1
|
Fernandez CJ, Nagendra L, Alkhalifah M, Pappachan JM. Endocrine Hypertension: The Urgent Need for Greater Global Awareness. TOUCHREVIEWS IN ENDOCRINOLOGY 2023; 19:31-41. [PMID: 38187076 PMCID: PMC10769474 DOI: 10.17925/ee.2023.19.2.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/04/2023] [Indexed: 01/09/2024]
Abstract
Hypertension affects about 1.28 billion adults globally, and significantly increases the risk of chronic morbidity and mortality among sufferers. About 15% of these individuals have secondary hypertension, the majority of whom have dysfunction of one or more endocrine systems as the cause of hypertension. Although adrenal disorders are often identified as the cause of endocrine hypertension, extra-adrenal disease and pituitary disorders also can cause the disease. Timely diagnosis is of paramount importance, because of the potential for a surgical cure or optimal disease control with pharmacotherapy to prevent hypertensive complications. Even with its relatively high prevalence compared with many other chronic illnesses, the diagnosis of endocrine hypertension is often delayed or never made because of poor awareness about the disease among physicians. This review attempts to provide an overview of the disease, with some practical aspects of diagnosis and management of a few of the important disorders causing endocrine hypertension.
Collapse
Affiliation(s)
- Cornelius J Fernandez
- Department of Endocrinology and Metabolism, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - Lakshmi Nagendra
- Department of Endocrinology, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, India
| | - Mohammed Alkhalifah
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston, UK
- Department of Family Medicine & Diabetes, King Saud University Medical City, Riyad, Saudi Arabia
| | - Joseph M Pappachan
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston, UK
- Faculty of Science, Manchester Metropolitan University, Manchester, UK
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| |
Collapse
|
2
|
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
|
3
|
Libianto R, Stowasser M, Russell G, Fuller PJ, Yang J. Improving Detection Rates for Primary Aldosteronism. Exp Clin Endocrinol Diabetes 2023; 131:402-408. [PMID: 37160153 DOI: 10.1055/a-2048-6213] [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: 05/11/2023]
Abstract
Primary aldosteronism (PA), once considered a rare disease, is being increasingly recognized as an important cause of hypertension. It is associated with higher rates of cardiovascular complications compared to blood pressure-matched essential hypertension. Targeted treatments are available which can mitigate the excess cardiovascular risks and, in some cases, cure hypertension. Making a timely diagnosis of PA is, therefore, highly beneficial for patients. Furthermore, numerous studies from different parts of the world have found PA to be a relatively common disease that can affect patients in any stage of hypertension, regardless of their age or potassium levels. Despite this well-established data, the current rate of PA detection is appallingly low, much below its actual prevalence. This review explores the challenges that clinicians often face in diagnosing PA and offers strategies that may improve the detection of this potentially curable form of hypertension.
Collapse
Affiliation(s)
- Renata Libianto
- Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Monash Health, Clayton, Victoria
- Monash University, Clayton, Victoria, Australia
| | | | | | - Peter J Fuller
- Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Monash Health, Clayton, Victoria
| | - Jun Yang
- Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Monash Health, Clayton, Victoria
- Monash University, Clayton, Victoria, Australia
| |
Collapse
|
4
|
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
|
5
|
Abstract
Primary aldosteronism is a common cause of hypertension and is a risk factor for cardiovascular and renal morbidity and mortality, via mechanisms mediated by both hypertension and direct insults to target organs. Despite its high prevalence and associated complications, primary aldosteronism remains largely under-recognized, with less than 2% of people in at-risk populations ever tested. Fundamental progress made over the past decade has transformed our understanding of the pathogenesis of primary aldosteronism and of its clinical phenotypes. The dichotomous paradigm of primary aldosteronism diagnosis and subtyping is being redefined into a multidimensional spectrum of disease, which spans subclinical stages to florid primary aldosteronism, and from single-focal or multifocal to diffuse aldosterone-producing areas, which can affect one or both adrenal glands. This Review discusses how redefining the primary aldosteronism syndrome as a multidimensional spectrum will affect the approach to the diagnosis and subtyping of primary aldosteronism.
Collapse
Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA.
