The Use of Aldosterone-Renin Ratio as a Diagnostic Test for Primary Hyperaldosteronism and Its Test Characteristics under Different Conditions of Blood Sampling

Tiu, Sau Cheung; Choi, Cheung-Hei; Shek, Chi Chung; Ng, Ying-Wai; Chan, Fredriech K. W.; Ng, Chiu-Ming; Kong, Alice Pik Shan

doi:10.1210/jc.2004-1149

Cited by 139 publications

(101 citation statements)

References 33 publications

(35 reference statements)

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“…Normo-K C denotes patients with normal spontaneous potassium, hypo-K C denotes patients with spontaneous hypokalaemia or potassium supplementation due to hypokalaemia. To convert aldosterone concentrations to pmol/l, multiply by 27.74. specificity (10,28). Since differentiation to low renin states such as low renin hypertension and essential hypertension treated with beta-blockers is difficult (32), the putative diagnosis of primary aldosteronism based on a raised aldosterone/renin ratio requires confirmatory testing in order to establish the autonomous character of aldosterone secretion in Conn Syndrome (3,13).…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Confirmatory testing in normokalaemic primary aldosteronism: the value of the saline infusion test and urinary aldosterone metabolites

Schirpenbach¹,

Seiler²,

Maser-Gluth³

et al. 2006

eur j endocrinol

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Objective: Primary aldosteronism has recently been recognized as the most frequent cause of secondary hypertension. Since most patients are normokalaemic, differentiation to essential hypertension is challenging. As differentiation by baseline aldosterone/renin ratio may be insufficient, diagnosis should be confirmed by additional tests. However, as most confirmatory tests have been evaluated in hypokalaemic primary aldosteronism only, we reassessed the value of the saline infusion test and 24 h urinary aldosterone metabolites as confirmatory tests for both normo-and hypokalaemic primary aldosteronism under current antihypertensive medication. Patients and methods: 25 patients with primary aldosteronism (11 hypokalaemic, 14 normokalaemic), 29 patients with essential hypertension and 47 normotensive subjects were studied. The hypertensives received their usual medication with the exception of spironolactone. All subjects underwent a standard saline infusion test (determination of plasma aldosterone before and after 2.0 liters of isotonic saline for 4 hours i.v.) and collected a 24 h urine sample for examination of urinary tetrahydroaldosterone and aldosterone-18-glucuronide. Results: In hypokalaemic primary aldosteronism the saline infusion test showed a reasonable sensitivity (91%) and specificity (90%). However, the test failed to differentiate sufficiently between essential hypertension and normokalaemic primary aldosteronism (sensitivity 57%, specificity 90%). Similarly, urinary tetrahydroaldosterone had higher sensitivity in hypokalaemic than in normokalaemic primary aldosteronism (sensitivity 64% vs 36%, specificity 100%), whereas for aldosterone-18-glucuronide, no differences in hypo-and normokalaemic primary aldosteronism were found (sensitivity 45% and 43%, specificity 100%). Conclusions: These data show that the saline infusion test as an established test in classical hypokalaemic primary aldosteronism is not a reliable test in the normokalaemic variant of the disease. Due to its low accuracy, determination of urinary aldosterone metabolites did not prove useful in confirming either normo-or hypokalaemic patients. We conclude from our data that these tests should not be used as confirmatory testing in the normokalaemic variant of primary aldosteronism.European Journal of Endocrinology 154 865-873

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Section: Discussionmentioning

confidence: 99%

“…The aldosterone/renin ratio is currently the most recommended screening test for primary aldosteronism (3,(6)(7)(8)(9)(10). Application of the ratio even under antihypertensive medication is increasingly advocated (8,11,12).…”

Section: Introductionmentioning

confidence: 99%

Confirmatory testing in normokalaemic primary aldosteronism: the value of the saline infusion test and urinary aldosterone metabolites

Schirpenbach¹,

Seiler²,

Maser-Gluth³

et al. 2006

eur j endocrinol

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“…Aldosterone levels are known to vary considerably in the same subject and various factors have been identified that affect this variability; among them sodium and potassium balance, posture, circadian rhythm and drug treatment are well known. 19,20 Another determinant of aldosterone variability that has been identified in normal women is the ovarian cycle [21][22][23][24] but this has not so much been taken into account in hypertension.…”

