ranked by adjusted p-value. Proteins that emerged as common between both analytic approaches are color-coded. E) KEGG pathway enrichment analysis of the overlap between the top 50 pathways implicated in overt PA and the 26 pathways associated with proteins exhibiting a stepwise trend across the PA continuum. 14 of these pathways overlapped with pathways identified in the overt PA signature, generally related to cardiovascular disease, hormone and cell signaling, and inflammation Pathway enrichment analysis using KEGG and Reactome identified 194 and 392 significant pathways, respectively ( Supplemental Figure 2 ). Top KEGG pathways were implicated in cell signalling (PI3K-Akt signalling pathway (hsa04151), MAPK signalling pathway (hsa04010)), inflammation (cytokine-cytokine receptor interaction (hsa04060)), cell adhesion (focal adhesion (hsa04510)), and cardiovascular disease (lipid and atherosclerosis (hsa05417)) ( Supplemental Figure 2A ), whereas top Reactome pathways implicated immune and inflammatory signalling, energy/redox metabolism, and vascular remodeling ( Supplemental Figure 2B ). Proteomic Trends Across the Spectrum of PA Trend analyses requiring plasma proteins to exhibit progressive upward or downward trajectories across the continuum of normotensive SubPA and into the overt PA circulation identified 82 proteins ( Figure 2B & C ). Notably, the top proteins trending upward across this PA continuum, were also among the top 20 most significant proteins found to be more abundant in overt PA (GLO1, BPGM, S100A6, PKLR, NDP, CA1 and HMBS) ( Figure 2D ). Of the 26 KEGG pathways identified from these 82 trending proteins, 14 overlapped with pathways identified in the overt PA signature, generally related to cardiovascular disease, hormone and cell signaling, and inflammation ( Figure 2E ). Similarly, of the 20 Reactome pathways identified from these 82 trending proteins, 7 overlapped with pathways identified in the overt PA signature ( Supplemental Figure 3 ). Adrenal Vein Proteomics to Identify Adrenal-Sourced Proteins When including adrenal vein proteomics, 42 proteins displayed a statistically significant and consistently upward or downward trend across the PA continuum, into the dominant adrenal vein, and with inversion of this trend in the contralateral vein, reflecting potential adrenal-sourced proteins ( Figure 3A ). Using the STRING database ( 21 ), these 42 proteins showed a significant protein-protein interaction (PPI) enrichment (p <0.001), indicating that the observed interactions were significantly more numerous than expected for a random set of proteins of similar size and functionally connected via shared biological pathways or processes ( Supplemental Figure 4 ). Among these 42 proteins, several were recognized from known literature as potentially implicated in the pathogenesis of PA, or with regulation of aldosterone production, or with adrenal cortex physiology, including: NDP, ID1, CD36, DUSP6, RASA1, PRKCD and MMP9 ( 22 – 26 ). Download figure Open in new tab Figure 3: Adrenal Vein Proteomics and Physiologic Replication Studies A) Heatmap of the 42 proteins exhibiting consistent upward or downward trends across the PA continuum, and into the dominant adrenal vein, but with inversion of this trend in the contralateral adrenal vein, ordered by trend direction and adjusted p-value. B) Physiologic replication study results for NDP and ID1 proteins via three independent methods: overnight 1mg dexamethasone suppression test (DST), 250 mcg cosyntropin stimulation test (ACTHstim), and upright posture test following extreme dietary sodium restriction. The slope and associated p-values are shown for each test, with statistically significant p-values in bold. C) From left to right: Association between log 10 mean of NDP with: the continuum of renin - independent aldosterone production, ranging from SubPA to overt PA, and adrenal venous sampling in unilateral PA; the continuum of ACTH-independent aldosterone production following DST; the continuum of ACTH-dependent aldosterone production following ACTHstim; and the continuum of angiotensin II-dependent aldosterone production following extreme dietary sodium restriction and upright posture. D) Linear regression analyses showing the association between log 10 -transformed mean NDP abundance and 18-hydroxycortisol and 18-oxocortisol concentrations in the dominant adrenal vein of participants with unilateral overt PA. Functional Replication In vivo functional replication studies were performed by modulating ACTH-mediated (overnight dexamethasone suppression testing [DST] and ACTH-stimulation [ACTHstim] testing) and angiotensin II-mediated (upright posture following dietary sodium restriction) aldosterone production. Post-DST, post-ACTHstim, and post sodium-restricted upright proteomic profiles were used as separate physiological replication tools to determine whether the 42 putative adrenal-sourced proteins exhibited consistent aldosterone dose-dependent trends following functional testing. As expected, there was a continuum of aldosterone production following DST, ACTHstim, and sodium-restricted upright posture ( 11 – 13 ). In parallel, two of the 42 proteins identified (NDP and ID1) displayed statistically significant aldosterone dose-dependent trends in 2 out of the 3 replication conditions ( Figure 3B ), with NDP being the only protein demonstrating near significant trends in all 3 replication conditions ( Figure 3C ). A complete list of trending proteins and functional replication results is provided in Supplementary Table 3 . 18-Hybrid Steroid Validation NDP and ID1 were evaluated for their association with 18-hybrid steroid production, a biomarker of CYP11B2 activity, from the dominant adrenal vein of unilateral overt PA. NDP was positively and significantly associated with both 18-hydroxycortisol and 18-oxocortisol concentrations ( Figure 3D ). ID1 showed a negative association with both hybrid steroids, although these associations did not reach statistical significance ( Supplemental Figure 5 ). Candidate Gene Validation Candidate gene validation of NDP was performed through SNP association analyses with aldosterone traits in a separate cohort of participants from HyperPATH ( Table 2 ). In normotensive participants, 2 SNPs were associated with higher post-AngII infusion PAC, 6 SNPs showed positive and significant dose-dependent associations with 24-hour urinary aldosterone excretion following oral sodium loading, and 7 SNPs were significantly associated with sodium-restricted upright PAC. In the combined cohort of normotensive and hypertensive participants, 6 SNPs were significantly associated with supine PAC following oral sodium loading, 2 SNPs with post-AngII infusion PAC, 22 SNPs with 24-hour urinary aldosterone excretion following oral sodium loading, and 12 SNPs with sodium-restricted upright PAC. Notably, multiple SNPs were associated with more than one aldosterone trait and were supported by eQTL signals in adrenal tissue ( Table 2 ). View this table: View inline View popup Table 2: NDP gene SNP association analyses with aldosterone traits from participants in the HyperPATH cohort. The top associated SNP, rs5952411 (β = 1.42, P = 0.0025 for 24-hour urinary aldosterone), was functionally annotated using VannoPortal and found to lie in an enhancer region interacting with NDP-AS1 , a long non-coding RNA adjacent to the NDP gene, suggesting it may influence NDP expression through regulatory chromatin interactions. Discussion PA causes cardiovascular disease via excessive activation of the mineralocorticoid receptor (MR) ( 19 , 27 , 28 ). The last decade has witnessed a maturing recognition of the widespread prevalence of PA and identification of its earliest manifestations ( 1 , 2 ). Although PA is usually synonymous with hypertension, human physiology studies and large population-based cohort studies have consistently shown that a continuum of PA can even be detected in normotensive people (termed subclinical PA or SubPA) where it increases risk for developing hypertension and cardiovascular disease ( 1 , 12 , 13 , 15 – 18 , 29 – 32 ). Functional drivers of this continuum include pathogenic somatic mutations in the adrenal cortex, dysregulated aldosterone synthase expression, altered angiotensin II- and ACTH-mediated aldosterone production, and increased mineralocorticoid receptor activity ( 1 , 11 – 13 ). Building on these prior studies, we now show that this continuum is mirrored at the proteomic level. Using large-scale proteomics and detailed phenotyping of aldosterone production, we identified proteins with dose-dependent abundance patterns that spanned from normotensive people with renin-independent aldosterone production to those with overt PA, clustering in pathways known to be operative in cardiovascular disease. By leveraging the known physiology of unilateral PA, we used proteomic assessments of adrenal vein samples to further ensure that candidate proteins reflected the pattern expected for an adrenal-sourced protein in PA. Among these implicated proteins, the evidence to support Norrin (NDP) as a paracrine regulator of aldosterone production was robust and replicated and validated with multimodal assessments. These findings underscore that the continuum of PA pathophysiology might be an operative mechanism in a large proportion of hypertension and cardiovascular disease pathogenesis and implicate Norrin as a novel regulator and potential therapeutic target in PA. The revelation of a proteomic continuum of PA pathophysiology that originates in people with normal blood pressure has major impacts for understanding the mechanisms of hypertension and cardiovascular disease pathogenesis and targeting treatments for these conditions. The top proteins trending upward through the PA continuum (GLO1, BPGM, S100A6, PKLR, NDP, CA1, HMBS) were also among the top 20 most significant proteins found to be higher in categorical analyses of overt PA, suggesting their key contribution to defining the PA proteomic signature. Several of the identified proteins (GLO1, BPGM, PKLR) are involved in glycolysis, a pathway shown to be upregulated in aldosterone-producing adenomas ( 33 , 34 ) and in a subsets of aldosterone-producing cell clusters ( 34 ) to support increased energy production and cell growth. The stepwise increase in glycolytic proteins across the continuum of PA suggests early metabolic reprogramming might be a feature of the pathogenesis of PA. We also show that hemoglobin and oxygen-related proteins (HBB|HBA1, HPX, HMBS, CA1, CA3, BPGM) trended across the PA continuum. Incidentally, increased hemoglobin was also recently identified in another proteomic characterization of PA ( 35 ), possibly reflecting aldosterone-induced oxidative stress and increased red blood cell turnover ( 36 ). Degradation products of hemoglobin, such as hemorphins and carbon monoxide, have vasodilatory and anti-inflammatory properties ( 37 , 38 ), suggesting a potential compensatory response to mineralocorticoid receptor activation. Several other proteins involved in aldosterone biosynthesis or adrenal cortex physiology also displayed stepwise trends across the PA continuum, but did not retain consistent patterns in physiological replication tests. This does not diminish their potential relevance; rather, it suggests that their abundance might be differentially influenced by ACTH, angiotensin II, or cortisol. Other notable proteins that exhibited strong trends across the PA continuum included ID1, CD36, DUSP6, and RASA1, which trended downward, and PRKCD and MMP-9, which trended upward, broadly reflecting shifts in adrenocortical progenitor status, lipid uptake, adrenal cell signaling and proliferation ( 22 – 26 ), and warrant further study in PA. The protein that emerged with the most robust associations with the PA continuum and withstood multi-modal replication and validation was Norrin. The NDP gene encodes for Norrin, a protein originally identified through its association with Norrie disease, a rare congenital disorder characterized by abnormal development of retinal blood vessels ( 39 ). In the eye, Norrin activates canonical Wnt signalling by binding to Frizzled4 (FZD4) and LRP5/6, with TSPAN12 acting as a co-receptor that enhances ligand capture and facilitates complex formation. This interaction leads to stabilization of β-catenin, to nuclear translocation, and to transcriptional activation of Wnt target genes ( 40 ). In recent genome-wide association studies, NDP was identified as a potential contributor to PA and hypertension. In 2022, Le Floch et al. identified NDP as a risk locus for PA in a large French discovery cohort; although, this association was not statistically significant in other European validation cohorts, the lead SNP (rs5905587) was supported by adrenal-specific eQTL data (GTEx) linking genetic variation to local NDP RNA expression ( 41 ). In 2023, Naito et al. identified the NDP locus as significantly associated with risk for hypertension, but not with PA ( 42 ). Subsequently, Inoue et al. conducted a cross-ancestry meta-analysis combining data from these Japanese and French cohorts, as well as from the UK Biobank and Finnish cohorts, and affirmed the association of NDP with risk for PA ( 43 ). Although little is known about the role of Norrin in the adrenal gland, recent evidence has identified TSPAN12, a known co-receptor of Norrin, as a negative regulator of aldosterone production ( 44 ). TSPAN12 expression is reduced in aldosterone-producing adenomas, particularly those with KCNJ5 pathogenic variants, and its loss is associated with increased CYP11B2 expression and elevated basal and post-angiotensin II stimulated aldosterone production ( 44 ). Norrin has also been identified as a ligand for the R-spondin 4 receptor (LGR4), a widely expressed G protein–coupled receptor in the adrenals, capable of activating multiple downstream pathways depending on its ligand, including cAMP/PKA, Wnt/β-catenin, Gαq/GSK3β and Gαq/PKCα signalling cascades ( 45 ). LGR4 appears to play a critical role in adrenal cortex zonation and the structural integrity of the zona glomerulosa and possibly aldosterone production, as evidenced by a familial case of isolated hypoaldosteronism linked to a homozygous pathogenic variant in LGR4 ( 46 ). Moreover, in an in vivo mouse model, conditional inactivation of Lgr4 in steroidogenic adrenal cells led to disrupted zona glomerulosa differentiation, near-complete loss of CYP11B2 expression, and markedly reduced aldosterone production ( 46 ), possibly due to decreased canonical Wnt signalling ( 46 ). Both canonical and non-canonical Wnt signaling contribute to zona glomerulosa differentiation and aldosterone synthesis ( 46 – 50 ). Canonical Wnt/β-catenin signaling is activated in aldosterone-producing adenomas, promoting CYP11B2 expression and cell proliferation ( 50 ). Although CTNNB1 mutations explain some cases, most β-catenin activation likely occurs via non-mutational mechanisms ( 51 , 52 ). The totality of emerging evidence indicates that the pathologic aldosterone production in PA is almost certainly a multi-hit process involving genetic susceptibility, paracrine signaling, aberrant receptors, and altered receptor sensitivity ( 3 , 4 , 7 , 11 – 13 , 41 , 43 , 53 , 54 ). Our current results, demonstrate a continuum of Norrin abundance that parallels the phenotypic spectrum of aldosterone production in SubPA to overt PA, and also show increased Norrin abundance in the dominant