1. Registrar: C. Pretorius. Consultant: Dr. W.Grant. Screening for primary aldosteronism and the use of the renin aldosterone ratio.

2. Table of contents. 1. Introduction. 2. Pathology. 3. Evaluation of the RAAS axis. 4. Conclusion. 5. References.

3. 1. Introduction. RAAS system plays an integral role in the controle of: Arterial pressure Tissue perfusion Extracellular volume

4. Normal Physiology.

5. 2. Pathology. 2.1. Primary aldosteronism (PA). Group of disorders in which aldosterone production is: Inappropriately high Relatively autonomous from the renin angiotensin system Nonsuppressible by sodium loading Effects of PA: CVS damage Suppression of plasma renin Hypertension Sodium retension Potassium excretion (hypokalemia)

6. Incidence of PA: Previously: <1% of patients with ‘essential hypertension’ RSA: Community health centres: 7.1% Academic hypertension clinic: 32% Rayner et al. Screening for primary aldosteronism:normal ranges for aldosterone and renin in three South African population groups. S Afr Med J 2001; 91; 594–599 Rayner et al. Aldosterone/renin ratio as a screening test for primary aldosteronism. S Afr Med J 2000; 90: 387–394.

7. Subtypes of PA: Aldosterone producing adenomas Bilateral idiopathic hyperaldosteronism (bilateral adrenal hyperplasia) Familial hyperaldosteronism type I and type II Pure aldosterone producing adrenocortical carcinomas

8. Primary effect of aldosterone: Increases the number of open sodium channels in the luminal membrane of the principal cells in the cortical collecting tubule, leading to increased sodium reabsorption. Lumen is electronegative and the gradient favors the secretion of cellular potassium into the lumen.

9. Clinical features: a) Steady state: Aldosterone escape - Sodium retension - Potassium wasting - Lack of oedema Mechanisms of escape: Pressure natriuresis Increased atrial natriuretic peptide Decreased thiazide sensitive NaCl cotransporter that mediates sodium reabsorption

10. b) Hypertension Mild volume expansion Increase in systemic vascular resistance: due to persistent hypervolemia Suppression of renin release: low plasma renin activity Usually resistant hypertension Malignant hypertension is rare

11. c) Hypokalemia Inconsistent finding Urinary wasting of potassium Causes muscle weakness Some patients with PA have normal plasma potassium levels d) Metabolic acidosis Increased urinary hydrogen excretion mediated by hypokalemia and direct aldosterone effect

12. e) Mild hypernatremia Persistent volume expansion causes resetting of ADH release and thirst. f) Hypomagnesemia Urinary wasting g) Other renal effects Increased GFR Increased urinary albumin excretion

13. 2.2. Secondary aldosteronism. Causes: Renovascular disease Diuretic therapy Cushing syndrome Licorice ingestion Congenital adrenal hyperplasia Liddle’s syndrome Renin secreting tumours

14. WHY IS THE DIAGNOSIS OF PA SO IMPORTANT? 1. Aldosterone producing adenomas can be surgically treated and cured. 2. PA have a higher CVS morbidity and mortality that age- and sex-matched patients with essential hypertension and the same degree of blood pressure elevation - Resistant hypertension - Direct effects of aldosterone on the miocardium: Fibrosis, necrosis and hypertrophy - Aldosterone causes endothelial dysfunction 3. Specific treatment is available Struthers AD: Aldosterone: cardiovascular assault. Am Heart J 2002, 144:S2-7. Brilla CG, Matsubara LS, Weber KT: Anti-aldosterone treatment and the prevention of myocardial fibrosis in primary and secondary hyperaldosteronism. J Mol Cell Cardiol 1993, 25:563-575..

15. 3. Evaluation of the RAAS axis. Available tests: Plasma renin concentration Plasma renin activity (PRA) ARR Plasma aldosterone concentration (PAC) Urinary aldosterone concentration

16. Evaluation of RAAS: A) Case detection (screening) B) Confirmatory tests C) Subtype Classification

17. A) Case detection: ARR and plasma aldosterone level. ARR: First shown to be a usefull screening test to identify aldosterone producing adenomas in 1981. Hiramatsu Hiramatsu et al. A screening test to identify aldosterone-producing adenoma by measuring plasma renin activity. Results in hypertensive patients. Arch Intern Med. 1981 Nov;141(12):1589-93.

18. Case detection of PA should be done (Endocrine Society clinical practice guidelines of 2008): a) Stage 2/Stage 3 hypertension. Stage 2: SBP 160–179 mmHg, DBP 100–109 mmHg Stage 3: SBP more > 180 mmHg, DBP > 110 mmHg b) Resistant hypertension, defined as SBP > 140 and DBP > 90 despite treatment with three hypertensive medications. c) Hypertension with adrenal incidentaloma, defined as an adrenal mass detected incidentally during imaging performed for extraadrenal reasons. d) Hypertension and spontaneous or diuretic-induced hypokalemia. e) Hypertension and a family history of early-onset hypertension or cerebrovascular accident at a young age (<40 yr). f) All hypertensive first-degree relatives of patients with PA.

