Five Reasons for the Failure to Diagnose Aldosterone Excess in Hypertension

Abstract

Primary hyperaldosteronism (PA) is a well-known cause of hypertension although its exact prevalence amongst patients with apparent essential hypertension has been a matter of debate. A number of recent studies have suggested that mild forms of PA may be relatively common taking into consideration factors that were previously either overestimated or ignored when developing diagnostic tests of PA and when applying these tests into normotensive individuals. The performance characteristics and diagnostic accuracy of such tests are substantially increased when the adrenocorticotrophin effect, inappropriate potassium levels and their application in carefully selected normotensive individuals are considered. In the present review, we critically analyze these issues and provide evidence that several, particularly mild, forms of PA can be effectively identified exhibiting potentially important clinical implications.

Key words

primary aldosteronism - hypertension - ACTH - adrenal - aldosterone to renin ratio

Publikationsverlauf

Eingereicht: 28. Mai 2020

Angenommen nach Revision: 05. August 2020

Artikel online veröffentlicht:
03. September 2020

• References

• 1 Conn JW, Louis LH. Primary aldosteronism: A new clinical entity. Trans Assoc Am Physicians 1955; 68: 215-231
• 2 Schirpenbach C, Reincke M. Primary aldosteronism: Current knowledge and controversies in Conn’s syndrome. Nature clinical practice. Endocrinol Metab 2007; 3: 220-227
• 3 Gordon RD, Gomez-Sanchez CE, Hamlet SM. et al. Angiotensin-responsive aldosterone-producing adenoma masquerades as idiopathic hyperaldosteronism (IHA: Adrenal hyperplasia) or low renin essential hypertension. J Hypertens (Suppl) 1987; 5: S103-S106
• 4 Stowasser M, Gordon RD, Rutherford JC. et al. Diagnosis and management of primary aldosteronism. JRAAS 2001; 2: 156-169
• 5 Staruschenko A. Regulation of transport in the connecting tubule and cortical collecting duct. Compr Physiol 2012; 2: 1541-1584
• 6 Briet M, Schiffrin EL. The role of aldosterone in the metabolic syndrome. Curr Hypertens Rep 2011; 13: 163-172
• 7 Rossi GP, Sacchetto A, Pavan E. et al. Left ventricular systolic function in primary aldosteronism and hypertension. J Hypertens 1998; 6: 2075-2077
• 8 Rossi GP, Di Bello V, Ganzaroli C. et al. Excess aldosterone is associated with alterations of myocardial texture in primary aldosteronism. Hypertension 2002; 40: 23-27
• 9 Rossi GP, Bernini G, Desideri G. et al. Renal damage in primary aldosteronism: Results of the PAPY Study. Hypertension 2006; 48: 232-238
• 10 Rossi GP, Sechi LA, Giacchetti G. et al. Primary aldosteronism: Cardiovascular, renal and metabolic implications. Trends Endocrinol Metab 2008; 19: 88-90
• 11 Fritsch Neves M, Schiffrin EL. Aldosterone: A risk factor for vascular disease. Curr Hypertens Rep 2003; 5: 59-65
• 12 Gilbert KC, Brown NJ. Aldosterone and inflammation. Curr Opin Endocrinol Diabetes Obes 2010; 17: 199-204
• 13 Carey RM. Aldosterone and cardiovascular disease. Curr Opin Endocrinol Diabetes Obes 2010; 17: 194-198
• 14 Huang BS, Leenen FH. Mineralocorticoid actions in the brain and hypertension. Curr Hypertens Rep 2011; 13: 214-220
• 15 Funder JW, Carey RM, Mantero F. et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101: 1889-1916
• 16 Piaditis G, Markou A, Papanastasiou L. et al. Progress in aldosteronism: A review of the prevalence of primary aldosteronism in pre-hypertension and hypertension. Eur J Endocrinol 2015; 172: R191-R203
• 17 Rossi GP, Bernini G, Caliumi C. et al. A prospective study of the prevalence of primary aldosteronism in 1125 hypertensive patients. J Am Col Cardiol 2006; 48: 2293-2300
• 18 Stowasser M. Update in primary aldosteronism. J Clin Endocrinol Metab 2009; 94: 3623-3630
• 19 Douma S, Petidis K, Doumas M. et al. Prevalence of primary hyperaldosteronism in resistant hypertension: A retrospective observational study. Lancet 2008; 371: 1921-1926
• 20 Stowasser M, Gordon RD, Gunasekera TG. et al. High rate of detection of primary aldosteronism, including surgically treatable forms, after ‘non-selective’ screening of hypertensive patients. J Hypertens 2003; 21: 2149-2157
