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Parksook WW, Brown JM, Omata K, Tezuka Y, Ono Y, Satoh F, Tsai LC, Niebuhr Y, Milks J, Moore A, Honzel B, Liu H, Auchus RJ, Sunthornyothin S, Turcu AF, Vaidya A. The Spectrum of Dysregulated Aldosterone Production: An International Human Physiology Study. J Clin Endocrinol Metab 2024; 109:2220-2232. [PMID: 38450549 PMCID: PMC11319004 DOI: 10.1210/clinem/dgae145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 03/08/2024]
Abstract
CONTEXT Primary aldosteronism is a form of low-renin hypertension characterized by dysregulated aldosterone production. OBJECTIVE To investigate the contributions of renin-independent aldosteronism and ACTH-mediated aldosteronism in individuals with a low-renin phenotype representing the entire continuum of blood pressure. DESIGN/PARTICIPANTS Human physiology study of 348 participants with a low-renin phenotype with severe and/or resistant hypertension, hypertension with hypokalemia, elevated blood pressure and stage I/II hypertension, and normal blood pressure. SETTING 4 international centers. INTERVENTIONS/MAIN OUTCOME MEASURES The saline suppression test (SST) to quantify the magnitude of renin-independent aldosteronism; dexamethasone suppression and ACTH-stimulation tests to quantify the magnitude of ACTH-mediated aldosteronism; adrenal venous sampling to determine lateralization. RESULTS There was a continuum of nonsuppressible and renin-independent aldosterone production following SST that paralleled the magnitude of the blood pressure continuum and transcended conventional diagnostic thresholds. In parallel, there was a full continuum of ACTH-mediated aldosteronism wherein post-SST aldosterone levels were strongly correlated with ACTH-stimulated aldosterone production (r = 0.75, P < .0001) and nonsuppressible aldosterone production postdexamethasone (r = 0.40, P < .0001). Beyond participants who met the criteria for primary aldosteronism (post-SST aldosterone of ≥10 ng/dL or ≥277 pmol/L), the continuum of nonsuppressible and renin-independent aldosterone production persisted below this diagnostic threshold, wherein 15% still had lateralizing aldosteronism amenable to surgical adrenalectomy and the remainder were treated with mineralocorticoid receptor antagonists. CONCLUSION In the context of a low-renin phenotype, there is a continuum of primary aldosteronism and dysregulated aldosterone production that is prominently influenced by ACTH. A large proportion of individuals with low renin may benefit from aldosterone-directed therapy.
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Affiliation(s)
- Wasita W Parksook
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Endocrinology and Metabolism, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
- Division of General Internal Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Kei Omata
- Department of Diabetes, Metabolism and Endocrinology, Tohoku University Hospital, Sendai 980-8576, Japan
- Division of Nephrology, Rheumatology and Endocrinology, Tohoku University, Sendai 980-8576, Japan
| | - Yuta Tezuka
- Department of Diabetes, Metabolism and Endocrinology, Tohoku University Hospital, Sendai 980-8576, Japan
- Division of Nephrology, Rheumatology and Endocrinology, Tohoku University, Sendai 980-8576, Japan
| | - Yoshikiyo Ono
- Department of Diabetes, Metabolism and Endocrinology, Tohoku University Hospital, Sendai 980-8576, Japan
- Division of Nephrology, Rheumatology and Endocrinology, Tohoku University, Sendai 980-8576, Japan
| | - Fumitoshi Satoh
- Division of Nephrology, Rheumatology and Endocrinology, Tohoku University, Sendai 980-8576, Japan
| | - Laura C Tsai
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Yvonne Niebuhr
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Julia Milks
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Anna Moore
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Brooke Honzel
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Haiping Liu
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48104, USA
| | - Richard J Auchus
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48104, USA
- Pharmacology and Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI 48104, USA
- Endocrinology & Metabolism Section, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI 48104, USA
| | - Sarat Sunthornyothin
- Division of Endocrinology and Metabolism, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Adina F Turcu
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48104, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Miller BS. Surgical Management of Primary Aldosteronism. Surg Clin North Am 2024; 104:851-861. [PMID: 38944504 DOI: 10.1016/j.suc.2024.02.013] [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: 07/01/2024]
Abstract
Hypertension leads to multiple comorbidities and increased risk for mortality. Endocrine disorders contribute to the development of hypertension, including primary aldosteronism (PA). This article discusses the evaluation and management of PA.
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Affiliation(s)
- Barbra S Miller
- OSU Comprehensive Adrenal Program, Division of Surgical Oncology, Department of Surgery.
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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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4
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Brown JM. Adverse Effects of Aldosterone: Beyond Blood Pressure. J Am Heart Assoc 2024; 13:e030142. [PMID: 38497438 PMCID: PMC11179780 DOI: 10.1161/jaha.123.030142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Aldosterone is a steroid hormone that primarily acts through activation of the mineralocorticoid receptor (MR), a nuclear receptor responsible for downstream genomic regulation. Classically, activation of the MR in the renal tubular epithelium is responsible for sodium retention and volume expansion, raising systemic blood pressure. However, activation of the MR across a wide distribution of tissue types has been implicated in multiple adverse consequences for cardiovascular, cerebrovascular, renal, and metabolic disease, independent of blood pressure alone. Primary aldosteronism, heart failure, and chronic kidney disease are states of excessive aldosterone production and MR activity where targeting MR activation has had clinical benefits out of proportion to blood pressure lowering. The growing list of established and emerging therapies that target aldosterone and MR activation may provide new opportunities to improve clinical outcomes and enhance cardiovascular and renal health.
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Affiliation(s)
- Jenifer M. Brown
- Division of Cardiovascular Medicine, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMAUSA
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5
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Hundemer GL, Agharazii M, Madore F, Vaidya A, Brown JM, Leung AA, Kline GA, Larose E, Piché ME, Crean AM, Shaw JLV, Ramsay T, Hametner B, Wassertheurer S, Sood MM, Hiremath S, Ruzicka M, Goupil R. Subclinical Primary Aldosteronism and Cardiovascular Health: A Population-Based Cohort Study. Circulation 2024; 149:124-134. [PMID: 38031887 PMCID: PMC10841691 DOI: 10.1161/circulationaha.123.066389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Primary aldosteronism, characterized by overt renin-independent aldosterone production, is a common but underrecognized form of hypertension and cardiovascular disease. Growing evidence suggests that milder and subclinical forms of primary aldosteronism are highly prevalent, yet their contribution to cardiovascular disease is not well characterized. METHODS This prospective study included 1284 participants between the ages of 40 and 69 years from the randomly sampled population-based CARTaGENE cohort (Québec, Canada). Regression models were used to analyze associations of aldosterone, renin, and the aldosterone-to-renin ratio with the following measures of cardiovascular health: arterial stiffness, assessed by central blood pressure (BP) and pulse wave velocity; adverse cardiac remodeling, captured by cardiac magnetic resonance imaging, including indexed maximum left atrial volume, left ventricular mass index, left ventricular remodeling index, and left ventricular hypertrophy; and incident hypertension. RESULTS The mean (SD) age of participants was 54 (8) years and 51% were men. The mean (SD) systolic and diastolic BP were 123 (15) and 72 (10) mm Hg, respectively. At baseline, 736 participants (57%) had normal BP and 548 (43%) had hypertension. Higher aldosterone-to-renin ratio, indicative of renin-independent aldosteronism (ie, subclinical primary aldosteronism), was associated with increased arterial stiffness, including increased central BP and pulse wave velocity, along with adverse cardiac remodeling, including increased indexed maximum left atrial volume, left ventricular mass index, and left ventricular remodeling index (all P<0.05). Higher aldosterone-to-renin ratio was also associated with higher odds of left ventricular hypertrophy (odds ratio, 1.32 [95% CI, 1.002-1.73]) and higher odds of developing incident hypertension (odds ratio, 1.29 [95% CI, 1.03-1.62]). All the associations were consistent when assessing participants with normal BP in isolation and were independent of brachial BP. CONCLUSIONS Independent of brachial BP, a biochemical phenotype of subclinical primary aldosteronism is negatively associated with cardiovascular health, including greater arterial stiffness, adverse cardiac remodeling, and incident hypertension.
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Affiliation(s)
- Gregory L. Hundemer
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mohsen Agharazii
- Department of Medicine, Division of Nephrology, CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - François Madore
- Department of Medicine, Division of Nephrology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, QC, Canada
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jenifer M. Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - 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
| | - Gregory A. Kline
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eric Larose
- Department of Medicine, Division of Cardiology, Université Laval, Quebec City, QC, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Quebec City, QC, Canada
| | - Marie-Eve Piché
- Department of Medicine, Division of Cardiology, Université Laval, Quebec City, QC, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Quebec City, QC, Canada
| | - Andrew M. Crean
- Division of Cardiovascular Medicine, Ottawa Heart Institute, Ottawa, ON, Canada
| | - Julie L. V. Shaw
- Department of Pathology and Laboratory Medicine, Division of Biochemistry, Ottawa Hospital, Ottawa, ON, Canada
- Eastern Ontario Regional Laboratories Association, Ottawa, ON, Canada
| | - Tim Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bernhard Hametner
- Center for Health & Bioresources, AIT Austrian Institute of Technology, Vienna, Austria
| | | | - Manish M. Sood
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Swapnil Hiremath
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marcel Ruzicka
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Rémi Goupil
- Department of Medicine, Division of Nephrology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, QC, Canada
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6
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Freitas TC, Maciel AAW, Fagundes GFC, Petenuci J, Santana LS, Guimaraes AG, Freitas-Castro F, Srougi V, Tanno FY, Chambo JL, Pereira MAA, Brito LP, Pio-Abreu A, Bortolotto LA, Latronico AC, Fragoso MCBV, Drager LF, Mendonca BB, Almeida MQ. Efficacy of Oral Furosemide Test for Primary Aldosteronism Diagnosis. J Endocr Soc 2023; 8:bvad147. [PMID: 38075562 PMCID: PMC10701630 DOI: 10.1210/jendso/bvad147] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Indexed: 01/06/2024] Open
Abstract
Context Confirmatory tests represent a fundamental step in primary aldosteronism (PA) diagnosis, but they are laborious and often require a hospital environment due to the risks involved. Objective To evaluate the efficacy of oral furosemide as a new confirmatory test for PA diagnosis. Methods We prospectively evaluated the diagnostic performance of 80 mg of oral furosemide in 64 patients with PA and 22 with primary hypertension (controls). Direct renin concentration (DRC) was measured before, and 2 hours and 3 hours after the oral furosemide. In addition, the oral furosemide test was compared with 2 other confirmatory tests: the furosemide upright test (FUT) and saline infusion test (SIT) or captopril challenge test (CCT) in all patients with PA. Results The cut-off of 7.6 µU/mL for DRC at 2 hours after oral furosemide had a sensitivity of 92%, specificity of 82%, and accuracy of 90% for PA diagnosis. In 5 out of 6 controls with low-renin hypertension, which might represent a PA spectrum, renin remained suppressed. Excluding these 6 controls with low-renin hypertension, the DRC cut-off of 10 µU/mL at 2 hours after oral furosemide had a sensitivity of 95.3%, specificity of 93.7% and accuracy of 95% for PA diagnosis. DRC after 3 hours of oral furosemide did not improve diagnostic performance. Using the cut-off of 10 µU/mL, the oral furosemide test and the FUT were concordant in 62 out of 64 (97%) patients with PA. Only 4 out of 64 cases with PA (6.4%) ended the oral furosemide test with potassium <3.5 mEq/L. Hypotension was not evidenced in any patient with PA during the test. Conclusion The oral furosemide test was safe, well-tolerated and represents an effective strategy for PA investigation.
