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Angel Korman A, Rapoport V, Seged German HR, Nakash Niddam N, Katzir Z, Hausmann M, Leiba A. Elderly men are underscreened for primary aldosteronism even in Hypertension Excellence Centre. Blood Press 2024; 33:2378878. [PMID: 39037935 DOI: 10.1080/08037051.2024.2378878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 07/04/2024] [Indexed: 07/24/2024]
Abstract
Purpose The Endocrine Society (ES) guidelines recommend screening for primary aldosteronism (PA) in high risk hypertensive patients presenting with at least one of seven criteria (resistant HTN, hypokalaemia, adrenal nodule, etc.) Although guidelines are clear and screening is simple, compliance rates among clinicians are extremely low. This results in underdiagnosis of early disease, leading to cadiovasculaer complications and the extra-burden of advanced chronic kidney disease. We aimed to evaluate the screening rates in our Nephrology and Hypertension clinics, as an example of a dedicated Hypertension Excellence Centre. Materials and methods Data on adult hypertensive patients was retrieved from January 2018 to December 2020. Included in the study were hypertensive patients who had at least one of the ES criteria for PA screening. Of all suitable patients, we compared those who were screened for PA to patients who were not screened. Univariate and multivariate cox regression analyses were used for comparison between groups. Results Of 661 patients with HTN, 218 patients (33%) met the ES guidelines for PA screening. Forty-six of them (21.1%) were referred for screening. Advanced age and male gender were associated with lower screening referral rates. Odds ratio for age was 0.945 for every year (95% CI 0.915 - 0.975). There was a trend towards decreased referral rate in advanced kidney disease. Conclusions A 21% screening rate, suggests that many cases of PA are likely missed, more often in older patients. We therefore advocate for PA screening of all hypertensive patients, especially elderly patients with CKD, in whom clinicians' awareness is low but the absolute risk is high.
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Affiliation(s)
- Avital Angel Korman
- Joyce and Irving Goldman School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
- Nephrology and Hypertension Institute, Samson Assuta Ashdod University Hospital, Ashdod, Israel
| | - Vladimir Rapoport
- Nephrology and Hypertension Institute, Samson Assuta Ashdod University Hospital, Ashdod, Israel
| | - Hadassa Rimonie Seged German
- Joyce and Irving Goldman School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Naomi Nakash Niddam
- Nephrology and Hypertension Institute, Samson Assuta Ashdod University Hospital, Ashdod, Israel
| | - Zeev Katzir
- Nephrology and Hypertension Institute, Samson Assuta Ashdod University Hospital, Ashdod, Israel
| | - Michael Hausmann
- Joyce and Irving Goldman School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
- Nephrology and Hypertension Institute, Samson Assuta Ashdod University Hospital, Ashdod, Israel
| | - Adi Leiba
- Joyce and Irving Goldman School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
- Nephrology and Hypertension Institute, Samson Assuta Ashdod University Hospital, Ashdod, Israel
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Ruiz-Sanchez JG, Fernandez Sanchez Á, Cardenas-Salas J, Fernandez-Cagigao Y, Alegre Bellassai ER, Rossello MG, Fernandez-Fernandez B, Jimenez Moreno B, Paniagua A, Vazquez C, Meneses D. Primary aldosteronism prevalence enhanced by strict adherence to 2016 Endocrine Society guidelines: insights from an endocrine hypertension unit. J Hypertens 2024; 42:1813-1822. [PMID: 39196692 DOI: 10.1097/hjh.0000000000003822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2024]
Abstract
INTRODUCTION Primary aldosteronism is the most frequent cause of hypertension although is undetected. The 2016 Endocrine Society guidelines (2016-ESG) recommendations for primary aldosteronism detection are unfulfilled. We aimed to ascertain the prevalence of primary aldosteronism, following the screening criteria endorsed by the 2016-ESG. METHODS All adult patients tested for primary aldosteronism at an endocrine hypertension unit of a tertiary hospital during 2021-2023 were studied. Primary aldosteronism investigation was performed when at least one reason for its screening based on 2016-ESG was detected. When screening was positive, confirmatory tests were executed. Rates and diagnostic accuracy of the reasons for primary aldosteronism screening were analyzed. RESULTS Two hundred and sixty-five patients were included. Mean age was 55 ± 14 years, 124 of 265 (46.8%) were women, 24.6% had hypokalemia, and 16% adrenal incidentaloma(s) as indication for screening. Primary aldosteronism was diagnosed in 122 of 265 (46%). The presence of each reason for primary aldosteronism screening increased the probability of primary aldosteronism in 2.2-fold [95% confidence interval (CI): 1.63 to 2.97; P < 0.001]. The most frequent reason for primary aldosteronism screening was a blood pressure at least 150/100 mmHg on three measurements on different days, and had a sensitivity of 95%. Hypertension with spontaneous or diuretic-induced hypokalemia was the most specific reason (87.5%) but was not frequent. Adrenal incidentaloma(s) was not associated with primary aldosteronism diagnosis. CONCLUSION Primary aldosteronism prevalence is markedly high when the 2016-ESG recommendations are rigorously implemented. The greater the number of indications for primary aldosteronism investigation, the higher its prevalence. Further studies are needed to corroborate this observed primary aldosteronism prevalence.
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Affiliation(s)
- Jorge Gabriel Ruiz-Sanchez
- Endocrinology Department
- Instituto de Investigación Sanitaria Fundación Jiménez-Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM)
| | | | - Jersy Cardenas-Salas
- Endocrinology Department
- Instituto de Investigación Sanitaria Fundación Jiménez-Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM)
| | | | | | | | | | - Beatriz Jimenez Moreno
- Laboratory and Clinical Biochemistry Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | | | - Clotilde Vazquez
- Endocrinology Department
- Instituto de Investigación Sanitaria Fundación Jiménez-Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM)
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Marcelli M, Bi C, Funder JW, McPhaul MJ. Comparing ARR Versus Suppressed PRA as Screening Tests for Primary Aldosteronism. Hypertension 2024; 81:2072-2081. [PMID: 39041222 DOI: 10.1161/hypertensionaha.124.22884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 07/08/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND In many practices, the screening for primary aldosteronism relies on a single-blood draw for plasma aldosterone concentration (PAC) and plasma renin activity (PRA) to establish an aldosterone-to-renin ratio (ARR). ARR levels vary between expert centers and repeated assays in the same individual, emphasizing the potential variability of this screening approach. A suppressed PRA to <1 ng/mL per h has been proposed as an alternative test to the ARR. METHODS We compared 2 potential screening approaches to identify probable primary aldosteronism (ARR≥30 or ARR≥20 versus PRA suppressed below 1 ng/mL per h) in a cohort of 94 829 paired PRA and PAC samples submitted by clinicians to evaluate the presence of primary aldosteronism. RESULTS Of 94 829 patients, 20.3% tested positive based on ARR≥20 (95% CI, 20.0%-20.5%), 13.9% based on ARR≥30 (95% CI, 13.6%-14.1%), versus 45.9% based on suppressed PRA (<1 ng/mL per minute [95% CI, 45.5%-46.2%]). In the PRA group, a range of aldosterone levels was observed: 5.5% had PAC >15 ng/dL, 25.2% had PAC 5 to 15 ng/dL, and 15.2% had PAC <5 ng/dL, compared with 6%, 12.7%, and 1.6% in the ARR≥20 group and 4.7%, 8.5%, and 0.7% in the ARR≥30 group. CONCLUSIONS In this cohort of individuals being screened for primary aldosteronism, substantially more individuals were identified using criteria focused on suppression of renin activity compared with using the aldosterone renin ratio as a screening tool.
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Affiliation(s)
- Marco Marcelli
- Quest Diagnostics Nichols Institute, San Juan Capistrano, CA (M.M., C.B., M.J.M.)
| | - Caixia Bi
- Quest Diagnostics Nichols Institute, San Juan Capistrano, CA (M.M., C.B., M.J.M.)
| | - John W Funder
- Hudson Institute of Medical Research, Clayton, VIC, Australia (J.W.F.)
| | - Michael J McPhaul
- Quest Diagnostics Nichols Institute, San Juan Capistrano, CA (M.M., C.B., M.J.M.)
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Rossi GP, Rossi FB, Guarnieri C, Rossitto G, Seccia TM. Clinical Management of Primary Aldosteronism: An Update. Hypertension 2024; 81:1845-1856. [PMID: 39045687 DOI: 10.1161/hypertensionaha.124.22642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
Despite carrying an excess risk of cardiovascular events, primary aldosteronism (PA) is a commonly overlooked secondary form of arterial hypertension. An increased awareness of its high prevalence and broader screening strategies are urgently needed to improve its detection rate and allow early diagnosis and targeted treatment. For patients with unilateral PA, these measures can correct hyperaldosteronism and ensure cure of hypertension, even when resistant to drug treatment, thus preventing adverse cardiovascular events. Among these, atrial fibrillation is the most common, but left ventricular hypertrophy, stroke, chronic kidney disease, and myocardial infarction also occur more often than in patients with hypertension and no PA. Young patients, who have higher chances of being cured long term, and high-risk patients, such as those with stage III or resistant hypertension, are those who will benefit most from an early diagnosis of PA. Therefore, the implementation of strategies to detect PA by a simplified diagnostic algorithm is necessary. In the patients who seek for surgical cure, adrenal vein sampling is key for the identification of unilateral PA and the achievement of optimal outcomes. Unfortunately, being technically demanding and poorly available, adrenal vein sampling represents the bottleneck in the workup of PA. Considering the novel knowledge generated in the past 5 years in many studies, particularly in the AVIS-2 study (Adrenal Vein Sampling International Study-2), based on 4 decades of experience at our center and on the last guidelines, we herein provide an update on the management of PA with recommendations for drug treatment and strategies to avoid adrenal vein sampling wherever it is poorly, or not, available.
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Affiliation(s)
- Gian Paolo Rossi
- Internal and Emergency Medicine, Department of Medicine, DIME University of Padua, Italy (G.P.R., C.G., G.R., T.M.S.)
| | - Federico Bernardo Rossi
- International PhD Program in Arterial Hypertension and Vascular Biology, University of Rome, 'La Sapienza' Rome, Italy (F.B.R.)
| | - Chiara Guarnieri
- Internal and Emergency Medicine, Department of Medicine, DIME University of Padua, Italy (G.P.R., C.G., G.R., T.M.S.)
| | - Giacomo Rossitto
- Internal and Emergency Medicine, Department of Medicine, DIME University of Padua, Italy (G.P.R., C.G., G.R., T.M.S.)
| | - Teresa M Seccia
- Internal and Emergency Medicine, Department of Medicine, DIME University of Padua, Italy (G.P.R., C.G., G.R., T.M.S.)
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5
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Rossi GP, Bagordo D, Rossi FB, Pintus G, Rossitto G, Seccia TM. 'Essential' arterial hypertension: time for a paradigm change. J Hypertens 2024; 42:1298-1304. [PMID: 38748508 PMCID: PMC11216381 DOI: 10.1097/hjh.0000000000003767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 06/21/2024]
Abstract
The exclusion of causes of hypertension is not systematically exploited in clinical practice. Therefore, essential hypertension is consistently presented as the most prevalent 'cause'. The paradox of a condition with unknown causes being described as a common cause of hypertension translates into a diagnosis of essential hypertension in most patients, which precludes the detection of a curable cause of hypertension. The aim of this review is to investigate how the notion of essential hypertension has developed and whether scientific evidence still support the notion of its high prevalence by examining the most recent studies. These studies provided solid scientific evidence that, when systematically sought for, secondary hypertension is quite common and that secondary hypertension is highly prevalent. The increased awareness should lead to a systematic search for, with the goal of curing or achieving a better control of high blood pressure, and ultimately improving patients' quality of life.