adrenal vein of unilateral PA with only background levels in the contralateral, suppressed vein), thereby implicating Norrin as an intra-adrenal and/or paracrine factor. In this regard, Norrin has been previously implicated with paracrine activity in mediating angiogenesis in cancer ( 55 ). We hypothesize that genetic variation at the NDP locus (dose-dependent SNPs in NDP ) gives rise to increased local Norrin production, thus enhancing Wnt/β-catenin activation in the adrenal cortex via FZD4 and possibly β-catenin signaling through LGR4, leading to increased CYP11B2 transcription and aldosterone overproduction and increased cellular proliferation. In addition, Norrin-mediated inhibition of TGF-β signaling might further contribute to aldosterone excess by preventing TGF-β–mediated repression of CYP11B2 ( 56 , 57 ) ( Figure 4 ). Reduced TSPAN12 expression in aldosterone-producing adenomas might subsequently shift Norrin signaling preferentially toward LGR4, sustaining β-catenin activation. Although speculative, it is conceivable that excess Norrin might activate LGR4 and trigger downstream signaling pathways beyond Wnt/β-catenin, including PKA and PKC cascades. These pathways could, in turn, promote the expression of CYP17A1 , CYP11B1 and CYP11B2, facilitating the production of 18-hybrid steroids ( Figure 4 ), a phenomenon we demonstrate from adrenal vein samples, and that is known to parallel the continuum of PA severity ( 12 , 58 ). While current evidence supports Norrin-LGR4 signalling as primarily activating the Wnt/β-catenin pathway ( 45 ), the potential crosstalk to PKC and PKA pathways remains an area for future investigation. This proposed signaling cascade remains hypothetical, as Norrin has not yet been demonstrated to play an integral role in adrenal signaling in the zona glomerulosa. Download figure Open in new tab Figure 4: Hypothetical Model of the Role of Norrin in Primary Aldosteronism Pathophysiology A) In normal adrenal cortical and zona glomerulosa physiology, Norrin is expected to primarily signal through Frizzled-4 (FZD4) and LRP5/6, with TSPAN12 serving as a co-receptor that enhances canonical Wnt/β-catenin activation. Although Norrin can also bind LGR4, TSPAN12 preferentially facilitates its interaction with FZD4. In parallel, TGF-β1 suppresses aldosterone production by reducing β-catenin levels. B) Prior studies have shown that loss of LGR4 function in knockout models results in hypoaldosteronism, adrenal hypoplasia, and disrupted zona glomerulosa architecture due to insufficient Wnt/β-catenin signalling. C) In the pathophysiology of PA, genetic variation in the NDP locus might lead to increased local Norrin abundance, which could enhance paracrine activation of Wnt/β-catenin signaling primarily via FZD4 and potentially through LGR4, leading to increased CYP11B2 activity. Additionally, Norrin-induced inhibition of TGF-β1 signaling would potentially diminish its inhibitory effect on aldosterone production. Norrin–LGR4 interactions might also engage PKC and PKA pathways. D) In aldosterone producing adenomas, where prior studies have reported reduced expression of TSPAN12, higher levels of Norrin might shift signaling away from FZD4 toward LGR4, promoting Wnt/β-catenin activation and potentially engaging PKC and PKA pathways. This shift might enhance transcription of CYP11B2 and, more speculatively, CYP17A1 and CYP11B1 . This combined signaling cascade might drive adrenal cell proliferation, aldosterone overproduction, and hybrid steroid synthesis. In parallel, Norrin-mediated inhibition of TGF-β1 signaling might further contribute to aldosterone excess. While the strengths of this multimodal phenotyping study included comprehensive testing to characterize the continuum of PA and iterative physiological filters to exclude the possibility of false discovery, the results must be interpreted in the context of several limitations. First, the proteomic measurements included 1,500 proteins; therefore, thousands of proteins in the human proteome were unmeasured. Second, we compared a normotensive population with an overt PA group but did not study populations with hypertension or resistant hypertension. However, our approach permitted comparison of extreme phenotypes to more easily characterize the PA proteome; we then employed strict trend analyses to confirm that candidate proteins exhibited aldosterone dose-dependent patterns. Third, patients with unilateral overt PA had adrenal adenomas on imaging, therefore, the circulating and adrenal venous proteomes from these patients may have included proteins associated with adrenal neoplasia in addition to PA. However, our results are insulated from this potential contamination since we required candidate proteins to trend across the continuum of normotensive renin-independent aldosteronism (SubPA) to overt PA, wherein community-dwelling people akin to our normotensive participants have a very low probability (<1.5%) of having adrenal neoplasia ( 59 ). Thus, the candidate proteins that were identified in these analyses were highly likely to be linked to PA pathophysiology alone, which was subsequently confirmed with physiological replication studies and associations with NDP SNPs. Fourth, since the majority of the participants did not have available surgical specimens (44% had bilateral disease and did not undergo an operation), we could not conduct systematic tissue genotyping or immunohistochemistry to analyze how somatic pathogenic variants in driver genes for PA, and/or CYP11B2 staining patterns, might have predicted our results. Fifth, despite SNPs being associated with dose-dependent aldosterone production, there were negative normalized effect sizes for NDP expression in adrenal eQTL data, whereas Norrin abundance was seen to be higher across the PA continuum. This discrepancy could be explained by post-transcriptional or translational regulation, increased protein stability, or by the influence of tissue heterogeneity in eQTL datasets, which are derived from bulk adrenal samples containing cortex, medulla, and periadrenal fat, potentially masking zone-specific signals ( 60 ). Finally, although Norrin emerged as a strong candidate through proteomics, physiological replication, and genetic and steroidomic validation, its direct role in driving CYP11B2 expression was not directly evaluated. In conclusion, the evolution of PA is characterized by proteomic signatures that originate in normotensive individuals and involve biologic pathways known to be operative in the pathogenesis of cardiovascular disease. These results imply that a large proportion of essential hypertension might be driven by PA pathophysiology, and thus amenable to established and emerging therapies that target aldosterone and or the mineralocorticoid receptor ( 61 – 64 ). Our data support the presence of a proteomic continuum that mirrors the spectrum of renin-independent aldosterone production, representing gradations of disease severity rather than classifying PA as a categorical or binary diagnosis. Within this continuum, Norrin demonstrated robust aldosterone dose-dependent trends across proteomic, physiologic, genetic and steroidomic analyses, indicating its role as a potential novel paracrine regulator of PA pathophysiology that might be a target for future therapeutics. Methods General Study Design Participants were recruited through two prospective studies: one enrolling a cohort of community-dwelling normotensive individuals to undergo deep-phenotyping studies to characterize subclinical PA (SubPA) ( NCT03484130 ), and the other a prospective registry enrolling patients with overt PA: individuals with a diagnosis of clinical PA, referred to undergo adrenal vein sampling (AVS). First, the peripheral