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Fuld S, Constantinescu G, Pamporaki C, Peitzsch M, Schulze M, Yang J, Müller L, Prejbisz A, Januszewicz A, Remde H, Kürzinger L, Dischinger U, Ernst M, Gruber S, Reincke M, Beuschlein F, Lenders JWM, Eisenhofer G. Screening for Primary Aldosteronism by Mass Spectrometry Versus Immunoassay Measurements of Aldosterone: A Prospective Within-Patient Study. J Appl Lab Med 2024; 9:752-766. [PMID: 38532521 DOI: 10.1093/jalm/jfae017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/18/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Measurements of aldosterone by mass spectrometry are more accurate and less prone to interferences than immunoassay measurements, and may produce a more accurate aldosterone:renin ratio (ARR) when screening for primary aldosteronism (PA). METHODS Differences in diagnostic performance of the ARR using mass spectrometry vs immunoassay measurements of aldosterone were examined in 710 patients screened for PA. PA was confirmed in 153 patients and excluded in 451 others. Disease classifications were not achieved in 106 patients. Areas under receiver-operating characteristic curves (AUROC) and other measures were used to compare diagnostic performance. RESULTS Mass spectrometry-based measurements yielded lower plasma aldosterone concentrations than immunoassay measurements. For the ARR based on immunoassay measurements of aldosterone, AUROCs were slightly lower (P = 0.018) than those using mass spectrometry measurements (0.895 vs 0.906). The cutoff for the ARR to reach a sensitivity of 95% was 30 and 21.5 pmol/mU by respective immunoassay and mass spectrometry-based measurements, which corresponded to specificities of 57% for both. With data restricted to patients with unilateral PA, diagnostic sensitivities of 94% with specificities >81% could be achieved at cutoffs of 68 and 52 pmol/mU for respective immunoassay and mass spectrometry measurements. CONCLUSIONS Mass spectrometry-based measurements of aldosterone for the ARR provide no clear diagnostic advantage over immunoassay-based measurements. Both approaches offer limited diagnostic accuracy for the ARR as a screening test. One solution is to employ the higher cutoffs to triage patients likely to have unilateral PA for further tests and possible adrenalectomy, while using the lower cutoffs to identify others for targeted medical therapy.German Clinical Trials Register ID: DRKS00017084.
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Affiliation(s)
- Sybille Fuld
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Georgiana Constantinescu
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christina Pamporaki
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Manuel Schulze
- Center for Interdisciplinary Digital Sciences, Department Information Services and High Performance Computing, Technische Universität Dresden, Dresden, Germany
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Australia
| | - Lisa Müller
- Department of Medicine IV, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Aleksander Prejbisz
- Department of Epidemiology, Cardiovascular Prevention and Health Promotion, National Institute of Cardiology, Warsaw, Poland
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Hanna Remde
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Lydia Kürzinger
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Ulrich Dischinger
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Matthias Ernst
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
| | - Sven Gruber
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
| | - Martin Reincke
- Department of Medicine IV, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Felix Beuschlein
- Department of Medicine IV, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
- The LOOP Medical Research Center, Zurich, Switzerland
| | - Jacques W M Lenders
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Funes Hernandez M, Bhalla V. Underdiagnosis of Primary Aldosteronism: A Review of Screening and Detection. Am J Kidney Dis 2023; 82:333-346. [PMID: 36965825 DOI: 10.1053/j.ajkd.2023.01.447] [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: 08/26/2022] [Accepted: 01/08/2023] [Indexed: 03/27/2023]
Abstract
A clinical condition may be missed due to its higher-than-recognized prevalence or inadequate diagnostic screening. Both factors apply to primary aldosteronism, which is woefully underdiagnosed as a cause of hypertension and end-organ damage. Screening tests should be strongly considered for diseases that pose significant morbidity or mortality if left untreated, that have a high prevalence, and that have treatments that lead to improvement or cure. In this review we present the evidence for each of these points. We outline studies that estimate the prevalence of primary aldosteronism in different at-risk populations and how its recognition has changed over time. We also evaluate myriad studies of screening rates for primary aldosteronism and what factors do and do not influence current screening practices. We discuss the ideal conditions for screening, measuring the aldosterone to renin ratio in different populations that use plasma renin activity or direct renin concentration, and the steps for diagnostic workup of primary aldosteronism. Finally, we conclude with potential strategies to implement higher rates of screening and diagnosis of this common, consequential, and treatable disease.
