SFE/SFHTA/AFCE Consensus on Primary Aldosteronism, part 2: First diagnostic steps

Screening and diagnosis of primary aldosteronism. Consensus document of all the Spanish Societies involved in the management of primary aldosteronism

Primary aldosteronism (PA) is the most frequent cause of secondary hypertension (HT), and is associated with a higher cardiometabolic risk than essential HT. However, PA remains underdiagnosed, probably due to several difficulties clinicians usually find in performing its diagnosis and subtype classification. The aim of this consensus is to provide practical recommendations focused on the prevalence and the diagnosis of PA and the clinical implications of aldosterone excess, from a multidisciplinary perspective, in a nominal group consensus approach by experts from the Spanish Society of Endocrinology and Nutrition (SEEN), Spanish Society of Cardiology (SEC), Spanish Society of Nephrology (SEN), Spanish Society of Internal Medicine (SEMI), Spanish Radiology Society (SERAM), Spanish Society of Vascular and Interventional Radiology (SERVEI), Spanish Society of Laboratory Medicine (SEQC(ML)), Spanish Society of Anatomic-Pathology, Spanish Association of Surgeons (AEC).

Endocrine causes of hypertension: literature review and practical approach

Hypertension (HTN) affects more than 30% of adults worldwide. It is the most frequent modifiable cardiovascular (CV) risk factor, and is responsible for more than 10 million death every year. Among patients with HTN, we usually distinguish secondary HTN, that is HTN due to an identified cause, and primary HTN, in which no underlying cause has been found. It is estimated that secondary hypertension represents between 5 and 15% of hypertensive patients [1]. Therefore, routine screening of patients for secondary HTN would be too costly and is not recommended. In addition to the presence of signs suggesting a specific secondary cause, screening is based on specific criteria. Identifying secondary HTN can be beneficial for patients in certain situations, because it may lead to specific treatments, and allow better control of blood pressure and sometimes even a cure. Besides, it is now known that secondary HTN are more associated with morbidity and mortality than primary HTN. The main causes of secondary HTN are endocrine and renovascular (mainly due to renal arteries abnormalities). The most frequent endocrine cause is primary aldosteronism, which diagnosis can lead to specific therapies. Pheochromocytoma and Cushing syndrome also are important causes, and can have serious complications. Other causes are less frequent and can be suspected on specific situations. In this article, we will describe the endocrine causes of HTN and discuss their treatments.

Surgery for Primary Aldosteronism in France From 2010 to 2020 - Results from the French-Speaking Association of Endocrine Surgery (AFCE): Eurocrine Study Group

OBJECTIVE

Describe the diagnostic workup and postoperative results for patients treated by adrenalectomy for primary aldosteronism in France from 2010 to 2020.

BACKGROUND

Primary aldosteronism (PA) is the underlying cause of hypertension in 6% to 18% of patients. French and international guidelines recommend CT-scan and adrenal vein sampling as part of diagnostic workup to distinguish unilateral PA amenable to surgical treatment from bilateral PA that will require lifelong antialdosterone treatment.Adrenalectomy for unilateral primary aldosteronism has been associated with complete resolution of hypertension (no antihypertensive drugs and normal ambulatory blood pressure) in about one-third of patients and complete biological success in 94% of patients.These results are mainly based on retrospective studies with short follow-up and aggregated patients from various international high-volume centers.

METHODS

Here we report results from the French-Speaking Association of Endocrine Surgery (AFCE) using the Eurocrine® Database.

RESULTS

Over 11 years, 385 patients from 10 medical centers were eligible for analysis, accounting for >40% of adrenalectomies performed in France for primary aldosteronism over the period.Preoperative workup was consistent with guidelines for 40% of patients. Complete clinical success (CCS) at the last follow-up was achieved in 32% of patients, and complete biological success was not sufficiently assessed.For patients with 2 follow-up visits, clinical results were not persistent at 1 year for one-fifth of patients.Factors associated with CCS on multivariate analysis were body mass index, duration of hypertension, and number of antihypertensive drugs.

CONCLUSIONS

These results call for an improvement in thorough preoperative workup and long-term follow-up of patients (clinical and biological) to early manage hypertension and/or PA relapse.

