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Primary Aldosteronism in Diabetic Subjects With Resistant Hypertension

Response to Ng et al.

From the Endocrinology Section, Emory University, Atlanta, Georgia

Address correspondence to Guillermo E. Umpierrez, MD, Endocrinology Section, Emory University, 49 Jesse Hill Jr. Dr., Atlanta, Georgia

We reported that hypertension affects nearly 70% of patients with type 2 diabetes at our institution and that 45% of them require three or more antihypertensive agents (1). Despite the multidrug approach, one-third of patients do not achieve the recommended blood pressure goal of <130/80 mmHg. These findings led us to investigate the prevalence of primary hyperaldosteronism (PHA), the most common cause of endocrine hypertension, in diabetic patients with resistant hypertension. We found that 14% of diabetic patients with resistant hypertension had biochemical evidence of PHA. Thus, select patients with diabetes should be screened for PHA, and this in turn may lead to improvement in cardiovascular outcomes.

We acknowledge the viewpoints of Ng et al. (2), and we agree that it would be of great therapeutic relevance to know whether there are long-term differences between subjects with essential hypertension and those with PHA as it relates to cardiovascular injury and mortality. More than 80% of patients with type 2 diabetes have features of metabolic syndrome, and 40–70% of patients with surgically treated aldosterone-producing adenomas have long-term hypertension (3). Thus, we hypothesize that the early diagnosis and treatment of PHA in diabetic patients with resistant hypertension may afford them even better cardiovascular outcomes.

As Ng et al. outlined, we also agree that further investigations should be done related to screening and diagnosis of PHA in patients with type 2 diabetes. There are currently no studies to guide appropriate cutoff values for plasma aldosterone (PAC) or plasma renin activity for screening patients with diabetes or obesity. Similarly, there is no uniform acceptance of a best test to confirm diagnosis of PAH. The screening PAC–to–plasma renin activity ratio cutoff of >30 ng · ml^–1 · h^–1 and post–sodium load PAC cutoff of 5.0 ng/dl were arbitrarily selected from previously published diagnostic ranges noted in the general population (4,5).

Historically, most cases of PHA have been attributed to unilateral aldosterone-producing adenomas; however, we now know that the majority of PHA cases are most likely attributable to bilateral adrenal hyperplasia (5,6). Medical management with aldosterone antagonists is the treatment of choice for patients with bilateral adrenal hyperplasia. Independent of the antihypertensive effects, aldosterone blockade has been shown to improve potassium balance and decrease mortality in heart failure cases (7). Two-thirds of our study cohort had bilateral disease, and we are currently evaluating response to medical management as it relates to long-term renal and cardiovascular outcomes.

In conclusion, PAH is common in diabetic patients with resistant hypertension. Our study indicates that diabetic subjects with poorly controlled hypertension on three or more antihypertensive drugs should be screened for aldosteronism. Research is needed to better establish optimal diagnostic cutoffs and the true prevalence of PAH in patients with and without diabetes.

References

1. Umpierrez GE, Cantey P, Smiley D, Palacio A, Temponi D, Luster K, Chapman A: Primary aldosteronism in diabetic subjects with resistant hypertension. Diabetes Care 30:1699–1703, 2007[Abstract/Free Full Text]
   
2. Ng YW, Tiu SC, Ng JCM, Chan HY: Primary aldosteronism in diabetic subjects with resistant hypertension (Letter). Diabetes Care 31:e2, 2008. DOI: 10.2337/dc07-1740[Free Full Text]
   
3. Sawka AM, Young Jr WF, Thompson GB, Grant CS, Farley DR, Leibson C, van Heerden JA: Primary aldosteronism: factors associated with normalization of blood pressure after surgery. Ann Intern Med 135:258–261, 2001[Abstract/Free Full Text]
   
4. Schwartz GL, Turner ST: Screening for primary aldosteronism in essential hypertension: diagnostic accuracy of the ratio of plasma aldosterone concentration to plasma renin activity. Clin Chem 51:386–394, 2005[Abstract/Free Full Text]
   
5. Young WF Jr: Minireview: primary aldosteronism: changing concepts in diagnosis and treatment. Endocrinology 144:2208–2213, 2003[Abstract/Free Full Text]
   
6. Mulatero P, Stowasser M, Loh KC, Fardella CE, Gordon RD, Mosso L, Gomez-Sanchez CE, Veglio F, Young WF Jr: Increased diagnosis of primary aldosteronism, including surgically correctable forms, in centers from five continents. JCEM 89:1045–1050, 2004[Abstract/Free Full Text]
   
7. Ghose RP, Hall PM, Bravo EL: Medical management of aldosterone-producing adenomas. Ann Intern Med 131:105–108, 1999[Abstract/Free Full Text]
   

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This Article Extract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Smiley, D. Articles by Umpierrez, G. Search for Related Content PubMed Articles by Smiley, D. Articles by Umpierrez, G. Social Bookmarking                What's this?