scholarly journals Adrenal Vein Sampling Lateralization Despite Mineralocorticoid Receptor Antagonists Exposure in Primary Aldosteronism

2018 ◽  
Vol 104 (2) ◽  
pp. 487-492 ◽  
Author(s):  
Aya T Nanba ◽  
Taweesak Wannachalee ◽  
James J Shields ◽  
James B Byrd ◽  
William E Rainey ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Mineralocorticoid Receptor ◽  
Adrenal Vein ◽  
Mineralocorticoid Receptor Antagonists ◽  
Receptor Antagonists ◽  
Adrenal Vein Sampling

scholarly journals Approach to the Patient with Primary Aldosteronism: Utility and Limitations of Adrenal Vein Sampling

2020 ◽  
Author(s):  
Adina F Turcu ◽  
Richard Auchus
Keyword(s):  
Primary Aldosteronism ◽  
Mineralocorticoid Receptor ◽  
Interventional Procedures ◽  
Adrenal Vein ◽  
Mineralocorticoid Receptor Antagonists ◽  
Adrenal Vein Sampling ◽  
Hypertensive Patients ◽  
Case Identification ◽  
The Past ◽  
Aldosterone Production

Abstract Several studies over the past 3 decades document a higher prevalence of primary aldosteronism (PA) among hypertensive patients than generally presumed. PA exists as a spectrum from mild to severe aldosterone excess. Although a variety of PA subtypes exist, the two most common are aldosterone-producing adenomas (APAs) and bilateral hyperaldosteronism (BHA). The distinction is important, because APA – and other subtypes with aldosterone production mostly from one adrenal – can be cured surgically, and BHA should be treated medically with mineralocorticoid-receptor antagonists (MRAs). The major shortcomings in the tailored management of patients with possible PA are the low rates of screening for case identification and the expensive and technically challenging imaging and interventional procedures required to distinguish APA from BHA, especially adrenal vein sampling (AVS). When AVS identifies an APA and allows the patient to be cured surgically, the procedure is of great value. In contrast, the patient with BHA is treated with MRA whether AVS is performed or not. Consequently, it is prudent to gauge how likely it is to benefit from imaging and AVS in each case prior to embarking on these studies. The explosion of information about PA in the last decade, including predictors of APA and of surgical benefit, are useful in limiting the evaluation for some patients with a positive PA screening test. This article will review our suggestions for approaching these patients in a pragmatic style, recognizing the limitations to even the best resources and facilities.

scholarly journals Hyperparathyroidism in Patients with Primary Aldosteronism: Cross-Sectional and Interventional Data from the GECOH Study

2012 ◽  
Vol 97 (1) ◽  
pp. E75-E79 ◽  
Author(s):  
Stefan Pilz ◽  
Katharina Kienreich ◽  
Christiane Drechsler ◽  
Eberhard Ritz ◽  
Astrid Fahrleitner-Pammer ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Mineralocorticoid Receptor ◽  
Care Center ◽  
Tertiary Care ◽  
Experimental Studies ◽  
Mineralocorticoid Receptor Antagonists ◽  
Receptor Antagonists ◽  
Vitamin D Metabolism ◽  
Cross Sectional ◽  
The Impact

Context: Experimental studies suggest that aldosterone induces hypercalciuria and might contribute to hyperparathyroidism. Objective: We aimed to test for differences in PTH levels and parameters of calcium and vitamin D metabolism in patients with primary aldosteronism (PA) compared with patients with essential hypertension (EH) and to evaluate the impact of PA treatment on these laboratory values. Design, Setting, and Participants: The Graz Endocrine Causes of Hypertension study includes hypertensive patients referred for screening for endocrine hypertension at a tertiary care center in Graz, Austria. Main Outcome Measures: Differences in PTH levels between patients with PA and EH. Results: Among 192 patients, we identified 10 patients with PA and 182 with EH. PTH levels (mean ± sd in picograms per milliliter) were significantly higher in PA patients compared with EH (67.8 ± 26.9 vs. 46.5 ± 20.9; P = 0.002). After treatment of PA with either adrenal surgery (n = 5) or mineralocorticoid receptor antagonists (n = 5), PTH concentrations decreased to 43.9 ± 14.9 (P = 0.023). Serum 25-hydroxyvitamin D concentrations were similar in both groups. Compared with EH, serum calcium concentrations were significantly lower (2.35 ± 0.10 vs. 2.26 ± 0.10 mmol/liter; P = 0.013), and there was a nonsignificant trend toward an increased spot urine calcium to creatinine ratio in PA [median (interquartile range) 0.19 (0.11–0.31) vs. 0.33 (0.12–0.53); P = 0.094]. Conclusions: Our results suggest that PA contributes to secondary hyperparathyroidism. Further studies are warranted to evaluate whether PTH has implications for PA diagnostics and whether mineralocorticoid receptor antagonists have a general impact on PTH and calcium metabolism.