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Affiliation(s)
| | - Domenico Bagordo
- Specialized Hypertension Center
- ARHYVAB, International PhD Program in Arterial Hypertension and Vascular Biology, Department of Medicine – DIMED and Department of Biomedical Sciences, University of Padova, Padova
| | - Federico B. Rossi
- Specialized Hypertension Center
- ARHYVAB, International PhD Program in Arterial Hypertension and Vascular Biology, Department of Medicine – DIMED and Department of Biomedical Sciences, University of Padova, Padova
| | - Giovanni Pintus
- Specialized Hypertension Center
- ARHYVAB, International PhD Program in Arterial Hypertension and Vascular Biology, Department of Medicine – DIMED and Department of Biomedical Sciences, University of Padova, Padova
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, “Sapienza” University of Rome, Rome, Italy
| | - Giacomo Rossitto
- Internal & Emergency Medicine
- Specialized Hypertension Center
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
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Watson KE, Chan JC, Pan B, Al Hamarneh YN, Tsuyuki RT. Enhancing hypertension detection and control through a hypertension certification program for pharmacists: A cluster randomized trial (The R xPATH Study). Can Pharm J (Ott) 2024; 157:190-199. [PMID: 39092087 PMCID: PMC11290583 DOI: 10.1177/17151635241254089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 08/04/2024]
Abstract
Importance We designed an online educational program for primary care health care providers, the Hypertension Canada Professional Certification Program (HC-PCP), based upon its 2020 guidelines. Objective The objective was to determine the effect of the HC-PCP, taken by pharmacists, on systolic blood pressure (BP) in patients with poorly controlled hypertension. Design Stepped wedge cluster randomized trial (unit of randomization was the pharmacy). Participants Patients with poorly controlled hypertension (BP >140/90 mmHg or >130/80 mmHg [diabetes]) in community pharmacies in Alberta, Canada, were recruited by their pharmacist. Intervention Pharmacists completed the HC-PCP program, then provided care to their patients with poorly controlled hypertension according to what they learned in the course. Control Pharmacists were given a copy of the Hypertension Canada guidelines and provided their usual care to their patients prior to undertaking the HC-PCP later. Main outcome and measure The primary outcome was a difference in change in systolic BP at 3 months between groups, while the secondary outcome was patient satisfaction with using the Consultation Satisfaction Questionnaire. Results We enrolled 890 patients from 59 pharmacies (including 104 pharmacists). Using a linear mixed-effect model with BP reduction as the dependent variable and independent variables of treatment allocation, baseline BP, site effect and patient effect, the intervention was associated with a 4.76 mmHg (95% confidence interval, 2.02-7.50, p < 0.0001) systolic BP reduction at 3 months. Patient satisfaction with using the Consultation Satisfaction Questionnaire was high at 75.9 (/90). Conclusion and relevance Most educational programs are not evaluated at the patient care level. The HC-PCP taken by pharmacists resulted in a 4.76 mmHg systolic BP reduction in their patients over 3 months. This would have major implications for public health, reducing heart disease, stroke and kidney failure.
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Affiliation(s)
- Kaitlyn E. Watson
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Jonathan C.H. Chan
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Bo Pan
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Yazid N. Al Hamarneh
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Alberta
- Department of Pharmacology, University of Alberta, Edmonton, Alberta
| | - Ross T. Tsuyuki
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Alberta
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Araujo-Castro M, Ruiz-Sánchez JG, Parra Ramírez P, Martín Rojas-Marcos P, Aguilera-Saborido A, Gómez Cerezo JF, López Lazareno N, Torregrosa Quesada ME, Gorrin Ramos J, Oriola J, Poch E, Oliveras A, Méndez Monter JV, Gómez Muriel I, Bella-Cueto MR, Mercader Cidoncha E, Runkle I, Hanzu FA. Screening and diagnosis of primary aldosteronism. Consensus document of all the Spanish Societies involved in the management of primary aldosteronism. Endocrine 2024; 85:99-121. [PMID: 38448679 DOI: 10.1007/s12020-024-03751-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/15/2024] [Indexed: 03/08/2024]
Abstract
Primary aldosteronism (PA) is the most frequent cause of secondary hypertension (HT), and is associated with a higher cardiometabolic risk than essential HT. However, PA remains underdiagnosed, probably due to several difficulties clinicians usually find in performing its diagnosis and subtype classification. The aim of this consensus is to provide practical recommendations focused on the prevalence and the diagnosis of PA and the clinical implications of aldosterone excess, from a multidisciplinary perspective, in a nominal group consensus approach by experts from the Spanish Society of Endocrinology and Nutrition (SEEN), Spanish Society of Cardiology (SEC), Spanish Society of Nephrology (SEN), Spanish Society of Internal Medicine (SEMI), Spanish Radiology Society (SERAM), Spanish Society of Vascular and Interventional Radiology (SERVEI), Spanish Society of Laboratory Medicine (SEQC(ML)), Spanish Society of Anatomic-Pathology, Spanish Association of Surgeons (AEC).
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Affiliation(s)
- Marta Araujo-Castro
- Endocrinology & Nutrition Department, Hospital Universitario Ramón y Cajal. Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS)., Madrid, Spain.
| | - Jorge Gabriel Ruiz-Sánchez
- Endocrinology & Nutrition Department. Hospital Universitario Fundación Jiménez Díaz, Health Research Institute-Fundación Jiménez Díaz University Hospital (IIS-FJD, UAM), Madrid, Spain
| | - Paola Parra Ramírez
- Endocrinology & Nutrition Department, Hospital Universitario La Paz-IdiPAZ, Madrid, Spain
| | | | | | | | - Nieves López Lazareno
- Biochemical Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Jorge Gorrin Ramos
- Biochemical department, Laboratori de Referència de Catalunya, Barcelona, Spain
| | - Josep Oriola
- Biochemistry and Molecular Genetics Department, CDB. Hospital Clínic. University of Barcelona, Barcelona, Spain
| | - Esteban Poch
- Nephrology Department. Hospital Clinic, IDIBAPS. University of Barcelona, Barcelona, Spain
| | - Anna Oliveras
- Nephrology Department. Hospital del Mar, Universitat Pompeu Fabra, Barcelona, ES, Spain
| | | | | | - María Rosa Bella-Cueto
- Pathology Department, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA). Universitat Autònoma de Barcelona. Sabadell, Barcelona, Spain
| | - Enrique Mercader Cidoncha
- General Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Fellow European Board of Surgery -Endocrine Surgery, Madrid, Spain
| | - Isabelle Runkle
- Endocrinology and Nutrition Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Felicia A Hanzu
- Endocrinology & Nutrition Department, Hospital Clinic. IDIBAPS. University of Barcelona, Barcelona, Spain.
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Tsan K, Yang J, Nainani A, Libianto R, Russell G. Screening for primary aldosteronism in primary care: a scoping review. Fam Pract 2024:cmae033. [PMID: 38912620 DOI: 10.1093/fampra/cmae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND Primary aldosteronism (PA) is the most common treatable and potentially curable cause of secondary hypertension. Prompt diagnosis and management by primary care physicians (PCPs) is important given the increased risk of cardiovascular complications however screening rates are low in primary care. Our aim was to identify factors that influence screening behaviour for PA among PCPs. METHOD A rigorous scoping review of seven databases between 16/08/22 and 09/08/23 was used to investigate PA screening practices. Articles written in English from peer-reviewed literature within the last 20 years were eligible for inclusion if an aspect of their study was conducted in primary care. RESULTS A total of 1380 titles and abstracts, and 61 full texts were screened, with 20 studies selected for data extraction. We identified three broad categories of factors influencing screening by PCPs-the patient, the clinician, and the healthcare system. Some studies targeted these factors to improve screening rates although there is little data on implementation and outcomes. CONCLUSION Low awareness, inadequate guidelines, and poor access to testing were identified as key barriers to PA screening. Targeted education sessions for PCPs, clear guidelines, and closer proximity to diagnostic centres may be required to improve PA detection in primary care.
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Affiliation(s)
- Kirsten Tsan
- Department of Endocrinology, Monash Health, Clayton, Melbourne 3168, Australia
| | - Jun Yang
- Department of Endocrinology, Monash Health, Clayton, Melbourne 3168, Australia
- Department of Medicine, Monash University, Monash Health, Clayton, Melbourne 3168, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Melbourne 3168, Australia
| | | | - Renata Libianto
- Department of Endocrinology, Monash Health, Clayton, Melbourne 3168, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Melbourne 3168, Australia
| | - Grant Russell
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne 3168, Australia
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Fernandes Taboada G, Barbosa Moraes A, Vieira L. Evaluation of screening practices for primary hyperaldosteronism by specialists and general practitioners: an observational, cross-sectional study. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2024; 68:e230211. [PMID: 38530960 PMCID: PMC11081042 DOI: 10.20945/2359-4292-2023-0211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/17/2023] [Indexed: 03/28/2024]
Abstract
Objective Despite its recognized importance, primary hyperaldosteronism (PHA) remains an underdiagnosed condition in clinical practice. The objective of the present study was to evaluate PHA screening practices by general practitioners and specialists in endocrinology and cardiology. Subjects and methods This cross-sectional, observational study invited physicians to respond voluntarily to an online survey. The survey collected the respondents' sociodemographic data and answers to five hypothetical clinical cases meeting Endocrine Society criteria for PHA screening. Results In all, 126 physicians responded to the online survey. Endocrinologists were the specialists who most often chose PHA screening, although the screening rates were overall low, ranging from 36.5% to 92.9%, depending on the case and the respondents' specialty. The survey also assessed the reasons for not choosing PHA screening, which included limited availability of tests within the public health services, interference of antihypertensive medications on hormone levels, and failure to identify the screening indication. Being an endocrinologist was an independent predictor for choosing PHA screening for the patients in Cases #1 and #5 (p = 0.001 and p = 0.002, respectively). Conclusion Endocrinologists were the specialists who most often chose PHA screening, although the screening rates were overall low among all specialists. These findings highlight a need for continuing medical education programs addressing PHA screening and making the diagnosis of PHA more present in the daily clinical practice of physicians treating patients with hypertension.
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Affiliation(s)
- Giselle Fernandes Taboada
- Universidade Federal Fluminense, Departamento de Clínica Médica, Hospital Universitário Antônio Pedro, Niterói, RJ, Brasil,
- Disciplina de Clínica Médica, Universidade Estácio de Sá/ IDOMED, Rio de Janeiro, RJ, Brasil
| | - Aline Barbosa Moraes
- Universidade Federal Fluminense, Departamento de Clínica Médica, Hospital Universitário Antônio Pedro, Niterói, RJ, Brasil
| | - Leonardo Vieira
- Universidade Federal do Rio de Janeiro, Departamento de Clínica Médica, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, RJ, Brasil
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10
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Lin CH, Lin CH, Chung MC, Hung CS, Tseng FY, Er LK, Jia-Yin Hou C, Lin YH, Wu VC, Cheng HM, Kao HL, Wu KD, Lai TS. Aldosterone-to-renin ratio (ARR) as a screening tool for primary aldosteronism (PA). J Formos Med Assoc 2024; 123 Suppl 2:S98-S103. [PMID: 37173226 DOI: 10.1016/j.jfma.2023.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/16/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
The aldosterone-to-renin ratio (ARR) is the standard screening test for primary aldosteronism (PA). Because of the poor reproducibility of the ARR, repeat testing is recommended if the result is not compatible with the clinical condition. Various methods to measure renin are used in different hospitals in Taiwan, and the ARR cutoff values also differ among laboratories. The Task Force of Taiwan PA recommend using plasma renin activity (PRA) to calculate ARR instead of direct renin concentration (DRC) unless PRA is unavailable, because PRA is widely used in international guidelines and most studies.
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Affiliation(s)
- Chia-Hung Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Han Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Mu-Chi Chung
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chi-Sheng Hung
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Fen-Yu Tseng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Medical Education, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Leay Kiaw Er
- Division of Endocrinology, Department of Internal Medicine, Taipei Tzu-Chi Hospital, Buddhist Tzu-Chi Medical Foundation, New Taipei City, Taiwan; School of Medicine, Tzu-Chi University, Hualien, Taiwan
| | | | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Primary Aldosteronism Center at National Taiwan University Hospital, Taiwan
| | - Vin-Cent Wu
- Primary Aldosteronism Center at National Taiwan University Hospital, Taiwan; Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hao-Min Cheng
- Ph.D. Program of Interdisciplinary Medicine (PIM), National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Division of Faculty Development, Taipei Veterans General Hospital, Taiwan; Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tai-Shuan Lai
- Primary Aldosteronism Center at National Taiwan University Hospital, Taiwan; Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Charoensri S, Bashaw L, Dehmlow C, Ellies T, Wyckoff J, Turcu AF. Evaluation of a Best-Practice Advisory for Primary Aldosteronism Screening. JAMA Intern Med 2024; 184:174-182. [PMID: 38190155 PMCID: PMC10775078 DOI: 10.1001/jamainternmed.2023.7389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/10/2023] [Indexed: 01/09/2024]
Abstract
Importance Primary aldosteronism (PA) is a common cause of secondary hypertension and an independent risk factor for cardiovascular morbidity and mortality. Fewer than 2% to 4% of patients at risk are evaluated for PA. Objective To develop and evaluate an electronic health record best-practice advisory (BPA) that assists with PA screening. Design, Setting, and Participants This prospective quality improvement study was conducted at academic center outpatient clinics. Data analysis was performed between February and June 2023 and included adults with hypertension and at least 1 of the following: 4 or more current antihypertensive medications; hypokalemia; age younger than 35 years; or adrenal nodule(s). Patients previously tested for PA were excluded. Exposure A noninterruptive BPA was developed to trigger for PA screening candidates seen in outpatient setting by clinicians who treat hypertension. The BPA included an order set for PA screening and a link to results interpretation guidance. Main Outcomes and Measures (1) The number of PA screening candidates identified by the BPA between October 1, 2021, and December 31, 2022; (2) the rates of PA screening; and (3) the BPA use patterns, stratified by physician specialty were assessed. Results Over 15 months, the BPA identified 14 603 unique candidates (mean [SD] age, 65.5 [16.9] years; 7300 women [49.9%]; 371 [2.5%] Asian, 2383 [16.3%] Black, and 11 225 [76.9%] White individuals) for PA screening, including 7028 (48.1%) with treatment-resistant hypertension, 6351 (43.5%) with hypokalemia, 1537 (10.5%) younger than 35 years, and 445 (3.1%) with adrenal nodule(s). In total, 2040 patients (14.0%) received orders for PA screening. Of these, 1439 patients (70.5%) completed the recommended screening within the system, and 250 (17.4%) had positive screening results. Most screening orders were placed by internists (40.0%) and family medicine physicians (28.1%). Family practitioners (80.3%) and internists (68.9%) placed most orders via the embedded order set, while specialists placed most orders (83.0%-95.4%) outside the BPA. Patients who received screening were younger and included more women and Black patients than those not screened. The likelihood of screening was higher among patients with obesity and dyslipidemia and lower in those with chronic kidney disease and established cardiovascular complications. Conclusions and Relevance The study results suggest that noninterruptive BPAs are potentially promising PA screening-assistance tools, particularly among primary care physicians. Combined with artificial intelligence algorithms that optimize the detection yield, refined BPAs may contribute to personalized hypertension care.
