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Original Studies |
Endocrine Unit, Department of Medicine, Tan Tock Seng Hospital (K.-C.L.); Department of Pathology, National University of Singapore (E.S.K., M.-C.K.); and Family Health Service, Ministry of Health (S.C.E.), Republic of Singapore; and Department of Medicine, Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
Address all correspondence and requests for reprints to: Dr. Keh-Chuan Loh, Endocrine Unit, Department of Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Republic of Singapore. E-mail: keh_chuan_loh{at}notes.ttsh.gov.sg
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Abstract |
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This study was designed to determine the prevalence of primary aldosteronism in the predominantly Chinese population in Singapore. Three hundred and fifty unselected adult hypertensive patients attending two primary care clinics had random ambulatory measurements for PAC (nanograms per dL) and PRA (nanograms per mL/h). Serum urea, creatinine, and electrolyte measurements were obtained simultaneously. Subjects with renal insufficiency (serum creatinine, >140 µmol/L) and those treated with glucocorticoids or spironolactone were excluded. Screening was considered positive if the PAC:PRA ratio was more than 20 and the PAC was more than 15 ng/dL (>416 pmol/L). Primary aldosteronism was confirmed with the determination of PAC after 2 L saline administered iv over 4 h. Adrenal computed tomographic (CT) scans were performed in biochemically confirmed cases of primary aldosteronism. Further localization with adrenal vein sampling was carried out in selected patients with equivocal findings on adrenal CT scan.
Sixty-three (18%) of the 350 hypertensive patients (215 women and 135 men; age range, 23–75 yr) were screened positive for primary aldosteronism. Only 13 of these 63 subjects (21%) were hypokalemic (serum potassium, <3.5 mmol/L). Confirmatory studies were carried out in 56 (89%) of the subjects with a positive PAC:PRA ratio. Using a PAC above 10 ng/dL (>277 pmol/L) after saline infusion as the diagnostic cut-off, 16 of the 56 patients had biochemically confirmed primary aldosteronism. Hypokalemia was found in 6 of the 16 patients (37.5%) with primary aldosteronism. Subtype evaluation with adrenal CT scan and adrenal vein sampling indicated that half of the patients with primary aldosteronism may have had potentially curable unilateral adrenal adenoma.
Our data suggest that primary aldosteronism occurs in at least 5% of the adult Asian hypertensive population, and approximately half of these individuals may have potentially curable, unilateral, aldosterone-producing adrenal adenoma. Our findings also confirm the poor predictive value of hypokalemia in both the diagnosis and the exclusion of primary aldosteronism.
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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We undertook a prevalence-finding study on primary aldosteronism in hypertensive patients from Singapore to establish the potential value of routine screening for this entity in a predominantly Chinese population.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Three hundred and ninety-five consecutive adult patients
visiting the Hypertension Clinic in 2 large primary care polyclinics
from October through December 1998 were selected for the study. Fifteen
subjects were subsequently excluded because of renal impairment (serum
creatinine, >140 µmol/L) or treatment with either spironolactone or
glucocorticoids, and 30 subjects declined to participate. The study
consisted of 350 adult patients (135 men and 215 women), aged 23–75 yr
(mean age, 55.2 ± 8.6 yr). The mean duration of hypertension was
7.0 ± 6.7 yr. The ethnic composition reflected the predominantly
Chinese population in Singapore and consisted of 85% Chinese, 11%
Malay, 2% Indian, and 2% others (Table 1
).
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). Blood
samples were obtained in the morning as random ambulatory specimens and
under normal dietary sodium intake. Normokalemia and normotension were
confirmed for these subjects. The normal ranges for PAC and PRA, as
derived from the 95% confidence limits of the measurements obtained
from these healthy normotensive volunteers, were 2.47–23.80 ng/dL
(69–660 pmol/L) and 0.30–3.88 ng/mL·h (0.23–2.99 nmol/L·h),
respectively. The study was approved by the Tan Tock Seng Hospital ethics committee, and informed consent was obtained from all participants.
Laboratory methods
PAC was measured by a solid phase Coat-A-Count aldosterone RIA kit (Diagnostic Products, Los Angeles, CA). The intra- and interassay coefficients of variation for the aldosterone assay were 2.7–8.7% and 3.6–10.4%, respectively. PRA was measured as the generation of angiotensin I in vitro at pH 6.0 using a GammaCoat PRA RIA kit (INCSTAR Corp., Stillwater, MN). The intra- and interassay coefficients of variation for PRA were 4.6–10.0% and 5.6–7.6%, respectively. Serum urea, creatinine, and electrolyte concentrations were measured by the Vitros 950 automated multichannel analyzer (Ortho-Clinical Diagnostics, Rochester, NY).
