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Lin CH, Lin CH, Chung MC, Hung CS, Tseng FY, Er LK, Jia-Yin Hou C, Lin YH, Wu VC, Cheng HM, Kao HL, Wu KD, Lai TS. Aldosterone-to-renin ratio (ARR) as a screening tool for primary aldosteronism (PA). J Formos Med Assoc 2024; 123 Suppl 2:S98-S103. [PMID: 37173226 DOI: 10.1016/j.jfma.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/16/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
The aldosterone-to-renin ratio (ARR) is the standard screening test for primary aldosteronism (PA). Because of the poor reproducibility of the ARR, repeat testing is recommended if the result is not compatible with the clinical condition. Various methods to measure renin are used in different hospitals in Taiwan, and the ARR cutoff values also differ among laboratories. The Task Force of Taiwan PA recommend using plasma renin activity (PRA) to calculate ARR instead of direct renin concentration (DRC) unless PRA is unavailable, because PRA is widely used in international guidelines and most studies.
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Affiliation(s)
- Chia-Hung Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Han Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Mu-Chi Chung
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chi-Sheng Hung
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Fen-Yu Tseng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Medical Education, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Leay Kiaw Er
- Division of Endocrinology, Department of Internal Medicine, Taipei Tzu-Chi Hospital, Buddhist Tzu-Chi Medical Foundation, New Taipei City, Taiwan; School of Medicine, Tzu-Chi University, Hualien, Taiwan
| | | | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Primary Aldosteronism Center at National Taiwan University Hospital, Taiwan
| | - Vin-Cent Wu
- Primary Aldosteronism Center at National Taiwan University Hospital, Taiwan; Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hao-Min Cheng
- Ph.D. Program of Interdisciplinary Medicine (PIM), National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Division of Faculty Development, Taipei Veterans General Hospital, Taiwan; Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tai-Shuan Lai
- Primary Aldosteronism Center at National Taiwan University Hospital, Taiwan; Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Faconti L, Kulkarni S, Delles C, Kapil V, Lewis P, Glover M, MacDonald TM, Wilkinson IB. Diagnosis and management of primary hyperaldosteronism in patients with hypertension: a practical approach endorsed by the British and Irish Hypertension Society. J Hum Hypertens 2024; 38:8-18. [PMID: 37964158 PMCID: PMC10803267 DOI: 10.1038/s41371-023-00875-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/03/2023] [Accepted: 10/30/2023] [Indexed: 11/16/2023]
Abstract
Alongside the lack of homogeneity among international guidelines and consensus documents on primary hyperaldosteronism, the National UK guidelines on hypertension do not provide extensive recommendations regarding the diagnosis and management of this condition. Local guidelines vary from area to area, and this is reflected in the current clinical practice in the UK. In an attempt to provide support to the clinicians involved in the screening of subjects with hypertension and clinical management of suspected cases of primary hyperaldosteronism the following document has been prepared on the behalf of the BIHS Guidelines and Information Service Standing Committee. Through remote video conferences, the authors of this document reviewed an initial draft which was then circulated among the BIHS Executive members for feedback. A survey among members of the BIHS was carried out in 2022 to assess screening strategies and clinical management of primary hyperaldosteronism in the different regions of the UK. Feedback and results of the survey were then discussed and incorporated in the final document which was approved by the panel after consensus was achieved considering critical review of existing literature and expert opinions. Grading of recommendations was not performed in light of the limited available data from properly designed randomized controlled trials.
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Affiliation(s)
- Luca Faconti
- King's College London British Heart Foundation Centre, Department of Clinical Pharmacology, 4th Floor, North Wing, St. Thomas' Hospital, Westminster Bridge, London, SE17EH, UK.
| | - Spoorthy Kulkarni
- Cambridge University hospitals NHS foundation trust, Cambridge United Kingdom (S.K.), Cambridge, UK
| | - Christian Delles
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, G12 8TA, UK
| | - Vikas Kapil
- William Harvey Research Institute, Centre for Cardiovascular Medicine and Devices, Queen Mary University London, London, EC1M 6BQ, UK
- Barts BP Centre of Excellence, Barts Heart Centre, London, EC1A 7BE, UK
| | - Philip Lewis
- Department of Cardiology, Stockport NHS Foundation Trust, Stockport, UK
| | - Mark Glover
- Deceased, formerly Division of Therapeutics and Molecular Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Thomas M MacDonald
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Ian B Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
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Ha J, Park JH, Kim KJ, Kim JH, Jung KY, Lee J, Choi JH, Lee SH, Hong N, Lim JS, Park BK, Kim JH, Jung KC, Cho J, Kim MK, Chung CH. 2023 Korean Endocrine Society Consensus Guidelines for the Diagnosis and Management of Primary Aldosteronism. Endocrinol Metab (Seoul) 2023; 38:597-618. [PMID: 37828708 PMCID: PMC10765003 DOI: 10.3803/enm.2023.1789] [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: 07/25/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 10/14/2023] Open
Abstract
Primary aldosteronism (PA) is a common, yet underdiagnosed cause of secondary hypertension. It is characterized by an overproduction of aldosterone, leading to hypertension and/or hypokalemia. Despite affecting between 5.9% and 34% of patients with hypertension, PA is frequently missed due to a lack of clinical awareness and systematic screening, which can result in significant cardiovascular complications. To address this, medical societies have developed clinical practice guidelines to improve the management of hypertension and PA. The Korean Endocrine Society, drawing on a wealth of research, has formulated new guidelines for PA. A task force has been established to prepare PA guidelines, which encompass epidemiology, pathophysiology, clinical presentation, diagnosis, treatment, and follow-up care. The Korean clinical guidelines for PA aim to deliver an evidence-based protocol for PA diagnosis, treatment, and patient monitoring. These guidelines are anticipated to ease the burden of this potentially curable condition.
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Affiliation(s)
- Jeonghoon Ha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Hwan Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Kyoung Jin Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyong Yeun Jung
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Jeongmin Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Han Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Soo Lim
- Department of Internal Medicine and Research Institute of Metabolism and Inflammation, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Byung Kwan Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Han Kim
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeong Cheon Jung
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Jooyoung Cho
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Mi-kyung Kim
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Choon Hee Chung
- Department of Internal Medicine and Research Institute of Metabolism and Inflammation, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - The Committee of Clinical Practice Guideline of Korean Endocrine Society
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Research Institute of Metabolism and Inflammation, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - The Korean Adrenal Study Group of Korean Endocrine Society
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Research Institute of Metabolism and Inflammation, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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Rossi GP, Bagordo D, Amar L, Azizi M, Riester A, Reincke M, Degenhart C, Widimský J, Naruse M, Deinum J, Kocjan T, Negro A, Rossi E, Kline G, Tanabe A, Satoh F, Rump LC, Vonend O, Willenberg HS, Fuller PJ, Yang J, Chee NYN, Magill SB, Shafigullina Z, Quinkler M, Oliveras A, Lee BC, Chang CC, Wu VC, Krátká Z, Battistel M, Rossitto G, Seccia TM. Unilaterally Selective Adrenal Vein Sampling for Identification of Surgically Curable Primary Aldosteronism. Hypertension 2023; 80:2003-2013. [PMID: 37317838 DOI: 10.1161/hypertensionaha.123.21247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/23/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Adrenal venous sampling is recommended for the identification of unilateral surgically curable primary aldosteronism but is often clinically useless, owing to failed bilateral adrenal vein cannulation. OBJECTIVES To investigate if only unilaterally selective adrenal vein sampling studies can allow the identification of the responsible adrenal. METHODS Among 1625 patients consecutively submitted to adrenal vein sampling in tertiary referral centers, we selected those with selective adrenal vein sampling results in at least one side; we used surgically cured unilateral primary aldosteronism as gold reference. The accuracy of different values of the relative aldosterone secretion index (RASI), which estimates the amount of aldosterone produced in each adrenal gland corrected for catheterization selectivity, was examined. RESULTS We found prominent differences in RASI values distribution between patients with and without unilateral primary aldosteronism. The diagnostic accuracy of RASI values estimated by the area under receiver operating characteristic curves was 0.714 and 0.855, respectively, in the responsible and the contralateral side; RASI values >2.55 and ≤0.96 on the former and the latter side furnished the highest accuracy for detection of surgically cured unilateral primary aldosteronism. Moreover, in the patients without unilateral primary aldosteronism, only 20% and 16% had RASI values ≤0.96 and >2.55. CONCLUSIONS With the strength of a large real-life data set and use of the gold reference entailing an unambiguous diagnosis of unilateral primary aldosteronism, these results indicate the feasibility of identifying unilateral primary aldosteronism using unilaterally selective adrenal vein sampling results. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01234220.
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Affiliation(s)
- Gian Paolo Rossi
- Hypertension Unit, Department of Medicine, DIMED, University Hospital, University of Padova, Italy (G.P.R., D.B., G.R., T.M.S.)
| | - Domenico Bagordo
- Hypertension Unit, Department of Medicine, DIMED, University Hospital, University of Padova, Italy (G.P.R., D.B., G.R., T.M.S.)
| | - Laurence Amar
- Université Paris Cité, INSERM UMRS 970 and CIC1418, F-75015 Paris, France; AP-HP, Hôpital Européen Georges Pompidou, Hypertension Unit, F-75015 Paris, France (L.A., M.A.)
| | - Michel Azizi
- Université Paris Cité, INSERM UMRS 970 and CIC1418, F-75015 Paris, France; AP-HP, Hôpital Européen Georges Pompidou, Hypertension Unit, F-75015 Paris, France (L.A., M.A.)
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Germany (A.R., M.R., C.D.)
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Germany (A.R., M.R., C.D.)
| | - Christoph Degenhart
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Germany (A.R., M.R., C.D.)
| | - Jiří Widimský
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic (J.W., Z.K.)
| | - Mitsuhide Naruse
- Department of Endocrinology Clinical Research Institute, National Hospital Organization Kyoto Medical Center and Endocrine Center, Ijinkai Takeda General Hospital, Kyoto, Japan (M.N.)
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands (J.D.)
| | - Tomaz Kocjan
- University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia (T.K.)
| | - Aurelio Negro
- Internal Medicine and Hypertension Center, Ospedale Sant'Anna di Castelnovo Ne' Monti, Azienda Usl-IRCCS di Reggio Emilia (A.N., E.R.)
| | - Ermanno Rossi
- Internal Medicine and Hypertension Center, Ospedale Sant'Anna di Castelnovo Ne' Monti, Azienda Usl-IRCCS di Reggio Emilia (A.N., E.R.)
| | - Gregory Kline
- Foothills Medical Centre, University of Calgary, Canada (G.K.)
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine (A.T.)
| | - Fumitoshi Satoh
- Department of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai, Japan (F.S.)
| | - Lars Christian Rump
- Department of Nephrology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany (L.C.R., O.V.)
| | - Oliver Vonend
- Department of Nephrology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany (L.C.R., O.V.)
| | - Holger S Willenberg
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Rostock, Germany (H.S.W.)
| | - Peter J Fuller
- Monash Health, Clayton, VIC, Australia (P.J.F., J.Y., N.Y.N.C.)
| | - Jun Yang
- Monash Health, Clayton, VIC, Australia (P.J.F., J.Y., N.Y.N.C.)
| | | | - Steven B Magill
- Endocrinology Center, North Hills Health Center, Medical College of Wisconsin, Menomonee Falls (S.B.M.)
| | | | | | - Anna Oliveras
- Hypertension Unit, Nephrology Department, Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Spain (A.O.)
| | - Bo-Ching Lee
- Department of Medical Imaging, National Taiwan University Hospital (B.-C.L., C.-C.C.), Taipei
| | - Chin-Chen Chang
- Department of Medical Imaging, National Taiwan University Hospital (B.-C.L., C.-C.C.), Taipei
- National Taiwan University College of Medicine (C.-C.C.), Taipei
| | - Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine (V.C.W.), Taipei
| | - Zuzana Krátká
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic (J.W., Z.K.)
| | | | - Giacomo Rossitto
- Hypertension Unit, Department of Medicine, DIMED, University Hospital, University of Padova, Italy (G.P.R., D.B., G.R., T.M.S.)
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (G.R.)
| | - Teresa Maria Seccia
- Hypertension Unit, Department of Medicine, DIMED, University Hospital, University of Padova, Italy (G.P.R., D.B., G.R., T.M.S.)
