Donate and represent!
#NephJC

At our center we do the initial screen without altering the existing meds. Don’t wanna miss the opportunity. Patients with the most overt PA have suppressed renin even on RAASi+thiazide. If results aren’t conclusive and suspicion still there can then washout or try empiric MRA. #NephJC

Implementing will be a challenge but that shouldn't discourage broader screening.

From the recent Endo Society guideline - the majority of these newly detected cases can be managed with MRA.

Commentary on expanded screening for primary aldosteronism in the new HTN guideline.

www.ahajournals.org/doi/10.1161/... 🔓

1/ Even outside of AVS the intra-individual variability of plasma aldo is important. Another study with the same message. www.ahajournals.org/doi/10.1161/...

Agree that the most spironolactone-responsive cases of RHTN are on that spectrum of PA. I have used a similar approach and this practice, along with monitoring for an increase in renin, has been adapted in the new Endo society guideline.

Should adrenalectomy still be first-line treatment of unilateral PA?
▶️adrenalectomy associates with greater decrease in LVM despite similar BP
▶️shorter duration of HTN associates with greater benefit after surgery
▶️high 24hr urine Na negatively impacts benefit of MRA
tiny.cc/jf2o001 🔒
#nephsky

3/ I was interested to learn about the modulatory effect that spiro has on CTD-related sympathetic activation and insulin resistance. Maybe there is some specific benefit in adding MRA to thiazide. Just not sure if it’s directly related to blocking aldosterone. (Figure from the referenced study.)

2/ Is secondary (renin-angiotensin-dependent) hyperaldosteronism occurring secondary to diuretics / sodium depletion analogous to physiologic hyperaldosteronism seen with very low Na diet? I don't know.

1/ Interesting read. The conclusion to use MRAs (or maybe ASIs) sooner makes sense to me. But is the main benefit just due to the high prevalence of primary aldosteronism, rather than in offsetting the secondary aldosteronism that accompanies thiazides? #nephsky #cardiosky #endosky #medsky

And a more visually agreeable figure from an excellent review article from @anandvaidya17.bsky.social et al. academic.oup.com/edrv/article...

I can't this question, but it gives me a good excuse to mention the 1970s study by Oliver et al demonstrating that high levels of renin / aldosterone alone don't drive blood pressure. It's some combination of salt+RAAS+(?). pubmed.ncbi.nlm.nih.gov/1132118/ #NephJC

Anecdotally I still find the switch useful in RHTN. Maybe just my⚓️ bias but most of the patients in that study did not have RHTN and were on lower doses of CTD than I typically use for RHTN. I'm open to being enlightend but for now... #nephmadness

SGLT2i as well! Modest BP effect but bank on hard outcome data. Here is my rough draft of where they might fit (in red) into the RHTN treatment algorithm. From a talk to #OSUNephrology fellows just last week ! Would love feedback! #nephmadness @jordybc.bsky.social @stephanietr612.bsky.social

I got a link to the new Endocrine Society guideline for primary aldosteronism (draft open for public comments).

www.surveymonkey.com/r/endopacpg

>Suggests screening all individuals with hypertension
>Proposes various strategies re: handling of confounding BP meds during testing

#NephJC #Nephsky

3/ Prognostic value of renin as a biomarker in pharmacologic treatment. In PA treated with MRA, non-suppressed renin status (PRA > 1) associates better CV outcomes independent of BP. (I think this is still up for debate, needs prospective data.) #NephJC

academic.oup.com/edrv/article...

Up for debate - from a reveiw from some of the authors of today's paper.

@jenifermbr.bsky.social @anandvaidya17.bsky.social

pmc.ncbi.nlm.nih.gov/articles/PMC...

#NephJC

What's the highest renin you've ever seen?

An extreme example of a common issue. Severe hyperreninemia secondary to combination ARB+thiazide.

www.ccjm.org/content/91/2... (free)

@amyaimei.bsky.social

#medsky #nephsky

Outstanding! Compare to primary aldosteronism:
->autonomous aldosterone
->excessive MR activation / ENaC
->distal Na reabsorption despite expanding CV
->renin/angII suppressed, no stimulus for proximal Na reabsorption
->greater Na delivery to ASDN
->inappropriate K excretion

tinyurl.com/3yd46a5c