Figure 2 - available via license: Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International
Content may be subject to copyright.
Adrenal venography performed to carry out segmental adrenal venous sampling (S-AVS) (A) and coronal CT image (B) of the left adrenal gland in a 56-year-old man who was finally diagnosed recurrent APA. The adrenal tumor was detected by CT (B, arrowheads) and projected into the venography (A, dotted circle). The sampling point from a central vein is indicated by black arrow number 1 (A). Sampling points from tributary veins are indicated by white arrows 2, 3, and 4 in (A). Abbreviations: APA, aldosterone-producing adenoma; CT, computed tomography.
Source publication
Primary aldosteronism (PA) is now considered as one of leading causes of secondary hypertension, accounting for 5-10% of all hypertensive patients and more strikingly 20% of those with resistant hypertension. Importantly, those with the unilateral disease could be surgically cured when diagnosed appropriately. On the other hand, only a very limited...
Context in source publication
Context 1
... First, those with unilateral APA located distal to the central vein might miss a surgical indication due to dilution effect ( Figure 1). 45 A second case suitable for segmental AVS might be recurrence of APA in a patient whose contralateral gland was already resected (Figure 2). 45 Using the segmental sampling, we revealed that aldosterone secretion was suppressed at the nontumor segments, compared to the secretion from APA segment within the ipsilateral adrenal gland. ...
Citations
... Hypertension can be divided into primary hypertension with unknown causes and secondary hypertension with clear causes [2]. Previously, primary hypertension was believed to be the most common form of the disease, with secondary hypertension only accounting for 5-10% of cases [3][4][5][6]. However, with a comprehensive understanding of the etiology of hypertension and the improvements in clinical diagnostic techniques, the proportion of secondary hypertension has been found to significantly exceed current expectations [4,7,8]. ...
... At present, PA is considered one of the most common causes of hypertension. Hiramatsu et al. first introduced the aldosterone-renin ratio (ARR) as an indicator of PA screening [25] . Although ARR is now an important screening method for the diagnosis of PA, the high false-positive rates exhibited by ARR methods are a concern. ...
Aldosterone is a steroid hormone secreted from the adrenal cortex and metabolized primarily in the kidneys. It promotes sodium retention and potassium excretion. Most plasma aldosterone exists in free form, with a rapid turnover rate. The increased in aldosterone in the body may lead to various metabolic diseases, such as primary aldosteronism, diabetes, and chronic kidney disease. The clinical detection methods for aldosterone include radioimmunoassay, chemiluminescence immunoassay, and liquid chromatography tandem mass spectrometry (LC-MS/MS). In addition to addressing the issue of false negatives and false positives from cross-reaction in immunoassays, the advantages of high-throughput detection are reflected through the use of LC-MS/MS. Furthermore, there is also new progress in the development of a related mineralocorticoid receptor (MR) antagonist, from spironolactone to eplerenone, and to a third-generation MR antagonist, and finerenone, which has been approved by the United States Food and Drug Administration in 2021. The side effects of spironolactone and eplerenone can be overcome by finerenone, and the third-generation antagonist has shown significant effect in the treatment of chronic kidney disease associated with Type 2 diabetes. In this paper, aldosterone-related diseases, the clinical detection methods, and the corresponding treatment methods are discussed.
... PA is diagnosed by a screening test, followed by a confirmatory or exclusionary test and a subtype test using computed tomography and adrenal vein sampling (AVS). The aldosterone to renin ratio (ARR) is used to screen for PA (8,9). The number of patients diagnosed with PA has increased due to more frequent screening (10,11). ...
