Diagnosis Of Primary Aldosteronism Research Articles

EARLY INDICES OF SUBCLINICAL CARDIOVASCULAR DAMAGE IN PATIENTS WITH ESSENTIAL HYPERTENSION AND PRIMARY ALDOSTERONISM. A PRELIMINARY OBSERVATIONAL STUDY

Objective: In hypertensive patients, the activation of the renin-angiotensin-aldosterone system is associated with an increase of subclinical vascular and cardiac damage. Our study aimed to compare some early markers of cardiovascular organ damage between patients with essential hypertension and patients with secondary hypertension, in particular primary aldosteronism. Design and method: Fifty-seven hypertensive patients (mean age: 44,4±13,6 years, 60.7% males) were included, 47 with essential hypertension and 10 with primary hyperaldosteronism. Peripheral blood pressure (pBP), central blood pressure (cBP) and pulse wave velocity (PWV) were assessed by the SphygmoCorXCEL. The carotid Intima-Media Thickness (cIMT) and the carotid Distensibility Coefficient (cCD) were measured by a scanner connected with an image acquisition and analysis system (CardiovascularSuite). Left ventricular mass index (LVMI) and relative wall thickness (RWT) were evaluated by transthoracic echocardiography. Results: Patients with primary aldosteronism have higher cIMT and PWV values compared to patients with essential hypertension (0.7±0.1mm vs. 0.6±0.1 mm, p = 0.02 and 8.6±2.5 m/s vs. 7.2±1.5 m/s, p = 0.02; respectively). By linear regression, age was the only variable independently associated with cIMT. On the other hand, various factors such as age, the diagnosis of primary aldosteronism, pSBP and cSBP were independently associated with PWV. Although not statistically significant, LVMI and RWT tended to be higher in the group with primary aldosteronism in comparison to patients with essential hypertension (14.3% vs. 0% exhibited concentric hypertrophy and 42.8% vs. 28.1% showed findings consistent with concentric cardiac remodelling). No differences were found in cDC values between the two groups. Conclusions: The results of this study confirm a possible deleterious impact of aldosteronism on cardiovascular damage in hypertensive patients, more evident for PWV than for cIMT or DC. This fact could suggest a possible different effect of the abnormal hormone secretion at different vascular districts.

DISCREPANCIES IN THE OUTCOME OF PLASMA ALDOSTERONE LEVELS ASSESSED BY IMMUNOASSAY AND MASS SPECTROMETRY - CLINICAL RELEVANCE FOR THE DIAGNOSIS OF PRIMARY HYPERALDOSTERONISM

Objective: To assess potential discrepancies in the clinical interpretation of the salt loading test (SLT) resulting from the assessment of aldosterone concentrations by two different methods - immunoassay and mass spectrometry. Design and method: Eighty-one patients (47F, 34M, mean age 47.7 ± 14.1 years) with suspected primary hyperaldosteronism (PA) who underwent an SLT were included in the ongoing study. Patients had their treatment modified according to current guidelines prior to the test. The SLT was performed in the sitting position and blood samples were taken before and after 4 hours of administration of 2 litres of saline. An aldosterone concentration higher than 61 ng/dL (170 pmol/L) was considered indicative of a diagnosis of PA. Plasma aldosterone concentrations from the same samples were assessed by: (1) chemiluminescence-based immunoassay (CLIA), LIAISON® by DiaSorin, and (2) liquid chromatography-mass spectrometry (LC-MS), MassChrom Chromsystems kit, UHPLC technique using a QTRAP 6500+ instrument (Sciex). Renin concentration was assessed by CLIA. Results: Median plasma aldosterone concentrations after saline administration assessed by CLIA were significantly higher than those assessed by LC-MS (64.4 vs 44.0 ng/dL; p < 0.001). The correlation coefficients for plasma aldosterone concentration after saline administration was 0.69 (p < 0.001). PA was diagnosed by one of the methods in 22 of patients and by both methods in 16 patients. Conflicting results were obtained in 6 patients (7.4%): in 5 patients CLIA was suggestive of PA but LC-MS not and in one patient LC-MS was suggestive of PA but CLIA not. In four cases, plasma aldosterone concentrations were slightly above or below the cut-off values (CLIA vs LC-MS: 62.9 vs 53; 61.9 vs 50; 97.8 vs 61 and 112 vs 58 ng/dL) in at least one of the methods. In the other two cases, the discrepancies were more pronounced (50 vs 80 ng/dL and 126 vs 24 ng/dL). Conclusions: Discrepant results of aldosterone assessment by CLIA and LC-MS methods were obtained in 7.4% of patients. Discrepancies were generally related to borderline results. If a plasma aldosterone concentration value close to the cut-off values is obtained, a repeat determination using another method should be considered.