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Affiliation(s)
- Thais C Freitas
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Unidade de Adrenal, Laboratório de Endocrinologia Molecular e Celular LIM/25, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Ana Alice W Maciel
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Unidade de Adrenal, Laboratório de Endocrinologia Molecular e Celular LIM/25, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Gustavo F C Fagundes
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Unidade de Adrenal, Laboratório de Endocrinologia Molecular e Celular LIM/25, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Janaina Petenuci
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Unidade de Adrenal, Laboratório de Endocrinologia Molecular e Celular LIM/25, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Lucas S Santana
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Unidade de Adrenal, Laboratório de Endocrinologia Molecular e Celular LIM/25, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Augusto G Guimaraes
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Unidade de Adrenal, Laboratório de Endocrinologia Molecular e Celular LIM/25, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Felipe Freitas-Castro
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Unidade de Adrenal, Laboratório de Endocrinologia Molecular e Celular LIM/25, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Victor Srougi
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Fabio Y Tanno
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Jose L Chambo
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Maria Adelaide A Pereira
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Unidade de Adrenal, Laboratório de Endocrinologia Molecular e Celular LIM/25, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Luciana P Brito
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Unidade de Adrenal, Laboratório de Endocrinologia Molecular e Celular LIM/25, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Andrea Pio-Abreu
- Unidade de Hipertensão, Disciplina de Nefrologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Luiz A Bortolotto
- Unidade de Hipertensão, Instituto do Coração (InCor), Faculdade de Medicna da Universidade de São Paulo, São Paulo, 05403-900, Brazil
| | - Ana Claudia Latronico
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Unidade de Adrenal, Laboratório de Endocrinologia Molecular e Celular LIM/25, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Maria Candida B V Fragoso
- Divisão de Endocrinologia e Metabologia, Laboratório de Hormônios e Genética Molecular LIM/42, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
- Divisão de Oncologia Endócrina, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brazil
| | - Luciano F Drager
- Unidade de Hipertensão, Disciplina de Nefrologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
- Unidade de Hipertensão, Instituto do Coração (InCor), Faculdade de Medicna da Universidade de São Paulo, São Paulo, 05403-900, Brazil
| | - Berenice B Mendonca
- Divisão de Endocrinologia e Metabologia, Laboratório de Hormônios e Genética Molecular LIM/42, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
| | - Madson Q Almeida
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Unidade de Adrenal, Laboratório de Endocrinologia Molecular e Celular LIM/25, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
- Divisão de Oncologia Endócrina, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brazil
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7
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Lamba R. Redefining primary hyperaldosteronism as "The Syndrome of Inappropriate Aldosterone Secretion (SIALDS)": A common but unrecognized cause of hypertension. J Clin Hypertens (Greenwich) 2023; 25:1045-1052. [PMID: 37877173 PMCID: PMC10710549 DOI: 10.1111/jch.14740] [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] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/26/2023]
Abstract
The current screening and diagnostic recommendations for detecting Primary Hyperaldosteronism (PHA) focus on diagnosing the more severe and overt instances of renin-independent aldosterone production. However, milder forms of autonomous aldosterone secretion have been demonstrated to exist below the diagnostic thresholds of current PHA guidelines, and associate with clinically relevant cardiovascular risk. PHAencompasses a spectrum of renin independent aldosterone production, progressing from a subclinical state in normotensives to a full-blown clinical syndrome representing the resistant hypertension population. The authors propose the Syndrome of Inappropriately Elevated Aldosterone Secretion (SIALDS) concept as a potential new paradigm for understanding and diagnosing PHA and expanded diagnostic approach to improve early detection even in well-controlled hypertension. The authors also delve into the impact of treatments, including mineralocorticoid receptor antagonists and emerging aldosterone synthase inhibitors. Furthermore, The authors outline future research directions, proposing clinical trials to investigate the long-term identification and treatment outcomes of SIALDS.
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Affiliation(s)
- Rajat Lamba
- Department for Continuing EducationKellogg CollegeUniversity of OxfordOxfordshireUK
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8
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Mansur A, Vaidya A, Turchin A. Using Renin Activity to Guide Mineralocorticoid Receptor Antagonist Therapy in Patients with Low Renin and Hypertension. Am J Hypertens 2023; 36:455-461. [PMID: 37013957 PMCID: PMC10345476 DOI: 10.1093/ajh/hpad032] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/21/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Mineralocorticoid receptor antagonists (MRAs) are often empirically used for patients with low-renin hypertension (LRH) or probable primary aldosteronism (PA) who decline surgery. However, the optimal approach to MRA therapy is unknown. Studies have shown that a rise in renin is an effective biomarker of prevention of cardiovascular complications of PA. This study aimed to determine whether empiric MRA therapy in patients with LRH or probable PA targeting unsuppressed renin is associated with a decrease in blood pressure and/or proteinuria. METHODS Retrospective single-center cohort study from 2005 to 2021 included adults with LRH or probable PA (renin activity <1.0 ng/ml/h and detectable aldosterone levels). All patients were empirically treated with an MRA, targeting renin ≥1.0 ng/ml/h. RESULTS Out of 39 patients studied, 32 (82.1%) achieved unsuppressed renin. Systolic and diastolic blood pressure decreased from 148.0 and 81.2 to 125.8 and 71.6 mm Hg, respectively (P < 0.001 for both). Similar blood pressure reductions were seen whether patients had high (>10 ng/dl) or low (<10 ng/dl) aldosterone levels. The majority (24/39; 61.5%) of patients had at least one baseline anti-hypertensive medication stopped. Among the six patients who had detectable proteinuria and albumin-to-creatinine (ACR) measurements post-treatment, the mean ACR decreased from 179.0 to 36.1 mg/g (P = 0.03). None of the patients studied had to completely stop treatment due to adverse reactions. CONCLUSIONS Empiric MRA therapy in patients with LRH or probable PA targeting unsuppressed renin can safely and effectively improve blood pressure control and reduce proteinuria.
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Affiliation(s)
- Arian Mansur
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Anand Vaidya
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander Turchin
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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9
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Alnazer RM, Veldhuizen GP, de Leeuw PW, Kroon AA. The effect of age, sex and BMI on the aldosterone-to-renin ratio in essential hypertensive individuals. J Hypertens 2023; 41:618-623. [PMID: 36723461 DOI: 10.1097/hjh.0000000000003377] [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: 02/02/2023]
Abstract
OBJECTIVE The aldosterone-to-renin ratio (ARR) is widely used as a screening test for primary aldosteronism, but its determinants in patients with essential hypertension are not fully known. The purpose of the present investigation is to identify the impact of age, sex and BMI on renin, aldosterone and the ARR when measured under strict, standardized conditions in hypertensive patients without primary aldosteronism. METHODS We analysed the data of 423 consecutive hypertensive patients with no concomitant cardiac or renal disorders from two different hospitals (Rotterdam and Maastricht) who had been referred for evaluation of their hypertension. Those who were diagnosed with secondary causes of hypertension, including primary aldosteronism, were excluded from analysis. Patients who used oral contraceptives or had hormonal replacement therapy were excluded as well. Plasma aldosterone concentration (PAC), active plasma renin concentration (APRC) and the ARR were measured under standardized conditions. All measurements were taken in the supine position at 10.00 h in the morning, with one subgroup of patients adhering to a sodium-restricted diet (55 mmol/day) for no less than 3 weeks, and the other subgroup maintaining an ad libitum diet. In those who were receiving antihypertensive treatment, all medications were discontinued at least 3 weeks before testing. RESULTS In neither group did aldosterone correlate with age. Renin, however, was inversely related to age both during low-salt diet ( P < 0.001) and during ad lib salt intake ( P = 0.05). This resulted in a significant positive correlation between age and the ARR in both groups. Although on both dietary regimens, PAC and APRC were significantly higher in men when compared with women, the ARR was not significantly different between the two sexes. The age-relationships of renin and the ARR were comparable in men and women on both diets, albeit with greater variability in women. There was an upward trend between BMI and the ARR, which reached statistical significance only in men on low-salt diet. In multivariable regression analysis, age remained the only independent determinant of the ARR. CONCLUSION In our essential hypertensive population, the ARR increased significantly with age but was not affected by sex or BMI.
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Affiliation(s)
- Rawan M Alnazer
- Department of Internal Medicine, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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10
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Arnold N, Hermanns IM, Schulz A, Hahad O, Schmitt VH, Panova-Noeva M, Prochaska JH, Binder H, Pfeiffer N, Beutel M, Lackner KJ, Münzel T, Wild PS. Renin, aldosterone, the aldosterone-to-renin ratio, and incident hypertension among normotensive subjects from the general population. Cardiovasc Res 2023; 119:294-301. [PMID: 35199135 PMCID: PMC10022856 DOI: 10.1093/cvr/cvac019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 02/21/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS To investigate the predictive ability of direct plasma renin and aldosterone concentrations as well as their ratio [aldosterone-to-renin (ARR)] for incident hypertension in the general population. METHODS AND RESULTS Concentration of renin and aldosterone were measured by a chemiluminescence immunoassay using the fully automated LIAISON® platform (DiaSorin) among 5362 participants of the population-based Gutenberg Health Study, who were normotensive and had no clinically overt cardiovascular disease at baseline. During a follow-up period of 5 years, 18.6% (n = 996) developed a new-onset hypertension. Comparing extreme quartiles of biomarker distribution, the relative risk (RR) for incident arterial hypertension was found to be 1.58 [95% confidence interval (CI) 1.25-2.00; P = 0.00015; Q1 vs. Q4ref] for renin; 1.29 (95% CI 1.05-1.59, P = 0.018; Q4 vs. Q1ref) for aldosterone and 1.70 (95% CI 1.33-2.12; P < 0.0001; Q4 vs. Q1ref) for ARR after multivariable adjustment in men. In females, only high ARR was independently predictive for incident hypertension over 5 years [RR 1.29 (95% CI 1.04-1.62); P = 0.024]. Even in the subgroup of individuals having biomarker concentrations within the reference range, high ARR was predictive for new-onset hypertension in men [RR 1.44 (95% CI 1.13-1.83); P = 0.003]. Finally, synergistic effects of co-prevalent obesity and ARR on incident hypertension were also demonstrated, resulting in markedly higher risk estimates as seen for biomarker alone [RR of 2.70 (95% CI 2.05-3.6) for Q4 of ARR and having body mass index ≥ 30 kg/m2 vs. low ARR (Q1ref) and normal weight; P < 0.0001]. CONCLUSION Among normotensives from the general population ARR possesses a stronger predictive value for incident hypertension than renin or aldosterone alone. The prediction of arterial hypertension by ARR was even stronger in obese subjects.
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Affiliation(s)
- Natalie Arnold
- Preventive Cardiology and Preventive Medicine, Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Iris M Hermanns
- Preventive Cardiology and Preventive Medicine, Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
| | - Andreas Schulz
- Preventive Cardiology and Preventive Medicine, Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Omar Hahad
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
- Department of Cardiology—Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Volker H Schmitt
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
- Department of Cardiology—Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Marina Panova-Noeva
- Preventive Cardiology and Preventive Medicine, Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes-Gutenberg University Mainz, Mainz, Germany
| | - Jürgen H Prochaska
- Preventive Cardiology and Preventive Medicine, Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
- Department of Cardiology—Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes-Gutenberg University Mainz, Mainz, Germany
| | - Harald Binder
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Manfred Beutel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Karl J Lackner
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
- Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Münzel
- Corresponding authors. Tel: +49 (0) 6131 17 7250; fax: +49 (0) 6131 17 6615, E-mail: (T.M.); Tel: +49 (0) 6131 17 7163; fax: +49 (0) 6131 17 3403, E-mail: (P.S.W.)
| | - Philipp S Wild
- Corresponding authors. Tel: +49 (0) 6131 17 7250; fax: +49 (0) 6131 17 6615, E-mail: (T.M.); Tel: +49 (0) 6131 17 7163; fax: +49 (0) 6131 17 3403, E-mail: (P.S.W.)
