Primary Aldosteronism Screening Rates Differ with Sex, Race, and Comorbidities

Abstract

Background Primary aldosteronism (PA) is a common but under‐recognized cause of secondary hypertension. Data directly comparing screening rates across single and overlapping indications are lacking. Methods and Results We conducted a retrospective review of adults with hypertension seen in outpatient clinics at a tertiary referral academic center between January 1, 2017, and June 30, 2020. We included patients with hypertension plus at least one of the following: resistant hypertension; age<35 years; obstructive sleep apnea; hypokalemia; or an adrenal mass. We excluded patients with adrenal insufficiency, severe renal disease, or heart failure, and renovascular hypertension. Of 203 535 patients with hypertension, 86044 (42.3%) met at least 1 PA screening criterion, and of these, 2898 (3.4%) were screened for PA. Screening occurred in 2.7% of patients with resistant hypertension; 4.2% of those with obstructive sleep apnea; 5.1% of those <35 years; 10.0% of those with hypokalemia; and 47.3% of patients with an adrenal mass. Screening rates were higher in patients with multiple risk factors: 16.8% for ≥3, 5.7% for 2, and 2.5% for 1 criterion. Multiple logistic regression showed that the odds of PA screening were higher in patients with hypokalemia: odds ratio (95% CI): 3.0 (2.7–3.3); women: 1.3 (1.2–1.4); Black versus White: 1.5 (1.4–1.7); those with obstructive sleep apnea, chronic renal disease, stroke, and dyslipidemia. Conclusions Consideration for PA is given in a small subset of at‐risk patients, and typically after comorbidities have developed.

Primary Aldosteronism in Chronic Kidney Disease: Blood Pressure Control and Kidney and Cardiovascular Outcomes After Surgical Versus Medical Management

“…Our findings support diagnosis and management of PA in patients with CKD to potentially mitigate further target organ damage from aldosterone. PA is underdiagnosed in patients with resistant hypertension, 11,12,23 and the diagnosis may be pursued even less often in patients with CKD. 9 Excessive mineralocorticoid receptor activation results in kidney and cardiac fibrosis and 24 Histopathology results showed a higher concentration of mineralocorticoid receptors (11.9% versus 0%; P<0.01) and 11β-hydroxysteroid dehydrogenase type 2 (H-score 58.5 versus 33.5, P=0.03) in kidney tubules as well as marked interstitial fibrosis (4.2% versus 1.1%; P<0.01) and increased segmental glomerulosclerosis (5.9% versus 0%; P<0.01) and glomerular size (153.3 versus 150.9 µm; P<0.01) in patients with PA.…”

“…Our findings support diagnosis and management of PA in patients with CKD to potentially mitigate further target organ damage from aldosterone. PA is underdiagnosed in patients with resistant hypertension, 11,12,23 and the diagnosis may be pursued even less often in patients with CKD. 9 Excessive mineralocorticoid receptor activation results in kidney and cardiac fibrosis and progression of CKD.…”

Primary Aldosteronism Prevalence – An Unfolding Story

“…Although reports of PA prevalence among patients with hypertension have been heterogeneous due to the vast differences in PA definition between studies, findings consistently suggest that PA prevalence increases in parallel with hypertension severity, ranging from 11-22% in individual with treatment-resistant hypertension (Table 1). [14,27,36,[41][42][43][44][45][46] On average, only under 3-4% of individuals with treatment-resistant hypertension are screened for PA. [14,16,47,48] When conducted, PA screening usually targets patients with multiple risk factors and those who have already developed cardiovascular and renal complications. [47] Physicians with secondary hypertension expertise, including endocrinologists and nephrologists, who typically also perform confirmatory testing and oversee the management of PA, are more likely to consider and screen for PA than primary care providers.…”

“…[14,27,36,[41][42][43][44][45][46] On average, only under 3-4% of individuals with treatment-resistant hypertension are screened for PA. [14,16,47,48] When conducted, PA screening usually targets patients with multiple risk factors and those who have already developed cardiovascular and renal complications. [47] Physicians with secondary hypertension expertise, including endocrinologists and nephrologists, who typically also perform confirmatory testing and oversee the management of PA, are more likely to consider and screen for PA than primary care providers. [48] As very few patients with hypertension are referred to specialists, the true prevalence of PA across hypertension stages in the general population remains uncertain.…”

“…Although reports of PA prevalence among patients with hypertension have been heterogeneous due to the vast differences in PA definition between studies, findings consistently suggest that PA prevalence increases in parallel with hypertension severity, ranging from 11–22% in the individual with treatment-resistant hypertension ( Table 1 ) 14 27 36 41 42 43 44 45 46 . On average, only under 3–4% of individuals with treatment-resistant hypertension are screened for PA 14 16 47 48 . When conducted, PA screening usually targets patients with multiple risk factors and those who have already developed cardiovascular and renal complications 47 .…”