[Adverse effects of licorice consumed as food: An update]

The word "licorice" refers to the plant, its root, and its aromatic extract. From a commercial point of view, Glycyrrhiza glabra is the most important species with a wide range of uses (herbal medicine, tobacco industry, cosmetics, food and pharmaceutical). Glycyrrhizin is one of the main constituents of licorice. Glycyrrhizin is hydrolyzed in the intestinal lumen by bacterial β-glucuronidases to 3β-monoglucuronyl-18β-glycyrrhetinic acid (3MGA) and 18β-glycyrrhetinic acid (GA), which are metabolized in the liver. Plasma clearance is slow due to enterohepatic cycling. 3MGA and GA can bind to mineralocorticoid receptors with very low affinity, and 3MGA induces apparent mineralocorticoid excess syndrome through dose-dependent inhibition of 11β-hydroxysteroid dehydrogenase type 2 in renal tissue. The cases of apparent mineralocorticoid excess syndrome reported in the literature are numerous and sometimes severe, even fatal, most often in cases of chronic high dose consumption. Glycyrrhizin poisonings are characterized by hypertension, fluid retention, and hypokalemia with metabolic alkalosis and increased kaliuresis. Toxicity depends on the dose, the type of product consumed, the mode of consumption (acute or chronic) and a very large inter-individual variability. The diagnosis of glycyrrhizin-induced apparent mineralocorticoid excess syndrome is based on the history, clinical examination, and biochemical analysis. Management is primarily based on symptomatic care and stopping licorice consumption.

Underdiagnosis of Primary Aldosteronism: A Review of Screening and Detection

A clinical condition may be missed due to its higher-than-recognized prevalence or inadequate diagnostic screening. Both factors apply to primary aldosteronism, which is woefully underdiagnosed as a cause of hypertension and end-organ damage. Screening tests should be strongly considered for diseases that pose significant morbidity or mortality if left untreated, that have a high prevalence, and that have treatments that lead to improvement or cure. In this review we present the evidence for each of these points. We outline studies that estimate the prevalence of primary aldosteronism in different at-risk populations and how its recognition has changed over time. We also evaluate myriad studies of screening rates for primary aldosteronism and what factors do and do not influence current screening practices. We discuss the ideal conditions for screening, measuring the aldosterone to renin ratio in different populations that use plasma renin activity or direct renin concentration, and the steps for diagnostic workup of primary aldosteronism. Finally, we conclude with potential strategies to implement higher rates of screening and diagnosis of this common, consequential, and treatable disease.

Relationship between accessory renal arteries and resistant hypertension: A cohort study

BACKGROUND

Resistant hypertension (RHT) is a major health care concern affecting 20 to 30% of hypertensive patients and increasing cardiovascular risk. Recent renal denervation trials have suggested a high prevalence of accessory renal arteries (ARA) in RHT. Our objective was to compare the prevalence of ARA in RHT vs. non-resistant hypertension (NRHT).

METHODS

Eighty-six patients with essential hypertension who benefited from an abdominal CT-scan or MRI during their initial workup were retrospectively recruited in 6 French ESH (European Society of Hypertension) centers. At the end of a follow-up period of at least 6 months, patients were classified between RHT or NRHT. RHT was defined as uncontrolled blood pressure despite the optimal doses of three antihypertensive agents of which one is a diuretic or similar, or controlled by ≥ 4 medications. Blinded independent central review of all radiologic renal artery charts was performed.

RESULTS

Baseline characteristics were: age 50±15 years, 62% males, BP 145±22/87±13mmHg. Fifty-three (62%) patients had RHT and 25 (29%) had at least one ARA. Prevalence of ARA was comparable between RHT (25%) and NRHT patients (33%, P=0.62), but there were more ARA per patient in NRHT (2±0.9) vs. RHT (1.3±0.5, P=0.05), and renin levels were higher in ARA group (51.6±41.7 mUI/L vs. 20.4±25.4 mUI/L, P=0.001). ARA were similar in diameter or length between the 2 groups.

CONCLUSIONS

In this retrospective series of 86 essential hypertension patients, we found no difference in the prevalence of ARA in RHT and NRHT. More comprehensive studies are needed to answer this question.

Clinical, pathophysiologic, genetic and therapeutic progress in Primary Bilateral Macronodular Adrenal Hyperplasia

Patients with primary bilateral macronodular adrenal hyperplasia (PBMAH) usually present bilateral benign adrenocortical macronodules at imaging and variable levels of cortisol excess. PBMAH is a rare cause of primary overt Cushing's syndrome, but may represent up to one third of bilateral adrenal incidentalomas with evidence of cortisol excess. The increased steroidogenesis in PBMAH is often regulated by various G-protein coupled receptors aberrantly expressed in PBMAH tissues; some receptor ligands are ectopically produced in PBMAH tissues creating aberrant autocrine/paracrine regulation of steroidogenesis. The bilateral nature of PBMAH and familial aggregation, led to the identification of germline heterozygous inactivating mutations of the ARMC5 gene, in 20-25% of the apparent sporadic cases and more frequently in familial cases; ARMC5 mutations/pathogenic variants can be associated with meningiomas. More recently, combined germline mutations/pathogenic variants and somatic events inactivating the KDM1A gene were specifically identified in patients affected by GIP-dependent PBMAH. Functional studies demonstrated that inactivation of KDM1A leads to GIP-receptor (GIPR) overexpression and over or down-regulation of other GPCRs. Genetic analysis is now available for early detection of family members of index cases with PBMAH carrying identified germline pathogenic variants. Detailed biochemical, imaging, and co-morbidities assessment of the nature and severity of PBMAH is essential for its management. Treatment is reserved for patients with overt or mild cortisol/aldosterone or other steroid excesses taking in account co-morbidities. It previously relied on bilateral adrenalectomy; however recent studies tend to favor unilateral adrenalectomy, or less frequently, medical treatment with cortisol synthesis inhibitors or specific blockers of aberrant GPCR.