A 120-MINUTE SALINE INFUSION TEST FOR THE CONFIRMATION OF PRIMARY ALDOSTERONISM

Objective: Saline infusion test (SIT) for confirmation of primary aldosteronism (PA) traditionally requires two liters of normal saline and is 240 minutes long. Previous studies have raised concerns regarding increased blood pressure (BP) and worsening hypokalemia during and after SIT. Therefore, we aim to evaluate the diagnostic applicability of a shorter, one liter 120-minute-long SIT. Design and method: A cross-sectional study, including all consecutive patients with suspected PA who underwent SIT from 1st January 2015 to 31st December 2022 in a large, tertiary medical center in Israel. Blood samples were drawn for renin and aldosterone at baseline (t = 0), after 2 hours (t = 120 min), and after 4 hours (t = 240 min) of saline infusion. Receiver-operator curve (ROC) analysis was used to evaluate the sensitivity and specificity of various aldosterone cutoff values at t = 120 for the confirmation of PA. Logistic regression was performed to analyze the association of baseline variables and aldosterone levels after 120 minutes and after 240 minutes. Results: The final analysis included 55 patients. ROC analysis with an area under the curve (AUC) of 0.97 (95% CI [0.93, 1.00], P < 0.001) demonstrated 90% specificity and 92% sensitivity for an aldosterone cutoff value of 342 pmol/L at t = 120 to confirm PA. 45% (25/55) of patients did not suppress aldosterone levels after 240 minutes, of them 92% (23/25) did not suppress aldosterone at t = 120 according to the 342 pmol/L cutoff. Univariate analysis showed that male sex, hypokalemia, and elevated systolic BP were all associated with failure to suppress aldosterone levels below the traditional threshold for PA confirmation at t = 240 (i.e. <276 pmol/L), as well as below 342 pmol/L at t = 120. Mean systolic BP (SBP) at t = 0 was 139.9±21.2 mm/Hg and increased to 146.2±14.1 mm/Hg (p = 0.016) during the SIT. Conclusions: We present data showing that an aldosterone cutoff of 342 pmol/l at t = 120 has both high sensitivity and specificity for PA diagnosis confirmation.

Recent progress in the diagnosis and treatment of primary aldosteronism.

Primary aldosteronism (PA) is caused by excessive secretion of aldosterone from the adrenal glands, with subsequent changes in the renin-angiotensin system. In Japan, chemiluminescent enzyme immunoassay is currently performed for aldosterone assay rather than the earlier method of radioimmunoassay. This change in aldosterone measurement methods has resulted in faster and more accurate measurement of blood aldosterone levels. Since 2019, esaxerenone, a mineralocorticoid receptor antagonist (MRA) with a non-steroidal skeleton, has been available in Japan for the treatment of hypertension. Esaxerenone has been reported to have various effects, such as strong antihypertensive and anti-albuminuric/proteinuric effects. Treatment of PA with MRAs has been reported to improve the patient's quality of life and to suppress the onset of cardiovascular events independent of their effects on blood pressure. Measuring renin levels is recommended for monitoring the extent of mineralocorticoid receptor blockade during MRA treatment. Patients receiving MRAs are prone to developing hyperkalemia, and combining MRAs with sodium/glucose cotransporter 2 inhibitors is expected to prevent severe hyperkalemia and provide additional cardiorenal protection. Mineralocorticoid receptor-associated hypertension is a broad concept of hypertension that includes not only PA, but also hypertension caused by borderline aldosteronism, obesity, diabetes, and sleep apnea syndrome. New findings on primary aldosteronism, which is part of MR-associated hypertension. Aldosterone measurements have been changed to the CLEIA method. Treatment of primary aldosteronism with MRAs has a variety of positive effects. CT-guided radiofrequency ablation and transarterial embolization are alternatives to surgery for aldosterone-producing adenomas. BP blood pressure, CLEIA chemiluminescent enzyme immunoassay, CT computed tomography, K serum potassium, MR mineralocorticoid receptor, MRA mineralocorticoid receptor antagonist, QOL quality of life, SGLT2i sodium/glucose cotransporter 2 inhibitor.

