Thursday, 06 June 2013
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Dear Expert

1-what ratio would you use to diagnose primary hyperaldosteronism if renin is reported as renin concentration in ng/L and aldosterone is reported in pmol/L (ratio of aldosterone/renin)

2-would you think that the presence of CKD may change the interpretation of the result for renin/aldosterone to diagnose primary hyperaldosteronism, assuming pt is not on Spironolactone?

3-How high would you go on spironolactone dose in pts with primary hyperaldosteronism to control their blood pressure and what is your second chose (on top of Spironolactone) for lowering blood pressure in this pt population?

more than a month ago

  1. A PAC/PRA (plasma aldosterone concentration to plasma renin activity) greater than 20 AND a PAC of greater than 15 ng/dl (416 pmol/L). Below is a table from UpToDate and originally from the J Clin Endocrinol Metab which shows cut-off values for the ratio, depending on the type of units used to measure each component value (source: UptoDate)
  2. I would not think GFR is an important contributor to interpreting the results
  3. Assuming that medical management is selected (rather than surgical removal of an adenoma), then the goal of titrating the spironolactone is normokalemia, off potassium supplements. The dosage of spironolactone required might be as high as 200 mg per day, though usually less is needed. If normokalemia is achieved and hypertension persists, recall that patients may also have a component of essential hypertension which requires the addition of other agents. You could select a calcium channel blocker, ACE inhibitor or angiotensin blocker. Very careful attention should be paid to plasma potassium if selecting the latter two options.
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