How to Explore an Endocrine Cause of Hypertension

Hypertension (HTN) is the most frequent modifiable risk factor in the world, affecting almost 30 to 40% of the adult population in the world. Among hypertensive patients, 10 to 15% have so-called “secondary” HTN, which means HTN due to an identified cause. The most frequent secondary causes of HTN are renal arteries abnormalities (renovascular HTN), kidney disease, and endocrine HTN, which are primarily due to adrenal causes. Knowing how to detect and explore endocrine causes of hypertension is particularly interesting because some causes have a cure or a specific treatment available. Moreover, the delayed diagnosis of secondary HTN is a major cause of uncontrolled blood pressure. Therefore, screening and exploration of patients at risk for secondary HTN should be a serious concern for every physician seeing patients with HTN. Regarding endocrine causes of HTN, the most frequent is primary aldosteronism (PA), which also is the most frequent cause of secondary HTN and could represent 10% of all HTN patients. Cushing syndrome and pheochromocytoma and paraganglioma (PPGL) are rarer (less than 0.5% of patients). In this review, among endocrine causes of HTN, we will mainly discuss explorations for PA and PPGL.

Draft of the clinical practice guidelines “Adrenal incidentaloma”

The wider application and technical improvement of abdominal imaging procedures in recent years has led to an increasingly frequent detection of adrenal gland masses — adrenal incidentaloma, which have become a common clinical problem and need to be investigated for evidence of hormonal hypersecretion and/or malignancy. Clinical guidelines are the main working tool of a practicing physician. Laconic, structured information about a specific nosology, methods of its diagnosis and treatment, based on the principles of evidence-based medicine, make it possible to give answers to questions in a short time, to achieve maximum efficiency and personalization of treatment. These clinical guidelines include data on the prevalence, etiology, radiological features and assessment of hormonal status of adrenal incidentalomas. In addition, this clinical practice guideline provides information on indications for surgery, postoperative rehabilitation and follow-up.

Symptomatic Hypokalemia in a 19-Year-Old Student

Primary hyperaldosteronism (PA) is the most common cause of secondary arterial hypertension and is frequently undiagnosed. It affects all ages but is more frequent between 20 and 60 years old. The clinical presentation is variable, and the diagnosis is based on screening and, in equivocal cases, confirmatory tests. A 19-year-old student presented with complaints of extreme fatigue, arterial hypertension, hypokalemia and metabolic alkalosis, raising a high index of suspicion for PA. Screening tests were performed and its expressiveness excluded the need of confirmatory tests. CT-scan showed a unilateral adrenal adenoma and the patient was submitted to laparoscopic adenectomy without complications. Prompt diagnosis and treatment are essential to avoid long term complications of PA.

Comparison of the Chemiluminescence Immunoassay LIAISON® with the Radioimmunoassay for Aldosterone and Renin Measurement

Determination of renin plasma levels is useful in the diagnosis of hypertension and in the therapeutic follow-up of hypertensive patients. Plasmatic concentration of renin decreases in patients with hypertension due to a primary hyperaldosteronism, contrary to renovascular hypertension where concentrations of renin and aldosterone are both elevated. Blood samples (serum, EDTA plasma) were analysed using two different chemiluminiscent methods CLIA LIAISON® and radioimmunoassay for aldosterone (IMMUNOTECH Beckman Coulter) and renin (Cisbio Bioassay) measurements were compared. We used both methods to ascertain the correlation between serum vs. EDTA plasma levels of aldosterone (RIA, CLIA) and renin (IRMA, CLIA) and to compare aldosterone to renin ratios for CLIA and for radioimmunoassay: serum aldosterone to plasma renin and plasma aldosterone to plasma renin. We compared serum aldosterone CLIA vs. RIA (rP=0.933, P<0.001) and plasma renin determined using CLIA vs. IRMA (rP=0.965, P=0.062). Furthermore, we used both methods to establish the correlation between the serum vs. plasma levels of aldosterone: RIA (rP=0.980, P<0.001); CLIA (rP=0.994, P=0.353) and serum vs. plasma levels of renin: IRMA (rP=0.948, P<0.001); CLIA (rP=0.921, P=0.011). Aldosterone (serum, plasma) to plasmatic renin ratios for CLIA (rP=0.999, P=0.286) and for radioimmunoassay (rP=0.992, P=0.025). Our data demonstrate that renin and aldosterone concentrations obtained using CLIA correlate with renin and aldosterone concentrations using radioimmunoassay methods. Correlation coefficients of pair results ranged from 0.921 to 0.994. Aldosterone (serum, EDTA plasma) to plasmatic renin ratios are comparable and any of them can be used with no significant differences found.

