卡托普利抑制试验中原醛症最佳诊断指标的探讨

Studies on the optimal diagnostic criteria of primary aldosteronism in captopril challenge test

目的探讨卡托普利抑制试验(CCT)中不同评价指标对原发性醛固酮增多症(PA,简称原醛症)的诊断价值。方法回顾性分析2014年1月-2016年3月在解放军总医院内分泌科诊治的222例高血压患者的临床资料,其中醛固酮瘤(APA)90例,特发性醛固酮增多症(IHA)44例及原发性高血压(EH)88例。所有患者均行CCT,应用受试者工作特征曲线(ROC)对CCT后醛固酮绝对值、醛固酮抑制率、肾素活性上升率、肾素活性上升率联合醛固酮抑制率和血浆醛固酮/肾素活性比值(ARR)进行评价,确定最佳诊断切点及其敏感性和特异性。结果 CCT后APA、IHA和EH组醛固酮抑制率分别为0.3%、0.7%和4.0%。PA组(APA组和IHA组)肾素活性上升率明显低于EH组(P<0.05),APA组、IHA组和EH组肾素活性上升率分别为0(0,1)、0.25(0,1)和0.97(0.23,2.27)。CCT后醛固酮绝对值、醛固酮抑制率、肾素活性上升率、肾素活性上升率联合醛固酮抑制率和ARR的ROC曲线下面积(AUC)分别为0.703、0.575、0.318、0.616和0.901,最佳切点分别为417.20、2.90、–0.44、0.53和22.70[醛固酮浓度(PAC)单位采用ng/dl,1pmol/L=27.7ng/dl;肾素活性(PR A)单位为μg/(L·h)],敏感度分别为81.7%、10.1%、95.5%、62.4%和81.7%,特异度分别为51.1%、97.8%、7.8%、60.4%和87.7%。结论高血压患者包括EH及原醛症CCT后醛固酮抑制率远低于30%,CCT后ARR对原醛症的诊断价值优于醛固酮绝对值、醛固酮抑制率、肾素活性上升率及肾素活性上升率联合醛固酮抑制率。

Objective To investigate the diagnostic value of different evaluation indexes of captopril challenge test（CCT） on primary aldosteronism. Methods The biochemical parameters were collected of patients with aldosterone producing adenoma（APA, 90 cases）, with idiopathic hyperaldosteronism（IHA, 44 cases） and with essential hypertension（EH, 88 cases） who were diagnosed and undergone CCT in the General Hospital of PLA from Jan. 2014 to Mar. 2016. The clinical characteristics were compared, the receiver operating characteristic cur ve（ROC） was conducted to evaluate the diagnostic value of different evaluation indexes including the absolute value and suppression percentage of aldosterone, the increasing percentage of plasma renin activity（PRA） and the ratio of aldosterone/renin（ARR）, and then the optimal diagnostic criteria and its sensitivity and specificity were determined. Results After CCT the suppression percentage of aldosterone in APA, IHA and EH groups were 0.3%, 0.7% and 4.0%, respectively. The increasing percentage of renin in APA, IHA and EH groups was 0（0, 1）, 0.25（0, 1） and 0.97（0.23, 2.27）, respectively. The increasing percentage of renin in primary aldosterone group was significantly lower than that in EH group（P〈0.05）. After CCT, the area under ROC curve（AUC） for plasma aldosterone level, the suppression percentage of aldosterone,the increasing percentage of renin, the suppression percentage of aldosterone and the increasing percentage of renin and ARR were 0.703, 0.575, 0.318, 0.616 and 0.901, respectively. The optimal cut-off point of plasma aldosterone level, the suppression percentage of aldosterone, the increasing percentage of renin, the suppression percentage of aldosterone and the increasing percentage of renin and ARR were 417.20 pmol/L, 2.90, –0.44, 0.53 and 22.70, and the diagnostic sensitivity were 81.7%, 10.1%, 95.5%, 62.4% and 81.7%, and the specificity was 51.1%, 97.8%, 7.8%, 60.4% and 87.7%, respectively. Conclusions In hypertensive patients including EH and primary aldosteronism, the inhibition of aldosterone after CCT is significantly lower than 30%. The diagnostic value of ARR after CCT is superior to that of the CCT in terms of plasma aldosterone level, the suppression percentage of aldosterone, the increasing percentage of renin, the suppression percentage of aldosterone and the increasing percentage of renin.