plasma proteome of participants with overt PA was compared to that of normotensive participants following an oral sodium loading test (OSLT) to identify the proteomic signature associated with PA. Second, to facilitate analyses to identify proteins that consistently trended across the continuum of PA severity in an aldosterone dose-dependent manner, normotensive participants were stratified into unbiased categories of SubPA, defined as the magnitude of non-suppressible and renin-independent aldosterone production, despite supine posture and following the OSLT ( Figure 1 ). Third, this trend analysis was extended to include the adrenal venous proteome from participants with unilateral overt PA to identify proteins with an adrenal source. Finally, potential adrenal-sourced proteins were then subjected to multimodal in vivo replication and validation, including physiological testing (using ACTH- and Angiotensin II-modulated proteomics), targeted steroidomic testing (using 18-hybrid steroid measurements from adrenal venous blood), and genetic testing (candidate gene SNP association studies from a distinct cohort) ( Figure 1 ). Normotensive Participants Normotensive participants with risk factors for developing incident hypertension (BMI ≥ 25 kg/m², family history of hypertension prior to the age of 60 years in a parent or sibling, diabetes with a hemoglobin A1c < 9%) were prospectively recruited from the Boston, MA metropolitan area between July 2018 and October 2022 as previously described ( 13 ). Participants completed an OSLT to assess the magnitude or renin-independent aldosterone production and were then stratified into unbiased tertiles of SubPA, magnitude of plasma aldosterone level while in a supine position following an OSLT, to facilitate trend analyses. The OSLT involved consuming >200 mmol/d of sodium for 5-7 days after which the combination of supine posture and sodium loading was used to induce a physiologic nadir in aldosterone production to characterize the spectrum of SubPA ( 13 ). Overt PA Participants 50 patients with overt PA who underwent AVS as part of their individualized clinical evaluation were included if they had clearly unilateral (n=28) or clearly bilateral PA (n=22). The AVS protocol used in this study has been previously described and includes simultaneous bilateral catheterization with triplicate sampling, before and after ACTH stimulation ( 65 , 66 ). Participants were included if they had successful catheterization of both adrenal veins during AVS, defined as having an ACTH-stimulated selectivity index of ≥ 5 (mean adrenal vein cortisol following a bolus of 250 mcg of ACTH divided by the mean inferior vena cava cortisol following ACTH) in both adrenal veins and/or an unstimulated selectivity index ≥ 2 (mean adrenal vein cortisol divided by the mean inferior vena cava cortisol at baseline) ( 67 ). Unilateral PA was defined as having an unstimulated (pre-ACTH) lateralization index of ≥ 2 and a stimulated (post-ACTH) lateralization index ≥ 4 ( 67 ), as well as contralateral suppression (aldosterone-to-cortisol ratio of the non-dominant vein divided by the aldosterone-to-cortisol ratio in the peripheral vein < 1 and/or an absolute aldosterone concentration in the non-dominant vein that was lower than the peripheral vein) ( 68 ). The lateralization index was defined as the mean aldosterone-to-cortisol ratios from the dominant adrenal vein divided by the mean aldosterone-to-cortisol ratios from the contralateral adrenal vein. Bilateral PA was defined as an unstimulated lateralization index < 2 or a stimulated lateralization index < 4 with absent contralateral suppression (aldosterone-to-cortisol ratio of the non-dominant vein divided by the aldosterone-to-cortisol ratio in the peripheral vein ≥ 1 or an absolute aldosterone concentration in the non-dominant vein that was higher than the peripheral vein). Laboratory Assays Normotensive participants had plasma aldosterone concentration (PAC) and plasma renin activity (PRA) measured as previously described ( 13 ) and participants with overt PA had PAC and cortisol measured as previously described ( 66 ). 18-hybrid steroids (18-hydroxycortisol and 18-oxocortisol) were measured from the adrenal veins of patients with overt PA as previously described ( 69 ). Plasma Proteomics Normotensive participants had proteomic measurements performed on four separate occasions: following OSLT, following an overnight 1mg dexamethasone suppression test (DST), following an ACTH stimulation (ACTHstim) test, and following an extreme sodium restriction intervention while in upright posture (protocols described below). Participants with unilateral overt PA had three proteomic measurements during AVS, collected from the peripheral circulation and each adrenal vein before ACTH stimulation. Participants with bilateral overt PA had proteomic measurements performed on the peripheral circulating blood obtained during AVS only. Proteomic measurements were performed using the SomaScan® assay, an aptamer-based platform that quantifies proteins using chemically modified single-stranded DNA aptamers called SOMAmers (Slow Ofrate Modifed Aptamer) ( 70 ). Detailed methods of the SomaScan® assay have been previously described ( 71 , 72 ). This platform is well-validated and widely used in large-scale proteomic studies ( 73 – 75 ). Proteomic profiles were characterized using the 7k SomaScan assay v4.1 for the normotensive participants and the SomaScan® 11K Assay v5.0 (SomaLogic, Inc.; Boulder, CO, USA) for overt PA participants. Both assays have been well validated ( 70 , 76 ). 1500 proteins were measured to reflect cardiovascular, metabolic, and inflammation profiles and are shown in Supplemental Table 1 . The SomaLogic normalization procedure, including adaptive normalization by maximum likelihood, was used for the SomaScan® data for all analyses. Data from the 11K SomaScan assay were bridged to the 7K format using the SomaDataIO R package for cross-platform comparability ( 76 ). Data were processed in R v4.3.2 using the SomaDataIO package for loading raw proteomic data. Normality of protein abundance distributions was evaluated using visual inspection (i.e., histograms, QQ plots), and log-transformation (log 10 ) was applied to approximate normality and stabilize variance. Statistical Analysis Categorical variables were reported as percentages, normally distributed variables were reported as mean + standard deviation, and non-normally distributed variables were reported as median (25 th -75 th percentile interquartile range). Differential abundance of plasma proteins between normotensive participants and those with overt PA was assessed using the limma package in R, which applies linear modeling with empirical Bayes moderation to improve variance estimation. To establish an overt PA proteomic signature, Pathway enrichment was conducted using Kyoto Encyclopedia of Genes and Genomes (KEGG)( 77 ) and Reactome ( 78 ). The top 50 pathways from each tool were used to represent the overt PA proteomic signature. Proteomic trend analyses were performed using linear regression across 4 categories of the PA continuum: unbiased tertiles of SubPA (termed T1, T2, T3) and the peripheral circulation of participants with overt PA. Proteins that exhibited statistically significant aldosterone dose-dependent trends, and a consistent direction of change across all four categories (e.g. either progressively increasing or progressively decreasing across all four categories), were classified as relevant proteins of interest. Identified trending proteins were visualized using a volcano plot and heatmap. Pathway enrichment analyses were used to identify overlapping pathways identified in the overt PA signature. To determine whether