Screening for primary aldosteronism in pregnancy

Primary aldosteronism, the most common secondary cause of hypertension is likely to be significantly underdiagnosed in pregnancy and is associated with high rates of adverse maternal and fetal outcomes. Normal pregnancy is associated with a rise in aldosterone and renin levels early in pregnancy making the aldosterone:renin ratio which is normally used to screen for primary aldosteronism, difficult to interpret. Additionally, many laboratories have moved from performing plasma renin activity to measurements of direct renin. Aldosterone, direct renin and aldosterone: renin ratios were determined in 9 women with primary aldosteronism and compared to levels in 33 women with chronic hypertension. All women with primary aldosteronism had a direct renin levels of less than 20 mU/L together with aldosterone:renin ratio of greater than 40. Values for direct renin were significantly lower, and the aldosterone:renin ratio was significantly higher in pregnancy in women with primary aldosteronism compared to women with chronic hypertension. Pregnant women with chronic hypertension who have a direct renin level less than 20 mU/L and aldosterone:renin ratio of greater than 40 should have close surveillance for maternal and fetal complications, and follow-up postpartum should be ensured for definitive testing.

Radiofrequency ablation for adenoma in patients with primary aldosteronism and hypertension: ADERADHTA, a pilot study

OBJECTIVE

To evaluate the efficacy and the feasibility of radiofrequency ablation to treat aldosterone-producing adenomas.

METHODS

In an open prospective bicentric pilot study, patients with hypertension on ambulatory blood pressure measurement, a primary aldosteronism, an adenoma measuring less than 4 cm, and confirmation of lateralization by adrenal venous sampling were recruited. The primary endpoint, based on ABPM performed at 6 months after the radiofrequency ablation, was a daytime SBP/DBP less than 135/85 mmHg without any antihypertensive drugs or a reduction of at least 20 mmHg for SBP or 10 mmHg for DBP.

RESULTS

Thirty patients have been included (mean age = 51 ± 11 years; 50% women). Mean baseline daytime SBP and DBP were 144 ± 19 / 95 ± 15 mmHg and 80% received at least two antihypertensive drugs. At 6 months: 47% (95% CI 28-66) of patients reached the primary endpoint, mean daytime SBP and DBP were 131 ± 14 (101-154)/87 ± 10 (71-107) mmHg; 43% of them did not take any antihypertensive drug and 70% of them did not take potassium supplements. Few complications were recorded: four cases of back pain at day 1 postablation; three limited pneumothoraxes, which resolved spontaneously; one lesion of a polar renal artery.

CONCLUSION

Radiofrequency ablation for hypertensive patients with aldosterone-producing adenomas seems to be an emerging promising alternative to surgery. Its efficacy and its feasibility have to be confirmed in a larger sample of patients.

Recent Development toward the Next Clinical Practice of Primary Aldosteronism: A Literature Review

For the last seven decades, primary aldosteronism (PA) has been gradually recognized as a leading cause of secondary hypertension harboring increased risks of cardiovascular incidents compared to essential hypertension. Clinically, PA consists of two major subtypes, surgically curable and uncurable phenotypes, determined as unilateral or bilateral PA by adrenal venous sampling. In order to further optimize the treatment, surgery or medications, diagnostic procedures from screening to subtype differentiation is indispensable, while in the general clinical practice, the work-up rate is extremely low even in the patients with refractory hypertension because of the time-consuming and labor-intensive nature of the procedures. Therefore, a novel tool to simplify the diagnostic flow has been recently in enormous demand. In this review, we focus on recent progress in the following clinically important topics of PA: prevalence of PA and its subtypes, newly revealed histopathological classification of aldosterone-producing lesions, novel diagnostic biomarkers and prediction scores. More effective strategy to diagnose PA based on better understanding of its epidemiology and pathology should lead to early detection of PA and could decrease the cardiovascular and renal complications of the patients.

[Hypokalemia with pseudo-hyperaldosteronism: Is it Lidl® syndrome?]

INTRODUCTION

Intoxication induced by glycyrrhizin is a common cause of hypokalaemia by pseudo-hyperaldosteronism.

