Role of Aldosterone and Potassium Levels in Sparing Confirmatory Tests in Primary Aldosteronism

2019 ◽  
Vol 105 (4) ◽  
pp. 1284-1289 ◽  
Author(s):  
Hironobu Umakoshi ◽  
Ryuichi Sakamoto ◽  
Yayoi Matsuda ◽  
Maki Yokomoto-Umakoshi ◽  
Hiromi Nagata ◽  
...  
Keyword(s):  
Serum Potassium ◽  
Primary Aldosteronism ◽  
Challenge Test ◽  
Plasma Renin ◽  
Diagnostic Value ◽  
Cross Sectional Study ◽  
Cross Sectional ◽  
Plasma Aldosterone Concentration ◽  
Confirmatory Tests

Abstract Context The current clinical guidelines suggest that confirmatory tests for primary aldosteronism (PA) may be excluded in some of patients who have elevated plasma aldosterone concentration (PAC) under plasma renin suppression. However, this has low-priority evidence and is under debate in use of serum potassium. Objective This study aimed to investigate an appropriate setting for sparing confirmatory tests in PA. Design and Setting A retrospective cross-sectional study in a single referral center. Participants This study included 327 patients who had hypertension under plasma renin suppression and underwent the captopril challenge test (CCT) between January 2007 and April 2019. CCT results were used to diagnose PA. Main Outcome Measure Diagnostic value of PAC and serum potassium in confirmation of PA. Results Of the studied patients, 252 of 327 (77%) were diagnosed with PA. All 61 patients with PAC > 30 ng/dL were diagnosed with PA. In patients with PAC between 20 and 30 ng/dL, 44 of 55 (80%) were diagnosed with PA, while all 26 with PAC between 20 to 30 ng/dL who had spontaneous hypokalemia were diagnosed with PA. The proportion of unilateral PA determined by adrenal vein sampling (AVS) was higher in patients who had PAC > 30 ng/dL or those with spontaneous hypokalemia who had PAC between 20 and 30 ng/dL than those who did not meet the criteria (76% vs. 17%, P < .001). Conclusion Confirmatory tests in PA could be spared in patients who have typical features of PA and these patients had a high probability of unilateral PA on AVS.

scholarly journals SAT-551 Sparing Confirmatory Tests in Primary Aldosteronism

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Hironobu Umakoshi ◽  
Ryuichi Sakamoto ◽  
Yayoi Matsuda ◽  
Maki Yokomoto-Umakoshi ◽  
Hiromi Nagata ◽  
...  
Keyword(s):  
Serum Potassium ◽  
Primary Aldosteronism ◽  
Challenge Test ◽  
Plasma Renin ◽  
Diagnostic Value ◽  
Cross Sectional Study ◽  
Cross Sectional ◽  
Plasma Aldosterone Concentration ◽  
Confirmatory Tests ◽  
Operator Curve

Abstract Context: The current clinical guidelines suggest that confirmatory tests for primary aldosteronism (PA) may be excluded in some of patients who have elevated plasma aldosterone concentration (PAC) under plasma renin suppression. However, this has low priority evidence and is under debate in use of serum potassium. Objective: This study aimed to investigate an appropriate setting for sparing confirmatory tests in PA. Design and Setting: A retrospective cross-sectional study in a single referral center. Participants: This study included 327 patients who had hypertension under plasma renin suppression and underwent captopril challenge test (CCT) between January 2007 and April 2019. CCT results were used to diagnose PA. Main outcome measure: Diagnostic value of PAC and serum potassium in confirmation of PA. Results: Of the studied patients, 252 of 327 (77%) were diagnosed with PA. All 61 patients with PAC >30 ng/dl were diagnosed with PA. In patients with PAC between 20 and 30 ng/dl, 44 of 55 (80%) were diagnosed with PA, while all 26 with PAC between 20 to 30 ng/dl who had spontaneous hypokalemia were diagnosed with PA. Areceiver operator curve analysis showed that the sensitivity of diagnosis of PA is 100% in our patients, when PAC set at > 28.8 ng/dl and showed that the sensitivity of diagnosis of PA is 100% in our patients with spontaneous hypokalemia, who had PAC < 30 ng/dl, when PAC was set at > 19.2 ng/dl. While, the prevalence of PA was higher in patients with hypokalemia, who had PAC between 10 and 20 ng/dl than in those with PAC < 10 ng/dl. Collectively, 100 out of 102 (98%) with hypokalemia, who had PAC > 10 ng/dl were diagnosed as PA. The proportion of unilateral PA determined by adrenal vein sampling (AVS) was higher in patients who had PAC >30 ng/dl or those with spontaneous hypokalemia who had PAC between 20 and 30 ng/dl than those who did not meet the criteria (76% vs. 17%, P<0.001). Conclusion: Confirmatory tests in PA could be spared in patients who have typical features of PA and these patients had a high probability of unilateral PA on AVS.

