洗脱前醛固酮/肾素浓度比值在原发性醛固酮增多症筛查中的应用

Application of aldosterone/direct renin ratio before drug washout in the screening of primary aldosteronism

目的探讨洗脱前醛固酮/肾素浓度比值(ADRR)筛查中国人群原发性醛固酮增多症(PA)的切点值,降低PA筛查中洗脱药物带来的风险。方法入选2017年1月到2019年10月在中国医学科学院阜外医院高血压病房住院的高血压患者。参照美国2016年PA诊断指南及我国2016年PA诊断共识进行PA诊断。测定药物洗脱前后的血醛固酮浓度(PAC)、肾素浓度(DRC)及ADRR。绘制ADRR的受试者工作特征(ROC)曲线并以Youden指数最大时,确定最佳切点值。结果入选高血压患者542例,其中确诊为原发性高血压(EHT)患者467例(男297例,女170例),确诊为PA患者75例(男51例,女24例)。PA患者洗脱前后的PAC、ADRR均高于EHT患者[150.0(130.0,210.0)比120.0(80.0,170.0)ng/L,170.0(120.0,260.0)比130.0(90.0,180.0)ng/L;28.9(15.9,63.5)比4.3(1.9,11.8)(ng/L)/(mU/L),55.6(39.0,109.0)比9.8(4.5,21.3)(ng/L)/(mU/L),P≤0.001],而洗脱前后的DRC均低于EHT[4.0(2.0,10.0)比27.0(10.0,64.0)mU/L,3.0(2.0,4.0)比12.2(5.0,27.0)mU/L,P<0.001]。EHT及PA组洗脱后均为PAC升高(P=0.001,P<0.001),DRC降低(均P<0.001),ADRR升高(均P<0.001),差异有统计学意义。洗脱前ADRR的ROC曲线下面积为0.868(95%CI:0.836~0.895)。洗脱前ADRR以7.8(ng/L)/(mU/L)为切点值筛查PA的灵敏度、特异度分别为94.7%、66.8%,此时Youden指数最大(0.615)。结论洗脱前ADRR>7.8(ng/L)/(mU/L)可作为切点,在不能进行药物洗脱条件下作为筛查PA的替代指标。

Objective To explore the cut-off point of aldosterone/direct renin ratio(ADRR)before drug washout in the screening for primary aldosteronism(PA)in the Chinese population and reduce the potential risk caused by drug washout during PA screening.Methods Hospitalized hypertensive patients in the Hypertension Ward of Fuwai Hospital,Chinese Academy of Medical Sciences from January 2017 to October 2019 were enrolled.PA was diagnosed according to the criterion of 2016 American Guideline and 2016 Chinese Consensus for PA.The plasma aldosterone concentration(PAC),direct renin concentration(DRC)and ADRR before and after drug washout were measured.The receiver operating characteristic(ROC)curve of ADRR was drawn and the maximal Youden index was used to determine the best cut-off value.Results A total of 542 hypertensive patients were included,with 467 patients diagnosed with essential hypertension(EHT)(297 males and 170 females),and 75 patients diagnosed with PA(51 males and 24 females).Patients with PA had higher PAC and ADRR before and after drug washout than those with EHT(150.0(130.0,210.0)vs 120.0(80.0,170.0)ng/L,170.0(120.0,260.0)vs 130.0(90.0,180.0)ng/L;28.9(15.9,63.5)vs 4.3(1.9,11.8)(ng/L)/(mU/L),55.6(39.0,109.0)vs 9.8(4.5,21.3)(ng/L)/(mU/L),all P<0.001).However,DRC of PA patients before and after washout were lower than those with EHT(4.0(2.0,10.0)vs 27.0(10.0,64.0)mU/L,3.0(2.0,4.0)vs 12.2(5.0,27.0)mU/L,P<0.001).In EHT and PA groups,PAC and ADRR significantly increased(P=0.001,P<0.001),but DRC significantly decreased after drug washout(all P<0.001).The area under the ROC curve of ADRR before drug washout was 0.868(95%CI 0.836-0.895)with the best cut-off value of 7.8(ng/L)/(mU/L)for the screening of PA.The sensitivity and specificity was 94.7%and 66.8%,respectively,with the maximal Youden index of 0.615.Conclusion ADRR before drug washout>7.8(ng/L)/(mU/L)can be used as an alternative cut-off point to screen PA when drug washout is not available.