Since April 2021, the plasma aldosterone concentration has been measured by chemiluminescent enzyme immunoassay (CLEIA) in Japan. In the present study, we developed a new CLEIA using a two-step sandwich method to measure the 24-hour urine aldosterone level. We collected 115 urine samples and measured 24-hour urine aldosterone levels employing radioimmunoassay (RIA), CLEIA, and liquid chromatography–tandem mass spectrometry (LC-MS/MS). The results showed that the 24-hour urine aldosterone levels measured using CLEIA and LC-MS/MS were significantly correlated (ρ = 0.992, P < 0.0001). Based on the results of Passing–Bablok regression analysis, the slope was 0.992 and the intercept –19.3. The 24-hour urine aldosterone levels measured using CLEIA and RIA were also significantly correlated (ρ = 0.905, P < 0.0001). However, the aldosterone level measured by CLEIA was lower than that measured by RIA (slope, 0.729; intercept, 120.9). In Japan, a new guideline for primary aldosteronism has been announced, with changes in the aldosterone measurement method. The cutoff values for oral sodium loading test (OSLT) were changed, but clinical verification using real-world urine samples has not been performed. Therefore, we examined the cut-off value of the 24-hour urine aldosterone level after the OSLT. Receiver operating characteristic analysis revealed a cut-off value for primary aldosteronism of 3 μg/day.
... However, there are several other symptoms that differentiate the root causes of hypertension. In most cases of secondary hypertension, primary aldosteronism is the cause [3][4][5]. ...
A 52-year-old patient from Bangladesh, known for hypertension for the last year, was taking oral antihypertensives. Nonetheless, he still had uncontrolled blood pressure, and no associated symptoms. The patient was referred to Emergency with a presenting complaint of high blood pressure, and high aldosterone and low renin levels. Therefore, a subsequent work-up plan was recommended for him. As per the lab reports, the patient was found to be suffering from primary aldosteronism. This was concluded by looking at his lab values, which were seen to be as follows: Aldosterone: 320 ng/L, Renin: 2.55 ng/L, Potassium: 5.2 mmol/L. An MRI of the adrenal gland was ordered for this patient, both with and without contrast. The findings of the MRI were consistent with left adrenal adenoma. An approximately 14 x 10.4 x 10.8 mm, oblong-shaped focal lesion, along the maximum TS, AP, and CC dimensions was appreciated. This lesion was implicating the inferior portion of the left adrenal gland lateral limb, and exhibiting low to intermediate signal intensity on all provided sequences with signal dropout on out of the phase sequence. Moreover, minimal peripheral contrast enhancement was noted in the post-contrast administration images. This led to a prompt referral to the surgery department where the patient was evaluated and, within a week, operated on for the tumor successfully. This paper deals with the evaluation, diagnosis, and postoperative management of this patient who arrived at the hospital with no suspicion of the tumor that he had in his adrenal glands. Finally, it also summarizes the post-operative symptoms experienced by the patient and how they were managed on the spot to prevent any ensuing complications.
... However, if the rate is higher than 30%, PH can be considered with 90% sensitivity and 91% specificity. If the rate is above 50%, the possibility of the diagnosis of PH is much higher (2). ...
Hypokalemia is a common electrolyte abnormality. Generally being asymptomatic, muscular fatigue, paresis and arrhythmia can be seen as the severity of hypokalemia increases. Severe rhabdomyolysis and neuromuscular findings can be seen in severe hypokalemia cases. Presence of hypokalemia can be a precursor of secondary hypertension in hypertensive patients, and also should bring hyperaldosteronism into consideration. Mild hypokalemia is usually seen in primary hype-raldosteronism. However, deficient potassium levels are also seen in some cases. We have shared the case of a hypertensive patient, who presented to the emergency department with findings of rhabdomyo-lysis and neuromuscular findings secondary to severe hypokalemia. The potassium level of our patient was 1.3 mmol, and it was one of the lowest potassium levels reported up to today.
... Primary aldosteronism (PA) is the most frequent cause of secondary hypertension, and 5-10% of patients with hypertension have PA [1][2][3]. PA causes hypertension and hypokalemia due to excessive aldosterone secretion by the adrenal glands [4,5]. ...
... PA is diagnosed via a screening test, followed by a confirmatory or exclusion test and subtype test using computed tomography and adrenal vein sampling (AVS). The aldosterone to renin ratio (ARR) is used as a screening test for PA [2,10,11]. In Japan, the screening cutoff values for PA diagnosis are a plasma aldosterone concentration (PAC) > 120 pg/mL and a PAC to plasma renin activity ratio of >200 or a PAC to active renin concentration ratio (ARC) of >40. ...