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Lai JH, Gwini SM, Chen G, Long KM, Russell G, Schlaich MP, Stowasser M, Young MJ, Fuller PJ, Mori TA, Wolley M, Reid CM, Yang J. Willingness to be tested for a secondary cause of hypertension: a survey of the Australian general community. Intern Med J 2023; 53:1826-1836. [PMID: 36321804 DOI: 10.1111/imj.15955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/08/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Primary aldosteronism (PA) represents the most common and potentially curable cause of secondary hypertension. However, PA is not commonly screened for, and up to 34% of patients who screen positive do not complete the full diagnostic process. This suggests that the diagnostic process may pose a barrier to patients and may contribute to the under-diagnosis of PA. AIMS To evaluate the willingness of the Australian general public to undergo testing for secondary causes of hypertension and identify enablers or barriers to testing from the patients' perspective. METHODS An online survey containing questions on knowledge and attitudes towards hypertension, willingness to be tested and enablers/barriers towards testing was distributed to the Australian community. RESULTS Of 520 adult respondents (mean age 50.4 years, SD 27.3 years; 28.8% hypertensive; 56.0% female), the majority of non-hypertensive and hypertensive respondents (82.7% vs 70.0%; P = 0.03) were willing to undergo testing for a secondary cause of hypertension that involved blood and urine tests. Greater knowledge of hypertensive risk modification strategies and complications was predictive of willingness to be tested, whereas age, sex, education level, geographic location, socio-economic status and cardiovascular comorbidities were not. The top three barriers to testing included fear of a serious underlying condition, lack of belief in further testing and increased stress associated with further testing. CONCLUSION A high proportion of patients are willing to engage in testing for a secondary cause of hypertension. Education about the risks associated with hypertension and the testing process may overcome several barriers to testing.
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Affiliation(s)
- Jordan H Lai
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Stella M Gwini
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Epidemiology, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Gang Chen
- Centre for Health Economics, Monash University, Melbourne, Victoria, Australia
| | - Katrina M Long
- School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia
| | - Grant Russell
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School, The University of Western Australia - Royal Perth Hospital Campus, Perth, Western Australia, Australia
- Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
- Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland Diamantina Institute, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Morag J Young
- Cardiovascular Endocrinology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Peter J Fuller
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia
| | - Trevor A Mori
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Martin Wolley
- Endocrine Hypertension Research Centre, University of Queensland School of Medicine; Greenslopes and Princess Alexandra Hospitals, Brisbane, Queensland, Australia
- Department of Nephrology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia
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6
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Bertolone L, Castagna A, Manfredi M, De Santis D, Ambrosani F, Antinori E, Mulatero P, Danese E, Marengo E, Barberis E, Veneri M, Martinelli N, Friso S, Pizzolo F, Olivieri O. Proteomic analysis of urinary extracellular vesicles highlights specific signatures for patients with primary aldosteronism. Front Endocrinol (Lausanne) 2023; 14:1096441. [PMID: 37223008 PMCID: PMC10200877 DOI: 10.3389/fendo.2023.1096441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 04/03/2023] [Indexed: 05/25/2023] Open
Abstract
Background Urinary extracellular vesicles (uEVs) can be released by different cell types facing the urogenital tract and are involved in cellular trafficking, differentiation and survival. UEVs can be easily detected in urine and provide pathophysiological information "in vivo" without the need of a biopsy. Based on these premises, we hypothesized that uEVs proteomic profile may serve as a valuable tool in the differential characterization between Essential Hypertension (EH) and primary aldosteronism (PA). Methods Patients with essential hypertension (EH) and PA were enrolled in the study (EH= 12, PA=24: 11 Bilateral Primary Aldosteronism subtype (BPA) and 13 Aldosterone Producing Adenoma (APA)). Clinical and biochemical parameters were available for all the subjects. UEVs were isolated from urine by ultracentrifugation and analysed by Transmission Electron Microscopy (TEM) and nanotrack particle analysis (NTA). UEVs protein content was investigated through an untargeted MS-based approach. Statistical and network analysis was performed to identify potential candidates for the identification and classification of PA. Results MS analysis provided more than 300 protein identifications. Exosomal markers CD9 and CD63 were detected in all samples. Several molecules characterizing EH vs PA patients as well as BPA and APA subtypes were identified after statistical elaboration and filtering of the results. In particular, some key proteins involved in water reabsorption mechanisms, such as AQP1 and AQP2, were among the best candidates for discriminating EH vs PA, as well as A1AG1 (AGP1). Conclusion Through this proteomic approach, we identified uEVs molecular indicators that can improve PA characterization and help in the gain of insights of the pathophysiological features of this disease. In particular, PA was characterized by a reduction of AQP1 and AQP2 expression as compared with EH.
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Affiliation(s)
- Lorenzo Bertolone
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
| | - Annalisa Castagna
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
| | - Marcello Manfredi
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
- Center for Translational Research on Autoimmune and Allergic Diseases, University of Piemonte Orientale, Novara, Italy
| | - Domenica De Santis
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
| | - Francesca Ambrosani
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
| | - Elisa Antinori
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
| | - Paolo Mulatero
- Department of Medical Sciences, Division of Internal Medicine and Hypertension University of Torino, Torino, Italy
| | - Elisa Danese
- Section of Clinical Biochemistry, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Emilio Marengo
- Department of Sciences and Technological Innovation, University of Piemonte Orientale, Alessandria, Italy
| | - Elettra Barberis
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Mariangela Veneri
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
| | - Nicola Martinelli
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
| | - Simonetta Friso
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
| | - Francesca Pizzolo
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
| | - Oliviero Olivieri
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
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7
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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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8
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Urinary extracellular vesicle mRNA analysis of sodium chloride cotransporter in hypertensive patients under different conditions. J Hum Hypertens 2022:10.1038/s41371-022-00744-3. [PMID: 35978099 DOI: 10.1038/s41371-022-00744-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/19/2022] [Accepted: 07/27/2022] [Indexed: 11/09/2022]
Abstract
Urinary extracellular vesicles (UEV) mainly derive from cells of the urogenital tract and their cargo (proteins, nucleic acids, lipids, etc.) reflects their cells of origin. Na chloride cotransporter (NCC) is expressed at the kidney level in the distal convoluted tubule, is involved in salt reabsorption, and is the target of the diuretic thiazides. NCC protein has been recognized and quantified in UEV in previous studies; however, UEV NCC mRNA has never been studied. This study aimed to identify and analyze NCC mRNA levels in primary aldosteronism (PA). The rationale for this investigation stems from previous observations regarding NCC (protein) as a possible biomarker for the diagnosis of PA. To evaluate modulations in the expression of NCC, we analyzed NCC mRNA levels in UEV in PA and essential hypertensive (EH) patients under different conditions, that is, before and after saline infusion, anti-aldosterone pharmacological treatment, and adrenal surgery. NCC mRNA was measured by RT-qPCR in all the samples and was regulated by volume expansion. Its response to mineralocorticoid receptor antagonist was correlated with renin, and it was increased in PA patients after adrenalectomy. NCC mRNA is evaluable in UEV and it can provide insights into the pathophysiology of distal convolute tubule in different clinical conditions including PA.
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9
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Chikhladze NM. Primary hyperaldosteronism: indications for screening. TERAPEVT ARKH 2022; 94:107-113. [DOI: 10.26442/00403660.2022.01.201324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 11/22/2022]
Abstract
The review discusses the current state of the problem of screening patients for early detection of primary hyperaldosteronism (PHA) as a potential cause of arterial hypertension (AH). The features of screening, methodological errors that make it difficult to interpret the results of the study are considered. The screening criteria are analyzed, based on which it is possible to assess the probability of diagnosis of PHA and judge its prevalence in various populations of patients with AH categories of high risk for the development of PHA. Attention is drawn to the low level of screening in patients with AH in order to detect PHA , and to the need for wider familiarization of doctors with the methods of screening and diagnosis of PHA as the cause of uncontrolled AH. The importance of timely diagnosis of PHA and its targeted treatment to reduce the risk of cardiovascular complications associated with hypersecretion of aldosterone is emphasized.
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10
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Obesity-associated cardiovascular risk in women: hypertension and heart failure. Clin Sci (Lond) 2021; 135:1523-1544. [PMID: 34160010 DOI: 10.1042/cs20210384] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/14/2021] [Accepted: 06/07/2021] [Indexed: 02/07/2023]
Abstract
The pathogenesis of obesity-associated cardiovascular diseases begins long prior to the presentation of a cardiovascular event. In both men and women, cardiovascular events, and their associated hospitalizations and mortality, are often clinically predisposed by the presentation of a chronic cardiovascular risk factor. Obesity increases the risk of cardiovascular diseases in both sexes, however, the clinical prevalence of obesity, as well as its contribution to crucial cardiovascular risk factors is dependent on sex. The mechanisms via which obesity leads to cardiovascular risk is also discrepant in women between their premenopausal, pregnancy and postmenopausal phases of life. Emerging data indicate that at all reproductive statuses and ages, the presentation of a cardiovascular event in obese women is strongly associated with hypertension and its subsequent chronic risk factor, heart failure with preserved ejection fraction (HFpEF). In addition, emerging evidence indicates that obesity increases the risk of both hypertension and heart failure in pregnancy. This review will summarize clinical and experimental data on the female-specific prevalence and mechanisms of hypertension and heart failure in women across reproductive stages and highlight the particular risks in pregnancy as well as emerging data in a high-risk ethnicity in women of African ancestry (AA).
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11
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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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12
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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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13
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Rossi GP, Bisogni V, Bacca AV, Belfiore A, Cesari M, Concistrè A, Del Pinto R, Fabris B, Fallo F, Fava C, Ferri C, Giacchetti G, Grassi G, Letizia C, Maccario M, Mallamaci F, Maiolino G, Manfellotto D, Minuz P, Monticone S, Morganti A, Muiesan ML, Mulatero P, Negro A, Parati G, Pengo MF, Petramala L, Pizzolo F, Rizzoni D, Rossitto G, Veglio F, Seccia TM. The 2020 Italian Society of Arterial Hypertension (SIIA) practical guidelines for the management of primary aldosteronism. INTERNATIONAL JOURNAL CARDIOLOGY HYPERTENSION 2020; 5:100029. [PMID: 33447758 PMCID: PMC7803025 DOI: 10.1016/j.ijchy.2020.100029] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/07/2020] [Indexed: 02/06/2023]
Abstract
Background and aim Considering the amount of novel knowledge generated in the last five years, a team of experienced hypertensionlogists was assembled to furnish updated clinical practice guidelines for the management of primary aldosteronism. Methods To identify the most relevant studies, the authors utilized a systematic literature review in international databases by applying the PICO strategy, and then they were required to make use of only those meeting predefined quality criteria. For studies of diagnostic tests, only those that fulfilled the Standards for Reporting of Diagnostic Accuracy recommendations were considered. Results Each section was jointly prepared by at least two co-authors, who provided Class of Recommendation and Level of Evidence following the American Heart Association methodology. The guidelines were sponsored by the Italian Society of Arterial Hypertension and underwent two rounds of revision, eventually reexamined by an External Committee. They were presented and thoroughly discussed in two face-to-face meetings with all co-authors and then presented on occasion of the 36th Italian Society of Arterial Hypertension meeting in order to gather further feedbacks by all members. The text amended according to these feedbacks was subjected to a further peer review. Conclusions After this process, substantial updated information was generated, which could simplify the diagnosis of primary aldosteronism and assist practicing physicians in optimizing treatment and follow-up of patients with one of the most common curable causes of arterial hypertension.
