醛固酮受体拮抗剂降低原发性醛固酮增多症阳性筛查率。
Mineralocorticoid Receptor Antagonists Decrease the Rates of Positive Screening for Primary Aldosteronism.
机构信息
From the (1)Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, and; Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.
From the (1)Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, and.
出版信息
Endocr Pract. 2020 Dec;26(12):1416-1424. doi: 10.4158/EP-2020-0277.
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.
目的
在患有难治性高血压和/或原发性醛固酮增多症（PA）的患者中，醛固酮受体拮抗剂（MRA）是有效的。理想情况下，应在停止可能干扰肾素-血管紧张素-醛固酮系统的药物后进行 PA 筛查，但在难治性高血压或低钾血症患者中这具有挑战性。在此，我们旨在评估 MRA 在临床实践中对 PA 筛查的影响。
方法
我们对在一家三级转诊中心使用 MRA 前后进行了血浆醛固酮和肾素测量的高血压患者进行了回顾性队列研究，时间跨度为 19 年。
结果
共纳入 146 例患者，其中 91 例患有 PA，并进行了长达 18 个月的随访。总体而言，MRA 起始后血浆肾素和醛固酮均升高（中位数，四分位距：0.5[0.1，0.8]至 1.2[0.6，4.8]ng/mL/h 和 19.1[12.9，27.7]至 26.4[17.1，42.3]ng/dL，均<0.0001），而醛固酮/肾素比值（ARR）从 40.3（18.5，102.7）降至 23.1（8.6，58.7）ng/dL/ng/mL/h（<0.0001）。无论 MRA 治疗持续时间和其他降压药的使用如何，均观察到类似的变化。在 94 例患者中有 45 例（48%）患者在开始 MRA 治疗后阳性 PA 筛查结果被消除。相反，17%的患者仅在开始 MRA 治疗后才有阳性 PA 筛查结果，主要是由于低钾血症得到纠正。最初的阳性筛查试验更可能因高 MRA 剂量而改变，并且在确诊的 PA 患者或服用β受体阻滞剂的患者中更可能持续存在。
结论
MRA 通常会降低 ARR 和阳性 PA 筛查结果的比例。当怀疑有 PA 时，应在停用 MRA 后重复进行筛查。
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