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The Role of Renin and Aldosterone in Primary Aldosteronism

Mindray 2021-05-17

Renin and Aldosterone in RAAS
(Renin-Angiotensin-Aldosterone System)

Water and salt retention. Effective circulating volume increase. Increase in the perfusion of the juxtaglomerular apparatus.

Different direction of renin and aldosterone in primary and secondary hyperaldosteronism

The syndrome of primary aldosteronism was first described by Conn in 1955 . It is characterized by hypertension, suppressed plasma renin activity (PRA), increased plasma aldosterone concentration (PAC), and insuppressible aldosterone levels in the blood or urine.

PA signs and symptoms are nonspecific. These may include:

PA diagnosis is insufficient

All patients with hypertension should get tested

Who to Consider Testing for Primary Aldosteronism:

All patients with hypertension should be tested at least once

What to Consider Testing for Primary Aldosteronism:

Morning blood sample in seated ambulant patient

· Plasma aldosterone concentration (PAC)

· Plasma renin activity (PRA) or plasma renin concentration(PRC)

PAC 2 277 pmol/L (210 ng dL-1) and PRA (< 1.0 ng mL-1h-1) or
PRC ((< lower limit of reference)

Confirmatory Testing (if spontaneous K+ absent):

· 24-h urine for aldosterone and sodium on a high sodium diet, or

· 4-h saline infusion test

ARR is a useful tool for PA detection

ARR screening leads to 10-fold increase in the annual detection rate of primary aldosteronism.

ARR=PAC/PRA
PAC: Plasma aldosterone concentration
PRA: Plasma renin activity

Distinguishing the subtype of primary aldosteronism is critical to deciding on the appropriate therapy

Subtyping algorithm

APA, aldosterone-producing adenoma;
AVS, adrenal venous sampling;
CT, computed tomography;
IHA, idiopathic hyperaldosteronism; PA, primary aldosteronism;
PAH, primary adrenal hyperplasia.

Due to the limitation of computerized Tomography, adrenal venous sampling is needed

Mindray renin & aldosterone assay

References

[1] Young, WF (Mayo Clinic, Rochester, MN, USA). Diagnosis and treatment of primary aldosteronism: practical clinical perspectives (Review). J Intern Med 2019; 285: 126– 148.
[2] https://www.amazon.com/Secondary-Hypertension-Presentation-Diagnosis-Treatment/dp/ 1588291413> [Accessed 25 March 2021].
[3] <Effect of age on aldosterone/renin ratio (ARR) and comparison of screening accuracy of ARR plus elevated serum aldosterone concentration for primary aldosteronism screening in different age groups> Yin G, Zhang S Endocrine. 2012 Aug; 42(1):182-9.
[4] Williams textbook of endocrinology 13th edition
[5] Young WF, Stanson AW, Thompson GB, et al. Role for adrenal venous sampling in primary aldosteronism. Surgery. 2004;136:1227-1235

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