Improving Detection Rates for Primary Aldosteronism.

Primary aldosteronism (PA), once considered a rare disease, is being increasingly recognized as an important cause of hypertension. It is associated with higher rates of cardiovascular complications compared to blood pressure-matched essential hypertension. Targeted treatments are available which can mitigate the excess cardiovascular risks and, in some cases, cure hypertension. Making a timely diagnosis of PA is, therefore, highly beneficial for patients. Furthermore, numerous studies from different parts of the world have found PA to be a relatively common disease that can affect patients in any stage of hypertension, regardless of their age or potassium levels. Despite this well-established data, the current rate of PA detection is appallingly low, much below its actual prevalence. This review explores the challenges that clinicians often face in diagnosing PA and offers strategies that may improve the detection of this potentially curable form of hypertension.

Predictive performance of aldosterone-to-renin ratio in the diagnosis of primary aldosteronism in patients with resistant hypertension.

The systematic use of confirmatory tests in the diagnosis of primary aldosteronism (PA) increases costs, risks and complexity to the diagnostic work-up. In light of this, some authors proposed aldosterone-to-renin (ARR) cut-offs and/or integrated flow-charts to avoid this step. Patients with resistant hypertension (RH), however, are characterized by a dysregulated renin-angiotensin-aldosterone system, even in the absence of PA. Thus, it is unclear whether these strategies might be applied with the same diagnostic reliability in the setting of RH. We enrolled 129 consecutive patients diagnosed with RH and no other causes of secondary hypertension. All patients underwent full biochemical assessment for PA, encompassing both basal measurements and a saline infusion test. 34/129 patients (26.4%) were diagnosed with PA. ARR alone provided a moderate-to-high accuracy in predicting the diagnosis of PA (AUC=0.908). Among normokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 41.8 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 67%, respectively (AUC=0.882); an ARR > 179.6 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, but was associated with a very low sensitivity of 20%. Among hypokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 49.2 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 83%, respectively (AUC=0.941); an ARR > 104.0 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, with a sensitivity of 64%. Among normokalemic patients, there was a wide overlap in ARR values between those with PA and those with essential RH; the possibility to skip a confirmatory test should thus be considered with caution in this setting. A better discriminating ability could be seen in the presence of hypokalemia; in this case, ARR alone may be sufficient to skip confirmatory tests in a suitable percentage of patients.

An Abbreviated History of Aldosterone Metabolism, Current and Future Challenges.

The initial isolation of adrenal steroids from large quantities of animal adrenals resulted in an amorphous fraction resistant to crystallization and identification and had potent effects on electrolyte transport. Aldosterone was eventually isolated and identified in the fraction and was soon shown to cause hypertension when in excess. The autonomous and excessive production of aldosterone, primary aldosteronism, is the most common cause of secondary hypertension. Aldosterone is metabolized in the liver and kidney, and its metabolites are conjugated with glucuronic acid for excretion. The most common liver metabolite is 3α,5β-tetrahydroaldosterone-3-glucuronide, while that of the kidney is aldosterone-18-oxo-glucuronide. In terms of their value, especially the aldosterone-18-oxo-glucuronide, is commonly used for the diagnosis of primary aldosteronism because they provide an integrated value of the total daily production of aldosterone. Conversion of aldosterone to 18-oxo-glucuronide is impeded by drugs, like some common non-steroidal anti-inflammatory drugs that compete for UDP-glucuronosyltransferase-2B7, the most important glucuronosyltransferase for aldosterone metabolism. Tetrahydroaldosterone is the most abundant metabolite and the most reliable for the diagnosis of primary aldosteronism, but it is not commonly measured.

Optimal application of captopril challenge test in the diagnosis of primary aldosteronism

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Predictive performance of aldosterone-to-renin ratio in the diagnosis of primary aldosteronism in patients with resistant hypertension

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Prevalence of Cortisol Cosecretion in Patients With Primary Aldosteronism: Role of Metanephrine in Adrenal Vein Sampling.

