scholarly journals MANAGEMENT OF ENDOCRINE DISEASE: The role of confirmatory tests in the diagnosis of primary aldosteronism

2019 ◽  
Vol 180 (2) ◽  
pp. R45-R58 ◽  
Author(s):  
Julia Morera ◽  
Yves Reznik
Keyword(s):  
Primary Aldosteronism ◽  
Dynamic Testing ◽  
High Sensitivity ◽  
Plasma Aldosterone ◽  
Plasma Aldosterone Concentration ◽  
Aldosterone Production ◽  
Confirmatory Tests ◽  
Aldosterone To Renin Ratio ◽  
Work Up

The strategy for diagnosis of primary aldosteronism (PA) in the hypertensive population includes firstly a screening step, based on the measurement of plasma aldosterone-to-renin ratio (ARR), a test which must have high sensitivity, and secondly a confirmatory step based on the demonstration of excessive aldosterone production independent of the renin-angiotensin-aldosterone system (RAAS) activity. The high proportion of false-positive ARR results and conversely of actual PA without a persistent elevation in baseline plasma aldosterone concentration necessitates the addition of a confirmatory step in the work-up of PA diagnosis. The present review focuses on the description of the different dynamic tests available for demonstrating autonomy of aldosterone secretion, on the performance and limitations of confirmatory tests and on possible strategies for PA diagnosis which may either include or avoid the confirmatory step for PA diagnosis. Large prospective studies comparing different strategies with and without dynamic testing are mandatory to delineate clearly the role and limits of confirmatory tests in the work-up of PA.

Evaluation of Biochemical Conditions Allowing Bypass of Confirmatory Testing in The Workup of Primary Aldosteronism: A Retrospective Study in a French Hypertensive Population

2019 ◽  
Vol 51 (03) ◽  
pp. 172-177 ◽  
Author(s):  
Maud Vivien ◽  
Emilie Deberles ◽  
Remy Morello ◽  
Aimi Haddouche ◽  
David Guenet ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Dynamic Testing ◽  
Challenge Test ◽  
Plasma Aldosterone ◽  
Aldosterone Secretion ◽  
Plasma Aldosterone Concentration ◽  
Hypertensive Patients ◽  
Hypertensive Population ◽  
Tertiary Center ◽  
Aldosterone To Renin Ratio

AbstractThe diagnostic workup for primary aldosteronism includes a screening step using the aldosterone-to-renin ratio (ARR) and a confirmatory step based on dynamic testing of aldosterone secretion autonomy. International guidelines suggest that precise clinical and biochemical conditions may allow the bypassing of the confirmatory step, however, data which validate hormone thresholds defining such conditions are lacking. At our tertiary center, we retrospectively examined a cohort of 173 hypertensive patients screened for PA by the ARR, of whom 120 had positive screening and passed a saline infusion test (SIT) or a captopril challenge test (CCT). Fifty-nine had PA, including 34 Conn adenomas and 25 with idiopathic aldosteronism (IA). Using a threshold of 160 pmol/l, post-SIT plasma aldosterone concentration (PAC) identified PA with 86.4% sensitivity, 94.7% specificity, and a negative predictive value of 92.3%. Of those subjects with a high ARR and a PAC above 550 pmol/l, 93% had a positive SIT, while 100% of subjects with a high ARR, but a PAC under 240 pmol/l had a negative SIT. Our results thus validate the biochemical conditions defined in the French and US guidelines for bypassing the confirmatory step in the workup for PA diagnosis.

scholarly journals Determination of adrenal hypersecretion in primary Aldosteronism without aldosterone-production adenomas

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Fang Sun ◽  
Yangning Hong ◽  
Hexuan Zhang ◽  
Xiaoli Liu ◽  
Zhigang Zhao ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Metabolic Diseases ◽  
Heart Diseases ◽  
Confirmatory Test ◽  
Plasma Aldosterone Concentration ◽  
Aldosterone Production ◽  
Confirmatory Tests ◽  
Biochemical Evaluation ◽  
Aldosterone To Renin Ratio