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Affiliation(s)
- Suranut Charoensri
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Linda Bashaw
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Cheryl Dehmlow
- Health Information and Technology Systems, University of Michigan, Ann Arbor
| | - Tammy Ellies
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jennifer Wyckoff
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Adina F. Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor
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12
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Ekman N, Grossman AB, Dworakowska D. What We Know about and What Is New in Primary Aldosteronism. Int J Mol Sci 2024; 25:900. [PMID: 38255973 PMCID: PMC10815558 DOI: 10.3390/ijms25020900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Primary aldosteronism (PA), a significant and curable cause of secondary hypertension, is seen in 5-10% of hypertensive patients, with its prevalence contingent upon the severity of the hypertension. The principal aetiologies of PA include bilateral idiopathic hypertrophy (BIH) and aldosterone-producing adenomas (APAs), while the less frequent causes include unilateral hyperplasia, familial hyperaldosteronism (FH) types I-IV, aldosterone-producing carcinoma, and ectopic aldosterone synthesis. This condition, characterised by excessive aldosterone secretion, leads to augmented sodium and water reabsorption alongside potassium loss, culminating in distinct clinical hallmarks: elevated aldosterone levels, suppressed renin levels, and hypertension. Notably, hypokalaemia is present in only 28% of patients with PA and is not a primary indicator. The association of PA with an escalated cardiovascular risk profile, independent of blood pressure levels, is notable. Patients with PA exhibit a heightened incidence of cardiovascular events compared to counterparts with essential hypertension, matched for age, sex, and blood pressure levels. Despite its prevalence, PA remains frequently undiagnosed, underscoring the imperative for enhanced screening protocols. The diagnostic process for PA entails a tripartite assessment: the aldosterone/renin ratio (ARR) as the initial screening tool, followed by confirmatory and subtyping tests. A positive ARR necessitates confirmatory testing to rule out false positives. Subtyping, achieved through computed tomography and adrenal vein sampling, aims to distinguish between unilateral and bilateral PA forms, guiding targeted therapeutic strategies. New radionuclide imaging may facilitate and accelerate such subtyping and localisation. For unilateral adrenal adenoma or hyperplasia, surgical intervention is optimal, whereas bilateral idiopathic hyperplasia warrants treatment with mineralocorticoid antagonists (MRAs). This review amalgamates established and emerging insights into the management of primary aldosteronism.
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Affiliation(s)
- Natalia Ekman
- Department of Hypertension & Diabetology, Medical University of Gdańsk, 80-214 Gdańsk, Poland;
| | - Ashley B. Grossman
- Centre for Endocrinology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 4NS, UK;
| | - Dorota Dworakowska
- Department of Hypertension & Diabetology, Medical University of Gdańsk, 80-214 Gdańsk, Poland;
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13
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Mullen N, Curneen J, Donlon PT, Prakash P, Bancos I, Gurnell M, Dennedy MC. Treating Primary Aldosteronism-Induced Hypertension: Novel Approaches and Future Outlooks. Endocr Rev 2024; 45:125-170. [PMID: 37556722 PMCID: PMC10765166 DOI: 10.1210/endrev/bnad026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 07/11/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023]
Abstract
Primary aldosteronism (PA) is the most common cause of secondary hypertension and is associated with increased morbidity and mortality when compared with blood pressure-matched cases of primary hypertension. Current limitations in patient care stem from delayed recognition of the condition, limited access to key diagnostic procedures, and lack of a definitive therapy option for nonsurgical candidates. However, several recent advances have the potential to address these barriers to optimal care. From a diagnostic perspective, machine-learning algorithms have shown promise in the prediction of PA subtypes, while the development of noninvasive alternatives to adrenal vein sampling (including molecular positron emission tomography imaging) has made accurate localization of functioning adrenal nodules possible. In parallel, more selective approaches to targeting the causative aldosterone-producing adrenal adenoma/nodule (APA/APN) have emerged with the advent of partial adrenalectomy or precision ablation. Additionally, the development of novel pharmacological agents may help to mitigate off-target effects of aldosterone and improve clinical efficacy and outcomes. Here, we consider how each of these innovations might change our approach to the patient with PA, to allow more tailored investigation and treatment plans, with corresponding improvement in clinical outcomes and resource utilization, for this highly prevalent disorder.
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Affiliation(s)
- Nathan Mullen
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| | - James Curneen
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| | - Padraig T Donlon
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| | - Punit Prakash
- Department of Electrical and Computer Engineering, Kansas State University, Manhattan, KS 66506, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Mark Gurnell
- Wellcome-MRC Institute of Metabolic Science, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK
| | - Michael C Dennedy
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
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14
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Faconti L, Kulkarni S, Delles C, Kapil V, Lewis P, Glover M, MacDonald TM, Wilkinson IB. Diagnosis and management of primary hyperaldosteronism in patients with hypertension: a practical approach endorsed by the British and Irish Hypertension Society. J Hum Hypertens 2024; 38:8-18. [PMID: 37964158 PMCID: PMC10803267 DOI: 10.1038/s41371-023-00875-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/03/2023] [Accepted: 10/30/2023] [Indexed: 11/16/2023]
Abstract
Alongside the lack of homogeneity among international guidelines and consensus documents on primary hyperaldosteronism, the National UK guidelines on hypertension do not provide extensive recommendations regarding the diagnosis and management of this condition. Local guidelines vary from area to area, and this is reflected in the current clinical practice in the UK. In an attempt to provide support to the clinicians involved in the screening of subjects with hypertension and clinical management of suspected cases of primary hyperaldosteronism the following document has been prepared on the behalf of the BIHS Guidelines and Information Service Standing Committee. Through remote video conferences, the authors of this document reviewed an initial draft which was then circulated among the BIHS Executive members for feedback. A survey among members of the BIHS was carried out in 2022 to assess screening strategies and clinical management of primary hyperaldosteronism in the different regions of the UK. Feedback and results of the survey were then discussed and incorporated in the final document which was approved by the panel after consensus was achieved considering critical review of existing literature and expert opinions. Grading of recommendations was not performed in light of the limited available data from properly designed randomized controlled trials.
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Affiliation(s)
- Luca Faconti
- King's College London British Heart Foundation Centre, Department of Clinical Pharmacology, 4th Floor, North Wing, St. Thomas' Hospital, Westminster Bridge, London, SE17EH, UK.
| | - Spoorthy Kulkarni
- Cambridge University hospitals NHS foundation trust, Cambridge United Kingdom (S.K.), Cambridge, UK
| | - Christian Delles
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, G12 8TA, UK
| | - Vikas Kapil
- William Harvey Research Institute, Centre for Cardiovascular Medicine and Devices, Queen Mary University London, London, EC1M 6BQ, UK
- Barts BP Centre of Excellence, Barts Heart Centre, London, EC1A 7BE, UK
| | - Philip Lewis
- Department of Cardiology, Stockport NHS Foundation Trust, Stockport, UK
| | - Mark Glover
- Deceased, formerly Division of Therapeutics and Molecular Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Thomas M MacDonald
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Ian B Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
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15
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Azizan EAB, Drake WM, Brown MJ. Primary aldosteronism: molecular medicine meets public health. Nat Rev Nephrol 2023; 19:788-806. [PMID: 37612380 PMCID: PMC7615304 DOI: 10.1038/s41581-023-00753-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/25/2023]
Abstract
Primary aldosteronism is the most common single cause of hypertension and is potentially curable when only one adrenal gland is the culprit. The importance of primary aldosteronism to public health derives from its high prevalence but huge under-diagnosis (estimated to be <1% of all affected individuals), despite the consequences of poor blood pressure control by conventional therapy and enhanced cardiovascular risk. This state of affairs is attributable to the fact that the tools used for diagnosis or treatment are still those that originated in the 1970-1990s. Conversely, molecular discoveries have transformed our understanding of adrenal physiology and pathology. Many molecules and processes associated with constant adrenocortical renewal and interzonal metamorphosis also feature in aldosterone-producing adenomas and aldosterone-producing micronodules. The adrenal gland has one of the most significant rates of non-silent somatic mutations, with frequent selection of those driving autonomous aldosterone production, and distinct clinical presentations and outcomes for most genotypes. The disappearance of aldosterone synthesis and cells from most of the adult human zona glomerulosa is the likely driver of the mutational success that causes aldosterone-producing adenomas, but insights into the pathways that lead to constitutive aldosterone production and cell survival may open up opportunities for novel therapies.
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Affiliation(s)
- Elena A B Azizan
- Department of Medicine, Faculty of Medicine, The National University of Malaysia (UKM), Kuala Lumpur, Malaysia
- Endocrine Hypertension, Department of Clinical Pharmacology and Precision Medicine, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - William M Drake
- St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
- NIHR Barts Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Morris J Brown
- Endocrine Hypertension, Department of Clinical Pharmacology and Precision Medicine, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom.
- NIHR Barts Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.
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16
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Sudano I, Suter P, Beuschlein F. Secondary hypertension as a cause of treatment resistance. Blood Press 2023; 32:2224898. [PMID: 37334480 DOI: 10.1080/08037051.2023.2224898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/20/2023]
Abstract
In secondary hypertension, elevated blood pressure is caused by a known and/or potentially treatable underlying disease.Although the prevalence of secondary hypertension depends on the patient population and the thoroughness of applied diagnostic approaches, arterial hypertension is classified in 90 to 95% as primary in nature. In young patients, individuals without a family history of hypertension, late onset of hypertension or worsening of a previous well-controlled hypertension as well as in patients who have a difficult to treat hypertension, the prevalence of secondary hypertension is significantly higher.Because the identification and the specific therapy of secondary hypertension may result in normalisation or improvement of elevated blood pressure in many cases, a targeted diagnostics is of great importance.
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Affiliation(s)
- Isabella Sudano
- Department of Cardiology, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich Switzerland
| | - Paolo Suter
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich Switzerland
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich Switzerland
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
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17
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Beger C, Karg T, Hinrichs JB, Ringe B, Haller H, Meyer BC, Limbourg FP. RAS-challenge as a first-look test for detection of primary aldosteronism in patients with treatment-resistant hypertension. Blood Press 2023; 32:2179340. [PMID: 36803263 DOI: 10.1080/08037051.2023.2179340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
PURPOSE Primary aldosteronism (PA), characterised by low-renin hypertension, confers a high cardiovascular risk and is the most common cause of secondary hypertension, with an increased prevalence in patients with treatment-resistant hypertension. However, it is estimated that only a small percentage of affected patients are identified in routine clinical practice. Inhibitors of the renin-angiotensin system cause an increase in renin levels in patients with intact aldosterone regulation, and inadequate low renin with concurrent RAS inhibition (RASi) may therefore indicate PA, which could serve as a first look screening test for selection for formal work-up. METHODS We analysed patients between 2016-2018 with treatment-resistant hypertension who had inadequate low renin in the presence of RASi (i. e. at risk for PA) and who were offered systematic work-up with adrenal vein sampling (AVS). RESULTS A total of 26 pts were included in the study (age 54.8 ± 11, male 65%). Mean office blood pressure (BP) was 154/95 mmHg on 4.5 antihypertensive drug classes. AVS had a high technical success rate (96%) and demonstrated unilateral disease in the majority of patients (57%), most of which (77%) were undetected by cross-sectional imaging. CONCLUSION In patients with resistant hypertension, low renin in the presence of RASi is a strong indicator for autonomous aldosterone secretion. It may serve as an on-medication screening test for PA to select for formal PA work up.