Adrenal venous sampling (AVS) is the gold standard procedure for subtype diagnosis in patients with primary aldosteronism (PA). Cortisol is usually adopted for the normalization of aldosterone levels in peripheral and adrenal samples. However, asymmetrical cortisol secretion can potentially affect the lateralization index, leading to subtype misdiagnosis. We aimed to assess the prevalence of asymmetrical cortisol secretion in patients undergoing AVS and whether variations in adrenal vein cortisol might influence AVS interpretations. We then evaluated the use of metanephrines for the normalization of aldosterone levels for lateralization index. We retrospectively included 101 patients with PA who underwent AVS: 49 patients underwent unstimulated AVS, while 52 patients underwent both unstimulated and cosyntropin-stimulated AVS. Eighty-eight patients had bilateral successful AVS according to metanephrine ratio. We assessed the prevalence of asymmetrical cortisol secretion through the cortisol to metanephrine (C/M) lateralization index (LI). We then evaluated whether the use of aldosterone to metanephrine (A/M) LI can improve the diagnostic accuracy of AVS compared with aldosterone to cortisol (A/C) LI. Asymmetrical cortisol secretion is present in 18% of patients with PA. Diagnosis with A/M LI and A/C LI is discordant in 14% of patients: 9% had a diagnosis of unilateral PA with A/M LI instead of bilateral PA with A/C LI and 5% had a diagnosis of bilateral PA with A/M LI instead of unilateral PA. The assessment of metanephrine levels in AVS is useful for the determination of selectivity and lateralization, allowing an accurate diagnosis, especially in patients with asymmetrical cortisol secretion.

Prevalence of primary aldosteronism in patients with concomitant hypertension and obstructive sleep apnea, baseline data of a cohort.

Obstructive sleep apnea (OSA) and primary aldosteronism (PA) often coexist in hypertension, whereas whether hypertensive patients with OSA should be screened for PA is controversial and whether gender, age, obesity and OSA severity should be considered is unexplored. We explored cross-sectionally prevalence and associated factors of PA in co-existent hypertension and OSA by considering gender, age, obesity and OSA severity. OSA was defined as AHI ≥5 events/h. PA diagnosis was defined, based on the 2016 Endocrine Society Guideline. We included 3306 patients with hypertension (2564 with OSA). PA prevalence was significantly higher in hypertensives with OSA than in those without OSA (13.2 vs 10.0%, P = 0.018). In gender-specific analysis, PA prevalence was significantly higher in hypertensive men with OSA, compared to non-OSA ones (13.8 vs 7.7%, P = 0.001). In further analysis, PA prevalence was significantly higher in hypertensive men with OSA aged <45 years (12.7 vs 7.0%), 45-59 years (16.6 vs 8.5%), and with overweight and obesity (14.1 vs 7.1%) than did their counterparts (P < 0.05). For OSA severity, men participants showed increased PA prevalence from non to moderate OSA and a decrease in the severe OSA group (7.7 vs 12.9 vs 15.1 vs 13.7%, P = 0.008). Young and middle age, moderate-severe OSA, weight, and blood pressure showed a positive independent association with PA presence in logistic regression. In conclusion, PA is prevalent in co-existent hypertension and OSA, indicating the need for PA screening. Studies are needed for women, older and lean population due to the smaller samples in this study.

NP-59 Scintigraphy for Primary Aldosteronism Lateralization in a Patient With Polycystic Kidney Disease