• 21 Young WF. Primary aldosteronism: renaissance of a syndrome. Clin Endocrinol 2007; 66: 607-618
• 22 Gouli A, Kaltsas G, Tzonou A. et al. High prevalence of autonomous aldosterone secretion among patients with essential hypertension. Eur J Clin Inves 2011; 41: 1227-1236
• 23 Piaditis GP, Kaltsas GA, Androulakis II. et al. High prevalence of autonomous cortisol and aldosterone secretion from adrenal adenomas. Clin Endocrinol (Oxf) 2009; 71: 772-778
• 24 Markou A, Sertedaki A, Kaltsas G. et al. Stress induced aldosterone hyper-secretion in a substantial subset of patients with essential hypertension. J Clin Endocrinol Metab 2015; 100: 2857-2864
• 25 Luger A, Deuster PA, Debolt JE. et al. Acute exercise stimulates the renin-angiotensin-aldosterone axis: Adaptive changes in runners. Horm Res 1988; 30: 5-9
• 26 Luger A, Deuster PA, Kyle SB. et al. Acute hypothalamic-pituitary-adrenal responses to the stress of treadmill exercise. Physiologic adaptations to physical training. N Engl J Med 1987; 316: 1309-1315
• 27 El Ghorayeb N, Bourdeau I, Lacroix A. Role of ACTH and other hormones in the regulation of aldosterone production in primary aldosteronism. Front Endocrinol 2016; 7 Article 72
• 28 Seely EW, Conlin PR, Brent GA. et al. Adrenocorticotropin stimulation of aldosterone: prolonged continuous versus pulsatile infusion. J Clin Endocrinol Metab 1989; 69: 1028-1032
• 29 Turchin A, Guo CZ, Adler GK. et al. Effect of acute aldosterone administration on gene expression profile in the heart. Endocrinology 2006; 147: 3183-3189
• 30 Schmidt BM, Georgens AC, Martin N. et al. Interaction of rapid nongenomic cardiovascular aldosterone effects with the adrenergic system. J Clin Endocrinol Metab 2001; 86: 761-767
• 31 Winter C, Kampik NB, Vedovelli L. et al. Aldosterone stimulates vacuolar H⁺-ATPase activity in renal acid-secretory intercalated cells mainly via a protein kinase C-dependent pathway. Am J Physiol Cell Physiol 2011; 301: C1251-C1261
• 32 Hiramatsu K, Yamada T, Yukimura Y. et al. A screening test to identify aldosterone-producing adenoma by measuring plasma renin activity. Results in hypertensive patients. Arch Intern Med 1981; 141: 1589-1593
• 33 Schwartz GL. Screening for primary aldosteronism in essential hypertension: Diagnostic accuracy of the ratio of plasma aldosterone concentration to plasma renin activity. Clin Chem 2005; 51: 386-394
• 34 Papanastasiou L, Markou A, Pappa T. et al. Primary aldosteronism in hypertensive patients: Clinical implications and target therapy. Eur J Clin Invest 2014; 44: 697-706
• 35 Montori VM, Young WF. Use of plasma aldosterone concentration to plasma renin ratio as a screening test for primary aldosteronism: A systematic review of the literature. Endocrinol Metab Clin North Am 2002; 31: 619-632
• 36 Pappa T, Papanastasiou L, Kaltsas G. et al. Pattern of adrenal hormonal secretion in patients with adrenal adenomas: the relevance of aldosterone in arterial hypertension. J Clin Endocrinol Metab 2012; 97: E537-E545
• 37 Mansmann G, Lau J, Balk E. et al. The clinically inapparent adrenal mass: Update in diagnosis and management. Endocr Rev 2004; 25: 309-340
• 38 Markou A, Pappa T, Kaltsas G. et al. Evidence of primary aldosteronism in a predominantly female cohort of normotensive individuals: A very high odds ratio for progression into arterial hypertension. J Clin Endocrinol Metab 2013; 98: 1409-1416
• 39 Baudrand R, Guarda FJ, Fardella C. et al. A continuum of renin-independent aldosteronism in normotension. Hypertension 2017; 69: 950-956
• 40 Brown JM, Siddiqui M, Calhoun DA. et al. The unrecognized prevalence of primary aldosteronism. Ann Inter Med 2020; 173: 10-20
• 41 Himathongkam T, Dluhy RG, Williams GH. Potassium-aldosterone-rennin interrelationships. J Clin Endocrinol Metab 1975; 41: 153-159
• 42 Bauer JH, Gauntner WC. Effect of potassium chloride on plasma rennin activity and plasma aldosterone during sodium restriction in normal man. Kidney Int 1979; 15: 286-293
• 43 Hattangady N, Olala L, Bollag WB. et al. Acute and chronic regulation of aldosterone production. Mol Cell Endocrinol 2012; 350: 151-162
• 44 Tsiavos V, Markou A, Papanastasiou L. et al. A new highly sensitive and specific overnight combined screening and diagnostic test for primary aldosteronism. Eur J Endocrinol 2016; 175: 21-28