Screening and diagnosis of primary aldosteronism. Consensus document of all the Spanish Societies involved in the management of primary aldosteronism

• Published in: Endocrine 2024-03, Vol.85 (1), p.99-121
• Main Authors: Araujo-Castro, Marta, Ruiz-Sánchez, Jorge Gabriel, Parra Ramírez, Paola, Martín Rojas-Marcos, Patricia, Aguilera-Saborido, Almudena, Gómez Cerezo, Jorge Francisco, López Lazareno, Nieves, Torregrosa Quesada, María Eugenia, Gorrin Ramos, Jorge, Oriola, Josep, Poch, Esteban, Oliveras, Anna, Méndez Monter, José Vicente, Gómez Muriel, Isabel, Bella-Cueto, María Rosa, Mercader Cidoncha, Enrique, Runkle, Isabelle, Hanzu, Felicia A.
• Format: Article
• Language: English
• Subjects: a1-Adrenergic receptors; Aldosterone; Calcium antagonists; Diabetes; Diagnosis; Dihydropyridine; Endocrinology; Humanities and Social Sciences; Hypertension; Hypokalemia; Internal Medicine; Medicine; Medicine & Public Health; Mineralocorticoid receptors; multidisciplinary; Radiology; Renin; Review; Salt loading; Science
• ISSN: 1559-0100; 1355-008X; 1559-0100
• DOI: 10.1007/s12020-024-03751-1

Primary aldosteronism (PA) is the most frequent cause of secondary hypertension (HT), and is associated with a higher cardiometabolic risk than essential HT. However, PA remains underdiagnosed, probably due to several difficulties clinicians usually find in performing its diagnosis and subtype classification. The aim of this consensus is to provide practical recommendations focused on the prevalence and the diagnosis of PA and the clinical implications of aldosterone excess, from a multidisciplinary perspective, in a nominal group consensus approach by experts from the Spanish Society of Endocrinology and Nutrition (SEEN), Spanish Society of Cardiology (SEC), Spanish Society of Nephrology (SEN), Spanish Society of Internal Medicine (SEMI), Spanish Radiology Society (SERAM), Spanish Society of Vascular and Interventional Radiology (SERVEI), Spanish Society of Laboratory Medicine (SEQC(ML)), Spanish Society of Anatomic-Pathology, Spanish Association of Surgeons (AEC). Highlights Following a positive screening test, no further studies are needed for diagnosis of PA if a plasma aldosterone concentration (PAC) > 20 ng/dL and a low circulating direct renin or plasma renin activity (PRA) are detected in a patient with spontaneous hypokalemia. In all other patients, one (or more) of four different tests is (are) currently recommended: the fludrocortisone suppression test, the oral salt loading test, the intravenous saline test, and/or the captopril challenge test. In all cases, hypokalemia must be corrected prior to testing. Interfering medication must be progressively withdrawn before testing, while introducing alpha-1 adrenergic blockers, long-acting non-dihydropyridine calcium antagonists, and/or hydralazine as needed for control of hypertension. All but the captopril challenge test run the risk of inducing hypokalemia, fluid overload, and a worsening of hypertension. In the case of borderline results, the initial test employed can be repeated, or a second test performed. Patients with both a negative saline infusion and captopril challenge test appear to be at a low risk for harboring unilateral disease, whereas those positive for both are more likely to exhibit unilateral aldosterone secretion than when tests render conflicting results. Patients showing a positive screening aldosterone to renin ratio (ARR) with normal/high PAC and a low renin/PRA, yet with negative diagnostic testing, presenting mild hyperaldosteronism, can benefit from targeted therapy of hy