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11
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Zwain Z, Nwayyir HA, Alidrisi HA, Mansour AA. Prevalence of High Aldosterone-Renin Ratio in Patients With Hypertension in Basrah. Cureus 2023; 15:e36085. [PMID: 37065379 PMCID: PMC10095600 DOI: 10.7759/cureus.36085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND AND AIM Aldosterone-renin ratio (ARR) is an important screening tool for the assessment of primary aldosteronism as a cause of secondary hypertension. This study aimed to measure the prevalence of patients with elevated ARR among samples of Iraqi patients with hypertension. METHODS A retrospective study was conducted at Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC) in Basrah during the period of February 2020 to November 2021. We evaluated the records of patients with hypertension whom were screened for endocrine cause, and an ARR cut-off equal or more than 5.7 was considered elevated. RESULTS Of the total 150 patients enrolled, 39 (26%) of them had an elevated ARR. No statistically significant association for the elevated ARR with age, gender, BMI, duration of hypertension, systolic and diastolic blood pressure, pulse rate, and presence or absence of diabetes mellitus or lipid profile. CONCLUSION High frequency of elevated ARR was seen in 26% of patients with hypertension. More studies need to be conducted in the future taking larger samples.
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12
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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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13
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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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14
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Le Floch E, Cosentino T, Larsen CK, Beuschlein F, Reincke M, Amar L, Rossi GP, De Sousa K, Baron S, Chantalat S, Saintpierre B, Lenzini L, Frouin A, Giscos-Douriez I, Ferey M, Abdellatif AB, Meatchi T, Empana JP, Jouven X, Gieger C, Waldenberger M, Peters A, Cusi D, Salvi E, Meneton P, Touvier M, Deschasaux M, Druesne-Pecollo N, Boulkroun S, Fernandes-Rosa FL, Deleuze JF, Jeunemaitre X, Zennaro MC. Identification of risk loci for primary aldosteronism in genome-wide association studies. Nat Commun 2022; 13:5198. [PMID: 36057693 PMCID: PMC9440917 DOI: 10.1038/s41467-022-32896-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/23/2022] [Indexed: 11/23/2022] Open
Abstract
Primary aldosteronism affects up to 10% of hypertensive patients and is responsible for treatment resistance and increased cardiovascular risk. Here we perform a genome-wide association study in a discovery cohort of 562 cases and 950 controls and identify three main loci on chromosomes 1, 13 and X; associations on chromosome 1 and 13 are replicated in a second cohort and confirmed by a meta-analysis involving 1162 cases and 3296 controls. The association on chromosome 13 is specific to men and stronger in bilateral adrenal hyperplasia than aldosterone producing adenoma. Candidate genes located within the two loci, CASZ1 and RXFP2, are expressed in human and mouse adrenals in different cell clusters. Their overexpression in adrenocortical cells suppresses mineralocorticoid output under basal and stimulated conditions, without affecting cortisol biosynthesis. Our study identifies the first risk loci for primary aldosteronism and highlights new mechanisms for the development of aldosterone excess.
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Affiliation(s)
- Edith Le Floch
- Centre National de Recherche en Génomique Humaine, Institut de biologie François Jacob, CEA, Université Paris-Saclay, Evry, France
| | | | - Casper K Larsen
- Université Paris Cité, Inserm, PARCC, F-75015, Paris, France
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, 80336, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich (USZ) und Universität Zürich (UZH), Zürich, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, 80336, Munich, Germany
| | - Laurence Amar
- Université Paris Cité, Inserm, PARCC, F-75015, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Unité Hypertension artérielle, Paris, France
| | - Gian-Paolo Rossi
- DMCS 'G. Patrassi' University of Padova Medical School, University Hospital, 35126, Padova, Italy
| | - Kelly De Sousa
- Université Paris Cité, Inserm, PARCC, F-75015, Paris, France
| | - Stéphanie Baron
- Université Paris Cité, F-75006, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Physiologie, Paris, France
| | - Sophie Chantalat
- Centre National de Recherche en Génomique Humaine, Institut de biologie François Jacob, CEA, Université Paris-Saclay, Evry, France
| | - Benjamin Saintpierre
- Université Paris Cité, Institut Cochin, Genom'IC platform, INSERM, CNRS, 75014, Paris, France
| | - Livia Lenzini
- DMCS 'G. Patrassi' University of Padova Medical School, University Hospital, 35126, Padova, Italy
| | - Arthur Frouin
- Centre National de Recherche en Génomique Humaine, Institut de biologie François Jacob, CEA, Université Paris-Saclay, Evry, France
| | | | - Matthis Ferey
- Université Paris Cité, Inserm, PARCC, F-75015, Paris, France
| | | | - Tchao Meatchi
- Université Paris Cité, Inserm, PARCC, F-75015, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service d'Anatomie Pathologique, Paris, France
| | | | - Xavier Jouven
- Université Paris Cité, Inserm, PARCC, F-75015, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Cardiologie, Paris, France
| | - Christian Gieger
- Research Unit of Molecular Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Melanie Waldenberger
- Research Unit of Molecular Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- German Research Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Annette Peters
- Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- German Research Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Daniele Cusi
- Institute of Biomedical Technologies National Research Council of Italy, Milan, Italy
- Bio4Dreams-Business Nursery for Life Sciences, Milan, Italy
| | - Erika Salvi
- Neuroalgology Unit, Fondazione IRCCS Istituto Neurologico 'Carlo Besta', Milan, Italy
| | - Pierre Meneton
- UMR_1142, INSERM, Sorbonne Université, Université Paris 13, Paris, France
| | - Mathilde Touvier
- Sorbonne Paris Nord University, INSERM U1153, INRAe U1125, CNAM, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Center - Université Paris Cité (CRESS), 93017, Bobigny, France
| | - Mélanie Deschasaux
- Sorbonne Paris Nord University, INSERM U1153, INRAe U1125, CNAM, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Center - Université Paris Cité (CRESS), 93017, Bobigny, France
| | - Nathalie Druesne-Pecollo
- Sorbonne Paris Nord University, INSERM U1153, INRAe U1125, CNAM, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Center - Université Paris Cité (CRESS), 93017, Bobigny, France
| | | | | | - Jean-François Deleuze
- Centre National de Recherche en Génomique Humaine, Institut de biologie François Jacob, CEA, Université Paris-Saclay, Evry, France
| | - Xavier Jeunemaitre
- Université Paris Cité, Inserm, PARCC, F-75015, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France
| | - Maria-Christina Zennaro
- Université Paris Cité, Inserm, PARCC, F-75015, Paris, France.
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France.
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15
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Brown JM, Wijkman MO, Claggett BL, Shah AM, Ballantyne CM, Coresh J, Grams ME, Wang Z, Yu B, Boerwinkle E, Vaidya A, Solomon SD. Cardiac Structure and Function Across the Spectrum of Aldosteronism: the Atherosclerosis Risk in Communities Study. Hypertension 2022; 79:1984-1993. [PMID: 35582954 PMCID: PMC9759338 DOI: 10.1161/hypertensionaha.122.19134] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aldosterone production and mineralocorticoid receptor activation are implicated in myocardial fibrosis and cardiovascular events. METHODS Cardiac structure and function were assessed in 4547 participants without prevalent heart failure (HF) in the ARIC study (Atherosclerosis Risk in Communities), with echocardiography, aldosterone, and plasma renin activity measurement (2011-2013). Subjects were characterized by plasma renin activity as suppressed (≤0.5 ng/mL per hour) or unsuppressed (>0.5 ng/mL per hour). Cross-sectional relationships with cardiac structure and function, and longitudinal relationships with outcomes (HF hospitalization; HF and all-cause death; HF, death, myocardial infarction, and stroke; and incident atrial fibrillation) were assessed. Models were adjusted for demographic and anthropometric characteristics and additively, for blood pressure and antihypertensives. RESULTS Evidence of primary aldosteronism physiology was prevalent (11.6% with positive screen) and associated with echocardiographic parameters. Renin suppression was associated with greater left ventricular mass, left ventricular volumes, and left atrial volume index, and a lower E/A ratio (adjusted P<0.001 for all). Higher aldosterone was associated with greater left ventricular mass and lower global longitudinal strain and lateral E'. The highest tertile of aldosterone was associated with a hazard ratio of 1.37 (95% CI, 1.06-1.77; 5.5-year follow-up) for incident atrial fibrillation relative to the lowest. Renin suppression was associated with HF (hazard ratio, 1.34 [95% CI, 1.05-1.72]; 7.3-year follow-up), although these relationships did not remain statistically significant after additional adjustment for hypertension. CONCLUSIONS Renin suppression and aldosterone excess, consistent with primary aldosteronism pathophysiology, were associated with cardiac structural and functional alterations and may represent an early target for mitigation of fibrosis with mineralocorticoid receptor antagonists.
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Affiliation(s)
- Jenifer M. Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Magnus O. Wijkman
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
- Department of Internal Medicine and Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden
| | - Brian L. Claggett
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Amil M. Shah
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
| | | | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Zhiying Wang
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center, Houston, TX
| | - Bing Yu
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center, Houston, TX
| | - Eric Boerwinkle
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center, Houston, TX
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA
| | - Scott D. Solomon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
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16
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Brown JM, Auchus RJ, Honzel B, Luther JM, Yozamp N, Vaidya A. Recalibrating Interpretations of Aldosterone Assays Across the Physiologic Range: Immunoassay and Liquid Chromatography-Tandem Mass Spectrometry Measurements Under Multiple Controlled Conditions. J Endocr Soc 2022; 6:bvac049. [PMID: 35475027 PMCID: PMC9032635 DOI: 10.1210/jendso/bvac049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Indexed: 11/19/2022] Open
Abstract
Context Clinicians frequently rely on aldosterone thresholds derived from older immunoassays to diagnose primary aldosteronism. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) is increasingly widespread and reported to yield lower aldosterone concentrations. Objective Given the health impact of incorrect interpretations of aldosterone levels, we compared measurements using LC-MS/MS and immunoassay across the full range of aldosterone physiology by evaluating distinct regulation by angiotensin II and adrenocorticotropin (ACTH). Methods Normotensive volunteers underwent prospective characterization of aldosterone production by immunoassay and LC-MS/MS during 4 conditions (n = 188): oral sodium suppression and restriction (to assess angiotensin II-mediated aldosterone production) and dexamethasone suppression and cosyntropin stimulation (to assess ACTH-mediated aldosterone production). Results Serum aldosterone concentrations by LC-MS/MS and immunoassay had a correlation of 0.69 (P < .001), with good agreement (intraclass correlation 0.76; 95% CI 0.52-0.87). Aldosterone was lower by LC-MS/MS than immunoassay (median 10.5 [3.8, 21.9] vs 19.6 [9.5, 28.0] ng/dL; P < .001), with an average difference of 37.2%. The most notable discrepancy was in the clinically discriminatory range <20 ng/dL: 9.9 (7.1, 13.8) ng/dL using immunoassay corresponded to 5.5 (1.4, 8.9) ng/dL by LC-MS/MS (P < .001). Following oral sodium suppression, the aldosterone-to-renin ratio was 4-fold higher using immunoassay (27.2 [19.7, 62.4] vs 6.4 [3.5, 19.1] ng/dL per ng/mL/hour; P < .001). Conclusion Aldosterone measurements are substantially lower by LC-MS/MS than immunoassay across the full physiologic range, especially when aldosterone levels were less than 20 ng/dL. These findings highlight the need to recalibrate diagnostic interpretations when measuring aldosterone via LC-MS/MS and provide insights into potential biologic causes of assay differences.
