1
|
Yu CG, Cao B, Gong HL, Ke J, Xian SZ, Wu NN, Zhao D. Primary aldosteronism with postoperative elevation of aldosterone treated effectively by finerenone: A case report. J Clin Hypertens (Greenwich) 2024. [PMID: 39119826 DOI: 10.1111/jch.14877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 07/10/2024] [Accepted: 07/16/2024] [Indexed: 08/10/2024]
Abstract
The authors report a case of primary aldosteronism (PA) with postoperative elevation of aldosterone treated effectively by finerenone. The patient was a hypertensive man with a 30-year history of hypertension and sustained an acute myocardial infarction 5 years ago. Bilateral adrenal nodules with hyperplasia were detected and PA was confirmed. His blood potassium, direct renin concentration, and aldosterone level returned to normal after surgery of right adrenalectomy. However, 1 year after surgery, he experienced a decrease in blood potassium and an increase in aldosterone. A saline infusion test revealed an aldosterone level of 124.47 pg/mL. The patient consented to treatment with finerenone. His aldosterone and potassium levels and blood pressure have been controlled well during follow-up. This case highlights the need to screen for secondary hypertension as early as possible. Finerenone may be effective for patients with PA who are not candidates for surgery and those not relieved after surgery.
Collapse
Affiliation(s)
- Cai-Guo Yu
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Diabetes Research and Care, Capital Medical University, Beijing, China
| | - Bin Cao
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Diabetes Research and Care, Capital Medical University, Beijing, China
| | - Hao-Lin Gong
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Diabetes Research and Care, Capital Medical University, Beijing, China
| | - Jing Ke
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Diabetes Research and Care, Capital Medical University, Beijing, China
| | - Shao-Zhong Xian
- Department of Urology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Nan-Nan Wu
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Diabetes Research and Care, Capital Medical University, Beijing, China
| | - Dong Zhao
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Diabetes Research and Care, Capital Medical University, Beijing, China
| |
Collapse
|
2
|
Han M, Cao X, Zhang J, Yang X, Zhang Y, Liu Y. Association of Aldosterone, Renin, and Aldosterone to Renin Ratio with Metabolic Profile in Primary Aldosteronism. Diabetes Metab Syndr Obes 2024; 17:2065-2074. [PMID: 38778907 PMCID: PMC11110821 DOI: 10.2147/dmso.s457243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/23/2024] [Indexed: 05/25/2024] Open
Abstract
Purpose This study aimed to investigate the glycometabolism, fat mass, and lean mass in primary aldosteronism (PA) during disease progression. Patients and Methods Patients diagnosed with PA and healthy controls (HCs) were enrolled. A flash glucose monitoring system (FGMS) and dual-energy X-ray absorptiometry (DEXA) were used to measure glucose variability and glucose target rate along with fat mass and lean mass. Comparative analysis of FGMS- or DEXA-derived parameters along with correlation analyses between these parameters and PA progression were performed. Results Increased glucose variability and poor glucose target rate, along with an increased proportion of truncal fat mass, and decreased proportion of appendicular lean mass, were identified in PA group compared to those in HCs. Plasma aldosterone concentration was positively correlated with glucose variability and poor glucose target rate. Plasma renin concentration was positively correlated with the proportion of truncal fat mass and lean mass, and negatively correlated with the proportion of appendicular fat mass. Aldosterone-to-renin ratio was negatively correlated with the proportion of truncal fat mass and lean mass, and positively correlated with the proportion of appendicular fat mass. Conclusion Patients with PA presented significant differences in glycometabolism, fat mass, and lean mass compared with HCs, and these alterations correlated with PA progression.
Collapse
Affiliation(s)
- Minmin Han
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, 030000, People’s Republic of China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, 030000, People’s Republic of China
| | - Xiaoming Cao
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, 030000, People’s Republic of China
| | - Jian Zhang
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, 030000, People’s Republic of China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, 030000, People’s Republic of China
| | - Xifeng Yang
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, 030000, People’s Republic of China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, 030000, People’s Republic of China
| | - Yi Zhang
- Department of Pharmacology, Shanxi Medical University, Taiyuan, 030000, People’s Republic of China
- Medicinal Basic Research Innovation Center of Chronic Kidney Disease, Ministry of Education, Shanxi Medical University, Taiyuan, 030000, People’s Republic of China
| | - Yunfeng Liu
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, 030000, People’s Republic of China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, 030000, People’s Republic of China
| |
Collapse
|
3
|
Mullen N, Curneen J, Donlon PT, Prakash P, Bancos I, Gurnell M, Dennedy MC. Treating Primary Aldosteronism-Induced Hypertension: Novel Approaches and Future Outlooks. Endocr Rev 2024; 45:125-170. [PMID: 37556722 PMCID: PMC10765166 DOI: 10.1210/endrev/bnad026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 07/11/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023]
Abstract
Primary aldosteronism (PA) is the most common cause of secondary hypertension and is associated with increased morbidity and mortality when compared with blood pressure-matched cases of primary hypertension. Current limitations in patient care stem from delayed recognition of the condition, limited access to key diagnostic procedures, and lack of a definitive therapy option for nonsurgical candidates. However, several recent advances have the potential to address these barriers to optimal care. From a diagnostic perspective, machine-learning algorithms have shown promise in the prediction of PA subtypes, while the development of noninvasive alternatives to adrenal vein sampling (including molecular positron emission tomography imaging) has made accurate localization of functioning adrenal nodules possible. In parallel, more selective approaches to targeting the causative aldosterone-producing adrenal adenoma/nodule (APA/APN) have emerged with the advent of partial adrenalectomy or precision ablation. Additionally, the development of novel pharmacological agents may help to mitigate off-target effects of aldosterone and improve clinical efficacy and outcomes. Here, we consider how each of these innovations might change our approach to the patient with PA, to allow more tailored investigation and treatment plans, with corresponding improvement in clinical outcomes and resource utilization, for this highly prevalent disorder.
Collapse
Affiliation(s)
- Nathan Mullen
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| | - James Curneen
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| | - Padraig T Donlon
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| | - Punit Prakash
- Department of Electrical and Computer Engineering, Kansas State University, Manhattan, KS 66506, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Mark Gurnell
- Wellcome-MRC Institute of Metabolic Science, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK
| | - Michael C Dennedy
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| |
Collapse
|
4
|
Hundemer GL, Leung AA, Kline GA, Brown JM, Turcu AF, Vaidya A. Biomarkers to Guide Medical Therapy in Primary Aldosteronism. Endocr Rev 2024; 45:69-94. [PMID: 37439256 PMCID: PMC10765164 DOI: 10.1210/endrev/bnad024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/23/2023] [Accepted: 07/11/2023] [Indexed: 07/14/2023]
Abstract
Primary aldosteronism (PA) is an endocrinopathy characterized by dysregulated aldosterone production that occurs despite suppression of renin and angiotensin II, and that is non-suppressible by volume and sodium loading. The effectiveness of surgical adrenalectomy for patients with lateralizing PA is characterized by the attenuation of excess aldosterone production leading to blood pressure reduction, correction of hypokalemia, and increases in renin-biomarkers that collectively indicate a reversal of PA pathophysiology and restoration of normal physiology. Even though the vast majority of patients with PA will ultimately be treated medically rather than surgically, there is a lack of guidance on how to optimize medical therapy and on key metrics of success. Herein, we review the evidence justifying approaches to medical management of PA and biomarkers that reflect endocrine principles of restoring normal physiology. We review the current arsenal of medical therapies, including dietary sodium restriction, steroidal and nonsteroidal mineralocorticoid receptor antagonists, epithelial sodium channel inhibitors, and aldosterone synthase inhibitors. It is crucial that clinicians recognize that multimodal medical treatment for PA can be highly effective at reducing the risk for adverse cardiovascular and kidney outcomes when titrated with intention. The key biomarkers reflective of optimized medical therapy are unsurprisingly similar to the physiologic expectations following surgical adrenalectomy: control of blood pressure with the fewest number of antihypertensive agents, normalization of serum potassium without supplementation, and a rise in renin. Pragmatic approaches to achieve these objectives while mitigating adverse effects are reviewed.
Collapse
Affiliation(s)
- Gregory L Hundemer
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON K1H 8L6, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada
| | - Alexander A Leung
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Gregory A Kline
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
5
|
Parra Ramírez P, Martín Rojas-Marcos P, Paja Fano M, González-Boillos M, Pascual-Corrales E, García Cano AM, Ruiz-Sanchez JG, Vicente Delgado A, Gómez Hoyos E, Ferreira R, García Sanz I, Recasens Sala M, Barahona San Millan R, Picón César MJ, Díaz Guardiola P, Perdomo CM, Manjón-Miguélez L, Rebollo Román Á, Robles Lázaro C, Morales-Ruiz M, Calatayud M, Andree Furio Collao S, Meneses D, Sampedro-Nuñez MA, Mena Ribas E, Sanmartín Sánchez A, Gonzalvo Diaz C, Lamas C, Guerrero-Vázquez R, Del Castillo Tous M, Serrano Gotarredona J, Michalopoulou Alevras T, Tenés Rodrigo S, Roa Chamorro R, Jaen Aguila F, Moya Mateo EM, Hanzu FA, Araujo-Castro M. Renin as a Biomarker to Guide Medical Treatment in Primary Aldosteronism Patients. Findings from the SPAIN-ALDO Registry. High Blood Press Cardiovasc Prev 2024; 31:43-53. [PMID: 38225508 DOI: 10.1007/s40292-023-00618-w] [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: 10/28/2023] [Accepted: 12/12/2023] [Indexed: 01/17/2024] Open
Abstract
INTRODUCTION Primary aldosteronism (PA) is associated with several cardiometabolic comorbidities. Specific treatment by mineralocorticoid receptor antagonists (MRA) or adrenalectomy has been reported to reduce the cardiometabolic risk. However, the cardiovascular benefit could depend on plasma renin levels in patients on MRA. AIM To compare the development of cardiovascular, renal and metabolic complications between medically treated patients with PA and those who underwent adrenalectomy, taking the renin status during MRA treatment into account. METHODS A multicenter retrospective study (SPAIN-ALDO Register) of patients with PA treated at 35 Spanish tertiary hospitals. Patients on MRA were divided into two groups based on renin suppression (n = 90) or non-suppression (n = 70). Both groups were also compared to unilateral PA patients (n = 275) who achieved biochemical cure with adrenalectomy. RESULTS Adrenalectomized patients were younger, had higher plasma aldosterone concentration, and lower potassium levels than MRA group. Patients on MRA had similar baseline characteristics when stratified into treatment groups with suppressed and unsuppressed renin. 97 (55.1%) of 176 patients without comorbidities at diagnosis, developed at least one comorbidity during follow-up (median 12 months vs. 12.5 months' follow-up after starting MRA and surgery, respectively). Surgery group had a lower risk of developing new cardiovascular events (HR 0.40 [95% CI 0.18-0.90]) than MRA group. Surgical treatment improved glycemic and blood pressure control, increased serum potassium levels, and required fewer antihypertensive drugs than medical treatment. However, there were no differences in the cardiometabolic profile or the incidence of new comorbidities between the groups with suppressed and unsuppressed renin levels (HR 0.95 [95% CI 0.52-1.73]). CONCLUSION Cardiovascular, renal, and metabolic events were comparable in MRA patients with unsuppressed and suppressed renin. Effective surgical treatment of PA was associated with a decreased incidence of new cardiovascular events when compared to MRA therapy.
