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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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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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Case detection in primary aldosteronism: high-diagnostic value of the aldosterone-to-renin ratio when performed under standardized conditions. J Hypertens 2019. [PMID: 29528872 DOI: 10.1097/hjh.0000000000001718] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aldosterone-to-renin ratio is widely used and is the recommended screening modality for primary aldosteronism by the Endocrine Society Guideline. However, studies on its diagnostic accuracy have been inconsistent, which is mainly because of methodological limitations. We set out to evaluate this diagnostic value by using a highly standardized study protocol, which is in line with the Endocrine Society Guideline recommendations regarding indications for screening, testing conditions and reference standards in daily clinical practice. METHODS In this prospective study, 233 consecutive patients referred to the University Medical Center Utrecht with difficult-to-control hypertension were enrolled. In addition to aldosterone-to-renin ratio measurements, all patients underwent a saline infusion test as a reference standard. A plasma aldosterone concentration greater than 280 pmol/l after saline infusion was considered diagnostic for aldosteronism and the plasma renin activity was assessed to exclude patients with secondary aldosteronism from the final primary aldosteronism diagnosis. RESULTS Correlation of the aldosterone-to-renin ratio (cut-off >5) with primary aldosteronism diagnosis showed 16 true positive, 29 false positive, 188 true negative and 0 false negative aldosterone-to-renin ratios, resulting in a sensitivity of 100% (CI 75.9-100), specificity of 86.7% (CI 81.2-90.7), positive-predictive value of 35.6% (CI 22.3-51.3) and negative-predictive value of 100% (CI 97.5-100.0). The corresponding area under the curve was 0.933 (CI 0.900-0.966). CONCLUSION These findings show that the aldosterone-to-renin ratio is a good screening modality for primary aldosteronism and is without a high risk of missing a primary aldosteronism diagnosis whenever performed under well standardized conditions.
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Criteria for diagnosing primary aldosteronism on the basis of liquid chromatography-tandem mass spectrometry determinations of plasma aldosterone concentration. J Hypertens 2019; 36:1592-1601. [PMID: 29677048 DOI: 10.1097/hjh.0000000000001735] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Primary aldosteronism is affecting about 10% of hypertensive patients. Primary aldosteronism should be diagnosed by screening tests based on plasma aldosterone concentration (PAC) and aldosterone-to-renin ratio (ARR), followed by confirmatory test. The cutoff values for PAC and ARR depend on PAC and plasma renin measurement methods. Liquid chromatography-tandem mass spectrometry (LC-MS/MS), the new gold standard method for aldosterone determination, is now widespread but shows lower values than immunoassays. New cutoff values have yet to be determined with LC-MS/MS PAC. METHODS In a retrospective cohort, we measured PAC by LC-MS/MS in 93 healthy volunteers, 77 patients with essential hypertension and 82 primary aldosteronism patients (42 lateralized, 24 bilateral, 16 primary aldosteronism without adrenal vein sampling) after 30 min in a seated position. RESULTS PAC ranged from 42 to 309 pmol/l in healthy volunteers and from 63 to 362 pmol/l in essential hypertensive patients. A cutoff value of 360 pmol/l for basal PAC had a sensitivity of 90.5% and a specificity of 95.1% to differentiate lateralized primary aldosteronism from essential hypertensive patients. ARR ranged from 2.3 to 22.3 in healthy volunteers and from 3.2 to 55.6 pmol/mU in essential hypertensive patients. Using ROC curves, we selected an ARR of 46 pmol/mU, which provided a sensitivity of 100% and a specificity of 93.4% to distinguish between essential hypertensive and lateralized primary aldosteronism patients (sensitivity 94.4%, specificity 93.9% for the overall primary aldosteronism population). CONCLUSION Criteria for primary aldosteronism screening need to be adapted, given the increasing use of LC-MS/MS to determine PAC. We suggest to use 360 pmol/l and 46 pmol/mU as cutoff values, respectively, for basal PAC and ARR after 30 min of seated rest.
