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

Vivien, M.; Deberles, E.; Morello, Rémy; Haddouche, Aimi; Guénet, D.; Reznik, Yves

doi:10.1055/a-0857-1620

Cited by 11 publications

(13 citation statements)

References 24 publications

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“…According to the Endocrine Society clinical practice guideline for PA, we can bypass the confirmatory test in cases with spontaneous hypokalemia, a PAC >200 pg/mL, and renin suppression [4]. According to the French Endocrine Society guideline, we can confirm PA diagnosis in cases with positive screening results (ARR >300 and baseline PAC >90 pg/mL) or a baseline PAC >200 pg/mL at two different opportunities [64,65].…”

Section: Evidence and Commentsmentioning

confidence: 99%

Japan Endocrine Society clinical practice guideline for the diagnosis and management of primary aldosteronism 2021

et al. 2022

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Primary aldosteronism (PA) is associated with higher cardiovascular morbidity and mortality rates than essential hypertension. The Japan Endocrine Society (JES) has developed an updated guideline for PA, based on the evidence, especially from Japan. We should preferentially screen hypertensive patients with a high prevalence of PA with aldosterone to renin ratio ≥200 and plasma aldosterone concentrations (PAC) ≥60 pg/mL as a cut-off of positive results. While we should confirm excess aldosterone secretion by one positive confirmatory test, we could bypass patients with typical PA findings. Since PAC became lower due to a change in assay methods from radioimmunoassay to chemiluminescent enzyme immunoassay, borderline ranges were set for screening and confirmatory tests and provisionally designated as positive. We recommend individualized medicine for those in the borderline range for the next step. We recommend evaluating cortisol cosecretion in patients with adrenal macroadenomas. Although we recommend adrenal venous sampling for lateralization before adrenalectomy, we should carefully select patients rather than all patients, and we suggest bypassing in young patients with typical PA findings. A selectivity index ≥5 and a lateralization index >4 after adrenocorticotropic hormone stimulation defines successful catheterization and unilateral subtype diagnosis. We recommend adrenalectomy for unilateral PA and mineralocorticoid receptor antagonists for bilateral PA. Systematic as well as individualized clinical practice is always warranted. This JES guideline 2021 provides updated rational evidence and recommendations for the clinical practice of PA, leading to improved quality of the clinical practice of hypertension.

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Section: Evidence and Commentsmentioning

confidence: 99%

Japan Endocrine Society clinical practice guideline for the diagnosis and management of primary aldosteronism 2021

et al. 2022

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“…Less than two-thirds of studies were prospective (61.8%) and interpretation of tests were commonly performed post hoc without blinding (72.7%). In the majority of studies (67.3%), a confirmatory test was used as a reference standard, 18,22–25,28,29,31,32,34,36–42,44,47,50,53,55–59,61,63–67,69–74 and in nearly a quarter (23.6%), the same test was used as part of its own reference standard. 23,28,29,31,36–39,41,42,53,71,74 Few studies applied complete verification with the same reference standard to all participants (25.5%) and of those that did, only one study (1.8%) used an independent reference that was not contingent upon a confirmatory test (ie, adrenal vein sampling to identify unilateral aldosterone excess, and where it was assumed that patients without lateralization were negative).…”

Section: Resultsmentioning

confidence: 99%

“…There were 55 studies included (Supplemental Material), comprising 26 studies (3654 participants) for the recumbent SIT, 14–42 4 studies (633 participants) for the seated SIT, 34,35,41,43–45 2 studies (99 participants) for the SLT, 46,47 7 studies (386 participants) for the FST, 28,48–53 and 25 studies (2585 participants) for the CCT (see Supplemental Material). 24,26,29,32,33,37,44,54–74…”