Collapse
Affiliation(s)
- Paola Parra Ramírez
- Endocrinology and Nutrition Department, Hospital Universitario La Paz, Madrid, Spain
| | | | - Miguel Paja Fano
- Endocrinology and Nutrition Department, OSI Bilbao-Basurto, Hospital Universitario de Basurto, Bilbao, Spain
- University of the Basque Country UPC/EHU, Bilbao, Spain
| | - Margarita González-Boillos
- Endocrinology and Nutrition Department, Hospital Universitario de Castellón, Castelló de la Plana, Castellón, Spain
| | - Eider Pascual-Corrales
- Endocrinology and Nutrition Department, Hospital Universitario Ramón y Cajal, Colmenar Viejo Street km 9, 28034, Madrid, Spain
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
| | | | | | | | - Emilia Gómez Hoyos
- Endocrinology and Nutrition Department, Hospital Universitario de Valladolid, Valladolid, Spain
| | - Rui Ferreira
- Endocrinology and Nutrition Department, Hospital Universitario Rey Juan Carlos, Madrid, Spain
| | - Iñigo García Sanz
- General and Digestive Surgery Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - Mònica Recasens Sala
- Endocrinology and Nutrition Department, Hospital De Girona Doctor Josep Trueta, Girona, Spain
| | | | - María José Picón César
- Endocrinology and Nutrition Department, Hospital Universitario Virgen de la Victoria de Málaga, IBIMA Malaga, Málaga, Spain
- CIBEROBN, Madrid, Spain
| | | | - Carolina M Perdomo
- Endocrinology and Nutrition Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Laura Manjón-Miguélez
- Endocrinology and Nutrition Department, Hospital Universitario Central de Asturias, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Ángel Rebollo Román
- Endocrinology and Nutrition Department, Hospital Reina Sofía, Córdoba, Spain
| | - Cristina Robles Lázaro
- Endocrinology and Nutrition Department, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | - Manuel Morales-Ruiz
- Biochemistry and Molecular Genetics Department-CDB, Hospital Clinic, IDIBAPS, CIBERehd, Barcelona, Spain
| | - María Calatayud
- Endocrinology and Nutrition Department, Hospital Doce de Octubre, Madrid, Spain
| | | | - Diego Meneses
- Endocrinology and Nutrition Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | | | - Elena Mena Ribas
- Endocrinology and Nutrition Department, Hospital Universitario Son Espases, Palma, Islas Baleares, Spain
| | - Alicia Sanmartín Sánchez
- Endocrinology and Nutrition Department, Hospital Universitario Son Espases, Palma, Islas Baleares, Spain
| | - Cesar Gonzalvo Diaz
- Endocrinology and Nutrition Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Cristina Lamas
- Endocrinology and Nutrition Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Raquel Guerrero-Vázquez
- Endocrinology and Nutrition Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - María Del Castillo Tous
- Endocrinology and Nutrition Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | | | | | | | - Ricardo Roa Chamorro
- Internal Medicine Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Fernando Jaen Aguila
- Internal Medicine Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - Felicia A Hanzu
- Endocrinology and Nutrition Department, Hospital Clinic, University of Barcelona, IDIPAS, Barcelona, Spain
| | - Marta Araujo-Castro
- Endocrinology and Nutrition Department, Hospital Universitario Ramón y Cajal, Colmenar Viejo Street km 9, 28034, Madrid, Spain.
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain.
| |
Collapse
|
6
|
Graudal N, Hubeck-Graudal T, Jurgens G. A low dietary sodium dose is associated with a more pronounced aldosterone response in normotensive than in hypertensive individuals. Sci Rep 2023; 13:19027. [PMID: 37923769 PMCID: PMC10624927 DOI: 10.1038/s41598-023-46285-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 10/30/2023] [Indexed: 11/06/2023] Open
Abstract
In this comprehensive meta-regression analysis encompassing 79 randomized controlled trials, we observed that in populations assigned to a high sodium intake level exceeding 94 mmol, there was no discernible link between plasma aldosterone levels and sodium intake. However, among populations with normal blood pressure subjected to a lower sodium intake, falling below 111 mmol (N = 1544), the association between sodium intake and plasma aldosterone levels manifested as a decrease of 192 pg/ml per 100 mmol of sodium (95% CI - 303 to - 81). In hypertensive populations (N = 1145), this association was less pronounced, with a reduction of 46 pg/ml per 100 mmol sodium, (95% CI - 112 to 20). Furthermore, in normotensive populations the plasma aldosterone increase associated with a decrease in sodium intake was 70 pg/ml per 100 mmol sodium (95% CI 27 to 113). In hypertensive populations, the observed increase was more modest, at 30 pg/ml per 100 mmol sodium, (95% CI 6.8 to 54). A limitation of this study lies in the absence of individual participant data. Our analysis included adjustments for potential effect-modifiers, encompassing bias estimation, which did not substantially alter these associations. One perspective of the present results may be to prompt a reconsideration of current sodium reduction recommendations.
Collapse
Affiliation(s)
- Niels Graudal
- Center for Rheumatology and Spine Diseases, The Lupus and Vasculitis Clinic 4242, Copenhagen University Hospital Rigshospitalet, Juliane Maries Vej 10, Copenhagen, Denmark.
| | - Thorbjørn Hubeck-Graudal
- Department of Nuclear Medicine, Zealand University Hospital, Næstved, Ringstedgade 61, 4700, Næstved, Denmark
| | - Gesche Jurgens
- Clinical Pharmacology Unit, Zealand University Hospital, Roskilde, Sygehusvej 10, 4000, Roskilde, Denmark
| |
Collapse
|
7
|
Charoensri S, Turcu AF. Primary Aldosteronism Prevalence - An Unfolding Story. Exp Clin Endocrinol Diabetes 2023; 131:394-401. [PMID: 36996879 DOI: 10.1055/a-2066-2696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
Primary aldosteronism (PA) is characterized by dysregulated, renin-independent aldosterone excess. Long perceived as rare, PA has emerged as one of the most common causes of secondary hypertension. Failure to recognize and treat PA results in cardiovascular and renal complications, through processes mediated by both direct target tissue insults and indirectly, by hypertension. PA spans a continuum of dysregulated aldosterone secretion, which is typically recognized in late stages after treatment-resistant hypertension and cardiovascular and/or renal complications develop. Determining the precise disease burden remains challenging due to heterogeneity in testing, arbitrary thresholds, and populations studied. This review summarizes the reports on PA prevalence among the general population and in specific high-risk subgroups, highlighting the impact of rigid versus permissive criteria on PA prevalence perception.
Collapse
Affiliation(s)
- Suranut Charoensri
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, USA. Ann Arbor, Michigan
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, USA. Ann Arbor, Michigan
| |
Collapse
|
8
|
Bingöl G, Özmen E, Özden Ö, Bulut Arsoy L, Uzun YE, Nasifov M, Şüheda Hatipoğlu E. Screening of Hyperaldosteronism on the Investigation of Secondary Hypertension: Single-centre Experience. ISTANBUL MEDICAL JOURNAL 2023. [DOI: 10.4274/imj.galenos.2022.22309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
|
9
|
Vaidya A, Hundemer GL, Nanba K, Parksook WW, Brown JM. Primary Aldosteronism: State-of-the-Art Review. Am J Hypertens 2022; 35:967-988. [PMID: 35767459 PMCID: PMC9729786 DOI: 10.1093/ajh/hpac079] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022] Open
Abstract
We are witnessing a revolution in our understanding of primary aldosteronism (PA). In the past 2 decades, we have learned that PA is a highly prevalent syndrome that is largely attributable to pathogenic somatic mutations, that contributes to cardiovascular, metabolic, and kidney disease, and that when recognized, can be adequately treated with widely available mineralocorticoid receptor antagonists and/or surgical adrenalectomy. Unfortunately, PA is rarely diagnosed, or adequately treated, mainly because of a lack of awareness and education. Most clinicians still possess an outdated understanding of PA; from primary care physicians to hypertension specialists, there is an urgent need to redefine and reintroduce PA to clinicians with a modern and practical approach. In this state-of-the-art review, we provide readers with the most updated knowledge on the pathogenesis, prevalence, diagnosis, and treatment of PA. In particular, we underscore the public health importance of promptly recognizing and treating PA and provide pragmatic solutions to modify clinical practices to achieve this.
Collapse
Affiliation(s)
- Anand Vaidya
- Department of Medicine, Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Kazutaka Nanba
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Wasita W Parksook
- Department of Medicine, Division of Endocrinology and Metabolism, and Division of General Internal Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
10
|
Maciel AAW, Freitas TC, Fagundes GFC, Petenuci J, Vilela LAP, Brito LP, Goldbaum TS, Zerbini MCN, Ledesma FL, Tanno FY, Srougi V, Chambo JL, Pereira MAA, Coelho FMA, Cavalcante ACBS, Carnevale FC, Pilan B, Pio-Abreu A, Silveira JV, Consolim-Colombo FM, Bortolotto LA, Latronico AC, Fragoso MCBV, Drager LF, Mendonca BB, Almeida MQ. Intraindividual variability of serum aldosterone and its implication for primary aldosteronism screening. J Clin Endocrinol Metab 2022; 108:1143-1153. [PMID: 36413507 DOI: 10.1210/clinem/dgac679] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 11/10/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022]
Abstract
CONTEXT Primary aldosteronism (PA) screening relies on an elevated aldosterone to renin ratio with a minimum aldosterone level, which varies from 10 to 15 ng/dL (277 to 415.5 pmol/L) using immunoassay. AIM To evaluate intraindividual coefficient of variation (CV) of aldosterone and aldosterone to direct renin concentration ratio (A/DRC) and its impact on PA screening. METHODS A total of 671 aldosterone and DRC measurements were performed by the same chemiluminescence assays in a large cohort of 216 patients with confirmed PA and at least two screenings. RESULTS The median intraindividual CV of aldosterone and A/DRC was 26.8% and 26.7%. Almost 40% of the patients had at least one aldosterone level <15 ng/dL, 19.9% had at least two aldosterone levels <15 ng/dL and 16.2% had mean aldosterone levels <15 ng/dL. A lower cut-off of 10 ng/dL was associated with false negative rates for PA screening of 14.3% for a single aldosterone measurement, 4.6% for two aldosterone measurements and only 2.3% for mean aldosterone levels. Considering the minimum aldosterone, true positive rate of aldosterone thresholds was 85.7% for 10 ng/dL and 61.6% for 15 ng/dL. An A/DRC >2 ng/dL/µIU/mL had a true positive rate for PA diagnosis of 94.4% and 98.4% when based on one or two assessments, respectively. CV of aldosterone and A/DRC were not affected by sex, use of interfering anti-hypertensive medications, PA lateralization, hypokalemia, age and number of hormone measurements. CONCLUSION Aldosterone concentrations had a high CV in PA patients, which results in an elevated rate of false negative test in a single screening for PA. Therefore, PA screening should be based in at least two screenings with concomitant aldosterone and renin measurements.
