Hipertensión resistente en un paciente con aldosteroninsmo primario. Una presentación clínica inusual

En este reporte se presenta el caso de una paciente con hipertensión resistente que requería triple terapia antihipertensiva. Presentaba episodios súbitos de hipertensión, de predominio nocturno, cefalea, disnea, palpitaciones, dolor precordial, y se documentó ultrasonográficamente una masa suprarrenal izquierda. Estas manifestaciones clínicas podrían corresponder a hipertensión endocrina debida a feocromocitoma. No obstante, las pruebas de laboratorio mostraron hipocalemia, elevación de la aldosterona plasmática y supresión de la actividad de renina plasmática. Estos resultados fueron consistentes con aldosteronismo primario. Con la resección laparoscópica del adenoma suprarrenal, se normalizaron las cifras tensionales y las concentraciones de aldosterona y actividad de renina plasmática.

In this report we present a case of a patient with resistant hypertension treated with triple antihypertensive medication. The patient suffered of sudden episodes of nocturnal hypertension, headache, dyspnoea, palpitations, precordial pain and a left suprarenal mass was found in the abdominal ultrasound. These findings suggested endocrine hypertension due to pheochromocytoma.However, the laboratory tests showed hypokalemia, high plasma aldosterone concentrations and suppressed plasma renin activity. This results were consistent with primary aldosteronism. After the laparoscopic removal of the suprarenal adenoma blood pressure, plasma aldosterone concentrations and plasma renine activity returned to normal.

The value of plasma renin concentration in diagnosis of primary aldosteronism / 中华内分泌外科杂志

Primary aldosteronism(PA) is one of the most common causes of secondary hypertension,plasma aldosterone concentration(PAC)/plasma renin activity (PRA) ratio is widely used in clinical practice.However,PRA reflects the level of plasma renin indirectly.In recent years,plasma renin concentration (PRC) has been measured by automatic chemiluminescence immunoassay,which is more stable,convenient and with less confounding factors than conventional renin activity.This review briefly introduces methods of examining PRA,PRC and PAC,and compares the value of PAC/PRC ratio with PAC/PRA ratio in PA detection.

Diagnostic Role of Captopril Challenge Test in Korean Subjects with High Aldosterone-to-Renin Ratios

BACKGROUND: Diagnosis of primary aldosteronism (PA) begins with aldosterone-to-renin ratio (ARR) measurement followed by confirmative tests. However, the ARR has high false positive rates which led to unnecessary confirmatory tests. Captopril challenge test (CCT) has been used as one of confirmatory tests, but the accuracy of it in the diagnosis of PA is still controversial. We aimed to examine the clinical efficacy of CCT as a post-screening test in PA. METHODS: In a prospective study, we enrolled subjects with suspected PA who had hypertension and ARR >20 (ng/dL)/(ng/mL/hr). Sixty-four patients who underwent both the saline infusion test and the CCT were included. RESULTS: The diagnostic performance of plasma aldosterone concentration (PAC) post-CCT was greater than that of ARR post-CCT and ARR pre-CCT in PA (area under the curve=0.956, 0.797, and 0.748, respectively; P=0.001). A cut-off value of 13 ng/dL showed the highest diagnostic odds ratio considering PAC post-CCT at 60 and 90 minutes. A PAC post-CCT of 19 ng/dL had a specificity of 100%, which can be used as a cut-off value for the confirmative test. Determining the diagnostic performance of PAC post-CCT at 90 minutes was sufficient for PA diagnosis. Subjects with PAC post-CCT at 90 minutes <13 ng/dL are less likely to have PA, and those with PAC post-CCT at 90 minutes ≥13 but <19 ng/dL should undergo secondary confirmatory tests. CONCLUSION: The CCT test may be a reliable post-screening test to avoid the hospitalization in the setting of falsely elevated ARR screening tests.

Value of combination strategy based on plasma aldosterone/renin concentration ratio in screening of primary aldosteronism / 军事医学

Objective To explore the best way for clinical screening of primary aldosteronism (PA).Methods Three hundred and three suspected cases of PA were collected and divided into groups of primary aldosteronism group, essential hypertension group, and nonsecreting cortical adrenal tumor group.The plasma aldosterone concentration/plasma renin concentration ratio ( ARR) was used to draw the receiver operating characteristic ( ROC) curve and obtain the best cut-off point.Furthermore, the current screening schemes for PA were compared.Results Upright ARR yield had larger areas under the ROC curve than plasma aldosterone concentration or plasma renin concentration under all conditions of testing. The best cut-off point of upright ARR[(pg/ml)/(μIU/ml)] for the diagnosis of PA was 43.45.During the two postural stimulation tests,the two upright ARR exceeded 43.45 with the highest diagnostic sensitivity of PA reaching 0.94.During the two upright tests ARR was less than 43.45, with a sensitivity of 0.74, and a specificity of 0.94.Conclusion To screen for PA in high-risk populations, twice postural stimulation test is recommended.As long as the upright ARR is above 43.45, PA may be considered and further confirmation is needed to prevent misdiagnosis.