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A cross-sectional study of the effects of β-blocker therapy on the interpretation of the aldosterone/renin ratio: can dosing regimen predict effect? J Hypertens 2016; 34:307-15. [PMID: 26867057 DOI: 10.1097/hjh.0000000000000775] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT AND AIM Aldosterone/renin ratio (ARR) is used as the primary screening tool for primary aldosteronism. Its interpretation is often challenging because of the interference of antihypertensive medication. β-blocker therapy suppresses renin production by inhibiting β-adrenergic receptors in the juxtaglomerular apparatus of the kidney and consequently aldosterone secretion (to a lesser extent). Therefore, β-blocker therapy has the potential to elevate the ARR. The aim of this study was to investigate whether or not the effect of β-blocker therapy on the ARR could be predicted from the dosing regimen. METHODS A prospective cross-sectional study was conducted. Participants were stratified into one of four groups (control/low/medium/high) based on the quantity of β-blocker prescribed. ARR was calculated from renin/aldosterone, measured using two assay systems. RESULTS Eighty-nine volunteers were recruited to our study. In the control group, zero patients had a positive ARR using plasma renin activity (PRA)/direct renin concentration (DRC). In the low, medium, and high-dose β-blocker groups between 8-25% of patients demonstrated screen positive ARR results for primary aldosteronism using DRC and PRA. DRC was significantly lower in patients in the medium/high-dose groups and PRA significantly lower in the low/medium/high-dose groups compared with controls. ARR using DRC was significantly higher in the medium/high-dose groups and ARR using PRA was significantly higher in the low/medium/high-dose groups compared with controls. CONCLUSION Our study suggests that β-blocker therapy is associated with an increased risk of positive ARR screens for primary aldosteronism irrespective of the dose of β-blocker prescribed, in patients in whom it is clinically reasonable to expect that primary aldosteronism may be present.
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Douillard C, Houillier P, Nussberger J, Girerd X. SFE/SFHTA/AFCE Consensus on Primary Aldosteronism, part 2: First diagnostic steps. ANNALES D'ENDOCRINOLOGIE 2016; 77:192-201. [PMID: 27177498 DOI: 10.1016/j.ando.2016.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 12/09/2022]
Abstract
In patients with suspected primary aldosteronism (PA), the first diagnostic step, screening, must have high sensitivity and negative predictive value. The aldosterone-to-renin ratio (ARR) is used because it has higher sensitivity and lower variability than other measures (serum potassium, plasma aldosterone, urinary aldosterone). ARR is calculated from the plasma aldosterone (PA) and plasma renin activity (PRA) or direct plasma renin (DR) values. These measurements must be taken under standard conditions: in the morning, more than 2hours after awakening, in sitting position after 5 to 15minutes, with normal dietary salt intake, normal serum potassium level and without antihypertensive drugs significantly interfering with the renin-angiotensin-aldosterone system. To rule out ARR elevation due to very low renin values, ARR screening is applied only if aldosterone is>240pmol/l (90pg/ml); DR values<5mIU/l are assimilated to 5mIU/l and PRA values<0.2ng/ml/h to 0.2ng/ml/h. We propose threshold ARR values depending on the units used and a conversion factor (pg to mIU) for DR. If ARR exceeds threshold, PA should be suspected and exploration continued. If ARR is below threshold or if plasma aldosterone is<240pmol/l (90pg/ml) on two measurements, diagnosis of PA is excluded.
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Affiliation(s)
- Claire Douillard
- Service d'endocrinologie et des maladies métaboliques, centre hospitalier régional universitaire de Lille, 59037 Lille, France.
| | - Pascal Houillier
- Département des maladies rénales et métaboliques, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 75015 Paris, France.
| | - Juerg Nussberger
- Service de médecine interne, unité vasculaire et d'hypertension, centre hospitalier universitaire de Lausanne, CH-1011 Lausanne, Switzerland.
| | - Xavier Girerd
- Pôle cœur métabolisme, unité de prévention cardiovasculaire, groupe hospitalier universitaire Pitié-Salpêtrière, 83, boulevard de l'Hôpital, 75013 Paris, France
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Cheema MU, Damkier HH, Nielsen J, Poulsen ET, Enghild JJ, Fenton RA, Praetorius J. Distal renal tubules are deficient in aggresome formation and autophagy upon aldosterone administration. PLoS One 2014; 9:e101258. [PMID: 25000288 PMCID: PMC4085037 DOI: 10.1371/journal.pone.0101258] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 06/04/2014] [Indexed: 11/18/2022] Open
Abstract
Prolonged elevations of plasma aldosterone levels are associated with renal pathogenesis. We hypothesized that renal distress could be imposed by an augmented aldosterone-induced protein turnover challenging cellular protein degradation systems of the renal tubular cells. Cellular accumulation of specific protein aggregates in rat kidneys was assessed after 7 days of aldosterone administration. Aldosterone induced intracellular accumulation of 60 s ribosomal protein L22 in protein aggregates, specifically in the distal convoluted tubules. The mineralocorticoid receptor inhibitor spironolactone abolished aldosterone-induced accumulation of these aggregates. The aldosterone-induced protein aggregates also contained proteasome 20 s subunits. The partial de-ubiquitinase ataxin-3 was not localized to the distal renal tubule protein aggregates, and the aggregates only modestly colocalized with aggresome transfer proteins dynactin p62 and histone deacetylase 6. Intracellular protein aggregation in distal renal tubules did not lead to development of classical juxta-nuclear aggresomes or to autophagosome formation. Finally, aldosterone treatment induced foci in renal cortex of epithelial vimentin expression and a loss of E-cadherin expression, as signs of cellular stress. The cellular changes occurred within high, but physiological aldosterone concentrations. We conclude that aldosterone induces protein accumulation in distal renal tubules; these aggregates are not cleared by autophagy that may lead to early renal tubular damage.