scholarly journals Significance of Discordant Results: between Confirmatory Tests in Diagnosis of Primary Aldosteronism

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A95-A96
Author(s):  
Tazuru Fukumoto ◽  
Hironobu Umakoshi ◽  
Masatoshi Ogata ◽  
Maki Yokomoto-Umakoshi ◽  
Yayoi Matsuda ◽  
...  
Keyword(s):  
Positive Result ◽  
Primary Aldosteronism ◽  
Challenge Test ◽  
Cross Sectional Study ◽  
Confirmatory Test ◽  
Double Positive ◽  
Cross Sectional ◽  
Confirmatory Tests ◽  
Single Positive

Abstract Context: Current clinical guidelines recommend confirmation of positive result in at least one confirmatory test in the diagnosis of primary aldosteronism (PA). Clinical implication of multiple confirmatory tests has not been established, especially when patients show discordant results. Objective: The aim of the present study was to explore the role of two confirmatory tests in subtype diagnosis of PA. Design: Retrospective cross-sectional study. Setting: The study was conducted at two referral centers. Participants and Method: We identified 360 hypertensive patients who underwent both captopril challenge test (CCT) and saline infusion test (SIT) and exhibited at least one positive result. Among them, we studied 193 patients with PA whose data were available for subtype diagnosis based on adrenal vein sampling (AVS). Main Outcome Measure: The prevalence of bilateral subtype on AVS according to the results of the confirmatory tests. Results: Of patients studied, 127 were positive for both CCT and SIT (double-positive), while 66 were positive for either CCT or SIT (single-positive) (n = 34 and n = 32, respectively). Altogether, 135 were diagnosed with bilateral subtype on AVS. The single-positive patients had milder clinical features of PA than the double-positive patients. The prevalence of bilateral subtype on AVS was significantly higher in the single-positive patients than in the double-positive patients. (63/66 [95.5%] vs. 72/127 [56.7%], P < 0.01). Several clinical parameters were different between CCT single-positive and SIT single-positive patients. Conclusion: Patients with discordant results between CCT and SIT have a high probability of bilateral subtype of PA on AVS.

Development and Validation of Criteria for Sparing Confirmatory Tests in Diagnosing Primary Aldosteronism

2020 ◽  
Vol 105 (7) ◽  
pp. e2449-e2456 ◽  
Author(s):  
Kanran Wang ◽  
Jinbo Hu ◽  
Jun Yang ◽  
Ying Song ◽  
Peter J Fuller ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Challenge Test ◽  
Plasma Renin ◽  
Diagnostic Value ◽  
Endocrine Society ◽  
Plasma Aldosterone Concentration ◽  
Hypertensive Patients ◽  
Confirmatory Tests ◽  
Chinese Cohort ◽  
Development And Validation

Abstract Context The Endocrine Society Guidelines for the diagnosis of primary aldosteronism (PA) suggest that confirmatory tests (CFT) are not required when the following criteria are met: plasma aldosterone concentration (PAC) is >20 ng/dL, plasma renin is below detection levels, and hypokalemia is present. The evidence for the applicability of the guideline criteria is limited. Objective To develop and validate optimized criteria for sparing CFT in the diagnosis of PA. Design and Setting The optimized criteria were developed in a Chinese cohort using the captopril challenge test, verified by saline infusion test (SIT) and fludrocortisone suppression test (FST), and validated in an Australian cohort. Participants Hypertensive patients who completed PA screening and CFT. Main Outcome Measure Diagnostic value of the optimized criteria. Results In the development cohort (518 PA and 266 non-PA), hypokalemia, PAC, and plasma renin concentration (PRC) were selected as diagnostic indicators by multivariate logistic analyses. The combination of PAC >20 ng/dL plus PRC <2.5 μIU/mL plus hypokalemia had much higher sensitivity than the guideline criteria (0.36 vs 0.11). The optimized criteria remained superior when the SIT or FST were used as CFT. Non-PA patients were not misdiagnosed by either criteria, but the percentage of patients in whom CFT could be spared was higher with the optimized criteria. In the validation cohort (125 PA and 81 non-PA), the sensitivity of the optimized criteria was also significantly higher (0.12 vs 0.02). Conclusions Hypertensive patients with PAC >20 ng/dL, PRC <2.5 μIU/mL, plus hypokalemia can be confidently diagnosed with PA without confirmatory tests.