Abstract Background Primary aldosteronism (PA) is highly prevalent in hypertensive population. Adrenal vein sampling (AVS) is the only procedure to assess adrenal aldosterone hypersecretion in PA. PA patients without aldosterone-producing adenomas (APA) frequently have unilateral aldosterone hypersecretion (UAH). These patients could bear inappropriate adrenalectomy without AVS. This study aims to identify which clinical characteristics should be recommended to perform AVS in these PA patients. Methods This study was performed from January 2018 to July 2019 at a center for hypertension and metabolic diseases. Adrenal computed tomography (CT) scan, biochemical evaluation, and AVS were performed. Results Total 141 patients were included in this study. Aldosterone to renin ratio (ARR) after confirmatory test is highly associated with adrenal laterality. The specificity of ARR > 10 (ng/dL)/(mU/L) after confirmatory test is 100%. After confirmatory test, patients with ARR > 10 (ng/dL)/(mU/L) had higher plasma aldosterone concentration and incidences of ischemic heart diseases and renal damage(p < 0.05). Conclusions After confirmatory tests, ARR > 10 (ng/dL)/(mU/L) indicates adrenal laterality, with increasingly cardiorenal damage in PA patients without APA. Thus, AVS should be recommended in these patients before surgery. Trial registration NCT03398785, Date of Registration: December 24, 2017.

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.

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 &gt; 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 &gt; 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 &lt; .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 Comparisons of plasma aldosterone and renin data between an automated chemiluminescent immunoanalyzer and conventional radioimmunoassays in the screening and diagnosis of primary aldosteronism

PLoS ONE ◽  
2021 ◽  
Vol 16 (7) ◽  
pp. e0253807
Author(s):  
Naohisa Tamura ◽  
Erika Watanabe ◽  
Rumi Shirakawa ◽  
Eiji Nakatani ◽  
Kanako Yamada ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Plasma Aldosterone ◽  
Adrenal Venous Sampling ◽  
Regression Equations ◽  
Venous Sampling ◽  
Characteristic Analysis ◽  
Optimal Cutoff ◽  
Endocrine Society ◽  
Plasma Aldosterone Concentration ◽  
Confirmatory Tests

Determining values of plasma renin activity (PRA) or plasma active renin concentration (ARC), plasma aldosterone concentration (PAC), and aldosterone-to-renin ratio (ARR) is essential to diagnose primary aldosteronism (PA), but it takes several days with conventional radioimmunoassays (RIAs). Chemiluminescent enzyme immunoassays for PAC and ARC using the Accuraseed® immunoanalyzer facilitated the determination, but relations between Accuraseed® immunoanalyzer-based and RIA-based values in samples of PA confirmatory tests and adrenal venous sampling remained to be elucidated. We addressed this issue in the present study. This is a prospective, cross-sectional study. ARC and PAC values were measured by the Accuraseed® immunoanalyzer in samples, in which PRA and PAC values had been measured by the PRA-FR® RIA and SPAC®-S Aldosterone kits, respectively. The relations between Accuraseed® immunoanalyzer-based and RIA-based values were investigated with regression analyses. The optimal cutoff of Accuraseed® immunoanalyzer-based ARR for PA screening was determined by the receiver operating characteristic analysis. After log-log transformations, linear relations with high coefficients of determination were observed between Accuraseed® immunoanalyzer-based and RIA-based data of renin and aldosterone. Following the PA guidelines of Japan Endocrine Society, Accuraseed® immunoanalyzer-based cutoffs were calculated from the regression equations: the basal PAC for PA screening >12 ng/dL, PAC for the saline infusion test >8.2 ng/dL, ARC for the furosemide-upright test <15 pg/mL, and ARR for the captopril challenge test >3.09 ng/dL per pg/mL. The optimal cutoff of Accuraseed® immunoanalyzer-based ARR for PA screening was >2.43 ng/dL over pg/mL not to overlook bilateral PA patients. The present study provided conversion formulas between Accuraseed® immunoanalyzer-based and RIA-based values of renin, aldosterone, and ARR, not only in basal samples but also in samples of PA confirmatory tests and adrenal venous sampling. Although validation studies are awaited, the present study will become priming water of harmonization of renin and aldosterone immunoassays.

scholarly journals A case of Williams syndrome with suspected coexisting ectopic aldosterone-producing tumor in the liver

