Clinical and biochemical predictors and predictive model of primary aldosteronism

Primary aldosteronism in hypertensive patients with obstructive sleep apnea

OBJECTIVE

To investigate the prevalence and clinical characteristics of primary aldosteronism (PA) in patients with hypertension and obstructive sleep apnoea (OSA) in a newly established cohort, given inconsistencies in previous studies and intolerance to drug washout in some cases.

DESIGN AND METHOD

A single-centre cross-sectional study enrolled 316 hypertensive patients diagnosed with OSA via polysomnography. All participants underwent PA screening, followed by confirmatory testing for positive cases. Patients with confirmed PA underwent further subtype diagnosis and were assigned to the OSA and PA group. Those unable to undergo antihypertensive drug washout but with a high clinical suspicion of PA were categorised into the OSA and suspected PA group.

RESULTS

Among 316 patients, 41 (13.0%) were PA. The prevalence was 4.8% in OSA alone, and 50.0% in OSA with hypokalaemia. Compared to the OSA group, the OSA and PA group had a lower proportion of current smokers, a longer duration of hypertension, lower serum triglycerides, lower serum potassium, higher plasma aldosterone concentration, urinary aldosterone excretion, and lower renin. Multivariable logistic regression showed that the diagnosis of PA in OSA patients was positively associated with hypertension duration, and negatively associated with serum potassium levels and smoking.

CONCLUSIONS

PA screening may be considered in patients with hypertension and OSA; however, given the relatively low prevalence in those with OSA alone, routine screening may not be cost-effective. In contrast, the presence of hypokalaemia was strongly associated with a higher prevalence of PA, suggesting that targeted screening is warranted in this subgroup.

Measurement accuracy and cutoffs for predicting primary aldosteronism diagnosis using Lumipulse® for renin and aldosterone measurements

OBJECTIVES

Primary aldosteronism (PA) diagnosis is a multistep process that begins with screening based on the plasma aldosterone-to-renin ratio (ARR). As cut-off values depend on the methods used, the aim of this study was 1) to validate the performances of new aldosterone and renin chemiluminescent immuno-assays using the Lumipulse® analyzer (Fujirebio®) and then 2) to define the criteria to distinguish PA patients from those with essential hypertension (EH).

METHODS

This monocentric retrospective study included 297 patients admitted to Georges Pompidou European Hospital, France, between January 2021 and December 2022 for the assessment of hypertension etiology. We evaluated analytical performances and compared Lumipulse® results for plasma renin (PRC) and plasma aldosterone (PAC) concentrations (n = 196) as well as 24-hour urine aldosterone excretion (24UA) (n = 201) to the reference methods (PRC: Liaison XL® Diasorin®; PAC and 24UA: LC-MS/MS). Receiver operating characteristic curve analysis was used to define the cut-off values for ARR, PAC, and 24UA to distinguish between PA and EH patients.

RESULTS

Analytical characteristics were in accordance with requested performances. Our results showed excellent correlations between Lumipulse® and our reference methods. We propose cut-off values of 35 pmol/mIU as the ARR, 260 pmol/L for PAC, and 49 nmol/24h for 24UA for predicting PA diagnosis.

CONCLUSIONS

Lumipulse® (Fujirebio®) is a reliable alternative for measuring PRC, PAC, and 24UA for predicting PA diagnosis with the use of corresponding cut-off values for each criterion.

Influence of smoking on cardiometabolic profile and surgical outcomes in patients with primary aldosteronism: a cohort study

AIM

To evaluate the influence of smoking on cardiometabolic profile and surgical outcomes in patients with primary aldosteronism (PA).

METHODS

Multicentre retrospective study of patients with PA evaluated in 36 Spanish tertiary hospitals with available information on smoking habits [smokers and non-smokers (never smokers and ex-smokers)].

RESULTS

A total of 881 patients were included, of whom 180 (20.4%) were classified as smokers and 701 as non-smokers. At diagnosis, smokers and non-smokers did not differ in blood pressure or serum potassium levels between. However, smokers had a higher prevalence of left ventricular hypertrophy (LVH) than non-smokers [odds ratio (OR) 2.0, 95% confidence interval (CI) 1.23-3.25], and smokers were more likely to have severe LVH than non-smokers (12.5% vs 6.6%, P = .164). A larger mean tumour size of the adrenal nodule/s was observed in the smoking group (18.6 ± 9.66 vs 15.8 ± 8.66 mm, P = .002). In addition, the odds of mild autonomous cortisol secretion (MACS) was greater in smokers than in non-smokers (OR 2.1, 95% CI 1.14-4.06), but these differences disappeared when adjusted for the size of the adrenal nodule/s (adjusted OR 1.6, 95% CI 0.76-3.37). The rate of biochemical and hypertension cure was similar in both groups; however, hypertension cure tended to be more frequent in the non-smoker group (41.2% vs 29.9%, P = .076).