Collapse
Affiliation(s)
- Ana Alice W Maciel
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Thais C Freitas
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Gustavo F C Fagundes
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Janaina Petenuci
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Leticia A P Vilela
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
- Disciplina de Endocrinologia, Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, 38400-902, Brasil
| | - Luciana P Brito
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Tatiana S Goldbaum
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Maria Claudia N Zerbini
- Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Felipe L Ledesma
- Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Fabio Y Tanno
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Victor Srougi
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Jose L Chambo
- Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Maria Adelaide A Pereira
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Fernando M A Coelho
- Instituto de Radiologia InRad, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Aline C B S Cavalcante
- Instituto de Radiologia InRad, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Francisco C Carnevale
- Instituto de Radiologia InRad, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Bruna Pilan
- Instituto de Radiologia InRad, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Andrea Pio-Abreu
- Unidade de Hipertensão, Instituto do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-900, Brasil
| | | | - Fernanda M Consolim-Colombo
- Universidade Nove de Julho, São Paulo, 03155-000, Brasil
- Unidade de Hipertensão, Disciplina de Nefrologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | | | - Ana Claudia Latronico
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Maria Candida B V Fragoso
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
- Divisão de Oncologia Endócrina, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brasil
| | - Luciano F Drager
- Unidade de Hipertensão, Instituto do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-900, Brasil
- Universidade Nove de Julho, São Paulo, 03155-000, Brasil
| | - Berenice B Mendonca
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
| | - Madson Q Almeida
- Unidade de Adrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brasil
- Divisão de Oncologia Endócrina, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brasil
| |
Collapse
|
11
|
Characteristics of aldosterone-producing adenomas in patients without plasma renin activity suppression. PLoS One 2022; 17:e0267732. [PMID: 35482752 PMCID: PMC9049528 DOI: 10.1371/journal.pone.0267732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 04/13/2022] [Indexed: 01/13/2023] Open
Abstract
Primary aldosteronism (PA) usually accompanies suppressed plasma renin activity (PRA) through a negative feedback mechanism. While some cases of PA with unsuppressed PRA were reported, there have been no studies about the characteristics of PA with unsuppressed PRA; thus, these characteristics were examined herein. Nine patients with unsuppressed PRA and 86 patients with suppressed PRA were examined. All patients underwent segmental adrenal venous sampling (sAVS) and adrenalectomy, and were pathologically confirmed to have cytochrome P450 11B2 (CYP11B2)-positive aldosterone-producing adenoma according to international histopathology consensus criteria. Unsuppressed and suppressed PRA were defined as PRA levels of > 1.0 and ≤ 1.0 ng/mL/hr, respectively, in multiple blood samples obtained in the resting position. The unsuppressed PRA group had higher morning cortisol levels (12.6 [8.5, 13.5] vs. 8.5 [7.1, 11.0] μg/dL, P = 0.03) and higher cortisol levels after a 1 mg dexamethasone suppression test (DST) (2.2 [1.6, 2.5] vs. 1.3 [1.0, 1.9] μ g/dL, P = 0.004) than the suppressed PRA group. The unsuppressed PRA group also showed higher aldosterone levels on the non-surgical side during sAVS (P = 0.02 before adrenocorticotropic hormone (ACTH) stimulation, P = 0.002 after ACTH stimulation), a higher intensity of CYP17 expression in the resected adrenal gland (P = 0.02), and a lower clinical complete success rate 1 year after surgery (P = 0.04) compared with those in the suppressed PRA group. These findings suggest that PA should not be ruled out by unsuppressed PRA among patients with hypertension, particularly when their cortisol levels remain unsuppressed in the 1 mg DST. Meanwhile, it should be acknowledged that patients with unsuppressed PRA have higher aldosterone levels on the non-surgical side, and a lower likelihood of postoperative complete clinical success is to be expected.
Collapse
|
12
|
Obata Y, Takayama K, Maruo Y, Yamaguchi H, Fujii K, Hata S, Togawa Y, Sanda A, Kosugi M, Hazama Y, Yasuda T. Coexistence of renin-independent aldosterone secretion and multiple endocrine neoplasia type 1 within a family. J Endocr Soc 2022; 6:bvac009. [PMID: 35187382 PMCID: PMC8852679 DOI: 10.1210/jendso/bvac009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Indexed: 11/19/2022] Open
Abstract
Abstract
Primary aldosteronism (PA) is a state of renin-independent aldosterone secretion that can range from subclinical to overt. Some normotensive individuals for whom PA screening is not routinely recommended are reported to fulfill the loading test criterion used for the diagnosis of PA. Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant disorder characterized by the development of various endocrine tumors. Cases of PA associated with MEN1 have been reported; however, there has been no previous report on renin-independent aldosterone secretion within a family with MEN1. Herein, we present the case of a normotensive family presenting with both MEN1 and renin-independent aldosterone secretion. A 49-year-old man was admitted to our hospital for PA evaluation owing to the plasma aldosterone concentration/plasma renin activity ratio being greater than the screening cut-off value; the patient was normotensive. The patient had a history of left nephrectomy and adrenalectomy for left renal carcinoma and adrenal tumor at the age of 39 years. Subsequently, he was diagnosed with MEN1 concurrent with primary hyperparathyroidism, insulinoma, and novel MEN1 gene mutations (c.655-5_655-4insC, and c.818delC). The loading tests for PA confirmation, including saline infusion, and furosemide upright and captopril challenge tests yielded positive findings, confirming a case of renin-independent aldosterone secretion. The patient’s mother, brother, and sister were also genetically or clinically diagnosed with MEN1. All of them were also normotensive and confirmed to have renin-independent aldosterone secretion. The coexistence of renin-independent aldosterone secretion and MEN1 within this family suggests a relationship between the two entities.
Collapse
Affiliation(s)
- Yoshinari Obata
- Department of Diabetes and Endocrinology, Osaka Police Hospital, Osaka, Japan
| | - Kana Takayama
- Department of Diabetes and Endocrinology, Osaka Police Hospital, Osaka, Japan
| | - Yumiko Maruo
- Department of Diabetes and Endocrinology, Osaka Police Hospital, Osaka, Japan
| | - Hiroki Yamaguchi
- Department of Diabetes and Endocrinology, Osaka Police Hospital, Osaka, Japan
| | - Kohei Fujii
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Sonyun Hata
- Diabetes Center, National Hospital Organization Osaka Medical Center, Osaka, Japan
| | - Yuri Togawa
- Department of Internal Medicine, Japan Community Healthcare Organization, Osaka Hospital, Osaka, Japan
| | - Azusa Sanda
- Department of Internal Medicine, Japan Community Healthcare Organization, Osaka Hospital, Osaka, Japan
| | - Motohiro Kosugi
- Department of Diabetes and Endocrinology, Osaka Police Hospital, Osaka, Japan
| | - Yoji Hazama
- Department of Diabetes and Endocrinology, Osaka Police Hospital, Osaka, Japan
| | - Tetsuyuki Yasuda
- Department of Diabetes and Endocrinology, Osaka Police Hospital, Osaka, Japan
| |
Collapse
|
13
|
Abstract
Primary aldosteronism, the most common secondary form of hypertension, is thought to be present in ≈5% to 10% of hypertensive adults. However, recent studies indicate that its prevalence may be at least 3-fold higher based on the identification of renin-independent (autonomous) aldosterone production that is not suppressible with dietary sodium loading in a large fraction of adults with primary hypertension. Currently, the screening rate for primary aldosteronism in adults with primary hypertension is <1%. This review summarizes current thinking about primary aldosteronism from the standpoint of 3 key questions: Where are we now? Where to from here? So how do we get there?
Collapse
Affiliation(s)
- John W. Funder
- Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia. Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville
| | - Robert M. Carey
- Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia. Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville
| |
Collapse
|
14
|
Eplerenone Improves Vascular Endothelial Function in Patients with Primary Aldosteronism: A Pilot Study. J UOEH 2021; 43:379-384. [PMID: 34897166 DOI: 10.7888/juoeh.43.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Primary aldosteronism (PA) is associated with a high risk of cardiovascular complications. Large-scale clinical studies have demonstrated that mineralocorticoid receptor antagonists (MRA) exhibit organ-protective effects and improve the prognosis of patients with heart failure and myocardial infarction, and daily clinical practice suggests that MRA seem to improve vascular endothelial dysfunction. In this pilot study, we treated 10 PA patients with eplerenone for 3 months. We used Endo-PAT to evaluate the effects of MRA on vascular endothelial function and analyzed the data for correlative factors. The primary outcome measure, the reactive hyperemia index (RHI), was 1.71 before therapy and increased significantly to 2.21. Univariate analysis showed a significant correlation between the rate of change in RHI and that in plasma renin activity (PRA). Since plasma aldosterone concentration increases during MRA therapy, PRA may be the best marker for selecting the most appropriate dose of MRA. PRA can potentially be used for adjusting the dose of MRA, in addition to adjusting blood pressure and serum potassium level.
Collapse
|
15
|
Abstract
Adrenal masses are frequently incidentally identified from cross-sectional imaging studies, which are performed for other reasons. The intensity of the approach to the patient with such a mass is tailored to the clinical situation, ranging from a quick evaluation to a detailed work-up. In all cases, the three components of the evaluation are clinical assessment, review of the images, and biochemical testing with the goal of ruling out malignancy and identifying hormonally active lesions. This article incorporates recent information to produce a logical, systematic assessment of these patients with risk stratification and proportionate follow-up.
Collapse
Affiliation(s)
- Xin He
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Patricia R Peter
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, FMP 110, PO Box 208020, New Haven, CT 06520, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; Department of Pharmacology, University of Michigan, Ann Arbor, MI, USA; Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI, USA.
| |
Collapse
|
16
|
Wannachalee T, Turcu AF. Primary Aldosteronism: a Continuum from Normotension to Hypertension. Curr Cardiol Rep 2021; 23:105. [PMID: 34196827 DOI: 10.1007/s11886-021-01538-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Primary aldosteronism (PA) is the most common cause of secondary hypertension. Emerging evidence suggests that PA is associated with cardiovascular, metabolic, and renal complications, that likely develop insidiously, due to prolonged inappropriate mineralocorticoid receptor activation. In this review, we discuss the expanding clinical and pathological spectrum of PA. RECENT FINDINGS Clinical and molecular studies conducted over the recent years reveal that PA traverses a series of contiguous stages. Pre-clinical, but hormonally overt PA has been identified in patients with normal blood pressure, and such patients harbor an increased risk of developing hypertension. Similarly, genetic and histopathological advancements have exposed a spectrum of PA pathology that corresponds to a continuum that spans from pre-clinical stages to florid PA. PA evolves from pre-hypertensive stages to resistant hypertension, along with serious cardiovascular and renal consequences. Early recognition of PA and targeted therapy will be essential for cardiovascular morbidity and mortality prevention in a large number of patients.