Section: -13mentioning

confidence: 99%

The ovarian cycle as a factor of variability in the laboratory screening for primary aldosteronism in women

et al. 2008

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Primary aldosteronism is increasingly investigated in hypertension being associated with an elevated cardiovascular risk. Aldosterone has been reported to increase in the luteal phase in normal women but to our knowledge the influence of the ovarian cycle on the first screening for primary aldosteronism (that is, on the levels of plasma aldosterone and its relationship to PRA levels) was never investigated. We measured hormonal levels during one cycle in 26 low-renin mild hypertensive outpatients. LH, FSH, 17 b-estradiol, progesterone, aldosterone and PRA were assayed at the seventh, fourteenth, twenty-first and twenty-eighth days of the cycle after 30 min of recumbency. Aldosterone and PRA increased from the seventh (follicular phase) to twentyfirst day (luteal phase) from 11.2 to 17.8 ng 100 ml À1 and from 0.23 to 0.35 ng ml À1 h À1 , respectively (both P ¼ 0.004) The proportion of patients with aldosterone 415 ng 100 ml À1 significantly increased from the follicular to the luteal phase, (8/26 vs 19/25, P ¼ 0.018); a similar increase was found for Aldosterone-PRA Ratio 430 combined with either a minimum PRA value of 0.5 ng ml À1 h À1 or aldosterone 415 ng 100 ml À1 (7/26 vs 16/25 and 7/26 vs 17/25 respectively, Po0.05).Aldosterone was positively related to PRA and progesterone. Higher aldosterone levels may be frequently encountered in the second part of the ovarian cycle in low-renin hypertensive women. This variability appears to be an important factor to be taken into account in the first-step laboratory screening for primary aldosteronism and should be considered in the process of standardization of the diagnostic work-up for this disease.

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“…One of the reasons for these inconsistent results could be the confounding effect of antihypertensive medications, differences in time of blood sampling, body position and dietary sodium intake, which significantly affect aldosterone levels. 9,10 In most studies, longterm dietary sodium intake has not been considered. Most studies 1,[3][4][5][6][7][8] use spot urine samples, 1,7,8 24-h urine collection 4,6 and short-term dietary sodium restriction; 5,6 only one study 3 measured long-term habitual sodium intake using a dietary record.…”

Section: Introductionmentioning

confidence: 99%

Aldosterone-to-renin ratio and home blood pressure in subjects with higher and lower sodium intake: the Ohasama Study

Satoh

Kikuya

Hara³

et al. 2010

Hypertens Res

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Aldosterone-to-renin ratio (ARR) is used to screen primary hyperaldosteronism. We investigated the association between ARR and the prevalence of hypertension using home blood pressure (HBP) measurements in community residents stratified for long-term habitual dietary sodium intake. We obtained HBP and conventional blood pressure (CBP) data for 514 participants aged X35 years not receiving antihypertensive treatment in the general population of Ohasama (mean age: 59.7 ± 10.8 years; 71.2% women). A standardized method was used to calculate habitual sodium intake from a food-frequency questionnaire. The prevalence of HBP hypertension (X135/85 mm Hg) and CBP hypertension (X140/90 mm Hg) were 12.6 and 20.2%, respectively. The median plasma renin activity (PRA), plasma aldosterone concentration (PAC) and ARR were 1.1 ng ml -1 h -1 , 6.4 ng per 100 ml and 5.5 ng per 100 ml per ng ml -1 h -1 , respectively. After adjustment for possible confounding factors, each 1 s.d. increase in logARR was associated with the prevalence of HBP hypertension (odds ratio 1.37; P¼0.04), but not with the prevalence of CBP hypertension (P¼0.2). The association of ARR with HBP hypertension was strengthened for subjects with high sodium intake (greater than or equal to the median of 4822 mg day -1 ), whereas it became nonsignificant for those with low sodium intake (interaction P¼0.03). Among subjects with high sodium intake, HBP hypertensives had significantly lower PRA than normotensives, despite no differences in PAC. In conclusion, relative aldosterone excess or low-renin hypertension may have an important role in HBP hypertension in the general population with high sodium intake.

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The Use of Aldosterone-Renin Ratio as a Diagnostic Test for Primary Hyperaldosteronism and Its Test Characteristics under Different Conditions of Blood Sampling

Cited by 139 publications

References 33 publications

Confirmatory testing in normokalaemic primary aldosteronism: the value of the saline infusion test and urinary aldosterone metabolites

Confirmatory testing in normokalaemic primary aldosteronism: the value of the saline infusion test and urinary aldosterone metabolites

The ovarian cycle as a factor of variability in the laboratory screening for primary aldosteronism in women

Aldosterone-to-renin ratio and home blood pressure in subjects with higher and lower sodium intake: the Ohasama Study

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