proteomic trends represented adrenal-sourced proteins, aldosterone dosedependent trend analyses were extended to include a 5 th and 6 th category among participants with unilateral overt PA: proteomic measurements from the dominant and suppressed adrenal veins, respectively. For example, candidate proteins were required to exhibit a consistent and progressive trend across the tertiles of SubPA, then progression into the peripheral blood of those with overt unilateral PA, and then into the dominant adrenal vein; the protein abundance in the contralateral (suppressed) adrenal vein was required to then invert to mirror peripheral circulation ( Figure 1 ). For upward-trending proteins, contralateral vein levels were required to be lower than, or closer to, the peripheral content than the dominant vein; conversely, for downward-trending proteins, contralateral vein levels had to be higher than, or closer to, the peripheral content than the dominant vein. All statistical analyses were conducted using R, version 4.3.2 (R Project for Statistical Computing). P-values were adjusted for multiple testing using the Benjamini-Hochberg method ( 79 ). An adjusted p-value less than 0.05 was considered statistically significant. Validation and Replication Studies Functional Replication: Proteomic Profiling Following ACTH- and Angiotensin II-Modulations To validate the involvement of adrenal-sourced proteins in the pathogenesis of PA and minimize false positives among the proteins that displayed archetypal trends in the adrenal veins of unilateral overt PA, proteomic profiles were measured across 3 independent physiological studies conducted in the same participants on two separate days. These maneuvers to interrogate ACTH-dependent, ACTH-independent, and AngII-dependent production have been previously used to characterize both normotensive and overt PA ( 11 – 13 ). On a separate study day, normotensive participants underwent pharmacological modulation of ACTH-mediated aldosterone production. A DST (1mg of dexamethasone administered at 23h00-0h00 with blood sampling at 08h00 the following morning) was used to evaluate ACTH-independent aldosterone production, while an ACTHstim (250 mcg bolus of cosyntropin with sampling 60 minutes later) was used to assess ACTH-dependent aldosterone secretion, as previously described ( 13 ). Blood samples were collected after each intervention to measure serum PAC and to measure the plasma proteome. On a separate study day, participants underwent assessment of AngII-dependent aldosterone production. Participants completed 5 to 7 days of extreme dietary sodium restriction (∼10 mEq per day) prepared by professional dietary staff in the metabolic kitchen to achieve a mean urine sodium excretion of 16.1 ± 11.2 mEq/24h ( 72 ). They were then evaluated while fasting at 08h00 in the ambulatory clinical research center with venipuncture following 30 minutes of upright posture to measure PAC and the peripheral proteome. The combination of sodium restriction and upright posture was used as a maneuver to maximally stimulate endogenous AngII, and consequently AngII-dependent aldosterone production ( 13 ). Targeted Steroidomic Validation: 18-Hybrid Steroid Measurements 18-hybrid steroids, biomarkers of dysregulated CYP11B2 (aldosterone synthase) activity and co-expression with CYP17A1, are known to be a reflection of the spectrum of PA pathophysiology, from subclinical to overt ( 12 , 80 , 81 ). Candidate proteins identified through the above trend analyses, and replicated with the above physiological testing via ACTH- and AngII-modulated proteomics, were subsequently analyzed using linear regression to assess their association with 18-hybrid steroid concentrations (18-oxocortisol and 18-hydroxycortisol) in the dominant adrenal vein of participants with unilateral overt PA. Candidate Gene Validation: Dose-Dependent SNP Associations To validate the most robustly identified protein that emerged from the aforementioned analyses (NDP/ Norrin), a candidate-gene association study was performed in the HyperPATH cohort. The HyperPATH cohort was designed to elucidate the genetic determinants of adrenal hypertension and has been previously described ( 82 ). Study participants included both normotensive (n=228) and hypertensive (n=330) individuals without clinically diagnosed PA, studied without interfering anti-hypertensive medications, and who underwent strictly controlled dietary sodium interventions to evaluate PA pathophysiology as well as genotyping. Single nucleotide polymorphisms (SNPs) within the NDP gene region were selected based on chromosomal coordinates chrX:43,808,022–43,832,750 (GRCh37), including ±5 kb flanking regions to capture regulatory and promoter variation. Genotyping data were imputed using the TOPMed Imputation Server ( https://imputation.biodatacatalyst.nhlbi.nih.gov ) with the 1000 Genomes Project Phase 3 as the reference panel, thereby increasing genomic coverage and resolution beyond directly typed variants. To ensure accurate imputation and harmonization across genotyping platforms, we excluded SNPs with imputation quality scores (INFO) < 0.8 or minor allele frequency < 1%. Association analyses were conducted for 4 aldosterone production phenotypes, reflecting suppressed and stimulated angiotensin II conditions, and treated as continuous variables: ( 1 ) Supine PAC following OSLT: a reflection of renin- and angiotensin II-independent aldosterone production; ( 2 ) 24-hour urinary aldosterone excretion following an OSLT: another distinct reflection of renin- and angiotensin II-independent aldosterone production; ( 3 ) PAC following an infusion of exogenous angiotensin II (3 ng/kg/min for 60 mins): a reflection of angiotensin II-dependent aldosterone production; ( 4 ) Upright PAC following extreme dietary sodium restriction (10 mEq per day for 5-7 days): another reflection of angiotensin II-dependent aldosterone production. Genotype-phenotype associations were assessed using additive linear regression models, implemented in the PLINK software (v1.9). SNP genotypes were coded additively based on the number of effect alleles (A1: 0, 1, or 2), under the assumption that the effect of each additional allele is additive on the trait scale. Effect sizes (β coefficients) were interpreted as the expected change in aldosterone level per additional copy of the A1 allele. To account for multiple testing, false discovery rate (FDR)-adjusted p-values were computed, and statistical significance was defined as FDR <0.05. To ensure robustness of findings, sensitivity analyses were conducted using quantile-normalized aldosterone traits and controlling for potential confounders such as age, sex, and BMI. These did not materially alter the associations. Given that NDP resides on the X chromosome, genotype coding was harmonized across sexes: male hemizygous genotypes were recoded as either 0 or 2 to match the dosage scale in females (0, 1, 2), thereby enabling uniform modeling of additive genetic effects. This approach preserves comparability between sexes while retaining statistical power. SNPs were analyzed for tissue-specific expression quantitative trait loci (eQTLs) using data from the GTEx Portal ( https://gtexportal.org ), accessed on April 14, 2025. To further elucidate functional consequences, we cross-referenced the top SNP signal at NDP (rs5952411; associated with higher urinary aldosterone excretion, β = 1.42, P = 0.0025) using the VannoPortal platform ( http://www.mulinlab.org/vportal/index.html ). Study Approval All normotensive participants provided written informed consent prior to participating and the study protocol was approved and monitored by the Mass General Brigham Institutional Review Board. All participants with overt