Primary hyperaldosteronism Screening: Difference between revisions
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==Overview== | ==Overview== | ||
There is insufficient evidence to recommend routine screening for primary hyperaldosteronism but according to the Endocrine Society Clinical Practice Guideline, screening for hyperaldosteronism is recommended for resistant hypertension by checking the plasma aldosterone to renin ratio (PAC/PRA). | |||
==Screening== | ==Screening== | ||
=== Screening population === | === Screening population === | ||
The following | The following individuals should be [[Screening (medicine)|screened]] for primary hyperaldosteronism:<ref name="pmid3230101">{{cite journal |vauthors=Horsley MG, Bailie GR |title=Effectiveness of theophylline monitoring by the use of serum assays |journal=J Clin Pharm Ther |volume=13 |issue=5 |pages=359–64 |year=1988 |pmid=3230101 |doi= |url= |issn=}}</ref> | ||
* [[Blood pressure]] > 160/100 (particularly in age < 50 years) | |||
* Resistant [[hypertension]] or refractory [[hypertension]] (use of > 3 [[Antihypertensive|anti-hypertensives]] and poor control of [[blood pressure]]) | |||
* [[Hypokalemia]] (provoked by [[diuretic]] therapy or unprovoked) | |||
* [[Hypertension]] and incidentally discovered [[Adrenal gland|adrenal]] [[adenoma]] | |||
* [[Hypertension]] with a family history of early-onset [[hypertension]] (< 20 years) or [[Cerebrovascular disease|cerebrovascular]] accident at age less than 40 years | |||
* [[Hypertension|Hypertensive]] first-degree relatives of patients with primary aldosteronism (PA) | |||
=== Plasma Aldosterone to Renin Ratio (PAC/PRA) === | === Plasma Aldosterone to Renin Ratio (PAC/PRA) === | ||
The [[Blood plasma|plasma]] [[aldosterone]] to [[renin]] ratio is widely used as a [[Screening (medicine)|screening]] test for hyperaldosteronism.<ref name="pmid22167725">{{cite journal |vauthors=Ríos MC, Izquierdo A, Sotelo M, Honnorat E, Rodríguez Cuimbra S, Catay E, Popescu BM |title=[Aldosterone/renin ratio in the diagnosis of primary aldosteronism] |language=Spanish; Castilian |journal=Medicina (B Aires) |volume=71 |issue=6 |pages=525–30 |year=2011 |pmid=22167725 |doi= |url= |issn=}}</ref><ref name="pmid24526370">{{cite journal |vauthors=Pilz S, Kienreich K, Gaksch M, Grübler M, Verheyen N, Bersuch LA, Schmid J, Drechsler C, Ritz E, Moosbrugger A, Stepan V, Pieber TR, Meinitzer A, März W, Tomaschitz A |title=Aldosterone to active Renin ratio as screening test for primary aldosteronism: reproducibility and influence of orthostasis and salt loading |journal=Horm. Metab. Res. |volume=46 |issue=6 |pages=427–32 |year=2014 |pmid=24526370 |doi=10.1055/s-0034-1367033 |url= |issn=}}</ref><ref name="urlThe Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline: The Journal of Clinical Endocrinology & Metabolism: Vol 101, No 52">{{cite web |url=http://press.endocrine.org/doi/10.1210/jc.2015-4061 |title=The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline: The Journal of Clinical Endocrinology & Metabolism: Vol 101, No 5 |format= |work= |accessdate=}}</ref> | |||
==== Protocol ==== | ==== Protocol ==== | ||
* Drugs that affect the renin–angiotensin-aldosterone axis should be | * Drugs that affect the [[Renin angiotensin aldosterone system|renin–angiotensin-aldosterone axis]] should be discontinued before testing, such as [[Beta blockers|beta-blockers]], [[ACE inhibitor|ACE inhibitors]], [[ARBs]] ([[angiotensin receptor blockers]]), [[Renin inhibitor|renin inhibitors]], [[Calcium channel blockers|dihydropyridine calcium channel blockers]], and central [[Alpha2-adrenergic agonists|alpha 2-agonists]], for about fourteen days, and [[spironolactone]], [[eplerenone]], [[amiloride]], and [[triamterene]], and [[Loop diuretic|loop diuretics]] for about twenty eight days. | ||
* The test should be conducted between 8 | * The test should be conducted between 8 AM and 10 AM. The patient is advised to stay upright for 2 hours prior to testing, and then sit for about 10 minutes before testing.<sup>[[Primary hyperaldosteronism laboratory findings#cite note-pmid11881117-1|[1]]]</sup> | ||
==== Interpretation ==== | ==== Interpretation ==== | ||
* Primary hyperaldosteronism (Conn's syndrome) is associated with an increased aldosterone levels (PAC) in plasma along with suppressed renin concentration (PRA) due to feedback inhibition of aldosterone on renin levels in the plasma. | * Primary hyperaldosteronism (Conn's syndrome) is associated with an increased [[aldosterone]] levels (PAC) in [[Blood plasma|plasma]] along with suppressed [[renin]] concentration (PRA) due to [[feedback inhibition]] of [[aldosterone]] on [[renin]] levels in the [[Blood plasma|plasma]]. | ||
