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Predictive performance of aldosterone-to-renin ratio in the diagnosis of primary aldosteronism in patients with resistant hypertension

BACKGROUND: The systematic use of confirmatory tests in the diagnosis of primary aldosteronism (PA) increases costs, risks and complexity to the diagnostic work-up. In light of this, some authors proposed aldosterone-to-renin (ARR) cut-offs and/or integrated flow-charts to avoid this step. Patients...

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Autores principales: Bioletto, Fabio, Lopez, Chiara, Bollati, Martina, Arata, Stefano, Procopio, Matteo, Ponzetto, Federico, Beccuti, Guglielmo, Mengozzi, Giulio, Ghigo, Ezio, Maccario, Mauro, Parasiliti-Caprino, Mirko
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Frontiers Media S.A. 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10200868/
https://www.ncbi.nlm.nih.gov/pubmed/37223051
http://dx.doi.org/10.3389/fendo.2023.1145186
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author Bioletto, Fabio
Lopez, Chiara
Bollati, Martina
Arata, Stefano
Procopio, Matteo
Ponzetto, Federico
Beccuti, Guglielmo
Mengozzi, Giulio
Ghigo, Ezio
Maccario, Mauro
Parasiliti-Caprino, Mirko
author_facet Bioletto, Fabio
Lopez, Chiara
Bollati, Martina
Arata, Stefano
Procopio, Matteo
Ponzetto, Federico
Beccuti, Guglielmo
Mengozzi, Giulio
Ghigo, Ezio
Maccario, Mauro
Parasiliti-Caprino, Mirko
author_sort Bioletto, Fabio
collection PubMed
description BACKGROUND: The systematic use of confirmatory tests in the diagnosis of primary aldosteronism (PA) increases costs, risks and complexity to the diagnostic work-up. In light of this, some authors proposed aldosterone-to-renin (ARR) cut-offs and/or integrated flow-charts to avoid this step. Patients with resistant hypertension (RH), however, are characterized by a dysregulated renin-angiotensin-aldosterone system, even in the absence of PA. Thus, it is unclear whether these strategies might be applied with the same diagnostic reliability in the setting of RH. METHODS: We enrolled 129 consecutive patients diagnosed with RH and no other causes of secondary hypertension. All patients underwent full biochemical assessment for PA, encompassing both basal measurements and a saline infusion test. RESULTS: 34/129 patients (26.4%) were diagnosed with PA. ARR alone provided a moderate-to-high accuracy in predicting the diagnosis of PA (AUC=0.908). Among normokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 41.8 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 67%, respectively (AUC=0.882); an ARR > 179.6 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, but was associated with a very low sensitivity of 20%. Among hypokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 49.2 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 83%, respectively (AUC=0.941); an ARR > 104.0 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, with a sensitivity of 64%. CONCLUSIONS: Among normokalemic patients, there was a wide overlap in ARR values between those with PA and those with essential RH; the possibility to skip a confirmatory test should thus be considered with caution in this setting. A better discriminating ability could be seen in the presence of hypokalemia; in this case, ARR alone may be sufficient to skip confirmatory tests in a suitable percentage of patients.
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spelling pubmed-102008682023-05-23 Predictive performance of aldosterone-to-renin ratio in the diagnosis of primary aldosteronism in patients with resistant hypertension Bioletto, Fabio Lopez, Chiara Bollati, Martina Arata, Stefano Procopio, Matteo Ponzetto, Federico Beccuti, Guglielmo Mengozzi, Giulio Ghigo, Ezio Maccario, Mauro Parasiliti-Caprino, Mirko Front Endocrinol (Lausanne) Endocrinology BACKGROUND: The systematic use of confirmatory tests in the diagnosis of primary aldosteronism (PA) increases costs, risks and complexity to the diagnostic work-up. In light of this, some authors proposed aldosterone-to-renin (ARR) cut-offs and/or integrated flow-charts to avoid this step. Patients with resistant hypertension (RH), however, are characterized by a dysregulated renin-angiotensin-aldosterone system, even in the absence of PA. Thus, it is unclear whether these strategies might be applied with the same diagnostic reliability in the setting of RH. METHODS: We enrolled 129 consecutive patients diagnosed with RH and no other causes of secondary hypertension. All patients underwent full biochemical assessment for PA, encompassing both basal measurements and a saline infusion test. RESULTS: 34/129 patients (26.4%) were diagnosed with PA. ARR alone provided a moderate-to-high accuracy in predicting the diagnosis of PA (AUC=0.908). Among normokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 41.8 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 67%, respectively (AUC=0.882); an ARR > 179.6 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, but was associated with a very low sensitivity of 20%. Among hypokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 49.2 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 83%, respectively (AUC=0.941); an ARR > 104.0 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, with a sensitivity of 64%. CONCLUSIONS: Among normokalemic patients, there was a wide overlap in ARR values between those with PA and those with essential RH; the possibility to skip a confirmatory test should thus be considered with caution in this setting. A better discriminating ability could be seen in the presence of hypokalemia; in this case, ARR alone may be sufficient to skip confirmatory tests in a suitable percentage of patients. Frontiers Media S.A. 2023-05-08 /pmc/articles/PMC10200868/ /pubmed/37223051 http://dx.doi.org/10.3389/fendo.2023.1145186 Text en Copyright © 2023 Bioletto, Lopez, Bollati, Arata, Procopio, Ponzetto, Beccuti, Mengozzi, Ghigo, Maccario and Parasiliti-Caprino https://creativecommons.org/licenses/by/4.0/This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
spellingShingle Endocrinology
Bioletto, Fabio
Lopez, Chiara
Bollati, Martina
Arata, Stefano
Procopio, Matteo
Ponzetto, Federico
Beccuti, Guglielmo
Mengozzi, Giulio
Ghigo, Ezio
Maccario, Mauro
Parasiliti-Caprino, Mirko
Predictive performance of aldosterone-to-renin ratio in the diagnosis of primary aldosteronism in patients with resistant hypertension
title Predictive performance of aldosterone-to-renin ratio in the diagnosis of primary aldosteronism in patients with resistant hypertension
title_full Predictive performance of aldosterone-to-renin ratio in the diagnosis of primary aldosteronism in patients with resistant hypertension
title_fullStr Predictive performance of aldosterone-to-renin ratio in the diagnosis of primary aldosteronism in patients with resistant hypertension
title_full_unstemmed Predictive performance of aldosterone-to-renin ratio in the diagnosis of primary aldosteronism in patients with resistant hypertension
title_short Predictive performance of aldosterone-to-renin ratio in the diagnosis of primary aldosteronism in patients with resistant hypertension
title_sort predictive performance of aldosterone-to-renin ratio in the diagnosis of primary aldosteronism in patients with resistant hypertension
topic Endocrinology
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10200868/
https://www.ncbi.nlm.nih.gov/pubmed/37223051
http://dx.doi.org/10.3389/fendo.2023.1145186
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