Collapse
Affiliation(s)
- Taweesak Wannachalee
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, 1150 W Medical Center Drive, MSRB II, 5570B, Ann Arbor, MI, 48109, USA.,Division of Endocrinology and Metabolism, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, 1150 W Medical Center Drive, MSRB II, 5570B, Ann Arbor, MI, 48109, USA.
| |
Collapse
|
17
|
Wachtel H, Fraker DL. Therapeutic Outcomes with Surgical and Medical Management of Primary Aldosteronism. Curr Cardiol Rep 2021; 23:89. [PMID: 34081226 DOI: 10.1007/s11886-021-01516-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW Primary aldosteronism (PA) is the most common cause of secondary hypertension and is significantly under-diagnosed. Delays in diagnosis and treatment can lead to cardiovascular morbidity and mortality. The goal of this study is to review the management of PA, with a focus on medical and surgical treatment outcomes. RECENT FINDINGS PA causes cardiovascular dysfunction in excess of degree of hypertension. Adrenalectomy demonstrates a therapeutic advantage over mineralocorticoid antagonist (MRA) therapy, after controlling for degree of hypertension and subtype of PA. Higher rates of atrial fibrillation, heart failure, stroke, and incidence of chronic kidney disease are observed in subjects treated with MRAs than in subjects treated with adrenalectomy. The therapeutic benefit of surgery may reflect definitive resolution of excess aldosterone. Complete mineralocorticoid blockade may achieve similar benefit to adrenalectomy. Adrenalectomy is the most effective treatment for unilateral PA. Biomarkers for MRA therapy might inform optimal medical therapy of bilateral adrenal hyperplasia.
Collapse
Affiliation(s)
- Heather Wachtel
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Pavilion, Philadelphia, PA, 19104, USA. .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Douglas L Fraker
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Pavilion, Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
18
|
Urinary sodium-to-potassium ratio and plasma renin and aldosterone concentrations in normotensive children: implications for the interpretation of results. J Hypertens 2021; 38:671-678. [PMID: 31790052 DOI: 10.1097/hjh.0000000000002324] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To identify associations among the plasma renin concentration (PRC), plasma aldosterone and urinary sodium (Na)/potassium (K) ratio, and to integrate these variables into a nomogram with the aim of estimating the expected versus observed aldosterone concentration. METHODS We studied 40 healthy normotensive children (5-8 years old, 57.5% girls) who were born at term and were adequate for their gestational age. Following overnight fasting, the PRC and plasma aldosterone in blood samples were measured, and the Na/K ratio was calculated from a simultaneously obtained urinary spot sample. A mathematical function was defined with these three variables, and a nomogram was built that would return the expected aldosterone concentration from the obtained plasma renin and urinary Na/K ratio values. RESULTS The PRC (B = 5.9, P < 0.001) and urinary Na/K ratio (B = -98.1, P = 0.003) were significant independent predictors of plasma aldosterone. The correlation between the observed plasma aldosterone and the expected plasma aldosterone, as obtained from the nomogram, was r = 0.88, P < 0.001. The average difference between the observed and expected plasma aldosterone was -0.89, with a standard deviation of ±30%. CONCLUSION The strong correlation between the urinary Na/K ratio, from urine samples taken at the same as the blood samples, and plasma renin and aldosterone concentrations allowed us to build a nomogram to predict aldosterone levels. This approach may be useful for evaluating the renin-angiotensin-aldosterone system (RAAS) in pediatric patients with hypertension and RAAS dysfunction.
Collapse
|
19
|
Kline GA, Leung AAC, Sam D, Chin A, So B. Repeat Adrenal Vein Sampling in Aldosteronism: Reproducibility and Interpretation of Persistently Discordant Results. J Clin Endocrinol Metab 2021; 106:e1170-e1178. [PMID: 33320942 PMCID: PMC7947749 DOI: 10.1210/clinem/dgaa930] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT The reproducibility of adrenal vein sampling (AVS) is unknown. OBJECTIVE This work aimed to determine reproducibility of biochemical results and diagnostic lateralization in patients undergoing repeat AVS. METHODS A retrospective chart review was conducted of single-center, single-operator AVS procedures at a tertiary care center. Included were patients with confirmed primary aldosteronism (PA) undergoing repeat AVS because of concerns about technical success or discordant diagnostic results. Simultaneous AVS was performed by an experienced operator using a consistent protocol of precosyntropin and postcosyntropin infusion. Among successfully catheterized adrenal veins (selectivity index ≥ 2), the correlation of the adrenalaldosterone/cortisol (A/C) ratio was measured between the first and second AVS. The secondary outcome measure was diagnostic agreement on repeat AVS lateralization (lateralization index ≥ 3). RESULTS There were 46 sets of AVS from 23 patients at a median of 3 months apart. There was moderate correlation in A/C ratios in the adrenal veins and inferior vena cava (Spearman r = 0.49-0.59, P < .05) pre cosyntropin. Post cosyntropin, the correlation was better (Spearman r = 0.67-0.76, P < .05). In technically successful AVS, there was moderate correlation between the repeated lateralization indices (Spearman r = 0.53, P < .05). In 15 patients in whom repeat AVS was performed because of apparent lateralization discordance with computed tomography imaging, the final diagnosis was the same in the second AVS procedure. Initial failed AVS was successful 75% of the time on repeat attempt. CONCLUSION Repeat AVS was feasible and usually successful when an initial attempt failed. There was modest correlation between individual repeat adrenal A/C ratios and lateralization indices when AVS was performed twice. The final lateralization diagnosis was identical in all cases. This demonstrates that AVS is a reliable and reproducible localizing test in PA.
Collapse
Affiliation(s)
- Gregory A Kline
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Correspondence: Gregory A. Kline, MD, Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, 1820 Richmond Rd SW, Calgary, AB, T2T 5C7 Canada.
| | - Alexander Ah-Chi Leung
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Davis Sam
- Division of Endocrinology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alex Chin
- Department of Clinical Pathology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Precision Laboratories, AB, Canada
| | - Benny So
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
20
|
Veldhuizen GP, Alnazer RM, Kroon AA, de Leeuw PW. Confounders of the aldosterone-to-renin ratio when used as a screening test in hypertensive patients: A critical analysis of the literature. J Clin Hypertens (Greenwich) 2020; 23:201-207. [PMID: 33368994 PMCID: PMC8030008 DOI: 10.1111/jch.14117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/21/2022]
Abstract
The aldosterone‐to‐renin ratio (ARR) is a common screening test for primary aldosteronism in hypertensives. However, there are many factors which could confound the ARR test result and reduce the accuracy of this test. The present review's objective is to identify these factors and to describe to what extent they affect the ARR. Our analysis revealed that sex, age, posture, and sodium‐intake influence the ARR, whereas assay techniques do not. Race and body mass index have an uncertain effect on the ARR. We conclude that several factors can affect the ARR. Not taking these factors into account could lead to misinterpretation of the ARR.
Collapse
Affiliation(s)
- Gregory P Veldhuizen
- Department of Internal Medicine, Maastricht University Medical Center & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Rawan M Alnazer
- Department of Internal Medicine, Maastricht University Medical Center & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Abraham A Kroon
- Department of Internal Medicine, Maastricht University Medical Center & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Peter W de Leeuw
- Department of Internal Medicine, Maastricht University Medical Center & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| |
Collapse
|
21
|
Yozamp N, Hundemer GL, Moussa M, Underhill J, Fudim T, Sacks B, Vaidya A. Intraindividual Variability of Aldosterone Concentrations in Primary Aldosteronism: Implications for Case Detection. Hypertension 2020; 77:891-899. [PMID: 33280409 DOI: 10.1161/hypertensionaha.120.16429] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Primary aldosteronism is an underdiagnosed cause of hypertension. Although inadequate screening is one reason for underdiagnosis, another important contributor is that clinicians may inappropriately exclude the diagnosis when screening aldosterone concentrations fall below traditionally established thresholds. We evaluated the intraindividual variability in screening aldosterone concentrations and aldosterone-to-renin ratios, and how this variability could impact case detection, among 51 patients with confirmed primary aldosteronism who had 2 or more screening measurements of renin and aldosterone on different days. There were a total of 137 screening measurements with a mean of 3 (range 2-6) per patient. The mean intraindividual variability, expressed as coefficients of variation, was 31% for aldosterone and 45% for the aldosterone-to-renin ratio. Aldosterone concentrations ranged from 4.9 to 51 ng/dL; 49% of patients had at least one aldosterone measurement below 15 ng/dL, 29% had at least 2 aldosterone measurements below 15 ng/dL, and 29% had at least one measurement below 10 ng/dL. Individual aldosterone-to-renin ratios ranged from 8.2 to 427 ng/dL per ng/mL·hour; 57% had at least one ratio below 30 ng/dL per ng/mL·hour, 27% had at least 2 ratios below 30 ng/dL per ng/mL·hour, and 24% had at least one ratio below 20 ng/dL per ng/mL·hour. Aldosterone concentrations and aldosterone-to-renin ratios are highly variable in patients with primary aldosteronism, with many screening values falling below conventionally accepted diagnostic thresholds. The diagnostic yield for primary aldosteronism may be substantially increased by recalibrating the definition of a positive screen to include more liberal thresholds for aldosterone and the aldosterone-to-renin ratio.
Collapse
Affiliation(s)
- Nicholas Yozamp
- From the Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital (N.Y., A.V.), Harvard Medical School, Boston, MA
| | - Gregory L Hundemer
- Division of Nephrology, The Ottawa Hospital, University of Ottawa, Canada (G.L.H.)
| | - Marwan Moussa
- Department of Radiology, Beth Israel Deaconess Medical Center (M.M., J.U., T.F., B.S.), Harvard Medical School, Boston, MA
| | - Jonathan Underhill
- Department of Radiology, Beth Israel Deaconess Medical Center (M.M., J.U., T.F., B.S.), Harvard Medical School, Boston, MA
| | - Tali Fudim
- Department of Radiology, Beth Israel Deaconess Medical Center (M.M., J.U., T.F., B.S.), Harvard Medical School, Boston, MA
| | - Barry Sacks
- Department of Radiology, Beth Israel Deaconess Medical Center (M.M., J.U., T.F., B.S.), Harvard Medical School, Boston, MA
| | - Anand Vaidya
- From the Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital (N.Y., A.V.), Harvard Medical School, Boston, MA
| |
Collapse
|
22
|
Vaidya A, Carey RM. Evolution of the Primary Aldosteronism Syndrome: Updating the Approach. J Clin Endocrinol Metab 2020; 105:5899581. [PMID: 32865201 PMCID: PMC7899564 DOI: 10.1210/clinem/dgaa606] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 08/26/2020] [Indexed: 12/19/2022]
Abstract
CONTEXT New approaches are needed to address the evolution of the primary aldosteronism syndrome and to increase its recognition. Herein, we review evidence indicating that primary aldosteronism is a prevalent syndrome that is mostly unrecognized, and present a pragmatic and pathophysiology-based approach to improve diagnosis and treatment. METHODS Evidence was gathered from published guidelines and studies identified from PubMed by searching for primary aldosteronism, aldosterone, renin, and hypertension. This evidence was supplemented by the authors' personal knowledge, research experience, and clinical encounters in primary aldosteronism. INTERPRETATION OF EVIDENCE Renin-independent aldosterone production is a prevalent phenotype that is diagnosed as primary aldosteronism when severe in magnitude, but is largely unrecognized when milder in severity. Renin-independent aldosterone production can be detected in normotensive and hypertensive individuals, and the magnitude of this biochemical phenotype parallels the magnitude of blood pressure elevation, the risk for incident hypertension and cardiovascular disease, and the likelihood and magnitude of blood pressure reduction with mineralocorticoid receptor antagonist therapy. Expansion of the indications to screen for primary aldosteronism, combined with the use of a pathophysiology-based approach that emphasizes inappropriate aldosterone production in the context of renin suppression, will substantially increase the diagnostic and therapeutic yields for primary aldosteronism. CONCLUSIONS The landscape of primary aldosteronism has evolved to recognize that it is a prevalent syndrome of renin-independent aldosterone production that contributes to the pathogenesis of hypertension and cardiovascular disease. Expanding screening indications and simplifying the diagnostic approach will enable implementation of targeted treatment for primary aldosteronism.