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Affiliation(s)
- Gian Paolo Rossi
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
- Corresponding author. DIMED –Clinica dell’Ipertensione Arteriosa, University Hospital, via Giustiniani, 2; 35126, Padova, Italy.
| | - Valeria Bisogni
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
| | | | - Anna Belfiore
- Clinica Medica "A. Murri", Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy
| | - Maurizio Cesari
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
| | - Antonio Concistrè
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Italy
| | - Rita Del Pinto
- University of L'Aquila, Department of Life, Health and Environmental Sciences, San Salvatore Hospital, L'Aquila, Italy
| | - Bruno Fabris
- Department of Medical Sciences, Università degli Studi di Trieste, Cattinara Teaching Hospital, Trieste, Italy
| | - Francesco Fallo
- Department of Medicine, DIMED, Internal Medicine 3, University of Padua, Italy
| | - Cristiano Fava
- Department of Medicine, University of Verona, Policlinico "G.B. Rossi", Italy
| | - Claudio Ferri
- University of L'Aquila, Department of Life, Health and Environmental Sciences, San Salvatore Hospital, L'Aquila, Italy
| | | | | | - Claudio Letizia
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Italy
| | - Mauro Maccario
- Endocrinology, Diabetology, and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Francesca Mallamaci
- CNR-IFC Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Giuseppe Maiolino
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
| | - Dario Manfellotto
- UO Medicina Interna, Ospedale Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Pietro Minuz
- Department of Medicine, University of Verona, Policlinico "G.B. Rossi", Italy
| | - Silvia Monticone
- Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences, University of Turin, Italy
| | - Alberto Morganti
- Centro Fisiologia Clinica e Ipertensione, Ospedale Policlinico, Università Milano, Milan, Italy
| | - Maria Lorenza Muiesan
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Paolo Mulatero
- Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences, University of Turin, Italy
| | - Aurelio Negro
- Department of Medicine, Center for Hypertension, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca and Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Martino F. Pengo
- Department of Medicine and Surgery, University of Milano-Bicocca and Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Luigi Petramala
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Italy
| | - Francesca Pizzolo
- Department of Medicine, University of Verona, Policlinico "G.B. Rossi", Italy
| | - Damiano Rizzoni
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Giacomo Rossitto
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Franco Veglio
- Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences, University of Turin, Italy
| | - Teresa Maria Seccia
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
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14
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Rossi GP, Rossitto G, Amar L, Azizi M, Riester A, Reincke M, Degenhart C, Widimsky J, Naruse M, Deinum J, Schultze Kool L, Kocjan T, Negro A, Rossi E, Kline G, Tanabe A, Satoh F, Christian Rump L, Vonend O, Willenberg HS, Fuller PJ, Yang J, Chee NYN, Magill SB, Shafigullina Z, Quinkler M, Oliveras A, Dun Wu K, Wu VC, Kratka Z, Barbiero G, Battistel M, Chang CC, Vanderriele PE, Pessina AC. Clinical Outcomes of 1625 Patients With Primary Aldosteronism Subtyped With Adrenal Vein Sampling. Hypertension 2019; 74:800-808. [PMID: 31476901 DOI: 10.1161/hypertensionaha.119.13463] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We sought to measure the clinical benefits of adrenal venous sampling (AVS), a test recommended by guidelines for primary aldosteronism (PA) patients seeking surgical cure, in a large registry of PA patients submitted to AVS. Data of 1625 consecutive patients submitted to AVS in 19 tertiary referral centers located in Asia, Australia, Europe, and North America were collected in a large multicenter international registry. The primary end points were the rate of bilateral success, ascertained lateralization of PA, adrenalectomy, and of cured arterial hypertension among AVS-guided and non AVS-guided adrenalectomy patients. AVS was successful in 80.1% of all cases but allowed identification of unilateral PA in only 45.5% by the criteria in use at each center. Adrenalectomy was performed in 41.8% of all patients and cured arterial hypertension in 19.6% of the patients, 2-fold more frequently in women than men (P<0.001). When AVS-guided, surgery provided a higher rate of cure of hypertension than when non-AVS-guided (40.0% versus 30.5%; P=0.027). Compared with surgical cases, patients treated medically needed more antihypertensive medications (P<0.001) and exhibited a higher rate of persistent hypokalemia requiring potassium supplementation (4.9% versus 2.3%; P<0.01). The low rate of adrenalectomy and cure of hypertension in PA patients seeking surgical cure indicates suboptimal AVS use, possibly related to issues in patient selection, technical success, and AVS data interpretation. Given the better outcomes of AVS-guided adrenalectomy, these results call for actions to improve the diagnostic use of this test that is necessary for detection of surgical PA candidates. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01234220.
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Affiliation(s)
- Gian Paolo Rossi
- From the Department of Medicine-DIMED, University of Padova, Hypertension Unit, University Hospital, Padova, Italy (G.P.R., G.R., P.-E.V., A.C.P.)
| | - Giacomo Rossitto
- From the Department of Medicine-DIMED, University of Padova, Hypertension Unit, University Hospital, Padova, Italy (G.P.R., G.R., P.-E.V., A.C.P.).,Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (G.R.)
| | - Laurence Amar
- AP-HP, Hôpital Européen Georges Pompidou, Hypertension Unit, Paris, France (L.A., M.A.).,Faculty of Medicine, Université de Paris, INSERM, UMR970, Paris-Cardiovascular Research Center, France (L.A.)
| | - Michel Azizi
- AP-HP, Hôpital Européen Georges Pompidou, Hypertension Unit, Paris, France (L.A., M.A.).,INSERM, CIC1418, F-75015, Paris, France (M.A.)
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München (A.R., M.R., C.D.)
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München (A.R., M.R., C.D.)
| | - Christoph Degenhart
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München (A.R., M.R., C.D.)
| | - Jiri Widimsky
- 3rd Department of Medicine, Charles University Prague, General Hospital, Czech Republic (J.W., Z.K.)
| | - Mitsuhide Naruse
- Department of Endocrinology, National Hospital Organization Kyoto Medical Center, Clinical Research Institute, Japan (M.N.)
| | | | - Leo Schultze Kool
- Radiology (L.S.K.).,Radboud University Medical Center, Nijmegen, Netherlands (L.S.)
| | | | - Aurelio Negro
- Department of Internal Medicine, Azienda Unità Sanitaria Locale, IRCCS Arcispedale S. Maria Nuova, Hypertension Unit, Reggio Emilia, Italy (A.N., E.R.)
| | - Ermanno Rossi
- Department of Internal Medicine, Azienda Unità Sanitaria Locale, IRCCS Arcispedale S. Maria Nuova, Hypertension Unit, Reggio Emilia, Italy (A.N., E.R.)
| | - Gregory Kline
- Foothills Medical Centre, University of Calgary, Canada (G.K.)
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine (A.T.)
| | - Fumitoshi Satoh
- Department of Nephrology, Tohoku University Hospital, Endocrinology and Vascular Medicine, Sendai (F.S.)
| | | | - Oliver Vonend
- Heinrich Heine University Düsseldorf, Nephrologie, Germany (L.C.R., O.V.)
| | - Holger S Willenberg
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Germany (H.S.W.)
| | - Peter J Fuller
- Endocrinology Unit, Monash Health, Clayton, VIC, Australia (P.J.F., J.Y., N.Y.N.C.)
| | - Jun Yang
- Endocrinology Unit, Monash Health, Clayton, VIC, Australia (P.J.F., J.Y., N.Y.N.C.)
| | | | - Steven B Magill
- Medical College of Wisconsin, Endocrinology Center, North Hills Health Center, Menomonee Falls (S.B.M.)
| | | | | | - Anna Oliveras
- Department of Nephrology, Hypertension Unit, Hosp. del Mar Universitat Autònoma de Barcelona, Spain (A.O.)
| | - Kwan Dun Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei (K.D.W., V-C.W.)
| | - Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei (K.D.W., V-C.W.)
| | - Zusana Kratka
- 3rd Department of Medicine, Charles University Prague, General Hospital, Czech Republic (J.W., Z.K.).,Department of Endocrinology, North-Western State Medical University named after I.I. Mechnikov, St. Petersburg, Russia (Z.K.)
| | - Giulio Barbiero
- Institute of Radiology, University of Padova, Italy (G.B., M.B.)
| | | | - Chin-Chen Chang
- Department of Medical Imaging, National Taiwan University Hospital, Taipei (C.-C.C.)
| | - Paul-Emmanuel Vanderriele
- From the Department of Medicine-DIMED, University of Padova, Hypertension Unit, University Hospital, Padova, Italy (G.P.R., G.R., P.-E.V., A.C.P.)
| | - Achille C Pessina
- From the Department of Medicine-DIMED, University of Padova, Hypertension Unit, University Hospital, Padova, Italy (G.P.R., G.R., P.-E.V., A.C.P.)
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15
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Williams TA, Burrello J, Sechi LA, Fardella CE, Matrozova J, Adolf C, Baudrand R, Bernardi S, Beuschlein F, Catena C, Doumas M, Fallo F, Giacchetti G, Heinrich DA, Saint-Hilary G, Jansen PM, Januszewicz A, Kocjan T, Nishikawa T, Quinkler M, Satoh F, Umakoshi H, Widimský J, Hahner S, Douma S, Stowasser M, Mulatero P, Reincke M. Computed Tomography and Adrenal Venous Sampling in the Diagnosis of Unilateral Primary Aldosteronism. Hypertension 2019; 72:641-649. [PMID: 29987100 DOI: 10.1161/hypertensionaha.118.11382] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Unilateral primary aldosteronism is the most common surgically correctable form of endocrine hypertension and is usually differentiated from bilateral forms by adrenal venous sampling (AVS) or computed tomography (CT). Our objective was to compare clinical and biochemical postsurgical outcomes of patients with unilateral primary aldosteronism diagnosed by CT or AVS and identify predictors of surgical outcomes. Patient data were obtained from 18 internationally distributed centers and retrospectively analyzed for clinical and biochemical outcomes of adrenalectomy of patients with surgical management based on CT (n=235 patients, diagnosed from 1994-2016) or AVS (526 patients, diagnosed from 1994-2015) using the standardized PASO (Primary Aldosteronism Surgical Outcome) criteria. Biochemical outcomes were highly different according to surgical management approach with a smaller proportion in the CT group achieving complete biochemical success (188 of 235 [80%] patients versus 491 of 526 [93%], P<0.001) and a greater proportion with absent biochemical success (29 of 235 [12%] versus 10 of 526 [2%], P<0.001). A diagnosis by CT was associated with a decreased likelihood of complete biochemical success compared with AVS (odds ratio, 0.28; 0.16-0.50; P<0.001). Clinical outcomes were not significantly different, but the absence of a postsurgical elevated aldosterone-to-renin ratio was a strong marker of complete clinical success (odds ratio, 14.81; 1.76-124.53; P=0.013) in the CT but not in the AVS group. In conclusion, patients diagnosed by CT have a decreased likelihood of achieving complete biochemical success compared with a diagnosis by AVS.
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Affiliation(s)
- Tracy A Williams
- From the Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany (T.A.W., C.A., F.B., D.A.H., M.R.)
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Italy (T.A.W., J.B., P.M.)
| | - Jacopo Burrello
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Italy (T.A.W., J.B., P.M.)
| | - Leonardo A Sechi
- Hypertension Unit, Internal Medicine, Department of Medicine (DAME), University of Udine, Italy (L.A.S., C.C.)
| | - Carlos E Fardella
- Departamento Endocrinología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago (C.E.F., R.B.)
| | - Joanna Matrozova
- Clinical Centre of Endocrinology, Medical University, Sofia, Bulgaria (J.M.)
| | - Christian Adolf
- From the Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany (T.A.W., C.A., F.B., D.A.H., M.R.)
| | - René Baudrand
- Departamento Endocrinología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago (C.E.F., R.B.)
| | - Stella Bernardi
- Department of Medical Sciences, University of Trieste, Italy (S.B.)
- ASUITS-Azienda Sanitaria Universitaria Integrata di Trieste, Cattinara Teaching Hospital, Italy (S.B.)
| | - Felix Beuschlein
- From the Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany (T.A.W., C.A., F.B., D.A.H., M.R.)