PA provided written informed consent prior to participating, and the study protocol was approved and monitored by the Beth Israel Deaconess Medical Center Institutional Review Board. Data Availability Data supporting the results are available from the corresponding author. Trial Registration Human participants in this study were involved in a prospective physiology protocol ( NCT03484130 ) and from a longitudinal patient registry. All human study protocols were approved and supervised by the human ethics and research committees and Mass General Brigham and Beth Israel Deaconess Medical Center. Funding This work was supported by the National Institutes of Health awards R01DK115392 (AV, RA), R01HL153004 (AV), R01HL155834 (AV, AT). Disclosures AV reports consulting fees unrelated to the contents of this work from Corcept Therapeutics, Mineralys, HRA Pharma, Moderna, SideraBio. JMB reports consulting fees unrelated to the contents of this work from Recordati and Astra Zeneca. RJA reports consulting fees and or contracted research support from Neurocrine Biosciences/Neurocrine UK, LTD, Spruce Biosciences, Corcept Therapeutics, Crinetics Pharmaceuticals, Recordati Rare Diseases, Adrenas Therapeutics, Mineralys Pharmaceuticals, Quest Diagnostics, Roche Diagnostics, Xeris Pharmaceuticals, Novo Nordisk, H Lundbeck A/S, Sparrow Pharmaceuticals, Astellas Pharmaceuticals, Acerand Therapeutics, OMass Therapeutics, Blue Earth Diagnostics, LTD, Aspect Biosystems, all of which are unrelated to this work. The other authors have no funding to disclose. Data Availability Data supporting the results are available from the corresponding author. Bibliography 1. ↵ Brown JM , Siddiqui M , Calhoun DA , Carey RM , Hopkins PN , Williams GH , et al. The Unrecognized Prevalence of Primary Aldosteronism: A Cross-sectional Study . Ann Intern Med . 2020 ; 173 ( 1 ): 10 – 20 . OpenUrl CrossRef PubMed 2. ↵ Monticone S , Burrello J , Tizzani D , Bertello C , Viola A , Buffolo F , et al. Prevalence and Clinical Manifestations of Primary Aldosteronism Encountered in Primary Care Practice . J Am Coll Cardiol . 2017 ; 69 ( 14 ): 1811 – 20 . OpenUrl FREE Full Text 3. ↵ Scholl UI . Genetics of Primary Aldosteronism . Hypertension . 2022 ; 79 ( 5 ): 887 – 97 . OpenUrl 4. ↵ Fernandes-Rosa FL , Boulkroun S , Zennaro MC . Genetic and Genomic Mechanisms of Primary Aldosteronism . Trends Mol Med . 2020 ; 26 ( 9 ): 819 – 32 . OpenUrl PubMed 5. ↵ Omata K , Anand SK , Hovelson DH , Liu CJ , Yamazaki Y , Nakamura Y , et al. Aldosterone-Producing Cell Clusters Frequently Harbor Somatic Mutations and Accumulate With Age in Normal Adrenals . J Endocr Soc . 2017 ; 1 ( 7 ): 787 – 99 . OpenUrl PubMed 6. ↵ Nishimoto K , Tomlins SA , Kuick R , Cani AK , Giordano TJ , Hovelson DH , et al. Aldosterone-stimulating somatic gene mutations are common in normal adrenal glands . Proc Natl Acad Sci U S A . 2015 ; 112 ( 33 ): E4591 – 9 . OpenUrl Abstract / FREE Full Text 7. ↵ Turcu AF , Yang J , Vaidya A . Primary aldosteronism - a multidimensional syndrome . Nat Rev Endocrinol . 2022 ; 18 ( 11 ): 665 – 82 . OpenUrl CrossRef PubMed 8. ↵ van de Wiel E , Chaman Baz AH , Küsters B , Mukai K , van Bonzel L , van Erp M , et al. Changes of the CYP11B2 Expressing Zona Glomerulosa in Human Adrenals From Birth to 40 Years of Age . Hypertension . 2022 ; 79 ( 11 ): 2565 – 72 . OpenUrl 9. Nanba K , Vaidya A , Rainey WE . Aging and Adrenal Aldosterone Production . Hypertension . 2018 ; 71 ( 2 ): 218 – 23 . OpenUrl CrossRef 10. ↵ Nanba K , Vaidya A , Williams GH , Zheng I , Else T , Rainey WE . Age-Related Autonomous Aldosteronism . Circulation . 2017 ; 136 ( 4 ): 347 – 55 . OpenUrl Abstract / FREE Full Text 11. ↵ Parksook WW , Brown JM , Omata K , Tezuka Y , Ono Y , Satoh F , et al. The Spectrum of Dysregulated Aldosterone Production: An International Human Physiology Study . J Clin Endocrinol Metab . 2024 ; 109 ( 9 ): 2220 – 32 . OpenUrl PubMed 12. ↵ Brown JM , Honzel B , Tsai L , Milks J , Neibuhr Y , Newman A , et al. Characterizing the Origins of Primary Aldosteronism . Hypertension . 2025 ; 82 ( 2 ): 306 – 18 . OpenUrl 13. ↵ Parisien-La Salle S , Brown JM , Mahrokhian S , Hanna I , Honzel B , Tsai LC , et al. Subclinical Primary Aldosteronism is Characterized by Maladaptive Natriuretic Peptide and Adrenal Hormonal Physiology . J Clin Endocrinol Metab . 2025 . 14. Savard S , Amar L , Plouin PF , Steichen O . Cardiovascular complications associated with primary aldosteronism: a controlled cross-sectional study . Hypertension . 2013 ; 62 ( 2 ): 331 – 6 . OpenUrl CrossRef 15. ↵ Hundemer GL , Agharazii M , Madore F , Vaidya A , Brown JM , Leung AA , et al. Subclinical Primary Aldosteronism and Cardiovascular Health: A Population-Based Cohort Study . Circulation . 2024 ; 149 ( 2 ): 124 – 34 . OpenUrl CrossRef PubMed 16. Brown JM , Robinson-Cohen C , Luque-Fernandez MA , Allison MA , Baudrand R , Ix JH , et al. The Spectrum of Subclinical Primary Aldosteronism and Incident Hypertension: A Cohort Study . Ann Intern Med . 2017 ; 167 ( 9 ): 630 – 41 . OpenUrl CrossRef PubMed 17. Markou A , Pappa T , Kaltsas G , Gouli A , Mitsakis K , Tsounas P , et al. Evidence of primary aldosteronism in a predominantly female cohort of normotensive individuals: a very high odds ratio for progression into arterial hypertension . J Clin Endocrinol Metab . 2013 ; 98 ( 4 ): 1409 – 16 . OpenUrl CrossRef PubMed Web of Science 18. ↵ Ananda RA , Gwini S , Beilin LJ , Schlaich MP , Stowasser M , Young MJ , et al. Relationship Between Renin, Aldosterone, Aldosterone-to-Renin Ratio and Arterial Stiffness and Left Ventricular Mass Index in Young Adults . Circulation . 2024 ; 150 ( 25 ): 2019 – 30 . OpenUrl PubMed 19. ↵ Vaidya A , Mulatero P , Baudrand R , Adler GK . The Expanding Spectrum of Primary Aldosteronism: Implications for Diagnosis, Pathogenesis, and Treatment . Endocr Rev . 2018 ; 39 ( 6 ): 1057 – 88 . OpenUrl CrossRef PubMed 20. ↵ World Health Organization . Priorities for research on hypertension care delivery . Geneva ; 2024 . 21. ↵ Szklarczyk D , Kirsch R , Koutrouli M , Nastou K , Mehryary F , Hachilif R , et al. The STRING database in 2023: protein-protein association networks and functional enrichment analyses for any sequenced genome of interest . Nucleic Acids Res . 2023 ; 51 ( D1 ): D638 – d46 . OpenUrl CrossRef PubMed 22. ↵ Ahmad MK , Abdollah NA , Shafie NH , Yusof NM , Razak SRA . Dual-specificity phosphatase 6 (DUSP6): a review of its molecular characteristics and clinical relevance in cancer . Cancer Biol Med . 2018 ; 15 ( 1 ): 14 – 28 . OpenUrl Abstract / FREE Full Text 23. Zhang Y , Li Y , Wang Q , Su B , Xu H , Sun Y , et al. Role of RASA1 in cancer: A review and update (Review) . Oncol Rep . 2020 ; 44 ( 6 ): 2386 – 96 . OpenUrl CrossRef PubMed 24. Mori Sequeiros Garcia MM , Paz C , Castillo AF , Benzo Y , Belluno MA , Balcázar Martínez A , et al. New insights into signal transduction pathways in adrenal steroidogenesis: role of mitochondrial fusion, lipid mediators, and MAPK phosphatases . Front Endocrinol (Lausanne) . 2023 ; 14 : 1175677 . OpenUrl PubMed 25. Spaulding SC , Bollag WB . The role of lipid second messengers in aldosterone synthesis and secretion . J Lipid Res . 2022 ; 63 ( 4 ): 100191 . OpenUrl CrossRef PubMed 26. ↵ Berker D , Isik S , Erden G , Tutuncu YA , Ozcan HN , Caner S , et al. Serum matrix metalloproteinase-9 levels in the diagnosis of functioning adrenal tumors . Endocr Pract . 2010 ; 16 ( 3 ): 419 – 27 . OpenUrl PubMed 27. ↵ Hundemer GL , Curhan GC , Yozamp N , Wang M , Vaidya A . Cardiometabolic outcomes and mortality in medically treated primary aldosteronism: a retrospective cohort study . Lancet Diabetes Endocrinol . 