Primary Aldosteronism / 대한내과학회지

Primary aldosteronism (PA) is characterized by inappropriately high production of aldosterone relatively autonomous from the renin-angiotensin system and no suppression by sodium loading. The prevalence of PA is estimated more than 10% among nonseleted hypertensive patients. PA is clinically very important since patients with PA have higher cardiovascular morbidity and mortality than age- and sex-matched patients with essential hypertension and the same degree of blood pressure elevation. The ratio of plasma aldosterone concentration to plasma renin activity (ARR) has been generally accepted as a first-line screening test. ARR might be affected by patient age, anti-hypertensive drugs, posture and menstrual cycles. Once the ARR is measured, confirmative test should be performed. Although a gold standard confirmative test for PA is not yet identified, intravenous saline loading test is widely used. Adrenal venous sampling (AVS) is a gold standard for differentiation of unilateral from bilateral forms of PA. Since adrenal CT imaging has limitations to accurate diagnosis of PA, AVS is recommended for all patients who wish to pursue surgical treatment. Although unilateral laparoscopic adernalectomy is the optimal treatment for patients with aldosterone producing adenoma or unilateral hyperplasia, strong evidence linking adernalectomy with improved quality of life, morbidity or mortality is not available. Mneralocorticoid receptor antagonists, spironolactone or eplerenone, are recommended for pharmacologic therapy of PA.

Assessing the quality of studies on screening primary aldosteronism by using plasma aldosterone to renin activity ratio / 中华内分泌外科杂志

Objective To assess the quality of international studies on using aldosterone to renin activity ratio (ARR) to diagnose primary aldesteronism. Methods We searched the Cachrane Library (1962-2007.12), PubMed(1970-2007.12) ,VIP(1989-2007.12) ,Wan Fang database(1982-2007.12) ,CBMdisc(1978 -2007.12) systematically. Language was limited to Chinese and English. The Quality Assessment of Diagnostic Accuracy Studies(QUADAS) was used to assess the quality of induced diagnostic studies by two reviewers inde-pendently. Results Fourteen studies were included and assessed. We found that most of the studies were not met with QUADAS items. Nine studies didn't chose correct cases that included miscellaneous cases and confused ca-ses. Eight studies didn't describe internalized or exclusive references clearly. The gold standard in three studies could not discriminate whether the diagnosis of patients was confirmed or not. Thirteen studies did not use blind trial to compare the diagnostic test and the gold standard. Conclusions The studies using ARR to diagnose pri-mary aldesteronism should be improved in patients selection, the gold standard selection, comparison of blind trial and bias control.

The Role of Aldosterone on the Development of Renal Tubular Reabsorption in Low Birth Weight Infants

PURPOSE: To determine the postnatal changes in aldosterone action on the renal tubular reabsorption in low birth weight(LBW) infants, we assessed the relation of the aldosterone concentrations to renal parameters during the first 10 days of life. METHODS: Twenty LBW infants were evaluated and their gestational ages ranged from 32.4 to 39.3 weeks and their birth weights ranged from 1,440 to 2,500 g. Estimated glomerular filtration rate, fractional excretion of sodium(FENa) and potassium(FEK), and plasma aldosterone concentrations were analyzed according to the postnatal age and the conceptional age(CA). RESULTS: Glomerular functions were improved after birth and were correlated with CA. FENa and FEK decreased after birth and correlated with CA. Plasma aldosterone concentrations increased to 318.6 +/- 147.2 ng/dL at 48 hours and then decreased to 162.0 +/- 72.2 ng/dL at 10 days after birth. Plasma aldosterone concentrations of infants less than 38th week of CA were higher than that of infants more than 38th week. There was a significant negative correlation coefficient between plasma aldosterone concentrations and FENa in infants more than 34th week of CA, but not in that of less than 34th week. CONCLUSIONS: LBW infants have higher plasma aldosterone concentrations, but a poor correlation between plasma aldosterone concentration and urinary sodium excretion for the first few days of life and in lower chronologic aged infants. These results show that the renal tubule reabsorption of sodium is less responsive to plasma aldosterone in these infants and, therefore, the careful management of fluid and electrolyte balance is mandatory.