Use of plasma aldosterone concentration-to-plasma renin activity ratio as a screening test for primary aldosteronism

Abstract Primary aldosteronism affects 5–13% of patients with hypertension. Patients with hypertension and hypokalemia and most patients with treatment-resistant hypertension should undergo screening for primary aldosteronism with a plasma aldosterone concentration to plasma renin activity ratio. A high plasma aldosterone concentration to plasma renin activity ratio is a positive screening test result, a finding that warrants confirmatory testing. For those patients that want to pursue a surgical cure, the accurate distinction between the subtypes (unilateral vs. bilateral adrenal disease) of primary aldosteronism is a critical step. The subtype evaluation may require one or more tests, the first of which is imaging the adrenal glands with computed tomography, followed by selective use of adrenal venous sampling. Because of the deleterious cardiovascular effects of aldosterone, normalization of circulating aldosterone or aldosterone receptor blockade should be part of the management plan for all patients with primary aldosteronism. Unilateral laparoscopic adrenalectomy is an excellent treatment option for patients with unilateral aldosterone-producing adenoma. Bilateral idiopathic hyperaldosteronism should be treated medically. In addition, aldosterone-producing adenoma patients may be treated medically if the medical treatment includes mineralocorticoid receptor blockade.

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Effects of Ramipril on the Aldosterone/Renin Ratio and the Aldosterone/Angiotensin II Ratio in Patients With Primary Aldosteronism

Hypertension ◽

10.1161/hypertensionaha.120.14871 ◽

2020 ◽

Vol 76 (2) ◽

pp. 488-496 ◽

Cited By ~ 2

Author(s):

Zeng Guo ◽

Marko Poglitsch ◽

Diane Cowley ◽

Oliver Domenig ◽

Brett C. McWhinney ◽

...

Keyword(s):

Angiotensin Ii ◽

Plasma Renin Activity ◽

Ace Inhibitors ◽

Primary Aldosteronism ◽

Characteristic Curve ◽

False Negative ◽

Plasma Renin ◽

Plasma Aldosterone ◽

Renin Activity ◽

Plasma Aldosterone Concentration

The aldosterone/renin ratio (ARR) is currently considered the most reliable approach for case detection of primary aldosteronism (PA). ACE (Angiotensin-converting enzyme) inhibitors are known to raise renin and lower aldosterone levels, thereby causing false-negative ARR results. Because ACE inhibitors lower angiotensin II levels, we hypothesized that the aldosterone/equilibrium angiotensin II (eqAngII) ratio (AA2R) would remain elevated in PA. Receiver operating characteristic curve analysis involving 60 patients with PA and 40 patients without PA revealed that the AA2R was not inferior to the ARR in screening for PA. When using liquid chromatography-tandem mass spectrometry to measure plasma aldosterone concentration, the predicted optimal AA2R cutoff for PA screening was 8.3 (pmol/L)/(pmol/L). We then compared the diagnostic performance of the AA2R with the ARR among 25 patients with PA administered ramipril (5 mg/day) for 2 weeks. Compared with basally, plasma levels of equilibrium angiotensin I (eqAngI) and direct renin concentration increased significantly ( P <0.01 or P <0.05) after ramipril treatment, whereas eqAngII and ACE activity (eqAngII/eqAngI) decreased significantly ( P <0.01). The changes of plasma renin activity and plasma aldosterone concentration in the current study were not significant. On day 14, 4 patients displayed false-negative results using ARR_direct renin concentration (plasma aldosterone concentration/direct renin concentration), 3 of whom also showed false-negative ARR_plasma renin activity (plasma aldosterone concentration/plasma renin activity). On day 15, 2 patients still demonstrated false-negative ARR_plasma renin activity, one of whom also showed a false-negative ARR_direct renin concentration. No false-negative AA2R results were observed on either day 14 or 15. In conclusion, compared with ARR which can be affected by ACE inhibitors causing false-negative screening results, the AA2R seems to be superior in detecting PA among subjects receiving ACE inhibitors.

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Screening for Primary Aldosteronism in Essential Hypertension: Diagnostic Accuracy of the Ratio of Plasma Aldosterone Concentration to Plasma Renin Activity

Yearbook of Surgery ◽

10.1016/s0090-3671(08)70424-5 ◽

2006 ◽

Vol 2006 ◽

pp. 161

Author(s):

T.J. Fahey

Keyword(s):

Essential Hypertension ◽

Plasma Renin Activity ◽

Diagnostic Accuracy ◽

Primary Aldosteronism ◽

Plasma Renin ◽

Plasma Aldosterone ◽

Renin Activity ◽

Plasma Aldosterone Concentration

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Diagnostics of primary aldosteronism: is obligatory use of confirmatory tests justified?

Journal of the Renin-Angiotensin-Aldosterone System ◽

10.1177/1470320312438791 ◽

2012 ◽

Vol 13 (3) ◽

pp. 367-371 ◽

Cited By ~ 6

Author(s):

Janusz Myśliwiec ◽

Łukasz żukowski ◽

Anna Grodzka ◽

Agata Piłaszewicz ◽

Szymon Drągowski ◽

...

Keyword(s):

Plasma Renin Activity ◽

Primary Aldosteronism ◽

Plasma Renin ◽

Cost Effective ◽

Plasma Aldosterone ◽

Renin Activity ◽

Plasma Aldosterone Concentration ◽

Number Of Patients ◽

Confirmatory Tests ◽

Medical University

Introduction: Assessment of the renin-angiotensin-aldosterone system has been recently granted a much greater role in the evaluation of patients with arterial hypertension. There is no single test efficient in selection of patients for second-step etiological investigation. Methods: Altogether, 198 consecutive patients − 119 women (60%) and 79 men (40%) – hospitalized in years 2009–2011 at the Clinical Department of Endocrinology Medical University of Bialystok were diagnosed with primary aldosteronism. In each patient, plasma renin activity and plasma aldosterone concentration (basic and after 2 l NaCl infusion) were evaluated. Results: The percentage of patients with plasma aldosterone concentration ≥15 ng/ml was 53 and the percentage of patients with plasma renin activity ≤0.1 ng/ml/h was 20. The percentage of patients screened for primary aldosteronism in which the aldosterone:renin ratio exceeded consecutive cut-offs of 20, 30, 40 and 50 were respectively 57, 45, 34 and 29. Among 15 patients in which plasma aldosterone concentration after infusion of 2 l of saline was ≥6.5 ng/dl (8.6%), 13 (6.6%) were diagnosed with primary aldosteronism. Conclusion: The obligatory use of tests confirming autonomy of aldosterone secretion in patients screened for primary aldosteronism seems cost-effective in limiting the number of patients for further diagnosis.

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