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Affiliation(s)
- Mario Funes Hernandez
- Stanford Hypertension Center and Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Vivek Bhalla
- Stanford Hypertension Center and Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California.
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Zhu R, Shagjaa T, Rossitto G, Caroccia B, Seccia TM, Gregori D, Rossi GP. Exclusion Tests in Unilateral Primary Aldosteronism (ExcluPA) Study. J Clin Endocrinol Metab 2023; 108:496-506. [PMID: 36373399 DOI: 10.1210/clinem/dgac654] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022]
Abstract
CONTEXT Determining the diagnostic accuracy of "exclusion" tests for primary aldosteronism (PA) compared to the aldosterone to renin ratio (ARR) is fundamental to avoid invasive subtyping in false-positive patients at screening. OBJECTIVE To assess the accuracy of exclusion tests for PA using the diagnosis of unilateral PA as reference. METHODS PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for studies published from January 1, 1970, to December 31, 2021, meeting tight quality criteria. Data were extracted following the PRISMA methodology. We performed a two-stage meta-analysis that entailed an exploratory and a validation phase based on a "golden" or "gold" diagnostic standard, respectively. Pooled specificity, negative likelihood ratio, diagnostic odds ratio, and summary area under the ROC curve (sAUROC) were calculated to analyze the accuracy of exclusion tests. RESULTS A meta-analysis of 31 datasets comprising a total of 4242 patients fulfilling the predefined inclusion criteria found that pooled accuracy estimates (sAUROC) did not differ between the ARR (0.95; 95% CI, 0.92-0.98), the captopril challenge test (CCT) (0.92; 95% CI, 0.88-0.97), and the saline infusion test (SIT) (0.96; 95% CI, 0.94-0.99). Solid information could not be obtained for the fludrocortisone suppression test and the furosemide upright test, which were assessed in only 1 study each. CONCLUSION The apparently high diagnostic accuracy of the CCT and the SIT was due to the selection of patients with an elevated ARR and thus a high pretest probability of unilateral PA; however, neither test furnished a diagnostic gain over the ARR. Therefore, the systematic use of these exclusion tests in clinical practice is not justified by available evidence.
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Affiliation(s)
- Rui Zhu
- Internal & Emergency Medicine Unit, Department of Medicine - DIMED, University of Padua, 35128 Padua, Italy
- Department of Endocrinology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, 610072 Chengdu, China
| | - Tungalagtamir Shagjaa
- Internal & Emergency Medicine Unit, Department of Medicine - DIMED, University of Padua, 35128 Padua, Italy
- Department of Neurology, Mongolian National University of Medical Sciences, 14200 Ulaanbaatar, Mongolia
| | - Giacomo Rossitto
- Internal & Emergency Medicine Unit, Department of Medicine - DIMED, University of Padua, 35128 Padua, Italy
- School of Cardiovascular & Metabolic Health, University of Glasgow, 126 University Place, G12 8TA Glasgow, UK
| | - Brasilina Caroccia
- Internal & Emergency Medicine Unit, Department of Medicine - DIMED, University of Padua, 35128 Padua, Italy
| | - Teresa Maria Seccia
- Internal & Emergency Medicine Unit, Department of Medicine - DIMED, University of Padua, 35128 Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy
| | - Gian Paolo Rossi
- Internal & Emergency Medicine Unit, Department of Medicine - DIMED, University of Padua, 35128 Padua, Italy
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Eisenhofer G, Kurlbaum M, Peitzsch M, Constantinescu G, Remde H, Schulze M, Kaden D, Müller LM, Fuss CT, Kunz S, Kołodziejczyk-Kruk S, Gruber S, Prejbisz A, Beuschlein F, Williams TA, Reincke M, Lenders JWM, Bidlingmaier M. The Saline Infusion Test for Primary Aldosteronism: Implications of Immunoassay Inaccuracy. J Clin Endocrinol Metab 2022; 107:e2027-e2036. [PMID: 34963138 PMCID: PMC9016451 DOI: 10.1210/clinem/dgab924] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Indexed: 11/24/2022]
Abstract
CONTEXT Diagnosis of primary aldosteronism (PA) for many patients depends on positive results for the saline infusion test (SIT). Plasma aldosterone is often measured by immunoassays, which can return inaccurate results. OBJECTIVE This study aimed to establish whether differences in aldosterone measurements by immunoassay versus mass spectrometry (MS) might impact confirmatory testing for PA. METHODS This study, involving 240 patients tested using the SIT at 5 tertiary care centers, assessed discordance between immunoassay and MS-based measurements of plasma aldosterone. RESULTS Plasma aldosterone measured by Liaison and iSYS immunoassays were respectively 86% and 58% higher than determined by MS. With an immunoassay-based SIT cutoff for aldosterone of 170 pmol/L, 78 and 162 patients had, respectivel, negative