OBSERVATION

We hereby present the observation of a 68-year old patient hospitalised following a full hip-prosthesis operation after a deep hypokalaemia at 2.5mM was observed, with ECG signs (flat T waves and appearance of U waves). The kaliuresis was not adapted at 8,4mmol/mmol of creatininuria. We noted a history of axonal and demyelinising polyneuropathy, of psoriasis and chronic ethylism.The evolution after intravenous potassic supplementation and then per os was favourable leading to a normalisation of the blood and urinary potassic concentrations. The blood concentrations of renin and of aldosterone upon admission were lower than the detection threshold and the tests carried out 7 days later were normal with a plasmatic renin of 35.2 pg/mL and a plasmatic aldosterone of 74 pg/mL, therefore indicating a toxic cause. It is the interview of the patient that allowed for the diagnosis, identifying a daily, prolonged and important consumption (around 1L every 2-3 days for several years) of a pastis produced by supermarket brand Lidl®. The composition of the drink mentions 'liquorice infusion' without giving any more information as regards to the real concentration; it was later estimated at 170 mg/L by the distributor.

DISCUSSION

The consumption of glycyrrhizin is a well-known aetiology for pseudo-hyperaldosteronism. It is commonly mentioned amongst excessive consumers of liquorice or of non-alcoholic anise drinks. Drinks that are derived from original pastis contain varying levels of glycyrrhizin, which is used as a flavour enhancer and can become toxic in cases of prolonged and important consumption.

Development and Validation of Criteria for Sparing Confirmatory Tests in Diagnosing Primary Aldosteronism

CONTEXT

The Endocrine Society Guidelines for the diagnosis of primary aldosteronism (PA) suggest that confirmatory tests (CFT) are not required when the following criteria are met: plasma aldosterone concentration (PAC) is >20 ng/dL, plasma renin is below detection levels, and hypokalemia is present. The evidence for the applicability of the guideline criteria is limited.

OBJECTIVE

To develop and validate optimized criteria for sparing CFT in the diagnosis of PA.

DESIGN AND SETTING

The optimized criteria were developed in a Chinese cohort using the captopril challenge test, verified by saline infusion test (SIT) and fludrocortisone suppression test (FST), and validated in an Australian cohort.

PARTICIPANTS

Hypertensive patients who completed PA screening and CFT.

MAIN OUTCOME MEASURE

Diagnostic value of the optimized criteria.

RESULTS

In the development cohort (518 PA and 266 non-PA), hypokalemia, PAC, and plasma renin concentration (PRC) were selected as diagnostic indicators by multivariate logistic analyses. The combination of PAC >20 ng/dL plus PRC <2.5 μIU/mL plus hypokalemia had much higher sensitivity than the guideline criteria (0.36 vs 0.11). The optimized criteria remained superior when the SIT or FST were used as CFT. Non-PA patients were not misdiagnosed by either criteria, but the percentage of patients in whom CFT could be spared was higher with the optimized criteria. In the validation cohort (125 PA and 81 non-PA), the sensitivity of the optimized criteria was also significantly higher (0.12 vs 0.02).

CONCLUSIONS

Hypertensive patients with PAC >20 ng/dL, PRC <2.5 μIU/mL, plus hypokalemia can be confidently diagnosed with PA without confirmatory tests.

The Quality of Clinical Practice Guidelines and Consensuses on the Management of Primary Aldosteronism: A Critical Appraisal

Background: Several guidelines and expert consensuses have been developed for management of primary aldosteronism (PA). It is important to understand the detailed recommendations and quality of these guidelines to help physicians make informed and reliable decision.

Methods: PubMed, EMBASE, and three websites were searched for practice guidelines or consensuses of PA from inception to January 24, 2019. We summarized the major recommendations on the management of PA from these guidelines and consensuses. The Appraisal of Guidelines for Research and Evaluation II was used to assess quality of the included guidelines and consensuses.

Results: We identified three clinical practice guidelines and three consensus statements. Most of the recommendations on the diagnosis and treatment of PA from these guidelines and consensuses were consistent. Some minor conflicts were recorded for patient's screen and confirmation test. All included guideline documents have a good quality (score, >70%) on the scope and purpose (mean score, 81.02%) and clarity of presentation of the recommendations (mean score, 86.88%). However, the reporting for the stakeholder involvement (mean score, 54.32%) and applicability (mean score, 47.92%) were insufficient. There was an insufficient rigorousness in most of the guideline documents (mean score, 45.56%) on the development process. The Endocrine Society practice guideline 2016 ranked highest in quality (score, 81.13%).

Conclusions: Existing guideline documents provided valuable recommendations on the management of PA, but further efforts are needed to improve the methodological quality. The Endocrine Society practice guideline 2016 was recommended for use.

A clinical prediction score using age at diagnosis and saline infusion test parameters can predict aldosterone-producing adenoma from idiopathic adrenal hyperplasia

PURPOSE

Accurate subtyping of the primary aldosteronism into aldosterone-producing adenoma (APA) and idiopathic adrenal hyperplasia (IAH) is important to direct for specific treatment modalities. The objective of the study was to compare the clinical and biochemical parameters of APA and IAH patients to derive a Clinical Prediction Score reliably predicting APA from IAH.