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Affiliation(s)
- Christian Beger
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Theresa Karg
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Jan B Hinrichs
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Bastian Ringe
- Department of General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Hermann Haller
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Bernhard C Meyer
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Florian P Limbourg
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
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18
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Fernandez CJ, Nagendra L, Alkhalifah M, Pappachan JM. Endocrine Hypertension: The Urgent Need for Greater Global Awareness. TOUCHREVIEWS IN ENDOCRINOLOGY 2023; 19:31-41. [PMID: 38187076 PMCID: PMC10769474 DOI: 10.17925/ee.2023.19.2.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/04/2023] [Indexed: 01/09/2024]
Abstract
Hypertension affects about 1.28 billion adults globally, and significantly increases the risk of chronic morbidity and mortality among sufferers. About 15% of these individuals have secondary hypertension, the majority of whom have dysfunction of one or more endocrine systems as the cause of hypertension. Although adrenal disorders are often identified as the cause of endocrine hypertension, extra-adrenal disease and pituitary disorders also can cause the disease. Timely diagnosis is of paramount importance, because of the potential for a surgical cure or optimal disease control with pharmacotherapy to prevent hypertensive complications. Even with its relatively high prevalence compared with many other chronic illnesses, the diagnosis of endocrine hypertension is often delayed or never made because of poor awareness about the disease among physicians. This review attempts to provide an overview of the disease, with some practical aspects of diagnosis and management of a few of the important disorders causing endocrine hypertension.
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Affiliation(s)
- Cornelius J Fernandez
- Department of Endocrinology and Metabolism, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - Lakshmi Nagendra
- Department of Endocrinology, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, India
| | - Mohammed Alkhalifah
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston, UK
- Department of Family Medicine & Diabetes, King Saud University Medical City, Riyad, Saudi Arabia
| | - Joseph M Pappachan
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston, UK
- Faculty of Science, Manchester Metropolitan University, Manchester, UK
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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19
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Lai JH, Gwini SM, Chen G, Long KM, Russell G, Schlaich MP, Stowasser M, Young MJ, Fuller PJ, Mori TA, Wolley M, Reid CM, Yang J. Willingness to be tested for a secondary cause of hypertension: a survey of the Australian general community. Intern Med J 2023; 53:1826-1836. [PMID: 36321804 DOI: 10.1111/imj.15955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/08/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Primary aldosteronism (PA) represents the most common and potentially curable cause of secondary hypertension. However, PA is not commonly screened for, and up to 34% of patients who screen positive do not complete the full diagnostic process. This suggests that the diagnostic process may pose a barrier to patients and may contribute to the under-diagnosis of PA. AIMS To evaluate the willingness of the Australian general public to undergo testing for secondary causes of hypertension and identify enablers or barriers to testing from the patients' perspective. METHODS An online survey containing questions on knowledge and attitudes towards hypertension, willingness to be tested and enablers/barriers towards testing was distributed to the Australian community. RESULTS Of 520 adult respondents (mean age 50.4 years, SD 27.3 years; 28.8% hypertensive; 56.0% female), the majority of non-hypertensive and hypertensive respondents (82.7% vs 70.0%; P = 0.03) were willing to undergo testing for a secondary cause of hypertension that involved blood and urine tests. Greater knowledge of hypertensive risk modification strategies and complications was predictive of willingness to be tested, whereas age, sex, education level, geographic location, socio-economic status and cardiovascular comorbidities were not. The top three barriers to testing included fear of a serious underlying condition, lack of belief in further testing and increased stress associated with further testing. CONCLUSION A high proportion of patients are willing to engage in testing for a secondary cause of hypertension. Education about the risks associated with hypertension and the testing process may overcome several barriers to testing.
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Affiliation(s)
- Jordan H Lai
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Stella M Gwini
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Epidemiology, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Gang Chen
- Centre for Health Economics, Monash University, Melbourne, Victoria, Australia
| | - Katrina M Long
- School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia
| | - Grant Russell
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School, The University of Western Australia - Royal Perth Hospital Campus, Perth, Western Australia, Australia
- Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
- Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland Diamantina Institute, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Morag J Young
- Cardiovascular Endocrinology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Peter J Fuller
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia
| | - Trevor A Mori
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Martin Wolley
- Endocrine Hypertension Research Centre, University of Queensland School of Medicine; Greenslopes and Princess Alexandra Hospitals, Brisbane, Queensland, Australia
- Department of Nephrology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia
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20
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Dogra P, Bancos I, Young WF. Primary Aldosteronism: A Pragmatic Approach to Diagnosis and Management. Mayo Clin Proc 2023; 98:1207-1215. [PMID: 37536806 DOI: 10.1016/j.mayocp.2023.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/17/2023] [Accepted: 04/20/2023] [Indexed: 08/05/2023]
Abstract
Primary aldosteronism is a prevalent but underdiagnosed cause of hypertension, contributing to increased cardiovascular and cerebrovascular events and end-organ damage independent of blood pressure. Prompt diagnosis and treatment with targeted surgical or medical therapy reduce the risk of complications and improve prognosis. This review outlines a practical approach to diagnosis and management of primary aldosteronism for global practitioners.
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Affiliation(s)
- Prerna Dogra
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN.
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21
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Libianto R, Stowasser M, Russell G, Fuller PJ, Yang J. Improving Detection Rates for Primary Aldosteronism. Exp Clin Endocrinol Diabetes 2023; 131:402-408. [PMID: 37160153 DOI: 10.1055/a-2048-6213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Primary aldosteronism (PA), once considered a rare disease, is being increasingly recognized as an important cause of hypertension. It is associated with higher rates of cardiovascular complications compared to blood pressure-matched essential hypertension. Targeted treatments are available which can mitigate the excess cardiovascular risks and, in some cases, cure hypertension. Making a timely diagnosis of PA is, therefore, highly beneficial for patients. Furthermore, numerous studies from different parts of the world have found PA to be a relatively common disease that can affect patients in any stage of hypertension, regardless of their age or potassium levels. Despite this well-established data, the current rate of PA detection is appallingly low, much below its actual prevalence. This review explores the challenges that clinicians often face in diagnosing PA and offers strategies that may improve the detection of this potentially curable form of hypertension.
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Affiliation(s)
- Renata Libianto
- Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Monash Health, Clayton, Victoria
- Monash University, Clayton, Victoria, Australia
| | | | | | - Peter J Fuller
- Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Monash Health, Clayton, Victoria
| | - Jun Yang
- Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Monash Health, Clayton, Victoria
- Monash University, Clayton, Victoria, Australia
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22
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Bioletto F, Lopez C, Bollati M, Arata S, Procopio M, Ponzetto F, Beccuti G, Mengozzi G, Ghigo E, Maccario M, Parasiliti-Caprino M. Predictive performance of aldosterone-to-renin ratio in the diagnosis of primary aldosteronism in patients with resistant hypertension. Front Endocrinol (Lausanne) 2023; 14:1145186. [PMID: 37223051 PMCID: PMC10200868 DOI: 10.3389/fendo.2023.1145186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 04/20/2023] [Indexed: 05/25/2023] Open
Abstract
Background The systematic use of confirmatory tests in the diagnosis of primary aldosteronism (PA) increases costs, risks and complexity to the diagnostic work-up. In light of this, some authors proposed aldosterone-to-renin (ARR) cut-offs and/or integrated flow-charts to avoid this step. Patients with resistant hypertension (RH), however, are characterized by a dysregulated renin-angiotensin-aldosterone system, even in the absence of PA. Thus, it is unclear whether these strategies might be applied with the same diagnostic reliability in the setting of RH. Methods We enrolled 129 consecutive patients diagnosed with RH and no other causes of secondary hypertension. All patients underwent full biochemical assessment for PA, encompassing both basal measurements and a saline infusion test. Results 34/129 patients (26.4%) were diagnosed with PA. ARR alone provided a moderate-to-high accuracy in predicting the diagnosis of PA (AUC=0.908). Among normokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 41.8 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 67%, respectively (AUC=0.882); an ARR > 179.6 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, but was associated with a very low sensitivity of 20%. Among hypokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 49.2 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 83%, respectively (AUC=0.941); an ARR > 104.0 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, with a sensitivity of 64%. Conclusions Among normokalemic patients, there was a wide overlap in ARR values between those with PA and those with essential RH; the possibility to skip a confirmatory test should thus be considered with caution in this setting. A better discriminating ability could be seen in the presence of hypokalemia; in this case, ARR alone may be sufficient to skip confirmatory tests in a suitable percentage of patients.
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Affiliation(s)
- Fabio Bioletto
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Chiara Lopez
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Martina Bollati
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Stefano Arata
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Matteo Procopio
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Federico Ponzetto
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - Guglielmo Beccuti
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giulio Mengozzi
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - Ezio Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Mauro Maccario
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Mirko Parasiliti-Caprino
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
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23
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Karashima S, Kawakami M, Nambo H, Kometani M, Kurihara I, Ichijo T, Katabami T, Tsuiki M, Wada N, Oki K, Ogawa Y, Okamoto R, Tamura K, Inagaki N, Yoshimoto T, Kobayashi H, Kakutani M, Fujita M, Izawa S, Suwa T, Kamemura K, Yamada M, Tanabe A, Naruse M, Yoneda T, Kometani M, Kurihara I, Ichijo T, Katabami T, Tsuiki M, Wada N, Oki K, Ogawa Y, Okamoto R, Tamura K, Inagaki N, Yoshimoto T, Kobayashi H, Kakutani M, Fujita M, Izawa S, Suwa T, Kamemura K, Yamada M, Tanabe A, Naruse M, Yoneda T, Ito H, Takeda Y, Rakugi H, Yamamoto K, Soma M, Yanase T, Fukuda H, Hashimoto S, Ohno Y, Takahashi K, Shibata H, Fujii Y, Suzuki T, Ogo A, Sakamoto R, Kai T, Fukuoka T, Miyauchi S. A hyperaldosteronism subtypes predictive model using ensemble learning. Sci Rep 2023; 13:3043. [PMID: 36810868 PMCID: PMC9943838 DOI: 10.1038/s41598-023-29653-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 02/08/2023] [Indexed: 02/23/2023] Open
Abstract
This study aimed to develop a machine-learning algorithm to diagnose aldosterone-producing adenoma (APA) for predicting APA probabilities. A retrospective cross-sectional analysis of the Japan Rare/Intractable Adrenal Diseases Study dataset was performed using the nationwide PA registry in Japan comprised of 41 centers. Patients treated between January 2006 and December 2019 were included. Forty-six features at screening and 13 features at confirmatory test were used for model development to calculate APA probability. Seven machine-learning programs were combined to develop the ensemble-learning model (ELM), which was externally validated. The strongest predictive factors for APA were serum potassium (s-K) at first visit, s-K after medication, plasma aldosterone concentration, aldosterone-to-renin ratio, and potassium supplementation dose. The average performance of the screening model had an AUC of 0.899; the confirmatory test model had an AUC of 0.913. In the external validation, the AUC was 0.964 in the screening model using an APA probability of 0.17. The clinical findings at screening predicted the diagnosis of APA with high accuracy. This novel algorithm can support the PA practice in primary care settings and prevent potentially curable APA patients from falling outside the PA diagnostic flowchart.
