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Fernandez CJ, Nagendra L, Alkhalifah M, Pappachan JM. Endocrine Hypertension: The Urgent Need for Greater Global Awareness. touchREV Endocrinol 2023; 19:31-41. [PMID: 38187076 PMCID: PMC10769474 DOI: 10.17925/ee.2023.19.2.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/04/2023] [Indexed: 01/09/2024]
Abstract
Hypertension affects about 1.28 billion adults globally, and significantly increases the risk of chronic morbidity and mortality among sufferers. About 15% of these individuals have secondary hypertension, the majority of whom have dysfunction of one or more endocrine systems as the cause of hypertension. Although adrenal disorders are often identified as the cause of endocrine hypertension, extra-adrenal disease and pituitary disorders also can cause the disease. Timely diagnosis is of paramount importance, because of the potential for a surgical cure or optimal disease control with pharmacotherapy to prevent hypertensive complications. Even with its relatively high prevalence compared with many other chronic illnesses, the diagnosis of endocrine hypertension is often delayed or never made because of poor awareness about the disease among physicians. This review attempts to provide an overview of the disease, with some practical aspects of diagnosis and management of a few of the important disorders causing endocrine hypertension.
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Affiliation(s)
- Cornelius J Fernandez
- Department of Endocrinology and Metabolism, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - Lakshmi Nagendra
- Department of Endocrinology, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, India
| | - Mohammed Alkhalifah
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston, UK
- Department of Family Medicine & Diabetes, King Saud University Medical City, Riyad, Saudi Arabia
| | - Joseph M Pappachan
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston, UK
- Faculty of Science, Manchester Metropolitan University, Manchester, UK
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Ng E, Gwini SM, Stowasser M, Young MJ, Fuller PJ, Singh GR, Yang J. Aldosterone and renin concentrations and blood pressure in young Indigenous and non-Indigenous adults in the Northern Territory: a cross-sectional study. Med J Aust 2023; 219:263-269. [PMID: 37573148 DOI: 10.5694/mja2.52062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/20/2023] [Accepted: 06/20/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVES To evaluate aldosterone and renin levels and aldosterone-to-renin ratios (ARRs) in young Indigenous and non-Indigenous adults in the Northern Territory, and their association with blood pressure levels. DESIGN Cross-sectional study; single time point sub-study of two prospective birth cohort studies. SETTING, PARTICIPANTS Participants in the Aboriginal Birth Cohort (ABC) - born to Indigenous mothers at the Royal Darwin Hospital during 1987-1990 - and the Top End Cohort (TEC) - people born to non-Indigenous mothers in Darwin, recruited during 2007-2009 - aged 32-35 years at the time of this sub-study. MAIN OUTCOME MEASURES Plasma aldosterone and direct renin concentrations; ARRs (positive screening test result for primary aldosteronism defined as > 70 pmol/mU); systolic and diastolic blood pressure. RESULTS A total of 255 ABC (205 in remote, 50 in urban locations) and 76 TEC members participated. Median aldosterone concentration was similar for all three groups. The median renin concentration was 7.5 mU/L (interquartile range [IQR], 4.1-12.4 mU/L) in the TEC group, 12.4 mU/L (IQR, 5.1-19 mU/L) in the urban ABC group, and 29.3 mU/L (IQR, 15.0-52.9 mU/L) in the remote ABC group. The median ARR was 10 pmol/mU (IQR, 6-19 pmol/mU) in the remote ABC group, 28 pmol/mU (IQR, 16-70 pmol/mU) in the urban ABC group, and 43 pmol/mU (IQR, 26-74 pmol/mU) in the TEC group. Thirteen urban ABC participants (26%), 21 TEC participants (28%), and six people in the remote ABC group (3%) had ARR values above 70 pmol/mU. Adjusted for age and body mass index (BMI), mean systolic and diastolic blood pressure were lower for women than men in all participant groups; after adjusting for age, sex, and BMI, larger ARR was associated with higher systolic blood pressure in the TEC group but not the two ABC groups. CONCLUSION Screening test results for primary aldosteronism were positive for about one-quarter of urban Indigenous and non-Indigenous participants. A prospective study that includes confirmatory testing would more accurately assess the prevalence of primary aldosteronism among Indigenous Australians in the Northern Territory.
