Primary Aldosteronism Screening Interpretation

The current Endocrine Society guideline suggests screening all individuals with hypertension by measuring aldosterone and renin and determining the aldosterone-to-renin ratio (ARR). Oxford AcademicOxford AcademicPrimary Aldosteronism: An Endocrine Society Clinical Practice ... In settings using risk-enriched testing, prioritize resistant hypertension, hypokalemia, an adrenal nodule, atrial fibrillation, obstructive sleep apnea, early stroke before age 40 years in the family, early-onset hypertension, or hypertension in a first-degree relative of a patient with primary aldosteronism. ScienceDirect+1ScienceDirectDiagnosis and treatment of primary aldosteronism - ScienceDirectPubMedPrimary Aldosteronism - PubMed

Do not use normal potassium to exclude primary aldosteronism. Expansion of ARR-based testing has identified many normokalemic patients, and primary aldosteronism has been reported in approximately 6% of primary care hypertension and is more frequent in resistant hypertension. ScienceDirect+1ScienceDirectDiagnosis and treatment of primary aldosteronism - ScienceDirectPubMedPrimary Aldosteronism - PubMed The practical threshold for testing should therefore be low when renin is suppressed, hypertension is difficult to control, or a potentially curable adrenal cause would alter management.

Measure plasma aldosterone concentration and either plasma renin activity or direct renin concentration at the same draw, then calculate the ARR using the laboratory's assay-specific units and reference framework. Oxford Academic+1Oxford AcademicPrimary Aldosteronism: An Endocrine Society Clinical Practice ...ESCPrimary hyperaldosteronism in hypertension For higher sensitivity, collect blood in the morning after the patient has been out of bed for at least 2 hours and seated for 5 to 15 minutes. PubMedPubMedDiagnosis and management of primary aldosteronism - PMC - NIH

Before testing, correct hypokalemia and avoid dietary sodium restriction; potassium depletion can reduce aldosterone secretion, while sodium and potassium status alter both components of the ARR. ESC+1ESCPrimary hyperaldosteronism in hypertensionPubMedDiagnosis and management of primary aldosteronism - PMC - NIH A low potassium value accompanying a low or modest aldosterone concentration should trigger potassium repletion and repeat paired testing rather than dismissal of the diagnosis.

Medication withdrawal is a tradeoff between analytic purity and blood pressure safety. Mineralocorticoid receptor antagonists and other diuretics are ideally withdrawn for at least 4 weeks before testing; one review recommends 4 to 6 weeks for spironolactone or eplerenone because these agents increase renin and can obscure renin suppression. PubMed+1PubMedPrimary Aldosteronism: Diagnosis and Treatment - PMC - NIHPubMedDiagnosis and management of primary aldosteronism - PMC - NIH If withdrawal is unsafe, suppressed renin with high aldosterone remains strongly suggestive of primary aldosteronism. PubMedPubMedDiagnosis and management of primary aldosteronism - PMC - NIH

A positive screen requires renin suppression with aldosterone that is inappropriately elevated for the renin state. A commonly applied screening pattern is ARR greater than 30 when aldosterone is greater than 10 ng/dL, using aldosterone in ng/dL and plasma renin activity in ng/mL/hour. ccjm+2ccjmOur evolving understanding of primary aldosteronism | Cleveland Clinic Journal of medicineccjmPrint Article | Cleveland Clinic Journal of medicinePubMedPrimary Aldosteronism - PubMed This is a screening threshold, not a universal diagnostic cutoff: ARR thresholds vary by assay and unit system, and no single cutoff has uniform sensitivity or specificity. cell+1cellPrimary aldosteronism, a major form of low renin hypertensionESCPrimary hyperaldosteronism in hypertension

A high ARR driven only by very low renin is less persuasive when aldosterone is not clearly elevated, particularly during beta-blocker treatment, sodium excess, or uncorrected testing conditions. ESC+1ESCPrimary hyperaldosteronism in hypertensionPubMedPrimary Aldosteronism: Diagnosis and Treatment - PMC - NIH Repeat a borderline or discordant result after correcting potassium, ensuring unrestricted salt intake, and modifying interfering antihypertensive therapy when feasible. ESC+1ESCPrimary hyperaldosteronism in hypertensionPubMedDiagnosis and management of primary aldosteronism - PMC - NIH

A low or non-elevated ARR does not reliably exclude primary aldosteronism when renin has been pharmacologically stimulated by ACE inhibitors, ARBs, or diuretics. PubMedPubMedPrimary Aldosteronism: Diagnosis and Treatment - PMC - NIH In a patient with resistant hypertension or hypokalemia, repeat under more interpretable conditions or proceed to an alternative diagnostic strategy based on the total phenotype; ARR reproducibility and sensitivity are limited under some testing conditions. Wolters Kluwer+1Wolters KluwerTest characteristics of the aldosterone-to-renin... : Journal of HypertensionccjmOur evolving understanding of primary aldosteronism | Cleveland Clinic Journal of medicine