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Affiliation(s)
- Muhammad Umar Cheema
- Department of Biomedicine, Membranes Center & InterPrET Pilot Center, Health, Aarhus University, Aarhus, Denmark
| | - Helle Hasager Damkier
- Department of Biomedicine, Membranes Center & InterPrET Pilot Center, Health, Aarhus University, Aarhus, Denmark
| | - Jakob Nielsen
- Department of Biomedicine, Membranes Center & InterPrET Pilot Center, Health, Aarhus University, Aarhus, Denmark
| | - Ebbe Toftgaard Poulsen
- Department of Molecular Biology and Genetics, iNano, Science and Technology, Aarhus University, Aarhus, Denmark
| | - Jan J. Enghild
- Department of Molecular Biology and Genetics, iNano, Science and Technology, Aarhus University, Aarhus, Denmark
| | - Robert A. Fenton
- Department of Biomedicine, Membranes Center & InterPrET Pilot Center, Health, Aarhus University, Aarhus, Denmark
| | - Jeppe Praetorius
- Department of Biomedicine, Membranes Center & InterPrET Pilot Center, Health, Aarhus University, Aarhus, Denmark
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Tomaschitz A, Piecha G, Ritz E, Meinitzer A, Haas J, Pieske B, Wiecek A, Rus-Machan J, Toplak H, März W, Verheyen N, Gaksch M, Amrein K, Kraigher-Krainer E, Fahrleitner-Pammer A, Pilz S. Marinobufagenin in essential hypertension and primary aldosteronism: a cardiotonic steroid with clinical and diagnostic implications. Clin Exp Hypertens 2014; 37:108-15. [PMID: 24785704 DOI: 10.3109/10641963.2014.913604] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The cardiotonic steroid marinobufagenin (MBG) is increasingly suggested to be responsible for some of the cardiovascular injury that has been previously attributed to aldosterone. We examined the clinical correlates of circulating MBG concentrations in hypertensive patients and tested the hypothesis that MBG serves as a reliable diagnostic tool for detecting primary aldosteronism (PA). METHODS Plasma MBG concentrations (mean: 0.51±0.25 nmol/l) were measured in the morning fasting samples in 20 patients with PA and 20 essential hypertensive (EH) controls matched for age, sex, body mass index, renal function, urinary sodium and intake of antihypertensive medication (mean age: 51.6 years; 52.2% women). RESULTS Overall, plasma MBG was directly correlated with plasma aldosterone, aldosterone to active renin ratio (AARR), diastolic blood pressure, mean carotid intima-media thickness, serum sodium, urinary protein to creatinine ratio and inversely with serum potassium levels. Plasma MBG levels were significantly higher in patients with PA compared to EH (mean: 0.68±0.12 versus 0.35±0.24 nmol/l; p<0.001). ROC analysis yielded a greater AUC for plasma MBG compared to the AARR, PAC and serum potassium levels for detecting PA. Youden's Index analyses yielded the optimal plasma MBG cut-off score for diagnosing PA at >0.49 nmol/l with specificity and sensitivity values of 0.85 and 0.95, respectively, which were higher than those at the optimum AARR cut-off at >3.32 ng/dl/µU/ml. CONCLUSIONS In a well-characterized cohort, values of plasma MBG were significantly related to clinical correlates of cardiovascular and renal disease. Plasma MBG emerged as a valuable alternative to the AARR for screening of PA.