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Affiliation(s)
- Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Richard J Auchus
- Departments of Pharmacology and Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MA 48105, USA
- Endocrinology and Metabolism Section, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MA 48105, USA
| | - Brooke Honzel
- Center for Adrenal Disorders, Division of Diabetes, Endocrinology, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - James M Luther
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Nicholas Yozamp
- Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Diabetes, Endocrinology, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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17
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Jung J, Kim H. Shared genetic etiology and antagonistic relationship of plasma renin activity and systolic blood pressure in a Korean cohorts. Genomics 2022; 114:110334. [PMID: 35278618 DOI: 10.1016/j.ygeno.2022.110334] [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: 11/08/2021] [Revised: 02/11/2022] [Accepted: 03/06/2022] [Indexed: 01/14/2023]
Abstract
Despite extensive studies on blood pressure, its genetic risk factors remain uncertain. Even one of the most researched blood pressure-related traits - renin - is not fully understood genetically. Here, we determine the genetic relationship and associated predisposition between blood pressure and baseline renin. In 8840 Korean individuals, we observed a strong negative genome-wide genetic correlation (rg = -0.484) between systolic blood pressure (SBP) and plasma renin activity (PRA), suggesting that antagonistic genetic signals explain the variance in the two traits. We found 51 significant pleiotropic SNPs affecting the two traits, which could contribute to the Renin-Angiotensin-Aldosterone System (RAAS). Our findings provide insight into studies on RAAS by identifying the genome-wide relationship and susceptibility loci of SBP and PRA.
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Affiliation(s)
- Jaehoon Jung
- Research Institute of Agriculture and Life Sciences, Seoul National University, Seoul 151-742, Republic of Korea; eGnome, 26 Beobwon-ro, Songpa-gu, Seoul 05836, Republic of Korea.
| | - Heebal Kim
- Research Institute of Agriculture and Life Sciences, Seoul National University, Seoul 151-742, Republic of Korea; eGnome, 26 Beobwon-ro, Songpa-gu, Seoul 05836, Republic of Korea; Interdisciplinary Program in Bioinformatics, Seoul National University, Seoul 151-742, Republic of Korea.
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18
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Hu J, Shen H, Huo P, Yang J, Fuller PJ, Wang K, Yang Y, Ma L, Cheng Q, Gong L, He W, Luo T, Mei M, Wang Y, Du Z, Luo R, Cai J, Li Q, Song Y, Yang S. Heightened Cardiovascular Risk in Hypertension Associated With Renin-Independent Aldosteronism Versus Renin-Dependent Aldosteronism: A Collaborative Study. J Am Heart Assoc 2021; 10:e023082. [PMID: 34889107 PMCID: PMC9075265 DOI: 10.1161/jaha.121.023082] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/02/2021] [Indexed: 11/16/2022]
Abstract
Background While both renin-dependent and renin-independent aldosterone secretion contribute to aldosteronism, their relative associations with cardiovascular disease (CVD) risk has not been investigated. Methods and Results A total of 2909 participants from the FOS (Framingham Offspring Study) with baseline, serum aldosterone concentration, and plasma renin concentration who attended the sixth examination cycle and were followed up until 2014 and who were free of CVD were included. We further recruited 2612 hypertensive participants from the CONPASS (Chongqing Primary Aldosteronism Study). Captopril challenge test was performed to confirm renin-dependent or -independent aldosteronism in CONPASS. Among 1433 hypertensive subjects of FOS, when compared with those with serum aldosterone concentration <10 ng dL-1 (normal aldosterone), participants who had serum aldosterone concentration ≥10 ng dL-1 and plasma renin concentration ≤15 mIU L-1 (identified as renin-independent aldosteronism) showed a higher risk of CVD (hazard ratio, 1.40 [95% CI, 1.08-1.82]), while those who had serum aldosterone concentration ≥10 ng dL-1 and plasma renin concentration >15 mIU L-1 (identified as renin-dependent aldosteronism) showed an unchanged CVD risk. In CONPASS, renin-independent aldosteronism carried a significantly higher risk of CVD than normal aldosterone (odds ratio, 2.57 [95% CI, 1.13-5.86]), while the CVD risk remained unchanged in renin-dependent aldosteronism. Elevation of the urinary potassium-to-sodium excretion ratio, reflective of mineralocorticoid receptor activity, was only observed in participants with renin-independent aldosteronism. Conclusions Among patients with hypertension, renin-independent aldosteronism is more closely associated with CVD risk than renin-dependent aldosteronism.
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Affiliation(s)
- Jinbo Hu
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Hang Shen
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Peiqi Huo
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Jun Yang
- Centre for Endocrinology and MetabolismHudson Institute of Medical ResearchClaytonVic.Australia
- Department of MedicineMonash UniversityClaytonVic.Australia
| | - Peter J Fuller
- Centre for Endocrinology and MetabolismHudson Institute of Medical ResearchClaytonVic.Australia
- Department of MedicineMonash UniversityClaytonVic.Australia
| | - Kanran Wang
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Yi Yang
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Linqiang Ma
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Qingfeng Cheng
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Lilin Gong
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Wenwen He
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Ting Luo
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Mei Mei
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Yue Wang
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Zhipeng Du
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Rong Luo
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Jun Cai
- Hypertension CenterFuwai HospitalState Key Laboratory of Cardiovascular DiseaseNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Qifu Li
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Ying Song
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Shumin Yang
- Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
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19
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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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20
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Kmieć P, Sworczak K. Autonomous Aldosterone Secretion as a Subclinical Form of Primary Aldosteronism: Pathogenesis and Clinical Significance. Exp Clin Endocrinol Diabetes 2021; 130:7-16. [PMID: 34614533 DOI: 10.1055/a-1556-7784] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In recent years, a substantial prevalence of primary aldosteronism (PA) has been demonstrated in both normotensive and mildly hypertensive cohorts. Consequently, a classic presentation of the syndrome, i. e. moderate-to-severe and resistant hypertension with concomitant hypokalemia, should be considered a tip-of-the-iceberg phenotype of a wide PA spectrum. Its entire range encompasses the non-classic clinical forms of mild hypertension and prehypertension but also several biochemical presentations, including patients who meet PA screening and confirmation test criteria, as well as those with either of them and those with other parameters indicating mineralocorticoid excess. In the current review, research insights on the pathogenetic background and clinical significance of autonomous aldosterone secretion (AAS) are presented, which is defined as a constellation of either: 1) normotension, normokalemia, a positive PA screening (high aldosterone-to-renin ratio) and/or confirmation test, or 2) hypertension, normokalemia and a positive PA screening but negative confirmation test. For this purpose, a literature search of the PubMed database was conducted. Advances in immunohistochemistry and genetic sequencing of isolated adrenal cells are provided as probable morphologic basis of the wide range of aldosterone secretion autonomy. Also, the role of corticotropin as an aldosterone secretagogue is discussed. To date, clinical studies depict consequences of subclinical PA phenotypes, such as increased mortality and risk of developing hypertension, impaired arterial and kidney function, association with metabolic syndrome and age, as well as osteoporosis.
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Affiliation(s)
- Piotr Kmieć
- Department of Endocrinology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Krzysztof Sworczak
- Department of Endocrinology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
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21
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Kline G. Primary aldosteronism is everywhere but does anyone see it? Clin Endocrinol (Oxf) 2021; 95:410-411. [PMID: 33682143 DOI: 10.1111/cen.14450] [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: 02/08/2021] [Accepted: 02/21/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Gregory Kline
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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22
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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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23
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Wannachalee T, Turcu AF. Primary Aldosteronism: a Continuum from Normotension to Hypertension. Curr Cardiol Rep 2021; 23:105. [PMID: 34196827 DOI: 10.1007/s11886-021-01538-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Primary aldosteronism (PA) is the most common cause of secondary hypertension. Emerging evidence suggests that PA is associated with cardiovascular, metabolic, and renal complications, that likely develop insidiously, due to prolonged inappropriate mineralocorticoid receptor activation. In this review, we discuss the expanding clinical and pathological spectrum of PA. RECENT FINDINGS Clinical and molecular studies conducted over the recent years reveal that PA traverses a series of contiguous stages. Pre-clinical, but hormonally overt PA has been identified in patients with normal blood pressure, and such patients harbor an increased risk of developing hypertension. Similarly, genetic and histopathological advancements have exposed a spectrum of PA pathology that corresponds to a continuum that spans from pre-clinical stages to florid PA. PA evolves from pre-hypertensive stages to resistant hypertension, along with serious cardiovascular and renal consequences. Early recognition of PA and targeted therapy will be essential for cardiovascular morbidity and mortality prevention in a large number of patients.
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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
| | - 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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24
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Yang J, May Gwini S, Beilin LJ, Schlaich M, Stowasser M, Young MJ, Fuller PJ, Mori TA. Relationship Between the Aldosterone-to-Renin Ratio and Blood Pressure in Young Adults: A Longitudinal Study. Hypertension 2021; 78:387-396. [PMID: 34120455 DOI: 10.1161/hypertensionaha.121.17336] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia (J.Y., P.J.F.).,Department of Medicine (J.Y.), Monash University, Clayton, Victoria, Australia
| | - Stella May Gwini
- Department of Epidemiology, School of Public Health and Preventive Medicine (S.M.G.), Monash University, Clayton, Victoria, Australia.,University Hospital Geelong, Barwon Health, Victoria, Australia (S.M.G.)
| | - Lawrence J Beilin
- Medical School, The University of Western Australia (L.J.B., T.A.M.)
| | - Markus Schlaich
- Dobney Hypertension Centre, Medical School, The University of Western Australia, Royal Perth Hospital Campus (M. Schlaich).,Departments of Cardiology and Nephrology, Royal Perth Hospital, Australia (M. Schlaich).,Neurovascular Hypertension and Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia (M. Schlaich)
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland Diamantina Institute, Princess Alexandra Hospital, Brisbane, Australia (M. Stowasser)
| | - Morag J Young
- Cardiovascular Endocrinology Laboratory, Baker Heart and Diabetes Institute, Victoria, Australia (M.J. Young)
| | - Peter J Fuller
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia (J.Y., P.J.F.)
| | - Trevor A Mori
- Medical School, The University of Western Australia (L.J.B., T.A.M.)
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25
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Abstract
PURPOSE OF REVIEW Primary aldosteronism, characterized by renin-independent aldosterone secretion from one or both adrenal glands, is the most common and modifiable form of secondary hypertension. The prevalence of primary aldosteronism is increasingly recognized to be much higher than previously thought with many cases still undetected. RECENT FINDINGS Prior prevalence studies on primary aldosteronism have reported a wide range of estimates due to heterogeneity of both disease definitions and study populations such that it is difficult to claim a single point estimate. More recent evidence demonstrates that primary aldosteronism, as defined by conventional biochemical diagnostic criteria, is highly prevalent within populations where it is not typically considered such as mild-to-moderate hypertension, prehypertension, and even normotension. Yet, our current screening approach fails to capture many cases. Furthermore, there is mounting evidence that renin-independent aldosteronism exists as a continuum of disease that extends below the current biochemical diagnostic thresholds used to define primary aldosteronsim and has clinically relevant treatment and outcome implications for a much broader patient population. Indeed, much of what we current label as 'essential hypertension' is, in fact, renin-independent aldosterone-mediated hypertension. SUMMARY Primary aldosteronism and milder forms of renin-independent aldosteronism are highly prevalent, yet vastly under-recognized, in the general population.
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26
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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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27
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Vaidya A, Carey RM. Evolution of the Primary Aldosteronism Syndrome: Updating the Approach. J Clin Endocrinol Metab 2020; 105:5899581. [PMID: 32865201 PMCID: PMC7899564 DOI: 10.1210/clinem/dgaa606] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 08/26/2020] [Indexed: 12/19/2022]
Abstract
CONTEXT New approaches are needed to address the evolution of the primary aldosteronism syndrome and to increase its recognition. Herein, we review evidence indicating that primary aldosteronism is a prevalent syndrome that is mostly unrecognized, and present a pragmatic and pathophysiology-based approach to improve diagnosis and treatment. METHODS Evidence was gathered from published guidelines and studies identified from PubMed by searching for primary aldosteronism, aldosterone, renin, and hypertension. This evidence was supplemented by the authors' personal knowledge, research experience, and clinical encounters in primary aldosteronism. INTERPRETATION OF EVIDENCE Renin-independent aldosterone production is a prevalent phenotype that is diagnosed as primary aldosteronism when severe in magnitude, but is largely unrecognized when milder in severity. Renin-independent aldosterone production can be detected in normotensive and hypertensive individuals, and the magnitude of this biochemical phenotype parallels the magnitude of blood pressure elevation, the risk for incident hypertension and cardiovascular disease, and the likelihood and magnitude of blood pressure reduction with mineralocorticoid receptor antagonist therapy. Expansion of the indications to screen for primary aldosteronism, combined with the use of a pathophysiology-based approach that emphasizes inappropriate aldosterone production in the context of renin suppression, will substantially increase the diagnostic and therapeutic yields for primary aldosteronism. CONCLUSIONS The landscape of primary aldosteronism has evolved to recognize that it is a prevalent syndrome of renin-independent aldosterone production that contributes to the pathogenesis of hypertension and cardiovascular disease. Expanding screening indications and simplifying the diagnostic approach will enable implementation of targeted treatment for primary aldosteronism.