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Affiliation(s)
- Shigehiro Karashima
- grid.9707.90000 0001 2308 3329Institute of Liberal Arts and Science, Kanazawa University, Kanazawa, Japan
| | - Masaki Kawakami
- grid.9707.90000 0001 2308 3329School of Electrical Information Communication Engineering, College of Science and Engineering, Kanazawa University, Kanazawa, Japan
| | - Hidetaka Nambo
- grid.9707.90000 0001 2308 3329School of Electrical Information Communication Engineering, College of Science and Engineering, Kanazawa University, Kanazawa, Japan
| | - Mitsuhiro Kometani
- grid.9707.90000 0001 2308 3329Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Isao Kurihara
- grid.416614.00000 0004 0374 0880Department of Medical Education, National Defense Medical College, Tokorozawa, Japan ,grid.26091.3c0000 0004 1936 9959Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine, Tokyo, Japan
| | - Takamasa Ichijo
- Department of Diabetes and Endocrinology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Takuyuki Katabami
- grid.417363.4Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University Yokohama City Seibu Hospital, Yokohama, Japan
| | - Mika Tsuiki
- grid.410835.bDepartment of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Norio Wada
- grid.415261.50000 0004 0377 292XDepartment of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Kenji Oki
- grid.257022.00000 0000 8711 3200Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshihiro Ogawa
- grid.177174.30000 0001 2242 4849Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryuji Okamoto
- grid.260026.00000 0004 0372 555XDepartment of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Kouichi Tamura
- grid.268441.d0000 0001 1033 6139Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan ,grid.413045.70000 0004 0467 212XDivision of Nephrology and Hypertension, Yokohama City University Medical Center, Yokohama, Japan
| | - Nobuya Inagaki
- grid.258799.80000 0004 0372 2033Department of Diabetes, Endocrinology, and Nutrition, Kyoto University, Kyoto, Japan
| | - Takanobu Yoshimoto
- grid.265073.50000 0001 1014 9130Department of Molecular Endocrinology and Metabolism, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroki Kobayashi
- grid.260969.20000 0001 2149 8846Division of Nephrology, Hypertension, and Endocrinology, Nihon University School of Medicine, Tokyo, Japan
| | - Miki Kakutani
- grid.272264.70000 0000 9142 153XDivision of Diabetes, Endocrinology, and Clinical Immunology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Megumi Fujita
- grid.26999.3d0000 0001 2151 536XDivision of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Shoichiro Izawa
- grid.265107.70000 0001 0663 5064Division of Endocrinology and Metabolism, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Tetsuya Suwa
- grid.256342.40000 0004 0370 4927Department of Diabetes and Endocrinology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Kohei Kamemura
- grid.415766.70000 0004 1771 8393Department of Cardiology, Shinko Hospital, Hyogo, Japan
| | - Masanobu Yamada
- grid.256642.10000 0000 9269 4097Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, 371-8511 Japan
| | - Akiyo Tanabe
- grid.45203.300000 0004 0489 0290Division of Endocrinology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mitsuhide Naruse
- grid.414554.50000 0004 0531 2361Endocrine Center, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Takashi Yoneda
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medicine, Kanazawa, Japan. .,Department of Health Promotion and Medicine of the Future, Kanazawa University Graduate School of Medicine, Kanazawa, Japan. .,Faculty of Transdisciplinary Sciences, Institute of Transdisciplinary Sciences, Kanazawa University, 13-1, Takara-Machi, Kanazawa, 920-8641, Japan.
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Miyamoto S, Yoshida Y, Ozeki Y, Okamoto M, Gotoh K, Masaki T, Nishida H, Fujinami H, Shin T, Daa T, Asayama Y, Shibata H. Pitfalls in the diagnosis and treatment of a hypertensive patient with unilateral primary aldosteronism and contralateral pheochromocytoma: a case report. BMC Endocr Disord 2023; 23:44. [PMID: 36797699 PMCID: PMC9933392 DOI: 10.1186/s12902-023-01297-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 02/08/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Primary aldosteronism (PA) is a common cause of secondary hypertension, whereas pheochromocytoma is a rare cause of it. Thus, concomitant PA and pheochromocytoma is a very rare condition. CASE PRESENTATION A 52-year-old woman was admitted to our hospital with suspected PA based on the presence of hypertension, spontaneous hypokalemia, and a high aldosterone-to-renin ratio. She had no catecholamine excess symptoms other than hypertension. Abdominal computed tomography (CT) showed a right lipid-rich adrenal mass and a left lipid-poor adrenal mass. PA was diagnosed by the captopril challenge test. The 24-h urinary fractionated metanephrines were slightly elevated. Adrenal vein sampling (AVS) confirmed that the right adrenal gland was responsible for aldosterone hypersecretion. Medical therapy with eplerenone was started because the patient refused surgery. Five years later, she requested surgery for PA. The second AVS confirmed right unilateral hyperaldosteronism, as expected. Repeated abdominal CT showed the enlargement of the left adrenal mass. The 24-h urinary fractionated metanephrines had risen to the diagnostic level. 123I- metaiodobenzylguanidine (MIBG) scintigraphy showed a marked tracer uptake in the left adrenal mass with no metastatic lesion. After preoperative management with α-blockade, laparoscopic left partial adrenalectomy was performed. Immunohistochemical examination of the tumor showed chromogranin A positivity leading to the diagnosis of left pheochromocytoma. CONCLUSIONS We report an extremely rare case of concomitant unilateral PA and contralateral pheochromocytoma. When diagnosing unilateral PA by AVS, especially in cases with a lipid-poor adrenal mass, clinicians should rule out the possibility of the presence of pheochromocytoma before proceeding to undergo unilateral adrenalectomy. Although there is no standard treatment for this rare condition, it is essential to select personalized treatment from the perspective of conserving the adrenal gland.
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Affiliation(s)
- Shotaro Miyamoto
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Yufu City, Oita, 879-5593, Japan
| | - Yuichi Yoshida
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Yufu City, Oita, 879-5593, Japan
| | - Yoshinori Ozeki
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Yufu City, Oita, 879-5593, Japan
| | - Mitsuhiro Okamoto
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Yufu City, Oita, 879-5593, Japan
| | - Koro Gotoh
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Yufu City, Oita, 879-5593, Japan
| | - Takayuki Masaki
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Yufu City, Oita, 879-5593, Japan
| | - Haruto Nishida
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Yufu City, Oita, 879-5593, Japan
| | - Hiroyuki Fujinami
- Department of Urology, Faculty of Medicine, Oita University, Yufu City, Oita, 879-5593, Japan
| | - Toshitaka Shin
- Department of Urology, Faculty of Medicine, Oita University, Yufu City, Oita, 879-5593, Japan
| | - Tsutomu Daa
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Yufu City, Oita, 879-5593, Japan
| | - Yoshiki Asayama
- Department of Radiology, Faculty of Medicine, Oita University, Yufu City, Oita, 879-5593, Japan
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Yufu City, Oita, 879-5593, Japan.
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Abstract
Primary aldosteronism (PA) is the most common form of secondary hypertension. Although hypertensive disorders seem to affect around 5-10% of pregnancies worldwide, literature counts less than 80 cases of PA diagnosed during the peri-partum period. In this review we discuss about current knowledge on pathophysiology, natural history, diagnosis and treatment of PA in pregnancy. Because of the physiologic changes in the renin-angiotensin-aldosterone system (RAAS) and the contraindication to both confirmatory test and subtype differentiation, diagnosis of PA during pregnancy is challenging and relies mostly on detection of low/suppressed renin and high aldosterone levels. The course of pregnancy in patients with PA is highly variable, ranging from progesterone-induced amelioration of blood pressure (BP) control to severe and resistant hypertension with potential maternal and fetal complications. Mineralcorticoid receptor antagonists (MRA) are the recommended and most effective drugs for treatment of PA. As the anti-androgenic effect of spironolactone can potentially interfere with sexual development, their prescription is not recommended during pregnancy. On the other side, eplerenone, has proven to be safe and effective in 6 pregnant women and may be added to conventional first line drug regimen in presence of resistant hypertension or persistent hypokalemia. Ideally, patients with unilateral forms of PA should undergo adrenalectomy prior to conception, however, when PA is diagnosed during pregnancy and medical therapy fails to adequately control hypertension or its complications, adrenalectomy can be considered during the second trimester in case of unilateral adrenal mass at MRI-scan.
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Affiliation(s)
- Vittorio Forestiero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Torino, Italy
| | - Elisa Sconfienza
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Torino, Italy
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Torino, Italy.
| | - Silvia Monticone
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Torino, Italy
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26
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Parra Ramírez P, Martín Rojas-Marcos P, Cuesta Hernández M, Ruiz-Sánchez JG, Lamas Oliveira C, Hanzu FA, Araujo-Castro M. First survey on the diagnosis and treatment of primary aldosteronism by Spanish Endocrinology and Nutrition specialists. ENDOCRINOL DIAB NUTR 2022:S2530-0180(22)00241-4. [PMID: 36517385 DOI: 10.1016/j.endien.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/17/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To evaluate the indication and the resources for the screening/diagnosis of primary aldosteronism (PA) in Endocrinology units in Spain. MATERIAL AND METHODS An anonymous 2-phase (2020/2021) online survey was conducted by the AdrenoSEEN group among SEEN members with data about screening, confirmation tests, availability of catheterisation and the treatment of PA. RESULTS Eighty-eight (88) specialists completed the survey. Plasma aldosterone concentration and plasma renin activity were available at all centres; urinary aldosterone was available in 55% of them. The most frequent indications for determining the aldosterone/renin ratio (ARR) were adrenal incidentaloma (82.6%), hypertension with hypokalaemia (82.6%), hypertension in patients <40 years (79.1%) and a family history of PA (77.9%). 61% and 18% of the respondents used an ARR cut-off value of PA of ≥30 and 20ng/dl per ng/mL/, respectively. The intravenous saline loading test was the most commonly used confirmatory test (66.3%), followed by the captopril challenge test (24.4%), with the 25mg dose used more than the 50mg dose (65% versus 35%). 67.4% of the participants confirmed the availability of adrenal vein catheterization (AVC). 41% of this subgroup perform it with a continuous infusion versus 30.5% with an ACTH (1-24) bolus, whereas 70.3% employ sequential adrenal vein catheterization. 48% of the participants reported an AVC success <50%. Total laparoscopic adrenalectomy was the treatment of choice (90.6%), performed by specialists in General and Digestive Surgery specialising in endocrinological pathology. CONCLUSION PA screening and diagnostic tests are extensively available to Spanish endocrinologists. However, there is a major variability in their use and in the cut-off points of the diagnostic methods. The AVS procedure remains poorly standardised and is far from delivering optimal performance. Greater standardisation in the study and diagnosis of PA is called for.
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Affiliation(s)
- Paola Parra Ramírez
- Servicio de Endocrinología y Nutrición, Hospital Universitario La Paz, Madrid, Spain.
| | | | - Martín Cuesta Hernández
- Servicio de Endocrinología y Nutrición, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | - Cristina Lamas Oliveira
- Servicio de Endocrinología y Nutrición, Complejo Universitario Hospitalario de Albacete, Albacete, Spain
| | - Felicia A Hanzu
- Servicio de Endocrinología y Nutrición, Hospital Clínic, Universidad de Barcelona, IDIBAPS, Barcelona, Spain
| | - Marta Araujo-Castro
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Departamento de Ciencias de la Salud, Universidad Alcalá, Madrid, Spain
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27
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Vaidya A, Hundemer GL, Nanba K, Parksook WW, Brown JM. Primary Aldosteronism: State-of-the-Art Review. Am J Hypertens 2022; 35:967-988. [PMID: 35767459 PMCID: PMC9729786 DOI: 10.1093/ajh/hpac079] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022] Open
Abstract
We are witnessing a revolution in our understanding of primary aldosteronism (PA). In the past 2 decades, we have learned that PA is a highly prevalent syndrome that is largely attributable to pathogenic somatic mutations, that contributes to cardiovascular, metabolic, and kidney disease, and that when recognized, can be adequately treated with widely available mineralocorticoid receptor antagonists and/or surgical adrenalectomy. Unfortunately, PA is rarely diagnosed, or adequately treated, mainly because of a lack of awareness and education. Most clinicians still possess an outdated understanding of PA; from primary care physicians to hypertension specialists, there is an urgent need to redefine and reintroduce PA to clinicians with a modern and practical approach. In this state-of-the-art review, we provide readers with the most updated knowledge on the pathogenesis, prevalence, diagnosis, and treatment of PA. In particular, we underscore the public health importance of promptly recognizing and treating PA and provide pragmatic solutions to modify clinical practices to achieve this.
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Affiliation(s)
- Anand Vaidya
- Department of Medicine, Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Kazutaka Nanba
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Wasita W Parksook
- Department of Medicine, Division of Endocrinology and Metabolism, and Division of General Internal Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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28
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Ragnarsson O, Muth A, Johannsson G, Gkaniatsa E, Ung EJ, Jakobsson S. Illness perspectives in patients with primary aldosteronism. PLoS One 2022; 17:e0277902. [PMID: 36441675 PMCID: PMC9704575 DOI: 10.1371/journal.pone.0277902] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 11/05/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The burden of symptoms and treatment in patients with primary aldosteronism (PA), as well as the patients' experience of the health care is sparsely studied. The objectives of this study were to describe symptoms considered to be the most troublesome by patients with PA, and to explore health related worries and expectations following treatment. METHODS This was an explorative qualitative study where 25 patients with PA, diagnosed between 2017 and 2019, were included; 13 patients who had undergone adrenalectomy and 12 who were receiving medical treatment. Data was collected during six group interviews and analyzed using a thematic approach. RESULTS Three main themes were identified: 1) Distress of the past, where the most important issues were struggle to receive a correct diagnosis, impaired well-being and the consumption of a large number of tablets, 2) Satisfaction after receiving a correct diagnosis, both in patients with unilateral and bilateral disease, but also dissatisfaction with lack of information about the disease, and 3) Future concerns, where worries about the long-term effects of PA on health in general dominated. CONCLUSIONS Our findings illustrate several important issues related to PA where improvements in patient care are needed, including actions aiming at shortening the long diagnostic delay, a thorough information to the patients about the disease is of great importance, and that all patients with PA, regardless of treatment, would benefit from a structured long-term follow-up.