Collapse
Affiliation(s)
- Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, & Hypertension, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Correspondence and Reprint Requests: Anand Vaidya, MD, MMSc, Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, RFB, Boston, MA 02115, USA. E-mail:
| | - Robert M Carey
- Division of Endocrinology and Metabolism, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|
23
|
Hundemer GL, Vaidya A. MANAGEMENT OF ENDOCRINE DISEASE: The role of surgical adrenalectomy in primary aldosteronism. Eur J Endocrinol 2020; 183:R185-R196. [PMID: 33077688 PMCID: PMC7853245 DOI: 10.1530/eje-20-0863] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/30/2020] [Indexed: 12/17/2022]
Abstract
Primary aldosteronism is common and contributes to adverse cardiovascular, kidney, and metabolic outcomes. When instituted early and effectively, targeted therapies can mitigate these adverse outcomes. Surgical adrenalectomy is among the most effective treatments because it has the potential to cure, or attenuate the severity of, pathologic aldosterone excess, resulting in a host of biochemical and clinical changes that improve health outcomes. Herein, we review the role of surgical adrenalectomy in primary aldosteronism while emphasizing the physiologic ramifications of surgical intervention, and compare these to other targeted medical therapies for primary aldosteronism. We specifically review the role of curative adrenalectomy for unilateral primary aldosteronism, the role of non-curative adrenalectomy for bilateral primary aldosteronism, and how these interventions influence biochemical and clinical outcomes in relation to medical therapies for primary aldosteronism.
Collapse
Affiliation(s)
- Gregory L. Hundemer
- Division of Nephrology, Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| |
Collapse
|
24
|
Abstract
Primary aldosteronism remains a leading cause of secondary hypertension, and its diagnosis and management continue to pose a challenge for clinicians. In this article, we review the diagnosis of primary aldosteronism along with its cardiovascular manifestations. Treatment is described depending on the diagnostic outcome, focusing on medical management with mineralocorticoid receptor antagonists and unilateral adrenalectomy. Although screening and diagnosing hyperaldosteronism follows well-known algorithms, in practice, physicians may find difficulty establishing the best course of action due to complexity in testing and confirming laterality of aldosterone production by the adrenals. Recognizing and treating primary aldosteronism requires a multidisciplinary approach with primary care physicians, cardiologists, endocrinologists, and radiologists working collaboratively.
Collapse
|
25
|
Lattanzio MR, Weir MR. Hyperaldosteronism: How Current Concepts Are Transforming the Diagnostic and Therapeutic Paradigm. KIDNEY360 2020; 1:1148-1156. [PMID: 35368778 PMCID: PMC8815485 DOI: 10.34067/kid.0000922020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 07/16/2020] [Indexed: 06/14/2023]
Abstract
Nearly seven decades have elapsed since the clinical and biochemical features of primary hyperaldosteronism (PA) were described by Conn. PA is now widely recognized as the most common form of secondary hypertension. PA has a strong correlation with cardiovascular disease and failure to recognize and/or properly diagnose this condition has profound health consequences. With proper identification and management, PA has the potential to be surgically cured in a proportion of affected individuals. The diagnostic pursuit for PA is not a simplistic endeavor, particularly because an enhanced understanding of the disease process is continually redefining the diagnostic and treatment algorithm. These new concepts have emerged in all areas of this clinical condition, including identification, diagnosis, and treatment. Here, we review the recent advances in this field and summarize the effect these advances have on both diagnostic and therapeutic modalities.
Collapse
Affiliation(s)
- Michael R. Lattanzio
- Division of Nephrology, Department of Medicine, The Chester County Hospital/University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Matthew R. Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
26
|
Mulatero P, Monticone S, Deinum J, Amar L, Prejbisz A, Zennaro MC, Beuschlein F, Rossi GP, Nishikawa T, Morganti A, Seccia TM, Lin YH, Fallo F, Widimsky J. Genetics, prevalence, screening and confirmation of primary aldosteronism: a position statement and consensus of the Working Group on Endocrine Hypertension of The European Society of Hypertension. J Hypertens 2020; 38:1919-1928. [PMID: 32890264 DOI: 10.1097/hjh.0000000000002510] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
: Autonomous aldosterone overproduction represents the underlying condition of 5-10% of patients with arterial hypertension and carries a significant burden of mortality and morbidity. The diagnostic algorithm for primary aldosteronism is sequentially based on hormonal tests (screening and confirmation tests), followed by lateralization studies (adrenal CT scanning and adrenal venous sampling) to distinguish between unilateral and bilateral disease. Despite the recommendations of the Endocrine Society guideline, primary aldosteronism is largely underdiagnosed and undertreated with high between-centre heterogeneity. Experts from the European Society of Hypertension have critically reviewed the available literature and prepared a consensus document constituting two articles to summarize current knowledge on the epidemiology, diagnosis, treatment, and complications of primary aldosteronism.
Collapse
Affiliation(s)
- Paolo Mulatero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Silvia Monticone
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Medicine III, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Laurence Amar
- Hypertension Unit, Assistance Publique-Hôpitaux de Paris, Hôpital européen Georges-Pompidou, Université de Paris, PARCC, Inserm, Paris, France
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Maria-Christina Zennaro
- Université de Paris, PARCC, INSERM, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France
| | - Felix Beuschlein
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Gian Paolo Rossi
- Hypertension Unit and Specialized Center for Blood Pressure Disorders - Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Tetsuo Nishikawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Alberto Morganti
- Centro Fisiologia Clinica e Ipertensione, Ospedale Policlinico, Università di Milano, Milan, Italy
| | - Teresa Maria Seccia
- Hypertension Unit and Specialized Center for Blood Pressure Disorders - Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Yen-Hung Lin
- Division of cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Francesco Fallo
- Department of Medicine -DIMED, University of Padova, Padova, Italy
| | - Jiri Widimsky
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| |
Collapse
|
27
|
Brown JM, Siddiqui M, Calhoun DA, Carey RM, Hopkins PN, Williams GH, Vaidya A. The Unrecognized Prevalence of Primary Aldosteronism: A Cross-sectional Study. Ann Intern Med 2020; 173:10-20. [PMID: 32449886 PMCID: PMC7459427 DOI: 10.7326/m20-0065] [Citation(s) in RCA: 305] [Impact Index Per Article: 76.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Primary aldosteronism is a nonsuppressible renin-independent aldosterone production that causes hypertension and cardiovascular disease. OBJECTIVE To characterize the prevalence of nonsuppressible renin-independent aldosterone production, as well as biochemically overt primary aldosteronism, in relation to blood pressure. DESIGN Cross-sectional study. SETTING 4 U.S. academic medical centers. PARTICIPANTS Participants with normotension (n = 289), stage 1 hypertension (n = 115), stage 2 hypertension (n = 203), and resistant hypertension (n = 408). MEASUREMENTS Participants completed an oral sodium suppression test, regardless of aldosterone or renin levels, as a confirmatory diagnostic for primary aldosteronism and to quantify the magnitude of renin-independent aldosterone production. Urinary aldosterone was measured in participants in high sodium balance with suppressed renin activity. Biochemically overt primary aldosteronism was diagnosed when urinary aldosterone levels were higher than 12 μg/24 h. RESULTS Every blood pressure category had a continuum of renin-independent aldosterone production, where greater severity of production was associated with higher blood pressure, kaliuresis, and lower serum potassium levels. Mean adjusted levels of urinary aldosterone were 6.5 μg/24 h (95% CI, 5.2 to 7.7 μg/24 h) in normotension, 7.3 μg/24 h (CI, 5.6 to 8.9 μg/24 h) in stage 1 hypertension, 9.5 μg/24 h (CI, 8.2 to 10.8 μg/24 h) in stage 2 hypertension, and 14.6 μg/24 h (CI, 12.9 to 16.2 μg/24 h) in resistant hypertension; corresponding adjusted prevalence estimates for biochemically overt primary aldosteronism were 11.3% (CI, 5.9% to 16.8%), 15.7% (CI, 8.6% to 22.9%), 21.6% (CI, 16.1% to 27.0%), and 22.0% (CI, 17.2% to 26.8%). The aldosterone-renin ratio had poor sensitivity and negative predictive value for detecting biochemically overt primary aldosteronism. LIMITATION Prevalence estimates rely on arbitrary and conventional thresholds, and the study population may not represent nationwide demographics. CONCLUSION The prevalence of primary aldosteronism is high and largely unrecognized. Beyond this categorical definition of primary aldosteronism, there is a prevalent continuum of renin-independent aldosterone production that parallels the severity of hypertension. These findings redefine the primary aldosteronism syndrome and implicate it in the pathogenesis of "essential" hypertension. PRIMARY FUNDING SOURCE National Institutes of Health.
Collapse
Affiliation(s)
- Jenifer M Brown
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (J.M.B., G.H.W., A.V.)
| | - Mohammed Siddiqui
- University of Alabama at Birmingham, Birmingham, Alabama (M.S., D.A.C.)
| | - David A Calhoun
- University of Alabama at Birmingham, Birmingham, Alabama (M.S., D.A.C.)
| | - Robert M Carey
- University of Virginia Health System, Charlottesville, Virginia (R.M.C.)
| | - Paul N Hopkins
- University of Utah School of Medicine, Salt Lake City, Utah (P.N.H.)
| | - Gordon H Williams
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (J.M.B., G.H.W., A.V.)
| | - Anand Vaidya
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (J.M.B., G.H.W., A.V.)
| |
Collapse
|
28
|
The Role of the CYP11B2 Promoter Polymorphism in the Diagnosis of Primary Aldosteronism. J Clin Med 2020; 9:jcm9051519. [PMID: 32443509 PMCID: PMC7290355 DOI: 10.3390/jcm9051519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/03/2020] [Accepted: 05/15/2020] [Indexed: 11/17/2022] Open
Abstract
Background: nowadays, primary aldosteronism (PA) is suggested to be the most frequent cause of secondary hypertension and it reaches 10% of whole hypertensive population. The CYP11B2 promoter polymorphism might cause aldosterone overproduction. The aim of this study was to establish whether the polymorphism CYP11B2 promoter has a significant impact on diagnostic of PA. Material and Methods: study group consisted of 239 hypertensive patients previously diagnosed with adrenal incidentaloma. For diagnose of PA were performed: screening test–aldosterone-renin ratio (ARR) and saline suppression test (SIT) as a confirmatory test. Genotyping was carried out by the real time PCR method. The significance of differences between the groups was evaluated through Student’s t-test. Results: our study revealed that genotype TT had plasma aldosterone concentration (PAC), ARR and SIT significantly higher in comparison with CC patients. The mean PAC in CC was 12.71 ng/dL vs. 20.55 ng/dL in TT patients (p = 0.037), which consequently gave a higher ARR in TT patients (119 vs. 44, p = 0.034). Mean aldosterone concentration in SIT was 2.40 ng/dL in CC patients and 9.99 ng/dL in TT patients (p = 0.046). Patients with CC genotype required less hypotensive drugs in comparison with TT genotype (p = 0.044). PA was recognized in 16 patients. Nine patients had TC genotype, six TT, and one with CC genotype. Conclusion: our study revealed predisposing TT genotype to PA. Additionally, patients with TT genotype, regardless of the PA presence, had more severe hypertension. The determination of the CYP11B2 promoter polymorphism seems to be useful in the diagnosis of PA, especially in cases where it is difficult to properly prepare patients for hormonal tests or even results of the hormonal test are incoherent.
