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Abstract：
The systematic use of confirmatory tests in the diagnosis of primary aldosteronism (PA) increases costs, risks and complexity to the diagnostic work-up. In light of this, some authors proposed aldosterone-to-renin (ARR) cut-offs and/or integrated flow-charts to avoid this step. Patients with resistant hypertension (RH), however, are characterized by a dysregulated renin-angiotensin-aldosterone system, even in the absence of PA. Thus, it is unclear whether these strategies might be applied with the same diagnostic reliability in the setting of RH.
We enrolled 129 consecutive patients diagnosed with RH and no other causes of secondary hypertension. All patients underwent full biochemical assessment for PA, encompassing both basal measurements and a saline infusion test.
34/129 patients (26.4%) were diagnosed with PA. ARR alone provided a moderate-to-high accuracy in predicting the diagnosis of PA (AUC=0.908). Among normokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 41.8 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 67%, respectively (AUC=0.882); an ARR > 179.6 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, but was associated with a very low sensitivity of 20%. Among hypokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 49.2 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 83%, respectively (AUC=0.941); an ARR > 104.0 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, with a sensitivity of 64%.
Among normokalemic patients, there was a wide overlap in ARR values between those with PA and those with essential RH; the possibility to skip a confirmatory test should thus be considered with caution in this setting. A better discriminating ability could be seen in the presence of hypokalemia; in this case, ARR alone may be sufficient to skip confirmatory tests in a suitable percentage of patients.
We enrolled 129 consecutive patients diagnosed with RH and no other causes of secondary hypertension. All patients underwent full biochemical assessment for PA, encompassing both basal measurements and a saline infusion test.
34/129 patients (26.4%) were diagnosed with PA. ARR alone provided a moderate-to-high accuracy in predicting the diagnosis of PA (AUC=0.908). Among normokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 41.8 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 67%, respectively (AUC=0.882); an ARR > 179.6 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, but was associated with a very low sensitivity of 20%. Among hypokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 49.2 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 83%, respectively (AUC=0.941); an ARR > 104.0 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, with a sensitivity of 64%.
Among normokalemic patients, there was a wide overlap in ARR values between those with PA and those with essential RH; the possibility to skip a confirmatory test should thus be considered with caution in this setting. A better discriminating ability could be seen in the presence of hypokalemia; in this case, ARR alone may be sufficient to skip confirmatory tests in a suitable percentage of patients.
摘要：
■在原发性醛固酮增多症（PA）的诊断中系统地使用确证试验会增加成本，诊断工作的风险和复杂性。鉴于此,一些作者提出醛固酮-肾素(ARR)截止值和/或综合流程图来避免这一步骤.顽固性高血压（RH）患者，然而,以肾素-血管紧张素-醛固酮系统失调为特征，即使没有PA。因此，目前尚不清楚这些策略在RH设置中是否可以以相同的诊断可靠性应用.
■我们连续纳入129例诊断为RH且无其他原因的继发性高血压患者。所有患者都接受了PA的全面生化评估，包括基础测量和生理盐水输注测试。
■34/129例患者（26.4%）被诊断为PA。单独的ARR在预测PA的诊断中提供了中等到高的准确性(AUC=0.908)。在正常血钾症患者中，最大限度地提高诊断准确性的ARR值，正如尤登指数所确定的那样，等于41.8(ng/dL)/(ng/mL/h)，以100%和67%的灵敏度和特异性为特征，分别（AUC=0.882）；ARR>179.6（ng/dL）/（ng/mL/h）为诊断PA提供了100％的特异性，但与20%的非常低的灵敏度相关。在低钾血症患者中，最大限度地提高诊断准确性的ARR值，正如尤登指数所确定的那样，等于49.2(ng/dL)/(ng/mL/h)，以100%和83%的灵敏度和特异性为特征，分别（AUC=0.941）；ARR>104.0（ng/dL）/（ng/mL/h）为诊断PA提供了100％的特异性，灵敏度为64%。
■在正常白血病患者中，PA患者和原发性RH患者的ARR值存在广泛重叠;因此,在这种情况下,应谨慎考虑跳过验证性试验的可能性.在低钾血症的存在下，可以看到更好的辨别能力；在这种情况下，单独的ARR可能足以在适当比例的患者中跳过确认测试。
■我们连续纳入129例诊断为RH且无其他原因的继发性高血压患者。所有患者都接受了PA的全面生化评估，包括基础测量和生理盐水输注测试。
■34/129例患者（26.4%）被诊断为PA。单独的ARR在预测PA的诊断中提供了中等到高的准确性(AUC=0.908)。在正常血钾症患者中，最大限度地提高诊断准确性的ARR值，正如尤登指数所确定的那样，等于41.8(ng/dL)/(ng/mL/h)，以100%和67%的灵敏度和特异性为特征，分别（AUC=0.882）；ARR>179.6（ng/dL）/（ng/mL/h）为诊断PA提供了100％的特异性，但与20%的非常低的灵敏度相关。在低钾血症患者中，最大限度地提高诊断准确性的ARR值，正如尤登指数所确定的那样，等于49.2(ng/dL)/(ng/mL/h)，以100%和83%的灵敏度和特异性为特征，分别（AUC=0.941）；ARR>104.0（ng/dL）/（ng/mL/h）为诊断PA提供了100％的特异性，灵敏度为64%。
■在正常白血病患者中，PA患者和原发性RH患者的ARR值存在广泛重叠;因此,在这种情况下,应谨慎考虑跳过验证性试验的可能性.在低钾血症的存在下，可以看到更好的辨别能力；在这种情况下，单独的ARR可能足以在适当比例的患者中跳过确认测试。