CONCLUSIONS

Patients with PA who smoke have a higher prevalence of LVH and MACS and larger adrenal nodule/s than non-smokers. Smoking has no significant effect on the probability of hypertension response after adrenalectomy in patients with PA; however, a tendency to a lower probability of hypertension cure is observed in smokers compared to non-smokers.

The Prevalence of Obstructive Sleep Apnea in Patients With Primary Aldosteronism

CONTEXT

Investigating the co-occurrence of obstructive sleep apnea (OSA) and primary aldosteronism (PA) is crucial for understanding their interrelation.

OBJECTIVE

This work aimed to evaluate the prevalence of OSA in individuals diagnosed with PA and to assess the prevalence of PA within the OSA population, with a specific focus on hypertensive individuals.

METHODS

An exhaustive search was performed across PubMed, Embase, CINAHL, Scopus, and Web of Science up to September 2023, without restrictions on language or publication date. Studies were selected based on their focus on the prevalence of OSA in PA patients and vice versa, specifically in hypertensive individuals. Data were extracted using standard guidelines, focusing on patient characteristics, prevalence rates, and other relevant clinical parameters.

RESULTS

Proportional meta-analysis using a random-effects model revealed a 59.8% prevalence of OSA in hypertensive PA patients, with 45.4% exhibiting moderate-to-severe OSA. Meta-regression showed no significant effect of age, sex, body mass index, antihypertensive medication, systolic blood pressure, diastolic blood pressure, or serum potassium on OSA prevalence. However, a significant positive association was found with the glomerular filtration rate (GFR) (P < .001). Subgroup analysis also revealed that a hyperfiltration rate (GFR ≥ 100 mL/min per 1.73 m2) may be associated with a higher prevalence of OSA (71%, P value for interaction < .01). Among hypertensive OSA patients, 11.2% had PA.

CONCLUSION

A substantial prevalence of OSA in individuals with PA was identified, demonstrating a complex interplay between these conditions in hypertensive patients. Notably, the prevalence of OSA was significantly associated with kidney hyperfiltration.

Association between smoking and alcohol drinking and benign adrenal tumors: a Mendelian randomization study

BACKGROUND

In recent years, the detection rate of adrenal tumors has increased, but it is unclear whether smoking and alcohol drinking are risk factors for benign adrenal tumors. The objective of this study is to employ Mendelian randomization (MR) analysis to explore the causal relationship between smoking, alcohol drinking and susceptibility to benign adrenal tumors.

METHODS

We acquired large-scale data from publicly accessible databases on genome-wide association studies (GWAS) pertaining to smoking, alcohol drinking and benign adrenal tumors. A total of 11 sets of instrumental variables (IVs) and 281 associated single nucleotide polymorphic (SNP) loci were identified. The Mendelian randomization analyses were conducted using inverse variance weighting (IVW), MR-Egger regression and weighted median estimation (WME) methods, in addition to sensitivity analyses.

RESULTS

There is no causal relationship between smoking status, alcohol drinking status, alcohol intake frequency, alcohol taken with meals, alcohol consumption and benign adrenal tumors, while pack years of smoking and cigarettes per day are risk factors for benign adrenal tumors. The IVW analysis revealed that both the pack years of smoking and cigarettes per day were positively associated with an increased risk of benign adrenal tumors (OR = 2.853, 95%CI = 1.384-5.878, p = 0.004; OR = 1.543, 95%CI = 1.147-2.076, p = 0.004). Two SNPs (rs8042849 in the analysis of pack years of smoking and rs8034191 in the analysis of cigarettes per day) significantly drove the observed causal effects.

CONCLUSION

Two-sample Mendelian randomization analysis showed a causal effect between smoking but not alcohol consumption and benign adrenal tumors.

Comparison between screening for primary aldosteronism with and without drug adjustment

OBJECTIVE

Few studies have evaluated the performance of non-drug-adjusted primary aldosteronism (PA) screening. Therefore, we aimed to examine the consistency between PA screening results with and without drug adjustment and to explore the effectiveness of screening without drug adjustment.

METHODS

This prospective study included 650 consecutive patients with a high risk of incidence PA. Patients who initially screened positive underwent rescreening with drug adjustments and confirmatory tests. Regarding the remaining patients, one of every three consecutive patients underwent rescreening with drug adjustments and confirmatory tests. The changes in aldosterone and renin concentrations were compared between patients with essential hypertension (EH) and those with PA before and after drug adjustment. Sensitivity and specificity were used to assess the diagnostic performance of screening without drug adjustment, using the confirmatory test results as the reference.