A 65-year-old-male presented to the endocrine clinic for further evaluation and treatment of primary aldosteronism (PA). His past medical history was notable for polycystic-kidney-disease (PCKD) leading to a kidney-transplantation at age 48, as well as a diagnosis of PA at the age of 52. The patient had initially elected for medical management of PA; thus, PA sub-type-classification was not pursued. Despite treatment with spironolactone and potassium supplements, subsequent blood-pressure control was poor, with progressive renal failure and persistent hypokalemia. Currently, the patient was being prepared for a staged-bilateral-nephrectomy to relieve some of the mass-effect from the giant polycystic-kidneys. The upcoming surgery gave rise to the option of a concomitant adrenalectomy as a potential cure for PA. However, at this point, PA-sub-type classification was quite challenging. Anatomically, the large cysts grossly distorted the retroperitoneum, hiding the adrenal glands from view on CT imaging ( Figure A). Biochemically, adrenal-vein-sampling (AVS) seemed both technically difficult due to the distorted vascular anatomy as well as potentially risky due to the expected prolonged exposure to radio-contrast in a kidney transplant patient pre-existing advanced chronic kidney disease (CKD). Following a multidisciplinary consultation, NP-59 SPECT/CT was performed (Figure B-D). Very few case reports of PA in patients with PCKD have been reported thus far ((1)Hoorn E.J. Hesselink D.A. Kho M.M. Roodnat J.I. Weimar W. Van Saase J.L. Van Den Meiracker A.H. Zietse R. A case of primary aldosteronism revealed after renal transplantation.Nature Reviews Nephrology. 2011; 7: 55-60Crossref PubMed Scopus (8) Google Scholar). In the setting of PCKD, a diagnosis of PA may be delayed or missed entirely due to pre-existing alternative explanations for resistant hypertension and CKD. Furthermore, adrenal adenomas may be overlooked on planar imaging due to their small size and distorted abdominal anatomy associated with PCKD. In general, AVS is considered the gold-standard For PA sub-type classification, but in complex cases such as with PCKD, alternative diagnostic methods may be useful. NP-59 (I-131-iodo-cholesterol) is a marker of adrenocortical cholesterol uptake. Dexamethasone-suppression NP-59 scintigraphy has been suggested for the differentiation of PA sub-types, but its use is limited by low resolution allowing for false negatives as well as limited tracer availability ((2)Nomura K, Kusakabe K, Maki M, Ito Y, Aiba M, Demura H. Iodomethylnorcholesterol uptake in an aldosteronoma shown by dexamethasone-suppression scintigraphy: relationship to adenoma size and functional activity. J Clin Endocrinol Metab. 1990 Oct;71(4):825-830. doi: 10.1210/jcem-71-4-825. PMID: 2401712.Google Scholar). The addition of SPECT/CT over planar imaging NP-59 scintigraphy, has been shown to increase sensitivity to 82%, including the detection of aldosterone producing adenomas smaller than 1.5 cm ((3)Yen R.F. Wu V.C. Liu K.L. Cheng M.F. Wu Y.W. Chueh S.C. Lin W.C. Wu K.D. Tzen K.Y. Lu C.C. TAIPAI Study Group131I-6β-iodomethyl-19-norcholesterol SPECT/CT for primary aldosteronism patients with inconclusive adrenal venous sampling and CT results.Journal of Nuclear Medicine. 2009; 50: 1631-1637Crossref PubMed Scopus (94) Google Scholar). In our patient, NP-59 SPECT/CT clearly identified a functional left-adrenal cortical adenoma (Figures B-D). Subsequent left adrenalectomy and nephrectomy resulted in normalization of potassium levels and improved blood-pressure control allowing for a reduction in the number of his anti-hypertensive medications. Pathological evaluation identified a 3cm cortical adenoma. Thus, NP-59 SPECT/CT should remain a part of the diagnostic armamentarium, especially for challenging cases of PA sub-type classification.

Unilateral adrenalectomy in bilateral adrenal hyperplasia with primary aldosteronism

Mineralocorticoid receptor antagonists are the first-line treatment for bilateral adrenal hyperplasia (BAH) with primary aldosteronism (PA), while unilateral adrenalectomy is the standard treatment for aldosterone-producing adenoma (APA). In this study, we investigated the outcomes of patients with BAH after unilateral adrenalectomy and compared them with those of patients with APA. From January 2010 to November 2018, 102 patients with a diagnosis of PA confirmed by adrenal vein sampling (AVS) and available NP-59 scans were enrolled. All patients underwent unilateral adrenalectomy based on the lateralization test results. We prospectively collected the clinical parameters over 12 months and compared the outcomes of BAH and APA. A total of 102 patients were enrolled in this study: 20 (19.6%) had BAH and 82 (80.4%) had APA. Significant improvements in serum aldosterone-renin ratio (ARR), potassium level, and reduction of antihypertensive drugs were observed in both groups at 12 months after surgery (all p<0.05). Patients with APA showed a significant decrease in blood pressure after surgery (p<0.001) than those with BAH. Additionally, multivariate logistic regression analysis indicated that APA was associated with biochemical success (odds ratio: 4.32, p=0.024) compared to BAH. Patients with BAH had a higher failure rate in clinical outcomes, and APA was associated with biochemical success after unilateral adrenalectomy. However, significant improvements in ARR, hypokalemia, and a decreased use of antihypertensive drugs were noted in patients with BAH after surgery. Unilateral adrenalectomy is feasible and beneficial in selected patients, and could potentially serve as a treatment option.

