Assessment of the Quantitative Value Usefulness of the Aldosterone-Renin Ratio (ARR) for Primary Aldosteronism (AQUARR)
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ORIGINAL ARTICLE
Assessment of the Quantitative Value Usefulness of the Aldosterone-Renin Ratio (ARR) for Primary Aldosteronism (AQUARR) Study Giuseppe Maiolino1 • Sara Mareso1 • Valeria Bisogni1 • Giacomo Rossitto1 • Matteo Azzolini1 • Maurizio Cesari1 • Teresa Maria Seccia1 • Lorenzo Calo`2 Gian Paolo Rossi1
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Received: 28 October 2015 / Accepted: 13 November 2015 Ó Springer International Publishing Switzerland 2015
Abstract Current guidelines recommend use of the aldosterone-renin ratio (ARR) for the case detection of primary aldosteronism (PA), the most common cause of secondary hypertension, in selected hypertensive patients. ‘‘Confirmatory’’ tests are then recommended in patients who tested positive at the ARR to exclude from further diagnostic work-up false positive results. Based on our experience we hypothesized that the ARR carries quantitative information, which can avoid the need of confirmatory tests. We herein describe a study protocol to identify the ARR cut-off value with a high specificity for the exclusion of aldosterone-producing adenoma (APA) based on analysis of two large prospectively collected datasets of patients in which a conclusive diagnosis of APA was made by the four corners criteria. This will also serve to investigate the diagnostic gain provided over this ARR cut-off value by one confirmatory test, the captopril challenge test. Hence, with this protocol we expect to identify an ARR cut-off value that might prevent further testing in patients with either a low or a high probability of APA. This could translate in a higher diagnostic accuracy and, by preventing unnecessary invasive testing, into a substantial saving of money, time, and resources.
& Gian Paolo Rossi [email protected] 1
Clinica dell’Ipertensione Arteriosa, DIMED-UOSD Ipertensione, University Hospital, University of Padua, via Giustiniani, 2, 35126 Padua, Italy
2
Department of Medicine, UOC Nefrologia, University of Padua, Padua, Italy
Keywords Aldosterone-renin ratio Primary aldosteronism Aldosterone-producing adenoma Diagnosis
1 Introduction The current guidelines recommend the use of the aldosterone-renin ratio (ARR) for the screening of primary aldosteronism (PA), the most common endocrine cause of secondary arterial hypertension [1–3]. To this end the use of liberal cut-off values for the ARR is usually exploited to maximize sensitivity, even though it carries the burden of a low specificity. Accordingly, confirmatory tests are advised in order to identify and exclude from further costly testing false positive results. The subtyping of PA, in fact, requires adrenal vein sampling (AVS), a minimally invasive, costly, and not widely available procedure [1, 3, 4]. We postulated that the ARR value carries important quantitative information, which, if taken into proper consideration, might render the use of exclusion tests not necessary when high or very high ARR values are detected. Therefore, a careful selection of the ARR cut-offs can prevent the use of confirmatory tests and assist physicians in
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