RESULTS

We screened 650 patients with hypertension for PA. Forty-nine patients were diagnosed with PA and 195 with EH. Regarding drugs, 519 patients were taking angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), or diuretics alone or in combination. Forty-one patients were taking beta-blockers. Ninety patients were taking beta-blockers in combination with other drugs. In patients treated with ACEIs, ARBs, CCBs, or diuretics alone, or in combination, or beta-blockers alone, PA positivity was determined using the criteria, aldosterone-to-renin ratio (ARR) >38 pg/mL/pg/mL and plasma aldosterone concentration (PAC) >100 pg/mL, and negativity, using the criteria, ARR <9 pg/mL/pg/mL; the sensitivity and specificity were 94.7% and 94.5%, respectively. After drug adjustment, the sensitivity and specificity of screening were 92.1% and 89%, respectively.

CONCLUSIONS

In patients not treated with beta-blockers combined with others, when ARR >38 pg/mL/pg/mL and plasma aldosterone concentration (PAC) >100 pg/mL, or, ARR <9 pg/mL/pg/mL, non-drug-adjusted screening results were identical to with drug adjustment. Non-drug-adjusted screening could reduce the chance of medication adjustment, enable patients to continue their treatments and avoiding adverse effects, is of clinical importance.

Primary aldosteronism and obstructive sleep apnea: A meta-analysis of prevalence and metabolic characteristics

BACKGROUND

Primary aldosteronism (PA) and obstructive sleep apnea (OSA) are both causes for resistant hypertension and contribute to adverse cardiovascular outcome. However, the association of these two disorders remains to be investigated. We conducted this meta-analysis to estimate the prevalence and metabolic characteristics of the coexistence of PA and OSA.

METHODS

The databases of MEDLINE, EMBASE and Cochrane Reviews were searched for studies investigating the prevalence or clinical characteristics of PA and OSA until Jan 2023. Single proportions of PA and OSA were meta-analyzed for pooled prevalence and 95% confidence intervals (CIs). Odds ratios (ORs) and 95% CIs were calculated for the comparison of the prevalence. Mean differences (MDs) and 95% CIs were calculated for comparisons of the characteristics between patients with both OSA and PA and control groups.

RESULTS

A total of 16 studies were included. The pooled prevalence of PA was 27% (95% CI = 24-29%) in all patients with OSA (n = 3498). The prevalence of PA in patients with OSA was significantly higher than that in the patients without OSA (OR = 2.03, 95% CI = 1.30, 3.16, p = 0.002). The pooled prevalence (95% CI) of OSA was 46% (39-54%) in patients with PA (n = 2335). Compared with the hypertensive patients without PA, the prevalence of OSA in the patients with PA was significantly higher (OR = 2.01, 95% CI = 1.37, 2.95, p < 0.001). Compared with the patients of control groups, the patients with both PA and OSA had higher blood pressure and body mass index (BMI).

CONCLUSION

Screening for the coexistence of PA and OSA was warranted.

Development of a risk-prediction model for primary aldosteronism in veterans with hypertension

BACKGROUND

Rates of screening for primary aldosteronism in patients who meet the criteria are exceedingly low (1%-3%). To help clinicians prioritize screening in patients most likely to benefit, we developed a risk-prediction model.

METHODS

Using national Veterans Health Administration data, we identified patients who met the criteria for primary aldosteronism screening between 2000 and 2019. We performed multivariable logistic regression to identify characteristics associated with positive primary aldosteronism testing before generating a risk-scoring system based on the coefficients (0< β < 0.5 = 1 pt, 0.5 ≤ β < 1 = 2 pts, 1 ≤ β < 1.5 = 3 pts) and then tested the system performance using an internal validation cohort.

RESULTS

We identified 502,190 patients who met primary aldosteronism screening criteria, of whom 1.6% were screened and 15% tested positive. Based on the regression model, we generated a risk-scoring system based on a total of 9 possible points in which age under 50, absence of smoking history, and resistant hypertension each scored 1 point; elevated serum sodium 2 points; and hypokalemia 3 points. Rates of positive screening increased with risk score, with 5.6% to 6.7% of those scoring 0 points testing positive; 7.9% to 9.0% 1 point; 8.6% to 10% 2 points; 13% to 14% 3 points; 21% 4 points; 22% to 38% 5 points; 27% to 38% 6 points; 42% to 49% 7 points; and 50% to 51% ≥8 points.

CONCLUSION

In hypertensive patients who meet the criteria for primary aldosteronism screening, rates of positive screening range from 5.6% to 51%. Use of our risk-predication model incorporating these factors can identify patients most likely to benefit from testing.