2020 ◽  
Vol 2020 ◽  
Author(s):  
Shuhei Baba ◽  
Arina Miyoshi ◽  
Shinji Obara ◽  
Hiroaki Usubuchi ◽  
Satoshi Terae ◽  
...  
Keyword(s):  
Williams Syndrome ◽  
Primary Aldosteronism ◽  
High Plasma ◽  
Plasma Aldosterone ◽  
Adrenal Tumors ◽  
Venous Sampling ◽  
Plasma Aldosterone Concentration ◽  
Adrenal Rest Tumor ◽  
Adrenal Rest ◽  
The Right

Summary A 31-year-old man with Williams syndrome (WS) was referred to our hospital because of a 9-year history of hypertension, hypokalemia, and high plasma aldosterone concentration to renin activity ratio. A diagnosis of primary aldosteronism (PA) was clinically confirmed but an abdominal CT scan showed no abnormal findings in his adrenal glands. However, a 13-mm hypervascular tumor in the posterosuperior segment of the right hepatic lobe was detected. Adrenal venous sampling (AVS) subsequently revealed the presence of an extended tributary of the right adrenal vein to the liver surrounding the tumor. Segmental AVS further demonstrated a high plasma aldosterone concentration (PAC) in the right superior tributary vein draining the tumor. Laparoscopic partial hepatectomy was performed. The resected tumor histologically separated from the liver was composed of clear cells, immunohistochemically positive for aldesterone synthase (CYP11B2), and subsequently diagnosed as aldosterone-producing adrenal adenoma. After surgery, his blood pressure, serum potassium level, plasma renin activity and PAC were normalized. To the best of our knowledge, this is the first report of WS associated with PA. WS harbors a high prevalence of hypertension and therefore PA should be considered when managing the patients with WS and hypertension. In this case, the CT findings alone could not differentiate the adrenal rest tumor. Our case, therefore, highlights the usefulness of segmental AVS to distinguish adrenal tumors from hepatic adrenal rest tumors. Learning points: Williams syndrome (WS) is a rare genetic disorder, characterized by a constellation of medical and cognitive findings, with a hallmark feature of generalized arteriopathy presenting as stenoses of elastic arteries and hypertension. WS is a disease with a high frequency of hypertension but the renin-aldosterone system in WS cases has not been studied at all. If a patient with WS had hypertension and severe hypokalemia, low PRA and high ARR, the coexistence of primary aldosteronism (PA) should be considered. Adrenal rest tumors are thought to arise from aberrant adrenal tissues and are a rare cause of PA. Hepatic adrenal rest tumor (HART) should be considered in the differential diagnosis when detecting a mass in the right hepatic lobe. Segmental adrenal venous sampling could contribute to distinguish adrenal tumors from HART.

Role of the pituitary in the effects of tonin on adrenal secretion of the rat

1983 ◽  
Vol 61 (3) ◽  
pp. 201-206 ◽  
Author(s):  
Ernesto L. Schiffrin ◽  
Raul Garcia ◽  
Jolanta Gutkowska ◽  
Jacques Genest
Keyword(s):  
Plasma Renin ◽  
Plasma Corticosterone ◽  
Plasma Aldosterone ◽  
High Rate ◽  
Pituitary Hormone ◽  
Plasma Aldosterone Concentration ◽  
Plasma Angiotensin ◽  
Hypophysectomized Rats ◽  
Adrenal Secretion

Chronically catheterized conscious rats were infused intravenously with tonin at 2.4 and 12 μg∙kg−1∙min−1 for 2 h. Plasma aldosterone concentration (PAC) at the end of the experiment was 11.2 ± 2.4 ng% in controls, 8.5 ± 2.8 ng% in rats infused with tonin at the lower rate, and 26.2 ± 3.6 ng% (p < 0.01 vs. controls) in rats infused at the higher rate. Plasma corticosterone (PC) was significantly higher (p < 0.05) in the group infused at the high rate while plasma renin activity (PRA) was significantly reduced in this group of rats. Plasma angiotensin II (AII) concentration was similar in all three groups. PAC was elevated after tonin infusion in the presence of AII blockade. PAC in conscious sodium-depleted rats infused with tonin was not significantly changed, but PRA was significantly reduced (p < 0.01). In chronically hypophysectomized rats, PAC remained unchanged by tonin infusion. The failure of tonin to stimulate aldosterone in hypophysectomized animals indicates a role of a pituitary hormone (probably ACTH) in the effect of tonin on adrenal secretion.

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