scholarly journals SAT-561 Effects of Mineralocorticoid Receptor Antagonists on Primary Aldosteronism Screening

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Yuta Tezuka ◽  
Adina Turcu
Keyword(s):  
Primary Aldosteronism ◽  
Mineralocorticoid Receptor ◽  
Antihypertensive Drugs ◽  
False Negative ◽  
Antihypertensive Agents ◽  
Rank Test ◽  
Mineralocorticoid Receptor Antagonists ◽  
Receptor Antagonists ◽  
Plasma Aldosterone Concentration ◽  
The Impact

Abstract Background: Mineralocorticoid receptor antagonists (MRAs) are the mainstay of medical therapy for primary aldosteronism (PA), and MRAs also benefit patients with other forms of resistant hypertension and cardiovascular disorders. MRAs impact the renin-angiotensin-aldosterone system (RAAS), raising concerns regarding the accuracy of PA screening. The rate of false negative and/or false positive screening for PA in patients taking MRAs has not been systematically evaluated. Herein, we assessed the alterations of both renin and aldosterone after MRA initiation in a large cohort of patients with hypertension. Patients and Methods: We conducted a retrospective cohort study of patients with hypertension seen in a tertiary referral center. We employed our center’s database search engine to identify adults with hypertension who were treated with MRAs. Of these, we included patients who had renin and aldosterone measured both before and after MRA treatment. We excluded patients with adrenal cortical cancer, end-stage renal disease, exogenous glucocorticoids, and critically ill. PA screening was considered positive when plasma aldosterone concentration (PAC) was 10 ng/dL, plasma renin activity (PRA) was 1.0 ng/mL/h, and the aldosterone-to renin ratio (ARR) was 20. Mann-Whitney test and Wilcoxon signed rank test were employed to compare independent or paired groups, respectively. Results: In total, 109 patients (57 women), mean age 55+/-13 years were included. Of these, 40% had confirmed PA (14% unilateral and 26% bilateral); in 38% PA was excluded; and in the remaining 22%, testing for PA was incomplete. On average, patients were on 3 +/- 1.6 antihypertensive agents; 60% of patients were prescribed beta blockers, 49% K+-wasting diuretics and 35% were on K+ supplements. Both PAC and PRA increased after MRA treatment (from 19.0 [12.6, 26.7] to 26.3 [17.2, 36.2]; and from 0.6 [0.10, 0.80] to 1.00 [0.60, 2.80], respectively, p < 0.0001 for both), while ARR decreased from 42.5 [18.5, 109.8] to 24.0 [10.9, 55.5] (p = 0.003). Of 71 patients with positive PA screening at baseline, 31 (43.7 %) no longer met positive screening criteria during MRA therapy. Conversely, 7 of 38 patients (18 %) with negative screening at baseline met criteria for positive PA screening while on MRA treatment, including 5 patients with a PAC > 20 ng/dL along with suppressed renin. The impact on PA screening accuracy remained similar irrespective of the MRA dose, duration of treatment, changes in concomitant antihypertensive drugs, or hypertension type. Conclusions: Commonly, MRA treatment leads to renin elevation, ARR reduction, and consequential false negative PA screening. In a minority of patients, MRA therapy can be followed by aldosterone elevations asynchronous from renin, possibly via short feedback loops, mimicking PA. Whenever possible, PA testing should be conducted after MRA discontinuation.

Mineralocorticoid Receptor Antagonists in Primary Aldosteronism

2019 ◽  
Vol 24 (46) ◽  
pp. 5508-5516 ◽  
Author(s):  
Konstantinos Stavropoulos ◽  
Christodoulos Papadopoulos ◽  
Konstantinos Koutsampasopoulos ◽  
Georgios Lales ◽  
Christos Mitas ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Mineralocorticoid Receptor ◽  
Target Organ Damage ◽  
Intima Media Thickness ◽  
Carotid Intima Media Thickness ◽  
Left Ventricular ◽  
Clinical Syndrome ◽  
Mineralocorticoid Receptor Antagonists ◽  
Receptor Antagonists ◽  
Mineralocorticoid Receptor Antagonist