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Switzerland (F.B.)
| | - Cristiana Catena
- Hypertension Unit, Internal Medicine, Department of Medicine (DAME), University of Udine, Italy (L.A.S., C.C.)
| | - Michalis Doumas
- 2nd Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece (M.D.)
| | - Francesco Fallo
- Department of Medicine (DIMED), University of Padova, Italy (F.F.)
| | - Gilberta Giacchetti
- Division of Endocrinology, Polytechnic University of Marche, Ancona, Italy (G.G.)
| | - Daniel A Heinrich
- From the Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany (T.A.W., C.A., F.B., D.A.H., M.R.)
| | - Gaëlle Saint-Hilary
- Dipartimento di Scienze Matematiche (DISMA), Giuseppe Luigi Lagrange, Politecnico di Torino, Italy (G.S.-H.)
| | - Pieter M Jansen
- Endocrine Hypertension Research Centre, University of Queensland Diamantina Institute, Greenslopes and Princess Alexandra Hospitals, Brisbane, Australia (P.M.J., M.S.)
| | | | - Tomaz Kocjan
- Department of Endocrinology, Diabetes and Metabolic diseases, University Medical Centre, Ljubljana, Slovenia (T.K.)
| | - Tetsuo Nishikawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan (T.N.)
| | | | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan (F.S.)
| | - Hironobu Umakoshi
- Department of Endocrinology, Metabolism and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Japan (H.U.)
| | - Jiří Widimský
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.W.)
| | - Stefanie Hahner
- Department of Internal Medicine I, Endocrinology and Diabetes Unit, University Hospital of Würzburg, University of Würzburg, Germany (S.H.)
| | - Stella Douma
- 3rd Department of Internal Medicine, Aristotle University, Thessaloniki, Greece (S.D.)
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland Diamantina Institute, Greenslopes and Princess Alexandra Hospitals, Brisbane, Australia (P.M.J., M.S.)
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Italy (T.A.W., J.B., P.M.)
| | - Martin Reincke
- From the Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany (T.A.W., C.A., F.B., D.A.H., M.R.)
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16
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Surprisingly low aldosterone levels in peripheral veins following intravenous sedation during adrenal vein sampling. J Hypertens 2019; 37:596-602. [DOI: 10.1097/hjh.0000000000001905] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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17
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Lana A, Alexander K, Castagna A, D'Alessandro A, Morandini F, Pizzolo F, Zorzi F, Mulatero P, Zolla L, Olivieri O. Urinary Metabolic Signature of Primary Aldosteronism: Gender and Subtype-Specific Alterations. Proteomics Clin Appl 2019; 13:e1800049. [PMID: 30580498 DOI: 10.1002/prca.201800049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 12/03/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE The current clinical investigation for primary aldosteronism (PA) diagnosis requires complex expensive tests from the initial suspicion to the final subtype classification, including invasive approaches; therefore, appropriate markers for subtype definition are greatly desirable. The present study performs a metabolomics analysis to further examine specific molecular signatures of PA urines EXPERIMENTAL DESIGN: The study considered PA subtype and gender-related differences using two orthogonal advanced UHPLC-MS metabolomics approaches. Patients with essential hypertension (n = 36) and PA (n = 50) who were referred to the outpatient hypertension clinic and matched healthy subjects (n = 10) are investigated. RESULTS Statistically significant changes (p < 0.05 ANOVA, Fc > 1.5) of metabolites involved in central carbon, energy, and nitrogen metabolism are identified, especially purine and pyrimidine nucleosides and precursors, and free amino acids. PLS-DA interpretation provides strong evidence of a disease-specific metabolic pattern with dAMP, diiodothyronine, and 5-methoxytryptophan as leading factors, and a sex-specific metabolic pattern associated with orotidine 5-phosphate, N-acetylalanine, hydroxyproline, and cysteine. The results are verified using an independent sample set, which confirms the identification of specific signatures. CONCLUSIONS AND CLINICAL RELEVANCE Metabolomics is used to identify low molecular weight molecular markers of PA, which paves the way for follow-up validation studies in larger cohorts.
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Affiliation(s)
- Alessandro Lana
- Department of Ecological and Biological Sciences, Tuscia University, 01100, Viterbo, Italy
| | - Keisha Alexander
- Departments of Biochemistry and Molecular Genetics, University of Colorado Denver, Anschutz Medical Campus, 80045, Aurora, CO, USA
| | - Annalisa Castagna
- Department of Medicine, Unit of Internal Medicine, University of Verona, 37134, Verona, Italy
| | - Angelo D'Alessandro
- Departments of Biochemistry and Molecular Genetics, University of Colorado Denver, Anschutz Medical Campus, 80045, Aurora, CO, USA
| | - Francesca Morandini
- Department of Medicine, Unit of Internal Medicine, University of Verona, 37134, Verona, Italy
| | - Francesca Pizzolo
- Department of Medicine, Unit of Internal Medicine, University of Verona, 37134, Verona, Italy
| | - Francesco Zorzi
- Department of Medicine, Unit of Internal Medicine, University of Verona, 37134, Verona, Italy
| | - Paolo Mulatero
- Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension Unit, University of Turin, 10124, Turin, Italy
| | - Lello Zolla
- Department of Ecological and Biological Sciences, Tuscia University, 01100, Viterbo, Italy
| | - Oliviero Olivieri
- Department of Medicine, Unit of Internal Medicine, University of Verona, 37134, Verona, Italy
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18
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Rossitto G, Cesari M, Ceolotto G, Maiolino G, Seccia TM, Rossi GP. Effects of mineralocorticoid and AT-1 receptor antagonism on the aldosterone–renin ratio (ARR) in primary aldosteronism patients (EMIRA Study): rationale and design. J Hum Hypertens 2018; 33:167-171. [DOI: 10.1038/s41371-018-0139-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 10/29/2018] [Accepted: 11/15/2018] [Indexed: 11/09/2022]
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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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20
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Takeda M, Yamamoto K, Akasaka H, Rakugi H, Naruse M, Takeda Y, Kurihara I, Itoh H, Umakoshi H, Tsuiki M, Ichijo T, Katabami T, Wada N, Shibayama Y, Yoshimoto T, Ogawa Y, Kawashima J, Sone M, Inagaki N, Takahashi K, Fujita M, Watanabe M, Matsuda Y, Kobayashi H, Shibata H, Kamemura K, Otsuki M, Fujii Y, Ogo A, Okamura S, Miyauchi S, Yanase T, Suzuki T, Kawamura T. Clinical Characteristics and Postoperative Outcomes of Primary Aldosteronism in the Elderly. J Clin Endocrinol Metab 2018; 103:3620-3629. [PMID: 30099522 DOI: 10.1210/jc.2018-00059] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 08/01/2018] [Indexed: 02/05/2023]
Abstract
CONTEXT Primary aldosteronism (PA) in the elderly has increased in importance in association with population aging. OBJECTIVE To investigate the characteristics and outcomes of elderly patients with PA undergoing adrenalectomy. PATIENTS AND METHODS Using a database of patients with PA who underwent adrenal venous sampling (AVS), we compared elderly patients (≥65 years old) with nonelderly patients (<65 years old) in terms of characteristics, subtype classification in ACTH-stimulated AVS, and outcomes after adrenalectomy. RESULTS The elderly group had a higher prevalence of comorbidities than the nonelderly group. The proportion of the unilateral subtype [defined as a lateralization index (LI) >4] was comparable between the age groups. In patients who received adrenalectomy, biochemical cure was comparable between the groups, whereas persistent hypertension was more common in the elderly group. The prevalences of hyperkalemia and renal impairment (chronic kidney disease stage 3b or higher) were higher in the elderly group. Multiple regression analysis showed that the duration of hypertension predicted persistent hypertension and hyperkalemia and that preoperative estimated glomerular filtration rate predicted renal impairment in the elderly group. LI >4 in AVS was an independent predictor of biochemical cure after adrenalectomy in the elderly group but not in the nonelderly group. Age was negatively associated with biochemical cure in patients with LI ≤4. CONCLUSION Adrenalectomy contributes to biochemical improvement in elderly patients if determined in accordance with AVS. The treatment strategy should be determined considering the high postoperative incidence of persistent hypertension and hyperkalemia in elderly patients with a long history of hypertension or renal impairment in those with reduced renal function.
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Affiliation(s)
- Masao Takeda
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Yamamoto
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Akasaka
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Mitsuhide Naruse
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yoshiyu Takeda
- Department of Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Isao Kurihara
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine Keio University, Tokyo, Japan
| | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine Keio University, Tokyo, Japan
| | - Hironobu Umakoshi
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Mika Tsuiki
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Takamasa Ichijo
- Department of Endocrinology and Metabolism, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Yui Shibayama
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Takanobu Yoshimoto
- Department of Molecular Endocrinology and Metabolism, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshihiro Ogawa
- Department of Molecular Endocrinology and Metabolism, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junji Kawashima
- Department of Metabolic Medicine, Faculty of Life Science, Kumamoto University, Kumamoto University, Kumamoto, Japan
| | - Masakatsu Sone
- Department of Diabetes, Endocrinology and Nutrition Kyoto University, Kyoto, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition Kyoto University, Kyoto, Japan
| | - Katsutoshi Takahashi
- Division of Nephrology and Endocrinology, University of Tokyo School of Medicine, Tokyo, Japan
- Division of Metabolism, Showa General Hospital, Tokyo, Japan
| | - Megumi Fujita
- Division of Nephrology and Endocrinology, University of Tokyo, Tokyo, Japan
| | - Minemori Watanabe
- Department of Endocrinology and Diabetes, Okazaki City Hospital, Okazaki, Japan
| | - Yuichi Matsuda
- Department of Cardiology, Sanda City Hospital, Sanda, Japan
| | - Hiroki Kobayashi
- Division of Nephrology, Hypertension and Endocrinology, Nihon University School of Medicine, Tokyo, Japan
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Yufu, Japan
| | - Kohei Kamemura
- Department of Cardiology, Akashi Medical Center, Akashi, Japan
| | - Michio Otsuki
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuichi Fujii
- Department of Cardiology, JR Hiroshima Hospital, Hiroshima, Japan
| | - Atsushi Ogo
- Clinical Research Institute, National Hospital Organization Kyusyu Medical Center, Fukuoka, Japan
| | - Shintaro Okamura
- Department of Endocrinology, Tenriyorozu Hospital, Tenri, Nara, Japan
| | - Shozo Miyauchi
- Department of Internal Medicine, Uwajima City Hospital, Uwajima, Japan
| | - Toshihiko Yanase
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Tomoko Suzuki
- Department of Public Health, School of Medicine, International University of Health and Welfare, Narita, Japan
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Park CH, Hong N, Han K, Kang SW, Lee CR, Park S, Rhee Y. C-Arm Computed Tomography-Assisted Adrenal Venous Sampling Improved Right Adrenal Vein Cannulation and Sampling Quality in Primary Aldosteronism. Endocrinol Metab (Seoul) 2018; 33:236-244. [PMID: 29766680 PMCID: PMC6021301 DOI: 10.3803/enm.2018.33.2.236] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/19/2018] [Accepted: 03/08/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Adrenal venous sampling (AVS) is a gold standard for subtype classification of primary aldosteronism (PA). However, this procedure has a high failure rate because of the anatomical difficulties in accessing the right adrenal vein. We investigated whether C-arm computed tomography-assisted AVS (C-AVS) could improve the success rate of adrenal sampling. METHODS A total of 156 patients, diagnosed with PA who underwent AVS from May 2004 through April 2017, were included. Based on the medical records, we retrospectively compared the overall, left, and right catheterization success rates of adrenal veins during the periods without C-AVS (2004 to 2010, n=32) and with C-AVS (2011 to 2016, n=124). The primary outcome was adequate bilateral sampling defined as a selectivity index (SI) >5. RESULTS With C-AVS, the rates of adequate bilateral AVS increased from 40.6% to 88.7% (P<0.001), with substantial decreases in failure rates (43.7% to 0.8%, P<0.001). There were significant increases in adequate sampling rates from right (43.7% to 91.9%, P<0.001) and left adrenal veins (53.1% to 95.9%, P<0.001) as well as decreases in catheterization failure from right adrenal vein (9.3% to 0.0%, P<0.001). Net improvement of SI on right side remained significant after adjustment for left side (adjusted SI, 1.1 to 9.0; P=0.038). C-AVS was an independent predictor of adequate bilateral sampling in the multivariate model (odds ratio, 9.01; P<0.001). CONCLUSION C-AVS improved the overall success rate of AVS, possibly as a result of better catheterization of right adrenal vein.