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Affiliation(s)
- Elisabeth Ng
- Monash Health, Melbourne, VIC
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, VIC
| | - Stella M Gwini
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, VIC
- Monash University, Melbourne, VIC
| | | | | | - Peter J Fuller
- Monash Health, Melbourne, VIC
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, VIC
| | | | - Jun Yang
- Monash Health, Melbourne, VIC
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, VIC
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Yang J, Gwini SM, Beilin LJ, Schlaich M, Stowasser M, Young MJ, Fuller PJ, Mori TA. Effect of Oral Contraception on Screening Tests for Primary Aldosteronism: A 10-Year Longitudinal Study. J Clin Endocrinol Metab 2023; 108:1686-1695. [PMID: 36633572 DOI: 10.1210/clinem/dgad010] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
CONTEXT Primary aldosteronism (PA) and oral contraception (OC) can both cause hypertension in young women. However, the effect of OC on the screening test for PA, the aldosterone to renin ratio (ARR), is not clear. OBJECTIVE We evaluated the impact of OC on the screening test for PA. METHODS In this retrospective cohort study, we analyzed data from the female offspring (Gen2) of women enrolled in the Raine Study, a population-based birth cohort, who had blood pressure (BP) measurements, blood samples, and information about OC use at age 17 years (N = 484) and/or age 27 years (N = 486). RESULTS Aldosterone concentration was significantly higher in OC users than nonusers at 17 years (median 486 pmol/L vs 347 pmol/L, P < 0.001). Renin concentration was significantly lower in OC users at both 17 years (13.4 mU/L vs 20.6 mU/L) and 27 years (9.2 mU/L vs 11.8 mU/L), hence the ARR was significantly higher in OC users compared to nonusers at both 17 years (31.5 vs 18.3) and 27 years (27.3 vs 21.1). The proportion of participants with ARR > 70 pmol/mU (current threshold for PA detection) was significantly higher in OC users at both 17 years (12.6% vs 2.1%) and 27 years (6.4% vs 0.4%); however, they had comparable BP to those with ARR < 70. OC use at any age abolished the relationship between ARR and BP that is observed in nonusers. CONCLUSION OC can increase the ARR and cause a false positive PA screening result. Until more reliable criteria for PA screening in OC users are established, alternative contraception should be considered during screening.
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Affiliation(s)
- Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
- Department of Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Stella May Gwini
- Department of Biostatistics, University Hospital Geelong, Barwon Health, Victoria 3220, Australia
- Biostatistics Unit, Division of Research Methodology, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria 3168, Australia
| | - Lawrence J Beilin
- Medical School, The University of Western Australia, Crawley, Western Australia 6009, Australia
| | - Markus Schlaich
- Dobney Hypertension Centre, Medical School, The University of Western Australia - Royal Perth Hospital Campus, Perth, Western Australia 6000, Australia
- Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth 6000, Australia
- Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Victoria 3004, Australia
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland Diamantina Institute, Princess Alexandra Hospital, Brisbane 4102, Australia
| | - Morag J Young
- Cardiovascular Endocrinology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria 3004, Australia
| | - Peter J Fuller
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Trevor A Mori
- Medical School, The University of Western Australia, Crawley, Western Australia 6009, Australia
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Arnold N, Hermanns IM, Schulz A, Hahad O, Schmitt VH, Panova-Noeva M, Prochaska JH, Binder H, Pfeiffer N, Beutel M, Lackner KJ, Münzel T, Wild PS. Renin, aldosterone, the aldosterone-to-renin ratio, and incident hypertension among normotensive subjects from the general population. Cardiovasc Res 2023; 119:294-301. [PMID: 35199135 PMCID: PMC10022856 DOI: 10.1093/cvr/cvac019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 02/21/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS To investigate the predictive ability of direct plasma renin and aldosterone concentrations as well as their ratio [aldosterone-to-renin (ARR)] for incident hypertension in the general population. METHODS AND RESULTS Concentration of renin and aldosterone were measured by a chemiluminescence immunoassay using the fully automated LIAISON® platform (DiaSorin) among 5362 participants of the population-based Gutenberg Health Study, who were normotensive and had no clinically overt cardiovascular disease at baseline. During a follow-up period of 5 years, 18.6% (n = 996) developed a new-onset hypertension. Comparing extreme quartiles of biomarker distribution, the relative risk (RR) for incident arterial hypertension was found to be 1.58 [95% confidence interval (CI) 1.25-2.00; P = 0.00015; Q1 vs. Q4ref] for renin; 1.29 (95% CI 1.05-1.59, P = 0.018; Q4 vs. Q1ref) for aldosterone and 1.70 (95% CI 1.33-2.12; P < 0.0001; Q4 vs. Q1ref) for ARR after multivariable adjustment in men. In females, only high ARR was independently predictive for incident hypertension over 5 years [RR 1.29 (95% CI 1.04-1.62); P = 0.024]. Even in the subgroup of individuals having biomarker concentrations within the reference range, high ARR was predictive for new-onset hypertension in men [RR 1.44 (95% CI 1.13-1.83); P = 0.003]. Finally, synergistic effects of co-prevalent obesity and ARR on incident hypertension were also demonstrated, resulting in markedly higher risk estimates as seen for biomarker alone [RR of 2.70 (95% CI 2.05-3.6) for Q4 of ARR and having body mass index ≥ 30 kg/m2 vs. low ARR (Q1ref) and normal weight; P < 0.0001]. CONCLUSION Among normotensives from the general population ARR possesses a stronger predictive value for incident hypertension than renin or aldosterone alone. The prediction of arterial hypertension by ARR was even stronger in obese subjects.