Collapse
|
29
|
Hundemer GL, Vaidya A. Primary Aldosteronism Diagnosis and Management: A Clinical Approach. Endocrinol Metab Clin North Am 2019; 48:681-700. [PMID: 31655770 PMCID: PMC6824480 DOI: 10.1016/j.ecl.2019.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Primary aldosteronism used to be considered a rare cause of secondary hypertension. However, accruing evidence indicates that primary aldosteronism is more common than previously recognized. The implications of this increased prevalence are important to public health because autonomous aldosterone production contributes to cardiovascular disease and can be treated in a targeted manner. This article focuses on clinical approaches for diagnosing primary aldosteronism more frequently and earlier in its course, as well as practical treatment objectives to reduce the risk for incident cardiovascular disease.
Collapse
Affiliation(s)
- Gregory L Hundemer
- Division of Nephrology, Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Box 511, Ottawa, ON K1H 8L6, Canada
| | - Anand Vaidya
- Center for Adrenal Disorders, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA.
| |
Collapse
|
30
|
Nakamaru R, Yamamoto K, Nozato S, Hongyo K, Nagasawa M, Hagiya H, Nakagami F, Akasaka H, Kurinami H, Takami Y, Takeya Y, Sugimoto K, Ujike T, Uemura M, Nonomura N, Rakugi H. A case of primary aldosteronism with resistant hypertension successfully treated by unilateral adrenalectomy after unsuccessful classification of subtype in adrenal venous sampling. Clin Case Rep 2019; 7:1895-1899. [PMID: 31624604 PMCID: PMC6787834 DOI: 10.1002/ccr3.2317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/29/2019] [Accepted: 06/16/2019] [Indexed: 11/07/2022] Open
Abstract
Despite being an established method to identify the unilateral subtype of primary aldosteronism with an indication of adrenalectomy, adrenal venous sampling sometimes fails primarily due to unsuccessful cannulation to adrenal veins. In such cases, the analysis of clinical findings might help to identify the indication of surgery.
Collapse
Affiliation(s)
- Ryo Nakamaru
- Department of Geriatric and General MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Koichi Yamamoto
- Department of Geriatric and General MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Satoko Nozato
- Department of Geriatric and General MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Kazuhiro Hongyo
- Department of Geriatric and General MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Motonori Nagasawa
- Department of Geriatric and General MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Hideharu Hagiya
- Department of Geriatric and General MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Futoshi Nakagami
- Department of Geriatric and General MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Hiroshi Akasaka
- Department of Geriatric and General MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Hitomi Kurinami
- Department of Geriatric and General MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Yoichi Takami
- Department of Geriatric and General MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Yasushi Takeya
- Department of Geriatric and General MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Ken Sugimoto
- Department of Geriatric and General MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Takeshi Ujike
- Department of UrologyOsaka University Graduate School of MedicineSuitaJapan
| | - Motohide Uemura
- Department of UrologyOsaka University Graduate School of MedicineSuitaJapan
| | - Norio Nonomura
- Department of UrologyOsaka University Graduate School of MedicineSuitaJapan
| | - Hiromi Rakugi
- Department of Geriatric and General MedicineOsaka University Graduate School of MedicineSuitaJapan
| |
Collapse
|
31
|
Abstract
Primary aldosteronism (PA) is the most common form of secondary hypertension. In many cases, somatic mutations in ion channels and pumps within adrenal cells initiate the pathogenesis of PA, and this mechanism might explain why PA is so common and suggests that milder and evolving forms of PA must exist. Compared with primary hypertension, PA causes more end-organ damage and is associated with excess cardiovascular morbidity, including heart failure, stroke, nonfatal myocardial infarction, and atrial fibrillation. Screening is simple and readily available, and targeted therapy improves blood pressure control and mitigates cardiovascular morbidity. Despite these imperatives, screening rates for PA are low, and mineralocorticoid-receptor antagonists are underused for hypertension treatment. After the evidence for the prevalence of PA and its associated cardiovascular morbidity is summarized, a practical approach to PA screening, referral, and management is described. All physicians who treat hypertension should routinely screen appropriate patients for PA.
Collapse
Affiliation(s)
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., R.J.A.)
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., R.J.A.).,Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor
| |
Collapse
|
32
|
Lopez AG, Fraissinet F, Lefebvre H, Brunel V, Ziegler F. Pharmacological and analytical interference in hormone assays for diagnosis of adrenal incidentaloma. ANNALES D'ENDOCRINOLOGIE 2019; 80:250-258. [DOI: 10.1016/j.ando.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 09/27/2018] [Accepted: 11/19/2018] [Indexed: 12/19/2022]
|
33
|
Abstract
PURPOSE OF REVIEW Primary aldosteronism (PA) is a common form of hypertension characterized by autonomous aldosterone secretion from one or both adrenal glands. The purpose of this review is to synthesize recent research findings regarding cardiovascular disease risk in PA both pre- and post-targeted therapy. RECENT FINDINGS Previously considered a rare disease, recent prevalence studies demonstrate that PA is actually a very common, yet vastly under-diagnosed, etiology of hypertension. Prior to targeted therapy, PA is associated with substantially higher rates of cardiovascular disease compared with essential hypertension. Surgical adrenalectomy is highly effective in curing or improving hypertension as well as mitigating cardiovascular disease risk in patients with unilateral PA. For the remainder of PA patients, MR antagonists are recommended; however, several recent studies have brought into question their effectiveness in improving cardiovascular outcomes. PA is a common cause of hypertension that leads to disproportionately high rates of cardiovascular disease. Future studies are needed to enhance the clinical approach to both identification and treatment of patients with PA to optimize long-term cardiovascular outcomes.
Collapse
Affiliation(s)
- Gregory L Hundemer
- Division of Nephrology, Ottawa Hospital Research Institute, University of Ottawa, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada.
| |
Collapse
|
34
|
Abstract
Over six decades since primary aldosteronism was first described, much has been learned about its prevalence and optimal treatment. Estimates of the prevalence of primary aldosteronism have increased considerably over the years, even exceeding 20% in some populations of resistant hypertension. Even in patients with normal blood pressures, the prevalence of overt primary aldosteronism and dysregulated aldosterone production may be more common than appreciated. Emerging data support the concept that primary aldosteronism may be better characterized as a continuum of renin-independent aldosterone production, whose severity influences the clinical presentation and risk for incident cardiovascular disease. Mineralocorticoid receptor antagonists and adrenalectomy are the mainstay treatments for primary aldosteronism and have long been considered equally efficacious. However, recent data suggest that while surgical adrenalectomy can effectively reduce cardiovascular risk, mineralocorticoid receptor antagonist therapy may require a physiologic approach to optimize efficacy.
Collapse
|
35
|
Zhu KY, Zhang Y, Zhang WJ, Li HY, Feng WH, Zhu DL, Li P. The captopril challenge test for diagnosing primary Aldosteronism in a Chinese population. BMC Endocr Disord 2019; 19:65. [PMID: 31234846 PMCID: PMC6591899 DOI: 10.1186/s12902-019-0390-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 05/31/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The Captopril challenge test (CCT) is an easy-conduct confirmatory test for diagnosing primary aldosteronism (PA). Guidelines show that plasma aldosterone is normally suppressed by captopril (> 30%) in primary hypertension (PH) and in healthy people. It is unclear whether this standard is applicable in Chinese subjects. The aim of the present study was to investigate the post-CCT efficacy of plasma aldosterone concentration (PAC) suppression and determine the post-CCT aldosterone renin activity ratio (ARR) and PAC for PA diagnosis. METHODS We recruited 110 consecutive patients with PA, 163 with primary hypertension (PH), and 40 healthy volunteers (NC). The CCT was conducted in all patients. Total sodium intake was estimated from 24-h urinary excretions. ROC curves were used to analyze the efficiency of different CCT diagnostic criteria for diagnosing PA. RESULTS In NC and PH patients, PRA was increased and PAC was decreased post-CCT (P < 0.05). The mean degree of PAC decline after CCT was approximately 9.3%, and only 11.7% of the patients with PH showed a greater than 30% suppression of PAC after CCT. In patients with PA, the post-CCT change in PRA and PRC was slight. The post-CCT degree of PAC decline was unrelated to dietary salt intake. The areas under the ROC for the post-CCT ARR, PAC and PAC suppression % were 0.994, 0.754 and 0.606, respectively. The optimal post-CCT cutoff value for ARR for diagnosing PA was 20, which yielded a sensitivity and specificity of 94.0 and 99.4%, respectively. CONCLUSIONS The PAC suppression percentage after CCT recommended by current clinical guidelines is not applicable when diagnosing Chinese subjects with PA. Compared to post-CCT PAC, post-CCT ARR was a better approach, having an optimal cutoff of 20 when interpreting the results of the CCT in Chinese patients. We found no relationship between high salt intake and low responses of the renin-angiotensin system (RAS) to the CCT.
Collapse
Affiliation(s)
- Ke-ying Zhu
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008 People’s Republic of China
| | - Yan Zhang
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing Medical University School, Nanjing, 210008 People’s Republic of China
| | - Wen-jing Zhang
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008 People’s Republic of China
| | - Hong-yun Li
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008 People’s Republic of China
| | - Wen-huan Feng
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008 People’s Republic of China
| | - Da-long Zhu
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008 People’s Republic of China
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing Medical University School, Nanjing, 210008 People’s Republic of China
| | - Ping Li
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008 People’s Republic of China
| |
Collapse
|
36
|
Vaidya A, Mulatero P, Baudrand R, Adler GK. The Expanding Spectrum of Primary Aldosteronism: Implications for Diagnosis, Pathogenesis, and Treatment. Endocr Rev 2018; 39:1057-1088. [PMID: 30124805 PMCID: PMC6260247 DOI: 10.1210/er.2018-00139] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 08/10/2018] [Indexed: 12/14/2022]
Abstract
Primary aldosteronism is characterized by aldosterone secretion that is independent of renin and angiotensin II and sodium status. The deleterious effects of primary aldosteronism are mediated by excessive activation of the mineralocorticoid receptor that results in the well-known consequences of volume expansion, hypertension, hypokalemia, and metabolic alkalosis, but it also increases the risk for cardiovascular and kidney disease, as well as death. For decades, the approaches to defining, diagnosing, and treating primary aldosteronism have been relatively constant and generally focused on detecting and treating the more severe presentations of the disease. However, emerging evidence suggests that the prevalence of primary aldosteronism is much greater than previously recognized, and that milder and nonclassical forms of renin-independent aldosterone secretion that impart heightened cardiovascular risk may be common. Public health efforts to prevent aldosterone-mediated end-organ disease will require improved capabilities to diagnose all forms of primary aldosteronism while optimizing the treatment approaches such that the excess risk for cardiovascular and kidney disease is adequately mitigated. In this review, we present a physiologic approach to considering the diagnosis, pathogenesis, and treatment of primary aldosteronism. We review evidence suggesting that primary aldosteronism manifests across a wide spectrum of severity, ranging from mild to overt, that correlates with cardiovascular risk. Furthermore, we review emerging evidence from genetic studies that begin to provide a theoretical explanation for the pathogenesis of primary aldosteronism and a link to its phenotypic severity spectrum and prevalence. Finally, we review human studies that provide insights into the optimal approach toward the treatment of primary aldosteronism.