* A PAC/PRA ratio of >30 is a strong evidence of primary | * A PAC/PRA ratio of > 30 is a strong evidence of primary hyperaldosteronism and value > 50 is considered diagnostic in the presence of resistant [[hypertension]], [[hypokalemia]], and [[metabolic alkalosis]].<ref name="pmid16617310">{{cite journal |vauthors=Doi SA, Abalkhail S, Al-Qudhaiby MM, Al-Humood K, Hafez MF, Al-Shoumer KA |title=Optimal use and interpretation of the aldosterone renin ratio to detect aldosterone excess in hypertension |journal=J Hum Hypertens |volume=20 |issue=7 |pages=482–9 |year=2006 |pmid=16617310 |doi=10.1038/sj.jhh.1002024 |url= |issn=}}</ref><ref name="pmid245263702">{{cite journal |vauthors=Pilz S, Kienreich K, Gaksch M, Grübler M, Verheyen N, Bersuch LA, Schmid J, Drechsler C, Ritz E, Moosbrugger A, Stepan V, Pieber TR, Meinitzer A, März W, Tomaschitz A |title=Aldosterone to active Renin ratio as screening test for primary aldosteronism: reproducibility and influence of orthostasis and salt loading |journal=Horm. Metab. Res. |volume=46 |issue=6 |pages=427–32 |year=2014 |pmid=24526370 |doi=10.1055/s-0034-1367033 |url= |issn=}}</ref> | ||
==References== | ==References== | ||
Latest revision as of 16:59, 3 November 2017
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Primary hyperaldosteronism Microchapters |
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Differentiating Primary Hyperaldosteronism from other Diseases |
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Diagnosis |
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Treatment |
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Case Studies |
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Primary hyperaldosteronism Screening On the Web |
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American Roentgen Ray Society Images of Primary hyperaldosteronism Screening |
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Risk calculators and risk factors for Primary hyperaldosteronism Screening |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]
Overview
There is insufficient evidence to recommend routine screening for primary hyperaldosteronism but according to the Endocrine Society Clinical Practice Guideline, screening for hyperaldosteronism is recommended for resistant hypertension by checking the plasma aldosterone to renin ratio (PAC/PRA).
Screening
Screening population
The following individuals should be screened for primary hyperaldosteronism:[1]
- Blood pressure > 160/100 (particularly in age < 50 years)
- Resistant hypertension or refractory hypertension (use of > 3 anti-hypertensives and poor control of blood pressure)
- Hypokalemia (provoked by diuretic therapy or unprovoked)
- Hypertension and incidentally discovered adrenal adenoma
- Hypertension with a family history of early-onset hypertension (< 20 years) or cerebrovascular accident at age less than 40 years
- Hypertensive first-degree relatives of patients with primary aldosteronism (PA)
Plasma Aldosterone to Renin Ratio (PAC/PRA)
The plasma aldosterone to renin ratio is widely used as a screening test for hyperaldosteronism.[2][3][4]
Protocol
- Drugs that affect the renin–angiotensin-aldosterone axis should be discontinued before testing, such as beta-blockers, ACE inhibitors, ARBs (angiotensin receptor blockers), renin inhibitors, dihydropyridine calcium channel blockers, and central alpha 2-agonists, for about fourteen days, and spironolactone, eplerenone, amiloride, and triamterene, and loop diuretics for about twenty eight days.
- The test should be conducted between 8 AM and 10 AM. The patient is advised to stay upright for 2 hours prior to testing, and then sit for about 10 minutes before testing.[1]
Interpretation
- Primary hyperaldosteronism (Conn's syndrome) is associated with an increased aldosterone levels (PAC) in plasma along with suppressed renin concentration (PRA) due to feedback inhibition of aldosterone on renin levels in the plasma.
- A PAC/PRA ratio of > 30 is a strong evidence of primary hyperaldosteronism and value > 50 is considered diagnostic in the presence of resistant hypertension, hypokalemia, and metabolic alkalosis.[5][6]
References
- ↑ Horsley MG, Bailie GR (1988). "Effectiveness of theophylline monitoring by the use of serum assays". J Clin Pharm Ther. 13 (5): 359–64. PMID 3230101.
- ↑ Ríos MC, Izquierdo A, Sotelo M, Honnorat E, Rodríguez Cuimbra S, Catay E, Popescu BM (2011). "[Aldosterone/renin ratio in the diagnosis of primary aldosteronism]". Medicina (B Aires) (in Spanish; Castilian). 71 (6): 525–30. PMID 22167725.
- ↑ Pilz S, Kienreich K, Gaksch M, Grübler M, Verheyen N, Bersuch LA, Schmid J, Drechsler C, Ritz E, Moosbrugger A, Stepan V, Pieber TR, Meinitzer A, März W, Tomaschitz A (2014). "Aldosterone to active Renin ratio as screening test for primary aldosteronism: reproducibility and influence of orthostasis and salt loading". Horm. Metab. Res. 46 (6): 427–32. doi:10.1055/s-0034-1367033. PMID 24526370.
- ↑ "The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline: The Journal of Clinical Endocrinology & Metabolism: Vol 101, No 5".
- ↑ Doi SA, Abalkhail S, Al-Qudhaiby MM, Al-Humood K, Hafez MF, Al-Shoumer KA (2006). "Optimal use and interpretation of the aldosterone renin ratio to detect aldosterone excess in hypertension". J Hum Hypertens. 20 (7): 482–9. doi:10.1038/sj.jhh.1002024. PMID 16617310.
- ↑ Pilz S, Kienreich K, Gaksch M, Grübler M, Verheyen N, Bersuch LA, Schmid J, Drechsler C, Ritz E, Moosbrugger A, Stepan V, Pieber TR, Meinitzer A, März W, Tomaschitz A (2014). "Aldosterone to active Renin ratio as screening test for primary aldosteronism: reproducibility and influence of orthostasis and salt loading". Horm. Metab. Res. 46 (6): 427–32. doi:10.1055/s-0034-1367033. PMID 24526370.