Background:Primary aldosteronism is the most common causes of secondary hypertension. Patients suffering from this clinical syndrome have an increased cardiovascular risk and target organ damage. Mineralocorticoid receptor antagonists are the optimal pharmaceutical option for the management of such patients.Objectives:The study aimed to assess the effects of mineralocorticoid receptor antagonist in the treatment of patients with primary aldosteronism.Method:We conducted an in-depth review of the literature and comprehensive identification of the clinical studies investigating the efficacy of mineralocorticoid receptor antagonists in individuals with primary aldosteronism.Results:Mineralocorticoid receptor antagonists result in significant improvement in blood pressure and serum potassium level among patients with primary aldosteronism. Moreover, mineralocorticoid receptor antagonists reverse left ventricular hypertrophy, albuminuria, and carotid intima-media thickness. However, a high risk for atrial fibrillation remains among subject with primary aldosteronism in such agents.Conclusion:Mineralocorticoid receptor antagonists are recommended as the first-line treatment in patients with bilateral primary aldosteronism. In patients with unilateral aldosterone-producing adenoma, adrenalectomy should be preferred. However, existing data presents significant limitations and is rather inconclusive. Future randomized control trials are required in order to illustrate the field.

scholarly journals Mineralocorticoid receptor antagonists and renal involvement in primary aldosteronism: opening of a new era

2013 ◽  
Vol 168 (1) ◽  
pp. C1-C5 ◽  
Author(s):  
Cristiana Catena ◽  
GianLuca Colussi ◽  
Leonardo A Sechi
Keyword(s):  
Primary Aldosteronism ◽  
Mineralocorticoid Receptor ◽  
Blood Pressure Response ◽  
Renal Involvement ◽  
Response To Treatment ◽  
Mineralocorticoid Receptor Antagonists ◽  
Receptor Antagonists ◽  
Unilateral Adrenalectomy ◽  
Functional Changes ◽  
Aldosterone To Renin Ratio

Primary aldosteronism (PA) is one of the commonest forms of curable hypertension, and use of the plasma aldosterone-to-renin ratio as a screening test has led to a more efficient identification of this condition. Both animal and human studies have indicated that PA is associated with a variety of cardiovascular and renal complications that reflect the capability of elevated aldosterone to induce tissue damage exceeding that induced by hypertension itself. Involvement of the kidney in PA is highly relevant because structural renal damage is associated with less favorable outcome, both in terms of blood pressure response to treatment and possibility to develop progressive renal failure. However, early involvement of the kidney in PA is characterized by functional changes that are largely reversible with treatment. Unilateral adrenalectomy or administration of mineralocorticoid receptor antagonists are the current options for treating an aldosterone-producing adenoma or idiopathic adrenal hyperplasia. Both treatments are effective in correcting hypertension and hypokalemia, and currently available information on their capability to prevent deterioration of renal function indicates that both surgery and medical treatment are of considerable value.

Mineralocorticoid receptor antagonist effect on aldosterone to renin ratio in patients with primary aldosteronism

2021 ◽  
Author(s):  
Alessio Pecori ◽  
Fabrizio Buffolo ◽  
Jacopo Burrello ◽  
Giulio Mengozzi ◽  
Francesca Rumbolo ◽  
...  
Keyword(s):  
Receptor Antagonist ◽  
Primary Aldosteronism ◽  
Mineralocorticoid Receptor ◽  
Study Cohort ◽  
Mineralocorticoid Receptor Antagonists ◽  
Receptor Antagonists ◽  
Mineralocorticoid Receptor Antagonist ◽  
Long Term Treatment ◽  
Aldosterone To Renin Ratio

Abstract Purpose We aimed to evaluate the effect of mineralocorticoid receptor antagonists on aldosterone-to-renin ratio in patients with primary aldosteronism. Methods We prospectively enrolled 121 patients with confirmed primary aldosteronism who started a mineralocorticoid receptor antagonist (canrenone) treatment. Eighteen patients (11 with unilateral and 7 with bilateral primary aldosteronism) composed the short-term study cohort and underwent aldosterone, renin and potassium measurement after 2 and 8 weeks of canrenone therapy. The long-term cohort comprised 102 patients (16 with unilateral and 67 with bilateral primary aldosteronism, and 19 with undetermined subtype) who underwent hormonal and biochemical re-assessment after 2 to 12 months of canrenone therapy. Results Renin and potassium levels showed a significant increase, and aldosterone-to-renin ratio displayed a significant reduction compared with baseline after both a short and long-term treatment. These effects were progressively more evident with higher doses of canrenone and after longer periods of treatment. We demonstrated that canrenone exerted a deep impact on the diagnostic accuracy of the screening test for primary aldosteronism: the rate of false negative tests raised to 16.7%, 38.9%, 54.5% and 72.5% after 2 weeks, 8 weeks, 2-6 months and 7-12 months of mineralocorticoid receptor antagonist treatment, respectively. Conclusions Mineralocorticoid receptor antagonists should be avoided in patients with hypertension before measurement of renin and aldosterone for screening of primary aldosteronism.

scholarly journals MINERALOCORTICOID RECEPTOR ANTAGONISTS DECREASE THE RATES OF POSITIVE SCREENING FOR PRIMARY ALDOSTERONISM