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Affiliation(s)
- Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, & Hypertension, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Correspondence and Reprint Requests: Anand Vaidya, MD, MMSc, Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, RFB, Boston, MA 02115, USA. E-mail:
| | - Robert M Carey
- Division of Endocrinology and Metabolism, University of Virginia Health System, Charlottesville, Virginia
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28
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Kokko E, Nevalainen PI, Choudhary MK, Koskela J, Tikkakoski A, Huhtala H, Niemelä O, Viukari M, Mustonen J, Matikainen N, Pörsti I. Aldosterone-to-renin ratio is related to arterial stiffness when the screening criteria of primary aldosteronism are not met. Sci Rep 2020; 10:19804. [PMID: 33188272 PMCID: PMC7666146 DOI: 10.1038/s41598-020-76718-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/02/2020] [Indexed: 11/28/2022] Open
Abstract
Aldosterone-to-renin ratio (ARR) is a screening tool for primary aldosteronism (PA), but the significance of ARR when the PA criteria are not met remains largely unknown. In this cross-sectional study we investigated the association of ARR with haemodynamic variables in 545 normotensive and never-medicated hypertensive subjects (267 men, 278 women, age range 19-72 years) without suspicion of PA. Supine haemodynamic data was recorded using whole-body impedance cardiography and radial tonometric pulse wave analysis. In sex-adjusted quartiles of ARR, determined as serum aldosterone to plasma renin activity ratio, the mean values were 282, 504, 744 and 1467 pmol/µg of angiotensin I/h, respectively. The only difference in haemodynamic variables between the ARR quartiles was higher pulse wave velocity (PWV) in the highest quartile versus other quartiles (p = 0.004), while no differences in blood pressure (BP), heart rate, wave reflections, cardiac output or systemic vascular resistance were observed between the quartiles. In linear regression analysis with stepwise elimination, ARR was an independent explanatory factor for PWV (β = 0.146, p < 0.001, R2 of the model 0.634). In conclusion, ARR was directly and independently associated with large arterial stiffness in individuals without clinical suspicion of PA. Therefore, ARR could serve as a clinical marker of cardiovascular risk.Trial registration: ClinicalTrails.gov: NCT01742702.
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Affiliation(s)
- Eeva Kokko
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Pasi I Nevalainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | | | - Jenni Koskela
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Antti Tikkakoski
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Clinical Physiology, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Onni Niemelä
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Clinical Laboratory and Medical Research Unit, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Marianna Viukari
- Endocrinology, Helsinki University Hospital and Research Programs Unit, Clinical and Molecular Medicine, University of Helsinki, Helsinki, Finland
| | - Jukka Mustonen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Niina Matikainen
- Endocrinology, Helsinki University Hospital and Research Programs Unit, Clinical and Molecular Medicine, University of Helsinki, Helsinki, Finland
| | - Ilkka Pörsti
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland.
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Solanki P, Gwini SM, Doery JCG, Choy KW, Shen J, Young MJ, Fuller PJ, Yang J. Age- and sex-specific reference ranges are needed for the aldosterone/renin ratio. Clin Endocrinol (Oxf) 2020; 93:221-228. [PMID: 32306417 DOI: 10.1111/cen.14199] [Citation(s) in RCA: 12] [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: 03/11/2020] [Revised: 04/01/2020] [Accepted: 04/15/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Current Endocrine Society Clinical Practice Guidelines use a specific aldosterone/renin ratio (ARR) threshold to screen for primary aldosteronism (a treatable disease causing up to 15% of hypertension in primary care) in all patients. We sought to characterize demographic variations in the ARR, hypothesizing a need for age- and sex-specific reference ranges to improve the accuracy of the test. DESIGN Retrospective cross-sectional analysis of ARR measurements at a single tertiary hospital from December 2016 to June 2018. PATIENTS A total of 442 patients with clinically indicated ARR were included, after excluding those who were on spironolactone or the oral contraceptive pill, were pregnant or had an existing adrenal condition. MEASUREMENTS Aldosterone, renin and the ARR. RESULTS Among those aged 20-39 years (n = 74), females had significantly higher median aldosterone (369 vs 244 pmol/L, P = .028), lower median renin (17.0 vs 27.6 mIU/L, P = .034) and higher median ARR (20.7 vs 10.3 (pmol/L)/(mIU/L), P = .001) than males, despite having lower systolic (135 vs 145 mmHg, P = .021) and diastolic (89 vs 96.5 mmHg, P = .007) blood pressure. The ≥ 60-year age group (n = 157) also had significant sex differences in the ARR. With increasing age (20-39 vs ≥ 60 years), there was a significant fall in plasma aldosterone in females (369 pmol/L vs 264 pmol/L, P = .005), with no change observed in males. CONCLUSIONS For those 20-39 years old, aldosterone and the ARR are significantly higher in females despite a lower systolic and diastolic BP, highlighting the potential for false-positive results. Our findings indicate the need for prospective studies with a control population to define age- and sex-specific ARR reference ranges.
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Affiliation(s)
- Pravik Solanki
- Department of Endocrinology, Monash Health, Clayton, Vic., Australia
- Department of Medicine, Monash University, Clayton, Vic., Australia
| | - Stella May Gwini
- Barwon Health, University Hospital Geelong, Geelong, Vic., Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
| | - James C G Doery
- Department of Medicine, Monash University, Clayton, Vic., Australia
| | - Kay Weng Choy
- Department of Endocrinology, Monash Health, Clayton, Vic., Australia
| | - Jimmy Shen
- Department of Endocrinology, Monash Health, Clayton, Vic., Australia
- Hudson Institute of Medical Research, Clayton, Vic., Australia
| | - Morag J Young
- Hudson Institute of Medical Research, Clayton, Vic., Australia
| | - Peter J Fuller
- Department of Endocrinology, Monash Health, Clayton, Vic., Australia
- Hudson Institute of Medical Research, Clayton, Vic., Australia
| | - Jun Yang
- Department of Endocrinology, Monash Health, Clayton, Vic., Australia
- Department of Medicine, Monash University, Clayton, Vic., Australia
- Hudson Institute of Medical Research, Clayton, Vic., Australia
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Brown JM, Siddiqui M, Calhoun DA, Carey RM, Hopkins PN, Williams GH, Vaidya A. The Unrecognized Prevalence of Primary Aldosteronism: A Cross-sectional Study. Ann Intern Med 2020; 173:10-20. [PMID: 32449886 PMCID: PMC7459427 DOI: 10.7326/m20-0065] [Citation(s) in RCA: 316] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Primary aldosteronism is a nonsuppressible renin-independent aldosterone production that causes hypertension and cardiovascular disease. OBJECTIVE To characterize the prevalence of nonsuppressible renin-independent aldosterone production, as well as biochemically overt primary aldosteronism, in relation to blood pressure. DESIGN Cross-sectional study. SETTING 4 U.S. academic medical centers. PARTICIPANTS Participants with normotension (n = 289), stage 1 hypertension (n = 115), stage 2 hypertension (n = 203), and resistant hypertension (n = 408). MEASUREMENTS Participants completed an oral sodium suppression test, regardless of aldosterone or renin levels, as a confirmatory diagnostic for primary aldosteronism and to quantify the magnitude of renin-independent aldosterone production. Urinary aldosterone was measured in participants in high sodium balance with suppressed renin activity. Biochemically overt primary aldosteronism was diagnosed when urinary aldosterone levels were higher than 12 μg/24 h. RESULTS Every blood pressure category had a continuum of renin-independent aldosterone production, where greater severity of production was associated with higher blood pressure, kaliuresis, and lower serum potassium levels. Mean adjusted levels of urinary aldosterone were 6.5 μg/24 h (95% CI, 5.2 to 7.7 μg/24 h) in normotension, 7.3 μg/24 h (CI, 5.6 to 8.9 μg/24 h) in stage 1 hypertension, 9.5 μg/24 h (CI, 8.2 to 10.8 μg/24 h) in stage 2 hypertension, and 14.6 μg/24 h (CI, 12.9 to 16.2 μg/24 h) in resistant hypertension; corresponding adjusted prevalence estimates for biochemically overt primary aldosteronism were 11.3% (CI, 5.9% to 16.8%), 15.7% (CI, 8.6% to 22.9%), 21.6% (CI, 16.1% to 27.0%), and 22.0% (CI, 17.2% to 26.8%). The aldosterone-renin ratio had poor sensitivity and negative predictive value for detecting biochemically overt primary aldosteronism. LIMITATION Prevalence estimates rely on arbitrary and conventional thresholds, and the study population may not represent nationwide demographics. CONCLUSION The prevalence of primary aldosteronism is high and largely unrecognized. Beyond this categorical definition of primary aldosteronism, there is a prevalent continuum of renin-independent aldosterone production that parallels the severity of hypertension. These findings redefine the primary aldosteronism syndrome and implicate it in the pathogenesis of "essential" hypertension. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Jenifer M Brown
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (J.M.B., G.H.W., A.V.)
| | - Mohammed Siddiqui
- University of Alabama at Birmingham, Birmingham, Alabama (M.S., D.A.C.)
| | - David A Calhoun
- University of Alabama at Birmingham, Birmingham, Alabama (M.S., D.A.C.)
| | - Robert M Carey
- University of Virginia Health System, Charlottesville, Virginia (R.M.C.)
| | - Paul N Hopkins
- University of Utah School of Medicine, Salt Lake City, Utah (P.N.H.)
| | - Gordon H Williams
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (J.M.B., G.H.W., A.V.)
| | - Anand Vaidya
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (J.M.B., G.H.W., A.V.)
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Inoue K, Goldwater D, Allison M, Seeman T, Kestenbaum BR, Watson KE. Serum Aldosterone Concentration, Blood Pressure, and Coronary Artery Calcium: The Multi-Ethnic Study of Atherosclerosis. Hypertension 2020; 76:113-120. [PMID: 32418495 PMCID: PMC10681368 DOI: 10.1161/hypertensionaha.120.15006] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/14/2020] [Indexed: 01/12/2023]
Abstract
Aldosterone is a steroid hormone regulating fluid and electrolyte homeostasis and is known to increase the risk of atherosclerosis. In this study, we examined the associations of serum aldosterone concentrations with subclinical atherosclerosis and all-cause mortality. This study included 948 adults aged 46 to 88 years from the MESA (Multi-Ethnic Study of Atherosclerosis) with measurements of serum aldosterone and plasma renin activity and not taking antihypertensive medications. Coronary calcification was longitudinally assessed using Agatston coronary artery calcium score from computed tomography scans. All-cause mortality was ascertained from the medical record. The average age (SD) was 62.3 (9.4) years and 53% were male. Among 700 subjects who had follow-up coronary artery calcium score (median follow-up of 6.4 years), higher aldosterone levels (per 100 pg/mL) were associated with higher coronary artery calcium (relative ratio, 1.17 [95% CI, 1.04-1.32]), with the association being stronger in individuals with suppressed plasma renin activity (≤0.5 μg/L/hr). Systolic or diastolic blood pressure mediated around 45% of the total effect of aldosterone on coronary artery calcium. Over a median follow-up of 12.5 years (120 deaths identified among 948 subjects), aldosterone was associated with the increased risk of all-cause mortality when plasma renin activity was suppressed; hazard ratio per 100 pg/mL, 1.70 (95% CI, 1.10-2.63). In this study, we found that higher aldosterone levels were associated with the increased risk of subclinical coronary atherosclerosis and all-cause mortality particularly when renin was suppressed. Our findings indicate the importance of aldosterone levels (even within the reference range) with respect to the cardiovascular system and overall health.