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Test characteristics of the aldosterone-to-renin ratio as a screening test for primary aldosteronism. J Hypertens 2014; 32:115-26. [DOI: 10.1097/hjh.0b013e3283656b54] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chao CT, Wu VC, Kuo CC, Lin YH, Chang CC, Chueh SJ, Wu KD, Pimenta E, Stowasser M. Diagnosis and management of primary aldosteronism: an updated review. Ann Med 2013; 45:375-83. [PMID: 23701121 DOI: 10.3109/07853890.2013.785234] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Primary aldosteronism (PA) is the most common secondary form of arterial hypertension, with a particularly high prevalence among patients with resistant hypertension. Aldosterone has been found to be associated with cardiovascular toxicity. Prolonged aldosteronism leads to higher incidence of cardiac events, glomerular hyperfiltration, and potentially bone/metabolic sequels. The wider application of aldosterone/renin ratio as screening test has substantially contributed to increasing diagnosis of PA. Diagnosis of PA consists of two phases: screening and confirmatory testing. Adrenal imaging is often inaccurate for differentiation between an adenoma and hyperplasia, and adrenal venous sampling is essential for selecting the appropriate treatment modality. The etiologies of PA have two main subtypes: unilateral (aldosterone-producing adenoma) and bilateral (micro- or macronodular hyperplasia). Aldosterone-producing adenoma is typically managed with unilateral adrenalectomy, while bilateral adrenal hyperplasia is amenable to pharmacological approaches using mineralocorticoid antagonists. Short-term treatment outcome following surgery is determined by factors such as preoperative blood pressure level and hypertension duration, but evidence regarding long-term treatment outcome is still lacking. However, directed treatments comprising of unilateral adrenalectomy or mineralocorticoid antagonists still potentially reduce the toxicities of aldosterone. Utilizing a physician-centered approach, we intend to provide up-dated information on the etiology, diagnosis, and the management of PA.
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Ducher M, Mounier-Véhier C, Baguet JP, Tartière JM, Sosner P, Régnier-Le Coz S, Perez L, Fourcade J, Jabourek O, Lejeune S, Stolz A, Fauvel JP. Aldosterone-to-renin ratio for diagnosing aldosterone-producing adenoma: a multicentre study. Arch Cardiovasc Dis 2012. [PMID: 23199617 DOI: 10.1016/j.acvd.2012.07.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Biological diagnostic criteria for diagnosing aldosterone-producing adenoma (APA) are not well-established. AIM The aim of the study was to establish the best biological predictors of APA. METHODS A prospective register was implemented in 17 secondary or tertiary hypertension centres. The inclusion criterion was one of the following: onset of hypertension before 40 years of age; history of hypokalaemia; drug-resistant hypertension (resistant to three drugs); or spironolactone efficiency on BP. RESULTS Among the 338 collected cases, 192 patients had two aldosterone-to-renin ratio (ARR) determinations (after 1 hour supine and at least 1 hour upright) on the same occasion. Twenty-five patients (8.2%) had biological hyperaldosteronism and an adrenal adenoma identified by computed tomography. APA was histologically confirmed in all 12 patients who underwent surgery. Histologically proven APAs were used as the 'gold standard' in receiver operating characteristic (ROC) curve analysis. ARRs were computed with a minimum renin value set at 5 ng/L to avoid misclassification of so-called 'low-renin hypertension'. To predict an APA, the ARR area under the ROC curve was 0.93. A supine ARR cut-off value of 32ng/ng provided the highest sum of sensitivity (92%) plus specificity (92%). On the basis of an ARR≥32 ng/ng in the supine and/or upright position, sensitivity reached 100%. CONCLUSION The proposed cut-off value of 32 ng/ng for ARR (minimum renin value set at 5 ng/L) in one of two determinations had 100% sensitivity and 72% specificity with 20% positive and 100% negative predictive values for diagnosing APA.