Accuracy of Gallium-68 Pentixafor Positron Emission Tomography–Computed Tomography for Subtyping Diagnosis of Primary Aldosteronism

Adrenal vein sampling (AVS) is the recommended procedure for subtyping primary aldosteronism (PA) as unilateral PA (UPA) or bilateral PA (BPA), with different treatment needed for each: adrenalectomy for UPA and medication for BPA. However, AVS is invasive and technically difficult, and how to subtype PA noninvasively is currently a great challenge. To evaluate the accuracy of gallium-68 pentixafor positron emission tomography-computed tomography (PET-CT) in subtyping PA using AVS as a reference standard. This diagnostic study was conducted at a tertiary hospital in China among patients diagnosed with PA. Enrollment was started in November 2021, with follow-up ending in May 2022. : Patients were recruited to undergo gallium-68 pentixafor PET-CT and AVS. Maximum standardized uptake value (SUVmax) of each adrenal gland during PET-CT was measured to calculate the lateralization index of SUVmax. Area under the receiver operating characteristic curve (AUROC), specificity, and sensitivity were used to analyze the accuracy of the lateralization index based on SUVmax for subtyping PA. Among 100 patients with PA who completed the study (47 female [47.0%] and 53 male [53.0%]; median [IQR] age, 49 [38-56] years), 43 individuals had UPA and 57 individuals had BPA. Aldosterone-cortisol ratio (Spearman ρ = 0.26; P < .001) in adrenal veins was positively correlated with SUVmax of adrenal glands at 10 minutes during PET-CT. Using lateralization index based on SUVmax at 10 minutes to identify UPA, the AUROC was 0.90 (95% CI, 0.83-0.97). A cutoff value for lateralization index based on SUVmax at 10 minutes set at 1.65 conferred a specificity of 1.00 (95% CI, 0.94-1.00) and sensitivity of 0.77 (95% CI, 0.61-0.88). The diagnostic concordance rate of PET-CT and AVS was 90 patients (90.0%) compared with 54 patients (54.0%) between traditional CT and AVS. This study found good diagnostic accuracy of gallium-68 pentixafor PET-CT in differentiating UPA from BPA. These findings suggest that gallium-68 pentixafor PET-CT may be used to avoid invasive AVS in some patients with PA.

Significance of computed tomography combined with postural stimulation test in predicting laterality of primary aldosteronism

BackgroundsAdrenal venous sampling (AVS) represents the gold standard for classifying primary aldosteronism (PA). However, AVS is a technically demanding, expensive and invasive procedure. Computed tomography (CT) scans is recommended as the initial study of classification diagnosis by the current guidelines. In addition, postural stimulation test (PST) has been used to provide additional subtype diagnostic information.ObjectiveThis work aimed to evaluate the diagnostic utility of the adrenal CT combined with PST in the classification diagnosis of PA.MethodsWe analyzed PA patients who underwent AVS from November 2017 to February 2022 at a single center. Subtype classification of PA was determined by AVS. We analyzed the concordance rate between AVS outcomes, adrenal CT, and PST, and explored the value of adrenal CT combined with PST for predicting laterality of PA.ResultsTotal 531 PA patients were included in the present study. The concordance rate between AVS and the adrenal CT was 51.0%(271/531). Receiver operating characteristic (ROC) curve of PST showed that the area under curve (AUC) was 0.604 [95% confidence interval (CI): 0.556, 0.652], the optimal cut-off value was 30%. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (+LR), and negative likelihood ratio (−LR) of PST for diagnosis bilateral PA on AVS was 72.8, 46.2%, 0.48, 0.71, 1.35, and 0.59, respectively. The prevalence of unilateral PA on AVS in patients with unilateral lesion on CT and negative PST, unilateral lesion on CT and positive PST, bilateral normal or lesions on CT and negative PST, and bilateral normal or lesions on CT and positive PST was 82.4% (108/131), 59.9% (91/152), 50.7% (37/73), and 44.6% (78/175), respectively. The sensitivity, specificity, PPV, NPV, +LR, and -LR of adrenal CT combined with PST for the diagnosis of unilateral PA were 34.4, 89.4%, 0.82, 0.49, 3.25, and 0.73, respectively.ConclusionsThe combination of CT findings and PST can improve the accuracy of predicting laterality of PA.