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Affiliation(s)
- Kosuke Inoue
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Deena Goldwater
- Department of Medicine, Division of Cardiology, UCLA, Los Angeles, CA
- Department of Medicine, Division of Geriatrics, UCLA, Los Angeles, CA
| | - Matthew Allison
- Department of Family Medicine and Public Health, Division of Preventive Medicine, UCSD, San Diego, CA
| | - Teresa Seeman
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
- Department of Medicine, Division of Geriatrics, UCLA, Los Angeles, CA
| | - Bryan R. Kestenbaum
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Karol E. Watson
- Department of Medicine, Division of Cardiology, UCLA, Los Angeles, CA
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Wu VC, Chueh JS, Hsieh MY, Hu YH, Huang KH, Lin YH, Yang SY, Chu TS, Kuo CF. Familial Aggregation and Heritability of Aldosteronism with Cardiovascular Events. J Clin Endocrinol Metab 2020; 105:5810354. [PMID: 32193536 DOI: 10.1210/clinem/dgz257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 12/10/2019] [Indexed: 01/13/2023]
Abstract
CONTEXT To date, the effect of positive family history as a risk factor of primary aldosteronism (PA) is largely unknown. Studies have failed to distinguish the heritability of PA as well as the associations between positive family history of PA and clinical outcomes. OBJECTIVES We quantified the prevalence, the extent of familial aggregation, the heritability of PA among family members of patients with PA, and the association between positive PA family history and major cardiovascular events (MACE). DESIGN AND SETTINGS Using the Taiwan National Health Insurance Database, 30 245 077 National Health Insurance beneficiaries (both alive and those deceased between January 1, 1999, and December 31, 2015) were identified. RESULTS We identified 7902 PA patients. Forty-four had PA (0.3%) among 10 234 individuals with affected parents, 2298 with affected offspring, 1924 with affected siblings, and 22 with affected twins. A positive family history was associated with the adjusted relative risk (RR) (95% confidence interval [CI]) of 11.60 (7.63-17.63) for PA in people with an affected first-degree relative. In subgroup analysis, the risk for PA across all relationships (parent, siblings, offspring, and spouse) showed highly significant differences to PA without family history. The accountability for phenotypic variance of PA was 51.0% for genetic factors, 24.9% for shared environmental factors, and 24.1% for nonshared environmental factors. PA patients with an affected first-degree relative were associated with an increased risk for composite major cardiovascular events (RR 1.31; 95% CI 1.24-1.40, P < .001) compared with PA patients without family history. CONCLUSION Familial clustering of PA exists among a population-based study, supporting a genetic susceptibility leading to PA. There is increased coaggregation of MACE in first-degree relatives of PA patients. Our findings suggest a strong genetic component in the susceptibility of PA, involving different kinships.
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Affiliation(s)
- Vin-Cent Wu
- Division of Nephrology and Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jeff S Chueh
- Cleveland Clinic Lerner College of Medicine and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mei-Yun Hsieh
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ya-Hui Hu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taipei, Taiwan
| | - Kuo-How Huang
- Division of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hung Lin
- Division of Nephrology and Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shao-Yu Yang
- Division of Nephrology and Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzong-Shinn Chu
- Division of Nephrology and Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chang-Fu Kuo
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Buffolo F, Monticone S, Pecori A, Pieroni J, Losano I, Cavaglià G, Tetti M, Veglio F, Mulatero P. The spectrum of low-renin hypertension. Best Pract Res Clin Endocrinol Metab 2020; 34:101399. [PMID: 32147420 DOI: 10.1016/j.beem.2020.101399] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Low-renin hypertension (LRH) is a frequent condition in patients with arterial hypertension, accounting for 30% of patients. Monogenic forms can cause LRH in a minority of cases. However, in the large majority of patients, LRH is caused by the combined effects of congenital and acquired factors, comprising dietary habits. Several genetic variants have been proposed as co-factors in the pathogenesis of LRH with normal-low serum aldosterone. Emerging evidences support the hypothesis that a large proportion of LRH with normal-high serum aldosterone is associated with subclinical primary aldosteronism (PA). The recent identification of aldosterone-producing cell clusters (APCCs) as the possible cause of subclinical PA, further supported the concept of a continuous spectrum of autonomous aldosterone secretion, from subclinical forms towards overt PA. In this review we describe the main aspects of LRH, focusing on molecular basis, clinical risk profile and patients' management.
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Affiliation(s)
- Fabrizio Buffolo
- 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
| | - Alessio Pecori
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Torino, Italy
| | - Jacopo Pieroni
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Torino, Italy
| | - Isabel Losano
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Torino, Italy
| | - Giovanni Cavaglià
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Torino, Italy
| | - Martina Tetti
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Torino, Italy
| | - Franco Veglio
- 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.
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Aeschbacher S, Mongiat M, Bernasconi R, Blum S, Meyre P, Krisai P, Ceylan S, Risch M, Risch L, Conen D. Aldosterone-to-renin ratio and blood pressure in young adults from the general population. Am Heart J 2020; 222:199-207. [PMID: 32105986 DOI: 10.1016/j.ahj.2019.11.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 11/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The effect of the renin angiotensin system on blood pressure (BP) values in young adults from the general population is not well studied. We investigated the relationship between the aldosterone-to-renin ratio (ARR) and various BP indices in this population. METHODS We assembled a population-based sample of adults aged 25-41 years. Conventional and 24-hour BP recordings were obtained in all patients. Direct renin concentration and plasma aldosterone concentration were measured. Multivariable regression models were constructed to assess the relationships of ARR with BP and hypertension. RESULTS We included 1,353 individuals (mean age 37 years, 56% women). The median (interquartile range) ARR, direct renin concentration, and plasma aldosterone concentration were 13.8 (8.7-22.9), 7.2 ng/L (4.4-11.0) and 94 ng/L (68-134). All BP indices were higher across sex-specific ARR quartiles. Per 1-unit increase in log-transformed ARR, the multivariable-adjusted β-coefficients (95% CI) for conventional, 24-hour, daytime, and nighttime systolic BP were 1.68 (0.87-2.48), P < .0001; 2.40 (1.68-3.12), P < .0001; 2.23 (1.48-2.99), P < .0001; and 2.80 (2.03-3.58), P < .0001, respectively. Per 1-unit increase in log-transformed ARR, the multivariable-adjusted odds ratio (95% CI) for conventional, 24-hour, sustained and masked hypertension was 1.70 (1.17-2.28), P = .0004; 1.29 (1.06-1.56), P = .01; 1.82 (1.33-2.49), P = .002; and 1.14 (0.94-1.38), P = .20, respectively. CONCLUSIONS In young adults, ARR was strongly associated with conventional and ambulatory BP. Our data suggest that an aldosterone-driven phenomenon occurs very early in the development of hypertension.
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Affiliation(s)
- Stefanie Aeschbacher
- Cardiology Division, Department of Medicine, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland.
| | - Michel Mongiat
- Cardiology Division, Department of Medicine, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Raffaele Bernasconi
- Cardiology Division, Department of Medicine, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Steffen Blum
- Cardiology Division, Department of Medicine, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Pascal Meyre
- Cardiology Division, Department of Medicine, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Philipp Krisai
- Cardiology Division, Department of Medicine, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Selinda Ceylan
- Cardiology Division, Department of Medicine, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Martin Risch
- Labormedizinisches Zentrum Dr. Risch, Vaduz, Principality of Liechtenstein; Division of Laboratory Medicine, Kantonsspital Graubünden, Chur, Switzerland
| | - Lorenz Risch
- Labormedizinisches Zentrum Dr. Risch, Vaduz, Principality of Liechtenstein; Department of Laboratory Medicine, Institute of Clinical Chemistry, Inselspital Bern, University Hospital, University of Bern, Bern, Switzerland; Private University, Triesen, Principality of Liechtenstein
| | - David Conen
- Cardiology Division, Department of Medicine, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Application of strict criteria in adrenal venous sampling increases the proportion of missed patients with unilateral disease who benefit from surgery for primary aldosteronism. J Hypertens 2019; 36:1407-1413. [PMID: 29465715 DOI: 10.1097/hjh.0000000000001693] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Adrenal vein sampling (AVS) is intended to confirm unilateral forms of primary aldosteronism, which are amenable to surgical cure. Excessively strict AVS criteria to define lateralization may result in many patients incorrectly categorized as bilateral primary aldosteronism and opportunity for surgical cure missed. METHODS Retrospective review of an AVS-primary aldosteronism database in which surgical cases are verified by standardized outcomes. Having used 'less strict' AVS criteria for lateralization, we examined the distribution of AVS lateralization indices in our confirmed unilateral primary aldosteronism cases both with and without cosyntropin stimulation. The proportion of proven unilateral cases that would have been missed with stricter AVS interpretation criteria was calculated. Particular focus was given to the proportion of missed cases according to use of international guidelines. False-positive lateralization with 'less strict' interpretation was also calculated. RESULTS Of 80 surgical primary aldosteronism cases, 10-23% would have been missed with AVS lateralization indices of 3 : 1 to 5 : 1, with or without cosyntropin. If strict selectivity indices (for confirmation of catheterization) were combined with strict lateralization indices, up to 70% of unilateral primary aldosteronism cases could have been missed. Use of Endocrine Society AVS guidelines would have missed 21-43% of proven unilateral cases. 'Less strict' AVS interpretation yielded one case (1.2%) of false lateralization. CONCLUSION Excessively strict AVS interpretation criteria will result in a high rate of missed unilateral primary aldosteronism with subsequent loss of opportunity for intervention. Use of more lenient lateralization criteria will improve the detection rate of unilateral primary aldosteronism with very low false-positive rate.
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Abstract
Over six decades since primary aldosteronism was first described, much has been learned about its prevalence and optimal treatment. Estimates of the prevalence of primary aldosteronism have increased considerably over the years, even exceeding 20% in some populations of resistant hypertension. Even in patients with normal blood pressures, the prevalence of overt primary aldosteronism and dysregulated aldosterone production may be more common than appreciated. Emerging data support the concept that primary aldosteronism may be better characterized as a continuum of renin-independent aldosterone production, whose severity influences the clinical presentation and risk for incident cardiovascular disease. Mineralocorticoid receptor antagonists and adrenalectomy are the mainstay treatments for primary aldosteronism and have long been considered equally efficacious. However, recent data suggest that while surgical adrenalectomy can effectively reduce cardiovascular risk, mineralocorticoid receptor antagonist therapy may require a physiologic approach to optimize efficacy.
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37
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O'Shea PM, Griffin TP, Denieffe S, Fitzgibbon MC. The aldosterone to renin ratio in the diagnosis of primary aldosteronism: Promises and challenges. Int J Clin Pract 2019; 73:e13353. [PMID: 31009143 DOI: 10.1111/ijcp.13353] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 03/16/2019] [Accepted: 04/18/2019] [Indexed: 12/20/2022] Open
Abstract
The complexity of evaluating patients for secondary treatable causes of hypertension is underappreciated. Primary aldosteronism (PA) is the most prevalent cause of secondary hypertension (3%-32% of hypertensive patients). The recent endocrine society clinical practice guideline (ESCPG), "The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment", differs from the previous version in the explicit recognition of PA as a major public health issue. Despite this, PA is underdiagnosed. The guidelines call on physicians to substantially ramp up the screening of hypertensive patients at risk of PA. Further, it recommends the plasma aldosterone to renin ratio (ARR), as the test of choice for screening for PA. However, the ARR is a highly variable test with reported diagnostic sensitivities and specificities ranging from 66% to 100% and 61% to 100%, respectively. Variability of the ARR can be attributed to the high degree of within-subject variation, differences in sampling protocols, laboratory assays, reporting units, the effect of medications and the population characteristics used to establish the decision thresholds. These factors render the possibility of false positive and false negative results-which have the potential to adversely impact patients. The limitations and caveats to the use of the ARR necessitate an effective clinic-laboratory interface, with specialist physician and clinical scientist collaboration for ARR result interpretation. Improvement in the diagnostic sensitivity and specificity of the ARR is predicated on harmonisation of pretesting patient preparation criteria, knowledge of the analytical methods used to derive the ratio and the method-specific threshold for PA.