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Affiliation(s)
- Oskar Ragnarsson
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
| | - Andreas Muth
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eleftheria Gkaniatsa
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Jakobsson Ung
- Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Sofie Jakobsson
- Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
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29
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Mulatero P, Bertello C, Veglio F, Monticone S. Approach to the Patient on Antihypertensive Therapy: Screen for Primary Aldosteronism. J Clin Endocrinol Metab 2022; 107:3175-3181. [PMID: 35964152 DOI: 10.1210/clinem/dgac460] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Indexed: 11/19/2022]
Abstract
Primary aldosteronism (PA) is a condition that is still largely overlooked, resulting in a considerable burden of mortality and morbidity. This is despite decades of clinical and translational research on the deleterious effects of aldosterone on the cardiovascular system and the publication of several guidelines and consensuses on its diagnosis and treatment. One of the main reasons for the low rate of testing is the difficulty of screening patients on antihypertensive therapy that potentially interferes with aldosterone and renin levels and thus confound the interpretation of the aldosterone to renin ratio, the accepted and conventionally used screening test. To avoid interference, usually the therapies that affect the renin-angiotensin aldosterone system are withdrawn and substituted with noninterfering medications. However, in many cases the screening test can be confidently interpreted even when such therapies are not discontinued. In this review, we will evaluate the effects of antihypertensive therapies on the screening test for PA and suggest a practical approach for its interpretation.
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Affiliation(s)
- Paolo Mulatero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, 10126, Torino, Italy
| | - Chiara Bertello
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, 10126, Torino, Italy
| | - Franco Veglio
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, 10126, Torino, Italy
| | - Silvia Monticone
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, 10126, Torino, Italy
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30
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Abstract
Primary aldosteronism is a common cause of hypertension and is a risk factor for cardiovascular and renal morbidity and mortality, via mechanisms mediated by both hypertension and direct insults to target organs. Despite its high prevalence and associated complications, primary aldosteronism remains largely under-recognized, with less than 2% of people in at-risk populations ever tested. Fundamental progress made over the past decade has transformed our understanding of the pathogenesis of primary aldosteronism and of its clinical phenotypes. The dichotomous paradigm of primary aldosteronism diagnosis and subtyping is being redefined into a multidimensional spectrum of disease, which spans subclinical stages to florid primary aldosteronism, and from single-focal or multifocal to diffuse aldosterone-producing areas, which can affect one or both adrenal glands. This Review discusses how redefining the primary aldosteronism syndrome as a multidimensional spectrum will affect the approach to the diagnosis and subtyping of primary aldosteronism.
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Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA.
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Obeid H, Chen Cardenas SM, Khairi S, Turcu AF. Personalized Treatment of Patients With Primary Aldosteronism. Endocr Pract 2022:S1530-891X(22)00649-8. [PMID: 36273684 DOI: 10.1016/j.eprac.2022.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/12/2022] [Accepted: 10/14/2022] [Indexed: 01/22/2023]
Abstract
Primary aldosteronism (PA) is a highly prevalent yet underdiagnosed secondary cause of hypertension. PA is associated with increased cardiovascular and renal morbidity compared with patients with primary hypertension. Thus, prompt identification and targeted therapy of PA are essential to reduce cardiovascular and renal morbidity and mortality in a large population with hypertension. Unilateral adrenalectomy is preferred for lateralized PA as the only potentially curative therapy. Surgery also mitigates the risk of cardiovascular and renal complications associated with PA. Targeted medical therapy, commonly including a mineralocorticoid receptor antagonist, is offered to patients with bilateral PA and those who are not surgical candidates. Novel therapies, including nonsteroidal mineralocorticoid receptor antagonists and aldosterone synthase inhibitors, are being developed as alternative options for PA treatment. In this review article, we discuss how to best individualize therapy for patients with PA.
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Affiliation(s)
- Hiba Obeid
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan
| | - Stanley M Chen Cardenas
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shafaq Khairi
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan
| | - Adina F Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan.
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Clinical Translationality of KCNJ5 Mutation in Aldosterone Producing Adenoma. Int J Mol Sci 2022; 23:ijms23169042. [PMID: 36012306 PMCID: PMC9409469 DOI: 10.3390/ijms23169042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022] Open
Abstract
Hypertension due to primary aldosteronism poses a risk of severe cardiovascular complications compared to essential hypertension. The discovery of the KCNJ5 somatic mutation in aldosteroene producing adenoma (APA) in 2011 and the development of specific CYP11B2 antibodies in 2012 have greatly advanced our understanding of the pathophysiology of primary aldosteronism. In particular, the presence of CYP11B2-positive aldosterone-producing micronodules (APMs) in the adrenal glands of normotensive individuals and the presence of renin-independent aldosterone excess in normotensive subjects demonstrated the continuum of the pathogenesis of PA. Furthermore, among the aldosterone driver mutations which incur excessive aldosterone secretion, KCNJ5 was a major somatic mutation in APA, while CACNA1D is a leading somatic mutation in APMs and idiopathic hyperaldosteronism (IHA), suggesting a distinctive pathogenesis between APA and IHA. Although the functional detail of APMs has not been still uncovered, its impact on the pathogenesis of PA is gradually being revealed. In this review, we summarize the integrated findings regarding APA, APM or diffuse hyperplasia defined by novel CYP11B2, and aldosterone driver mutations. Following this, we discuss the clinical implications of KCNJ5 mutations to support better cardiovascular outcomes of primary aldosteronism.
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Turcu AF, Nhan W, Grigoryan S, Zhang L, Urban C, Liu H, Holevinski L, Zhao L. Primary Aldosteronism Screening Rates Differ with Sex, Race, and Comorbidities. J Am Heart Assoc 2022; 11:e025952. [PMID: 35861830 PMCID: PMC9707846 DOI: 10.1161/jaha.122.025952] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background
Primary aldosteronism (PA) is a common but under‐recognized cause of secondary hypertension. Data directly comparing screening rates across single and overlapping indications are lacking.
Methods and Results
We conducted a retrospective review of adults with hypertension seen in outpatient clinics at a tertiary referral academic center between January 1, 2017, and June 30, 2020. We included patients with hypertension plus at least one of the following: resistant hypertension; age<35 years; obstructive sleep apnea; hypokalemia; or an adrenal mass. We excluded patients with adrenal insufficiency, severe renal disease, or heart failure, and renovascular hypertension. Of 203 535 patients with hypertension, 86044 (42.3%) met at least 1 PA screening criterion, and of these, 2898 (3.4%) were screened for PA. Screening occurred in 2.7% of patients with resistant hypertension; 4.2% of those with obstructive sleep apnea; 5.1% of those <35 years; 10.0% of those with hypokalemia; and 47.3% of patients with an adrenal mass. Screening rates were higher in patients with multiple risk factors: 16.8% for ≥3, 5.7% for 2, and 2.5% for 1 criterion. Multiple logistic regression showed that the odds of PA screening were higher in patients with hypokalemia: odds ratio (95% CI): 3.0 (2.7–3.3); women: 1.3 (1.2–1.4); Black versus White: 1.5 (1.4–1.7); those with obstructive sleep apnea, chronic renal disease, stroke, and dyslipidemia.
Conclusions
Consideration for PA is given in a small subset of at‐risk patients, and typically after comorbidities have developed.
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Affiliation(s)
- Adina F. Turcu
- Division of Metabolism, Endocrinology, and Diabetes University of Michigan Ann Arbor MI
| | - Winnie Nhan
- Division of Metabolism, Endocrinology, and Diabetes University of Michigan Ann Arbor MI
| | - Seda Grigoryan
- Division of Metabolism, Endocrinology, and Diabetes University of Michigan Ann Arbor MI
| | - Lei Zhang
- School of Public Health University of Michigan Ann Arbor MI
| | - Caitlin Urban
- Michigan State University College of Human Medicine East Lansing MI
| | - Haiping Liu
- Division of Metabolism, Endocrinology, and Diabetes University of Michigan Ann Arbor MI
| | - Lynn Holevinski
- University of Michigan Medical School, Data Office for Clinical and Translational Research Ann Arbor MI
| | - Lili Zhao
- School of Public Health University of Michigan Ann Arbor MI
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Parra Ramírez P, Martín Rojas-Marcos P, Cuesta Hernández M, Ruiz-Sánchez JG, Lamas Oliveira C, Hanzu FA, Araujo-Castro M. Primera encuesta sobre el diagnóstico y tratamiento del hiperaldosteronismo primario por especialistas españoles en Endocrinología y Nutrición. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Nainani AK, Yang J, Peters S, Russell G. 'I can't understand why others don't screen more': a qualitative study exploring why Australian general practitioners screen for primary aldosteronism. BMJ Open 2022; 12:e061671. [PMID: 35697463 PMCID: PMC9196168 DOI: 10.1136/bmjopen-2022-061671] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE We sought to understand the factors that influence a general practitioner's (GP's) experience of screening for primary aldosteronism (PA) in hypertensive patients. DESIGN A qualitative study, framed by phenomenology, using semistructured interviews that were audiorecorded, transcribed verbatim, entered into NVivo V.12.0 for coding and analysed for emerging themes. SETTING Melbourne, Australia. PARTICIPANTS Eligible GPs had received education on PA as part of a previous study. We recruited a purposive sample of 16 GPs (6 females, 10 males) who varied in practice location, clinical experience and the number of patients screened for PA. RESULTS Although GPs had been educated about PA, they found it challenging to explain the condition to patients and were uncertain about how to screen patients who were already taking antihypertensive medications. Most viewed the screening process to be practical, inexpensive and, by and large, acceptable to their patients. However, they found it inconvenient to alter antihypertensive medications before screening to allow for easier interpretation of the aldosterone-renin ratio. They were also less enthused about screening patients whom they thought fitted a clinical picture of essential hypertension. Knowledge of the screening process, cost and convenience of performing the aldosterone-renin ratio, conceptualisation of risk related to PA, and a desire to improve clinical care were influencing factors that modified the GPs' screening experience. CONCLUSION Our findings suggest that knowledge gaps, practical limitations of the aldosterone-renin ratio, and errors in diagnostic reasoning were challenges of routine PA screening. Most of these practical barriers could be addressed by relatively simple educational and practice modifications to increase PA screening rates and optimise detection for the most common cause of secondary hypertension in primary care.
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Affiliation(s)
| | - Jun Yang
- Department of Medicine, Monash Health, Clayton, Victoria, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Sanne Peters
- Department of General Practice, Monash University, Clayton, Victoria, Australia
| | - Grant Russell
- Department of General Practice, Monash University, Clayton, Victoria, Australia
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Prevalence and clinical characteristics of primary aldosteronism in a tertiary-care center in Korea. Hypertens Res 2022; 45:1418-1429. [PMID: 35681044 DOI: 10.1038/s41440-022-00948-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 11/08/2022]
Abstract
Approximately 29% of Korean adults have hypertension; however, the prevalence of primary aldosteronism among the hypertensive population is largely unknown. The aim of our study was to evaluate the prevalence and clinical characteristics of primary aldosteronism in a tertiary-care center in Korea. We retrospectively analyzed 1173 patients with newly diagnosed or preexisting hypertension who were referred to our tertiary-care hospital between January 2013 and December 2018. Patients were screened for primary aldosteronism with the aldosterone-renin ratio and underwent a saline infusion test for diagnostic confirmation. Adrenal computed tomography and adrenal venous sampling were performed for subtype classification for primary aldosteronism. Among the 1173 patients (mean age, 51.8 years; women, 53.2%), 360 (30.7%) had positive screening-test results, of whom 71 (6.1%) were finally diagnosed with primary aldosteronism. Conclusive subtype differentiation was made in 55 patients, of whom 15 (27%) had an aldosterone-producing adenoma, 4 (7%) had unilateral adrenal hyperplasia, and 36 (66%) had bilateral adrenal hyperplasia. Patients with primary aldosteronism had a higher ambulatory blood pressure, left ventricular mass index, and urinary albumin-to-creatinine ratio than those without. Moreover, the primary aldosteronism group had a higher prevalence of left ventricular hypertrophy and albuminuria than the non-primary aldosteronism group. Primary aldosteronism may be more common (6.1%) among Korean patients with hypertension than generally recognized. Primary aldosteronism was associated with a higher degree and prevalence of target organ damage and a higher blood pressure level. Wide application of screening tests for primary aldosteronism may be beneficial in detecting this potentially curable cause of hypertension.