Significance of Discordant Results Between Confirmatory Tests in Diagnosis of Primary Aldosteronism

2020 ◽  
Author(s):  
Tazuru Fukumoto ◽  
Hironobu Umakoshi ◽  
Masatoshi Ogata ◽  
Maki Yokomoto-Umakoshi ◽  
Yayoi Matsuda ◽  
...  
Keyword(s):  
Positive Result ◽  
Primary Aldosteronism ◽  
Challenge Test ◽  
Cross Sectional Study ◽  
Confirmatory Test ◽  
Double Positive ◽  
Cross Sectional ◽  
Confirmatory Tests ◽  
Single Positive

Abstract Context Current clinical guidelines recommend confirmation of a positive result in at least one confirmatory test in the diagnosis of primary aldosteronism (PA). Clinical implication of multiple confirmatory tests has not been established, especially when patients show discordant results. Objective The aim of the present study was to explore the role of 2 confirmatory tests in subtype diagnosis of PA. Design and Setting A retrospective cross-sectional study was conducted at two referral centers. Participants and Methods We identified 360 hypertensive patients who underwent both a captopril challenge test (CCT) and a saline infusion test (SIT) and exhibited at least one positive result. Among them, we studied 193 patients with PA whose data were available for subtype diagnosis based on adrenal vein sampling (AVS). Main Outcome Measure The prevalence of bilateral subtype on AVS according to the results of the confirmatory tests was measured. Results Of patients studied, 127 were positive for both CCT and SIT (double-positive), whereas 66 were positive for either CCT or SIT (single-positive) (n = 34 and n = 32, respectively). Altogether, 135 were diagnosed with bilateral subtype on AVS. The single-positive patients had milder clinical features of PA than the double-positive patients. The prevalence of bilateral subtype on AVS was significantly higher in the single-positive patients than in the double-positive patients. (63/66 [95.5%] vs 72/127 [56.7%], P < .01). Several clinical parameters were different between CCT single-positive and SIT single-positive patients. Conclusion Patients with discordant results between CCT and SIT have a high probability of bilateral subtype of PA on AVS.

scholarly journals The Value of Different Single or Combined Indexes of the Captopril Challenge Test in the Diagnosis of Primary Aldosteronism

2021 ◽  
Vol 12 ◽  
Author(s):  
Qiao Xiang ◽  
Tao Chen ◽  
Kai Yu ◽  
Yuanmei Li ◽  
Qianrui Li ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Characteristic Curve ◽  
Challenge Test ◽  
Influence Factors ◽  
Binary Logistic Regression ◽  
Plasma Renin ◽  
Diagnostic Value ◽  
Diagnostic Efficacy ◽  
Plasma Aldosterone Concentration ◽  
Logistic Regression Models

ObjectiveThe result interpretation of the captopril challenge test (CCT) for the diagnosis of primary aldosteronism (PA) is not standardized. Superiorities of different indexes in the CCT have not been fully investigated. We aimed to comprehensively evaluate the value and influence factors of different CCT-associated indexes in the diagnosis of PA.MethodsWe enrolled 312, 85, 179 and 97 patients in the groups of PA, essential hypertension (EH), unilateral PA (UPA) and bilateral PA (BPA), respectively. For each single index investigated, we computed diagnostic estimates including the area under the receiver operating characteristic curve (AUC). We performed pre-specified subgroup analyses to explore influence factors. We assessed the diagnostic value of combined indexes in binary logistic regression models.ResultsPost-CCT aldosterone to renin ratio (ARR) (AUC = 0.8771) and plasma aldosterone concentration (PAC) (AUC = 0.8769) showed high value in distinguishing PA from EH, and their combination (AUC = 0.937) was even superior to either alone. The diagnostic efficacy was moderately high for post-CCT aldosterone to angiotensin II ratio (AA2R) (AUC = 0.834) or plasma renin activity (PRA) (AUC = 0.795) but low for the suppression percentage of PAC (AUC = 0.679). Post-CCT PAC had a significantly higher AUC in the UPA than BPA subgroup (AUC = 0.914 vs 0.827, P<0.05).ConclusionWe can take post-CCT ARR and PAC altogether into account to distinguish PA from EH, while caution should be taken to interpret CCT results with the suppression percentage of PAC. Post-CCT PAC may perform better to identify the unilateral than bilateral form of PA.