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Affiliation(s)
- Paula M O'Shea
- Department of Clinical Biochemistry, Galway University Hospitals, Galway, Ireland
| | - Tomás P Griffin
- Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Galway, Ireland
| | - Stephanie Denieffe
- University College Dublin and Department of Clinical Biochemistry & Diagnostic Endocrinology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Maria C Fitzgibbon
- Department of Clinical Biochemistry & Diagnostic Endocrinology, Mater Misericordiae University Hospital, Dublin, Ireland
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Young MJ, Adler GK. Aldosterone, the Mineralocorticoid Receptor and Mechanisms of Cardiovascular Disease. VITAMINS AND HORMONES 2019; 109:361-385. [DOI: 10.1016/bs.vh.2018.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Dong H, Ou Y, Nie Z, Huang W, Liu Y, Zhou Y, Luo J, Li G. Association of renal artery stenosis with left ventricular remodeling in patients coexisting with renovascular and coronary artery disease. Vascular 2018; 27:190-198. [PMID: 30547720 DOI: 10.1177/1708538118819676] [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: 11/15/2022]
Abstract
OBJECTIVE Data about renal artery stenosis association with left ventricular remodeling in patients coexisting with coronary artery disease are scanty. METHODS Patients with suspected both coronary artery disease and renal artery stenosis undergoing coronary and renal arteriography between October 2013 and December 2015 were prospectively enrolled. Left ventricular remodeling patterns were compared among different severity of renal artery stenosis group. Logistic regression was done to investigate the determinants of the left ventricular morphology. RESULTS The overall prevalence of left ventricular hypertrophy was 40.5%, the highest in bilateral renal artery stenosis group compared to unilateral or normal ones (65.4% versus 41.8% versus 34.8%, p = 0.012). Significantly lower estimated glomerular filtration rate and higher cystatin C level were found in bilateral renal artery stenosis group than that in other two groups. Multivariate regression analysis showed that bilateral renal artery stenosis was associated with increased left ventricular hypertrophy and concentric hypertrophy with statistical significance (adjusted odds ratio = 2.909 (95%CI: 1.063-7.961), and 3.021 (95%CI: 1.136-8.033)). In addition, estimated glomerular filtration rate level was also related to left ventricular hypertrophy, while there was no significant interaction between renal artery stenosis and coronary artery disease on left ventricular hypertrophy/concentric hypertrophy occurrence. CONCLUSIONS Bilateral renal artery stenosis is significantly associated with increased left ventricular hypertrophy/concentric hypertrophy in patients with suspected concomitant coronary and renal artery disease, while no synergic effect could be found in coronary artery disease.
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Affiliation(s)
- Haojian Dong
- 1 Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong, People's Republic of China
| | - Yanqiu Ou
- 2 Department of Epidemiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong, People's Republic of China
| | - Zhiqiang Nie
- 2 Department of Epidemiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong, People's Republic of China
| | - Wenhui Huang
- 1 Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong, People's Republic of China
| | - Yuan Liu
- 1 Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong, People's Republic of China
| | - Yingling Zhou
- 1 Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong, People's Republic of China
| | - Jianfang Luo
- 1 Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong, People's Republic of China
| | - Guang Li
- 1 Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong, People's Republic of China
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Seccia TM, Caroccia B, Gomez-Sanchez EP, Gomez-Sanchez CE, Rossi GP. The Biology of Normal Zona Glomerulosa and Aldosterone-Producing Adenoma: Pathological Implications. Endocr Rev 2018; 39:1029-1056. [PMID: 30007283 PMCID: PMC6236434 DOI: 10.1210/er.2018-00060] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 07/03/2018] [Indexed: 01/09/2023]
Abstract
The identification of several germline and somatic ion channel mutations in aldosterone-producing adenomas (APAs) and detection of cell clusters that can be responsible for excess aldosterone production, as well as the isolation of autoantibodies activating the angiotensin II type 1 receptor, have rapidly advanced the understanding of the biology of primary aldosteronism (PA), particularly that of APA. Hence, the main purpose of this review is to discuss how discoveries of the last decade could affect histopathology analysis and clinical practice. The structural remodeling through development and aging of the human adrenal cortex, particularly of the zona glomerulosa, and the complex regulation of aldosterone, with emphasis on the concepts of zonation and channelopathies, will be addressed. Finally, the diagnostic workup for PA and its subtyping to optimize treatment are reviewed.
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Affiliation(s)
- Teresa M Seccia
- Department of Medicine-DIMED, University of Padua, Padua PD, Italy
| | | | - Elise P Gomez-Sanchez
- Department of Pharmacology and Toxicology, G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi
| | - Celso E Gomez-Sanchez
- Division of Endocrinology, G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi.,University of Mississippi Medical Center, Jackson, Mississippi
| | - Gian Paolo Rossi
- Department of Medicine-DIMED, University of Padua, Padua PD, Italy
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41
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Vaidya A, Mulatero P, Baudrand R, Adler GK. The Expanding Spectrum of Primary Aldosteronism: Implications for Diagnosis, Pathogenesis, and Treatment. Endocr Rev 2018; 39:1057-1088. [PMID: 30124805 PMCID: PMC6260247 DOI: 10.1210/er.2018-00139] [Citation(s) in RCA: 160] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 08/10/2018] [Indexed: 12/14/2022]
Abstract
Primary aldosteronism is characterized by aldosterone secretion that is independent of renin and angiotensin II and sodium status. The deleterious effects of primary aldosteronism are mediated by excessive activation of the mineralocorticoid receptor that results in the well-known consequences of volume expansion, hypertension, hypokalemia, and metabolic alkalosis, but it also increases the risk for cardiovascular and kidney disease, as well as death. For decades, the approaches to defining, diagnosing, and treating primary aldosteronism have been relatively constant and generally focused on detecting and treating the more severe presentations of the disease. However, emerging evidence suggests that the prevalence of primary aldosteronism is much greater than previously recognized, and that milder and nonclassical forms of renin-independent aldosterone secretion that impart heightened cardiovascular risk may be common. Public health efforts to prevent aldosterone-mediated end-organ disease will require improved capabilities to diagnose all forms of primary aldosteronism while optimizing the treatment approaches such that the excess risk for cardiovascular and kidney disease is adequately mitigated. In this review, we present a physiologic approach to considering the diagnosis, pathogenesis, and treatment of primary aldosteronism. We review evidence suggesting that primary aldosteronism manifests across a wide spectrum of severity, ranging from mild to overt, that correlates with cardiovascular risk. Furthermore, we review emerging evidence from genetic studies that begin to provide a theoretical explanation for the pathogenesis of primary aldosteronism and a link to its phenotypic severity spectrum and prevalence. Finally, we review human studies that provide insights into the optimal approach toward the treatment of primary aldosteronism.
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Affiliation(s)
- Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Rene Baudrand
- Program for Adrenal Disorders and Hypertension, Department of Endocrinology, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Gail K Adler
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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42
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Choo EH, Ha KH, Lee SW, Kim HC, Park S, Lee HY, Ihm SH. Low plasma renin activity is an independent predictor of near-term incidence of hypertension in Asian populations. Clin Exp Hypertens 2018; 41:330-335. [PMID: 29902069 DOI: 10.1080/10641963.2018.1481422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Plasma renin activity is involved in the regulation of body salt content and blood pressure. However, there is a paucity of data regarding the association between low or high plasma renin activity and the development of hypertension. METHOD We investigated the relation of baseline plasma renin activity to increases in blood pressure and the incidence of hypertension after four years in 2,146 non-hypertensive individuals from a community-based Korean population (mean age, 50 years), 58% of whom were women. We defined an "increase in blood pressure" as an increment of systolic blood-pressure ≥ 10 mmHg or initiation of antihypertensive drugs and defined "hypertension" as a systolic blood pressure of 140 mm Hg or higher, a diastolic blood pressure of 90 mm Hg or higher, or the use of antihypertensive medications. RESULTS After 4 years, the increase in blood pressure had increased in 27.9% of the participants, and hypertension had developed in 17.9%. After adjustment, the lowest sex-specific tertile of plasma renin activity was an independent risk factor of an elevation in blood pressure (Adjusted Odds Ratio 1.37, 95% confidence interval 1.07-1.74, p = 0.011) and hypertension (Adjusted Odds Ratio 1.84, 95% confidence interval 1.36-2.50, p < 0.001) compared to the highest sex-specific tertile. The associations between the plasma renin activity and blood-pressure outcomes were evident in adults with especially high urine sodium excretion. CONCLUSION Low plasma renin activity was associated with the development of hypertension in the middle-aged Asian population, especially in peoples with high sodium intake.
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Affiliation(s)
- Eun Ho Choo
- a Division of Cardiology , The Catholic University of Korea, College of Medicine , Seoul , Korea
| | - Kyoung Hwa Ha
- b Department of Public Health , Graduate School of Yonsei University , Seoul , Korea
| | - Seung-Won Lee
- b Department of Public Health , Graduate School of Yonsei University , Seoul , Korea
| | - Hyeon Chang Kim
- c Department of Preventive Medicine , Yonsei University College of Medicine , Seoul , Korea
| | - Sungha Park
- d Division of Cardiology , Yonsei Cardiovascular Hospital , Seoul , Korea
| | - Hae Young Lee
- e Department of Internal Medicine , Seoul National University Hospital , Seoul , Korea
| | - Sang-Hyun Ihm
- a Division of Cardiology , The Catholic University of Korea, College of Medicine , Seoul , Korea
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43
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Buffolo F, Monticone S, Tetti M, Mulatero P. Primary aldosteronism in the primary care setting. Curr Opin Endocrinol Diabetes Obes 2018; 25:155-159. [PMID: 29629943 DOI: 10.1097/med.0000000000000408] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW The aim of the present manuscript is to provide an overview of the most updated studies on the prevalence of primary aldosteronism in primary care and to compare these figures with the actual rate of diagnosis in clinical practice and with the prevalence of primary aldosteronism in specific subgroup of patients. RECENT FINDINGS Over the last 20 years the clinical spectrum of low renin hypertension and primary aldosteronism has changed dramatically. Once considered only in the presence of severe hypertension and hypokalemia, it is now well known that primary aldosteronism is not uncommon even in patients with mild forms of hypertension and/or normokalemia. Moreover, recent evidence points toward a large proportion of normotensive study participants as being affected by subclinical primary aldosteronism, which represents a strong risk factor for incident hypertension. Moreover, primary aldosteronism patients are exposed to an increased risk of cardio and cerebrovascular events and metabolic comorbidities compared with patients affected by essential hypertension. Disappointingly, primary aldosteronism remains a largely underdiagnosed and undertreated disorder. SUMMARY These recent findings further highlight the importance of widening the spectrum of patients who should be screened for primary aldosteronism, to reduce the cardiovascular risk associated with this medical condition.