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Affiliation(s)
- Chung Hyun Park
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kichang Han
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Wook Kang
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Cho Rok Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sungha Park
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yumie Rhee
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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22
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Chang CH, Hu YH, Tsai YC, Wu CH, Wang SM, Lin LY, Lin YH, Satoh F, Wu KD, Wu VC. Arterial stiffness and blood pressure improvement in aldosterone-producing adenoma harboring KCNJ5 mutations after adrenalectomy. Oncotarget 2018; 8:29984-29995. [PMID: 28415786 PMCID: PMC5444719 DOI: 10.18632/oncotarget.16269] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 03/09/2017] [Indexed: 12/18/2022] Open
Abstract
The aim of this study was to show the effect of KCNJ5 mutational status on arterial stiffness in aldosterone-producing adenomas after adrenalectomy. Between February 2008 and January 2010, we prospectively enrolled 108 aldosterone-producing adenoma patients undergoing adrenalectomy. We conducted repeated measurements of pulse wave velocity at baseline, 6 months, and 12 months after adrenalectomy, grouped by KCNJ5 mutational status. Prognostic factors of arterial stiffness and risk for hypertension at 12 months after adrenalectomy were analyzed after propensity score matching in a 1:1 ratio. After matching for age, sex and body mass index, 88 patients were divided equally into KCNJ5-mutant and non-mutant groups. KCNJ5 mutational status was not an independent variable in either the generalized estimating equation model (p = 0.147) or the percentage change of brachial-ankle pulse wave velocity (p = 0.106). The generalized additive model smoothing plot showed that aldosterone-producing adenoma patients who carried the KCNJ5 mutation and were aged between 37 and 60 may have a hypertension recovery advantage. According to our observations during a 12-month follow-up after adrenalectomy, KCNJ5 mutational status was not associated with improvement in arterial stiffness.
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Affiliation(s)
- Chia-Hui Chang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taiwan
| | - Ya-Hui Hu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Yao-Chou Tsai
- Division of Urology, Department of Surgery, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Che-Hsiung Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Shuo-Meng Wang
- Division of Urology, Department of Surgery, National Taiwan University Hospital, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taiwan
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taiwan
| | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University, Graduate School of Medicine, Sendai, Japan
| | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taiwan.,TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group, Taiwan
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23
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Aldosterone, SGK1, and ion channels in the kidney. Clin Sci (Lond) 2018; 132:173-183. [PMID: 29352074 PMCID: PMC5817097 DOI: 10.1042/cs20171525] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/15/2017] [Accepted: 12/19/2017] [Indexed: 12/14/2022]
Abstract
Hyperaldosteronism, a common cause of hypertension, is strongly connected to Na+, K+, and Mg2+ dysregulation. Owing to its steroidal structure, aldosterone is an active transcriptional modifier when bound to the mineralocorticoid receptor (MR) in cells expressing the enzyme 11β-hydroxysteroid dehydrogenase 2, such as those comprising the aldosterone-sensitive distal nephron (ASDN). One such up-regulated protein, the ubiquitous serum and glucocorticoid regulated kinase 1 (SGK1), has the capacity to modulate the surface expression and function of many classes of renal ion channels, including those that transport Na+ (ENaC), K+ (ROMK/BK), Ca2+ (TRPV4/5/6), Mg2+ (TRPM7/6), and Cl− (ClC-K, CFTR). Here, we discuss the mechanisms by which ASDN expressed channels are up-regulated by SGK1, while highlighting newly discovered pathways connecting aldosterone to nonselective cation channels that are permeable to Mg2+ (TRPM7) or Ca2+ (TRPV4).
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Kline GA, Prebtani APH, Leung AA, Schiffrin EL. The Potential Role of Primary Care in Case Detection/Screening of Primary Aldosteronism. Am J Hypertens 2017; 30:1147-1150. [PMID: 28992276 DOI: 10.1093/ajh/hpx064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 03/23/2017] [Indexed: 11/13/2022] Open
Abstract
Endocrine hypertension, particularly primary aldosteronism (PA), was previously considered to account for less than 1% of all hypertension and was suspected only when patients presented with spontaneous hypokalemia. However, the last 20 years of PA research has now clearly shown that PA is not a rarity, but rather, may account for up to 13% of unselected hypertensive individuals and between 10% and 20% of those with resistant hypertension. Most of these patients do not have spontaneous hypokalemia. The population prevalence of PA likely far exceeds actual detection rates in routine clinical care. As PA represents one of the most common, potentially reversible causes of hypertension, and is associated with significant cardiovascular complications over the long term, it is clear that a pragmatic strategy for targeted case detection in primary care is needed.
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Affiliation(s)
- Gregory A Kline
- Division of Endocrinology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ally P H Prebtani
- Department of Medicine, Internal Medicine, Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Alexander A Leung
- Division of Endocrinology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ernesto L Schiffrin
- Department of Medicine, Jewish General Hospital and Lady Davis Research Institute, McGill University, Montreal, Quebec, Canada
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25
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Pizzolo F, Chiecchi L, Morandini F, Castagna A, Zorzi F, Zaltron C, Pattini P, Chiariello C, Salvagno G, Olivieri O. Increased urinary excretion of the epithelial Na channel activator prostasin in patients with primary aldosteronism. J Hypertens 2017; 35:355-361. [PMID: 27841781 DOI: 10.1097/hjh.0000000000001168] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Prostasin is a glycosylphosphatidylinositol-anchored serine protease that is released in urine and is involved in epithelial Na channel activation. A direct association between urinary prostasin (u-prostasin) concentration and activation of the aldosterone-driven pathway has been suggested; however, in previous studies on primary aldosteronism, a semiquantitative evaluation, rather than a precise quantification, of prostasin was performed. We aim to investigate if u-prostasin concentrations are higher in patients with primary aldosteronism than in patients with essential hypertension and whether u-prostasin measurements could be a useful marker for diagnosing primary aldosteronism in hypertensive patients. METHODS A total of 62 primary aldosteronism and 56 essential hypertension patients were enrolled. Biochemical and hormonal parameters were measured by applying routine laboratory methods, and u-prostasin levels were assessed by ELISA. RESULTS Primary aldosteronism patients had higher u-prostasin levels than did essential hypertension patients. Prostasin levels were positively correlated with the aldosterone-to-renin ratio and inversely correlated with plasma K and urinary Na levels. In the highest concentration quartile, u-prostasin levels were associated with a several-fold higher probability of primary aldosteronism diagnosis in hypertensive patients. Receiver operating characteristic curve analysis showed that prostasin was specific but poorly sensitive as a diagnostic marker for primary aldosteronism. CONCLUSIONS The study shows that an elevated u-prostasin concentration in humans is a specific marker for primary aldosteronism, which involves the classical model of epithelial Na channel activation. There was no statistically significant difference in prostasin concentrations among patients with different primary aldosteronism subtypes. Studies with a larger series of patients are necessary to clarify the clinical usefulness of the prostasin assay.
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Affiliation(s)
- Francesca Pizzolo
- aDepartment of Medicine, Division of Internal Medicine, University of Verona bDepartment of Pathology and Diagnostics, Section Clinical Chemistry, University of Verona, Verona, Italy
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26
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Fully automated chemiluminescence vs RIA aldosterone assay in primary aldosteronism work-up. J Hum Hypertens 2017; 31:826-830. [DOI: 10.1038/jhh.2017.62] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/16/2017] [Accepted: 07/13/2017] [Indexed: 11/08/2022]
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Wu VC, Hu YH, Er LK, Yen RF, Chang CH, Chang YL, Lu CC, Chang CC, Lin JH, Lin YH, Wang TD, Wang CY, Tu ST, Jeff Chueh SC, Chang CC, Tseng FY, Wu KD. Case detection and diagnosis of primary aldosteronism - The consensus of Taiwan Society of Aldosteronism. J Formos Med Assoc 2017; 116:993-1005. [PMID: 28735660 DOI: 10.1016/j.jfma.2017.06.004] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/17/2017] [Accepted: 06/07/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND/PURPOSE Even though the increasing clinical recognition of primary aldosteronism (PA) as a public health issue, its heightened risk profiles and the availability of targeted surgical/medical treatment being more understood, consensus in its diagnosis and management based on medical evidence, while recognizing the constraints of our real-world clinical practice in Taiwan, has not been reached. METHODS The Taiwan Society of Aldosteronism (TSA) Task Force acknowledges the above-mentioned issues and reached this Taiwan PA consensus at its inaugural meeting, in order to provide updated information of internationally acceptable standards, and also to incorporate our local disease characteristics into the management of PA. RESULTS When there is suspicion of PA, a plasma aldosterone to renin ratio (ARR) should be obtained initially. Patients with abnormal ARR will undergo confirmatory laboratory and image tests. Subtype classification with adrenal venous sampling (AVS) or NP-59 nuclear imaging, if AVS not available, to lateralize PA is recommended when patients are considered for adrenalectomy. The strengths and weaknesses of the currently available identification methods are discussed, focusing especially on result interpretation. CONCLUSION With this consensus we hope to raise more awareness of PA among medical professionals and hypertensive patients in Taiwan, and to facilitate reconciliation of better detection, identification and treatment of patients with PA.
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Affiliation(s)
- Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Hui Hu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Leay Kiaw Er
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Ruoh-Fang Yen
- Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Hui Chang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Ya-Li Chang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Ching-Chu Lu
- Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Chen Chang
- Medical Imagine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jui-Hsiang Lin
- Division of Nephrology, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzung-Dau Wang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Yuan Wang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih Te Tu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Shih-Chieh Jeff Chueh
- Glickman Urological and Kidney Institute, and Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ching-Chung Chang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, 40402, Taiwan
| | - Fen-Yu Tseng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Cesari M, Ceolotto G, Rossitto G, Maiolino G, Seccia TM, Rossi GP. The Intra-Procedural Cortisol Assay During Adrenal Vein Sampling: Rationale and Design of a Randomized Study (I-Padua). High Blood Press Cardiovasc Prev 2017; 24:167-170. [DOI: 10.1007/s40292-017-0192-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 03/09/2017] [Indexed: 11/29/2022] Open
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Clinical validation for the aldosterone-to-renin ratio and aldosterone suppression testing using simultaneous fully automated chemiluminescence immunoassays. J Hypertens 2016; 33:2500-11. [PMID: 26372319 DOI: 10.1097/hjh.0000000000000727] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND As larger numbers of hypertensive patients are screened for primary aldosteronism with the aldosterone-to-renin ratio (ARR), automated analyzers present a practical solution for many laboratories. We report the method-specific ARR cutoff determined with direct, automated chemiluminescence immunoassays allowing the simultaneous measurement of plasma aldosterone concentrations (PACs) and plasma renin concentrations (PRCs). METHODS Method comparisons to commonly employed assays and tandem mass spectrometry were undertaken. Patients were previously diagnosed based on the local ARR cutoff of 1.2 (ng/dl)/(μIU/ml) in samples collected in upright seated position. Lack of aldosterone suppression in response to salt load to less than 5 ng/dl confirmed primary aldosteronism. For the new assays, the optimal ARR cutoff was established in 152 patients with essential hypertension, 93 with primary aldosteronism and 147 normotensive patients. Aldosterone suppression was assessed in 73 essential hypertensive and 46 primary aldosteronism patients. RESULTS PAC and PRC were significantly correlated to values determined with currently available methods (P < 0.001). In patients with primary aldosteronism, patients with essential hypertension and controls, mean (95% confidence interval) PAC was 28.4 (25.4-31.8), 6.4 (5.9-6.9) and 6.2 (5.6-6.9) ng/dl, respectively. In the same groups, PRC was 6.6 (5.6-7.7), 12.9 (11.2-14.8) and 26.5 (22.2-31.5) μIU/ml. An ARR cutoff of 1.12 provided 98.9% sensitivity and 78.9% specificity. Employing the new assay aldosterone suppression confirmed the diagnosis of primary aldosteronism and essential hypertension using the cutoff of 5 ng/dl. CONCLUSION Our data demonstrate that the new assays present a convenient alternative for the measurement of PAC and PRC on a single automated analyzer. Availability of these simultaneous assays should facilitate screening and diagnosis of primary aldosteronism.