... Subsequently, we performed an oral sodium loading test (OSLT), captopril challenge test (CCT), saline infusion test (SIT), and furosemide upright posture test to confirm or exclude the diagnosis of PA [2,6,8,11,12]. When at least one confirmatory test was positive, we diagnosed the patient with PA. ...
In the present study, we developed a new chemiluminescent enzyme immunoassay (CLEIA) using a two-step sandwich method to measure aldosterone concentrations. We investigated serum and plasma aldosterone concentrations in 75 blood samples from 27 patients using a radioimmunoassay (RIA) and the CLEIA (with current and newly improved reagents) as well as liquid chromatography-tandem mass spectrometry (LC-MS/MS). Based on the results of the Passing-Bablok regression analysis, the aldosterone levels measured using CLEIA with the new reagents and those measured by LC-MS/MS were found to be significantly correlated (slope, 0.984; intercept, 0.2). However, aldosterone levels varied depending on the measurement method (i.e., CLEIA with the new reagent, CLEIA with the current reagent, and RIA). Aldosterone levels were lower with the improved CLEIA method than with RIA and CLEIA using the current reagent. Therefore, the cutoff values of the screening test as well as those of the confirmatory test for primary aldosteronism (PA) should be adjusted to follow current clinical practice guidelines for PA. The formula that can be used to obtain the aldosterone level (pg/mL) when using CLEIA with the new reagent is 0.765 × RIA (pg/mL) - 33.7. This formula will enable PA cutoff values to be set for provisional screening and confirmatory tests.
... However, if the rate is higher than 30%, PH can be considered with 90% sensitivity and 91% specificity. If the rate is above 50%, the possibility of the diagnosis of PH is much higher (2,3). We here presented a case of a hypertensive patient, who attended to the emergency department with findings of rhabdomyolysis and neuromuscular findings due to severe hypokalemia. ...
Hypokalemia is a common electrolyte abnormality. Generally being asymptomatic, muscular fatigue, paresis and arrhythmia can be seen as the severity of hypokalemia increases. Severe rhabdomyolysis and neuromuscular findings can be seen in severe hypokalemia cases. Presence of hypokalemia can be a precursor of secondary hypertension in hypertensive patients, and also should bring hyperaldosteronism into consideration. Mild hypokalemia is usually seen in primary hyperaldosteronism. However, deficient potassium levels are also seen in some cases. We have shared the case of a hypertensive patient, who presented to the emergency department with findings of rhabdomyolysis and neuromuscular findings secondary to severe hypokalemia. The potassium level of our patient was 1.3 mmol, and it was one of the lowest potassium levels reported up to today.
... Primary aldosteronism (PA) is the most common form of secondary hypertension. It is characterized by the inappropriate production of aldosterone and accounts for 5-10% of all patients with hypertension [1]. Patients with PA experience more cardiovascular events and cardiovascular mortality than those with essential hypertension (EHT) [2]. ...
... Author details 1 Division of Endocrine and Diabetes, Department of Internal Medicine, ...
Background
Plasma aldosterone-to-renin ratio (ARR) is popularly used for screening primary aldosteronism (PA). Some medications, including diuretics, are known to have an effect on ARR and cause false-negative and false-positive results in PA screening. Currently, there are no studies on the effects of sodium–glucose cotransporter-2 (SGLT2) inhibitors, which are known to have diuretic effects, on ARR. We aimed to investigate the effects of SGLT2 inhibitors on ARR.
Methods
We employed a retrospective design; the study was conducted from April 2016 to December 2018 and carried out in three hospitals. Forty patients with diabetes and hypertension were administered SGLT2 inhibitors. ARR was evaluated before 2 to 6 months after the administration of SGLT2 inhibitors to determine their effects on ARR.
