Targeted treatment of confirmed and suspected primary aldosteronism in Bangladeshi patients: a prospective outcomes study — ASN Events
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Targeted treatment of confirmed and suspected primary aldosteronism in Bangladeshi patients: a prospective outcomes study (#350)

Sharmin prof. Jahan 1 , Zhong Dr. Lu 2 , Muhammad Dr. Akram 3 , Peter Prof. Fuller 3 , Jun Prof. Yang 3
  1. Bangabandhu Sheikh Mujib Medical University, Dhaka, SHAHBAG,DHAKA, Bangladesh
  2. Monash health patology, Monash Health, Melbourne, Victoria, Australia
  3. Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia

 

 

Primary aldosteronism (PA) is a prevalent but under-diagnosed cause of endocrine hypertension, especially in resource-limited settings in low to middle income countries (LMIC) where aldosterone suppression tests and adrenal vein sampling (AVS) are scarce. Patients missing strict PA criteria are often labeled with low-renin hypertension, though they may share the same disease spectrum and benefit from mineralocorticoid receptor antagonists (MRAs). This prospective observational study in a tertiary Endocrine hypertension clinic in Bangladesh evaluated the six-month clinical and biochemical response to spironolactone (an MRA) in patients with suspected PA, regardless of their aldosterone suppression test results.

From September to December 2024, consecutive hypertensive adults were screened for PA using the aldosterone-to-renin ratio (ARR). Patients with an ARR > 50 pmol/mIU underwent a seated saline suppression test (SST) and/or captopril challenge test (CCT). PA was biochemically confirmed if post-test aldosterone exceeded 170 pmol/L (SST) or 333 pmol/L (CCT). Because AVS was unavailable, patients with an elevated ARR received spironolactone irrespective of aldosterone suppression test outcomes, except for eight patients with clear unilateral adenomas who underwent adrenalectomy.

Out of 456 screened patients, 186 (40.8%) had an elevated ARR, and 96% of those had low renin (< 12 mIU/L). Ultimately, 108 patients met formal PA diagnostic criteria. Of the 175 medically treated patients with six-month follow-up, 74.3% achieved a complete biochemical response and 53.1% achieved a complete clinical response. Notably, baseline biomarkers significantly overlapped across response categories; among patients achieving a complete clinical response, 53% on SST and 90% on CCT failed to meet formal diagnostic thresholds for PA.

In conclusion, MRA therapy was effective in patients with suspected PA, regardless of their aldosterone suppression test results. Elevated ARR and low renin can be considered pragmatic and cost-effective biomarkers to treat aldosterone-mediated hypertension particularly in resource-limited environments in LMIC.