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Tabuchi Y, Otsuki M, Kasayama S, Kosugi K, Hashimoto K, Yamamoto T, Tsugawa M, Mineo I, Yamada Y, Kurebayashi S, Ohashi M, Umayahara Y, Kouhara H, Nakamura T, Taki H, Matsuoka TA, Imagawa A, Funahashi T, Shimomura I. Clinical and endocrinological characteristics of adrenal incidentaloma in Osaka region, Japan. Endocr J 2016; 63:29-35. [PMID: 26490049 DOI: 10.1507/endocrj.ej15-0404] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The aim of this study was to investigate the clinical and endocrinological characteristics of adrenal incidentalomas in Osaka region, Japan. The study was a multicenter retrospective analysis of 150 patients with adrenal incidentalomas who underwent radiographic and endocrine evaluations between 2005 and 2013. Most adrenal incidentalomas were discovered by computed tomography (77.0%) and the rest were identified by abdominal ultrasonography (14.6%), magnetic resonance imaging (4.2%), or positron emission tomography (4.2%). Adrenal incidentalomas were more frequently localized on the left side than on the right. The average diameter of tumors was 21 ± 11 mm. On endocrinological evaluation, 14 patients were diagnosed with primary aldosteronism (9.3%), 10 with subclinical Cushing's syndrome (6.7%), 7 with pheochromocytoma (4.7%), 7 with Cushing's syndrome (4.7%), 2 with both subclinical Cushing's syndrome and primary aldosteronism (1.3%), and 110 with non-functioning tumors (73.3%). Patients with functioning tumors were significantly younger and had larger tumor diameters than those with non-functioning tumors. Except for hypertension, complications were comparable between patients with functioning and non-functioning tumors, including the presence of glucose intolerance, cardiovascular disease, and dyslipidemia. In conclusion, a higher prevalence of primary aldosteronism was observed compared with a previous report. Complications were comparable between patients with functioning and non-functioning tumors, including the frequencies of glucose intolerance, cardiovascular disease, and dyslipidemia. Long-term follow-up is required in patients with non-functioning tumors because the frequency of complications, such as glucose intolerance, cardiovascular disease, and dyslipidemia, was equal to that in patients with functioning tumors.
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Affiliation(s)
- Yukiko Tabuchi
- Departments of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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Leal Reyna M, Gómez RM, Lupi SN, Belli SH, Fenili CA, Martínez MS, Ruibal GF, Rossi MA, Chervin RA, Cornaló D, Contreras LN, Costa L, Nofal MT, Damilano SA, Pardes EM. Screening for primary aldosteronism in an argentinian population: a multicenter prospective study. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2015. [PMID: 26222233 DOI: 10.1590/2359-3997000000075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Primary aldosteronism (PA) is characterized by the autonomous overproduction of aldosterone. Its prevalence has increased since the use of the aldosterone (ALD)/plasma renin activity (PRA) ratio (ARR). The objective of this study is to determine ARR and ARC (ALD/plasma renin concentration ratio) cut-off values (COV) and their diagnostic concordance (DC%) in the screening for PA in an Argentinian population.Design multicenter prospective study. SUBJECTS AND METHODS We studied 353 subjects (104 controls and 249 hypertensive patients). Serum aldosterone, PRA and ARR were determined. In 220 randomly selected subjects, 160 hypertensive patients and 60 controls, plasma renin concentration (PRC) was simultaneously measured and ARC was determined. RESULTS According to the 95th percentile of controls, we determined a COV of 36 for ARR and 2.39 for ARC, with ALD ≥ 15 ng/dL. In 31/249 hypertensive patients, ARR was ≥ 36. PA diagnosis was established in 8/31 patients (23/31 patients did not complete confirmatory tests). DC% between ARR and ARC was calculated. A significant correlation between ARR and ARC (r = 0.742; p < 0.0001) was found only with PRA > 0.3 ng/mL/h and PRC > 5 pg/mL. DC% for ARR and ARC above or below 36 and 2.39 was 79.1%, respectively. CONCLUSION This first Argentinian multicenter study determined a COV of 36 for ARR and 2.39 for ARC. Applying an ARR ≥ 36 in the hypertensive group, we confirmed PA in a higher percentage of patients than the previously reported one in our population. As for ARC, further studies are needed for its clinical application, since DC% is acceptable only for medium range renin values.
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Affiliation(s)
| | - Reynaldo M Gómez
- Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | | | | | | | | | | | - María A Rossi
- Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - Raúl A Chervin
- Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
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Piaditis G, Markou A, Papanastasiou L, Androulakis II, Kaltsas G. Progress in aldosteronism: a review of the prevalence of primary aldosteronism in pre-hypertension and hypertension. Eur J Endocrinol 2015; 172:R191-203. [PMID: 25538205 DOI: 10.1530/eje-14-0537] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Primary aldosteronism (PA) secondary to excessive and/or autonomous aldosterone secretion from the renin-angiotensin system accounts for ∼10% of cases of hypertension and is primarily caused by bilateral adrenal hyperplasia (BAH) or aldosterone-producing adenomas (APAs). Although the diagnosis has traditionally been supported by low serum potassium levels, normokalaemic and even normotensive forms of PA have been identified expanding further the clinical phenotype. Moreover, recent evidence has shown that serum aldosterone correlates with increased blood pressure (BP) in the general population and even moderately raised aldosterone levels are linked to increased cardiovascular morbidity and mortality. In addition, aldosterone antagonists are effective in BP control even in patients without evidence of dysregulated aldosterone secretion. These findings indicate a higher prevalence of aldosterone excess among hypertensive patients than previously considered that could be attributed to disease heterogeneity, aldosterone level fluctuations related to an ACTH effect or inadequate sensitivity of current diagnostic means to identify apparent aldosterone excess. In addition, functioning aberrant receptors expressed in the adrenal tissue have been found in a subset of PA cases that could also be related to its pathogenesis. Recently a number of specific genetic alterations, mainly involving ion homeostasis across the membrane of zona glomerulosa, have been detected in ∼50% of patients with APAs. Although specific genotype/phenotype correlations have not been clearly identified, differential expression of these genetic alterations could also account for the wide clinical phenotype, variations in disease prevalence and performance of diagnostic tests. In the present review, we critically analyse the current means used to diagnose PA along with the role that ACTH, aberrant receptor expression and genetic alterations may exert, and provide evidence for an increased prevalence of aldosterone dysregulation in patients with essential hypertension and pre-hypertension.
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Affiliation(s)
- George Piaditis
- Department of Endocrinology and Diabetes CenterG. Gennimatas Hospital, 154 Mesogion Avenue, 11527 Holargos, Athens, Greece andDepartment of PathophysiologyNational University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Athina Markou
- Department of Endocrinology and Diabetes CenterG. Gennimatas Hospital, 154 Mesogion Avenue, 11527 Holargos, Athens, Greece andDepartment of PathophysiologyNational University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Labrini Papanastasiou
- Department of Endocrinology and Diabetes CenterG. Gennimatas Hospital, 154 Mesogion Avenue, 11527 Holargos, Athens, Greece andDepartment of PathophysiologyNational University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Ioannis I Androulakis
- Department of Endocrinology and Diabetes CenterG. Gennimatas Hospital, 154 Mesogion Avenue, 11527 Holargos, Athens, Greece andDepartment of PathophysiologyNational University of Athens, Mikras Asias 75, 11527 Athens, Greece Department of Endocrinology and Diabetes CenterG. Gennimatas Hospital, 154 Mesogion Avenue, 11527 Holargos, Athens, Greece andDepartment of PathophysiologyNational University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Gregory Kaltsas
- Department of Endocrinology and Diabetes CenterG. Gennimatas Hospital, 154 Mesogion Avenue, 11527 Holargos, Athens, Greece andDepartment of PathophysiologyNational University of Athens, Mikras Asias 75, 11527 Athens, Greece
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Luo Q, Li NF, Yao XG, Zhang DL, Abulikemu SFY, Chang GJ, Zhou KM, Wang GL, Wang MH, Ouyang WJ, Cheng QY, Jia Y. Potential effects of age on screening for primary aldosteronism. J Hum Hypertens 2015; 30:53-61. [DOI: 10.1038/jhh.2015.21] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 01/26/2015] [Accepted: 02/17/2015] [Indexed: 11/09/2022]
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Rye P, Chin A, Pasieka J, So B, Harvey A, Kline G. Unadjusted Plasma Renin Activity as a "First-Look" Test to Decide Upon Further Investigations for Primary Aldosteronism. J Clin Hypertens (Greenwich) 2015; 17:541-6. [PMID: 25756935 DOI: 10.1111/jch.12523] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 12/19/2014] [Accepted: 12/20/2014] [Indexed: 11/27/2022]
Abstract
The authors sought to define the 95th percentile of plasma renin activity (PRA) in a sample of patients with confirmed primary aldosteronism (PA) prior to adjustment of medications as a practical "first-look" test to identify those with very low ultimate likelihood of having PA. The aldosterone to renin ratio (ARR) was measured without adjustment of antihypertensive medications, with further workup as appropriate. Two groups were defined: patients with surgically "confirmed PA" (n=58) and patients with "high-probability PA" (n=59), defined as having any of the following: computed tomography-confirmed adrenal adenoma plus lateralizing adrenal vein sampling (AVS) without surgery, high ARR and hypokalemia but nonlateralizing AVS, or ARR more than four times the upper limit of normal. The PRA 95th percentile was 1.0 ng/mL/h. All outliers had hypokalemia and two had adrenal adenomas. There was no difference between the confirmed and high probability groups. In the absence of highly suspicious clinical features, patients with unadjusted PRA >1.0 ng/mL/h do not warrant further investigation for PA.
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Affiliation(s)
- Peter Rye
- Department of Medicine, University of Calgary, Calgary, AB
| | - Alex Chin
- Calgary Laboratory Services, Department of Pathology and Laboratory Medicine, Section of Clinical Biochemistry, University of Calgary, Calgary, AB
| | - Janice Pasieka
- Department of Surgery, University of Calgary, Calgary, AB
| | - Benny So
- Department of Radiology, University of Calgary, Calgary, AB
| | - Adrian Harvey
- Department of Surgery, University of Calgary, Calgary, AB
| | - Gregory Kline
- Interim Division Head of Endocrinology, University of Calgary, Calgary, AB
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Nakama C, Kamide K, Kawai T, Hongyo K, Ito N, Onishi M, Takeya Y, Yamamoto K, Sugimoto K, Rakugi H. The influence of aging on the diagnosis of primary aldosteronism. Hypertens Res 2014; 37:1062-7. [DOI: 10.1038/hr.2014.129] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 06/27/2014] [Accepted: 07/07/2014] [Indexed: 11/09/2022]
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Glinicki P, Jeske W, Bednarek-Papierska L, Kruszyńska A, Gietka-Czernel M, Rosłonowska E, Słowińska-Srzednicka J, Kasperlik-Załuska A, Zgliczyński W. The ratios of aldosterone / plasma renin activity (ARR) versus aldosterone / direct renin concentration (ADRR). J Renin Angiotensin Aldosterone Syst 2014; 16:1298-305. [PMID: 25143328 DOI: 10.1177/1470320313519487] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Primary aldosteronism (PA) is estimated to occur in 5-12% of patients with hypertension. Assessment of aldosterone / plasma renin activity (PRA) ratio (ARR) has been used as a screening test in patients suspected of PA. Direct determination of renin (DRC) and calculation of aldosterone / direct renin concentration ratio (ADRR) could be similarly useful for screening patients suspected of PA. The study included 62 patients with indication for evaluation of the renin-angiotensin-aldosterone system and 35 healthy volunteers. In all participants we measured concentrations of serum aldosterone, plasma direct renin, and PRA after a night's rest and again after walking for two hours. The concentrations of aldosterone, direct renin, and PRA were measured by isotopic methods (radioimmunoassay (RIA) / immunoradiometric assay (IRMA)). Correlations of ARR with ADRR in the supine position were r = 0.9162, r(2) = 0.8165 (p < 0.01); and in the up-right position were r = 0.7765, r(2) = 0.9153 (p < 0.01). The cut-off values of ARR and ADRR ≥ 100 presented highest specificity (99%) for the diagnosis of PA; however, quite acceptable specificity and sensitivity (> 80% and 100%, respectively) appeared for the ratios ≥ 30. We suggest that for practical and economic reasons ARR can be replaced by ADRR.