2020 ◽  
Vol 26 (12) ◽  
pp. 1416-1424
Author(s):  
Yuta Tezuka ◽  
Adina F. Turcu
Keyword(s):  
Primary Aldosteronism ◽  
Mineralocorticoid Receptor ◽  
Plasma Renin ◽  
Plasma Aldosterone ◽  
Mineralocorticoid Receptor Antagonists ◽  
Receptor Antagonists ◽  
Mineralocorticoid Receptor Antagonist ◽  
Renin Angiotensin Aldosterone System ◽  
Renin Angiotensin ◽  
The Impact

Objective: Mineralocorticoid receptor antagonists (MRAs) are effective in patients with resistant hypertension and/or primary aldosteronism (PA). Screening for PA should ideally be conducted after stopping medications that might interfere with the renin-angiotensin-aldosterone system, but this is challenging in patients with recalcitrant hypertension or hypokalemia. Herein, we aimed to evaluate the impact of MRAs on PA screening in clinical practice. Methods: We conducted a retrospective cohort study of patients with hypertension who had plasma aldosterone and renin measurements before and after MRA use in a tertiary referral center, over 19 years. Results: A total of 146 patients, 91 with PA, were included and followed for up to 18 months. Overall, both plasma renin and aldosterone increased after MRA initiation (from median, interquartile range: 0.5 [0.1, 0.8] to 1.2 [0.6, 4.8] ng/mL/hour and from 19.1 [12.9, 27.7] to 26.4 [17.1, 42.3] ng/dL, respectively; P<.0001 for both), while the aldosterone/renin ratio (ARR) decreased from 40.3 (18.5, 102.7) to 23.1 (8.6, 58.7) ng/dL per ng/mL/hour ( P<.0001). Similar changes occurred irrespective of the MRA treatment duration and other antihypertensives used. Positive PA screening abrogation after MRA initiation was found in 45/94 (48%) patients. Conversely, 17% of patients had positive PA screening only after MRA treatment, mostly due to correction of hypokalemia. An initially positive screening test was more likely altered by high MRA doses and more likely persistent in patients with confirmed PA or taking beta-blockers. Conclusion: MRAs commonly reduce ARR and the proportion of positive PA screening results. When PA is suspected, screening should be repeated off MRAs. Abbreviations: ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; ARR = aldosterone/renin ratio; DRC = direct renin concentration; MRA = mineralocorticoid receptor antagonist; PA = primary aldosteronism; PAC = plasma aldosterone concentration; PRA = plasma renin activity; RAAS = renin-angiotensin-aldosterone system

scholarly journals A short review of primary aldosteronism in a question and answer fashion

2018 ◽  
Vol 52 (1) ◽  
pp. 27-40 ◽  
Author(s):  
Frederick-Anthony Farrugia ◽  
Nicolaos Zavras ◽  
Georgios Martikos ◽  
Panagiotis Tzanetis ◽  
Anestis Charalampopoulos ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Mineralocorticoid Receptor ◽  
Plasma Renin ◽  
Short Review ◽  
Secondary Hypertension ◽  
Mineralocorticoid Receptor Antagonists ◽  
Receptor Antagonists ◽  
Mineralocorticoid Receptor Antagonist ◽  
Question And Answer ◽  
Confirmatory Tests

Abstract Objectives. The aim of this study was to present up to date information concerning the diagnosis and treatment of primary aldosteronism (PA). PA is the most common cause of endocrine hypertension. It has been reported up to 24% of selective referred hypertensive patients. Methods. We did a search in Pub-Med and Google Scholar using the terms: PA, hyperaldosteronism, idiopathic adrenal hyperplasia, diagnosis of PA, mineralocorticoid receptor antagonists, adrenalectomy, and surgery. We also did cross-referencing search with the above terms. We had divided our study into five sections: Introduction, Diagnosis, Genetics, Treatment, and Conclusions. We present our results in a question and answer fashion in order to make reading more interesting. Results. PA should be searched in all high-risk populations. The gold standard for diagnosis PA is the plasma aldosterone/plasma renin ratio (ARR). If this test is positive, then we proceed with one of the four confirmatory tests. If positive, then we proceed with a localizing technique like adrenal vein sampling (AVS) and CT scan. If the lesion is unilateral, after proper preoperative preparation, we proceed, in adrenalectomy. If the lesion is bilateral or the patient refuses or is not fit for surgery, we treat them with mineralocorticoid receptor antagonists, usually spironolactone. Conclusions. Primary aldosteronism is the most common and a treatable case of secondary hypertension. Only patients with unilateral adrenal diseases are eligible for surgery, while patients with bilateral and non-surgically correctable PA are usually treated by mineralocorticoid receptor antagonist (MRA). Thus, the distinction between unilateral and bilateral aldosterone hypersecretion is crucial.

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