scholarly journals Patients with pheochromocytoma exhibit low aldosterone renin ratio

2020 ◽  
Author(s):  
Tomoko Yamada ◽  
Hidenori Fukuoka ◽  
Yusei Hosokawa ◽  
Yukiko Odake ◽  
Kenichi Yoshida ◽  
...  
Keyword(s):  
Operating Characteristic ◽  
Adrenal Adenoma ◽  
Characteristic Curve ◽  
Plasma Renin ◽  
Cross Sectional Study ◽  
University Hospital ◽  
Adrenal Tumors ◽  
Cross Sectional ◽  
Plasma Aldosterone Concentration ◽  
Sensitive Marker

Abstract Background Plasma renin activity (PRA) is generally increased in patients with pheochromocytoma (PCC) due to low circulating plasma volume and activation of β-1 adrenergic receptor signaling. However, there has been no study on the aldosterone renin ratio (ARR) in patients with PCC. To elucidate the issue, this study aimed to determine the PRA, plasma aldosterone concentration (PAC), and ARR in patients with PCC and compare them with those in patients with subclinical Cushing’s syndrome (SCS) and non-functioning adrenal adenoma (NFA). Methods In this retrospective single-center, cross-sectional study, 67 consecutive patients with adrenal tumors (PCC (n =18), SCS (n =18), and NFA (n =31)) diagnosed at Kobe University Hospital between 2008 and 2014 were enrolled. Results PRA was significantly higher in patients with PCC than in those with SCS and NFA (2.1 (1.3~2.8) vs. 0.7 (0.5~1.8) and 0.9 (0.6~1.4) ng/mL/h; p =0.018 and p =0.025). Although PACs were comparable among the three groups, ARR was significantly lower in patients with PCC than in those with SCS and NFA (70.5 (45.5~79.5) vs. 156.0 (92.9~194.5) and 114.9 (90.1~153.4); p =0.001 and p <0.001). Receiver operating characteristic curve analysis demonstrated that, in differentiating PCC from NFA, PRA >1.55 ng/mL/h showed a sensitivity of 70.0% and specificity of 80.6%. Interestingly, ARR <95.4 showed a sensitivity of 83.3% and specificity of 86.7%, which were higher than those in PRA. Conclusions ARR decreased in patients with PCC, which was a more sensitive marker than PRA. Further study is necessary to understand the usefulness of this convenient marker in the detection of PCC.

scholarly journals Reassessment of Urinary Aldosterone Measurement After Saline Infusion in Primary Aldosteronism

2020 ◽  
Vol 4 (9) ◽  
Author(s):  
Hiroki Kaneko ◽  
Hironobu Umakoshi ◽  
Yuki Ishihara ◽  
Kazutaka Nanba ◽  
Mika Tsuiki ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Sodium Intake ◽  
Characteristic Curve ◽  
Diagnostic Value ◽  
Cross Sectional Study ◽  
Saline Infusion ◽  
Loading Test ◽  
Cross Sectional ◽  
Sodium Loading ◽  
Oral Sodium

Abstract Context Urinary aldosterone levels (Uald) are widely measured in the oral sodium-loading test to confirm primary aldosteronism (PA), but reliable studies on their diagnostic value are limited. This may be due to the difficulty in collecting urine with reliable accuracy, keeping oral sodium intake constant between patients. Therefore, we focused on 24-hour Uald after intravenous saline infusion in a hospitalized setting, which provides a reliable sodium load in consistent amounts. Objective Comparing plasma aldosterone concentrations (PAC) and Uald after saline infusion in the sitting position, to evaluate the accuracy in determining PA subtypes and the correlation of both measurements. Design and Setting This was a retrospective cross-sectional study in a single referral center. Patients Of 53 patients without renal dysfunction who were diagnosed with PA and underwent adrenal venous sampling, 16 and 37 were diagnosed with unilateral and bilateral PA, respectively. Main Outcome Measures Uald collected for 24 hours and PAC after saline infusion. Results The area under the receiver operating characteristic curve for diagnosing unilateral PA was not significantly different between Uald and PAC after saline infusion (0.921 and 0.958, respectively; P = 0.370). The predicted optimal cutoff value of Uald was 16.5 μg/day (sensitivity, 87.5%; specificity, 100%), and that of PAC after saline infusion was 19.3 ng/dL (sensitivity, 87.5%; specificity, 97.3%). In studied patients with PA, Uald was positively correlated with PAC after saline infusion (r = 0.617; P &lt; 0.001). Conclusions We reassessed Uald in PA patients under sufficient sodium loading and demonstrated the correlation between Uald and PAC after saline infusion.

