Diagnostic efficacy of aldosterone-to-renin ratio to screen primary aldosteronism in hypertension: a systemic review and meta-analysis

Ting-Wei Kao; Jui-Yi Chen; Jung-Hua Liu; Wen-Hsin Tseng; Chih-Chia Hsieh; Vin-Cent Wu; Yen-Hung Lin; Zheng-Wei Chen

doi:10.1177/20420188241303429

Diagnostic efficacy of aldosterone-to-renin ratio to screen primary aldosteronism in hypertension: a systemic review and meta-analysis

Ther Adv Endocrinol Metab. 2024 Dec 11:15:20420188241303429. doi: 10.1177/20420188241303429. eCollection 2024.

Authors

Ting-Wei Kao¹, Jui-Yi Chen², Jung-Hua Liu³, Wen-Hsin Tseng⁴, Chih-Chia Hsieh⁴, Vin-Cent Wu⁵, Yen-Hung Lin⁶, Zheng-Wei Chen^{7

8}

Affiliations

¹ Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
² Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.
³ Department of Communication, National Chung Cheng University, Chiayi, Taiwan.
⁴ Division of Urology, Department of Surgery, Chi Mei Medical Center, Tainan, Taiwan.
⁵ Division of Nephrology, Primary Aldosteronism Center of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
⁶ Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
⁷ Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, No. 579, Sec. 2, Yunlin Road, Douliu City, Yunlin 640, Taiwan.
⁸ Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.

Abstract

Background: The aldosterone-to-renin ratio (ARR) is commonly used for screening primary aldosteronism (PA) in patients with difficult-to-control hypertension. Various thresholds have been proposed for the confirmatory tests, leading to inconsistency in the results.

Objectives: This study aimed to elucidate the performance of ARR screening in hypertensive patients.

Design: Systemic review and meta-analysis.

Data sources and methods: PubMed, Embase, and the Cochrane Library were systematically searched from inception to January 2024. Studies that used the ARR to screen for PA and provided a comprehensive probability panel specifically focusing on hypertensive individuals were considered for enrollment. Pooled diagnostic efficacy was evaluated, and subgroup analyses and meta-regression were conducted based on different demographic and clinical parameters.

Results: Eighteen observational studies encompassing 7150 participants were included in the meta-analysis. The overall prevalence of PA in the hypertensive cohort was 15.2%, and pooled sensitivity and specificity were 81.6% and 93.3%, respectively, resulting in a diagnostic odds ratio of 62.0. Fagan's nomogram showed that a positive ARR increased the post-test probability to 80% from a pre-test probability of 25%. Summary receiver operating characteristic curve analysis revealed an area under the curve of 94.7%. Notably, analysis of variability demonstrated that the diagnostic performance was consistent across either ARR based on plasma renin activity or direct renin concentration, geographic region, sex, mean age, potassium level, and systolic blood pressure.

Conclusion: ARR was validated as a viable screening methodology for PA in hypertensive individuals. Moreover, its diagnostic efficacy remained unchanged across diverse clinical contexts. Future studies are warranted to refine ARR methodologies and enhance diagnostic accuracy.

Trial registration: PROSPERO ID number CRD42023493680.

Infographics: Performance of PA screening by ARR. ARR, aldosterone-to-renin ratio; BP, blood pressure; DRC, direct renin concentration; hsROC, hierarchical summary receiver operating characteristic; PA, primary aldosteronism; PRA, plasma renin activity.

Keywords: hypertension; meta-analysis; primary aldosteronism; screening.

Plain language summary

Screening primary aldosteronism in patients with hypertension using aldosterone-to-renin ratio Primary aldosteronism constitutes a significant etiology of secondary hypertension. However, historical under-recognition has resulted in delayed diagnosis and compromised prognoses. The aldosterone-to-renin ratio is universally recommended as the primary screening tool for primary aldosteronism. This meta-analysis systematically reviewed existing literature to evaluate the diagnostic accuracy of aldosterone-to-renin ratio. Subgroup analyses and meta-regression incorporating covariates demonstrated consistent performance across diverse demographic and clinical contexts. These findings support the broader implementation of aldosterone-to-renin ratio screening in hypertensive patients.