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Leung AA, Symonds CJ, Hundemer GL, Ronksley PE, Lorenzetti DL, Pasieka JL, Harvey A, Kline GA. Performance of Confirmatory Tests for Diagnosing Primary Aldosteronism: a Systematic Review and Meta-Analysis. Hypertension 2022; 79:1835-1844. [PMID: 35652330 PMCID: PMC9278709 DOI: 10.1161/hypertensionaha.122.19377] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Confirmatory tests are recommended for diagnosing primary aldosteronism, but the supporting evidence is unclear. Methods: We searched Medline, EMBASE, and the Cochrane Central Register of Controlled Trials. Studies evaluating any guideline-recommended confirmatory test (ie, saline infusion test, salt loading test, fludrocortisone suppression test, and captopril challenge test), compared with a reference standard were included. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to assess the risk of bias. Meta-analyses were conducted using hierarchical summary receiver operating characteristic models. Results: Fifty-five studies were included, comprising 26 studies (3654 participants) for the recumbent saline infusion test, 4 studies (633 participants) for the seated saline infusion test, 2 studies (99 participants) for the salt loading test, 7 studies (386 participants) for the fludrocortisone suppression test, and 25 studies (2585 participants) for the captopril challenge test. Risk of bias was high, affecting more than half of studies, and across all domains. Studies with case-control sampling overestimated accuracy by 7-fold (relative diagnostic odds ratio, 7.26 [95% CI, 2.46–21.43]) and partial verification or use of inconsistent reference standards overestimated accuracy by 5-fold (5.12 [95% CI, 1.48–17.77]). There were large variations in how confirmatory tests were conducted, interpreted, and verified. Under most scenarios, confirmatory testing resulted in an excess of missed cases. The certainty of evidence underlying each test (Grading of Recommendations, Assessment, Development, and Evaluations) was very low. Conclusions: Recommendations for confirmatory testing in patients with abnormal screening tests and high probability features of primary aldosteronism are based on very low-quality evidence and their routine use should be reconsidered.
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Affiliation(s)
- Alexander A Leung
- Division of Endocrinology and Metabolism, Department of Medicine (A.A.L., C.J.S., G.A.K.), University of Calgary, AB.,Department of Community Health Sciences (A.A.L., P.E.R., D.L.L.), University of Calgary, AB
| | - Christopher J Symonds
- Division of Endocrinology and Metabolism, Department of Medicine (A.A.L., C.J.S., G.A.K.), University of Calgary, AB
| | - Gregory L Hundemer
- Division of Nephrology, Department of Medicine and the Ottawa Hospital Research Institute, University of Ottawa, ON (G.L.H.)
| | - Paul E Ronksley
- Department of Community Health Sciences (A.A.L., P.E.R., D.L.L.), University of Calgary, AB
| | - Diane L Lorenzetti
- Department of Community Health Sciences (A.A.L., P.E.R., D.L.L.), University of Calgary, AB
| | - Janice L Pasieka
- Department of Surgery (J.L.P., A.H.), University of Calgary, AB.,Department of Oncology (J.L.P., A.H.), University of Calgary, AB
| | - Adrian Harvey
- Department of Surgery (J.L.P., A.H.), University of Calgary, AB.,Department of Oncology (J.L.P., A.H.), University of Calgary, AB
| | - Gregory A Kline
- Division of Endocrinology and Metabolism, Department of Medicine (A.A.L., C.J.S., G.A.K.), University of Calgary, AB
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Song Y, Yang S, He W, Hu J, Cheng Q, Wang Y, Luo T, Ma L, Zhen Q, Zhang S, Mei M, Wang Z, Qing H, Bruemmer D, Peng B, Li Q. Confirmatory Tests for the Diagnosis of Primary Aldosteronism: A Prospective Diagnostic Accuracy Study. Hypertension 2017; 71:118-124. [PMID: 29158354 DOI: 10.1161/hypertensionaha.117.10197] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 08/22/2017] [Accepted: 10/12/2017] [Indexed: 11/16/2022]
Abstract
The diagnosis of primary aldosteronism typically requires at least one confirmatory test. The fludrocortisone suppression test is generally accepted as a reliable confirmatory test, but it is cumbersome. Evidence from accuracy studies of the saline infusion test (SIT) and the captopril challenge test (CCT) has provided conflicting results. This prospective study aimed to evaluate the diagnostic accuracy of the SIT and CCT using fludrocortisone suppression test as the reference standard. One hundred thirty-five patients diagnosed with primary aldosteronism and 101 patients diagnosed with essential hypertension who completed the 3 confirmatory tests were included for the diagnostic accuracy analysis. The areas under the receiver-operator characteristics curves of the CCT and SIT were 0.96 (95% confidence interval [CI], 0.92-0.98) and 0.96 (95% CI, 0.92-0.98), respectively, using post-test plasma aldosterone concentration (PAC) for diagnosis. However, the areas under the receiver-operator characteristics curves of the CCT decreased to 0.71 (95% CI, 0.65-0.77) when the PAC suppression percentage was used to diagnose primary aldosteronism. The optimal cutoff of PAC post-CCT was set at 11 ng/dL, resulting in a sensitivity of 0.90 (95% CI, 0.84-0.95) and a specificity of 0.90 (95% CI, 0.83-0.95), which were not significantly different from those of SIT (with PAC post-SIT set at 8 ng/dL, sensitivity: 0.85 [95% CI, 0.78-0.91], P=0.192; specificity: 0.92 [95% CI, 0.85-0.97], P=0.551). In conclusion, both CCT and SIT are accurate alternatives to the more complex fludrocortisone suppression test. Because CCT is safe and much easier to perform, it may serve as a more feasible alternative. When interpreting the results of CCT, PAC post-CCT is highly recommended.
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Affiliation(s)
- Ying Song
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Shumin Yang
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Wenwen He
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Jinbo Hu
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Qingfeng Cheng
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Yue Wang
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Ting Luo
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Linqiang Ma
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Qianna Zhen
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Suhua Zhang
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Mei Mei
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Zhihong Wang
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Hua Qing
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Dennis Bruemmer
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Bin Peng
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.)
| | - Qifu Li
- From the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University (Y.S., S.Y., W.H., J.H., Q.C., Y.W., T.L., L.M., Q.Z., S.Z., M.M., Z.W., H.Q., Q.L.) and School of Public Health and Management, Chongqing Medical University (B.P.), China; and Division of Cardiology, Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (D.B.).
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