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
6
|
Ariens J, Horvath AR, Yang J, Choy KW. Performance of the aldosterone-to-renin ratio as a screening test for primary aldosteronism in primary care. Endocrine 2022; 77:11-20. [PMID: 35622194 PMCID: PMC9242901 DOI: 10.1007/s12020-022-03084-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/16/2022] [Indexed: 11/03/2022]
Abstract
Primary aldosteronism (PA) is the most common and potentially curable form of secondary hypertension, affecting 5-10% of primary care patients with hypertension. Primary care physicians have an important role in initiating the screening for PA in patients with hypertension and referring to a specialist service depending on the screening test results. The currently recommended screening test for PA is the plasma aldosterone-to-renin ratio (ARR). Test results are influenced by medications so careful patient preparation is required including adjusting existing antihypertensive medications to avoid diagnostic errors. A range of laboratory method-dependent ARR thresholds are used for the screening of PA around the world. Periodic clinical audits and case reviews by clinicians and the laboratory may help refine the local thresholds. Patients with an abnormally elevated ARR should be referred to a specialist for confirmatory testing while patients with a high pre-test probability but a normal ARR could have a repeat test in view of the within-individual variability. Despite the heterogenous ARR thresholds, measuring the ARR is still more likely to detect PA than not screening at all.
Collapse
Affiliation(s)
- Joshua Ariens
- Northern Clinical School, The University of Melbourne, Melbourne, VIC, Australia
| | - Andrea R Horvath
- Department of Chemical Pathology, NSW Health Pathology, Prince of Wales Hospital, Sydney, NSW, Australia
- Australian Institute of Health Innovation, Centre for Health Systems and Safety Research, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Jun Yang
- Endocrine Hypertension Group, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Medicine, Monash University, Clayton, VIC, Australia
- Department of Endocrinology, Monash Health, Clayton, VIC, Australia
| | - Kay Weng Choy
- Department of Pathology, Northern Health, Epping, VIC, Australia.
| |
Collapse
|
7
|
Libianto R, Russell GM, Stowasser M, Gwini SM, Nuttall P, Shen J, Young MJ, Fuller PJ, Yang J. Detecting primary aldosteronism in Australian primary care: a prospective study. Med J Aust 2022; 216:408-412. [PMID: 35218017 DOI: 10.5694/mja2.51438] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 09/03/2021] [Accepted: 09/10/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the identification of primary aldosteronism (PA) in newly diagnosed, treatment-naïve patients with hypertension by screening in primary care. DESIGN Prospective study. SETTING General practices in the South Eastern Melbourne Primary Health Network with at least three general practitioners and general practices elsewhere in Victoria that had referred patients to the Endocrine Hypertension Clinic at Monash Health, 2017-2020. PARTICIPANTS Adults (18-80 years) with newly diagnosed hypertension (measurements of systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg on at least two occasions) and not taking antihypertensive medications were screened for PA by assessing their aldosterone-to-renin ratio (ARR). Participants with two ARR values exceeding 70 pmol/mU underwent saline suppression testing at the Endocrine Hypertension Service (Monash Health) to confirm the diagnosis of PA. MAIN OUTCOME MEASURES Prevalence of PA (number of patients with confirmed PA divided by number screened). RESULTS Sixty-two of 247 screened participants had elevated ARR values on screening (25%); for 35 people (14%; 95% CI, 10-19%), PA was confirmed by saline suppression testing. Baseline characteristics (mean age, sex distribution, median baseline blood pressure levels, and serum potassium concentration) were similar for people with or without PA. CONCLUSION PA was diagnosed in 14% of patients with newly diagnosed hypertension screened by GPs, indicating a potential role for GPs in the early detection of an important form of secondary hypertension for which specific therapies are available.