METHODS

This was a retrospective multi-centre study recruiting 38 APA patients and 42 IAH patients from four major hospitals in Hong Kong using database from Surgical Outcomes Monitoring and Improvement Programme and Clinical Data Analysis and Reporting System. Their clinical and biochemical parameters were evaluated.

RESULTS

Patients in APA group were younger than IAH group (mean age 48.6 ± 9.2 vs. 57.1 ± 7.3 years old, p < 0.001), had more suppressed renin before saline infusion in saline infusion test (SIT) (median 0.19 [IQR 0.15-0.37] vs. 0.39 [IQR 0.19-0.69] ng/mL/h, p = 0.01), and higher aldosterone level after saline infusion in SIT (median 674 [IQR 498-1000] vs. 327 [IQR 242-483] pmol/L, p < 0.001). A clinical prediction score using three parameters was devised, comprising age at diagnosis < 50 years, PRA before saline infusion in SIT ≤ 0.26 ng/mL/h, and aldosterone level after saline infusion in SIT ≥ 424 pmol/L. A score of 2 would predict APA with a sensitivity of 84.2% and specificity of 88.1%, and a score of 3 would predict APA with a sensitivity of 31.6% and specificity of 100%.

CONCLUSIONS

Clinical Prediction Score based on the combination of age at diagnosis, PRA, and aldosterone level in the saline infusion tests could reliably predict APA from IAH.

[Secondary hypertension in women]

The two main non-iatrogenic causes of secondary hypertension in women of childbearing age are primary aldosteronism and renal fibromuscular dysplasia. It is recommended to look for a secondary hypertension in women who remain hypertensive three months after pregnancy, in patients under 40 years of age or in patients with a grade 3 HTN (BP≥180/110mm Hg) (Professional agreement). It is suggested that the initial assessment of a secondary HTN in women is performed by a HTN specialist; it will include an assessment of renin and aldosterone concentrations and an angio-CT of the renal arteries (or angio-MRI if contraindicated) (Grade C - Class 2).

The aldosterone to renin ratio in the diagnosis of primary aldosteronism: Promises and challenges

The complexity of evaluating patients for secondary treatable causes of hypertension is underappreciated. Primary aldosteronism (PA) is the most prevalent cause of secondary hypertension (3%-32% of hypertensive patients). The recent endocrine society clinical practice guideline (ESCPG), "The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment", differs from the previous version in the explicit recognition of PA as a major public health issue. Despite this, PA is underdiagnosed. The guidelines call on physicians to substantially ramp up the screening of hypertensive patients at risk of PA. Further, it recommends the plasma aldosterone to renin ratio (ARR), as the test of choice for screening for PA. However, the ARR is a highly variable test with reported diagnostic sensitivities and specificities ranging from 66% to 100% and 61% to 100%, respectively. Variability of the ARR can be attributed to the high degree of within-subject variation, differences in sampling protocols, laboratory assays, reporting units, the effect of medications and the population characteristics used to establish the decision thresholds. These factors render the possibility of false positive and false negative results-which have the potential to adversely impact patients. The limitations and caveats to the use of the ARR necessitate an effective clinic-laboratory interface, with specialist physician and clinical scientist collaboration for ARR result interpretation. Improvement in the diagnostic sensitivity and specificity of the ARR is predicated on harmonisation of pretesting patient preparation criteria, knowledge of the analytical methods used to derive the ratio and the method-specific threshold for PA.

Criteria for diagnosing primary aldosteronism on the basis of liquid chromatography-tandem mass spectrometry determinations of plasma aldosterone concentration

BACKGROUND

Primary aldosteronism is affecting about 10% of hypertensive patients. Primary aldosteronism should be diagnosed by screening tests based on plasma aldosterone concentration (PAC) and aldosterone-to-renin ratio (ARR), followed by confirmatory test. The cutoff values for PAC and ARR depend on PAC and plasma renin measurement methods. Liquid chromatography-tandem mass spectrometry (LC-MS/MS), the new gold standard method for aldosterone determination, is now widespread but shows lower values than immunoassays. New cutoff values have yet to be determined with LC-MS/MS PAC.

METHODS

In a retrospective cohort, we measured PAC by LC-MS/MS in 93 healthy volunteers, 77 patients with essential hypertension and 82 primary aldosteronism patients (42 lateralized, 24 bilateral, 16 primary aldosteronism without adrenal vein sampling) after 30 min in a seated position.