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Affiliation(s)
- Piotr Glinicki
- Department of Endocrinology, The Centre of Postgraduate Medical Education, Poland
| | - Wojciech Jeske
- Department of Endocrinology, The Centre of Postgraduate Medical Education, Poland
| | | | | | | | - Elżbieta Rosłonowska
- Department of Endocrinology, The Centre of Postgraduate Medical Education, Poland
| | | | | | - Wojciech Zgliczyński
- Department of Endocrinology, The Centre of Postgraduate Medical Education, Poland
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Pizzolo F, Zorzi F, Chiecchi L, Consoli L, Aprili I, Guarini P, Castagna A, Salvagno GL, Pavan C, Olivieri O. NT-proBNP, a useful tool in hypertensive patients undergoing a diagnostic evaluation for primary aldosteronism. Endocrine 2014; 45:479-86. [PMID: 23943252 DOI: 10.1007/s12020-013-0028-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/30/2013] [Indexed: 11/24/2022]
Abstract
Primary aldosteronism (PA) is the most frequent form of secondary hypertension, but diagnostic tools for this disease still lack optimal accuracy. The heart is one important target tissue for damage due to excess aldosterone, and the role of natriuretic peptides is well recognized in diagnosing heart failure. We hypothesized that measuring the NT-proBNP could improve the diagnostic evaluation of PA. We enrolled 132 hypertensive patients, who underwent aldosterone to renin ratio (ARR) screening, and 81 underwent an intravenous saline loading test (ivSLT) because of a high ARR. The NT-proBNP level positively correlated with the ARR and inversely correlated with the renin level. The NT-proBNP level was higher in patients with a high ARR than in those with a low ARR and higher in patients with a positive ivSLT than in those with a negative ivSLT. After logistic regression analysis, an NT-proBNP value above the median and male gender were predictors of a positive ivSLT. The proportion of patients with a positive ivSLT ranged from only 23 % in females with a low NT-proBNP to 93 % in males with a high NT-proBNP. NT-proBNP and gender are predictors of a positive PA confirmatory test. These findings highlight the possibility of using NT-proBNP to identify which patients with a high ARR should receive a complete PA diagnostic evaluation.
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Affiliation(s)
- Francesca Pizzolo
- Division of Internal Medicine, Department of Medicine, University of Verona, pzz.le Scuro, 37134, Verona, Italy,
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Lu CC, Wu VC, Wu KD, Liu KL, Lin WC, Cheng MF, Tzen KY, Yen RF. Prognostic value of semiquantification NP-59 SPECT/CT in primary aldosteronism patients after adrenalectomy. Eur J Nucl Med Mol Imaging 2014; 41:1375-84. [PMID: 24525587 DOI: 10.1007/s00259-014-2692-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 01/02/2014] [Indexed: 01/02/2023]
Abstract
PURPOSE Primary aldosteronism (PA), characterized by an excessive production of aldosterone, affects 5-13 % of patients with hypertension. Accurate strategies are needed for the timely diagnosis of PA to allow curability and prevention of excessive cardiovascular events and related damage. This study aimed to evaluate the usefulness of semiquantification of (131)I-6β-iodomethyl-norcholesterol (NP-59) single photon emission computed tomography (SPECT)/CT in differentiating aldosterone-producing adenoma (APA) from idiopathic adrenal hyperplasia (IAH) and in predicting clinical outcomes after adrenalectomy. METHODS We retrospectively reviewed 49 PA patients who had undergone adrenalectomy after NP-59 SPECT/CT within 1 year. A conventional visual scale (VS) and two semiquantitative parameters generated from SPECT/CT, adrenal to liver ratio (ALR) and lesion to contralateral ratio of bilateral adrenal glands (CON), with cutoff values calculated by receiver-operating characteristic (ROC) analysis, were compared with pathology results and postsurgical outcomes to determine the accuracy. RESULTS An ALR cutoff of 1.84 and a CON cutoff of 1.15 showed an ability to distinguish adenoma from hyperplasia similar to VS (p = 0.2592 and 0.1908, respectively). An ALR cutoff of 2.28 and a CON cutoff of 1.11 yielded the highest sensitivity and specificity to predict postsurgical outcomes, and an ALR of 2.28 had an ability superior to VS (p = 0.0215), while a CON of 1.11 did not (p = 0.1015). Patients with either ALR or CON greater than the cutoff had a high probability of positive postsurgical outcomes (n = 36/38), while patients with both ALR and CON less than the cutoff had a low probability of positive postsurgical outcomes (n = 2/11). CONCLUSION Semiquantification of NP-59 scintigraphy has an ability similar to VS in differentiating APA from IAH, but an excellent ability to predict postsurgical outcomes of adrenalectomy. An ALR or CON greater than the cutoff strongly suggests benefits from adrenalectomy, and both ALR and CON less than the cutoff implies a reduced chance of improvement in postsurgical outcome.
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Affiliation(s)
- Ching-Chu Lu
- Department of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, 7 Chung-Shan South Road, Taipei, Taiwan, 100,
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Wu VC, Wu CK, Chang YC, Young GH, Chen SC, Yang WS, Chen CY, Wang WJ, Lin CY, Lin YH, Lin SL, Chueh SC, Wu KD. Association of the variations in the HSD3β gene with primary aldosteronism. J Hypertens 2014; 31:1396-405; discussion 1405. [PMID: 24006038 DOI: 10.1097/hjh.0b013e328360ef3c] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In mice, a lack of cryptochrome results in up-regulation of aldosterone production due to high expression of the 3β-hydroxysteroid dehydrogenases (HSD3β) gene. The HSD3β pathway might play a pivotal role in aldosterone synthesis. This study aimed to determine the association of HSD3β and HSD3β2 gene variations with primary aldosteronism in a Taiwanese population. METHOD In this case-control cohort, 688 consecutive ethnically matched unrelated individuals including 362 primary aldosteronism and 326 essential hypertension cases were recruited. Nineteen tag single-nucleotide polymorphisms (SNPs) across HSD3β1, HSD3β2, and CYP11β2 were genotyped. Expression of HSD3β mRNA and immunohistochemical stain of HSD3β in the specimens of aldosterone-producing adenoma (APA) was compared with that in nonfunctional incidentaloma. RESULTS The SNPs of rs12410453 A allele in HSD3β2 gene [odds ratio (OR) 1.92, 95% confidence interval (CI) 1.13-3.32, P=0.018] and rs6203 C allele in the HSD3β1 gene (OR 2.21, 95% CI 1.28-3.95, P=0.006) showed significant association with primary aldosteronism, with corresponding population attributable risk of 6.7 and 30.7%, respectively. Primary aldosteronism patients of non-CC in rs6203 and non-GA in rs12401453 had lower plasma aldosterone-to-renin ratio. A haplotype in a linkage disequilibrium block containing rs6203 associated significantly with serum potassium level (OR 1.24, 95% CI 1.02-1.24, P=0.026). The expressions of HSD3β1 mRNA, HSD3β2 mRNA and HSD3β protein were increased in APA, as compared to incidentaloma. CONCLUSION Risk-conferring genetic variations in the HSD3β gene influenced susceptibility of primary aldosteronism. Concomitant presence of rs6203 CC and rs12410453 GA genotypes synergistically increased aldosterone-to-renin ratio.
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Affiliation(s)
- Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Olivieri O, Cecconi D, Castagna A, Chiecchi L, Guarini P, Gunasekaran M, Morandini F, Brazzarola P, Zolla L, D'Alessandro A, Veglio F, Mulatero P, Pizzolo F. Urinary protease inhibitor Serpin B3 is higher in women and is further increased in female patients affected by aldosterone producing adenoma. MOLECULAR BIOSYSTEMS 2014; 10:1281-9. [DOI: 10.1039/c3mb70538b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Derlet F, Lepoutre T, Gruson D. Aldosterone testing: evaluation of a novel automated immunoassay. Biomarkers 2013; 19:86-91. [DOI: 10.3109/1354750x.2013.865276] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Rossi GP, Auchus RJ, Brown M, Lenders JWM, Naruse M, Plouin PF, Satoh F, Young WF. An expert consensus statement on use of adrenal vein sampling for the subtyping of primary aldosteronism. Hypertension 2013; 63:151-60. [PMID: 24218436 DOI: 10.1161/hypertensionaha.113.02097] [Citation(s) in RCA: 384] [Impact Index Per Article: 34.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Adrenal venous sampling is recommended by current guidelines to identify surgically curable causes of hyperaldosteronism but remains markedly underused. Key factors contributing to the poor use of adrenal venous sampling include the prevailing perceptions that it is a technically challenging procedure, difficult to interpret, and can be complicated by adrenal vein rupture. In addition, the lack of uniformly accepted standards for the performance of adrenal venous sampling contributes to its limited use. Hence, an international panel of experts working at major referral centers was assembled to provide updated advice on how to perform and interpret adrenal venous sampling. To this end, they were asked to use the PICO (Patient or Problem, Intervention, Control or comparison, Outcome) strategy to gather relevant information from the literature and to rely on their own experience. The level of evidence/recommendation was provided according to American Heart Association gradings whenever possible. A consensus was reached on several key issues, including the selection and preparation of the patients for adrenal venous sampling, the procedure for its optimal performance, and the interpretation of its results for diagnostic purposes even in the most challenging cases.
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Affiliation(s)
- Gian Paolo Rossi
- Department of Medicine-DIMED-Internal Medicine 4, University Hospital, Via Giustiniani, 2, 35126 Padova, Italy.
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Galati SJ, Hopkins SM, Cheesman KC, Zhuk RA, Levine AC. Primary aldosteronism: emerging trends. Trends Endocrinol Metab 2013; 24:421-30. [PMID: 23796656 DOI: 10.1016/j.tem.2013.05.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 05/15/2013] [Accepted: 05/16/2013] [Indexed: 01/07/2023]
Abstract
Primary aldosteronism (PA) is the most common etiology of endocrine hypertension (HTN), and recent prevalence studies suggest that it may be under-diagnosed. Indications for screening have been expanded with recognition that many patients with PA do not have hypokalemia and that the disease may be familial. The aldosterone:renin ratio (ARR) is the preferred screening test for PA. The ARR can be interpreted in patients on most anti-hypertensive agents, and can be used to guide medical therapy of HTN even in patients without PA. Once PA is confirmed, adrenal venous sampling (AVS) should be performed to determine if PA is due to bilateral disease or a unilateral adenoma, if surgery is being considered. Targeted medical or surgical therapy improves patient outcomes.
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Affiliation(s)
- Sandi-Jo Galati
- Division of Endocrinology, Metabolism and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, Adrenal Center at Mount Sinai Hospital, 1 Gustave L. Levy Place, #1055, New York, NY 10029, USA
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Chao CT, Wu VC, Kuo CC, Lin YH, Chang CC, Chueh SJ, Wu KD, Pimenta E, Stowasser M. Diagnosis and management of primary aldosteronism: an updated review. Ann Med 2013; 45:375-83. [PMID: 23701121 DOI: 10.3109/07853890.2013.785234] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Primary aldosteronism (PA) is the most common secondary form of arterial hypertension, with a particularly high prevalence among patients with resistant hypertension. Aldosterone has been found to be associated with cardiovascular toxicity. Prolonged aldosteronism leads to higher incidence of cardiac events, glomerular hyperfiltration, and potentially bone/metabolic sequels. The wider application of aldosterone/renin ratio as screening test has substantially contributed to increasing diagnosis of PA. Diagnosis of PA consists of two phases: screening and confirmatory testing. Adrenal imaging is often inaccurate for differentiation between an adenoma and hyperplasia, and adrenal venous sampling is essential for selecting the appropriate treatment modality. The etiologies of PA have two main subtypes: unilateral (aldosterone-producing adenoma) and bilateral (micro- or macronodular hyperplasia). Aldosterone-producing adenoma is typically managed with unilateral adrenalectomy, while bilateral adrenal hyperplasia is amenable to pharmacological approaches using mineralocorticoid antagonists. Short-term treatment outcome following surgery is determined by factors such as preoperative blood pressure level and hypertension duration, but evidence regarding long-term treatment outcome is still lacking. However, directed treatments comprising of unilateral adrenalectomy or mineralocorticoid antagonists still potentially reduce the toxicities of aldosterone. Utilizing a physician-centered approach, we intend to provide up-dated information on the etiology, diagnosis, and the management of PA.