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Affiliation(s)
- Fabrizio Buffolo
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Turin, Italy
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44
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Shu X, Mei M, Ma L, Wang Z, Yang S, Hu J, Song Y, He W, Luo T, Cheng Q, Wang Y, Zhen Q, Li Q. Postmenopausal osteoporosis is associated with elevated aldosterone/renin ratio. J Hum Hypertens 2018; 32:524-530. [PMID: 29789689 DOI: 10.1038/s41371-018-0069-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 03/18/2018] [Accepted: 04/16/2018] [Indexed: 12/31/2022]
Abstract
Plasma aldosterone/renin ratio (ARR) is a useful method for primary aldosteronism (PA) screening. However some confounders, such as medications and dietary, affect plasma renin and aldosterone levels, resulting in false-negative or -positive plasma ARR. This study investigated the association between postmenopausal osteoporosis (PMO) and plasma ARR. Bone mineral density (BMD) was measured by dual-energy X-ray-absorptiometry (DXA) in 324 normotensive postmenopausal women. Based on clinical characteristics and BMD, 186 and 96 subjects were diagnosed as PMO and osteopenia respectively, and the remaining 42 subjects were grouped as normal BMD. Plasma aldosterone concentration (PAC), plasma renin concentration (PRC), parathyroid hormone (PTH), bone alkaline phosphatase (BALP) and 25-Hydroxyvitamin D(25-(OH)D) were determined. Subjects with PMO showed significantly higher levels of PAC (121.0 ± 78.8 vs. 81.8 ± 71.5 pg/ml, p < 0.01 and 121.0 ± 78.8 vs. 91.7 ± 56.2 pg/ml, p < 0.01) and ARR (32.0 ± 53.6 vs. 9.0 ± 9.3 pg/μU, p < 0.01 and 32.0 ± 53.6 vs. 16.3 ± 32.1 pg/μU, p < 0.01) compared to women with normal BMD and osteopenia, respectively. Using ARR ≥ 37.0 pg/μU as the cutoff for positive screening, more false-positive was found in the PMO group when compared to the normal BMD group (24 vs. 2%) and osteopenia group (24 vs. 7%), respectively. PAC was negatively associated with lumbar spine BMD T-score (r = -0.239, p < 0.001), femur neck BMD T-score (r = -0.234, p < 0.001) and total hip BMD T-score (r = -0.228, p < 0.001). PTH was positively associated with PAC (r = 0.119, p < 0.05) and ARR (r = 0.136, p < 0.05). PAC and ARR are elevated in women with PMO, which might increase the risk of false-positive for case detection of PA.
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Affiliation(s)
- Xiaoyu Shu
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Department of Endocrinology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Mei Mei
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Linqiang Ma
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhihong Wang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shumin Yang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinbo Hu
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Song
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenwen He
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ting Luo
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qingfeng Cheng
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yue Wang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qianna Zhen
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qifu Li
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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45
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Paquette M, Baass A. Genetic Regulation of PCSK9 (Proprotein Convertase Subtilisin/Kexin Type 9) Plasma Levels: Another Piece of the Puzzle. Circ Genom Precis Med 2018; 11:e002165. [PMID: 29748320 DOI: 10.1161/circgen.118.002165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Martine Paquette
- Nutrition, Metabolism and Atherosclerosis Clinic, Institut de Recherches Cliniques de Montréal, QC, Canada (M.P., A.B.)
| | - Alexis Baass
- Nutrition, Metabolism and Atherosclerosis Clinic, Institut de Recherches Cliniques de Montréal, QC, Canada (M.P., A.B.) .,Divisions of Experimental Medicine and Medical Biochemistry, Department of Medicine, McGill University, Montreal, QC, Canada (A.B.)
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de Denus S, Dubé MP, Fouodjio R, Huynh T, LeBlanc MH, Lepage S, Sheppard R, Giannetti N, Lavoie J, Mansour A, Provost S, Normand V, Mongrain I, Langlois M, O'Meara E, Ducharme A, Racine N, Guertin MC, Turgeon J, Phillips MS, Rouleau JL, Tardif JC, White M. A prospective study of the impact of AGTR1 A1166C on the effects of candesartan in patients with heart failure. Pharmacogenomics 2018; 19:599-612. [PMID: 29701105 DOI: 10.2217/pgs-2018-0004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM To evaluate the impact of AGTR1 A1166C (rs5186) on the response to candesartan in patients with heart failure. MATERIALS & METHODS Prospective, multicentre, open-label study. We studied 299 symptomatic patients with heart failure presenting a left ventricular ejection fraction ≤40%. RESULTS Reductions in the primary end points of natriuretic peptides were not significantly associated with AGTR1 A1166C. Nevertheless, carrying the 1166C allele was associated with a greater compensatory increase in renin activity (p = 0.037) after 16 weeks of treatment with candesartan and a more modest effect on aldosterone concentrations (p = 0.022). CONCLUSION AGTR1 1166C carriers may experience a greater long-term compensatory renin-angiotensin-aldosterone system activation following treatment with candesartan. Whether these associations ultimately influence clinical outcomes requires investigation. Clinicaltrials.gov : NCT00400582.
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Affiliation(s)
- Simon de Denus
- Research Center, Montreal Heart Institute, Montreal, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, Canada
| | - Marie-Pierre Dubé
- Research Center, Montreal Heart Institute, Montreal, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - René Fouodjio
- Research Center, Montreal Heart Institute, Montreal, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada
| | - Thao Huynh
- McGill Health University, McGill University, Montreal, Canada
| | - Marie-Hélène LeBlanc
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Serge Lepage
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | | | - Nadia Giannetti
- Royal-Victoria Hospital, McGill University, Montreal, Canada
| | - Joël Lavoie
- Research Center, Montreal Heart Institute, Montreal, Canada
| | - Asmaa Mansour
- Montreal Health Innovations Coordinating Center, a division of the Montreal Heart Institute, Montreal Canada
| | - Sylvie Provost
- Research Center, Montreal Heart Institute, Montreal, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada
| | - Valérie Normand
- Research Center, Montreal Heart Institute, Montreal, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada
| | - Ian Mongrain
- Research Center, Montreal Heart Institute, Montreal, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada
| | - Mathieu Langlois
- Research Center, Montreal Heart Institute, Montreal, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada
| | - Eileen O'Meara
- Research Center, Montreal Heart Institute, Montreal, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Anique Ducharme
- Research Center, Montreal Heart Institute, Montreal, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Normand Racine
- Research Center, Montreal Heart Institute, Montreal, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Marie-Claude Guertin
- Montreal Health Innovations Coordinating Center, a division of the Montreal Heart Institute, Montreal Canada
| | - Jacques Turgeon
- CRCHUM, Research Center, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | | | - Jean-Lucien Rouleau
- Research Center, Montreal Heart Institute, Montreal, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Jean-Claude Tardif
- Research Center, Montreal Heart Institute, Montreal, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Center, Montreal, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Michel White
- Research Center, Montreal Heart Institute, Montreal, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Canada
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Genovesi S, Antolini L, Orlando A, Tassistro E, Giussani M, Nava E, Turolo L, Manolopoulou J, Parati G, Morganti A. Aldosterone-to-renin ratio depends on age and sex in children attending a clinic for cardiovascular risk assessment. J Hypertens 2018; 36:344-352. [DOI: 10.1097/hjh.0000000000001571] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Parathyroid hormone, aldosterone-to-renin ratio and fibroblast growth factor-23 as determinants of nocturnal blood pressure in primary hyperparathyroidism: the eplerenone in primary hyperparathyroidism trial. J Hypertens 2017; 34:1778-86. [PMID: 27379537 DOI: 10.1097/hjh.0000000000001004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES The high prevalence of arterial hypertension in primary hyperparathyroidism (pHPT) is largely unexplained. Apart from parathyroid hormone (PTH), the mineral hormones fibroblast growth factor (FGF)-23 and aldosterone-to-renin ratio (ARR) are upregulated in pHPT. We aimed to determine whether nocturnal blood pressure (BP) is related with PTH, FGF-23 or ARR in a relatively large sample of pHPT patients. METHODS Cross-sectional data of the single-center "Eplerenone in Primary Hyperparathyroidism" trial were used. All patients with a biochemical diagnosis of pHPT who had both available 24-h ambulatory BP monitoring and valid laboratory data were included. RESULTS Full data were available in 136 patients (mean age 67 ± 10 years, 78% women). Median PTH was 99 (interquartile range: 82-124) pg/ml and mean calcium was 2.63 ± 0.15 mmol/l. ARR, but not PTH or FGF-23, was significantly and directly related with nocturnal SBP (Pearson's r = 0.241, P < 0.01) and DBP (r = 0.328, P < 0.01). In multivariate regression analyses, with adjustment for age, sex, PTH, FGF-23, traditional cardiovascular risk factors, antihypertensive medication and parameters of calcium metabolism ARR remained significantly and directly related with nocturnal BP (SBP: adjusted β-coefficient = 0.289, P < 0.01; DBP: β = 0.399, P < 0.01). The relationship between ARR and nocturnal SBP was exclusively present in patients with PTH levels above the median of 99 pg/ml. CONCLUSION ARR, but not FGF-23 or PTH, was independently and directly related with nocturnal BP parameters in patients with pHPT, and this relationship was dependent on pHPT disease severity. Inappropriately, elevated aldosterone may partially explain the high prevalence of arterial hypertension in pHPT.
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49
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Hundemer GL, Baudrand R, Brown JM, Curhan G, Williams GH, Vaidya A. Renin Phenotypes Characterize Vascular Disease, Autonomous Aldosteronism, and Mineralocorticoid Receptor Activity. J Clin Endocrinol Metab 2017; 102:1835-1843. [PMID: 28323995 PMCID: PMC5470762 DOI: 10.1210/jc.2016-3867] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 02/14/2017] [Indexed: 01/13/2023]
Abstract
CONTEXT Mild cases of autonomous aldosterone secretion may go unrecognized using current diagnostic criteria for primary aldosteronism (PA). OBJECTIVE To investigate whether the inability to stimulate renin serves as a biomarker for unrecognized autonomous aldosterone secretion and mineralocorticoid receptor (MR) activation. PARTICIPANTS Six hundred sixty-three normotensive and mildly hypertensive participants, who were confirmed to not have PA using current guideline criteria and were on no antihypertensive medications. DESIGN Participants had their maximally stimulated plasma renin activity (PRA) measured while standing upright after sodium restriction. Tertiles of maximally stimulated PRA were hypothesized to reflect the degree of MR activation: lowest PRA tertile = "Inappropriate/Excess MR Activity;" middle PRA tertile = "Intermediate MR Activity;"; and highest PRA tertile = "Physiologic MR Activity." All participants underwent detailed biochemical and vascular characterizations under conditions of liberalized sodium intake, and associations with stimulated PRA phenotypes were performed. RESULTS Participants with lower stimulated PRA had greater autonomous aldosterone secretion [higher aldosterone-to-renin ratio (P = 0.002), higher urine aldosterone excretion rate (P = 0.003), higher systolic blood pressure (P = 0.004), and lower renal plasma flow (P = 0.04)] and a nonsignificant trend toward lower serum potassium and higher urine potassium excretion, which became significant after stratification by hypertension status. CONCLUSIONS In participants without clinical PA, the inability to stimulate renin was associated with greater autonomous aldosterone secretion, impaired vascular function, and suggestive trends in potassium handling that indicate an extensive spectrum of unrecognized MR activation.
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Affiliation(s)
- Gregory L. Hundemer
- Division of Renal Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115
| | - Rene Baudrand
- Program for Adrenal Disorders and Endocrine Hypertension, Department of Endocrinology, Pontificia Universidad Catolica de Chile School of Medicine, Santiago, Chile
| | - Jenifer M. Brown
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts 02115
| | - Gary Curhan
- Division of Renal Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115
| | - Gordon H. Williams
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts 02115
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts 02115
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50
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Ruilope LM, Tamargo J. Aldosterone a Relevant Factor in the Beginning and Evolution of Arterial Hypertension. Am J Hypertens 2017; 30:468-469. [PMID: 28338714 DOI: 10.1093/ajh/hpx010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 02/01/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Luis M Ruilope
- Instituto de Investigación imas12 y Unidad de Hipertensión, Hospital 12 de Octubre, Madrid, Spain
- Departamento de Medicina Preventiva y Salud Publica, Universidad Autónomaand Escuela de Estudios Postdoctorales e Investigación, Madrid, Spain
- School of Postdoctoral Studies, Universidad Europea de Madrid, Madrid, Spain
| | - Juan Tamargo
- Departamento de Farmacologia, Facultad de Medicina, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
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