2018 ; 6 ( 1 ): 51 – 9 . OpenUrl PubMed 28. ↵ Monticone S , D’Ascenzo F , Moretti C , Williams TA , Veglio F , Gaita F , et al. Cardiovascular events and target organ damage in primary aldosteronism compared with essential hypertension: a systematic review and meta-analysis . Lancet Diabetes Endocrinol . 2018 ; 6 ( 1 ): 41 – 50 . OpenUrl PubMed 29. ↵ Newton-Cheh C , Guo CY , Gona P , Larson MG , Benjamin EJ , Wang TJ , et al. Clinical and genetic correlates of aldosterone-to-renin ratio and relations to blood pressure in a community sample . Hypertension . 2007 ; 49 ( 4 ): 846 – 56 . OpenUrl CrossRef 30. Brown JM , Wijkman MO , Claggett BL , Shah AM , Ballantyne CM , Coresh J , et al. Cardiac Structure and Function Across the Spectrum of Aldosteronism: the Atherosclerosis Risk in Communities Study . Hypertension . 2022 ; 79 ( 9 ): 1984 – 93 . OpenUrl CrossRef 31. Baudrand R , Guarda FJ , Fardella C , Hundemer G , Brown J , Williams G , et al. Continuum of Renin-Independent Aldosteronism in Normotension . Hypertension . 2017 ; 69 ( 5 ): 950 – 6 . OpenUrl CrossRef 32. ↵ Vasan RS , Evans JC , Larson MG , Wilson PW , Meigs JB , Rifai N , et al. Serum aldosterone and the incidence of hypertension in nonhypertensive persons . N Engl J Med . 2004 ; 351 ( 1 ): 33 – 41 . OpenUrl CrossRef PubMed Web of Science 33. ↵ Gong S , Tetti M , Reincke M , Williams TA . Primary Aldosteronism: Metabolic Reprogramming and the Pathogenesis of Aldosterone-Producing Adenomas . Cancers (Basel ). 2021 ; 13 ( 15 ). 34. ↵ Sun N , Meyer LS , Feuchtinger A , Kunzke T , Knösel T , Reincke M , et al. Mass Spectrometry Imaging Establishes 2 Distinct Metabolic Phenotypes of Aldosterone-Producing Cell Clusters in Primary Aldosteronism . Hypertension . 2020 ; 75 ( 3 ): 634 – 44 . OpenUrl 35. ↵ Tsai C-H , Kong P-H , Hsieh C-C , Huang Y-C , Cheng H-M , Hung C-S , et al. Proteomic signatures to detect unilateral primary aldosteronism in hypertensive patients . European Journal of Clinical Investigation.n/a(n/a ): e70081 . 36. ↵ Bordin L , Donà G , Sabbadin C , Ragazzi E , Andrisani A , Ambrosini G , et al. Human Red Blood Cells Alterations in Primary Aldosteronism . The Journal of Clinical Endocrinology & Metabolism . 2013 ; 98 ( 6 ): 2494 – 501 . OpenUrl PubMed 37. ↵ Ndisang JF , Lane N , Jadhav A . Crosstalk between the heme oxygenase system, aldosterone, and phospholipase C in hypertension . J Hypertens . 2008 ; 26 ( 6 ): 1188 – 99 . OpenUrl CrossRef PubMed Web of Science 38. ↵ Ayoub MA , Vijayan R . Hemorphins Targeting G Protein-Coupled Receptors . Pharmaceuticals (Basel ). 2021 ; 14 ( 3 ). 39. ↵ Ke J , Harikumar KG , Erice C , Chen C , Gu X , Wang L , et al. Structure and function of Norrin in assembly and activation of a Frizzled 4-Lrp5/6 complex . Genes Dev . 2013 ; 27 ( 21 ): 2305 – 19 . OpenUrl Abstract / FREE Full Text 40. ↵ Bruguera ES, Mahoney JP, Weis WI. The co-receptor Tetraspanin12 directly captures Norrin to promote ligand-specific β-catenin signaling. bioRxiv. 2024 . 41. ↵ Le Floch E , Cosentino T , Larsen CK , Beuschlein F , Reincke M , Amar L , et al. Identification of risk loci for primary aldosteronism in genome-wide association studies . Nat Commun . 2022 ; 13 ( 1 ): 5198 . OpenUrl PubMed 42. ↵ Naito T , Inoue K , Sonehara K , Baba R , Kodama T , Otagaki Y , et al. Genetic Risk of Primary Aldosteronism and Its Contribution to Hypertension: A Cross-Ancestry Meta-Analysis of Genome-Wide Association Studies . Circulation . 2023 ; 147 ( 14 ): 1097 – 109 . OpenUrl CrossRef PubMed 43. ↵ Inoue K , Naito T , Fuji R , Sonehara K , Yamamoto K , Baba R , et al. Primary Aldosteronism and Risk of Cardiovascular Outcomes: Genome - Wide Association and Mendelian Randomization Study . Journal of the American Heart Association . 2024 ; 13 ( 15 ): e034180 . OpenUrl PubMed 44. ↵ Gong S , Tetti M , Kemter E , Peitzsch M , Mulatero P , Bidlingmaier M , et al. TSPAN12 (Tetraspanin 12) Is a Novel Negative Regulator of Aldosterone Production in Adrenal Physiology and Aldosterone-Producing Adenomas . Hypertension . 2023 ; 80 ( 2 ): 440 – 50 . OpenUrl 45. ↵ Zhang N , Yuan M , Wang J . LGR4: A New Receptor Member in Endocrine and Metabolic Diseases . Endocr Rev . 2023 ; 44 ( 4 ): 647 – 67 . OpenUrl PubMed 46. ↵ Lucas C , Sauter KS , Steigert M , Mallet D , Wilmouth J , Olabe J , et al. Loss of LGR4/GPR48 causes severe neonatal salt wasting due to disrupted WNT signaling altering adrenal zonation . J Clin Invest . 2023 ; 133 ( 4 ). 47. Berthon A , Sahut-Barnola I , Lambert-Langlais S , de Joussineau C , Damon-Soubeyrand C , Louiset E , et al. Constitutive beta-catenin activation induces adrenal hyperplasia and promotes adrenal cancer development . Hum Mol Genet . 2010 ; 19 ( 8 ): 1561 – 76 . OpenUrl CrossRef PubMed Web of Science 48. Pignatti E , Leng S , Yuchi Y , Borges KS , Guagliardo NA , Shah MS , et al. Beta-Catenin Causes Adrenal Hyperplasia by Blocking Zonal Transdifferentiation . Cell Rep . 2020 ; 31 ( 3 ): 107524 . OpenUrl PubMed 49. Borges KS, Little DW, 3rd, Magalhães TA, Ribeiro C, Dumontet T, Lapensee C, et al. Non-canonical Wnt signaling triggered by WNT2B drives adrenal aldosterone production. bioRxiv. 2024. 50. ↵ Berthon A , Drelon C , Ragazzon B , Boulkroun S , Tissier F , Amar L , et al. WNT/β-catenin signalling is activated in aldosterone-producing adenomas and controls aldosterone production . Hum Mol Genet . 2014 ; 23 ( 4 ): 889 – 905 . OpenUrl CrossRef PubMed Web of Science 51. ↵ Wu VC , Wang SM , Chueh SJ , Yang SY , Huang KH , Lin YH , et al. The prevalence of CTNNB1 mutations in primary aldosteronism and consequences for clinical outcomes . Sci Rep . 2017 ; 7 : 39121 . 52. ↵ Åkerström T , Maharjan R , Sven Willenberg H , Cupisti K , Ip J , Moser A , et al. Activating mutations in CTNNB1 in aldosterone producing adenomas . Sci Rep . 2016 ; 6 : 19546 . 53. ↵ Lefebvre H , Duparc C , Naccache A , Lopez AG , Castanet M , Louiset E . Paracrine Regulation of Aldosterone Secretion in Physiological and Pathophysiological Conditions . Vitam Horm . 2019 ; 109 : 303 – 39 . OpenUrl PubMed 54. ↵ St-Jean M , Bourdeau I , Martin M , Lacroix A . Aldosterone is Aberrantly Regulated by Various Stimuli in a High Proportion of Patients with Primary Aldosteronism . J Clin Endocrinol Metab . 2021 ; 106 ( 1 ): e45 – e60 . OpenUrl CrossRef PubMed 55. ↵ Planutis K , Planutiene M , Holcombe RF . A novel signaling pathway regulates colon cancer angiogenesis through Norrin . Sci Rep . 2014 ; 4 : 5630 . OpenUrl PubMed 56. ↵ Liakos P , Lenz D , Bernhardt R , Feige JJ , Defaye G . Transforming growth factor beta1 inhibits aldosterone and cortisol production in the human adrenocortical cell line NCI-H295R through inhibition of CYP11B1 and CYP11B2 expression . J Endocrinol . 2003 ; 176 ( 1 ): 69 – 82 . OpenUrl Abstract 57. ↵ Seitz R , Weber G , Albrecht S , Fuchshofer R , Tamm ER , Ohlmann A . Cross-Inhibition of Norrin and TGF-β Signaling Modulates Development of Retinal and Choroidal Vasculature . Investigative Ophthalmology & Visual Science . 2018 ; 59 ( 6 ): 2240 – 51 . OpenUrl PubMed 58. ↵ Tezuka Y , Ishii K , Zhao L , Yamazaki Y , Morimoto R , Sasano H , et al. ACTH Stimulation Maximizes the Accuracy of Peripheral Steroid Profiling in Primary Aldosteronism Subtyping . J Clin Endocrinol Metab . 2021 ; 106 ( 10 ): e3969 – e78 . OpenUrl PubMed 59. ↵ Jing Y , Hu J , Luo R , Mao Y , Luo Z , Zhang M , et al. Prevalence and Characteristics of Adrenal Tumors in an Unselected Screening Population : A Cross-Sectional Study . Ann Intern Med . 2022 ; 175 ( 10 ): 1383 – 91 . OpenUrl PubMed 60. ↵ Pott J , Garcia T , Hauck SM , Petrera A , Wirkner K , Loeffler M , et al. Genetically regulated gene expression and proteins revealed discordant effects . PLoS One . 2022 ; 17 ( 5 ): e0268815 . OpenUrl PubMed 61. ↵ Freeman MW , Halvorsen YD , Marshall W , Pater M , Isaacsohn J , Pearce C , et al. Phase 2 Trial of Baxdrostat for Treatment-Resistant Hypertension . N Engl J Med . 