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Poor Performance of Angiotensin II Enzyme-Linked Immuno-Sorbent Assays in Mostly Hypertensive Cohort Routinely Screened for Primary Aldosteronism. Diagnostics (Basel) 2022; 12:diagnostics12051124. [PMID: 35626280 PMCID: PMC9139787 DOI: 10.3390/diagnostics12051124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/23/2022] [Accepted: 04/27/2022] [Indexed: 01/27/2023] Open
Abstract
Primary aldosteronism (PA) is the most common, but broadly underdiagnosed, form of hormonal hypertension. To improve screening procedures, current biochemical approaches aim to determine newly appreciated angiotensin II (Ang II) and calculate the aldosterone-to-angiotensin II ratio (AA2R). Thus, the aim of this study was to assess the diagnostic performance of these screening tests in comparison to the aldosterone-to-direct renin ratio (ADRR), which is routinely used. Cheap and available ELISA was used for Ang II measurement. To our knowledge, this is the first study of this laboratory method’s usage in PA. The study cohort included 20 PA patients and 80 controls. Ang II concentrations were comparable between PA and non-PA patients (773.5 vs. 873.2 pg/mL, p = 0.23, respectively). The AA2R was statistically significantly higher in PA group when compared with non-PA (0.024 vs. 0.012 ng/dL/pg/mL, p < 0.001). However, the diagnostic performance of the AA2R was significantly worse than that of the ADRR (AUROC 0.754 vs. 0.939, p < 0.01). The sensitivity and specificity of the AA2R were 70% and 76.2%, respectively. Thus, the AA2R was not effective as a screening tool for PA. Our data provide important arguments in the discussion on the unsatisfactory accuracy of renin−angiotensin system evaluation by recently repeatedly used ELISA tests.
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Stavropoulos K, Imprialos KP, Patoulias D, Katsimardou A, Doumas M. Impact of Primary Aldosteronism in Resistant Hypertension. Curr Hypertens Rep 2022; 24:285-294. [PMID: 35445928 DOI: 10.1007/s11906-022-01190-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW In this narrative review, we aim to summarize the latest data on the association between primary aldosteronism and resistant hypertension, as well as to emphasize the necessity for screening for primary aldosteronism all patients with resistant hypertension. RECENT FINDINGS Epidemiological data suggests that up to one out of five patients with resistant hypertension suffer from primary aldosteronism. Patients with primary aldosteronism have increased incidence of renal disease, diabetes mellitus, atrial fibrillation, and obstructive sleep apnea, as well as they are characterized by an extended target organ damage and increased cardiovascular morbidity and mortality. Specific treatments for primary hyperaldosteronism (adrenalectomy and mineralocorticoid receptor antagonists) have significant impact on blood pressure, can reverse target organ damage, and mitigate cardiovascular risk. All patients with resistant hypertension should be evaluated for primary aldosteronism. Patients diagnosed with the disease may further undergo lateralization with adrenal vein sampling in order to receive the optimal therapeutic option which results in significant improvements in quality of life and cardiovascular profile.
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Affiliation(s)
| | | | - Dimitrios Patoulias
- 2nd Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Alexandra Katsimardou
- 2nd Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Michael Doumas
- 2nd Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
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Affiliation(s)
- Kay Weng Choy
- Department of Pathology, Northern Health, Epping, Australia
| | - Peter J Fuller
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Australia
- Department of Endocrinology, Monash Health, Clayton, Australia
- Department of Medicine, Monash University, Clayton, Australia
| | - Grant Russell
- Department of General Practice, Monash University, Clayton, Australia
| | - Qifu Li
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Marianne Leenaerts
- Governing Board, Primary Aldosteronism Foundation (primaryaldosteronism.org)
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Australia
- Department of Endocrinology, Monash Health, Clayton, Australia
- Department of Medicine, Monash University, Clayton, Australia
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40
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Wannachalee T, Lieberman L, Turcu AF. High Prevalence of Autonomous Aldosterone Production in Hypertension: How to Identify and Treat It. Curr Hypertens Rep 2022; 24:123-132. [PMID: 35165831 DOI: 10.1007/s11906-022-01176-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Primary aldosteronism (PA) affects millions of individuals worldwide. When unrecognized, PA leads to cardiovascular and renal complications via mechanisms independent from those mediated by hypertension. In this review, we emphasize the importance of PA screening in at-risk populations, and we provide options for customized PA therapy, with consideration for a variety of clinical care settings. RECENT FINDINGS Compelling evidence puts PA at the forefront of secondary hypertension etiologies. Cardiovascular and renal damage likely begins in early stages of renin-independent aldosterone excess. PA must be considered not only in patients with resistant hypertension or hypokalemia, but also when hypertension is associated with obstructive sleep apnea or atrial fibrillation, or in those with early-onset hypertension. Screening with plasma aldosterone and renin is widely accessible, and targeted PA therapy can successfully circumvent the excess cardiorenal risk relative to equivalent primary hypertension. Identifying and treating PA in early stages provide opportunities for personalized hypertension therapy in a large number of patients. Additionally, early targeted therapy of PA is essential for pivoting the care of such patients from reactive to preventive of cardiovascular and renal morbidity and mortality.
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Affiliation(s)
- Taweesak Wannachalee
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, 1150 W Medical Center Drive, MSRB II, 5570B, Ann Arbor, MI, 48109, USA.,Division of Endocrinology and Metabolism, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Leedor Lieberman
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, 1150 W Medical Center Drive, MSRB II, 5570B, Ann Arbor, MI, 48109, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, 1150 W Medical Center Drive, MSRB II, 5570B, Ann Arbor, MI, 48109, USA.
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41
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Chikhladze NM. Primary hyperaldosteronism: indications for screening. TERAPEVT ARKH 2022; 94:107-113. [DOI: 10.26442/00403660.2022.01.201324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 11/22/2022]
Abstract
The review discusses the current state of the problem of screening patients for early detection of primary hyperaldosteronism (PHA) as a potential cause of arterial hypertension (AH). The features of screening, methodological errors that make it difficult to interpret the results of the study are considered. The screening criteria are analyzed, based on which it is possible to assess the probability of diagnosis of PHA and judge its prevalence in various populations of patients with AH categories of high risk for the development of PHA. Attention is drawn to the low level of screening in patients with AH in order to detect PHA , and to the need for wider familiarization of doctors with the methods of screening and diagnosis of PHA as the cause of uncontrolled AH. The importance of timely diagnosis of PHA and its targeted treatment to reduce the risk of cardiovascular complications associated with hypersecretion of aldosterone is emphasized.
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Tan SJ, Libianto R, Yang J, Wong J. Screening for Primary Aldosteronism in the Diabetic Population: a cohort study. Intern Med J 2022; 53:709-716. [PMID: 35000250 DOI: 10.1111/imj.15690] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 12/08/2021] [Accepted: 12/14/2021] [Indexed: 11/30/2022]
Abstract
CONTEXT Primary aldosteronism (PA) is the most common endocrine cause of hypertension. It is associated with higher cardio-metabolic risk than essential hypertension. Hypertension is common in patients with type 2 diabetes who carry increased cardiovascular risk, however, it is unknown how frequently they are tested for PA. OBJECTIVE The study aims to assess the extent to which the Endocrine Society's 2016 PA screening guidelines have been applied in a tertiary diabetes care setting and evaluate the demographic, clinical and biochemical characteristics of patients who met screening criteria compared to those who did not. RESEARCH DESIGN & METHODS This is a retrospective cohort study. Data were collected from 272 patients who attended tertiary Diabetes Clinics and had two or more blood pressure measurements from January to December 2018. RESULTS Of 272 patients, 63 (23.2%) had indication(s) for PA screening but only 15 (23.8% of 63) were screened using the aldosterone-to-renin ratio (ARR). Four patients who did not meet screening criteria were screened. Only one of 19 patients screened had an abnormal ARR, however 16 were taking medications known to affect aldosterone and/or renin production. CONCLUSIONS In a tertiary diabetes outpatient setting, only a minority of patients who fulfilled the Endocrine Society criteria for PA screening were actually screened. Appropriate screening for PA in the diabetic hypertensive population is necessary for the diagnosis and targeted treatment of a highly modifiable cardiovascular risk factor. Further studies are needed to develop feasible strategies to identify patients with PA in this population. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Suzanne Joy Tan
- Monash Health Department of Endocrinology, Melbourne, VIC, Australia
| | - Renata Libianto
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, Australia, Research Fellow, Department of Medicine, Monash University
| | - Jennifer Wong
- Clinical Director Diabetes and Vascular Medicine, Monash Health, Melbourne, VIC, Australia and Dept of Medicine, School of Clinical Sciences, Monash University
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43
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Williams TA, Reincke M. Pathophysiology and histopathology of primary aldosteronism. Trends Endocrinol Metab 2022; 33:36-49. [PMID: 34743804 DOI: 10.1016/j.tem.2021.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/30/2021] [Accepted: 10/09/2021] [Indexed: 10/19/2022]
Abstract
Primary aldosteronism (PA) can be sporadic or familial and classified into unilateral and bilateral forms. Sporadic PA predominates with excessive aldosterone production usually arising from a unilateral aldosterone-producing adenoma (APA) or bilateral adrenocortical hyperplasia. Familial PA is rare and caused by germline variants, that partly correspond to somatic alterations in APAs. Classification into unilateral and bilateral PA determines the treatment approach but does not accurately mirror disease pathology. Some evidence indicates a disease continuum ranging from balanced aldosterone production from each adrenal to extreme asymmetrical bilateral aldosterone production. Nonetheless, surgical removal of the overactive adrenal in unilateral PA achieves highly successful outcomes and almost all patients are biochemically cured of their aldosteronism.
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Affiliation(s)
- Tracy Ann Williams
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany
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44
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Conroy PC, Hernandez S, Graves CE, Menut KCH, Pearlstein S, Liu C, Shen WT, Gosnell J, Sosa JA, Roman S, Duh QY, Suh I. Screening for Primary Aldosteronism is Underutilized in Patients with Obstructive Sleep Apnea. Am J Med 2022; 135:60-66. [PMID: 34508708 PMCID: PMC9289750 DOI: 10.1016/j.amjmed.2021.07.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/28/2021] [Accepted: 07/31/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Resistant hypertension is common in patients with primary aldosteronism and in those with obstructive sleep apnea. Primary aldosteronism treatment improves sleep apnea. Despite Endocrine Society guidelines' inclusion of sleep apnea and hypertension co-diagnosis as a primary aldosteronism screening indication, the state of screening implementation is unknown. METHODS All hypertensive adult patients with obstructive sleep apnea (n = 4751) at one institution between 2012 and 2020 were compared with a control cohort without sleep apnea (n = 117,815). We compared the association of primary aldosteronism diagnoses, risk factors, and screening between both groups. Patients were considered to have screening if they had a primary aldosteronism diagnosis or serum aldosterone or plasma renin activity evaluation. RESULTS Obstructive sleep apnea patients were predominantly men and had higher body mass index. On multivariable analysis, hypertensive sleep apnea patients had higher odds of drug-resistant hypertension (odds ratio [OR] 2.70; P < .001) and hypokalemia (OR 1.26; P < .001) independent of body mass index, sex, and number of antihypertensive medications. Overall, sleep apnea patients were more likely to be screened for primary aldosteronism (OR 1.45; P < .001); however, few patients underwent screening whether they had sleep apnea or not (pre-guideline publication 7.8% vs 4.6%; post-guidelines 3.6% vs 4.6%; P < .01). Screening among eligible sleep apnea patients remained low prior to and after guideline publication (4.4% vs 3.4%). CONCLUSIONS Obstructive sleep apnea is associated with primary aldosteronism risk factors without formal diagnosis, suggesting screening underutilization and underdiagnosis. Strategies are needed to increase screening adherence, as patients may benefit from treatment of concomitant primary aldosteronism to reduce sleep apnea severity and its associated cardiopulmonary morbidity.
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Affiliation(s)
| | - Sophia Hernandez
- Department of Surgery; School of Medicine, University of California San Francisco
| | - Claire E Graves
- Department of Surgery, University of California Davis, Sacramento
| | | | | | - Chienying Liu
- Department of Medicine, University of California San Francisco
| | | | | | - Julie A Sosa
- Department of Surgery; Department of Medicine, University of California San Francisco
| | | | | | - Insoo Suh
- Department of Surgery, New York University Langone Health, New York, NY.