19. Use of the ARR: Use of A/R ratio alone: Good sensitivity (75-100%) and specificity (75-100%) Problem: Studies were done on white populations off hypotensive drugs Rayner et al: Study in black and coloured populations Black: 32% of normotensive patients had an A/R ratio > 1000 Coloured: 19% normotensive patients had an A/R ratio > 1000 Reason: Inherently low renin levels in these populations Rayner et al. Screening for primary aldosteronism:normal ranges for aldosterone and renin in three South African population groups. S Afr Med J 2001; 91; 594–599.

20. In South Africa: A/R ratio combined with a plasma aldosterone level Rayner et al. study: No normotensive patient had: - A/R ratio > 1000 AND plasma aldosterone level > 750 pmol/l Young from the Mayo clinic: - A/R ratio > 555 and/or aldosterone > 416 pmol/l should prompt investigation.

21. Clinical pitfalls: False positives: Renal impairment: Decreased PRA – sodium retension Elevated p-aldosterone – hyperkalemia Drugs False negatives: Dietary salt restriction – Elevated p-renin Pregnancy – Elevated p-renin Malignant hypertension – Elevated p-renin Hypokalemic patients – Suppression of p-aldosterone

22. EFFECTS OF ANTIHYPERTENSIVE DRUGS ON PLASMA RENIN AND ALDOSTERONE Drug Renin Aldosterone Effect Diuretics Increased Increased False negative β -blockers Decreased Minimal False positive Dihydropyridine Increased Minimal False negative calcium channel blocker α -methyl dopa Decreased Minimal False positive

23. Drug. Renin. Aldosterone. Effect. Clonidine Decreased Minimal False positive ACE inhibitors Minimal Minimal No effect Verapamil Minimal Minimal No effect α -blockers Nil Nil No effect Hydralazine Minimal Minimal No effect Angiotensin Not known Not known Potential for receptor false negative blockers but probably similar to ACE inhibitor

24. Drugs can affect the screening of patients with PA Gallay et al. showed in a prospective study that patients with PA will still be identified in screening, using the ARR, despite hypertensive treatment. Rayner et al. also showed that the ARR and p-adosterone can still be used even if the patient is using antihypertensive treatment. Gallay, BJ, Ahmad, S, Xu, L, et al. Screening for primary aldosteronism without discontinuing hypertensive medications: plasma aldosterone-renin ratio. Am J Kidney Dis 2001; 37:699.

25. A) ARR cutoff values, depending on assay and based on whether PAC, PRA, and DRC are measured in conventional or SI units. (Endocrine Society Clinical Practice Guideline 2008) PRA PRA (ng/ml/h) (pmol/litre/min) PAC (ng/dl) 20 1.6 30 2.5 40 3.1 PAC (pmol/liter) 750 60 1000 80 B) ARR cutoff values used by Rayner et al. in a South African setting. ARR > 900 AND Aldosterone > 500 : Probable primary aldosteronism. ARR < 900 OR Aldosterone < 500: Unlikely to be primary aldosteronism.

26. BUT: Variability of assays between laboratories makes it difficult to provide firm recommendations Clinicians still have to make a clinical judgement with regards to the specific patient If clinically indicated, further investigations should be done, even if the ARR and aldosterone levels are normal

27. Measurement of the ARR: A. Preparation for ARR measurement: agenda 1. Attempt to correct hypokalemia, after measuring plasma potassium in blood collected slowly with a syringe and needle (preferably not a Vacutainer to minimize the risk of spuriously raising potassium); avoid fist clenching during collection; wait at least 5 sec after tourniquet release (if used to achieve insertion of needle) and ensure separation of plasma from cells within 30 min of collection. 2. Encourage patient to liberalize (rather than restrict) sodium intake. 3. Withdraw agents that markedly affect the ARR (48) for at least 4 wk: a. Spironolactone, eplerenone, amiloride, and triamterene b. Potassium-wasting diuretics c. Products derived from licorice root (e.g. confectionary licorice, chewing tobacco)

28. 4. If the results of ARR off the above agents are not diagnostic, and if hypertension can be controlled with relatively non interfering medications, withdraw other medications that may affect the ARR for at least 2 weeks. 5. If necessary to maintain hypertension control, commence other antihypertensive medications that have lesser effects on the ARR. 6. Establish OC and HRT status, because estrogen-containing medications may lower DRC and cause false-positive ARR when DRC (rather than PRA) is measured. Do not withdraw OC unless confident of alternative effective contraception.