Measurement of aldosterone by LCMS/MS and immunoassay before and after dichloromethane extraction in post seated saline suppression test samples

Background: The seated saline suppression test (SSST) is a confirmatory test for diagnosis of primary aldosteronism. Discordant results have been recently observed for LC-MS/MS compared to direct immunoassay in SSST patients.1 This study investigates the concordance of LC-MS/MS and immunoassay results after dichloromethane extraction for the SSST.

Primary Aldosteronism and COVID-19-related Management, Disease Severity, and Outcomes: A Retrospective Cohort Study.

The SARS-CoV-2 virus is dependent on components of the renin-angiotensin-aldosterone system for infectivity. Primary aldosteronism (PA) is a form of secondary hypertension mediated by autonomous aldosterone production. The intersection of COVID-19 and PA, both which may involve components of the renin-angiotensin-aldosterone system, remains unknown. We assessed PA as a risk factor for COVID-19 infection and compared management, severity of disease, and outcomes during COVID-19 with a matched population of patients with essential hypertension (EH) by conducting a retrospective observational cohort study. Of the patients with PA, 81 had a negative PCR test for COVID-19, whereas 43 had a documented positive PCR test for COVID-19. Those patients with PA who tested positive for COVID-19 tended to be female (P = .08) and the majority of those with COVID-19 infection identified as non-White race (P = .02) and Hispanic ethnicity (P = .02). In a subanalysis, 24-hour urine aldosterone on initial PA diagnosis tended to be higher those in the PA group who developed COVID-19 compared with those in the PA group who did not develop COVID-19 [median (interquartile range): 36.5 (16.9, 54.3) vs 22.0 (15.8, 26.8) mcg, P = .049] and was an independent predictor of COVID-19 infection controlling for sex, race, and ethnicity. Angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker, and mineralocorticoid receptor antagonist use did not differ between those patients with PA who did and did not have COVID-19 infection. Comparing those patients with PA and matched patients with EH (n = 286) who were COVID-19 PCR positive, there was a significantly higher incidence of cardiovascular complications (12 vs 2%, P = .004) in the PA vs EH group. These data begin to inform us as to whether PA should be a newly identified subpopulation at risk for COVID-19-related cardiovascular disease sequelae.

Saline suppression to distinguish the primary aldosteronism subtype: a diagnostic study.

The saline suppression test (SST) serves to confirm the diagnosis of primary aldosteronism (PA), while adrenal vein sampling (AVS) is used to subtype PA as unilateral or bilateral. Criteria that can accurately identify those with bilateral PA based on SST results could reduce the need for AVS. We previously demonstrated that a combination of plasma aldosterone concentration (PAC) < 300 pmol L-1 and a reduction in aldosterone-to-renin ratio (ARR) following recumbent SST had high specificity for predicting bilateral PA in an Australian cohort of 92 patients with PA who have undergone AVS. We sought to validate our predictive criteria in larger, independent cohorts of patients with PA. An international, multi-centre cohort study. Data from 55 patients at Monash Health, Victoria, Australia, 106 patients from the First Affiliated Hospital of Chongqing Medical University, China, and 105 patients from Nihon University Itabashi Hospital, Japan were analysed. A combination of PAC <300 pmol L-1 and a reduction in ARR following recumbent SST predicted bilateral PA with specificities of 88.2%, 97.0%, and 100.0% in Australian, Chinese, and Japanese cohorts, respectively. This criterion could allow 22%-38% of patients with PA to bypass AVS and proceed directly to medical treatment. In patients undergoing the recumbent SST, a post-saline PAC <300 pmol L-1 together with a reduction in ARR can predict bilateral PA with high specificity and may allow targeted treatment to be commenced without AVS in up to a third of patients.

Uncontrolled and resistant arterial hypertension: prevalence, methods of modification of therapy

