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

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Abstract

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  • Interfering medication must be progressively withdrawn before testing, while introducing alpha-1 adrenergic blockers, long-acting non-dihydropyridine calcium antagonists, and/or hydralazine as needed for control of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 hypertension with mineralocorticoid receptor antagonists.

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Acknowledgements

We thank Alberto Fernandez for the review of the manuscript. This consensus was sponsored by all implicated Societies.

Author contributions

MAC and FH wrote the main manuscript text and all authors reviewed the manuscript

Funding

This research was funded by all participating societies.

Author information

Authors and Affiliations

  1. Endocrinology & Nutrition Department, Hospital Universitario Ramón y Cajal. Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS)., Madrid, Spain

    Marta Araujo-Castro

  2. Endocrinology & Nutrition Department. Hospital Universitario Fundación Jiménez Díaz, Health Research Institute-Fundación Jiménez Díaz University Hospital (IIS-FJD, UAM), Madrid, Spain

    Jorge Gabriel Ruiz-Sánchez

  3. Endocrinology & Nutrition Department, Hospital Universitario La Paz-IdiPAZ, Madrid, Spain

    Paola Parra Ramírez & Patricia Martín Rojas-Marcos

  4. Cardiology Department, Hospital Universitario Virgen del Rocío, Sevilla, Spain

    Almudena Aguilera-Saborido

  5. Internal Medicine, Hospital Universitario Infanta Sofía. Universidad Europea de Madrid, Madrid, Spain

    Jorge Francisco Gómez Cerezo

  6. Biochemical Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain

    Nieves López Lazareno

  7. Biochemical Department, Hospital General Universitario Dr. Balmis de Alicante, Alicante, Spain

    María Eugenia Torregrosa Quesada

  8. Biochemical department, Laboratori de Referència de Catalunya, Barcelona, Spain

    Jorge Gorrin Ramos

  9. Biochemistry and Molecular Genetics Department, CDB. Hospital Clínic. University of Barcelona, Barcelona, Spain

    Josep Oriola

  10. Nephrology Department. Hospital Clinic, IDIBAPS. University of Barcelona, Barcelona, Spain

    Esteban Poch

  11. Nephrology Department. Hospital del Mar, Universitat Pompeu Fabra, Barcelona, ES, Spain

    Anna Oliveras

  12. Vascular and Interventional Radiology Department, Hospital Clínico San Carlos, Madrid, Spain

    José Vicente Méndez Monter

  13. Radiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain

    Isabel Gómez Muriel

  14. Pathology Department, Parc Taulí Hospital Universitari. Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA). Universitat Autònoma de Barcelona. Sabadell, Barcelona, Spain

    María Rosa Bella-Cueto

  15. General Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain

    Enrique Mercader Cidoncha

  16. Fellow European Board of Surgery -Endocrine Surgery, Madrid, Spain

    Enrique Mercader Cidoncha

  17. Endocrinology and Nutrition Department, Hospital Clínico San Carlos, Madrid, Spain

    Isabelle Runkle

  18. Endocrinology & Nutrition Department, Hospital Clinic. IDIBAPS. University of Barcelona, Barcelona, Spain

    Felicia A. Hanzu

Authors
  1. Marta Araujo-Castro
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  2. Jorge Gabriel Ruiz-Sánchez
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  18. Felicia A. Hanzu
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Consortia

In representation of the following medical Spanish societies: 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)

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Correspondence to Marta Araujo-Castro or Felicia A. Hanzu.

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Araujo-Castro, M., Ruiz-Sánchez, J.G., Parra Ramírez, P. et al. Screening and diagnosis of primary aldosteronism. Consensus document of all the Spanish Societies involved in the management of primary aldosteronism. Endocrine (2024). https://doi.org/10.1007/s12020-024-03751-1

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