Results
No significant changes in the levels of ARR (90.9 ± 51.6 vs. 81.4 ± 62.9) were found. Body mass index, diastolic blood pressure, heart rate, fasting plasma glucose, and hemoglobin A1c were significantly decreased by SGLT2 inhibitors. Serum creatinine was significantly increased.
Conclusion
SGLT2 inhibitor administration yielded minimal effects on ARR and did not increase false-negative results in PA screening in patients with diabetes and hypertension more than 2 months after administration.
... Therefore, serum potassium performed best if the cut-off to detect primary aldosteronism was set at <3.9 mmol/L which is above routine usage and guideline recommendations [16,17]. This may also be the cause to assume that the majority of patients affected by PA are normokalemic [18][19][20]. However, we could show that serum potassium along with SUSPPUP and renin normalizes during pharmacologic treatment and-even more and along with the ARR-after surgery, indicating that salt preservation on the expense of potassium is reversed with anti-mineralocorticoid treatment or removal of aldosterone-producing adenomas. ...
The serum sodium to urinary sodium ratio divided by the (serum potassium)2 to urinary potassium ratio (SUSPPUP formula) reflects aldosterone action. We here prospectively investigated into the usefulness of the SUSPPUP ratio as a diagnostic tool in primary hyperaldosteronism. Parallel measurements of serum and urinary sodium and potassium concentrations (given in mmol/L) in the fasting state were done in 225 patients. Of them, 69 were diagnosed with primary aldosteronism (PA), 102 with essential hypertension (EH), 26 with adrenal insufficiency (AI) and 28 did not suffer from the above-mentioned disorders and were assigned to the reference group (REF). The result of the SUSPPUP formula was highest in the PA group (7.4, 4.2–12.3 L/mmol), followed by EH (3.2, 2.3–4.3 L/mmol), PA after surgery (3.9, 3.0–6.0 L/mmol), REF (3.4 ± 1.4 L/mmol) and AI (2.9 +/– 1.2 L/mmol). The best sensitivity in distinguishing PA from EH was reached by multiplication of the aldosterone to renin-ratio (ARR) with the SUSPPUP formula (92.7% at a cut off > 110 L/mmol), highest specificity was reached by the SUSPPUP determinations (87.2%). The integration of the SUSPPUP ratio into the ARR helps to improve the diagnosis of hyperaldosteronism substantially.
... The investigational new drug LCI699 has been shown to inhibit aldosterone synthase and to provide a fair shortterm effect, however long-term data are lacking [102]. Newer generations of novel non-steroidal MRAs including finerenone (BAY 94-8862) and esaxerenone (CS-3150) have been evaluated in preclinical and clinical trials and have shown the potential to treat PA, however their effects on AF and long-term mortality have not been well studied [103]. In addition, for concurrent MRA treatment with spironolactone and eplerenone, the optimal dosage has not definitively been established. ...
Primary aldosteronism (PA) is the most common cause of secondary hypertension. Increasing evidence has demonstrated an increased cardiovascular risk in patients with PA compared to those with essential hypertension (EH), including atrial fibrillation (AF), the most prevalent arrhythmia among adults that is associated with an elevated risk of subsequent cerebro-cardiovascular adverse events. The mechanisms of increased prevalence of AF in PA patients are complex. Excessive aldosterone production is regarded to be a key component in the pathogenesis of AF, in addition to arterial hypertension and electrolyte imbalance. In addition, several translational and clinical studies have reported that structural remodeling with atrial fibrosis and electrical remodeling with arrhythmogenicity induced by an excess of aldosterone also play major roles in AF genesis. Clinical studies from several registries and meta-analysis have reported an increased prevalence and risk of AF in PA patients compared to EH patients. Recent trials have further demonstrated a reduction in the risk of new-onset atrial fibrillation (NOAF) after adrenalectomy, while the results of medical treatment with mineralocorticoid receptor antagonists (MRAs) have been inconsistent. This review outlines the current evidence of the relationship between PA and AF, and highlights recent progress in the management of PA with regards to the development of AF.