and positive results. All former patients had MS-based measurements of aldosterone < 117 pmol/L, below MS-based cutoffs of 162 pmol/L. Among the 162 patients with pathogenic SIT results, MS returned nonpathologic results in 62, including 32 under 117 pmol/L. Repeat measurements by an independent MS method confirmed nonpathogenic results in 53 patients with discordant results. Patients with discordant results showed a higher (P < 0.0001) prevalence of nonlateralized than lateralized adrenal aldosterone production than patients with concordant results (83% vs 28%). Among patients with nonlateralized aldosterone production, 66% had discordant results. Discordance was more prevalent for the Liaison than iSYS immunoassay (32% vs 16%; P = 0.0065) and was eliminated by plasma purification to remove interferents. CONCLUSION These findings raise concerns about the validity of immunoassay-based diagnosis of PA in over 60% of patients with presumed bilateral disease. We provide a simple solution to minimize immunoassay inaccuracy-associated misdiagnosis of PA.
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Affiliation(s)
- Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Max Kurlbaum
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Georgiana Constantinescu
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hanna Remde
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Manuel Schulze
- Center for Information Services and High Performance Computing, Technische Universität Dresden, Dresden, Germany
| | - Denise Kaden
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Lisa Marie Müller
- Department of Medicine IV, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Carmina T Fuss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Sonja Kunz
- Department of Medicine IV, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | | | - Sven Gruber
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Felix Beuschlein
- Department of Medicine IV, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
| | - Tracy Ann Williams
- Department of Medicine IV, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Martin Reincke
- Department of Medicine IV, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Jacques W M Lenders
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Martin Bidlingmaier
- Department of Medicine IV, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
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Diagnostic value of aldosterone to renin ratio calculated by plasma renin activity or plasma renin concentration in primary aldosteronism. Chin Med J (Engl) 2021; 135:639-647. [PMID: 35471479 PMCID: PMC9276467 DOI: 10.1097/cm9.0000000000001906] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Since the diagnostic value of aldosterone to renin ratio (ARR) calculated by plasma renin concentration (PRC) or plasma renin activity (PRA) is still inconclusive, we conducted a meta-analysis by systematically reviewing relevant literature to explore the difference in the diagnostic efficacy of ARR calculated by PRC or PRA, so as to provide guidance for clinical diagnosis. Methods: We searched PubMed, Embase, and Cochrane Library from the establishment of the database to March 2021. We included studies that report the true positive, false positive, true negative, and false negative values for the diagnosis of primary aldosteronism, and we excluded duplicate publications, research without full text, incomplete information, or inability to conduct data extraction, animal experiments, reviews, and systematic reviews. STATA 15.1 was used to analyze the data. Results: The pooled results showed that ARR (plasma aldosterone concentration [PAC]/PRC) had a sensitivity of 0.82 (95% confidence interval [CI]: 0.78–0.86), a specificity of 0.94 (95% CI: 0.92–0.95), a positive-likelihood ratio (LR) of 12.77 (95% CI: 7.04–23.73), a negative LR of 0.11 (95% CI: 0.07–0.17), and symmetric area under the curve (SAUC) of 0.982, respectively. Furthermore, the diagnostic odds ratio (DOR) of ARR (PAC/PRC) was 180.21. Additionally, the pooled results showed that ARR (PAC/PRA) had a sensitivity of 0.91 (95% CI: 0.86–0.95), a specificity of 0.91 (95% CI: 0.90–0.93), a positive LR of 7.30 (95% CI: 2.99–17.99), a negative LR of 0.10 (95% CI: 0.04–0.26), and SAUC of 0.976, respectively. The DOR of ARR (PAC/PRA) was 155.52. Additionally, we conducted a subgroup analysis for the different thresholds (<35 or ≥35) of PAC/PRC. The results showed that the DOR of the cut-off ≥35 groups was higher than the cut-off <35 groups (DOR = 340.15, 95% CI: 38.32–3019.66; DOR = 116.40, 95% CI = 23.28–581.92). Conclusions: The research results suggest that the determination of ARR (PAC/PRC) and ARR (PAC/PRA) was all effective screening tools for PA. The diagnostic accuracy and diagnostic value of ARR (PAC/PRC) are higher than ARR (PAC/PRA). In addition, within a certain range, the higher the threshold, the better the diagnostic value.
