醛固酮与肾素比值作为原发性醛固酮增多症筛查试验的检测特征。

Test characteristics of the aldosterone-to-renin ratio as a screening test for primary aldosteronism.

机构信息

aErasmus Medical Centre, Department of Internal Medicine, Rotterdam bAcademic Medical Centre, Department of Internal Medicine, Amsterdam cRed Cross Hospital, Department of Internal Medicine, Beverwijk dRadboud University Nijmegen Medical Centre, Department of Internal Medicine eUniversity of Groningen, University Medical Centre Groningen, Department of Endocrinology, Groningen fVrije Universiteit Medical Centre, Department of Internal Medicine, Amsterdam gZiekenhuis Groep Twente, Department of Internal Medicine, Almelo hVlietland Hospital, Department of Internal Medicine, Schiedam, The Netherlands.

出版信息

J Hypertens. 2014 Jan;32(1):115-26. doi: 10.1097/HJH.0b013e3283656b54.

DOI:10.1097/HJH.0b013e3283656b54

PMID:24018605

Abstract

BACKGROUND

The aldosterone-to-renin ratio (ARR) is a widely used screening test for primary aldosteronism. Current guidelines recommend a cut-off value of 91 pmol/mU. Studies on its sensitivity, specificity, reproducibility and the role of medication have been conflicting. We prospectively assessed the test characteristics of the ARR and the effect of combination antihypertensive treatment.

METHODS

In 178 patients with persistent hypertension despite the use of at least two antihypertensives, plasma renin and aldosterone were assessed twice within an interval of 4 weeks. All patients underwent an intravenous salt loading test. A posttest plasma aldosterone exceeding 235 pmol/l was considered diagnostic for primary aldosteronism. ARR was repeated after 4 weeks of standardized treatment with a calcium channel blocker and/or α-adrenergic-receptor blocker.

RESULTS

The prevalence of primary aldosteronism was 15.2%. The median ARR was 35.0 (interquartile range 16.2-82.0) in primary aldosteronism versus 7.1 (2.2-17.5) pmol/mU in essential hypertensive patients (P < 0.001). Under random medication, the ARR had 22.2% sensitivity and 98.7% specificity. On standardized treatment, the ARR rose from 9.6 (2.5-24.8) to 21.4 (10.8-52.1) (P < 0.001). Multivariate regression showed that angiotensin-converting enzyme (ACE)-inhibitors and angiotensin II-receptor blockers were responsible for the lower ARR during random treatment. The area under the receiver operating characteristic curve was, however, similar under random and standardized treatment (84 vs. 86%, respectively, P = 0.314). Bland-Altman plots showed an almost five-fold difference in ARR values taken under the same conditions.

CONCLUSION

ARR sensitivity for primary aldosteronism is low when the recommended cut-off is used. Reproducibility is also poor, stressing the need for alternative screening tests.

摘要

背景

醛固酮与肾素比值（ARR）是原发性醛固酮增多症的常用筛查试验。目前的指南建议截断值为 91pmol/mU。关于其敏感性、特异性、可重复性和药物作用的研究结果一直存在争议。我们前瞻性评估了 ARR 的检测特征以及联合降压治疗的效果。

方法

在 178 例持续高血压患者中，尽管使用了至少两种降压药物，在 4 周内两次评估血浆肾素和醛固酮。所有患者均进行静脉盐负荷试验。如果术后血浆醛固酮超过 235pmol/l，则考虑为原发性醛固酮增多症。4 周后，用钙通道阻滞剂和/或α肾上腺素能受体阻滞剂进行标准化治疗后，重复 ARR。

结果

原发性醛固酮增多症的患病率为 15.2%。原发性醛固酮增多症患者的中位数 ARR 为 35.0（四分位距 16.2-82.0），原发性高血压患者为 7.1（2.2-17.5）pmol/mU（P<0.001）。在随机药物治疗下，ARR 的敏感性为 22.2%，特异性为 98.7%。在标准化治疗下，ARR 从 9.6（2.5-24.8）升至 21.4（10.8-52.1）（P<0.001）。多变量回归显示，血管紧张素转换酶（ACE）抑制剂和血管紧张素 II 受体阻滞剂是随机治疗时 ARR 降低的原因。然而，随机和标准化治疗的受试者工作特征曲线下面积相似（分别为 84%和 86%，P=0.314）。Bland-Altman 图显示，在相同条件下，ARR 值的差异接近五倍。