2023 ; 388 ( 5 ): 395 – 405 . OpenUrl CrossRef PubMed 62. Laffin LJ , Kopjar B , Melgaard C , Wolski K , Ibbitson J , Bhikam S , et al. Lorundrostat Efficacy and Safety in Patients with Uncontrolled Hypertension . N Engl J Med . 2025 ; 392 ( 18 ): 1813 – 23 . OpenUrl PubMed 63. Laffin LJ , Rodman D , Luther JM , Vaidya A , Weir MR , Rajicic N , et al. Aldosterone Synthase Inhibition With Lorundrostat for Uncontrolled Hypertension: The Target-HTN Randomized Clinical Trial . Jama . 2023 ; 330 ( 12 ): 1140 – 50 . OpenUrl CrossRef PubMed 64. ↵ Mulatero P , Wuerzner G , Groessl M , Sconfienza E , Damianaki A , Forestiero V , et al. Safety and efficacy of once-daily dexfadrostat phosphate in patients with primary aldosteronism: a randomised, parallel group, multicentre, phase 2 trial . EClinicalMedicine . 2024 ; 71 : 102576 . 65. ↵ Yozamp N , Hundemer GL , Moussa M , Underhill J , Fudim T , Sacks B , et al. Adrenocorticotropic Hormone-Stimulated Adrenal Venous Sampling Underestimates Surgically Curable Primary Aldosteronism: A Retrospective Cohort Study and Review of Contemporary Studies . Hypertension . 2021 ; 78 ( 1 ): 94 – 103 . OpenUrl 66. ↵ Yozamp N , Hundemer GL , Moussa M , Underhill J , Fudim T , Sacks B , et al. Variability of Aldosterone Measurements During Adrenal Venous Sampling for Primary Aldosteronism . Am J Hypertens . 2021 ; 34 ( 1 ): 34 – 45 . OpenUrl PubMed 67. ↵ Younes N , Larose S , Bourdeau I , Therasse E , Lacroix A . Role of Adrenal Vein Sampling in Guiding Surgical Decision in Primary Aldosteronism . Exp Clin Endocrinol Diabetes . 2023 ; 131 ( 7-08 ): 418 – 34 . OpenUrl PubMed 68. ↵ Desrochers MJ , St-Jean M , El Ghorayeb N , Bourdeau I , So B , Therasse É , et al. Basal contralateral aldosterone suppression is rare in lateralized primary aldosteronism . Eur J Endocrinol . 2020 ; 183 ( 4 ): 399 – 409 . OpenUrl PubMed 69. ↵ Lee C , O’Day P , Stouffer DG , Auchus RJ , Turcu AF . Artifactual elevations of 11β-hydroxyandrostenedione and 11-ketoandrostenedione in mass spectrometry assays . J Steroid Biochem Mol Biol . 2025 ; 250 : 106717 . OpenUrl PubMed 70. ↵ Candia J , Daya GN , Tanaka T , Ferrucci L , Walker KA . Assessment of variability in the plasma 7k SomaScan proteomics assay . Sci Rep . 2022 ; 12 ( 1 ): 17147 . OpenUrl CrossRef PubMed 71. ↵ Rao P , Keyes MJ , Mi MY , Barber JL , Tahir UA , Deng S , et al. Plasma Proteomics of Exercise Blood Pressure and Incident Hypertension . JAMA Cardiol . 2024 ; 9 ( 8 ): 713 – 22 . OpenUrl PubMed 72. ↵ Solomon M , Heydarpour M , Tsai LC , Honzel B , Brown J , Newman AJ , et al. The Impact Of Modern Industrialized Dietary Sodium Intake On The Plasma Proteome . American Journal of Hypertension . 2025 . 73. ↵ Maretty L , Gill D , Simonsen L , Soh K , Zagkos L , Galanakis M , et al. Proteomic changes upon treatment with semaglutide in individuals with obesity . Nat Med . 2025 ; 31 ( 1 ): 267 – 77 . OpenUrl CrossRef PubMed 74. Eldjarn GH , Ferkingstad E , Lund SH , Helgason H , Magnusson OT , Gunnarsdottir K , et al. Large-scale plasma proteomics comparisons through genetics and disease associations . Nature . 2023 ; 622 (7982): 348 -58. OpenUrl CrossRef PubMed 75. ↵ Shah AM , Myhre PL , Arthur V , Dorbala P , Rasheed H , Buckley LF , et al. Large scale plasma proteomics identifies novel proteins and protein networks associated with heart failure development . Nat Commun . 2024 ; 15 ( 1 ): 528 . OpenUrl CrossRef PubMed 76. ↵ Candia J , Fantoni G , Delgado-Peraza F , Shehadeh N , Tanaka T , Moaddel R , et al. Variability of 7K and 11K SomaScan Plasma Proteomics Assays . J Proteome Res . 2024 ; 23 ( 12 ): 5531 – 9 . OpenUrl CrossRef PubMed 77. ↵ Kanehisa M , Furumichi M , Sato Y , Matsuura Y , Ishiguro-Watanabe M . KEGG: biological systems database as a model of the real world . Nucleic Acids Res . 2025 ; 53 ( D1 ): D672 – d7 . OpenUrl CrossRef PubMed 78. ↵ Milacic M , Beavers D , Conley P , Gong C , Gillespie M , Griss J , et al. The Reactome Pathway Knowledgebase 2024 . Nucleic Acids Research . 2023 ; 52 ( D1 ): D672 – D8 . OpenUrl 79. ↵ Benjamini Y , Hochberg Y . Controlling the False Discovery Rate: A Practical and Powerful Approach to Multiple Testing . Journal of the Royal Statistical Society: Series B (Methodological ). 2018 ; 57 ( 1 ): 289 – 300 . OpenUrl CrossRef 80. ↵ Gomez-Sanchez CE , Gomez-Sanchez EP . 18-Oxocortisol: A journey . J Steroid Biochem Mol Biol . 2023 ; 230 : 106291 . 81. ↵ Gomez-Sanchez CE , Sapiro DR , May KV , Rainey WE , Nishimoto K , Gomez-Sanchez EP . Origin of circulating 18-oxocortisol in the normal human adrenal . Mol Cell Endocrinol . 2022 ; 555 : 111720 . 82. ↵ Tan JW , Gupta T , Manosroi W , Yao TM , Hopkins PN , Williams JS , et al. Dysregulated aldosterone secretion in persons of African descent with endothelin-1 gene variants . JCI Insight . 2017 ; 2 ( 23 ). View the discussion thread. Back to top Previous Next Posted June 06, 2025. Download PDF Supplementary Material Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following The Evolution of Primary Aldosteronism and the Role of Norrin Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Share The Evolution of Primary Aldosteronism and the Role of Norrin Stéfanie Parisien-La Salle , Mahyar Heydarpour , Cheng-Hsuan Tsai , Jenifer M Brown , Andrew J Newman , Sanan Mahrokhian , Isabelle Hanna , Brooke Honzel , Laura C Tsai , Sushrut Waikar , Kosuke Inoue , Maria-Christina Zennaro , Richard Auchus , Adina F. Turcu , Jonathan S Williams , Barry Sacks , Marwan Moussa , Anand Vaidya medRxiv 2025.06.05.25329066; doi: https://doi.org/10.1101/2025.06.05.25329066 Share This Article: Copy Citation Tools The Evolution of Primary Aldosteronism and the Role of Norrin Stéfanie Parisien-La Salle , Mahyar Heydarpour , Cheng-Hsuan Tsai , Jenifer M Brown , Andrew J Newman , Sanan Mahrokhian , Isabelle Hanna , Brooke Honzel , Laura C Tsai , Sushrut Waikar , Kosuke Inoue , Maria-Christina Zennaro , Richard Auchus , Adina F. Turcu , Jonathan S Williams , Barry Sacks , Marwan Moussa , Anand Vaidya medRxiv 2025.06.05.25329066; doi: https://doi.org/10.1101/2025.06.05.25329066 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Endocrinology (including Diabetes Mellitus and Metabolic Disease) Subject Areas All Articles Addiction Medicine (568) Allergy and Immunology (863) Anesthesia (299) Cardiovascular Medicine (4425) Dentistry and Oral Medicine (443) Dermatology (382) Emergency Medicine (607) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1507) Epidemiology (15221) Forensic Medicine (30) Gastroenterology (1123) Genetic and Genomic Medicine (6588) Geriatric Medicine (667) Health Economics (997) Health Informatics (4524) Health Policy (1368) Health Systems and Quality Improvement (1612) Hematology (540) HIV/AIDS (1264) Infectious Diseases (except HIV/AIDS) (15910) Intensive Care and Critical Care Medicine (1103) Medical Education (623) Medical Ethics (145) Nephrology (667) Neurology (6588) Nursing (346) Nutrition (998) Obstetrics and Gynecology (1143) Occupational and Environmental Health (956) Oncology (3331) Ophthalmology (970) Orthopedics (369) Otolaryngology (420) Pain Medicine (435) Palliative Medicine (129) Pathology (663) Pediatrics (1690) Pharmacology and Therapeutics (691) Primary Care Research (710) Psychiatry and Clinical Psychology (5440) Public and Global Health (9220) Radiology and Imaging (2195) Rehabilitation Medicine and Physical Therapy (1369) Respiratory Medicine (1196) Rheumatology (593) Sexual and Reproductive Health (710) Sports Medicine (529) Surgery (710) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9ffdff6cb9a18e2e',t:'MTc3OTQ3NTczNA=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();