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6
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Hung A, Ahmed S, Gupta A, Davis A, Kline GA, Leung AA, Ruzicka M, Hiremath S, Hundemer GL. Performance of the Aldosterone to Renin Ratio as a Screening Test for Primary Aldosteronism. J Clin Endocrinol Metab 2021; 106:2423-2435. [PMID: 34008000 DOI: 10.1210/clinem/dgab348] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Indexed: 12/17/2022]
Abstract
CONTEXT The aldosterone to renin ratio (ARR) is the guideline-recommended screening test for primary aldosteronism. However, there are limited data in regard to the diagnostic performance of the ARR. OBJECTIVE To evaluate the sensitivity and specificity of the ARR as a screening test for primary aldosteronism. METHODS We searched the MEDLINE, Embase, and Cochrane databases until February 2020. Observational studies assessing ARR diagnostic performance as a screening test for primary aldosteronism were selected. To limit verification bias, only studies where dynamic confirmatory testing was implemented as a reference standard regardless of the ARR result were included. Study-level data were extracted and risk of bias and applicability were assessed using the QUADAS-2 tool. RESULTS Ten studies, involving a total of 4110 participants, were included. Potential risk of bias related to patient selection was common and present in half of the included studies. The population base, ARR positivity threshold, laboratory assay, and reference standard for confirmatory testing varied substantially between studies. The reported ARR sensitivity and specificity varied widely with sensitivity ranging from 10% to 100% and specificity ranging from 70% to 100%. Notably, 3 of the 10 studies reported an ARR sensitivity of <50%, suggesting a limited ability of the ARR to adequately identify patients with primary aldosteronism. CONCLUSIONS ARR performance varied widely based on patient population and diagnostic criteria, especially with respect to sensitivity. Therefore, no single ARR threshold for interpretation could be recommended. Limitations in accuracy and reliability of the ARR must be recognized in order to appropriately inform clinical decision-making.
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Affiliation(s)
- Annie Hung
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Sumaiya Ahmed
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Ankur Gupta
- Department of Medicine (Division of Nephrology), Whakatane Hospital, Whakatane, New Zealand
| | | | - Gregory A Kline
- Department of Medicine (Division of Endocrinology and Metabolism), Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alexander A Leung
- Department of Medicine (Division of Endocrinology and Metabolism), Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marcel Ruzicka
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON,Canada
| | - Swapnil Hiremath
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON,Canada
| | - Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON,Canada
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Vorselaars WMCM, van Beek DJ, Suurd DPD, Postma E, Spiering W, Borel Rinkes IHM, Valk GD, Vriens MR. Adrenalectomy for Primary Aldosteronism: Significant Variability in Work-Up Strategies and Low Guideline Adherence in Worldwide Daily Clinical Practice. World J Surg 2021; 44:1905-1915. [PMID: 32025781 DOI: 10.1007/s00268-020-05408-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Various diagnostic tests are available to establish the primary aldosteronism (PA) diagnosis and to determine the disease laterality. Combined with the controversies in the literature, unawareness of guidelines and technical demands and high costs of some of these diagnostics, this could lead to significant differences in work-up strategies worldwide. Therefore, we investigated the work-up before surgery for PA in daily clinical practice within a multicenter study. METHODS Patients who underwent unilateral adrenalectomy for PA within 16 centers in Europe, Canada, Australia and the USA between 2010 and 2016 were included. We did not exclude patients based on the performed diagnostic tests during work-up to make our data representative for current clinical practice. Adherence to the Endocrine Society Guideline and variables associated with not performing adrenal venous sampling (AVS) were analyzed. RESULTS In total, 435 patients were eligible. An aldosterone-to-renin ratio, confirmatory test, computed tomography (CT), magnetic resonance imaging and AVS were performed in 82.9%, 32.9%, 86.9%, 17.0% and 65.3% of patients, respectively. A complete work-up, as recommended by the guideline, was performed in 13.1% of patients. Bilateral disease or normal adrenal anatomy on CT (OR 16.19; CI 3.50-74.99), smaller tumor size on CT (OR 0.06; CI 0.04-0.08) and presence of hypokalemia (OR 2.00; CI 1.19-3.32) were independently associated with performing AVS. CONCLUSIONS This study is the first to examine the daily clinical practice work-up of PA within a worldwide cohort of surgical patients. The results demonstrate significant variability in work-up strategies and low adherence to The Endocrine Society guideline.