Screening test
All patients who participated in the study had their medical
records reviewed, with emphasis on the history and treatment of
hypertension. Blood pressure was checked with the subjects seated and
rested for 15 min. Blood was drawn in the seated position for
measurement of serum urea, creatinine, and electrolytes; PAC; and PRA.
Blood for the assay of PRA was collected in chilled tubes containing
sodium ethylenediamine tetraacetate, and plasma was separated in a
refrigerated centrifuge within 4 h of collection. The study was
carried out in the morning between 0800–1030 h without prior
discontinuation of the patient’s antihypertensive medications. A
positive screening test for primary aldosteronism was defined
arbitrarily as a PAC:PRA ratio above 20 and a PAC level above 15 ng/dL
(>416 pmol/L), based on the 95th percentile PAC:PRA ratio and the 75th
percentile PAC value, respectively, derived from our healthy
normotensive volunteers (Fig. 1).
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Confirmatory testing using iv saline loading (2 L 0.9% saline over 4 h from 0800–1200 h) was performed on patients who screened positive for primary aldosteronism (4, 5). Subjects with hypokalemia were given adequate oral KCl supplements before the study. The infusion was performed as an out-patient procedure after an overnight fast. The subjects were seated throughout the infusion, and blood was taken at completion from the contralateral arm for the measurement of PAC and serum electrolytes. Primary aldosteronism was confirmed if PAC failed to suppress below 10 ng/dL (277 pmol/L) post-saline loading (5).
Subtype studies
Patients with biochemically confirmed primary aldosteronism underwent computerized tomographic (CT) scan of the adrenal glands with 3-mm contiguous cuts. Diagnosis of an aldosterone-producing adenoma was considered clinically appropriate if the scan showed a unilateral solitary adrenal macroadenoma (>1 cm), provided the contralateral adrenal gland was morphologically normal. Bilateral adrenal vein sampling (AVS) for aldosterone and cortisol concentrations was offered to patients with a negative (normal) scan or other abnormal scan findings. AVS was performed in the morning with patients under continuous synthetic ACTH-(1–24) (Cosyntropin, Organon, West Orange, NY) infusion at 50 µg/h (6). Lateralization of aldosterone hypersecretion was established if the aldosterone to cortisol ratio (A:C) in the affected side was 4-fold greater than that of the contralateral adrenal gland and if the A:C from the contralateral side was suppressed below that of peripheral value (infrarenal portion of inferior vena cava) (7).
Statistical analysis
Statistical analysis of the results was performed using the
Statistical Package for Social Science (SPSS, Inc.,
Chicago, IL). The data were expressed as a range and an arithmetic mean
with either the SD or the SE. As most data,
such as PAC and PAC:PRA ratio, do not assume normal distribution,
comparison between groups was made using either the Mann-Whitney test
or Kruskal-Wallis test, whereas the 
2 test or
Fisher’s exact test was used as appropriate for categorical variables.
Observed differences were assumed to be statistically significant if
the probability of chance occurrence was P < 0.05.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Ninety-six percent of the patients were receiving pharmacological therapy for hypertension: ß-adrenergic blocker (60%), calcium channel blocker (38%), angiotensin-converting enzyme inhibitor (15%), diuretics (5%), and other classes of drugs (3%). Three quarters of the patients were taking a single antihypertensive drug, with the majority of the remaining patients taking two drugs. Satisfactory blood pressure control (defined as a mean blood pressure of 140/90 mm Hg or less measured on 3 different occasions) was recorded in 166 of the 350 patients (47.4%).
Screening and diagnosis
Sixty-three patients, or 18% of the hypertensive study
population, were screened positive for primary aldosteronism based on a
PAC:PRA ratio above 20 and a PAC level over 15 ng/dL (416 pmol/L).
Notably, this combination was found in only 1 subject among our 150
normotensive controls (0.7%). Confirmatory studies for primary
aldosteronism were performed in 56 of the 63 hypertensive patients who
had a positive screening test. The diagnosis of primary aldosteronism
was established in 16 of these 56 patients after they underwent iv
saline loading test. The relationship between PAC:PRA and PAC in the
patients with confirmed primary aldosteronism and those in normotensive
volunteers is depicted in Fig. 1. Figure 2 compares the central 95% interval for
PAC:PRA obtained from the normotensive controls and the subgroups of
hypertensive subjects with and without primary aldosteronism,
respectively.
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). Notably, none of the hypokalemic
subjects with primary aldosteronism was receiving diuretic therapy,
whereas 7 of the 21 hypokalemic subjects with negative screening
results for primary aldosteronism were receiving diuretic therapy.
