GUIDELINES - The Endocrine Society

AbstractObjective: To develop clinical practice guidelines forthe diagnosis and treatment of patients with primaryaldosteronism.Participants: The Task Force comprised a chair,selected by the Clinical Guidelines Subcommittee(CGS) of The Endocrine Society, six additionalexperts, one methodologist, and a medical writer. TheTask Force received no corporate funding orremuneration.Evidence: Systematic reviews of available evidencewere used to formulate the key treatment andprevention recommendations. We used the Gradingof Recommendations, Assessment, Development,and Evaluation (GRADE) group criteria to describeboth the quality of evidence and the strengthof recommendations. We used ‘recommend’ forstrong recommendations and ‘suggest’ for weakrecommendations.Consensus Process: Consensus was guided bysystematic reviews of evidence and discussions duringone group meeting, several conference calls, andmultiple e-mail communications. The drafts preparedby the task force with the help of a medical writerwere reviewed successively by The EndocrineSociety’s CGS, Clinical Affairs Core Committee(CACC), and Council. The version approved by theCGS and CACC was placed on The EndocrineSociety's Web site for comments by members. Ateach stage of review, the Task Force received writtencomments and incorporated needed changes.Conclusions: We recommend case detection ofprimary aldosteronism be sought in higher risk groupsof hypertensive patients and those with hypokalemiaby determining the aldosterone-renin ratio understandard conditions, and that the condition beconfirmed/excluded by one of four commonly usedconfirmatory tests. We recommend that all patientswith primary aldosteronism undergo adrenalcomputed tomography (CT) as the initial study insubtype testing and to exclude adrenocorticalcarcinoma. We recommend the presence of aunilateral form of primary aldosteronism should beestablished/excluded by bilateral adrenal venoussampling by an experienced radiologist and,where present, optimally treated by laparoscopicadrenalectomy. We recommend that patients withbilateral adrenal hyperplasia, or those unsuitablefor surgery, optimally be treated medically bymineralocorticoid receptor antagonists.(J Clin Endocrinol Metab 93: 3266–3281, 2008)Abbreviations:APA, aldosterone-producing adenoma; ARR, plasma aldosterone: renin ratio;AVS, adrenal venous sampling; CT, computed tomography; DRC, direct renninconcentration; FST, fludrocortisone suppression testing; GRA,glucocorticoidremediable aldosteronism; IHA, idiopathic hyperaldosteronism;MR, mineralocorticoid receptor; MRI, magnetic resonance imaging; PA,primary aldosteronism; PAC, plasma aldosterone concentration; PRA, plasmarennin activity; SIT, saline infusion test; UAH, unilateral adrenal hyperplasiaCASE DETECTION, DIAGNOSIS, AND TREATMENT OF PA TIENTS WITH PRIMARY ALDOSTERONISM3