The management of patients with uncontrolled arterial hypertension in real clinical practice remains a difficult task, despite the impressive arsenal of antihypertensive drugs. In most cases, correction of medical therapy and lifestyle modification in this group of patients can achieve success in treatment, but in some cases, the target levels of blood pressure (AH) cannot be achieved.Aim. To assess the incidence of true resistant arterial hypertension in patients with hypertension, to identify the main causes of uncontrolled hypertension and to determine the main methods of modification of therapy.Materials and methods. The study included 70 patients with uncontrolled hypertension who received antihypertensive therapy previously. All patients underwent office measurement of blood pressure at the initial visit and after correction of therapy, 24-hour blood pressure monitoring (ABPM) was performed. Correction of therapy included the prescription of a standard three-component regimen «RAAS blocker + calcium antagonist + thiazide diuretic». In case of failure to achieve the target BP levels, the measurement of aldosterone/renin in the blood was carried out to exclude primary hyperaldosteronism (PHA). In all patients, the body mass index (BMI) was calculated, echocardiography was performed to determine the target organ damage, complete blood count, biochemical blood tests were performed (to detect existing kidney damage).Results. In 86% of patients, target BP levels were achieved through lifestyle modification (weight loss) and correction of previous therapy. In 24% of the study subjects, low adherence to therapy (non-compliance) due to polypharmacy was revealed, in connection with which patients were recommended to switch to fixed combinations of drugs, which made it possible to significantly reduce blood pressure below 140/90 mm Hg. according to the results of ABPM in all patients. In 8% of patients, amlodipine/lercanidipine was replaced with long-acting nifedipine, which also led to a decrease in blood pressure (−5,5 mm Hg mean blood pressure according to ABPM). In two cases, the diagnosis of PHA was established, the tumor form of this disease was excluded using computed tomography of the adrenal glands, and treatment with aldosterone antagonists was prescribed. In 10% of patients, the diagnosis of «Resistant arterial hypertension» was confirmed, spironolactone in low doses (25-50 mg), doxazosin 1 mg, moxonidine 0,4 mg, bisoprolol 5 mg were sequentially added to the treatment. Spironolactone and doxazosin showed similar efficacy (−7,1 mmHg and −6,9 mmHg in mean BP, respectively), moxonidine and bisoprolol were less effective (−4,8 and −5,2 mmHg,respectively). In two patients, the addition of spironolactone or doxazosin did not lead to the achievement of the target BP level, a loop diuretic (furosemide 40 mg) was added to the treatment.Conclusion. The incidence of resistant hypertension among patients in the study was 10%. All patients with uncontrolled hypertension, if it is impossible to achieve the target values of blood pressure, provided that the treatment is correctly prescribed, it is necessary to exclude symptomatic hypertension, in particular, PHA. In case of confirmation of true RAH, it is necessary to prescribe aldosterone antagonists (spironolactone) in small doses, and doxazosin is also acceptable.

PS-C31-1: SIGNIFICANCE OF SCREENING AND DIAGNOSING PRIMARY ALDOSTERONISM (PA) IN GENERAL MEDICINE

Background: Primary aldosteronism (PA) is a frequent secondary hypertension that is more frequently associated with cerebrovascular disease than essential hypertension, and thus requires appropriate diagnosis and treatment. The Japan Endocrine Society has published the new guideline for the diagnosis and treatment of primary aldosteronism, following the change of aldosterone measurement system in 2021. In this presentation, we will discuss a case of PA experienced at a dental school hospital. Case 75 years old male Current medical history: He had been diagnosed as hypertensive more than 10 years ago and had been prescribed antihypertensive medication, but he had stopped taking it. When he visited an oral surgeon for a tooth extraction, hypertension was noted and he was referred to internal medicine. &lt;Physical findings&gt; Blood pressure: 208/120 mmHg, Pulse: 83/min, &lt;Biochemistry&gt; Cre 1.09 mg/dL, Na 139mEq/L, K 3.7mEq/L. &lt;Endocrine metabolism&gt; fT4 0.95ng/dL, TSH 2.58micro-IU/mL, Plasma renin activity: PRA (EIA method) 0.6ng/mL/hr, Plasma aldosterone concentration: PAC (CLEIA method) 130pg/mL. &lt;Abdominal CT&gt; There was a nodule on the right adrenal gland. &lt;Progress and discussion&gt; The patient had a high aldosterone-renin ratio: ARR = PAC/PRA = 130/0.6 = 217 at the time of initial examination, and PA was suspected. CT showed a nodule in the right adrenal gland, raising suspicion of unilateral disease. Because of the high basal plasma aldosterone level and low K level, we referred the patient to a specialized facility because we thought that if PA was confirmed by functional confirmation testing, the case could be aggressively localized and typed by adrenal vein sampling (AVS). In this presentation, we would like to discuss the significance of screening and diagnosis of PA in primary care and general practice settings such as dental school hospitals, based on the results of functional confirmation testing at specialized facilities, and in light of current guidelines.