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14
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Yin G, Zhang S, Yan L, Wu M, Xu M, Li F, Cheng H. Effect of age on aldosterone/renin ratio (ARR) and comparison of screening accuracy of ARR plus elevated serum aldosterone concentration for primary aldosteronism screening in different age groups. Endocrine 2012; 42:182-9. [PMID: 22302679 DOI: 10.1007/s12020-012-9609-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 01/15/2012] [Indexed: 02/05/2023]
Abstract
The serum aldosterone concentration (SAC)/plasma renin activity (PRA) ratio (ARR) is considered a useful screening test in the differential diagnosis of essential hypertension (EH) and primary aldosteronism (PA). The purpose of this study is to investigate the effect of age on ARR and compare the screening accuracy of ARR plus elevated SAC for PA screening in different age groups. Thirty-nine patients with PA, 274 patients with EH, and 153 healthy volunteers were recruited. Blood was sampled for SAC and PRA measuring under keeping upright posture for 1 h. Levels of SAC, PRA, and ARR were compared at different ages range for the respective three groups of subjects. The screening accuracy of ARR plus elevated SAC was compared in different age groups and PA patients served as the same positive subjects. In the EH group, logarithmically transformed ARR (Log-ARR) increased with advancing age and reached its peak in the ≥ 60 years group; in the normotensives group, Log-ARR reached its peak in the 40-49 years group and slightly declined with advancing age. In the PA group, Log-ARR was not age dependent. Screening accuracy increased when combined index of ARR and SAC was used in the ≥ 40 years group but not in the <40 years group. Although the number of EH patients with elevated ARR increased with advancing age, but the screening accuracy and cutoff values of ARR were not affected by age. Using the combined index of ARR and SAC increased the screening accuracy for the patients older than 40 years, but not necessary for the patients younger than 40 years.
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Affiliation(s)
- Guoshu Yin
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Shantou University Medical College, Shantou, 515041, Guangdong Province, China
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Rosenbaum D, Rigabert J, Villeneuve F, Girerd X. [An abdominal CT scan in first-line is an efficient investigation of uncontrolled hypertensives suspected to have an adrenal cause]. Ann Cardiol Angeiol (Paris) 2012; 61:209-12. [PMID: 22748398 DOI: 10.1016/j.ancard.2012.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 06/11/2012] [Indexed: 11/16/2022]
Abstract
UNLABELLED The prevalence of hypertension resistant to treatment to indicate for renal denervation. OBJECTIVE To evaluate the efficiency for imaging the adrenal glands with an abdominal CT scan in first-line in subjects with resistant hypertension suspected to have an adrenal cause. METHODS On 75 hypertensive patients uncontrolled by at least a combination therapy, but suspected to have secondary hypertension due to adrenal cause, an abdominal CT scan was performed in first intention. In all subjects, an exploration of the renin-aldosteron axis in standardized conditions, a 24-hour urinary cortisol and a WHO recommended biological analysis were also performed. RESULTS An abnormal morphology of adrenal was found by abdominal CT in 64% of patients. The abnormalities observed were: bilateral hyperplasia (27%), unilateral adenoma (15%), unilateral hyperplasia (15%), bilateral adenoma (7%). Abnormal biological and/or hormonal tests for adrenal disease were found in 29% of patients, with a primary aldosteronism (A/R corrected>23) in 11% or K less than 3.5mmol/L in 20%. According to the assessment conducted in first-line, indication to spironolactone is selected in 48% of patients investigated with CT as first-line and in 17% of patients investigated with biological tests (P<0.01) while the indication to adrenal surgery would be held in 15% and 11% of patients respectively. CONCLUSION In a population of subjects with uncontrolled hypertension in which an adrenal cause is suspected, achieving a first-line abdominal CT leads to adrenal abnormality observed in 64% of patients while a specific biological abnormality is noted in 29% of subjects. This study shows that assessment that starts with an abdominal CT scan allows to indicate treatment with spironolactone more frequently than when the first assessment is limited to a biological investigation.
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Affiliation(s)
- D Rosenbaum
- Unité de prévention cardiovasculaire, pôle cœur métabolisme, hôpital de La Pitié-Salpêtrière, 83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
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16
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Bernini G, Bacca A, Carli V, Carrara D, Materazzi G, Berti P, Miccoli P, Pisano R, Tantardini V, Bernini M, Taddei S. Cardiovascular changes in patients with primary aldosteronism after surgical or medical treatment. J Endocrinol Invest 2012; 35:274-80. [PMID: 21422805 DOI: 10.3275/7611] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Data on the cardiovascular middle-term follow-up of patients with primary aldosteronism (PA) are scanty. AIM To detect the cardiovascular effects of surgery in patients with aldosterone (ALD)-producing adenoma (APA) and of pharmacotherapy in those with bilateral adrenal hyperplasia (BAH), a prospective study involving 60 consecutive patients with PA was performed. MATERIAL/ METHODS: Clinical, biochemical, and cardiovascular assessment was obtained before and after (31.5±4.4 months) surgery or proper medical treatment (32.1±5.0 months) in 19 and 41 patients, respectively. RESULTS As expected, plasma ALD normalized in all operated patients, while in the other group it did not change. Systolic and diastolic blood pressure decreased (p<0.001) after both treatments. However, absolute and percentage reduction was significantly more pronounced (p<0.01) in operated than in non-operated patients. Left ventricular (LV) mass showed significant reduction after surgery (LV mass g/m(2), p<0.0007; LV mass g/m(2.7), p<0.01), but no change after medical treatment, so that the differences between absolute and percentage values at follow- up were statistically significant (p<0.01) between groups. Basal LV mass/m(2.7) was positively associated with age (p<0.009), body mass index (p<0.0008), drug number (p<0.03), and ALD/plasma renin activity ratio (p<0.01). Allocating the patients according to plasma ALD and cardiac parameters, patients who presented ALD reduction during the study also had a decrement in cardiac mass (p<0.04). CONCLUSIONS Our data indicate that in patients with PA the removal of ALD excess by surgery in APA is effective in reducing blood pressure and in improving cardiac parameters, while anti-hypertensive therapy in BAH shows less positive impact on cardiovascular system.