29. B. Conditions for collection of blood 1. Collect blood mid-morning, after the patient has been up (sitting, standing, or walking) for at least 2 h and seated for 5–15 min. 2. Collect blood carefully, avoiding stasis and hemolysis. 3. Maintain sample at room temperature (and not on ice, because this will promote conversion of inactive to active renin) during delivery to laboratory and before centrifugation and rapid freezing of plasma component pending assay.

30. C. Factors to take into account when interpreting results 1. Age: in patients aged >65 yr, renin can be lowered more than aldosterone by age alone, leading to a raised ARR 2. Time of day, recent diet, posture, and length of time in that posture 3. Medications 4. Method of blood collection, including any difficulty doing so 5. Level of potassium 6. Level of creatinine (renal failure can lead to false-positive ARR)

31. B. Case confirmation of PA. Testing procedures: 1. Oral sodium loading 2. Saline infusion 3. Fludrocortizone suppression 4. Captopril challenge Choice of test: Cost Patient compliance Lab routine Local expertise

32. C. Subtype classification. Adrenal CT as initial study If surgery is an option: Adrenal venous sampling - Distinguishing between unilateral and bilateral disease is NB - Unilateral disease: Unilateral adrenalectomy is the treatment of choice - Bilateral disease: Medical treatment is the treatment of choice

33. Summary of the approach to the patient with possible PA. Patients with hypertension that are at increased risk for PA positive PA unlikely Use ARR to detect cases (Screening) negative positive PA unlikely Conduct confirmatory testing negative positive Adrenal CT

34. Adrenal CT If surgery not desired If surgery desired AVS Treat with MR antagonist Bilateral Unilateral - Spirinolactone - Eplerone Treat with laparoscopic adrenolectomy

35. 4. Conclusion. The widespread application of the A/R ratio and plasma aldosterone to screen for PA allows identification of patients with a potential surgical cure and the appropriate medical treatment of their hypertension. The accurate detection of these patients requires understanding of the limitations of the ratio. Patients with a positive test require confirmation of the diagnosis, but in certain circumstances a practical approach may be adopted with a trial of spironolactone therapy. Clinicians should still depend on clinical judgement and not only on laboratory results. Suggested guidelines should be used in the treatment of patients with possible PA.

36. 5. References. 1. Hiramatsu 1. Hiramatsu et al. A screening test to identify aldosterone-producing adenoma by measuring plasma renin activity. Results in hypertensive patients. Arch Intern Med. 1981 Nov;141(12):1589-93. 2. John W. Funder et al. Case Detection, Diagnosis, and Treatment of Patients with Primary Aldosteronism: An Endocrine Society Clinical Practice Guideline J Clin Endocrinol Metab, September 2008, 93(9):3266–3281. 3. Sau-Cheung Tiu et al. The Use of Aldosterone-Renin Ratio as a Diagnostic Test for Primary Hyperaldosteronism and Its Test Characteristics under Different Conditions of Blood Sampling, J Clin Endocrinol Metab, January 2005, 90(1):72–78. 4. Rayner BL, Screening and diagnosis of primary aldosteronism. Cardiovascular Journal South Africa, July-August 2002, 13(4): 166-70. 5.Young WF. Primary aldosteronism: renaissance of a syndrome. Clinical Endocrinology, May 2007, 66(5): 607-18. 6. Rayner et al. The aldosterone/renin ratio as a screening test for primary aldosteronism, SAMJ, April 2000; 90(4): 394-400.

37. 7. Shwartz GL, Turner ST, Screening for primary aldosteronism in essential hypertension: diagnostic accuracy of the ratio of plasma aldosterone concentration to plasma renin activity, Clinical Chemistry, February 2005; 51(2): 386- 94. 8. Steven A. Atlas, The Renin-Angiotensin Aldosterone System: Pathophysiological Role and Pharmacologic Inhibition, JMCP; October 2007: Vol. 13, No. 8, S-b. 9. Rossi, GP, Bernini, G, Caliumi, C, et al. A prospective study of the prevalence of primary aldosteronism in 1,125 hypertensive patients. J Am Coll Cardiol 2006; 48:2293. 10.Gallay, BJ, Ahmad, S, Xu, L, et al. Screening for primary aldosteronism without discontinuing hypertensive medications: plasma aldosterone-renin ratio. Am J Kidney Dis 2001; 37:699. 11. Montori, VM, Schwartz, GL, Chapman, AB, et al. Validity of the aldosterone-renin ratio used to screen for primary aldosteronism. Mayo Clin Proc 2001; 76:877. 12. Struthers AD:Aldosterone: cardiovascular assault. Am Heart J 2002, 144:S2-7. 13. Brilla CG, Matsubara LS, Weber KT: Anti-aldosterone treatment and the prevention of myocardial fibrosis in primary and secondary hyperaldosteronism. J Mol Cell Cardiol 1993, 25:563-575.

38. Thank you.