RESULTS

PAC ranged from 42 to 309 pmol/l in healthy volunteers and from 63 to 362 pmol/l in essential hypertensive patients. A cutoff value of 360 pmol/l for basal PAC had a sensitivity of 90.5% and a specificity of 95.1% to differentiate lateralized primary aldosteronism from essential hypertensive patients. ARR ranged from 2.3 to 22.3 in healthy volunteers and from 3.2 to 55.6 pmol/mU in essential hypertensive patients. Using ROC curves, we selected an ARR of 46 pmol/mU, which provided a sensitivity of 100% and a specificity of 93.4% to distinguish between essential hypertensive and lateralized primary aldosteronism patients (sensitivity 94.4%, specificity 93.9% for the overall primary aldosteronism population).

CONCLUSION

Criteria for primary aldosteronism screening need to be adapted, given the increasing use of LC-MS/MS to determine PAC. We suggest to use 360 pmol/l and 46 pmol/mU as cutoff values, respectively, for basal PAC and ARR after 30 min of seated rest.

Familial hyperaldosteronism type III a novel case and review of literature

Less than 15% of hypertension cases in children are secondary to a primary hyperaldosteronism. This is idiopathic in 60% of the cases, secondary to a unilateral adenoma in 30% and 10% remaining by primary adrenal hyperplasia, familial hyperaldosteronism, ectopic aldosterone production or adrenocortical carcinoma.To date, four types of familial hyperaldosteronism (FH I to FH IV) have been reported. FH III is caused by germline mutations in KCNJ5, encoding the potassium channel Kir3.4. The mutations cause the channel to lose its selectivity for potassium, allowing large quantities of sodium to enter the cell. As a consequence, the membrane depolarizes, voltage-gated calcium channels open, calcium enters the cell, initiating the cascade that leads to aldosterone synthesis. Somatic mutations in KCNJ5 has also been described in aldosterone-producing adenomas. The most frequent presentation of FH III is with severe hyperaldosteronism symptoms and resistance to pharmacological therapy which leads to bilateral adrenalectomy. We will review current literature and describe a child with FH III due to a novel de novo deletion in KCNJ5 with wild phenotype as a sign of clinical variability of this disease.

Medication adherence during laboratory workup for primary aldosteronism: pilot study

PURPOSE

Current hypertension guidelines stipulate that all incompatible medications be stopped before performing laboratory screening for aldosteronism, but patient adherence is unclear. We measured plasma drug concentrations to determine drug adherence and potential drug bias during biochemical tests.

PATIENTS AND METHODS

Plasma concentrations of 10 antihypertensive drugs were quantified by mass spectrometry in 24 consecutive ambulatory patients with uncontrolled hypertension routinely evaluated for aldosteronism. Drug screening was done before (first visit), and on the day of biochemical tests (second visit) after stopping all incompatible medications. Concentrations above those expected at trough dosing interval defined same-day dose intake.

RESULTS

On the first and second visits, 76% vs 77% of prescribed antihypertensive doses could be verified in plasma. A total of 33% of patients were found to be nonadherent and showed divergent plasma drug results relative to prescriptions (21% drugs not detected/13% unprescribed drugs found) on first visit, 25% on the second (0%/25%), and 46% for both. A total of 21% used medication incompatible with the biochemical tests on the second visit. Moreover, 17% of drug concentrations were below expected trough levels on the first vs 15% on the second visit. This analysis revealed additional four (17%) vs three (13%) nonadherent patients who failed same-day dose intake and remained undetected by qualitative drug tests.

CONCLUSION

Nonadherence was frequent during laboratory evaluations for aldosteronism advocating cautious interpretation of results. A multicenter study is desirable to set the stage for new screening protocols that should incorporate also incentives and checks of drug adherence.

Stroke disclosing primary aldosteronism: Report on three cases and review of the literature

OBJECTIVES

There is a growing evidence of increased risk of cerebrovascular events in primary aldosteronism (PA). Nevertheless, acute neurologic ailment as presenting feature of PA is uncommon. Our aim is to highlight the diagnosis challenges in stroke unmasking PA and to discuss the underlying physiopathology and management dilemmas.

MATERIALS AND METHODS

We hereby describe three consecutive rare cases of stroke revealing PA. All patients had brain imaging and thorough biological and morphological assessment to rule out other etiologies of stroke. The diagnosis of primary aldosteronism was established according to the Endocrine Society Clinical Practice Guideline, with a review of the literature on the spectrum of neurologic manifestations in PA.

RESULTS

We report on three cases, two women and a man, presenting with ischemic or hemorrhagic stroke, of early onset in two of them. All of the reported patients had hypertension and hypokaliemia. This association prompted the assessment of renin angiotensin aldosterone system (RAAS) disclosing PA, which was due to bilateral adenomas in the first one or bilateral adrenal hyperplasia in the two others. All patients refused the surgical option and received spironolactone with recurrence of stroke in one of them due to treatment incompliance.

CONCLUSION

Although cerebrovascular events are quite common in PA, their occurrence as initial feature can be misleading. The association of hypokaliemia and refractory hypertension in ischemic or hemorrhagic strokes should prompt an assessment of the RAAS to rule out PA and initiate adequate management as soon as possible in order to avoid further complications.