For most positive screening results, confirm autonomous aldosterone secretion with an oral sodium suppression test, saline infusion suppression test, fludrocortisone suppression test, or captopril challenge test. ccjm+2ccjmOur evolving understanding of primary aldosteronism | Cleveland Clinic Journal of medicineccjmPrint Article | Cleveland Clinic Journal of medicinePubMedPrimary Aldosteronism - PubMed These tests evaluate whether aldosterone appropriately suppresses after sodium loading, mineralocorticoid exposure, or renin-angiotensin system manipulation; persistent secretion supports primary aldosteronism. ccjmccjmOur evolving understanding of primary aldosteronism | Cleveland Clinic Journal of medicine

There is no universally accepted gold-standard confirmatory test or uniform post-test cutoff. ccjm+1ccjmOur evolving understanding of primary aldosteronism | Cleveland Clinic Journal of medicinePubMedDiagnosis and management of primary aldosteronism - PMC - NIH Select the test according to local protocol and patient safety rather than treating numerical thresholds from another assay platform as interchangeable. For example, one prospective intravenous salt-loading protocol considered post-test plasma aldosterone above 235 pmol/L diagnostic, but this threshold is protocol-specific. Wolters KluwerWolters KluwerTest characteristics of the aldosterone-to-renin... : Journal of Hypertension

After confirmation—or after the unequivocal hypokalemic, suppressed-renin, aldosterone-greater-than-20-ng/dL presentation—obtain thin-cut adrenal CT. ccjm+1ccjmPrint Article | Cleveland Clinic Journal of medicinePubMedPrimary Aldosteronism: Diagnosis and Treatment - PMC - NIH CT identifies lesions requiring malignancy consideration but does not reliably establish aldosterone lateralization because nonfunctioning adrenal nodules are common and CT specificity for aldosterone-producing adenoma is poor. PubMedPubMedPrimary Aldosteronism: Diagnosis and Treatment - PMC - NIH

Offer adrenal venous sampling (AVS) to patients considering unilateral adrenalectomy when a lateralization result would change treatment. Bilateral AVS is the reference method for subtype classification and should be performed by an experienced radiologist. ESC+1ESCPrimary hyperaldosteronism in hypertensionPubMedDiagnosis and management of primary aldosteronism - PMC - NIH Screen for autonomous cortisol secretion with a 1-mg overnight dexamethasone suppression test before AVS or adrenalectomy because concurrent cortisol excess can distort AVS interpretation and can contribute to postoperative adrenal insufficiency. ScienceDirectScienceDirectThe role of confirmatory tests in the diagnosis of primary aldosteronism

Unilateral primary aldosteronism is generally treated with laparoscopic adrenalectomy when the patient is an operative candidate and lateralization supports unilateral disease. ESC+1ESCPrimary hyperaldosteronism in hypertensionPubMedDiagnosis and management of primary aldosteronism - PMC - NIH Patients with bilateral hyperplasia, nonlateralized AVS, operative contraindications, or preference against surgery should receive a mineralocorticoid receptor antagonist. ESC+2ESCPrimary hyperaldosteronism in hypertensionPubMedDiagnosis and management of primary hyperaldosteronism in patients with hypertension: a practical approach endorsed by the British and Irish Hypertension SocietyPubMedDiagnosis and management of primary aldosteronism - PMC - NIH

Spironolactone is the preferred first-line mineralocorticoid receptor antagonist in current Endocrine Society guidance because of affordability and broad availability. AHA JournalsAHA JournalsTreatment of Primary Aldosteronism | Hypertension Eplerenone is a reasonable alternative when spironolactone causes breast tenderness, gynecomastia, sexual dysfunction, or menstrual irregularities; eplerenone is less potent and generally requires higher dosing. PubMed+1PubMedDiagnosis and management of primary hyperaldosteronism in patients with hypertension: a practical approach endorsed by the British and Irish Hypertension SocietyPubMedPrimary Aldosteronism: Diagnosis and Treatment - PMC - NIH One practical equivalence cited in hypertension guidance is spironolactone 25 mg daily approximately equivalent to eplerenone 25 mg twice daily. PubMedPubMedDiagnosis and management of primary hyperaldosteronism in patients with hypertension: a practical approach endorsed by the British and Irish Hypertension Society

During mineralocorticoid receptor antagonist therapy, monitor blood pressure, serum potassium, and creatinine while titrating to the maximum tolerated dose needed for normokalemia and blood pressure control. PubMedPubMedDiagnosis and management of primary hyperaldosteronism in patients with hypertension: a practical approach endorsed by the British and Irish Hypertension Society Amiloride 5 to 40 mg/day may be used as a substitute for or adjunct to an MRA when MRA intolerance prevents adequate treatment. PubMedPubMedDiagnosis and management of primary hyperaldosteronism in patients with hypertension: a practical approach endorsed by the British and Irish Hypertension Society