Aldosterone-potassium ratio predicts primary aldosteronism subtype

Puar, Troy; Loh, Wann Jia; Lim, Dawn Shao Ting; Loh, L.; Zhang, Meifen; Foo, Roger; Lee, Lynette; Swee, Du Soon; Khoo, Joan; Tay, Donovan; Kam, Jia Wen; Dekkers, Tanja; Velema, Marieke; Deinum, Jaap; Kek, Peng Chin

doi:10.1097/hjh.0000000000002348

Cited by 31 publications

(44 citation statements)

References 42 publications

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“…This observational retrospective study was registered at http://ClinicalTrials.gov (NCT04428827). Baseline clinical data were obtained from patient medical records as previously described, 13 and all patients included in our study fulfilled the diagnostic criteria recommended by the Endocrine Society guidelines 14 . Details on diagnostic testing are available in Data S1.…”

Section: Methodsmentioning

confidence: 99%

“…We had developed a clinical prediction score, APR, to predict unilateral PA in our Asian cohort and validated this in a European cohort, utilizing only patients with a successful AVS 13 . A high APR was predictive of unilateral disease, with an 84.4% probability in those with APR >10, and 91.7% in those with APR >15.…”

Section: Methodsmentioning

confidence: 99%

“…This clinical prediction score, the aldosterone–potassium ratio (APR), was recently developed in our Asian cohort and validated externally in a European cohort. It was highly accurate in differentiating patients with unilateral PA from those with bilateral PA, 13 with an area under receiver‐operating characteristic curve of 0.80 (95% CI: 0.70–0.89). APR is calculated using the baseline aldosterone (ng/dl) divided by lowest‐recorded potassium, and patients with elevated APR are more likely to have unilateral PA.…”

Section: Introductionmentioning

confidence: 99%

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Outcomes in unilateral primary aldosteronism after surgical or medical therapy

Puar

Loh

et al. 2020

Clinical Endocrinology

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ContextStudies find surgery superior to medications in the treatment of primary aldosteronism (PA). It would be ideal to compare surgical and medical therapy in patients with unilateral PA only, who have the option between these treatment modalities. However, this is challenging as most patients with unilateral PA on adrenal vein sampling (AVS) undergo surgery.ObjectiveTo compare outcomes of surgery and medications in patients with confirmed or likely unilateral PA.DesignRetrospective cohort study of 274 patients with PA managed at two referral centres from 2000 to 2019.Patients154 patients identified with unilateral PA using AVS and a validated clinical prediction model were treated with surgical (n = 86) or medical (n = 68) therapy.MeasurementsPrimary outcome was a composite incident cardiovascular event comprising acute myocardial infarction, coronary revascularization, stroke, atrial fibrillation or congestive cardiac failure. Secondary outcomes were clinical and biochemical control.ResultsCardiovascular outcomes were comparable, with the surgery group having an adjusted hazard ratio of 0.93 (95% CI: 0.32–2.67), p = .89. Both treatments improved clinical and biochemical control, but surgery resulted in better systolic blood pressure, 133.0 ± 11.7 mmHg versus 137.9 ± 14.6 mmHg, p = .02, and lower defined daily dosages of antihypertensive medications, 1.0 (IQR 0.0–2.0) versus 2.6 (IQR 0.8–4.3), p < .001. In addition, 12 of 86 patients in the surgery group failed medical therapy before opting for surgery.ConclusionIn patients with unilateral PA who can tolerate medications, medical therapy improves clinical and biochemical control, and may offer similar cardiovascular protection. However, surgery reduces pill burden, may cure hypertension and is recommended for unilateral PA.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Outcomes in unilateral primary aldosteronism after surgical or medical therapy

Puar

Loh

et al. 2020

Clinical Endocrinology

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“…Hypokalaemia, if present, was corrected with potassium supplementation, aiming for serum potassium ≥3.5mmol/L before hormone measurements. Plasma aldosterone concentration (PAC) and plasma renin activity (PRA) were determined in all patients as previously reported 12 . Patients underwent intravenous seated saline infusion test, and all patients had a post-saline infusion PAC ≥140pmol/L 6 .…”

Section: Study Design and Patientsmentioning

confidence: 99%

Improvement in quality of life and psychological symptoms after treatment for primary aldosteronism: Asian Cohort Study