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). Subtype studies
Adrenal CT scans were performed in all 16 patients, of whom 6 were
considered to have aldosterone-producing adenoma based on the finding
of a solitary adrenal macro-adenoma (range, 1.1–2.5 cm; mean, 1.5
cm) and a normal appearing contralateral adrenal gland. Eight of the
remaining 10 patients with normal or other findings on CT adrenal scan
underwent bilateral AVS. Successful catheterization of both adrenal
veins was achieved in 6 patients, 2 of whom demonstrated unilateral
aldosterone excess with appropriate A:C ratios (Table 3). Combining the CT scan and AVS
results, 8 of the 16 patients (50%) with primary aldosteronism could
be potentially cured with unilateral adrenalectomy.
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) revealed
no significant differences between the two subgroups with respect to
age, duration of hypertension, proportion of subjects with poor blood
pressure control, biochemical indexes such as PAC and PAC:PRA, and
proportion of subjects with potentially curable aldosterone-producing
adrenal adenoma.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The apparent increase in the reported prevalence of primary aldosteronism over the last decade is likely to reflect the improvement in screening methodologies. Using the PAC:PRA ratio as a screening tool, Hiramatsu and colleagues (8) identified and successfully operated on 9 patients with aldosterone-producing adenoma from a study of 348 hypertensive patients, thus giving a prevalence of 2.6% for al-dosterone-producing adenoma in a hypertensive population from Japan. Importantly, they were able to demonstrate that the finding of normokalemia provided little assurance that aldosterone-producing adenoma was absent, as normokalemia was found in 6 of the 9 patients.
Using a similar screening strategy, Gordon and colleagues (15) reported a 12% probable incidence of primary aldos-teronism among 199 selected normokalemic hypertensive patients. As not all subjects who screened positive underwent confirmatory studies, the minimum incidence based on biochemically confirmed cases from this selected Caucasian hypertensive population was 8.5%. The reported prevalence of primary aldosteronism obtained from the small number of studies performed in other selected Caucasian hypertensive populations ranged from 2.7–16.6% (16, 17), whereas an Asian study reported an 8.7% prevalence of primary al-dosteronism and a 2.9% incidence of unilateral adrenal adenomas (18).
Results obtained from these prevalence studies could be biased because hypertensive subjects were recruited from specialist referral centers. Nevertheless, in the only study conducted in a primary care practice, Lim and colleagues in the United Kingdom (19) found elevated PAC:PRA ratios in 14.4% of their patients, similar to the proportion obtained from their earlier study in specialist referral clinics. They concluded that about 1 in 10 of their hypertensive patients had primary aldosteronism; however, these figures were based only on the projected positive predictive value of their PAC:PRA cut-off, as confirmatory tests were not performed in these subjects.
Our findings represent the first reported study in a predominantly Chinese hypertensive population that was performed in a primary care setting. Although cognizant of the fact that genetic and lifestyle differences may influence the prevalence and presentation of primary aldosteronism in distinct populations, our estimated 5% prevalence rate for primary aldosteronism in Singapore supports the idea that primary aldosteronism is more common than expected in Asian hypertensive subjects. Primary aldosteronism is underdiagnosed in Asian populations because of the conventional practice of using hypokalemia as the first-line screening test for primary aldosteronism; we would have missed more than 60% of patients with primary aldosteronism in our study cohort if patients with normokalemia were excluded from further evaluation. In addition to insensitivity, the detection of hypokalemia in the hypertensive population is not highly specific for primary aldosteronism; the majority of our hypokalemic subjects were screened negative for this entity, and a third were receiving diuretic therapy.
The prevalence figure for primary aldosteronism in Singapore could be
even higher if lower diagnostic PAC cut-offs were explored together
with more rigorous confirmatory tests, or if the study were confined to
newly diagnosed hypertensive subjects. As PAC values between 5–10
ng/dL (139–277 pmol/L) after saline infusion fall within the
intermediate zone, these individuals might have early or milder forms
of primary aldosteronism (4, 5). Using hypothetical postsaline loading
PAC diagnostic cut-offs of 7.5 ng/dL (208 pmol/L) and 5.0 ng/dL (139
pmol/L), the corresponding prevalence rate of primary aldosteronism in
our population would be 6.4% and 8.4%, respectively (Table 5).
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In conclusion, primary aldosteronism is frequently overlooked in Asian communities despite the fact that affected individuals may have a potentially curable condition. The traditional approach to primary aldosteronism with screening directed only at individuals with overt hypokalemia explains why this entity often escapes identification. Conversely, hypokalemia is a frequent finding in patients with essential hypertension treated with antihypertensive drugs. With improved screening methodologies, primary aldos-teronism appears to be a very common form of secondary hypertension. Early recognition and treatment are important to achieve the cure of hypertension in patients with unilateral aldosterone-producing adenoma, thus obviating the need for a lifetime of costly pharmacological therapy with its attendant side-effects as well as the complications of variably controlled hypertension.
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Acknowledgments |
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Footnotes |
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Received January 14, 2000.
Revised March 20, 2000.
Accepted May 14, 2000.
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References |
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