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

2012 ◽  
Vol 13 (3) ◽  
pp. 367-371 ◽  
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.

Baseline Plasma Aldosterone Level and Renin Activity Allowing Omission of Confirmatory Testing in Primary Aldosteronism

2020 ◽  
Vol 105 (5) ◽  
pp. e1990-e1998 ◽  
Author(s):  
Junji Kawashima ◽  
Eiichi Araki ◽  
Mitsuhide Naruse ◽  
Isao Kurihara ◽  
Katsutoshi Takahashi ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Challenge Test ◽  
Plasma Renin ◽  
Plasma Aldosterone ◽  
Renin Activity ◽  
Plasma Aldosterone Concentration ◽  
Cutoff Value ◽  
Confirmatory Testing ◽  
Cutoff Values ◽  
Number Of Patients

Abstract Context Previous studies have proposed cutoff value of baseline plasma aldosterone concentration (bPAC) under renin suppression that could diagnose primary aldosteronism (PA) without confirmatory testing. However, those studies are limited by selection bias due to a small number of patients and a single-center study design. Objective This study aimed to determine cutoff value of bPAC and baseline plasma renin activity (bPRA) for predicting positive results in confirmatory tests for PA. Design The multi-institutional, retrospective, cohort study was conducted using the PA registry in Japan (JPAS/JRAS). We compared bPAC in patients with PA who showed positive and negative captopril challenge test (CCT) or saline infusion test (SIT) results. Patients Patients with PA who underwent CCT (n = 2256) and/or SIT (n = 1184) were studied. Main outcome measures The main outcomes were cutoff value of bPAC (ng/dL) and bPRA (ng/mL/h) for predicting positive CCT and/or SIT results. Results In patients with renin suppression (bPRA ≤ 0.3), the cutoff value of bPAC that would give 100% specificity for predicting a positive SIT result was lower than that for predicting a positive CCT result (30.85 vs 56.35, respectively). Specificities of bPAC cutoff values ≥ 30.85 for predicting positive SIT and CCT results remained high (100.0% and 97.0%, respectively) in patients with bPRA ≤ 0.6. However, the specificities of bPAC cutoff values ≥ 30.85 for predicting positive SIT and CCT results decreased when patients with bPRA &gt; 0.6 were included. Conclusion Confirmatory testing could be omitted in patients with bPAC ≥ 30.85 in the presence of bPRA ≤ 0.6.

scholarly journals Aldosterone-to-renin ratio is related to arterial stiffness when the screening criteria of primary aldosteronism are not met

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Eeva Kokko ◽  
Pasi I. Nevalainen ◽  
Manoj Kumar Choudhary ◽  
Jenni Koskela ◽  
Antti Tikkakoski ◽  
...  
Keyword(s):  
Arterial Stiffness ◽  
Primary Aldosteronism ◽  
Pulse Wave ◽  
Linear Regression Analysis ◽  
Plasma Renin ◽  
Cross Sectional Study ◽  
Whole Body ◽  
Cross Sectional ◽  
Mean Values ◽  
Aldosterone To Renin Ratio

AbstractAldosterone-to-renin ratio (ARR) is a screening tool for primary aldosteronism (PA), but the significance of ARR when the PA criteria are not met remains largely unknown. In this cross-sectional study we investigated the association of ARR with haemodynamic variables in 545 normotensive and never-medicated hypertensive subjects (267 men, 278 women, age range 19–72 years) without suspicion of PA. Supine haemodynamic data was recorded using whole-body impedance cardiography and radial tonometric pulse wave analysis. In sex-adjusted quartiles of ARR, determined as serum aldosterone to plasma renin activity ratio, the mean values were 282, 504, 744 and 1467 pmol/µg of angiotensin I/h, respectively. The only difference in haemodynamic variables between the ARR quartiles was higher pulse wave velocity (PWV) in the highest quartile versus other quartiles (p = 0.004), while no differences in blood pressure (BP), heart rate, wave reflections, cardiac output or systemic vascular resistance were observed between the quartiles. In linear regression analysis with stepwise elimination, ARR was an independent explanatory factor for PWV (β = 0.146, p < 0.001, R2 of the model 0.634). In conclusion, ARR was directly and independently associated with large arterial stiffness in individuals without clinical suspicion of PA. Therefore, ARR could serve as a clinical marker of cardiovascular risk.Trial registration: ClinicalTrails.gov: NCT01742702.

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