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Affiliation(s)
- Wessel M C M Vorselaars
- Department of Surgical Oncology and Endocrine Surgery, University Medical Center Utrecht, Room G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Dirk-Jan van Beek
- Department of Surgical Oncology and Endocrine Surgery, University Medical Center Utrecht, Room G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Diederik P D Suurd
- Department of Surgical Oncology and Endocrine Surgery, University Medical Center Utrecht, Room G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Emily Postma
- Department of Surgical Oncology and Endocrine Surgery, University Medical Center Utrecht, Room G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Inne H M Borel Rinkes
- Department of Surgical Oncology and Endocrine Surgery, University Medical Center Utrecht, Room G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Menno R Vriens
- Department of Surgical Oncology and Endocrine Surgery, University Medical Center Utrecht, Room G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Veldhuizen GP, Alnazer RM, Kroon AA, de Leeuw PW. Confounders of the aldosterone-to-renin ratio when used as a screening test in hypertensive patients: A critical analysis of the literature. J Clin Hypertens (Greenwich) 2020; 23:201-207. [PMID: 33368994 PMCID: PMC8030008 DOI: 10.1111/jch.14117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/21/2022]
Abstract
The aldosterone‐to‐renin ratio (ARR) is a common screening test for primary aldosteronism in hypertensives. However, there are many factors which could confound the ARR test result and reduce the accuracy of this test. The present review's objective is to identify these factors and to describe to what extent they affect the ARR. Our analysis revealed that sex, age, posture, and sodium‐intake influence the ARR, whereas assay techniques do not. Race and body mass index have an uncertain effect on the ARR. We conclude that several factors can affect the ARR. Not taking these factors into account could lead to misinterpretation of the ARR.
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Affiliation(s)
- Gregory P Veldhuizen
- Department of Internal Medicine, Maastricht University Medical Center & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Rawan M Alnazer
- Department of Internal Medicine, Maastricht University Medical Center & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Abraham A Kroon
- Department of Internal Medicine, Maastricht University Medical Center & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Peter W de Leeuw
- Department of Internal Medicine, Maastricht University Medical Center & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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van Kleef MEAM, Visseren FLJ, Westerink J, Bots ML, Blankestijn PJ, van der Graaf Y, Spiering W. Development of a clinical decision tool to reduce diagnostic testing for primary aldosteronism in patients with difficult-to-control hypertension. BMC Endocr Disord 2020; 20:56. [PMID: 32349748 PMCID: PMC7191700 DOI: 10.1186/s12902-020-0528-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 03/26/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Satisfactory tools to preclude low-risk patients from intensive diagnostic testing for primary aldosteronism (PA) are lacking. Therefore, we aimed to develop a decision tool to determine which patients with difficult-to-control hypertension have a low probability of PA, thereby limiting the exposure to invasive testing while at the same time increasing the efficiency of testing in the remaining patients. METHODS Data from consecutive patients with difficult-to-control hypertension, analysed through a standardized diagnostic protocol between January 2010 and October 2017 (n = 824), were included in this cross-sectional study. PA was diagnosed by a combined approach: 1) elevated aldosterone-to-renin ratio (> 5.0 pmol/fmol/s), confirmed with 2) non-suppressible aldosterone after standardized saline infusion (≥280 pmol/L). Multivariable logistic regression analyses including seven pre-specified clinical variables (age, systolic blood pressure, serum potassium, potassium supplementation, serum sodium, eGFR and HbA1c) was performed. After correction for optimism, test reliability, discriminative performance and test characteristics were determined. RESULTS PA was diagnosed in 40 (4.9%) of 824 patients. Predicted probabilities of PA agreed well with observed frequencies and the c-statistic was 0.77 (95% confidence interval (95%CI) 0.70-0.83). Predicted probability cut-off values of 1.0-2.5% prevented unnecessary testing in 8-32% of the patients with difficult-to-control hypertension, carrying sensitivities of 0.98 (95%CI 0.96-0.99) and 0.92 (0.83-0.97), and negative predictive values of 0.99 (0.98-1.00) and 0.99 (0.97-0.99). CONCLUSIONS With a decision tool, based on seven easy-to-measure clinical variables, patients with a low probability of PA can be reliably selected and a considerable proportion of patients with difficult-to-control hypertension can be spared intensive diagnostic testing.