Section: Resultsmentioning

confidence: 99%

Performance of Confirmatory Tests for Diagnosing Primary Aldosteronism: a Systematic Review and Meta-Analysis

et al. 2022

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Background: Confirmatory tests are recommended for diagnosing primary aldosteronism, but the supporting evidence is unclear. Methods: We searched Medline, EMBASE, and the Cochrane Central Register of Controlled Trials. Studies evaluating any guideline-recommended confirmatory test (ie, saline infusion test, salt loading test, fludrocortisone suppression test, and captopril challenge test), compared with a reference standard were included. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to assess the risk of bias. Meta-analyses were conducted using hierarchical summary receiver operating characteristic models. Results: Fifty-five studies were included, comprising 26 studies (3654 participants) for the recumbent saline infusion test, 4 studies (633 participants) for the seated saline infusion test, 2 studies (99 participants) for the salt loading test, 7 studies (386 participants) for the fludrocortisone suppression test, and 25 studies (2585 participants) for the captopril challenge test. Risk of bias was high, affecting more than half of studies, and across all domains. Studies with case-control sampling overestimated accuracy by 7-fold (relative diagnostic odds ratio, 7.26 [95% CI, 2.46–21.43]) and partial verification or use of inconsistent reference standards overestimated accuracy by 5-fold (5.12 [95% CI, 1.48–17.77]). There were large variations in how confirmatory tests were conducted, interpreted, and verified. Under most scenarios, confirmatory testing resulted in an excess of missed cases. The certainty of evidence underlying each test (Grading of Recommendations, Assessment, Development, and Evaluations) was very low. Conclusions: Recommendations for confirmatory testing in patients with abnormal screening tests and high probability features of primary aldosteronism are based on very low-quality evidence and their routine use should be reconsidered.

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“…Diagnostic criteria were used which developed by the Cardiovascular Disease Branch of the Chinese Medical Association [ 28 ]. A theoretical domain consisting of elements involving symptoms, laboratory tests, and imaging was selected and determined by reviewing the statistical literature related to PA [ 29 ]. The evaluation test diagnosed it as having the disease, and the false positive result put the subject under great mental stress.…”

Section: Methods Of Pa Functional Diagnostic Test Reliability Based O...mentioning

confidence: 99%

Reliability Analysis of a Functional Diagnostic Test for Primary Hyperaldosteronism Based on Data Analysis

Wang

Cai

2022

Computational Intelligence and Neuroscience

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Primary aldosteronism (PA) is one of the most common causes of secondary hypertension, with a prevalence of 12–20% in the hypertensive population. To determine the characteristic function of a fuzzy concept based on the epidemiological data, clinical manifestations, and auxiliary examinations of PA, the essence is to select a suitable domain and determine the affiliation of each element in the domain. The aldosterone/renin ratio was proposed to increase the detection rate of PA, which has the shortcoming of a high underdiagnosis rate when relying only on clinical manifestations. However, there is no unified standard for the diagnostic cut point, and there are differences in testing methods and diagnostic cut point values for different populations, which require different laboratories to establish appropriate cut points according to different regional populations to improve the diagnostic accuracy. In this article, we analyzed the reliability of functional diagnostic tests for PA based on data analysis and compared the sensitivity and specificity of different plasma aldosterone cut points for the diagnosis of PA in the 40 mg kibbutz test. The results showed that when post-saline PAC and post-cato PAC were used to confirm the diagnosis of proaldosterone, respectively, there was a similar subject working area under the curve between SSST and CCT, 0.89 and 0.78, respectively, with no significant difference in the area under the curve between the two ( p = 0.546 ). Therefore, blood sodium and blood potassium have higher specificity and sensitivity than SUSPUP, but both are lower than ARR, and data analysis can be used as an auxiliary indicator for screening.

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

Cited by 11 publications

References 24 publications

Japan Endocrine Society clinical practice guideline for the diagnosis and management of primary aldosteronism 2021

Japan Endocrine Society clinical practice guideline for the diagnosis and management of primary aldosteronism 2021

Performance of Confirmatory Tests for Diagnosing Primary Aldosteronism: a Systematic Review and Meta-Analysis

Reliability Analysis of a Functional Diagnostic Test for Primary Hyperaldosteronism Based on Data Analysis

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