Collapse
Affiliation(s)
- Renata Libianto
- Monash Health, Melbourne, VIC.,Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC
| | | | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland, Brisbane, QLD
| | | | - Peta Nuttall
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC
| | - Jimmy Shen
- Monash Health, Melbourne, VIC.,Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC
| | - Morag J Young
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC
| | - Peter J Fuller
- Monash Health, Melbourne, VIC.,Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC
| | - Jun Yang
- Monash Health, Melbourne, VIC.,Monash University, Melbourne, VIC
| |
Collapse
|
8
|
Affiliation(s)
- Kay Weng Choy
- Department of Pathology, Northern Health, Epping, Australia
| | - Peter J Fuller
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Australia
- Department of Endocrinology, Monash Health, Clayton, Australia
- Department of Medicine, Monash University, Clayton, Australia
| | - Grant Russell
- Department of General Practice, Monash University, Clayton, Australia
| | - Qifu Li
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Marianne Leenaerts
- Governing Board, Primary Aldosteronism Foundation (primaryaldosteronism.org)
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Australia
- Department of Endocrinology, Monash Health, Clayton, Australia
- Department of Medicine, Monash University, Clayton, Australia
| |
Collapse
|
9
|
Tezuka Y, Yamazaki Y, Nakamura Y, Sasano H, Satoh F. Recent Development toward the Next Clinical Practice of Primary Aldosteronism: A Literature Review. Biomedicines 2021; 9:biomedicines9030310. [PMID: 33802814 PMCID: PMC8002562 DOI: 10.3390/biomedicines9030310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/08/2021] [Accepted: 03/15/2021] [Indexed: 11/24/2022] Open
Abstract
For the last seven decades, primary aldosteronism (PA) has been gradually recognized as a leading cause of secondary hypertension harboring increased risks of cardiovascular incidents compared to essential hypertension. Clinically, PA consists of two major subtypes, surgically curable and uncurable phenotypes, determined as unilateral or bilateral PA by adrenal venous sampling. In order to further optimize the treatment, surgery or medications, diagnostic procedures from screening to subtype differentiation is indispensable, while in the general clinical practice, the work-up rate is extremely low even in the patients with refractory hypertension because of the time-consuming and labor-intensive nature of the procedures. Therefore, a novel tool to simplify the diagnostic flow has been recently in enormous demand. In this review, we focus on recent progress in the following clinically important topics of PA: prevalence of PA and its subtypes, newly revealed histopathological classification of aldosterone-producing lesions, novel diagnostic biomarkers and prediction scores. More effective strategy to diagnose PA based on better understanding of its epidemiology and pathology should lead to early detection of PA and could decrease the cardiovascular and renal complications of the patients.
Collapse
Affiliation(s)
- Yuta Tezuka
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan; (Y.Y.); (H.S.)
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai 981-8558, Japan;
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan; (Y.Y.); (H.S.)
| | - Fumitoshi Satoh
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan
- Correspondence:
| |
Collapse
|
10
|
Primary aldosteronism is a public health issue: challenges and opportunities. J Hum Hypertens 2020; 34:478-486. [PMID: 32341439 DOI: 10.1038/s41371-020-0336-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/23/2020] [Accepted: 03/27/2020] [Indexed: 12/26/2022]
Abstract
A significant proportion of hypertension (potentially more than 5% in the general population) is due to primary aldosteronism (PA) which carries a worse prognosis when compared with blood pressure-matched essential hypertension. Effective targeted treatments are available which mitigate many of the cardiovascular complications of untreated PA. Despite this, the detection rate of PA in primary care is sub-optimal. In this review, we explore the challenges contributing to the under-diagnosis of PA in the community, including uncertainties regarding its actual prevalence. In order to detect PA early and offer targeted treatment before adverse cardiovascular consequences develop, routine screening for PA at the time of a diagnosis of hypertension would seem desirable. However, this is limited by a lack of studies to establish whether routine screening in primary care is cost-effective. Newer techniques are also being developed which could lessen the complexity of diagnosing PA. Most importantly, a dramatic increase in awareness of PA, as a treatable cause of hypertension, is needed amongst clinicians who manage hypertension.
Collapse
|
11
|
Yang Y, Reincke M, Williams TA. Prevalence, diagnosis and outcomes of treatment for primary aldosteronism. Best Pract Res Clin Endocrinol Metab 2020; 34:101365. [PMID: 31837980 DOI: 10.1016/j.beem.2019.101365] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Primary aldosteronism (PA) is the most common potentially curable form of hypertension. The overproduction of aldosterone leads to an increased risk of cardiovascular and cerebrovascular events as well as adverse effects to the heart and kidney and psychological disorders. PA is mainly caused by unilateral aldosterone excess due to an aldosterone-producing adenoma or bilateral excess due to bilateral adrenocortical hyperplasia. The diagnostic work-up of PA comprises three steps: screening, confirmatory testing and differentiation of unilateral surgically-correctable forms from medically treated bilateral PA. These specific treatments can mitigate or reverse the increased risks associated with PA. Herein we summarise the prevalence, outcomes and current and future clinical approaches for the diagnosis of primary aldosteronism.
Collapse
Affiliation(s)
- Yuhong Yang
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany
| | - Tracy Ann Williams
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy.
| |
Collapse
|