Rates of abnormal aldosterone/renin ratio in African‐origin compared to European‐origin patients: A retrospective study

Abstract

Primary hyperaldosteronism is reported to account for approximately 10% of hypertension depending on the population studied. [1][2][3] The initial screening test is the aldosterone/renin ratio. 4 Traditionally, a positive result has been followed by confirmatory testing; however, the importance of the aldosterone/renin ratio (ARR) has been enhanced by the recent Endocrine Society guideline which states that in the setting of spontaneous hypokalaemia, plasma renin activity or concentration (PRC) below detection levels and plasma aldosterone concentration (PAC) >20 ng/dL (550 pmol/L), confirmatory testing is not required.Hypertension and its complications are more common in Black than White populations. It was first observed in 1964 that 30% of Summary Introduction: The aldosterone/renin ratio is the initial screening test for primary hyperaldosteronism (PHA), but little data exists regarding ethnic variations in this. Methods:Following clinical observation of a high prevalence of abnormal aldosterone/renin ratio (ARR) in patients of African-origin, we retrospectively reviewed all ARR measurements in a single centre over 10 years. Rates of hypokalaemia, intraventricular septal thickness (IVS, by echocardiography) and adrenal imaging were recorded when available. Results: Aldosterone/renin ratio was available in 1473 patients, and abnormal in 374 (25.4%). Abnormal ARR was observed in 305/1349 (22.6%) of European-origin and 69/124 (55.6%) of African-origin patients (P < 0.001). Among those with abnormal ARR, hypokalaemia (<3.5 mmol/L) was documented on at least one occasion in 171/305 (56.1%) European-origin and 43/69 (62.3%) African-origin patients (P = 0.35). Median (range) IVS was 1.57 (0.78-2.80) cm in African-origin and 1.20 (0.69-2.18) cm in European-origin patients (P < 0.002); IVS did not correlate with aldosterone or ARR however. Adrenal adenoma was identified in 41/170 (24.1%) of European-origin and 4/29 (13.7%) African-origin patients (P = 0.15), while hyperplasia was identified in 35/170 (20.5%) of European and 8/29 (27.5%) African patients (P = 0.39). Conclusion: In summary, ARR was abnormal in 55.6% of African-origin patients screened at an Irish hospital. Rates of hypokalaemia were similar between Europeanorigin and African-origin patients. These findings have implications for the use of current screening guidelines for ARR in African-origin patients and also for the mechanistic role of aldosterone in hypertensive complications in African-origin patients. Alpha blocker 10.1% (n = 7) 9.6% (n = 29) Beta blocker 4.3% (n = 3) 12.1% (n = 37) Calcium channel blocker 33.3% (n = 23) 13.1% (n = 40)* ACE inhibitor 7.3% (n = 5) 10.8% (n = 33) ARB 8.7% (n = 6) 5.6% (n = 17) Diuretic 7.3% (n = 5) 4.5% (n = 14) *P < 0.05.

Clinical presentation and surgical outcomes in primary aldosteronism differ by race

“…Further, increased aldosterone‐to‐renin ratios (ARR) have been demonstrated in black patients in numerous studies globally . A recent study by Ahmed et al demonstrated that 57% of patients of African origin who were screened for PA had elevated ARR, which was associated with a lower likelihood of unilateral adenoma on imaging when compared to patients of European origin.…”

2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension

“…With regard to European immigrants, early arterial stiffening (indicating premature vascular aging independent of BP), has been observed in African Americans but only inconsistently in African origin groups in Europe [1032][1033][1034][1035]. Varying degrees of hyperaldosteronism have been found to raise BP disproportionally in people of SSA, African Caribbean and African American origin, probably via underlying salt-sensitivity [1036,1037]. In a recent diagnostic trial for primary aldosteronism, MATCH, 40% of patients were of African origin compared with <20% in the local population [1038].…”

Drug Profile and Therapeutic Adherence of African-Brazilians with Apparent Resistant Hypertension

“…14 Other studies have shown higher plasma levels of aldosterone in black people. 15,16 Given these facts, knowing that primary hyperaldosteronism is imputed in the genesis of RH, 6,8 it is reasonable to understand the importance of using aldosterone antagonists in the 17 when demonstrating that treatment with amiloride or spironolactone may provide an additional reduction in blood pressure in blacks already receiving conventional antihypertensive therapy. 17 In the present study, considering those who needed 4 drugs or more, only 49.5% used spironolactone, even without plausible justification for not using it.…”