Tan

Kwan

Teo

et al. 2021

Endocrine Connections

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Background: In addition to increased cardiovascular risk, patients with primary aldosteronism (PA) also suffer from impaired health–related quality of life (HRQoL) and psychological symptoms. We assessed for changes in HRQoL and depressive symptoms in a cohort of Asian patients with PA, after surgical and medical therapy. Methods: 34 patients with PA were prospectively recruited and completed questionnaires from 2017 to 2020. HRQoL was assessed using RAND–36 and EQ–5D–3L, and depressive symptoms were assessed using Beck Depression Inventory (BDI–II) at baseline, 6 months, and 1 year post–treatment. Results: At 1 year post–treatment, significant improvement was observed in both physical and mental summative scores of RAND–36, +3.65, P=0.023, and +3.41, P=0.033, respectively, as well as four subscale domains (physical functioning, bodily pain, role emotional and mental health). Significant improvement was also seen in EQ–5D dimension of anxiety/depression at 1 year post–treatment. Patients treated with surgery (N=21) had significant improvement in EQ–5D index score post–treatment, and better EQ–5D outcomes compared to medical group (N=13) at 1 year post–treatment. 37.9%, 41.6% and 58.6% of patients had symptoms in the cognitive, affective and somatic domains of BDI–II respectively. There was significant improvement in the affective domain of BDI–II at 1 year post–treatment. Conclusion: Both surgical and medical therapy improve HRQoL and psychological symptoms in patients with PA, with surgery providing better outcomes. This highlights the importance of early diagnosis, accurate subtyping and appropriate treatment of PA.

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“…In both centers, we confirmed the diagnosis of PA using the intravenous saline infusion test (SLT), and all patients had a post-SLT PAC at least 140 pmol/L. Clinical data were obtained as described in our prior study on this cohort [ 17 ] and include baseline demographics and pretreatment PAC and PRA. We excluded patients treated with adrenalectomy only and not started on medical therapy, prescribed medical therapy for less than 4 weeks before adrenalectomy, or those on medical therapy for less than 3 months.…”

Section: Methodsmentioning

confidence: 99%

Tolerability and Efficacy of Long-Term Medical Therapy in Primary Aldosteronism

Tang

Loh

Foo

et al. 2021

Journal of the Endocrine Society

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Introduction Patients with primary aldosteronism (PA) have increased cardiovascular risk, and some studies find medical therapy less effective than surgery. This may be due to side effects and limited efficacy of medications at tolerable doses. Methods We conducted a retrospective study on 201 patients with PA treated with medical therapy (spironolactone, eplerenone or amiloride) for PA from 2000-2020 at two tertiary centres. Patients were assessed for efficacy to achieve clinical and biochemical control, and for side effects. Results Amongst 155 patients on long-term medications, 57.4% achieved blood pressure <140/90mmHg, 90.1% achieved normokalemia(48.0% achieved potassium≥4.3mmol/L), and 63.2% achieved renin>1ng/ml/hr. Concordance of biochemical control using potassium and renin levels was 49.1%. 52.3% of patients experienced side effects, with 10.3% switching to another medication, 22.6% decreasing dose, and 11.0% stopping medications. Risk factors for side effects were spironolactone use, dose≥50mg, treatment duration ≥1year, male gender and unilateral PA. Patients with unilateral PA, compared to bilateral PA, used higher spironolactone doses, 57mg vs 50mg, P<0.001, and had more side effects, 63.2% versus 41.8%, P=0.008. Amongst 46 patients with unilateral PA who underwent surgery after initial medical therapy, surgery further improved systolic and diastolic BP, from 141 to 135mmHg, P=0.045, and from 85 to 79mmHg, P=0.002, respectively. Conclusion Dose-dependent side effects limit the efficacy of medical therapy in PA. Future prospective studies should assess the best monitoring strategy for biochemical control during long-term medical therapy. For unilateral PA, surgery remains preferable to medications, as surgery leads to better control with less long-term side-effects.

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Aldosterone-potassium ratio predicts primary aldosteronism subtype

Cited by 31 publications

References 42 publications

Outcomes in unilateral primary aldosteronism after surgical or medical therapy

Outcomes in unilateral primary aldosteronism after surgical or medical therapy

Improvement in quality of life and psychological symptoms after treatment for primary aldosteronism: Asian Cohort Study

Tolerability and Efficacy of Long-Term Medical Therapy in Primary Aldosteronism

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