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Affiliation(s)
- Monique E. A. M. van Kleef
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, 85500, 3508 GA Utrecht, The Netherlands
| | - Frank L. J. Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, 85500, 3508 GA Utrecht, The Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, 85500, 3508 GA Utrecht, The Netherlands
| | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Peter J. Blankestijn
- Department of Nephrology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Yolanda van der Graaf
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, 85500, 3508 GA Utrecht, The Netherlands
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10
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Yang J, Fuller PJ. Simplifying the Diagnosis of Primary Aldosteronism. J Clin Endocrinol Metab 2020; 105:5638302. [PMID: 31778165 DOI: 10.1210/clinem/dgz202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 11/22/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Victoria, Australia
- Department of Endocrinology, Monash Health, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Peter J Fuller
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Victoria, Australia
- Department of Endocrinology, Monash Health, Victoria, Australia
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11
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Pilz S, Keppel MH, Trummer C, Theiler-Schwetz V, Pandis M, Borzan V, Pittrof M, Obermayer-Pietsch B, Grübler MR, Verheyen N, Stepan V, Meinitzer A, Voelkl J, März W, Tomaschitz A. Diagnostic Accuracy of the Aldosterone-to-Active Renin Ratio for Detecting Primary Aldosteronism. J Endocr Soc 2019; 3:1748-1758. [PMID: 31528833 PMCID: PMC6735732 DOI: 10.1210/js.2019-00145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/15/2019] [Indexed: 11/19/2022] Open
Abstract
Context The aldosterone-to-active renin ratio (AARR) is the recommended screening test for primary aldosteronism (PA), but prospective study data on its sensitivity and specificity are sparse. Objective To investigate the diagnostic accuracy of the AARR for detecting PA. Design Prospective diagnostic accuracy study. Setting This study was conducted from February 2009 to August 2015 at the outpatient clinic of the Department of Endocrinology and Diabetology of the Medical University of Graz, Austria. Participants Four hundred patients with arterial hypertension who were referred to a tertiary care center for screening for endocrine hypertension. Intervention Participants had a determination of the AARR (index test) and a second AARR determination followed by a saline infusion test (SIT) after 2 to 6 weeks. PA was diagnosed in individuals with any AARR ≥3.7 ng/dL/µU/mL [including a plasma aldosterone concentration (PAC) of ≥9 ng/dL] who had a PAC ≥10 ng/dL after the SIT. We did not substantially alter antihypertensive drug intake. Main Outcome Measures Primary outcome was the receiver-operating characteristic (ROC) curve of the AARR in diagnosing PA. Results A total of 382 participants were eligible for analyses; PA was diagnosed in 18 (4.7%) patients. The area under the ROC curve of the AARR in detecting PA was 0.973 (95% CI, 0.956 to 0.990). Sensitivity and specificity for a positive AARR in diagnosing PA were 100% (95% CI, 81.5% to 100.0%) and 89.6% (95% CI, 86.0% to 92.5%), respectively. Conclusions The AARR has good diagnostic accuracy for detecting PA.
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Affiliation(s)
- Stefan Pilz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Martin H Keppel
- University Institute for Medical and Chemical Laboratory Diagnostics, Paracelsus Medical University, Salzburg, Austria
| | - Christian Trummer
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Verena Theiler-Schwetz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Marlene Pandis
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Valentin Borzan
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Matthias Pittrof
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Barbara Obermayer-Pietsch
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria.,CBmed, Center for Biomarker Research in Medicine, Graz, Austria
| | - Martin R Grübler
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Verheyen
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Vinzenz Stepan
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Andreas Meinitzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics Medical, University of Graz, Graz, Austria
| | - Jakob Voelkl
- Institute for Physiology, Johannes Kepler University Linz, Linz, Austria.,Departments of Nephrology and Medical Intensive Care and Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Berlin, Germany.,German Centre for Cardiovascular Research, Berlin, Germany
| | - Winfried März
- Clinical Institute of Medical and Chemical Laboratory Diagnostics Medical, University of Graz, Graz, Austria.,Synlab Academy, Mannheim, Germany.,Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology, Medical Clinic V, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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