MANAGEMENT OF ENDOCRINE DISEASE: The role of confirmatory tests in the diagnosis of primary aldosteronism

Abstract

The strategy for diagnosis of primary aldosteronism (PA) in the hypertensive population includes firstly a screening step, based on the measurement of plasma aldosterone-to-renin ratio (ARR), a test which must have high sensitivity, and secondly a confirmatory step based on the demonstration of excessive aldosterone production independent of the renin-angiotensin-aldosterone system (RAAS) activity. The high proportion of false-positive ARR results and conversely of actual PA without a persistent elevation in baseline plasma aldosterone concentration necessitates the addition of a confirmatory step in the work-up of PA diagnosis. The present review focuses on the description of the different dynamic tests available for demonstrating autonomy of aldosterone secretion, on the performance and limitations of confirmatory tests and on possible strategies for PA diagnosis which may either include or avoid the confirmatory step for PA diagnosis. Large prospective studies comparing different strategies with and without dynamic testing are mandatory to delineate clearly the role and limits of confirmatory tests in the work-up of PA.

Clinical outcomes of primary aldosteronism based on lateralization index and contralateral suppression index after adrenal venous sampling in real-world practice: a retrospective cohort study

“…The SIT started at 8: 00 A.M. Before the test, patients kept in the recumbent position for at least 2 h. After sampling for baseline PAC and renin with measurement of blood pressure (BP) with heart rate, 2 l of saline were infused over 4 h. PAC, renin, and BP with heart rate were measured after saline loading. PAC of 10 ng/dL in recumbent position or 6 ng/dL in seated position is considered as confirmative cut-off value [10]. All patients underwent adrenal CT scan imaging to check the morphological changes of both adrenal glands.…”

Diretrizes Brasileiras de Hipertensão Arterial – 2020

“…Os principais testes confirmatórios para HP são apresentados no Quadro 15.7. [920][921][922][923][924] O fluxograma de investigação diagnóstica é apresentado na Figura 15.3.…”

“…Além disso, o cateterismo de veias adrenais está indicado nos pacientes com nódulos adrenais pequenos (<1,5 cm) e idade de diagnóstico da HA superior a 40 anos, devido à possibilidade de tratar-se de um adenoma não funcionante. [920][921][922][923][924] Trata-se de método invasivo e dependente de experiência do radiologista. O tratamento preferencial em APA é a adrenalectomia unilateral, preferencialmente laparoscópica, a menos que contraindicada.…”

Evaluation of Biochemical Conditions Allowing Bypass of Confirmatory Testing in The Workup of Primary Aldosteronism: A Retrospective Study in a French Hypertensive Population

“…The present series offered us the opportunity to investigate whether precise clinical and/or biochemical conditions defined from the screening procedure in the workup for PA diagnosis could allow the bypass of the confirmatory step based on a dynamic testing of aldosterone secretion. International guidelines have questioned this issue and proposed different options for bypassing the confirmatory step [20]. The American Endocrine Society have proposed that in the setting of spontaneous hypokalemia, basal plasma renin below detection levels and baseline PAC above 550 pmol/l (20 ng/dl), confirmatory testing may be avoided [6].…”