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Affiliation(s)
- G Bernini
- Department of Internal Medicine, University of Pisa, Pisa, Italy.
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Abstract
This paper provides evidence that primary aldosteronism is likely much less common than is believed by the other authors of this collection. The basis for this contrarian view is simple: there is no way to know the true prevalence of PA because of the uncertain validity of all of the diagnostic procedures used to find and characterize this disease. Moreover, even if these uncertainties are overcome, the eventual treatment of most who have PA can be provided without the need for extensive testing and expensive treatment.
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Affiliation(s)
- Norman M Kaplan
- University of Texas Southwestern Medical School, Dallas, TX 75390, USA.
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Indicators of mineralocorticoid excess in the evaluation of primary aldosteronism. Hypertens Res 2010; 33:850-6. [DOI: 10.1038/hr.2010.76] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Galetta F, Bernini G, Franzoni F, Bacca A, Fivizzani I, Tocchini L, Bernini M, Fallahi P, Antonelli A, Santoro G. Cardiac remodeling in patients with primary aldosteronism. J Endocrinol Invest 2009; 32:739-45. [PMID: 19564719 DOI: 10.1007/bf03346529] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To evaluate the morpho-functional changes of the myocardium in patients with primary aldosteronism (PA). DESIGN An observational study in a university referral center for blood pressure diseases. PATIENTS Twenty- three patients with PA, 24 patients with essential hypertension (EH), and 15 normotensive controls (C) underwent conventional echocardiography with integrated backscatter (IBS) and tissue Doppler imaging (TDI) analysis. The corrected IBS (C-IBS) values and the systo-diastolic variation of IBS (CV-IBS) were performed at both interventricular septum and the posterior wall levels. TDI myocardial systolic (Sm), early diastolic (Em), and late diastolic (Am) velocities of both left ventricular walls were also determined. RESULTS In PA patients, septal and posterior wall CV-IBS were significantly lower than C (p<0.0001) and EH patients (p<0.001). In EH, CV-IBS was significantly lower than C (p<0.001). Patients with PA exhibited lower Sm, lower Em, and higher Am, and a subsequently reduced Em/Am ratio than C (p<0.001 for all) and EH (p<0.01 for all) at interventricular septum and lateral wall levels. In the latter, Sm, Em, and Em/Am ratio were lower and Am was higher than C (p<0.001 for all). In PA and EH patients, CV-IBS at both septum (r=-0.66, p<0.001) and posterior wall levels (r=-0.67, p<0.001) and Sm peak of both septum (r=-0.52, p<0.001) and lateral wall (r=-0.55, p<0.001) were inversely related to plasma aldosterone. CONCLUSIONS Patients with PA showed myocardial wall remodeling characterized by increased myocardial fibrosis and early left ventricular systodiastolic function abnormalities.
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Affiliation(s)
- F Galetta
- Department of Internal Medicine, University of Pisa, 56100 Pisa, Italy.
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21
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Current world literature. Curr Opin Endocrinol Diabetes Obes 2009; 16:260-77. [PMID: 19390324 DOI: 10.1097/med.0b013e32832c937e] [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] [Indexed: 11/27/2022]
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22
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Arterial stiffness, intima-media thickness and carotid artery fibrosis in patients with primary aldosteronism. J Hypertens 2008; 26:2399-405. [DOI: 10.1097/hjh.0b013e32831286fd] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Primary aldosteronism in newly diagnosed hypertensive patients. J Hypertens 2008; 26:2250. [PMID: 18854771 DOI: 10.1097/hjh.0b013e328306a3b5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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