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Yin G, Zhang S, Yan L, Wu M, Xu M, Li F, Cheng H. Effect of age on aldosterone/renin ratio (ARR) and comparison of screening accuracy of ARR plus elevated serum aldosterone concentration for primary aldosteronism screening in different age groups. Endocrine 2012; 42:182-9. [PMID: 22302679 DOI: 10.1007/s12020-012-9609-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 01/15/2012] [Indexed: 02/05/2023]
Abstract
The serum aldosterone concentration (SAC)/plasma renin activity (PRA) ratio (ARR) is considered a useful screening test in the differential diagnosis of essential hypertension (EH) and primary aldosteronism (PA). The purpose of this study is to investigate the effect of age on ARR and compare the screening accuracy of ARR plus elevated SAC for PA screening in different age groups. Thirty-nine patients with PA, 274 patients with EH, and 153 healthy volunteers were recruited. Blood was sampled for SAC and PRA measuring under keeping upright posture for 1 h. Levels of SAC, PRA, and ARR were compared at different ages range for the respective three groups of subjects. The screening accuracy of ARR plus elevated SAC was compared in different age groups and PA patients served as the same positive subjects. In the EH group, logarithmically transformed ARR (Log-ARR) increased with advancing age and reached its peak in the ≥ 60 years group; in the normotensives group, Log-ARR reached its peak in the 40-49 years group and slightly declined with advancing age. In the PA group, Log-ARR was not age dependent. Screening accuracy increased when combined index of ARR and SAC was used in the ≥ 40 years group but not in the <40 years group. Although the number of EH patients with elevated ARR increased with advancing age, but the screening accuracy and cutoff values of ARR were not affected by age. Using the combined index of ARR and SAC increased the screening accuracy for the patients older than 40 years, but not necessary for the patients younger than 40 years.
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Affiliation(s)
- Guoshu Yin
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Shantou University Medical College, Shantou, 515041, Guangdong Province, China
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Ye D, Dong F, Lu X, Zhang Z, Feng Y, Li C. Analysis of various etiologies of hypertension in patients hospitalized in the endocrinology division. Endocrine 2012; 42:174-81. [PMID: 22212439 DOI: 10.1007/s12020-011-9588-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 12/03/2011] [Indexed: 10/14/2022]
Abstract
This research aimed to analyze the clinical data of various etiologies of hypertension in patients hospitalized in the Endocrinology Division. The differences between essential and secondary hypertension were examined to provide a basis for clinical differential diagnosis. The data from all the inpatients with hypertension of unknown origin admitted in the Endocrinology Division of the First Affiliated Hospital of the Zhejiang University School of Medicine from January 2001 to May 2011 were reviewed. The patients were classified into either essential or secondary hypertensive groups. The differentiating parameters of these forms of hypertension were analyzed using the one-factor and multi-factor logistic regression analysis. A total of 1,001 cases were selected in which 346 cases (34.6%) were essential hypertensive and 655 cases (65.4%) were secondary hypertensive. Adrenal hypertension was the primary cause of secondary hypertension, followed by renal artery, central, psychogenic, and renal hypertension as well as others that have not been classified systematically. Using one-factor analysis, significant differences were found among duration of hypertension, age, the onset age, family history of hypertension, diastolic pressure on admission, Cushing syndrome, body mass index (BMI), urine protein, serum creatinine, orthostatic aldosterone, ratio of orthostatic aldosterone to renin activity, incidence of fatty liver displayed by type-B ultrasound, and computed tomography adrenal masses incidence (P < 0.05). Multi-factor regression analysis showed that family history of hypertension (OR = 7.196) and BMI above the normal range (OR = 15.124) were the independent factors that predicted essential hypertension, but failed to determine any other valid predictors of secondary causes except adrenal masses (OR = 10.114), orthostatic aldosterone value >200 pg/ml (OR = 9.742), and a ratio of orthostatic aldosterone and renin activity >40 (OR = 4.723).
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Affiliation(s)
- Dan Ye
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Medical School of Zhejiang University, 79, Qingchun Road, Hangzhou, Zhejiang, China.
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Satoh M, Kikuya M, Ohkubo T, Mori T, Metoki H, Hara A, Utsugi MT, Hashimoto T, Hirose T, Obara T, Inoue R, Asayama K, Kanno A, Totsune K, Hoshi H, Satoh H, Imai Y. Aldosterone-to-renin ratio as a predictor of stroke under conditions of high sodium intake: the Ohasama study. Am J Hypertens 2012; 25:777-83. [PMID: 22476023 DOI: 10.1038/ajh.2012.33] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Aldosterone is thought to have deleterious effects on the cardiovascular system. The aldosterone-to-renin ratio (ARR) is more reproducible than aldosterone levels alone and could be an index for inappropriate aldosterone secretion or activity. We previously reported the apparent relation between ARR and hypertension in subjects with high sodium intake. This prospective study investigated the risk of ARR for a first stroke in a general population stratified by sodium intake. METHODS We obtained plasma renin activity (PRA) and plasma aldosterone concentrations (PAC) for 883 participants aged ≥ 35 years not receiving antihypertensive treatment in the general population of Ohasama (mean age: 59.0 ± 11.3 years; 65.6% women). RESULTS Over a mean of 10.9 follow-up years, 45 strokes occurred. The median PRA, PAC, and ARR were 1.2 ng/ml/h, 6.4 ng/dl, and 5.3 ng/dl per ng/ml/h, respectively. Using Cox regression, we computed hazard ratios adjusted for sex, age, body mass index (BMI), and systolic blood pressure. No association between logARR and stroke was observed in subjects overall. However, in subjects with high sodium intake (≥ median of 4,058 mg/day (salt equivalent, 10.5 g/day)), each 1 s.d. increase in logARR was associated with an increased hazard ratio for stroke (hazard ratio: 1.49, P = 0.04). No significant association was observed in subjects with low sodium intake (P = 0.7). When we repeated all the analyses using logPRA or logPAC, no significant associations were found. CONCLUSION These results suggest that high ARR, that is, relative aldosterone excess, is a predictor for stroke under conditions of high sodium intake.
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Hannemann A, Bidlingmaier M, Friedrich N, Manolopoulou J, Spyroglou A, Völzke H, Beuschlein F, Seissler J, Rettig R, Felix SB, Biffar R, Döring A, Meisinger C, Peters A, Wichmann HE, Nauck M, Wallaschofski H, Reincke M. Screening for primary aldosteronism in hypertensive subjects: results from two German epidemiological studies. Eur J Endocrinol 2012; 167:7-15. [PMID: 22495491 DOI: 10.1530/eje-11-1013] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The prevalence of primary aldosteronism in unselected hypertensive patients is currently unknown. We investigated the frequency of positive screening results for primary aldosteronism based on the aldosterone-to-renin ratio (ARR) in hypertensive subjects aged 30-79 years from two German epidemiological studies. We further examined the frequency of positive screening results in subjects with resistant hypertension or stage III hypertension and assessed possible disparities between untreated and treated hypertensive subjects. METHODS Data were obtained from the first follow-ups of the population-based study of health in Pomerania (SHIP; n=1392) and the cooperative health research in the region of Augsburg (KORA; n=1052). Study-specific reference ranges for plasma aldosterone concentration (PAC), plasma renin concentration (PRC) and the ARR were applied. Confirmation tests for primary aldosteronism were not performed in these epidemiological studies.Three definitions for a positive screening for primary aldosteronism were applied: A) increased ARR; B) increased ARR and decreased PRC; and C) increased ARR and increased PAC and decreased PRC. RESULTS The frequency of positive screening results was 7.0, 3.8 and 0.2% according to definitions A-C respectively. In the subgroups of subjects with resistant hypertension (11.9, 5.5 and 0.9%) or stage III hypertension (18.3, 14.0 and 1.1%), these frequencies were markedly higher than those in the general hypertensive population. There was no difference in the frequency of positive screening results between the treated and untreated hypertensive subjects. CONCLUSIONS A maximum of 7.0% of the hypertensive population in Germany shows a positive screening result for primary aldosteronism. Thus, primary aldosteronism may be less frequent than previously expected based on data from referred hypertensive patients.
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Affiliation(s)
- A Hannemann
- Institute of Clinical Chemistry and Laboratory Medicine, Ernst-Moritz-Arndt-University Greifswald, Ferdinand-Sauerbruch-Strasse, D-17475 Greifswald, Germany.
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Mulatero P, di Cella SM, Monticone S, Schiavone D, Manzo M, Mengozzi G, Rabbia F, Terzolo M, Gomez-Sanchez EP, Gomez-Sanchez CE, Veglio F. 18-hydroxycorticosterone, 18-hydroxycortisol, and 18-oxocortisol in the diagnosis of primary aldosteronism and its subtypes. J Clin Endocrinol Metab 2012; 97:881-9. [PMID: 22238407 DOI: 10.1210/jc.2011-2384] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Diagnosis of primary aldosteronism (PA) is made by screening, confirmation testing, and subtype diagnosis (computed tomography scan and adrenal vein sampling). However, some tests are costly and unavailable in most hospitals. OBJECTIVE The aim of the study was to evaluate the role of serum 18-hydroxycorticosterone (s18OHB), urinary and serum 18-hydroxycortisol (u- and s18OHF), and urinary and serum 18-oxocortisol (u- and s18oxoF) in the diagnosis of PA and its subtypes, aldosterone-producing adenoma (APA) and bilateral adrenal hyperplasia (BAH). PATIENTS The study included 62 patients with low-renin essential hypertension (EH), 81 patients with PA (20 APA, 61 BAH), 24 patients with glucocorticoid-remediable aldosteronism, 16 patients with adrenal incidentaloma, and 30 normotensives. INTERVENTION AND MAIN OUTCOME MEASURES We measured s18OHB, s18OHF, and s18oxoF before and after saline load test (SLT) and 24-h u18OHF and u18oxoF. RESULTS PA patients displayed significantly higher levels of s18OHB, u18OHF, and u18oxoF compared to EH and normal subjects; APA patients displayed s18OHB, u18OHF, and u18oxoF levels significantly higher than BAH patients. Similar results were obtained for s18OHF and s18oxoF. SLT significantly reduced s18OHB, s18OHF, and s18oxoF in all groups, but steroid reduction was much less for APA patients compared to BAH and EH. The s18OHB/aldosterone ratio after SLT more than doubled in EH but remained unchanged in APA patients. CONCLUSIONS u18OHF, u18oxoF, and s18OHB measurements in patients with a positive aldosterone/plasma renin activity ratio correlate with confirmatory tests and adrenal vein sampling in PA patients. If verified, these steroid assays would refine the diagnostic workup for PA.
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Affiliation(s)
- Paolo Mulatero
- Department of Medicine and Experimental Oncology, Division of Internal Medicine and Hypertension Unit, University of Torino, and Clinical Chemistry Laboratory, San Giovanni Battista University Hospital, Via Genova 3, 10126 Torino, Italy.
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Primary aldosteronism: changes in cystatin C-based kidney filtration, proteinuria, and renal duplex indices with treatment. J Hypertens 2011; 29:1778-86. [PMID: 21738054 DOI: 10.1097/hjh.0b013e3283495cbb] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To obtain information about the effect of prolonged aldosterone excess on kidney function. METHODS We determined kidney function changes defined by cystatin C-based estimations of glomerular filtration rate (CysC-GFR). Pretreatment proteinuria and intrarenal Doppler velocimetric indices in primary aldosteronism were examined and followed after adrenalectomy or spironolactone treatment. RESULTS This prospective, multicenter study included 130 primary aldosteronism patients (56 men; age, 49.9 ± 13.4 years: 100 with adenoma and 30 with idiopathic hyperaldosteronism) and 73 essential hypertension patients (36 men; age, 51.4 ± 14.8 years) as controls. Patients with primary aldosteronism had higher CysC-GFR (P < 0.05) and heavier proteinuria (0.042) than those with essential hypertension. With primary aldosteronism, a higher aldosterone-renin ratio (odds ratio, OR = 7.85, P = 0.008) was independently related to pretreatment CysC-GFR. The factors related to pretreatment proteinuria included CysC-GFR (OR, -0.006, P = 0.001), plasma aldosterone concentration (OR, 0.004, P = 0.002), and duration of hypertension (OR, 0.016, P = 0.032). Duration of hypertension was also independently correlated with the pretreatment resistive index among primary aldosteronism patients (OR, 0.004, P = 0.035). CysC-GFR (all, P < 0.05), proteinuria (P < 0.001), and resistive index (P < 0.001) decreased 1 year after adrenalectomy but not with spironolactone treatment. CONCLUSION Our data suggest that prolonged hyperaldosteronism will cause relative kidney hyperfiltration and reversible intrarenal vascular structural changes, which disguise the consequent renal injury, including declining GFR and proteinuria. Adrenalectomy and spironolactone treatment exert different clinical impacts toward kidney damage even with a similar blood pressure-lowering effect.
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