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Affiliation(s)
- Natalie Arnold
- Preventive Cardiology and Preventive Medicine, Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Iris M Hermanns
- Preventive Cardiology and Preventive Medicine, Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
| | - Andreas Schulz
- Preventive Cardiology and Preventive Medicine, Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Omar Hahad
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
- Department of Cardiology—Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Volker H Schmitt
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
- Department of Cardiology—Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Marina Panova-Noeva
- Preventive Cardiology and Preventive Medicine, Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes-Gutenberg University Mainz, Mainz, Germany
| | - Jürgen H Prochaska
- Preventive Cardiology and Preventive Medicine, Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
- Department of Cardiology—Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes-Gutenberg University Mainz, Mainz, Germany
| | - Harald Binder
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Manfred Beutel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Karl J Lackner
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
- Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Münzel
- Corresponding authors. Tel: +49 (0) 6131 17 7250; fax: +49 (0) 6131 17 6615, E-mail: (T.M.); Tel: +49 (0) 6131 17 7163; fax: +49 (0) 6131 17 3403, E-mail: (P.S.W.)
| | - Philipp S Wild
- Corresponding authors. Tel: +49 (0) 6131 17 7250; fax: +49 (0) 6131 17 6615, E-mail: (T.M.); Tel: +49 (0) 6131 17 7163; fax: +49 (0) 6131 17 3403, E-mail: (P.S.W.)
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Ng E, Gwini SM, Libianto R, Choy KW, Lu ZX, Shen J, Doery JCG, Fuller PJ, Yang J. Aldosterone, Renin, and Aldosterone-to-Renin Ratio Variability in Screening for Primary Aldosteronism. J Clin Endocrinol Metab 2022; 108:33-41. [PMID: 36179243 DOI: 10.1210/clinem/dgac568] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/23/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT The plasma aldosterone concentration (PAC), renin, and aldosterone-to-renin ratio (ARR) are used to screen for primary aldosteronism (PA). Substantial intra-individual variability of PAC and ARR using plasma renin activity in the context of usual antihypertensive therapy has been described, but there is no data on ARR variability calculated using direct renin concentration (DRC). OBJECTIVE To describe the intra-individual variability of PAC, DRC, and ARR in the absence of interfering medications in patients with and without PA. DESIGN Retrospective cohort study. PATIENTS Hypertensive patients referred for investigation of PA, with at least 2 ARR measurements while off interfering medications. SETTING Endocrine hypertension service of a tertiary center, from May 2017 to July 2021. MAIN OUTCOME MEASURES PAC, DRC, and ARR variability was calculated as coefficient of variation (CV) and percent difference (PD). RESULTS Analysis of 223 patients (55% female, median age 52 years), including 162 with confirmed PA, demonstrated high variability with a sample CV of 22-25% in the PAC and sample CV of 41% to 42% in the DRC and ARR in both the PA and non-PA groups. The degree of variability was substantially higher than the assays' analytical CV. Sixty-two patients (38%) with PA had at least one ARR below 70 pmol/L:mU/L (2.4 ng/dL:mU/L), a cut-off for first-line screening of PA. CONCLUSIONS Significant intra-individual variability in PAC, DRC, and hence ARR occurs in a large proportion of patients being investigated for PA. These findings support the need for at least 2 ARR before PA is excluded or further investigated.
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Affiliation(s)
- Elisabeth Ng
- Department of Endocrinology, Monash Health, Clayton, Victoria, 3168, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Stella May Gwini
- University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Renata Libianto
- Department of Endocrinology, Monash Health, Clayton, Victoria, 3168, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Kay Weng Choy
- Department of Pathology, Northern Health, Epping, Victoria, Australia
| | - Zhong X Lu
- Department of Medicine, Monash University, Clayton, Victoria, Australia
- Monash Health Pathology, Monash Health, Clayton, Victoria, Australia
| | - Jimmy Shen
- Department of Endocrinology, Monash Health, Clayton, Victoria, 3168, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - James C G Doery
- Department of Medicine, Monash University, Clayton, Victoria, Australia
- Monash Health Pathology, Monash Health, Clayton, Victoria, Australia
| | - Peter J Fuller
- Department of Endocrinology, Monash Health, Clayton, Victoria, 3168, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Jun Yang
- Department of Endocrinology, Monash Health, Clayton, Victoria, 3168, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
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Carey RM. Does the Aldosterone: Renin Ratio Predict Future Blood Pressure in Young Adults? Hypertension 2021; 78:397-399. [PMID: 34232675 DOI: 10.1161/hypertensionaha.121.17651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Robert M Carey
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville
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