Collapse
Affiliation(s)
- Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Rene Baudrand
- Program for Adrenal Disorders and Hypertension, Department of Endocrinology, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Gail K Adler
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
37
|
Hundemer GL, Curhan GC, Yozamp N, Wang M, Vaidya A. Renal Outcomes in Medically and Surgically Treated Primary Aldosteronism. Hypertension 2018; 72:658-666. [PMID: 29987110 PMCID: PMC6202119 DOI: 10.1161/hypertensionaha.118.11568] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 06/11/2018] [Indexed: 01/12/2023]
Abstract
Lifelong therapy with mineralocorticoid receptor antagonists (MRAs) or surgical adrenalectomy are the recommended treatments for primary aldosteronism (PA). Whether these treatments mitigate the risk for kidney disease remains unknown. We performed a retrospective cohort study of patients with PA treated with MRAs (N=400) or surgical adrenalectomy (N=120) and age- and estimated glomerular filtration rate-matched patients with essential hypertension (N=15 474) to determine risk for chronic kidney disease and longitudinal estimated glomerular filtration rate decline. Despite similar blood pressures, patients with PA treated with MRAs had a higher risk for incident chronic kidney disease compared with essential hypertension patients (adjusted hazard ratio, 1.63; 95% confidence interval, 1.33-1.99). Correspondingly, the adjusted annual decline in estimated glomerular filtration rate was greater in PA patients treated with MRAs compared with essential hypertension patients (-1.6; 95% confidence interval, -1.4 to -1.8 versus -0.9; 95% confidence interval, -0.9 to -1.0 mL/min per 1.73 m2/y; P<0.001). In contrast, patients with unilateral PA treated with surgical adrenalectomy had no significant difference in risk for incident chronic kidney disease or in an annual decline in estimated glomerular filtration rate compared with essential hypertension patients. Among PA patients with diabetes mellitus treated with MRAs, there was a higher risk for incident albuminuria compared with essential hypertension (adjusted hazard ratio, 2.52; 95% confidence interval, 1.28-4.96). MRA therapy in PA is associated with higher risk for developing chronic kidney disease when compared with essential hypertension, and surgical adrenalectomy may mitigate this risk. When possible, curative surgical adrenalectomy may be superior to lifelong MRA therapy in preventing kidney disease in PA.
Collapse
Affiliation(s)
- Gregory L. Hundemer
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
| | - Gary C. Curhan
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
- Department of Epidemiology, Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Nicholas Yozamp
- Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
| | - Molin Wang
- Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
- Department of Epidemiology, Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Anand Vaidya
- Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
| |
Collapse
|
38
|
The Low-Renin Hypertension Phenotype: Genetics and the Role of the Mineralocorticoid Receptor. Int J Mol Sci 2018; 19:ijms19020546. [PMID: 29439489 PMCID: PMC5855768 DOI: 10.3390/ijms19020546] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 01/31/2018] [Accepted: 02/08/2018] [Indexed: 12/22/2022] Open
Abstract
A substantial proportion of patients with hypertension have a low or suppressed renin. This phenotype of low-renin hypertension (LRH) may be the manifestation of inherited genetic syndromes, acquired somatic mutations, or environmental exposures. Activation of the mineralocorticoid receptor is a common final mechanism for the development of LRH. Classically, the individual causes of LRH have been considered to be rare diseases; however, recent advances suggest that there are milder and "non-classical" variants of many LRH-inducing conditions. In this regard, our understanding of the underlying genetics and mechanisms accounting for LRH, and therefore, potentially the pathogenesis of a large subset of essential hypertension, is evolving. This review will discuss the potential causes of LRH, with a focus on implicated genetic mechanisms, the expanding recognition of non-classical variants of conditions that induce LRH, and the role of the mineralocorticoid receptor in determining this phenotype.
Collapse
|
39
|
Hundemer GL, Curhan GC, Yozamp N, Wang M, Vaidya A. Cardiometabolic outcomes and mortality in medically treated primary aldosteronism: a retrospective cohort study. Lancet Diabetes Endocrinol 2018; 6:51-59. [PMID: 29129576 PMCID: PMC5953512 DOI: 10.1016/s2213-8587(17)30367-4] [Citation(s) in RCA: 390] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 09/29/2017] [Accepted: 09/29/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Mineralocorticoid receptor (MR) antagonists are the recommended medical therapy for primary aldosteronism. Whether this recommendation effectively reduces cardiometabolic risk is not well understood. We aimed to investigate the risk of incident cardiovascular events in patients with primary aldosteronism treated with MR antagonists compared with patients with essential hypertension. METHODS We did a cohort study using patients from a research registry from Brigham and Women's Hospital, Massachusetts General Hospital, and their affiliated partner hospitals. We identified patients with primary aldosteronism using International Classification of Disease, 9th and 10th Revision codes, who were assessed between the years 1991-2016 and were at least 18 years of age. We excluded patients who underwent surgical adrenalectomy, had a previous cardiovascular event, were not treated with MR antagonists, or had no follow-up visits after study entry. From the same registry, we identified a population with essential hypertension that was frequency matched by decade of age at study entry. We extracted patient cohort data and collated it into a de-identified database. The primary outcome was an incident cardiovascular event, defined as a composite of incident myocardial infarction or coronary revascularisation, hospital admission with congestive heart failure, or stroke, which was assessed using adjusted Cox regression models. Secondary outcomes were the individual components of the composite cardiovascular outcome, as well as incident atrial fibrillation, incident diabetes, and death. FINDINGS We identified 602 eligible patients with primary aldosteronism treated with MR antagonists and 41 853 age-matched patients with essential hypertension from the registry. The two groups of patients had comparable cardiovascular risk profiles and blood pressure throughout the study. The incidence of cardiovascular events was higher in patients with primary aldosteronism on MR antagonists than in patients with essential hypertension (56·3 [95% CI 48·8-64·7] vs 26·6 [26·1-27·2] events per 1000 person-years, adjusted hazard ratio 1·91 [95% CI 1·63-2·25]; adjusted 10-year cumulative incidence difference 14·1 [95% CI 10·1-18·0] excess events per 100 people). Patients with primary aldosteronism also had higher adjusted risks for incident mortality (hazard ratio [HR] 1·34 [95% CI 1·06-1·71]), diabetes (1·26 [1·01-1·57]), and atrial fibrillation (1·93 [1·54-2·42]). Compared with essential hypertension, the excess risk for cardiovascular events and mortality was limited to patients with primary aldosteronism whose renin activity remained suppressed (<1 μg/L per h) on MR antagonists (adjusted HR [2·83 [95% CI 2·11-3·80], and 1·79 [1·14-2·80], respectively) whereas patients who were treated with higher MR antagonist doses and had unsuppressed renin (≥1 μg/L per h) had no significant excess risk. INTERPRETATION The current practice of MR antagonist therapy in primary aldosteronism is associated with significantly higher risk for incident cardiometabolic events and death, independent of blood pressure control, than for patients with essential hypertension. Titration of MR antagonist therapy to raise renin might mitigate this excess risk. FUNDING US National Institutes of Health.
Collapse
Affiliation(s)
- Gregory L Hundemer
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gary C Curhan
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nicholas Yozamp
- Department of Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Molin Wang
- Department of Epidemiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
40
|
Brown JM, Robinson-Cohen C, Luque-Fernandez MA, Allison MA, Baudrand R, Ix JH, Kestenbaum B, de Boer IH, Vaidya A. The Spectrum of Subclinical Primary Aldosteronism and Incident Hypertension: A Cohort Study. Ann Intern Med 2017; 167:630-641. [PMID: 29052707 PMCID: PMC5920695 DOI: 10.7326/m17-0882] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Primary aldosteronism is recognized as a severe form of renin-independent aldosteronism that results in excessive mineralocorticoid receptor (MR) activation. OBJECTIVE To investigate whether a spectrum of subclinical renin-independent aldosteronism that increases risk for hypertension exists among normotensive persons. DESIGN Cohort study. SETTING National community-based study. PARTICIPANTS 850 untreated normotensive participants in MESA (Multi-Ethnic Study of Atherosclerosis) with measurements of serum aldosterone and plasma renin activity (PRA). MEASUREMENTS Longitudinal analyses investigated whether aldosterone concentrations, in the context of physiologic PRA phenotypes (suppressed, ≤0.50 µg/L per hour; indeterminate, 0.51 to 0.99 µg/L per hour; unsuppressed, ≥1.0 µg/L per hour), were associated with incident hypertension (defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or initiation of antihypertensive medications). Cross-sectional analyses investigated associations between aldosterone and MR activity, assessed via serum potassium and urinary fractional excretion of potassium. RESULTS A suppressed renin phenotype was associated with a higher rate of incident hypertension than other PRA phenotypes (incidence rates per 1000 person-years of follow-up: suppressed renin phenotype, 85.4 events [95% CI, 73.4 to 99.3 events]; indeterminate renin phenotype, 53.3 events [CI, 42.8 to 66.4 events]; unsuppressed renin phenotype, 54.5 events [CI, 41.8 to 71.0 events]). With renin suppression, higher aldosterone concentrations were independently associated with an increased risk for incident hypertension, whereas no association between aldosterone and hypertension was seen when renin was not suppressed. Higher aldosterone concentrations were associated with lower serum potassium and higher urinary excretion of potassium, but only when renin was suppressed. LIMITATION Sodium and potassium were measured several years before renin and aldosterone. CONCLUSION Suppression of renin and higher aldosterone concentrations in the context of this renin suppression are associated with an increased risk for hypertension and possibly also with increased MR activity. These findings suggest a clinically relevant spectrum of subclinical primary aldosteronism (renin-independent aldosteronism) in normotension. PRIMARY FUNDING SOURCE National Institutes of Health.
