Ratio of serum aldosterone to plasma renin concentration in essential hypertension and primary aldosteronism

Summary

The ratio of serum aldosterone to plasma renin activity (PRA) has been proposed as sensitive screening method in the diagnosis of primary aldosteronism under random conditions. However, the method for determination of renin activity is hampered by the necessity of ice cooling during storage and transport. The present study was therefore conducted to examine the ratio of serum aldosterone to plasma renin concentration (ARR) and its usefulness in diagnosis of primary aldosteronism under ambulatory conditions and given antihypertensive medication. 146 patients with arterial hypertension who consecutively attended the outpatient clinic were studied prospectively. Patients with secondary hypertension besides primary aldosteronism were not included in the series. 37 normotensive patients served as control. Also, 17 patients with known primary aldosteronism were retrospectively examined. Among the hypertensive group 2 patients with Conn's syndrome were newly detected (1.4%). ARR was 7.92 ± 6.04 [pg/ml]/[pg/ml] in normotensive controls (range from 2.03 to 26.98), 14.61 ± 18.50 [pg/ml]/[pg/ml] in patients with essential hypertension (n = 144, range from 0.41 to 115.45) and 155.92 ± 127.84 [pg/ml]/[pg/ml] in patients with primary aldosteronism (n = 19, range from 6.75 to 515). 17 of the 19 patients with Conn's syndrome had an ARR of more than 50. Under ongoing drug treatment this represents a sensitivity of 89% and a specificity of 96%. Sensitivity decreased to 84% and specificity increased to 100% when a second criteria (aldosterone ≥ 200 pg/ml) was included. In summary, ARR using renin concentration is a useful screening parameter for primary aldosteronism.

Key words:

Primary aldosteronism - Aldosterone renin ratio - Plasma renin concentration

References

• 1 Abdelhamid S, Müller-Lobeck H, Pahl S, Remberger K, Bonhof J A, Walb D, Rockel A. Prevalenz of adrenal and extra-adrenal Conn syndrom in hypertensive patients.  Arch Intern Med. 1996;  156 1190-1195
• 2 Conn J W, Cohen E L, Rovner D R, Nisbit R M. Normokalemic Primary Aldosteronism. A Detectable Cause of Curable “Essential” Hypertension.  JAMA. 1965;  193 100-106
• 3 Dessi-Fulgheri P, Cocco F, Bandiera F, Mededdu P, Rappelli A. Immunoradiometric assay of active renin in human plasma: comparison with plasma renin activity.  Clin Exp Theory and Practice. A 9 ((8-9)) 1987;  1383-1390
• 4 Eng P HK, Tan K EK, Khoo D HC, Tan C E, Lim H S, Lim S C, Koh L KH, Ho S C, Tai E S, Fok A CK. Aldosterone to Renin Ratios in the Evaluation of Primary Aldosteronism.  Ann Acad Med Singapore. 1997;  26 762-766
• 5 Fardella C E, Mosso L, Gomez-Sanchez C, Cortes P, Soto J, Gomez L, Pinto M, Huete A, Oestreicher E, Foradori A, Montero J. Primary hyperaldosteronism in essential hypertensives: prevalence, biochemical profile and molecular biology.  J Clin Endocrinol Metab. 85 ((5)) 2000;  1863-1867
• 6 Gordon R D, Klemm S A, Tunny T J, Wicks J R, Elmfeldt D B. Effects of felodipin, metoprolol and their combination on blood pressure at rest and during exercise and on volume regulatory hormons in hypertensive patients.  Blood Press. 1995;  4 300-306
• 7 Gordon R D, Ziesak M D, Tunny T J, Stowasser M, Klemm S A. Evidence that primary aldosteronism may not be uncommon: 12% incidence among antihypertensive drug trial volunteers.  Clin Exp Pharmacol Physiol. 20 ((5)) 1993;  296-298
• 8 Grim C E, Weinberger M H, Higgins J T, Kramer N J. Diagnosis of secondary forms of hypertension. A comprehensive protocol.  J Am Med Assoc. 237 ((13)) 1977;  1331-1335
• 9 Hensen J, Oelkers W. Mineralokortikoidhochdruck [Mineralocorticoid-induced hypertension].  Med Klin. 1997;  92 5-8
• 10 Hiramatsu K, Yamada T, Yukimura Y. A screening test to identify aldosterone-producing adenomas by measuring plasma renin activity: results in hypertensive patients.  Arch Intern Med. 1981;  141 1589-1593
• 11 Hrnciar J, Hrnciarova M, Lepej J, Okalova D, Kreze A, Chamulova M. The importance of studying the renin-angiotensin-aldosterone system in essential arterial hypertension in clinical practise. Activity of the renin-angiotensin-aldosterone system during treatment of hypertension with ACE-inhibitors and beta-blockers.  Vnitr Lek. 1994;  40 557-562
• 12 Keeton T K, Campbell W B. The Pharmacologic Alteration of Renin Release.  Pharmacological Review. 1980;  32 81-203
• 13 Kem D C, Weinberger M H, Mayes D M, Nugent C A. Saline suppression of plasma aldosterone in hypertension.  Arch Intern Med. 128 ((3)) 1971;  380-386
• 14 Klumpp F, Braun B, Klaus D, Lemke R, Zehner J. Einfluß von Propanolol auf die Plasma-Renin-Aktivität, die Plasma-Aldosteron-Konzentration und den Blutdruck bei Patienten mit essentieller Hypertonie.  Verh Deutsch Gesell Inn Med. 1976;  82 1321-1325
• 15 Krüger C, Höper K, Weissörtel R, Hensen J, Dörr H G. Value of direkt measurement of active renin concentrations on congenital adrenal hyperplasia due to 21-hydroxylase deficiency.  Eur J Pediatr. 155 ((10)) 1996;  858-861
• 16 Lazurova I, Schwartz P, Trejbal D, Zachar M, Bober J, Sokol L, Wagnerova H, Trejbalova L, Valansky L. Incidence of primary hyperaldosteronism in hospitalized patients with hypertension.  Bratisl Lek Listy. 100 ((4)) 1999;  200-203
• 17 Lim P O, Dow E, Brennan G, Jung R T, MacDonald T M. High prevalence of primary aldosteronism in the Tayside hypertension clinic population.  J Hum Hypertens. 14 ((5)) 2000;  311-315
• 18 Loh K C, Koay E S, Khaw M C, Emmanuel S C, Young W F. Prevalence of primary aldosteronism among Asian hypertensive patients in Singapore.  J Clin Endocrinol Metab. 85 ((8)) 2000;  2854-2859
• 19 McKenna T J, Sequiera S J, Heffernan A, Chambers J, Cunningham S. Diagnosis under Random Conditions of All Disorders of the Renin-Angiotensin-Aldosterone Axis, Including Primary Hyperaldosteronism.  J Clin Endocrinol Metab. 1991;  73 952-957
• 20 Morganti A, Turolo L, Pulazzini E, Zanchetti A. Comparative measurements of immunoreactive renin, plasma renin activity and angiotensin II in human plasma.  Clin Exp Theory and Practice. A 9 ((8-9)) 1987;  1367-1381
• 21 Mosso L, Fardella C, Montero J, Rojas P, Sanchez O, Rojas V, Rojas A, Huete A, Soto J, Foradori A. High prevalence of undiagnosed primary hyperaldosteronism among patients with essential hypertension.  Rev Med Chil. 127 ((7)) 1999;  800-806
• 22 Oelkers W, Diederich S, Bahr V. Primary hyperaldosteronism without suppressed renin due to secondary hypertensive kidney damage.  J Clin Endocrinol Metab. 85 ((9)) 2000;  3266-3270
• 23 Plouin P F, Cudek P, Arnal J F, Guyene T T, Corvol P. Immunoradiometric assay of active renin versus determination of plasma renin activity in the clinical investigation of hypertension, congestive heart failure and liver cirrhosis.  Horm Res. 1990;  34 138-141
• 24 Rayner B L, Opie L H, Davidson J S. The aldosterone/renin ratio as a screening test for primary aldosteronism.  S Afr Med J. 90 ((4)) 2000;  394-400
• 25 Sakamoto H, Ichikawa S, Sakamaki T, Nakamura T, Ono Z, Takayama Y. Time-related changes in plasma adrenal steroids during treatment with spironolacton in primary aldosteronism.  Am J Hypertens. 1990;  3 533-537
• 26 Stumpe K O, Vetter H, Hessenbruch V, Dusing R, Kolloch R, Kruck F. Einfluß einer chronischen beta-Rezeptorenblockade auf Blutdruck, Renin-, Aldosteron- und Kortisolsekretion bei essentieller Hypertension.  Klin Wochenschr. 1975;  53 907-911
• 27 Vallotton M B. Primary aldosteronism. Part I Diagnosis of primary hyperaldosteronism.  Clinical Endocrinology. 1996;  45 47-52
• 28 Wada T, Sanada T, Ojima M, Kanagawa R, Nishikawa K, Inada Y. Combined Effects of the Angiotensin II Antagonist Candesartan Cilexetil (TCV-116) and Other Classes of Antihypertensive Drugs in Spontaneously Hypertensive Rats.  Hypertens Res. 1996;  19 247-254
• 29 Yagi A, Ichikawa S, Sakamaki T, Ono Z, Sato K, Nakamura T, Sakamoto H, Murata K. Aldosterone response to adrenocorticotrophin and furosemid in primary aldosteronism after prolonged spironolacton treatment.  Eur J Endocrinol. 1994;  131 215-220