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45
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Lin W, Gan W, Feng P, Zhong L, Yao Z, Chen P, He W, Yu N. Online prediction model for primary aldosteronism in patients with hypertension in Chinese population: A two-center retrospective study. Front Endocrinol (Lausanne) 2022; 13:882148. [PMID: 35983513 PMCID: PMC9380986 DOI: 10.3389/fendo.2022.882148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The prevalence of primary aldosteronism (PA) varies from 5% to 20% in patients with hypertension but is largely underdiagnosed. Expanding screening for PA to all patients with hypertension to improve diagnostic efficiency is needed. A novel and portable prediction tool that can expand screening for PA is highly desirable. METHODS Clinical characteristics and laboratory data of 1,314 patients with hypertension were collected for modeling and randomly divided into a training cohort (919 of 1,314, 70%) and an internal validation cohort (395 of 1,314, 30%). Additionally, an external dataset (n = 285) was used for model validation. Machine learning algorithms were applied to develop a discriminant model. Sensitivity, specificity, and accuracy were used to evaluate the performance of the model. RESULTS Seven independent risk factors for predicting PA were identified, including age, sex, hypokalemia, serum sodium, serum sodium-to-potassium ratio, anion gap, and alkaline urine. The prediction model showed sufficient predictive accuracy, with area under the curve (AUC) values of 0.839 (95% CI: 0.81-0.87), 0.814 (95% CI: 0.77-0.86), and 0.839 (95% CI: 0.79-0.89) in the training set, internal validation, and external validation set, respectively. The calibration curves exhibited good agreement between the predictive risk of the model and the actual risk. An online prediction model was developed to make the model more portable to use. CONCLUSION The online prediction model we constructed using conventional clinical characteristics and laboratory tests is portable and reliable. This allowed it to be widely used not only in the hospital but also in community health service centers and may help to improve the diagnostic efficiency of PA.
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Affiliation(s)
- Wenbin Lin
- Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- Department of Clinical Laboratory, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wenjia Gan
- Department of Clinical Laboratory, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Pinning Feng
- Department of Clinical Laboratory, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Liangying Zhong
- Department of Clinical Laboratory, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhenrong Yao
- Department of Clinical Laboratory, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Peisong Chen
- Department of Clinical Laboratory, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- *Correspondence: Nan Yu, ; Wanbing He, ; ; Peisong Chen,
| | - Wanbing He
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
- *Correspondence: Nan Yu, ; Wanbing He, ; ; Peisong Chen,
| | - Nan Yu
- Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- Department of Medical Laboratory, School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, China
- *Correspondence: Nan Yu, ; Wanbing He, ; ; Peisong Chen,
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46
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Menut KCH, Pearlstein SS, Conroy PC, Roman SA, Shen WT, Gosnell J, Sosa JA, Duh QY, Suh I. Screening for primary aldosteronism in the hypertensive obstructive sleep apnea population is cost-saving. Surgery 2022; 171:96-103. [PMID: 34238603 PMCID: PMC9308489 DOI: 10.1016/j.surg.2021.05.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/08/2021] [Accepted: 05/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Guidelines recommend screening for primary aldosteronism in patients diagnosed with hypertension and obstructive sleep apnea. Recent studies have shown that adherence to these recommendations is extremely low. It has been suggested that cost is a barrier to implementation. No analysis has been done to rigorously evaluate the cost-effectiveness of widespread implementation of these guidelines. METHODS We constructed a decision-analytic model to evaluate screening of the hypertensive obstructive sleep apnea population for primary aldosteronism as per guideline recommendations in comparison with current rates of screening. Probabilities, utility values, and costs were identified in the literature. Threshold and sensitivity analyses assessed robustness of the model. Costs were represented in 2020 US dollars and health outcomes in quality-adjusted life-years. The model assumed a societal perspective with a lifetime time horizon. RESULTS Screening per guideline recommendations had an expected cost of $47,016 and 35.27 quality-adjusted life-years. Continuing at current rates of screening had an expected cost of $48,350 and 34.86 quality-adjusted life-years. Screening was dominant, as it was both less costly and more effective. These results were robust to sensitivity analysis of disease prevalence, test sensitivity, patient age, and expected outcome of medical or surgical treatment of primary aldosteronism. The screening strategy remained cost-effective even if screening were conservatively presumed to identify only 3% of new primary aldosteronism cases. CONCLUSIONS For patients with hypertension and obstructive sleep apnea, rigorous screening for primary aldosteronism is cost-saving due to cardiovascular risk averted. Cost should not be a barrier to improving primary aldosteronism screening adherence.
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Affiliation(s)
| | | | - Patricia C. Conroy
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Sanziana A. Roman
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Wen T. Shen
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Jessica Gosnell
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Julie Ann Sosa
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Quan-Yang Duh
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Insoo Suh
- Division of Endocrine Surgery, New York University Langone Health, New York, NY,Reprint requests: Insoo Suh, MD, NYU Endocrine Surgery Associates, 530 1st Ave, Ste 6H New York, NY 10016. (I. Suh)
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47
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Reincke M, Bancos I, Mulatero P, Scholl UI, Stowasser M, Williams TA. Diagnosis and treatment of primary aldosteronism. Lancet Diabetes Endocrinol 2021; 9:876-892. [PMID: 34798068 DOI: 10.1016/s2213-8587(21)00210-2] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023]
Abstract
Primary aldosteronism is a common cause of secondary hypertension associated with excess cardiovascular morbidities. Primary aldosteronism is underdiagnosed because it does not have a specific, easily identifiable feature and clinicians can be poorly aware of the disease. The diagnostic investigation is a multistep process of screening, confirmatory testing, and subtype differentiation of unilateral from bilateral forms for therapeutic management. Adrenal venous sampling is key for reliable subtype identification, but can be bypassed in patients with specific characteristics. For unilateral disease, surgery offers the possibility of cure, with total laparoscopic unilateral adrenalectomy being the treatment of choice. Bilateral forms are treated mainly with mineralocorticoid receptor antagonists. The goals of treatment are to normalise both blood pressure and excessive aldosterone production, and the primary aims are to reduce associated comorbidities, improve quality of life, and reduce mortality. Prompt diagnosis of primary aldosteronism and the use of targeted treatment strategies mitigate aldosterone-specific target organ damage and with appropriate patient management outcomes can be excellent. Advances in molecular histopathology challenge the traditional concept of primary aldosteronism as a binary disease, caused by either a unilateral aldosterone-producing adenoma or bilateral adrenal hyperplasia. Somatic mutations drive autonomous aldosterone production in most adenomas. Many of these same mutations have been identified in nodular lesions adjacent to an aldosterone-producing adenoma and in patients with bilateral disease. In addition, germline mutations cause rare familial forms of aldosteronism (familial hyperaldosteronism types 1-4). Genetic testing for inherited forms in suspected cases of familial hyperaldosteronism avoids the burdensome diagnostic investigation in positive patients. In this Review, we discuss advances and future management approaches in the diagnosis of primary aldosteronism.
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Affiliation(s)
- Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany.
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ute I Scholl
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Center of Functional Genomics, Berlin, Germany
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland Diamantina Institute, Greenslopes and Princess Alexandra Hospitals, Brisbane, QLD, Australia
| | - Tracy Ann Williams
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy
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48
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Saito K, Kurihara I, Itoh H, Ichijo T, Katabami T, Tsuiki M, Wada N, Yoneda T, Sone M, Oki K, Yamada T, Kobayashi H, Tamura K, Ogawa Y, Kawashima J, Inagaki N, Yamamoto K, Yamada M, Kamemura K, Fujii Y, Suzuki T, Yasoda A, Tanabe A, Naruse M. Subtype-specific trends in the clinical picture of primary aldosteronism over a 13-year period. J Hypertens 2021; 39:2325-2332. [PMID: 34224538 DOI: 10.1097/hjh.0000000000002924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Primary aldosteronism has two main clinically and biologically distinct subtypes: unilateral aldosterone-producing adenoma (APA) and bilateral adrenal hyperplasia (BAH). We aimed to evaluate the changes of each subtype's clinical characteristics over a 13-year period. METHODS This retrospective study involved time-trend analyses to identify changes in the clinical features of APA and BAH at diagnosis (2006-2018). A nationwide database from 41 Japanese referral centers was searched, which identified 2804 primary aldosteronism patients with complete baseline information and adrenal venous sampling (AVS) data. RESULTS The proportion of patients with APA decreased from 51% in 2006-2009 to 22% in 2016-2018. Among the 1634 patients with BAH, trend analyses revealed decreases in hypertension duration (median 7--3 years; P < 0.01) and hypokalemia prevalence (18--11%; P < 0.01). However, among the 952 patients with APA, there were no significant changes in hypertension duration (median 8 years) and hypokalemia prevalence (overall 70%). Furthermore, the APA group had a trend towards increased use of multiple hypertensive drugs at diagnosis (30--43%; P < 0.01). When subtypes were reclassified according to the precosyntropin stimulation AVS data, APA patients tended to be diagnosed earlier and at milder forms, consistent with the trend in overall primary aldosteronism patients. CONCLUSION During 2006-2018, we identified marked subtype-specific trends in the clinical findings at the diagnosis of primary aldosteronism. Our results suggested that the emphasis on the implementing cosyntropin stimulation during AVS might lead to under-identification of APA, especially in patients with mild or early cases.
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Affiliation(s)
- Kohei Saito
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine, Keio University, Tokyo
- Center for Diabetes, Endocrinology and Metabolism, Shizuoka General Hospital, Shizuoka
| | - Isao Kurihara
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine, Keio University, Tokyo
- Department of Medical Education, National Defense Medical College, Tokorozawa
| | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine, Keio University, Tokyo
| | - Takamasa Ichijo
- Department of Endocrinology and Metabolism, Saiseikai Yokohamashi Tobu Hospital, Yokohama
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama
| | - Mika Tsuiki
- Clinical Research Institute of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo
| | - Takashi Yoneda
- Department of Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Masakatsu Sone
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki
| | - Kenji Oki
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima
| | - Tetsuya Yamada
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Hiroki Kobayashi
- Division of Nephrology, Hypertension, and Endocrinology, Nihon University School of Medicine, Tokyo
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Kanagawa
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Junji Kawashima
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology, and Nutrition, Kyoto University, Kyoto
| | - Koichi Yamamoto
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka
| | - Masanobu Yamada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma
| | | | - Yuichi Fujii
- Department of Cardiology, JR Hiroshima Hospital, Hiroshima
| | - Tomoko Suzuki
- Department of Public Health, International University of Health and Welfare School of Medicine, Chiba
| | - Akihiro Yasoda
- Clinical Research Institute of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto
| | - Akiyo Tanabe
- Division of Endocrinology, National Center for Global Health and Medicine, Tokyo
| | - Mitsuhide Naruse
- Clinical Research Institute of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto
- Endocrine Center, Ijinkai Takeda General Hospital, Kyoto, Japan
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49
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Choy KW. Early Diagnosis of Primary Aldosteronism: The Benefits Outweigh the Costs. Heart Lung Circ 2021; 31:e7-e8. [PMID: 34531141 DOI: 10.1016/j.hlc.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 08/10/2021] [Accepted: 08/15/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Kay Weng Choy
- Department of Pathology, The Northern Hospital, Melbourne, Vic, Australia.
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50
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Buffolo F, Burrello J, Burrello A, Heinrich D, Adolf C, Müller LM, Chen R, Forestiero V, Sconfienza E, Tetti M, Veglio F, Williams TA, Mulatero P, Monticone S. Clinical Score and Machine Learning-Based Model to Predict Diagnosis of Primary Aldosteronism in Arterial Hypertension. Hypertension 2021; 78:1595-1604. [PMID: 34488439 DOI: 10.1161/hypertensionaha.121.17444] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Fabrizio Buffolo
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (F.B., J.B., R.C., V.F., E.S., M.T., F.V., T.A.W., P.M., S.M.)
| | - Jacopo Burrello
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (F.B., J.B., R.C., V.F., E.S., M.T., F.V., T.A.W., P.M., S.M.)
| | - Alessio Burrello
- Department of Electrical, Electronic and Information Engineering "Guglielmo Marconi" (DEI), University of Bologna, Italy (A.B.)
| | - Daniel Heinrich
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany (D.H., C.A., L.M.M., T.A.W.)
| | - Christian Adolf
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany (D.H., C.A., L.M.M., T.A.W.)
| | - Lisa Marie Müller
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany (D.H., C.A., L.M.M., T.A.W.)
| | - Rusi Chen
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (F.B., J.B., R.C., V.F., E.S., M.T., F.V., T.A.W., P.M., S.M.)
| | - Vittorio Forestiero
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (F.B., J.B., R.C., V.F., E.S., M.T., F.V., T.A.W., P.M., S.M.)
| | - Elisa Sconfienza
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (F.B., J.B., R.C., V.F., E.S., M.T., F.V., T.A.W., P.M., S.M.)
| | - Martina Tetti
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (F.B., J.B., R.C., V.F., E.S., M.T., F.V., T.A.W., P.M., S.M.)
| | - Franco Veglio
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (F.B., J.B., R.C., V.F., E.S., M.T., F.V., T.A.W., P.M., S.M.)
| | - Tracy Ann Williams
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (F.B., J.B., R.C., V.F., E.S., M.T., F.V., T.A.W., P.M., S.M.).,Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany (D.H., C.A., L.M.M., T.A.W.)
| | - Paolo Mulatero
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (F.B., J.B., R.C., V.F., E.S., M.T., F.V., T.A.W., P.M., S.M.)
| | - Silvia Monticone
- From the Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy (F.B., J.B., R.C., V.F., E.S., M.T., F.V., T.A.W., P.M., S.M.)
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