Biomarkers to Guide Medical Therapy in Primary Aldosteronism.

Primary aldosteronism (PA) is an endocrinopathy characterized by dysregulated aldosterone production that occurs despite suppression of renin and angiotensin II, and that is non-suppressible by volume and sodium loading. The effectiveness of surgical adrenalectomy for patients with lateralizing PA is characterized by the attenuation of excess aldosterone production leading to blood pressure reduction, correction of hypokalemia, and increases in renin-biomarkers that collectively indicate a reversal of PA pathophysiology and restoration of normal physiology. Even though the vast majority of patients with PA will ultimately be treated medically rather than surgically, there is a lack of guidance on how to optimize medical therapy and on key metrics of success. Herein, we review the evidence justifying approaches to medical management of PA and biomarkers that reflect endocrine principles of restoring normal physiology. We review the current arsenal of medical therapies, including dietary sodium restriction, steroidal and nonsteroidal mineralocorticoid receptor antagonists, epithelial sodium channel inhibitors, and aldosterone synthase inhibitors. It is crucial that clinicians recognize that multimodal medical treatment for PA can be highly effective at reducing the risk for adverse cardiovascular and kidney outcomes when titrated with intention. The key biomarkers reflective of optimized medical therapy are unsurprisingly similar to the physiologic expectations following surgical adrenalectomy: control of blood pressure with the fewest number of antihypertensive agents, normalization of serum potassium without supplementation, and a rise in renin. Pragmatic approaches to achieve these objectives while mitigating adverse effects are reviewed.

Outcomes of a Specialized Clinic on Rates of Investigation and Treatment of Primary Aldosteronism.

Importance: Primary aldosteronism (PA) is one of the most common causes of secondary hypertension but remains largely unrecognized and untreated. Objective: To understand the outcomes of a specialized clinic on rates of evaluation and treatment of PA in the context of secondary factors. Design, Setting, and Participants: This population-based cohort study was conducted in Alberta, Canada, using linked administrative data between April 1, 2012, and July 31, 2019, on adults identified as having hypertension. Main Outcomes and Measures: We evaluated each step of the diagnostic and care pathway for PA to determine the proportion of people with hypertension who received screening, subtyping, and targeted treatment for PA. Variations in diagnosis and treatment were examined according to individual-level, clinician-level, and system-level characteristics. Results: Of the 1.1 million adults with hypertension, 7941 people (0.7%) were screened for PA. Among those who were screened, 1703 (21.4%) had positive test results consistent with possible PA, and 1005 (59.0%) of these were further investigated to distinguish between unilateral and bilateral forms of PA. Only 731 individuals (42.9%) with a positive screen result received disease-targeted treatment. Geographic zones and clinician specialty were the strongest determinants of screening, subtyping, and treatment of PA, with the highest rates corresponding to the location of the provincial endocrine hypertension program. Conclusions and Relevance: In this cohort, less than 1% of patients expected to have PA were ever formally diagnosed and treated. These findings suggest that a system-level approach to assist with investigation and treatment of PA may be highly effective in closing care gaps and improving clinical outcomes.

Predicting deficiency of vitamin D in renal transplant recipients in northern climates.

BACKGROUND: Renal transplant patients have been shown to have a higher risk of bone disease than the general population. The aim of this study was to examine vitamin D status, a modifiable risk factor in bone disease, in the renal transplant population in a northern climate. METHODS: This retrospective observational study included 331 subjects and analyzed demographic, biochemical, and medication information for associations with vitamin D. RESULTS: Of the study population, 45.3% were vitamin D deficient. The percentage of deficient subjects increases to 76.5% if those receiving supplementation are excluded. The mean daily dose of vitamin D was 1275 IU for sufficient patients. For every 1000 IU of vitamin D daily, the risk of deficiency is decreased by 40.3%. Time from transplantation had a significant positive association (P<0.001) in which every year out of transplantation decreased the risk of deficiency by 9.1%. Body mass index had a significant negative association (P=0.012) with vitamin D in which the risk of deficiency increased by 6% for each kilogram per meter squared. Ethnicity was found to be statistically significant on univariate analysis (P=0.034), with white patients having 9.1% decreased risk of deficiency. CONCLUSION: Despite a high rate of supplementation of vitamin D, close to half of the renal transplant population was still deficient. Those who were receiving over 1000 IU daily were more likely to be vitamin D sufficient. Early supplementation after transplantation along with higher doses for non-white patients or patients with a high body mass index may be warranted for normalization of vitamin D status.