Collapse
Affiliation(s)
- Jenifer M Brown
- From Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Vanderbilt University, Nashville, Tennessee; University of Washington, Seattle, Washington; London School of Hygiene & Tropical Medicine, London, United Kingdom; Pontificia Universidad Católica de Chile, Santiago, Chile; and University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Cassianne Robinson-Cohen
- From Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Vanderbilt University, Nashville, Tennessee; University of Washington, Seattle, Washington; London School of Hygiene & Tropical Medicine, London, United Kingdom; Pontificia Universidad Católica de Chile, Santiago, Chile; and University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Miguel Angel Luque-Fernandez
- From Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Vanderbilt University, Nashville, Tennessee; University of Washington, Seattle, Washington; London School of Hygiene & Tropical Medicine, London, United Kingdom; Pontificia Universidad Católica de Chile, Santiago, Chile; and University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Matthew A Allison
- From Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Vanderbilt University, Nashville, Tennessee; University of Washington, Seattle, Washington; London School of Hygiene & Tropical Medicine, London, United Kingdom; Pontificia Universidad Católica de Chile, Santiago, Chile; and University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Rene Baudrand
- From Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Vanderbilt University, Nashville, Tennessee; University of Washington, Seattle, Washington; London School of Hygiene & Tropical Medicine, London, United Kingdom; Pontificia Universidad Católica de Chile, Santiago, Chile; and University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Joachim H Ix
- From Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Vanderbilt University, Nashville, Tennessee; University of Washington, Seattle, Washington; London School of Hygiene & Tropical Medicine, London, United Kingdom; Pontificia Universidad Católica de Chile, Santiago, Chile; and University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Bryan Kestenbaum
- From Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Vanderbilt University, Nashville, Tennessee; University of Washington, Seattle, Washington; London School of Hygiene & Tropical Medicine, London, United Kingdom; Pontificia Universidad Católica de Chile, Santiago, Chile; and University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Ian H de Boer
- From Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Vanderbilt University, Nashville, Tennessee; University of Washington, Seattle, Washington; London School of Hygiene & Tropical Medicine, London, United Kingdom; Pontificia Universidad Católica de Chile, Santiago, Chile; and University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Anand Vaidya
- From Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Vanderbilt University, Nashville, Tennessee; University of Washington, Seattle, Washington; London School of Hygiene & Tropical Medicine, London, United Kingdom; Pontificia Universidad Católica de Chile, Santiago, Chile; and University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego, California
| |
Collapse
|
41
|
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.
Collapse
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
| |
Collapse
|
42
|
Kline GA, Prebtani APH, Leung AA, Schiffrin EL. Primary aldosteronism: a common cause of resistant hypertension. CMAJ 2017; 189:E773-E778. [PMID: 28584041 DOI: 10.1503/cmaj.161486] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Gregory A Kline
- Department of Endocrinology (Kline, Leung), University of Calgary, Calgary, Alta.; Department of Internal Medicine, Endocrinology and Metabolism (Prebtani), McMaster University, Hamilton, Ont.; Department of Medicine (Schiffrin), Jewish General Hospital and Lady Davis Research Institute, McGill University, Montréal, Que.
| | - Ally P H Prebtani
- Department of Endocrinology (Kline, Leung), University of Calgary, Calgary, Alta.; Department of Internal Medicine, Endocrinology and Metabolism (Prebtani), McMaster University, Hamilton, Ont.; Department of Medicine (Schiffrin), Jewish General Hospital and Lady Davis Research Institute, McGill University, Montréal, Que
| | - Alexander A Leung
- Department of Endocrinology (Kline, Leung), University of Calgary, Calgary, Alta.; Department of Internal Medicine, Endocrinology and Metabolism (Prebtani), McMaster University, Hamilton, Ont.; Department of Medicine (Schiffrin), Jewish General Hospital and Lady Davis Research Institute, McGill University, Montréal, Que
| | - Ernesto L Schiffrin
- Department of Endocrinology (Kline, Leung), University of Calgary, Calgary, Alta.; Department of Internal Medicine, Endocrinology and Metabolism (Prebtani), McMaster University, Hamilton, Ont.; Department of Medicine (Schiffrin), Jewish General Hospital and Lady Davis Research Institute, McGill University, Montréal, Que
| |
Collapse
|
43
|
Hundemer GL, Baudrand R, Brown JM, Curhan G, Williams GH, Vaidya A. Renin Phenotypes Characterize Vascular Disease, Autonomous Aldosteronism, and Mineralocorticoid Receptor Activity. J Clin Endocrinol Metab 2017; 102:1835-1843. [PMID: 28323995 PMCID: PMC5470762 DOI: 10.1210/jc.2016-3867] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 02/14/2017] [Indexed: 01/13/2023]
Abstract
CONTEXT Mild cases of autonomous aldosterone secretion may go unrecognized using current diagnostic criteria for primary aldosteronism (PA). OBJECTIVE To investigate whether the inability to stimulate renin serves as a biomarker for unrecognized autonomous aldosterone secretion and mineralocorticoid receptor (MR) activation. PARTICIPANTS Six hundred sixty-three normotensive and mildly hypertensive participants, who were confirmed to not have PA using current guideline criteria and were on no antihypertensive medications. DESIGN Participants had their maximally stimulated plasma renin activity (PRA) measured while standing upright after sodium restriction. Tertiles of maximally stimulated PRA were hypothesized to reflect the degree of MR activation: lowest PRA tertile = "Inappropriate/Excess MR Activity;" middle PRA tertile = "Intermediate MR Activity;"; and highest PRA tertile = "Physiologic MR Activity." All participants underwent detailed biochemical and vascular characterizations under conditions of liberalized sodium intake, and associations with stimulated PRA phenotypes were performed. RESULTS Participants with lower stimulated PRA had greater autonomous aldosterone secretion [higher aldosterone-to-renin ratio (P = 0.002), higher urine aldosterone excretion rate (P = 0.003), higher systolic blood pressure (P = 0.004), and lower renal plasma flow (P = 0.04)] and a nonsignificant trend toward lower serum potassium and higher urine potassium excretion, which became significant after stratification by hypertension status. CONCLUSIONS In participants without clinical PA, the inability to stimulate renin was associated with greater autonomous aldosterone secretion, impaired vascular function, and suggestive trends in potassium handling that indicate an extensive spectrum of unrecognized MR activation.
Collapse
Affiliation(s)
- Gregory L. Hundemer
- Division of Renal Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115
| | - Rene Baudrand
- Program for Adrenal Disorders and Endocrine Hypertension, Department of Endocrinology, Pontificia Universidad Catolica de Chile School of Medicine, Santiago, Chile
| | - Jenifer M. Brown
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts 02115
| | - Gary Curhan
- Division of Renal Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115
| | - Gordon H. Williams
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts 02115
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts 02115
| |
Collapse
|
44
|
Baudrand R, Guarda FJ, Fardella C, Hundemer G, Brown J, Williams G, Vaidya A. Continuum of Renin-Independent Aldosteronism in Normotension. Hypertension 2017; 69:950-956. [PMID: 28289182 DOI: 10.1161/hypertensionaha.116.08952] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 12/30/2016] [Accepted: 01/19/2017] [Indexed: 11/16/2022]
Abstract
Primary aldosteronism is a severe form of autonomous aldosteronism. Milder forms of autonomous and renin-independent aldosteronism may be common, even in normotension. We characterized aldosterone secretion in 210 normotensives who had suppressed plasma renin activity (<1.0 ng/mL per hour), completed an oral sodium suppression test, received an infusion of angiotensin II, and had measurements of blood pressure and renal plasma flow. Continuous associations between urinary aldosterone excretion rate, renin, and potassium handling were investigated. Severe autonomous aldosterone secretion that was consistent with confirmed primary aldosteronism was defined based on accepted criteria of an aldosterone excretion rate >12 μg/24 hours with urinary sodium excretion >200 mmol/24 hours. Across the population, there were strong and significant associations between higher aldosterone excretion rate and higher urinary potassium excretion, higher angiotensin II-stimulated aldosterone, and lower plasma renin activity, suggesting a continuum of renin-independent aldosteronism and mineralocorticoid receptor activity. Autonomous aldosterone secretion that fulfilled confirmatory criteria for primary aldosteronism was detected in 29 participants (14%). Normotensives with evidence suggestive of confirmed primary aldosteronism had higher 24-hour urinary aldosterone excretion rate (20.2±12.2 versus 6.2±2.9 μg/24 hours; P<0.001) as expected, but also higher angiotensin II-stimulated aldosterone (12.4±8.6 versus 6.6±4.3 ng/dL; P<0.001) and lower 24-hour urinary sodium-to-potassium excretion (2.69±0.65 versus 3.69±1.50 mmol/mmol; P=0.001); however, there were no differences in age, aldosterone-to-renin ratio, blood pressure, or renal plasma flow between the 2 groups. These findings indicate a continuum of renin-independent aldosteronism and mineralocorticoid receptor activity in normotension that ranges from subtle to overtly dysregulated and autonomous. Longitudinal studies are needed to determine whether this spectrum of autonomous aldosterone secretion contributes to hypertension and cardiovascular disease.
Collapse
Affiliation(s)
- Rene Baudrand
- From the Program for Adrenal Disorders and Endocrine Hypertension, Department of Endocrinology, School of Medicine, Pontificia Universidad Catolica De Chile, Santiago (R.B., F.J.G., C.F.); and Division of Renal Medicine (G.H.) and Center for Adrenal Disorders, Division of Endocrinology, Diabetes and Hypertension (J.B., G.W., A.V.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Francisco J Guarda
- From the Program for Adrenal Disorders and Endocrine Hypertension, Department of Endocrinology, School of Medicine, Pontificia Universidad Catolica De Chile, Santiago (R.B., F.J.G., C.F.); and Division of Renal Medicine (G.H.) and Center for Adrenal Disorders, Division of Endocrinology, Diabetes and Hypertension (J.B., G.W., A.V.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Carlos Fardella
- From the Program for Adrenal Disorders and Endocrine Hypertension, Department of Endocrinology, School of Medicine, Pontificia Universidad Catolica De Chile, Santiago (R.B., F.J.G., C.F.); and Division of Renal Medicine (G.H.) and Center for Adrenal Disorders, Division of Endocrinology, Diabetes and Hypertension (J.B., G.W., A.V.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gregory Hundemer
- From the Program for Adrenal Disorders and Endocrine Hypertension, Department of Endocrinology, School of Medicine, Pontificia Universidad Catolica De Chile, Santiago (R.B., F.J.G., C.F.); and Division of Renal Medicine (G.H.) and Center for Adrenal Disorders, Division of Endocrinology, Diabetes and Hypertension (J.B., G.W., A.V.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jenifer Brown
- From the Program for Adrenal Disorders and Endocrine Hypertension, Department of Endocrinology, School of Medicine, Pontificia Universidad Catolica De Chile, Santiago (R.B., F.J.G., C.F.); and Division of Renal Medicine (G.H.) and Center for Adrenal Disorders, Division of Endocrinology, Diabetes and Hypertension (J.B., G.W., A.V.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gordon Williams
- From the Program for Adrenal Disorders and Endocrine Hypertension, Department of Endocrinology, School of Medicine, Pontificia Universidad Catolica De Chile, Santiago (R.B., F.J.G., C.F.); and Division of Renal Medicine (G.H.) and Center for Adrenal Disorders, Division of Endocrinology, Diabetes and Hypertension (J.B., G.W., A.V.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Anand Vaidya
- From the Program for Adrenal Disorders and Endocrine Hypertension, Department of Endocrinology, School of Medicine, Pontificia Universidad Catolica De Chile, Santiago (R.B., F.J.G., C.F.); and Division of Renal Medicine (G.H.) and Center for Adrenal Disorders, Division of Endocrinology, Diabetes and Hypertension (J.B., G.W., A.V.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|