Hypertension: The role of biochemistry in the diagnosis and management

Hypertension is defined as a persistently elevated blood pressure ≥140/90mmHg. It is an important treatable risk factor for cardiovascular disease, with a high prevalence in the general population. The most common cause, essential hypertension, is a widespread disease - however, secondary hypertension is under investigated and under diagnosed. Collectively, hypertension is referred to as a "silent killer" - frequently it displays no overt symptomatology. It is a leading risk factor for death and disability globally, with >40% of persons aged over 25 having hypertension. A vast spectrum of conditions result in hypertension spanning essential through resistant, to patients with an overt endocrine cause. A significant number of patients with hypertension have multiple cardiovascular risk factors at the time of presentation. Both routine and specialised biochemical investigations are paramount for the evaluation of these patients and their subsequent management. Biochemical testing serves to identify those hypertensive individuals who are at higher risk on the basis of evidence of dysglycaemia, dyslipidaemia, renal impairment, or target organ damage and to exclude identifiable causes of hypertension. The main target of biochemical testing is the identification of patients with a specific and treatable aetiology of hypertension. Information gleaned from biochemical investigation is used to risk stratify patients and tailor the type and intensity of subsequent management and treatment. We review the approach to the biochemical investigation of patients presenting with hypertension and propose a diagnostic algorithm for work-up.

[Hypertension etiological work up: Hormonological assessment always before imaging?]

The purpose is to consider the practical management of etiological work up in hypertension, beyond national or international recommendations, leading to consider the prior practice of hormonal assays or renal, renovascular or adrenal imaging. The ease of access to imaging, difficulties to meet the requirements to obtain reliable hormonal assays explain the use of first-line imaging in clinical practice. The renal and adrenal CT angiography provides diagnostic orientation without allowing a formal conclusion. Incidentaloma prevalence in the general population, increasing with age, underlines the limitations of a decision based only on imaging. The discovery of adrenal morphological abnormalities justifies the realization of hormonal assays to determine their causal relationship with hypertension. The aldosterone/PRA ratio, in standardized conditions, has the best diagnostic performance to screen for primary aldosteronism and is the pivotal test of the etiological diagnosis of hypertension. The identification of a subclinical Cushing should be considered in patients with adrenal morphological abnormalities, particularly in case of metabolic syndrome. The abdominal CTscan is initially recommended in the diagnosis of pheochromocytoma, but the recommende boichemical testing is urine metanephrines whose result will lead to search a pheochromocytoma or an extra-abdominal paraganglioma. Many drug interactions must be considered in order to interpret hormonal measurements and avoid erroneous diagnosis. Finally, a genetic context and the possibility of endocrine causes with normal abdominal CT scan should be considered: extra-abdominal paraganglioma, parathyroid adenoma and Cushing's disease with pituitary adenoma, requiring a multidisciplinary decision. The efficiency of imaging as first-line in the screening of secondary hypertension is relative and confrontation with hormone assays will be critical to the diagnostic and therapeutic management. In young women, hormonal measurements precede imaging in the etiological investigation of hypertension.

SFE/SFHTA/AFCE primary aldosteronism consensus: Introduction and handbook

The French Endocrinology Society (SFE) French Hypertension Society (SFHTA) and Francophone Endocrine Surgery Association (AFCE) have drawn up recommendations for the management of primary aldosteronism (PA), based on an analysis of the literature by 27 experts in 7 work-groups. PA is suspected in case of hypertension associated with one of the following characteristics: severity, resistance, associated hypokalemia, disproportionate target organ lesions, or adrenal incidentaloma with hypertension or hypokalemia. Diagnosis is founded on aldosterone/renin ratio (ARR) measured under standardized conditions. Diagnostic thresholds are expressed according to the measurement units employed. Diagnosis is established for suprathreshold ARR associated with aldosterone concentrations >550pmol/L (200pg/mL) on 2 measurements, and rejected for aldosterone concentration<240pmol/L (90pg/mL) and/or subthreshold ARR. The diagnostic threshold applied is different if certain medication cannot be interrupted. In intermediate situations, dynamic testing is performed. Genetic forms of PA are screened for in young subjects and/or in case of familial history. The patient should be informed of the results expected from medical and surgical treatment of PA before exploration for lateralization is proposed. Lateralization is explored by adrenal vein sampling (AVS), except in patients under 35 years of age with unilateral adenoma on imaging. If PA proves to be lateralized, unilateral adrenalectomy may be performed, with adaptation of medical treatment pre- and postoperatively. If PA is non-lateralized or the patient refuses surgery, spironolactone is administered as first-line treatment, replaced by amiloride, eplerenone or calcium-channel blockers if insufficiently effective or poorly tolerated.